Do times change? I guess they do. Sixty years ago my father was a general practitioner in Lawrence. Except for a few fraternal lodges which insured its members for surgical procedures, he knew no third parties, did not need or have a bookkeeper, and made change for office fees from his pants' pockets, where he always had an interesting assortment of crumpled-up paper money. If a patient looked impoverished, Dad would wave his hand and nod his head when they tried to pay him and say, "No charge today", or some equally dismissive remark. The office was annexed to our house. If patients listened carefully they could hear me playing in the yard or fighting in the kitchen with my siblings.

When I opened my office in 1964, I invited Dad to see my first professional residence. He took one look at the pane of glass separating my bookkeeper from the waiting room, scowled a bit, and said: "It looks like a damned bank." His language was a little more politically incorrect than that! I silently made light of that scowl then, reckoning that his was the old way, mine the new, and times do change.

My epiphany came two decades later when I began to re-think the whole thing and wondered, uneasily, if perhaps he wasn't right about our medical enterprise. The third parties, our heath insurance systems, whether private or governmental, have played mid-wife to the commercialism which now contaminates our profession. Their rules have a perverse influence on the practice of medicine. To be paid, the physicians have had to learn the arcane rules of the game and, at the core, they are as follows:

1. All the ailments, injuries and insults that afflict mortal man are contained, defined and delimited in the code manual, the medical bookkeeper's Holy of Holies. Each separate code must be scrupulously identified and matched to a service rendered in order to be paid.

2. Each thing done, no matter how trifling, has a code lurking somewhere. Trivial pursuit consists in "cherchez la code" and an eagle-eyed bookkeeper pays for her lodgings very quickly.

3. Happiness is a higher-paying code. Each new physician or office manager tries as diligently as he or she can to establish the highest possible code for each service rendered. He must spend time, money and effort documenting as carefully as he can for the insurance inspectors who are always at the door. If this means more staff just to do the paper work, so be it.

4. Tinkerers are paid more than thinkers, so physicians must follow the ancient, received wisdom: "Do something, Doctor; don't just stand there."

5. Caring doesn't pay as much as catheterizing, and empathy is worth less than endoscopy.

6. Talking to a patient pays nothing; telemetering that patient may be worth a small fortune.

7. One house call, no code; two house calls, no code; ergo, no house calls.

The perversion of which I speak is inherent in these rules and does not need further amplification. The third parties, with malice towards none, have lured the profession more and more toward the technological end of the treating spectrum and moved the physician to abdicate his or her traditional roles as healer, comforter and counselor of the sick. Bad as this may be in itself, there is a worse trap in our foreseeable futures. The more technology-prone we become, the more we define ourselves, and are defined, as technicians. The trap is sprung when our machines finally replace us totally at the bedside while we hunker down in a remote place, satisfied with our mastery over the toggle switches. Small wonder that our incomes and reputations fall and lawsuits against us rise. Lawyers might entrap us, but third parties have set the bait.

There are no easy exits from this quandary, and I do not wish to be quixotic. We can hardly go back to Dad's day, shredding the third-party forms and firing the bookkeepers. Nor do many of us enjoy a fixed salary from a bottom line-oriented HMO demanding one-stop jiffy visits. The move to pay more for cognitive services, a step in the right direction, has proven to be as futile as what came before. Each step seems to plunge us deeper into the morass.

So long as we embrace the hazardous notion that a remote, impersonal third party must be petitioned, piecemeal, to reward us for services to patients, the sticking point persists.

Does caring count? Only the number of beans counted by the insurance overlords. Welcome to Handcuffed Medical Organizations, your new HMOs.

The writer is a Sunset Rock Road resident, surgeon and clinical instructor at Tufts University School of Medicine who wrote the book Choosing Your Doctor.