Where Does It Hurt? What Ails Medicine in America
MARGOLIS, RICHARD J.
WHAT AILS MEDICINE IN AMERICA The best medical care America presently has to offer may still be the best in the world, which is why ailing kings and potentates frequently repair to our famous...
...As a result, patients have had to rely on such feeble safeguards as "peer review," a process wherein physicians are expected to monitor their colleagues' performance...
...infant death rate last year had been proportional to Sweden's, 50,000 fewer babies would have died in this country...
...We need to assess our schemes and dreams in the light of a history that records many political failures and only an occasional success...
...Terrible things were happening on the operating table...
...They explained to me in five different ways that I was neurotic...
...A Detroit union official told the subcommittee what happened to a member of his union who went to a hospital for eye surgery: "Within 24 hours he required a lengthy emergency heart operation to save his life...
...The last item has been receiving the most attention...
...What it all added up to was that he took an interest in me as a human being, not as just a problem case...
...There was no physician that they would give me for help...
...Senate, estimates that American surgeons perform more than 2 million needless operations every year...
...Eventually Dr...
...Morris Fishbein, a former AMA president and organized medicine's staunchest defender, now concedes "there may be too many surgeons" and reports that surgeons are "dissatisfied with the amount of work . . . available...
...it might then proceed to the spotty way health care in this country is distributed—a surfeit in some towns and neighborhoods, a desperate shortage in others—and to the general unavailability, even for the affluent, of adequate, around-the-clock medical services...
...Andrew P. Sackett, the city's Commissioner of Health and Hospitals...
...In sum, a large portion of the citizenry is now saying that medical services are unaffordable or unobtainable, and that the practitioners are frequently unaccountable...
...and the same amount for a cardiac consultation specialist...
...Besides, most people are ineligible for the Federal programs—by virtue of being either too young or too affluent—and are but sketchily covered by insurance schemes...
...Herbert S. Denenberg, Pennsylvania's Nader-like insurance commissioner until he resigned last month to run for the U.S...
...Clearly, our health care system has tilted crazily when it charges a man $300 an hour for the privilege of expiring...
...Tushnet found a useful physician, a general practitioner...
...The system of distribution appears to have been designed for the convenience of physicians and hospital administrators...
...Then, perhaps, we can (to borrow from Joyce) "go to encounter for the millionth time the reality of experience," and forge an effective and equitable health care system...
...For instance, we rank 15th in infant mortality, 12th in life expectancy among females and 27th among males...
...I ran from specialist to specialist, finally seeing five in a single week...
...Lester Breslow, Dean of the School of Public Health at UCLA, writes of surgeons, albeit "a small minority," who are "knife-happy, incompetent and greedy...
...In 1973 the health bill for each American averaged $394, a 10 per cent jump over the previous year...
...Consider the experience recorded in last September's Medical Economics by Dr...
...Well, the surgeon thanked them...
...Along with others, Bert Seidman, Social Security Director of the AFL-CIO, links the surplus of surgeons in many American cities to the surplus of surgery...
...One person after another," the Senator has written, "startled our subcommittee by testifying to harassment by collection agencies after a serious illness...
...In 1950 total medical expenditures accounted for only 4.6 per cent of our gross national product...
...The writers of a white paper for the Department of Health, Education and Welfare (HEW), titled "Toward a Comprehensive Health Policy for the 1970s," have pointed to several of the advantages offered by "primary care physicians"—i.e., general practitioners, internists and pediatricians: "Their average fees are lower than specialists...
...he hadn't been consciously pushing tonsillectomies, just performing them routinely...
...In all, the average insured American can expect to have a mere third of his medical expenses met by his insurance company...
...No one would see him...
...But by now nearly everyone recognizes that the system itself is also to blame...
...Increasingly, doctors prefer to take the cash and let the credit go, often collecting the patient's fee before treating his illness...
...The medical system in this country is not monolithic—the several interest groups it shelters both compete and cooperate with each other —yet it tends to function beyond the public's reach...
...Ideas and proposals are whirling in profusion," notes Rosemary Stevens, a Yale professor and a commentator on our medical system, but "their ultimate importance and effect [is] uncertain...
...When Sam Houston Johnson, Lyndon's brother, declared himself bankrupt last year, he said that nearly two-thirds of his unpaid debts were bank loans to pay for medical treatment...
...Many of the "solutions" of yesteryear—from Blue Cross to Medicare—now seem hasty and misguided responses to mounting frustrations...
...Four-fifths of the insured families are not covered for care either at home or in the doctor's office...
...They'd arranged a top administrative job for him and a lot of consultation work...
...The process need not even be a conscious one on the part of the surgeon...
...Part of these increases can be attributed to genuine medical advances—improvements in the treatment of heart attack victims, for instance, requiring high-priced coronary care equipment and expensively trained personnel...
