HEALTH: The Care We Need and Want
Fallows, David Blumenthal and James
Health: The Care We Want and Need by David Blumenthal and James Fallows Two years ago Anthony Lewis wrote in The New York Times about the difference between American and British...
...Nearly all the health insurance bills before Congress manage to include an HMO clause, but some would turn the system’s financing over to existing insurance companies...
...Finally, we should remember that what we are after is health, and that there are other ways to improve it than expanding our hospitals and medical schools...
...Patients put up a set fee each year and are then entitled to all the care, including hospitalization, they need...
...Political notice has been taken of these problems and of the public support to be won by solving them...
...The rationale of the three-year law school is that the student is qualified to practice in none of these areas until he has his degree, but that once he graduates he is entitled to work in any of them he pleases...
...today’s major killers are heart disease, cancer, accidents, and strokes...
...an internist, about psychiatry...
...Some pieces of evidence are particularly hard to ignore: a Los Angeles surgeon, Alex Gerber, has said that in California the rate of tonsillectomies among Medicaid patients is 10 times higher than among children whose parents foot the bill...
...Ten years ago there were 59 primary physicians per 100,000 population...
...In medicine one’s natural intuition must be more heavily buttressed with scientific in forma tion (even the student with strong powers of deductive reasoning needs extensive scientific training before he can become a diagnostician), and the connections between different specialties are more complicated and perilous to ignore than in law (a psychiatrist must know something about pharmacology...
...An enormous amount has been written about medical care since then, but little of it has more concisely expressed the central failure of American medicine...
...too rare, even for well-to-do patients...
...Such indices are not in themselves conclusive: if poor people and blacks are sicker than the white middle class, the reasons may have more to do with nutrition, housing, and narcotics than with visits to the doctor...
...Both Simone de Beauvoir, in The Corning of Age, and psycluatrist Robert Butler, have stressed what is now often forgotten: that old age can be a time of fulfillment, of projects brought to completion, of “rage against the dying of the light...
...When the provincial health service in Saskatchewan, Canada, decided to charge a trivial fee ($1 S O ) as a way of reducing unnecessary visits to the doctors, it found that poorer patients, especially those with large families, promptly reduced their calls on the doctor...
...But in the meantime, those with the complete M.D...
...A recent article in the Harvard Business Review struck a characteris tic note :As the delivery of health care shifts to T~ strike the balance is the diffi- larger, more integrated, better organized firms with scores of physicians and annual incomes of millions of dollars, managers and ihose eli2ble for admission...
...Whenever medicine can compensate for this inequality it has performed its kindest function...
...If we think in these terms we may find another answer to limiting expenses and controlling the momentum of medical innovations...
...I11 health seems the cruelest of inequalities because we are so powerless to correct it...
...One indication of the relative infancy of medical policy is that, while we are willing to guarantee every citizen 12, and in many cases 16, years of education at public expense, no such “right” to medical care exists...
...More fully subsidizing medical education in the U. S. might be a step toward more reasonable medical salaries...
...Six months into law school, a student with a flair for debate and interrogation may be a more capable trial lawyer than half the attorneys in practice...
...KublerRoss has written about these rituals which the dying must endure: He may cry for rest, peace,-and dignity, but he will get infusions, transfusions, a heart machine, or tracheotomy if necessary...
...This means that a doctor’s advice still comes at a cost of $10 to $15enough to deter anyone who has a secret suspicion that the doctor will just tell him to wait and see what happens...
...Forrester was given a bill for $12,000...
...Not too long ago the Washington Hospital Center in the District of Columbia opened a new, $5.75-million intensive care unit, with equipment suitable for performing one open-heart operation each day...
...Counties Without Doctors There are two reasons for the unfair distribution of care...
...Few patients postpone emergency surgery because of the price, but in many cases people -may put off the routine visits that could prevent more costly treatment Insurance does much less to remove this barrier than is generally supposed...
...training have the monopoly on expertise...
...Not all of the health needs are best met by the doctor who can hardly tear himself from the laboratory or the microscope...
...I know the food won’t be great, because no one who’s really interested in preparing food would work in a place that gives him cooking instructions printed 1,500 miles away...
...When one company attempted to limit payments, the AMA launched a campaign of denunciation which continued until the company backed down...
...I’m reminded of the franchise fast-food chains-Kentucky Fried Chicken, Lum’s, and all the others...
