We physicians are not a trade union ("Got a better plan for reducing Medicare costs?" April 5). We have a monopoly on an essential service. As such, we are not permitted to unionize without violating antitrust laws. However, medical practice is voluntary. If pay does not cover costs, especially of massive student loan payback and practice startup costs, there will be less and less access to care. Marylanders should contact their legislators about real tort reform if they expect any reduction in their Medicare costs, as elderly patients and their families expect prompt diagnosis, timely treatment and excellent outcomes regardless of age or prior severe illness. They may sue if there is a bad outcome. There should be a federal award cap for care rendered under Medicare because it is a government program just like veteran care and the Indian health service, where lawsuits are limited.