...200 others were down to only one doctor, and more often than not he was in his 60s or 70s...
...Another is that doctors, like all entrepreneurs, tend to cluster where the money is, short-changing large areas in America...
...He died...
...During the 1960s hospital rates went up four times as fast as other items on the consumer price index, and doctors' fees rose at twice the index rate...
...235 for lab fees...
...To judge from the bills in Congress, the ways are manifold...
...A reasonable checklist of complaints would probably begin with the high cost of medical care and the widespread lack of adequate medical insurance coverage...
...Many physicians publicly endorse peer review but privately spurn it, and nearly every doctor one questions seems ready to offer a horrible example...
...He is eloquent on what that general practitioner did and did not do: "First, he listened...
...and $320 for eight transfusion 'hook-ups'— excluding the cost of 31 pints of blood...
...Even Dr...
...According to a recent editorial in Archives of Surgery, "Almost half the operations performed in the United States are carried out by noncertified surgeons...
...A 1965 study of 1,500 towns and cities in the upper-Midwest found two-thirds of those communities doctorless...
...The level of charges is scandalous...
...There is a joke going around the medical schools—Professor: What are the symptoms for a hysterectomy...
...he didn't brush me off...
...Such inequities plainly cry out for remedy...
...On the night after seeing the fifth specialist, I went into acute pulmonary edema...
...Alas, primary care physicians today comprise fewer than 30 per cent of the nation's doctors, as against 83 per cent in 1931, and the imbalance is one reason medical services are frequently so hard to come by...
...Kerr L. White of Johns Hopkins University...
...These social cures, as I shall try to make clear, have in many respects been worse than the disease, suggesting that health care is too complex, and its reform too urgent, to permit us the luxury of a weak sense of consequences...
...Then he went on an annual retainer and his tonsillectomy rate dropped sharply...
...he didn't look at pieces of paper to make a diagnosis...
...At last count, some 5,000 towns in 130 counties throughout the nation had no doctor at all...
...Testifying last year in Des Moines before Senator Edward M. Kennedy's Subcommittee on Health, Senator Harold E. Hughes told the following incredible tale: "Would it surprise you that when I was Governor of this state I tried to call a physician for my son-in-law in this city and could not get a physician to go to his home to see him when he was suffering severe cramps and intestinal distress...
...The pattern is repeated in countless urban ghettoes...
...Nor do the statistics tell the entire story...
...What we have instead is a literature abundant with comments about slipshod practices—-hasty examinations, inaccurate diagnoses and needless surgery...
...Many a hospital patient these days would concur in Oscar Wilde's death-bed complaint, "I am dying beyond my means...
...Americans now spend 56 per cent more on medical services than they did five years ago, and three times as much as in 1960...
...The bill for one day's hospitalization was $7,271...
...Is there no way of guaranteeing good health care at reasonable cost to every American...
...500 for anesthesia...
...Boston's Roxbury, according to Selig Green-berg in The Quality of Mercy, hasn't a single pediatrician...
...True, only about a third of the national health care bill is charged directly to consumers...
...717 for blood tests...
...It is embarrassing to me to take bankruptcy," Johnson said, "but it will be worth it if it points out to Congress that many millions of Americans are forced into bankruptcy by medical costs they simply cannot meet...
...The hospital trustee has got to stand up and be counted in an agonizing reappraisal of the system...
...From that day on," he says, "I made rapid progress to full recovery...
...It is hardly surprising that we keep demanding fresh remedies, drafting new legislation, organizing "demonstration" programs, and publishing still more analyses (like this one...
...When that happens to the Governor, you know, I wonder what happens to the rest of the people...
...Some of the physician charges include $2,700 for a two-man surgical team—another bill for the second team is pending...
...So we seem no closer to a solution than we were 50 years ago when Louis I. Dublin sensed that something was "seriously wrong" with health care in America...
...Because medical economics reverses the conventional rule of supply and demand by placing buying decisions in the hands of the doctor instead of the patient, it is not difficult to see how an excessive supply of surgeons begets an excessive "demand" for surgery...
...The rest is met by the Federal government, mainly through its Medicare and Medicaid programs, and by health insurance companies...
...Rieger had lost his premature child and had almost lost his wife when she suffered heart failure while giving birth...
...The doctor doesn't see patients who haven't paid their bills," the nurse told her...
...Yet the citizen pays those bills, too, in the form of higher taxes and stiffer premiums...
...I know of a case where a physician was making a helluva lot of money performing tonsillectomies on a fee-for-service basis," recalls Dr...
...their abstract tidiness tends to conceal a considerable amount of heartbreak...
...Student: A Blue Shield card and $200...
...Not long ago a woman in Washington who had recently had a hysterectomy called her surgeon for an office appointment...
...The state of Mississippi has only 82 physicians for every 100,000 persons, compared to 371 physicians for every 100,000 in Washington, D.C...