...The same student may never be competent in tax work, while someone else, with an interest in economics, may be ready for tax law long before he leaves school...
...performed on the wrong eye...
...Doctors become a rare, and exceedingly costly, commodity...
...Kubler-Ross says that even as they enter their terminal comas, patients are bargaining for an extra day...
...Doctors admit that beyond a certain point extra medical care does not provide extra health, and that extra dollars spent on it must be considered luxury expenditures...
...The price of medical care has risen twice as fast as other prices over the last decade...
...our own mortality...
...In a recent study, Increasing the Supply of Medical Personnel, Charles T. Stewart and Corazon Siddayao of George Washington University explained: Medical training can be reduced in duration by curtailing the generalist training which all medical students undergo before specializing...
...There are also sound technical reasons for training more primary specialists...
...and the black male’s life expectancy is seven years less than that of the white male...
...I’d like to hear how he the throat two years ago, or that we does...
...To bring costs under control we must give doctors and hospitals an incentive not to run up the bill...
...Deindorfer were given a room near him...
...Yet it does suggest the elements to support when prospects for a new system improve...
...now there are 41.5...
...Yet between the time a young applicant explains his dreams of a medical career in images drawn from Albert Schweitzer and the Brothers Mayo and the day he posts his first fee schedule, something happens to focus his thoughts on money...
...Recruiting booths set up by small, doctor-less communities have become a common feature of medical conventions...
...This approach, applied in the list below, does not pretend to yield an exhaustively detailed outline of a new medical system...
...When we want a baby delivered, or a chest pain diagnosed, or a fracture set, we want to find the doctor best able to perform each of these functions...
...In legal education students are exposed to the dozens of discrete areas which compose “the law”taxes, trial work, probate, government regulation, and the like...
...A licensed M.D...
...By reimbursing hospital expenses and denying routine physician’s charges, these programs reward the patient who can get his blood pressure checked and urine analyzed in the hospital rather than at the doctor’s office...
...another third did less than 12 per year...
...we should start at the beginning, asking ourselves what we want medicine to do for us...
...Over the past half-century, medical advances have removed much of the threat of disability and untimely death...
...For abundance and security of income, a medical degree has taken the place of a landed estate...
...Certainly, most doctors are scrupulous about providing only appropriate care, but it does no harm to remember that the doctors earn their living on a fee-forservice basis...
...Medicine as Mephistopheles Where is our medical technology leading us...
...Patients do find other guides, but each has its drawbacks: personal experience and first-hand recommendations may be hard to come by...
...It has often been remarked that death, and by extension old age, are our modem taboo subjects...
...In their book, The American Health Empire, Barbara and John Ehrenreich describe the resulting vicious cycle: Insurers pay the hospital whatever the hospital claims was its actual cost of providing service...
...Doctors are unique for their ability to set their own level of demand...
...It may be noted that doctors with general training who do not do general practice may forget the general training...
...Daniel Funkinstein of Harvard Medical School...
...Insurers especially have shied from paying hospitals and doctors anything less than they ask...
...Each patient is registered with a surgery in which the operation is general practitioner in his own town...
...It may be desirable to license doctors to practice only in the specific areas in which they have specialized...
...An analogy to another form of professional training may help explain why...
...Some of his more menial tasks may be farmed out to paramedical assistants, and nurses willing to endure a slower version of the doctor’s training may eventually earn his status...
...When 60,000 people die each year in auto wrecks, serious attention to highway safety may enable society to save more lives than an all-out program on a certain disease...
...Amputated Education Of course, the standards for each specialty should include a general scientific background and an understanding of the connections between the specialty and other branches of medicine...
...can now do most things in the field of medicine, whether or not in his area of specialization...
...Although such inequality is not unique in American life, it may be easier to correct in medicine than in, say, employment or the schools...
...Attached as they are to specific no n-m e di cal interestsEdward Kennedy’s in leading his major reform effort...
...The renal dialysis process, which enables people who would otherwise die to lead relatively normal lives, is an important example...
...Unless every patient has a primary practitioner responsible for his total health, doctors will continue to prescribe medicine patients don’t need and can’t afford, and patients will continue to to walk around with undiagnosed diseases in search of the specialist interested in their case...
...In 1900 polio, tuberculosis, and diphtheria were leading causes of death...
...high fees or prestigious affiliations distinguish Park Avenue doctors or medical school faculty members, but rarely apply to hometown doctors...
...Is the reason for this increasingly mechanical, depersonalized approach our own defensiveness...
...Stanford offers a physician ’s-assistant program for former medical corpsmen from the military...
...for specialists-has its faults, but it is fairer than the alternative: forcing patients to bid for care as they might, bid for items at an auction...
...The client, given no guidance by the legal diploma, must rely largely on word-of-mouth recommendations to find the lawyer best able to perform the specific task he requires...
...One way to do so that a good physician will observe and might be to give all patients registered remember...
...culty: between serving personal attention is a commodity far needed...
...Many of the most critical shortcomings of our health care system are connected with the extinction of the primary practitioner...
...We want someone specialist or hospital he is able to say, to know that we’re allergic to penicil- “Here are the things to watch out for lin, or that we had a funny lump on on this patient...
...But the profession aggravates some of its worst deficiencies by requiring that all students go in lock step through four years of general medical education, one of internship, and several more of residency in their specialty...
...The cost of this expensive-and unused-equipment is spread onto other patients’ billswhich is less alarming only than the possibility that the surgeons could have deliberately attempted to keep all the operating rooms busy...
...The legal diploma system, unable to account for such individual differences, prevents both kinds of students from doing either trial or tax work before they graduate...
...the AMA‘s in affixing itself to the public teat-the bills are likely to be either accepted or rejected on criteria other than further reflection on medical needs...
...Scott was in a private room, and Mr...
...Many schools now offer semidoctor degrees: at Duke University, students may take an undergraduate program leading to a “physician’s assistant” degree...
...For the last four years, since President Nixon announced that a “health care crisis” was upon us, Congress has been considering half a dozen major health-reform bills...
...Theoretically, this arrangement not only frees the doctor from the thishysterectomy -pays-next-week’s-rent mentality, but also encourages him to treat patients as efficiently as possible...
...it involves technical innovations whose value is hard to assess and whose momentum leads us in directions we do not always understand...
...The AMA reason9 that a combination of private insurance, public programs such as Medicare, charity on the part of doctors, and ,scrimping on the part of patients ensures that no one who needs help is denied...
...He died 16 days later, and Mrs...
...Since the days when the general practitioner was the workhorse of American medicine, the role of the primary doctor has steadily declined...
...He may want one single person .to stop for one single minute so that he can ask one single question-but he will get a dozen people around the clock, all busily preoccupied with his heart rate, pulse, electrocardiogram, or pulmonary functions, his secretions or excretions but not with him as a human being...
...But these plans are pipedreams unless we lure a different kind of student into medical school...
...later they work for far lower salaries than American doctors...
...Five hundred doctors applied for the initial 220 NHSC positions, but such enthusiasm should not be confused with pure altruism: the NHSC was an alternative to ‘military service...
...Michael Halberstam, a Washington physician, expressed the classic fear of socialized medicine in a recent Medical Economics article entitled “Will Limousine Liberals Ruin Medical Care...
...Even Medicare has “co-insurance” and “deductible” provisions which require the patient to pay the first $60 of physicians’ fees and 20 per cent of everything above that...
...Even cynics concede that money is not the main motive for entering the profession...
...Medical care, the remaining uncushioned expense, was the single largest cause of personal bankruptcies last year...
...The system denies patients guidance as they search for qualified care...
...Like all legislation, the current proposals overlook some inevitable long-term complications...
...Yet even mentioning this brings us close to the heart of our dilemma about medicine and old age, for it is equally obvious that many of the elderly feel not gratitude for their extra years of life but a despairing impatience for the end...
...From all the evidence, if half the adults in this country were physicians, their schedules would be nearly as crowded, and their fees nearly as high, as those of doctors today...
...But they are important criteria to bear in mind as we debate proposals over the next few years...
...Instead of merely equalizing the chances for life by preventing untimely deaths, new processes will enable many of us to survive beyond the point at which our physical machinery has worn out...
...Precisely because the gap between these two points is so long, there are too many opportunities for that “something” to happen...
...The rest is largely made up by public subsidies, such as the $3-billion manpower program enacted in 1971...
...Considering the long delay before the pay-off and the unpredictable hours, heavy responsibility, and continuing need to keep abreast of medical advances, anyone mainly concerned with striking it big will head to Wall Street...
...most $5,000...
...Cardiologists and neurosurgeons may brandish their skills with a flourish-and still practice bad medicine...
...for its part, the “third party” (usually either Medicare or a private insurer) that is covering the costs rarely exhibits discretion about payments...