...Yet three-quarters of the recent price hikes, according to HEW, are a consequence of soaring charges levied by doctors and hospitals...
...Last year nearly half of those who filed pleas of personal bankruptcy did so because of medical debts...
...There was this well-known surgeon at a big hospital in New York," a physician told me recently, "who was getting too old to practice...
...James Rieger, in Cleveland, described how such an agency took his family's car, stove, refrigerator, television and everything they were buying on credit to pay $20,000 in doctor and hospital bills...
...The average physician's income nowadays exceeds $45,000, and that figure includes the incomes of retired doctors, residents and doctors who work for the government...
...A whole system of medical care has collapsed...
...Americans with money and status can also find it hard to coax a response from our strangely recalcitrant health care system...
...Few Americans, in short, can ever be certain of getting prompt, adequate health care...
...His income wasn't going to suffer...
...He puts hysterectomies and tonsillectomies at the top of the list...
...Then he went home and put a bullet through his head...
...Moreover, the medical establishment's concerns may be more fiscal than physiological...
...200 for the use of a heart-lung machine...
...Forty years ago, he observes, "nobody . . . would have ever dreamed that reputable hospitals would be giving surgical privileges to people who had no surgical training whatsoever...
...Francis D. Moore at the Harvard Medical School voices a similar concern, blaming incompetent surgery on a system that permits any doctor, qualified or not, to perform operations...
...They are generally more concerned about their patients as a whole and as members of a family . . . and there is some evidence that patients who are cared for by primary care physicians tend to require less hospitalization...
...In all three categories, our relative rating is worse now than it was 20 years ago, a sign that other nations have been paying more attention of late to health problems...
...Second, he examined me...
...Senator Kennedy and his subcommittee spent the better part of the past year collecting testimony from citizens who had been driven to economic ruin by our health care system...
...today they amount to 7.6 per cent...
...Washington Park, another huge Boston ghetto, has just seven doctors, and their average age is 66...
...Finally, his fellow-surgeons got together and told him he had to quit...
...Neither the hospitals, the doctors nor the Federal government, however, seem ready for agonizing reappraisals...
...For example, the hospital bill of $3,588 includes $900 for the operating room...
...At the same time, Dr...
...Is there no balm in Gilead...
...Yet many of the standard health statistics comparing the United States with other industrialized nations suggest that something is very much amiss...
...Third, he explained to my wife—and later to me—the probable course of my illness and what should be done about it...
...I was told as Governor of this state to go to the house and get him and bring him to the emergency entrance...
...While spokesmen for the insurance industry make much of the fact that 80 per cent of the population has some kind of health plan, they usually neglect to mention that the protection these policies afford can be remarkably skimpy...
...He was as startled as anyone else...
...In all likelihood this melancholy list would include a lack of "quality" in many of the services physicians and hospitals provide, and an accompanying lack of "accountability" to the consumer...
...Such figures, to be sure, may tell us as much about our peculiarly destructive way of life—our dietary habits, air pollution, emotional pressures, etc.—as they do about our health care system...
...A single example will highlight the mortal meaning behind these figures: If the U.S...
...We were afraid to move him, and I called the Polk County Medical Society for help...
...There are areas of Boston that are deserts as far as medical care is concerned," says Dr...
...Albuquerque has 250 physicians per 100,000 population overall, but its Chicano and Indian section has only three physicians per 200,000...
...Back home...
...The Incredible Bill Collections grow more difficult as bills grow more outrageous...
...It is no accident," he says, "that the United States, which has twice as many surgeons [per capita] as Britain, also has proportionately twice as much surgery...
...he said he understood perfectly...
...But despite slight signs of renewed appreciation for general practitioners at the medical school level, specialists—particularly surgeons— are the wave of the present: Forty per cent of all first-year medical residencies and fellowships are in surgery...
...She still owed $270...
...Similarly, today's health care dollar represents about 6 per cent of the nation's disposable income, compared to 3.5 per cent in 1929...
...The difference today is that we are all "Dubliners"—chafing under the medical system's heavy financial burdens, its cussed intractability, its knack of prospering at our expense...
...WHAT AILS MEDICINE IN AMERICA The best medical care America presently has to offer may still be the best in the world, which is why ailing kings and potentates frequently repair to our famous medical centers...
...The increases have far outstripped our rate of economic growth...
...Do you think they're doing any peer review now at that hospital...
...Leonard Tushnet, a general practitioner in Maplewood, New Jersey, who underwent medical treatment last year for a supposed heart attack: "I spent two weeks in a hospital, where a team of eminent cardiologists grossly mismanaged my case...
...The public's call for accountability parallels a dramatic increase in specialization, which has made the practice of medicine arcane and impersonal without necessarily improving the quality of care...
...ROT I...
...Irrefutable data about "quality of care" are hard to come by...
Vol. 57 • April 1974 • No. 8