...Eliminating fees is not enough if patients must drive miles over rural roads to find a doctor or search vainly for one in the city...
...Now these infectious diseases are largely under control...
...It makes no difference whether the computer...
...It cuts to our deepest and least clearly resolved feelings about life and the prospect of death...
...Doctors are paid a’salary, and in some doctor-owned HMOs, they earn a bonus if their treatment costs are less than the annual fees...
...If the hospital buys and operates a computer, or an intensive care unit, the cost of providing a day’s services rises...
...Those who consider the person first may lose precious time to save his life...
...A year ago, Reginald Forrester, a businessman, was rushed to a hospital in New York in desperate condition...
...We need to realize that the finest surgeons, the most accurate diagnosticians, need not go through all the phases of the normal M.D...
...Medical schools don’t produce general practitioners because they fill the classes with would-be Nobel laureates who have piled up long strings of “A”s in their science courses...
...Or should the same amount of money be put into public education to eradicate streptococcal infection-the root cause of most damaged heart valves...
...James Fallows is an editor of The Washington Monthly...
...Then, by awarding both the same degree, it allows them to advertise themselves as all-purpose lawyers...
...One, a revolutionary change, is to build into the system incentives for efficiency...
...While the young doctor is still concerned about caring for his patients and perfecting his technique, caring for himself becomes increasingly important...
...Doctors have the highest earnings of any professional group: the average yearly income is now between $45,000 and $53,000...
...A great many people cannot get the care they need-a recent study by the National Academy of Science’s Institute of Medicine concluded that infant mortality rates in New York could be cut by 30 to 50 per cent simply by providing adequate care-while others, mainly the white, suburban majority, are overdoctored, some times to the point of danger...
...We should try to guarantee faint at the sight of blood, or that we that similar features are included in an have any of the dozens of other traits American system...
...these figures include interns and residents, who make $10,000 to $15,000...
...In the United States as a whole, there are 165 physicians per 100,000 people, but as Harry Schwartz points out in The Case for American Medicine, in Washington, D. C. there are 371 doctors per 100,000, while in Mississippi and Alaska the figure is 78...
...4 Care at a Cost the Nation Can Afford One of the great mysteries of the medical profession is why men who serve such noble aims should do so with dollar signs in their eyes...
...I Competent Care The question of competence is perhaps the least susceptible to reasoned discussion in a subject generally dominated by argumentthrough-anecdote...
...These operations are nationwide, they buy their food in carloads, they cook food with a standard set of spices for a standard period of time...
...A better metaphor might be one of the colonialists’ clubs in the middle of Calcutta or Hong Kong, providing incomparable service to feels less like a human in need of medical care than a Volkswagen being plugged into an automatic diagnostic machine...
...One cannot, as a young man, presume to speculate on the value of extra months or years to those preparing for death...
...There is, of course, nothing like the assumption of good health to blind us to disease...
...The romance of technology runs wild when medical administrators discuss the Health Maintenance Organization (HMO), a type of group practice whose economic advantages are especially attractive...
...In fan t mortality rates are nearly twice as high for blacks as for whites...
...For each story of malpractice and profiteering there is an offsetting example of dedication and scientific excellence...
...The no-fee principle is virtually alien to American medicine...
...The kind of physician people dream about,” he continues, “is not getting into medical school any more...
...This view of medical priorities need not imply a “medicine of youth,” one which counts the life of a teenager more precious than that of a person past 70...
...In fighting “death,” our medicine has often paid less attention to this form of support than to forestalling the moment when the heart stops beating and the brain waves cease...
...To cite one example, the...
...Health: The Care We Want and Need by David Blumenthal and James Fallows Two years ago Anthony Lewis wrote in The New York Times about the difference between American and British medicine: Robert Deindorfer, a .New York writer, was in London with his family last summer in Lower Slaughter, a Cotswold village...
...average hospital utilization rates for HMOs run about 20 per cent below those of the feeforservice sector...
...The second barrier to equally distributed health care is the ransom lone must pay to see a doctor...
...Such a system ignores several basic human traits-among them, that people have different talents and abilities and learn at different rates...
...The majority of medical horror stories While English doctors are famous come down to a failure of attentive- for their brusqueness, they may indiness: a doctor neglects to take note of cate a way out of the dilemma...
...along with race, the most complex public issue we face...
...That is not a unique experience for Americans in Britain...
...The most ambit io us- Cleveland Stat e University’s “credit by examination” system, which permits nurses and other middle-level medical employees to build gradually toward a physician’s degree-illustrates the belief that while abbreviated training may be all right for “paramedicals” and “medics,” for the puissant doctors themselves the traditional broad education is still indispensable...
...When one is available...
...We need a doctor we can rely on to do some things well...
...The “coronary artery bypass graft,” to give one example, may offer victims of heart disease extra years of life, but at a cost of many thousands of dollars...
...There is no reason to force medical students to go so heavily into debt and give up so many human pleasures that they begin to see themslves as a martyred sect, different from monks only in their plans to collect their heavenly reward while still on earth...
...If you’re the kind of guy who goes to college and gets into lots of extracurricular activities, gets “B”s, and likes to work with people, you’re not getting into medical school any more,’’ says Dr...
...The virtue of the Health Maintenance Organization is its supposed ability to provide the missing encouragement...
...The present medical hierarchy, which endows the specialist with a more honored title than the GP, creates an unnecessary stigma against such admissions of ignorance...
...Since the New Deal, the trend of domestic legislation has been to let society absorb the shock of individual financial calami ties...
...Is our concentration on equipment, on blood pressure, our desperate attempt to deny the impending death, which is so frightening and discomforting to us that we displace all our knowledge onto machines, since they are less close to us than the suffering face of another human being, which would remind us of...
...Automatically, the rate at which Blue Cross, Medicare, and Medicaid reimburse the hospitals also rises...
...If we are to canonize any medical innovators, it should be the doctors who make it possible to prevent mongolism or cerebral palsy rather than those who transplant hearts...
...yet when more people are potential beneficiaries of a process than we as a society can possibly afford to help, the medical inventions force upon us terrible choices between saving one life and saving another...
...Before the new technique exists, death when it comes may seem inevitable, even natural...
...The experience of Britons taken ill while visiting the United States is not exactly the same...
...Samuel Proger of Tufts University, has suggested the creation of a new specialty: Primary Medical Doctors, or P.M.D.s...
...The medical specialties are not such a mystery that students must spend four or more years malung their choice...
...This suggests that greatly expanding our output of doctors may not be the way to cope with medical care problems...
...The English system of “queuing”--granting appointments on a first-come, firstserved basis, with one- or two-week delays before seeing a general practitioner and a wait of a month or more...
...We know that for most of our lives we will be basically healthy, whether we get an annual checkup or not, and that when things start to deteriorate, the doctors will not be able to do too much...
...with HMOs or hospital-based groups a Is this impossible in a system “family” doctor, whom they could which opens the door to all patients...
...By the time he has gotten up in the pre-dawn cold to attend his clinical rotations, borrowed money from his parents or the banker (fortunately, 34 per cent of the medical students come from families in the top three per cent of the income brackets), taken his sleep in 15-minute bits during his internship, and postponed the pleasures of family and home that his contemporaries are already enjoying, the doctor may develop a quite understandable sense that he is going through longer and harder preparation than anyone else...
...Once we are sure that the overall supply of doctors is large enough to provide adequate care-a condition that the U. S., with more doctors per capita than nearly any other country, easily satisfies-we must devise a “rationing” system that will enable everyone to get the care he needs...
...Yet at the same time, we must face the practical dilemmas...
...If there has been no shortage of patients to occupy the beds, the credit must go to the private insurance companies and programs like Medicare...
...In his prime a doctor may earn $80,000 a year or more...
...Health care is, David Blumenthal is a fourth-year student at Harvard Medical School...
...Anyone who meets the standards should be allowed to practice, whether he has completed two years of medical training or 10...
...In return, the doctor would practice for three or four years in an underserved area...
...Nevertheless, the most obvious fact about American medicine is that some people get worse care than others, or even no care at all...
...Edmund Pelligrino, dean of the State University of New York medical school has questioned our sense of priorities: Is it socially acceptable to expend large sums to develop open-heart surgery which can at best alter the life expectancy of a limited few...
...To stay within the annual budget, the doctor will conduct tests in his office rather than in the hospital and will concentrate on inexpensive preventive care rather than waiting until the patient must be hospitalized...
...In order to give patients a better chance of finding competent care, of distinguishing between the quacks and the experts before learning the hard way, we need to work a fundamental change in our system of medical education and licensing...
...General medicine is for doctors who like people more than slide rules, who like listening to their patients, sympathzing with their problems, worrying about and soothing them...
...Another study, at the Yale-New Haven Hospital, showed that one fifth of the hospital patients were made ill by medical treatment...
...Of course, it need not be an either/or choice between prevention and treatment, but we might achieve the greatest improvement in health by devoting more attention to diet, environmental pollutants, and other important determinants of disease...
...Approval for one kind of practice should not entitle him to perform other specialties unless he can prove his competence in them, too...
...The hospital would not admit him until it obtained a financial guarantee...
...What statistical evidence is available shows that sickness and medical care are as unequally distributed as cars, housing, or any other marketplace commodity...
...Yet we may avoid some of the more agonizing choices by concentrating our medical research on ensuring more people a normal span of years rather than trying to offer eternal life...
...Naturally our guiding principle must be to provide as much care as we possibly can, mindful of the point at which we do more harm than good by applying the saving balm...
...Partly this is so because we have repulsed the elderly from us, relegated them to a silent and shameful waiting for death, ignored them because they remind us that we too are growing older...
...Doing so could eliminate the financial benefits of the HMOs, because the insurance industry is perhaps the only administrative system less efficient than the federal government...
...at Yale students may qualify as “surgical associates...
...Only the primary physician can provide the personal attention that is so essential...
...A con- When a patient is sick he goes to his genial bedside manner is an asset, but own doctor first...
...These doctors would receive an abbreviated version of the general training now given M.D.s...
...degree in two years...
...While the HMO’s efficiencies seem undeniable, its size may dwarf and isolate the patientespecially when the HMO management embraces a big-business approach...
...quite early, many know their preference...
...Rather than arguing over the bills...
...A fair number have discovered, to their amazement, that in emergencies they can receive free hospital care under the National Health Service...
...They only reinforce the notion that the doctor is king of the medical system...
...Suggesting as it does that the existing medical system offers service like that of the Ritz or the Four Seasons, Halberstam’s comparison is slightly unfair...
...The patient has no way of knowing whether he should really come back for an appointment two weeks from now, or if the extra pill or injection or minor operation is necessary...
...After listening to many of the “mediocaftl ecna rfee adrse litvhearty ”th aed amnisnwisetrr aisto yress, .o Anes Back to Basics they pull out their flow charts Since “primary ” phy sicians-usushowing how patients will be funneled ally general practitioners-are the ideal into the most efficient kind of treat- candidates for this role, our medical ment, and as they describe their com- training system must pay more attenputerized laboratory equipment, one tion to producing the primary-care practitioner...
...Abstractly, we kiiow, and may even take comfort from the fact, that our medical schools produce the world’s most highly skilled doctors...
...While the Cali fornia-based Kaiser-Permanente group is every HMO fan’s favorite allusion, New York’s Health Insurance Program (HIP) is constantly criticized for its Kafkaesque operating policies and its continually rising rates...
...Elisabeth Kubler-Ross has demonstrated with eloquence in On Death and Dying, the process of dying demands as much psychological support as any other part of the cycle of life...
...In Britain, medical students live on public subsidies during their training...
...Voluntary unemployment is virtually the only threat to steady earnings...
...As described in many management journals, delivering health care is a technical job for the efficiency experts, like providing water and sewerage...
...But not all the specialties demand such preparation...
...If we have any faith at all that doctors don’t start out with their eyes on the income charts, we can hope that a more humane medical education would loose doctors on the world with less economic vengeance...
...during much of their training expert diagnosticians would teach them, as craftsmen instruct their apprentices...
...Students who quite early in training might be qualified as surgeons, or psychiatrists, or pediatricians are required to complete the full course before being allowed to specialize, and efforts to expand the supply of physicians are constrained by the high cost of the protracted medical education...
...The student knows that his working life will be six or eight years shorter than the average worker’s, and that he will begin it many thousands of dollars in debt...
...Medical training should be no less rigorous than it is today (though it may be shorter and less diffuse), but it need not exact such a heavy financial and personal toll from the student...
...His four-year-old son, Scott, became seriously ill and spent three nights in a hospital, having numerous tests and intravenous feeding...
...a specialist’s label often does not guarantee competence...
...call first when they needed care...
...Lie-Ins, 1970s Style Apart from changing the training system to gwe doctors a more mellow outlook on money and medicine, there are other ways to get medical care at a reasonable price...
...The kind of nurse that patients hope for is also vanishing fast...
...label gives us little information about individual abilities...
...What makes the HMOs different from traditional practice is the way the doctors are paid...
...Common sense tells us that doctors will vary in their specific skills, but the undifferentiated M.D...
...The Administration has proposed raising the figures to $85 and 25 per cent...
...Yet as Dr...
...The average cost of a day in the hospital is now more than $100, and total spending on medical care was $83.4 billion last year, an amount that for the first time exceeded the Defense budget...
...It is the rare specialist who looks beyond the organ system he is treating to the patient’s total needs, physical and emotional...
...Even among doctors, this is an increasingly rare view...
...Just a few years ago, the nation watched in fascinated horror as General Eisenhower’s tired, beaten heart was dragged through one crisis after another amid the glint and hum of a technological task force...
...Instead of our current 400,000 doctors earning $45,000 to $55,000 a piece, we might find after a 15-year crash program that we have ended up with 1 ,500,000 doctors earning $80,000 each...
...From there we may work back to identify the features in a medical system that will provide the kind of care we want...
...This has had its effect on medical technology...
...Saskatchewan’s dilemma-how to control demand without driving the poor away-reflects the subtle issue of providing “enough” care without endlessly expanding the supply of doctors...
...In a recent poll commissioned by Potomac Associates, 49 per cent of the respondents listed “available on short notice” as an important quality in choosing a family physician...
...At latest report some 130 counties have no doctors at all practicing within their borders...
...The government might offer loans or grants to medical students, enabling them to end their training without being $15,000 in debt...
...A humane medical system must be able to care not only for the majority who are well, but for the minority who are disabled early or sick often...
...Each trip to the doctor requires a careful calculation of whether the illness or the bill will be more painful...
...If we are serious about equitable medicine, then imposing any fee at all would be a mistake...
...training...
...The a condition marked on the patient’s whole country is essentially one large chart, or he passes his patient on for HMO...
...A mighty debate rages over the decimal points in results from HMO studies, and the experiences of existing HMOs have not all been as glorious as some boosters suggest...
...was really necessary, whether it was overpriced, misused, or whether it adds significantly to the overall quality of health care...
...A recent study in Maryland showed that a typical hospital pays its department chiefs $1 50,000 to $200,000, its chief assistants $65,000, and its “rookie” physicians $35,000 to $40,000...
...the dying removed from the living...
...No one wants to create a central assignment agency which would post physicians here and there like so many salesmen...
...Once in the hospital, the patient no longer has to worry about the medical bills...
...While all this means that there will be no simple answers to the dilemmas of medical care, it also suggests how inadequate have been our public attempts to deal with medical questions...
...Boards of surgeons or neurologists should test candidates for their proficiency in those fields...
...On balance, however, it seems likely that the pre-payment system can reduce both hospitalization rates and the overall cost of medical care...
...We must have a revolution in the way we organize medical training, beginning with the recognition that competence is the quality we should measure...
...Another approach is that of the National Health Service Corps, which was created three years ago under the auspices of the Public Health Service to send young doctors to remote regions...
...In creating a fair health system we must make sure that “deductibles” and “co-insurance” do not creep in...
...Robert M. Sade arguing that to make medical care a “right” would be to impose involuntary servitude on physicians: under a guaranteed-care system, they would no longer be able to deny treatment to whom they pleased...
...He isn’t a cook, he’s a technician...
...Where is she going...
...It requires, rather, a different attitude toward the matter of age...
...But this was soon offset by extra visits from people who could afford the fee and knew they wouldn’t have to wait in line so long...
...The fee has since been removed...
...Even for those not absolutely impoverished by care, the cost is high and the quality uncertain...
...Who can be surprised if, in the midst of this painful training, the medical student fixes his thoughts on the reward his efforts will yield...
...Of the nearly 800 hospitals equipped to perform open-heart surgery as of 1972, one third had never performed such an operation...
...If the doctor’s training should become more specialized, the nurse’s should be more diffuse: some drop of humanity, of sensitivity to emotional needs, should enter the dry, scientific disciplines of the nurse’s training, and should not be baked out of the nurse’s soul by a promotion system that counts paper shuffling more important than loving care...
...As applied to medical care, the communist principle is sublimely correct: we should provide to each according to his need, and collect from each (via the income tax) according to his ability to pay...
...Unfortunately, even the best of the bills try to wish away some of the more immediate dilemmas, which simply will not disappear...
...We don’t need doctors nominally prepared to do everything...
...But we do possess some forms of leverage wholly consistent with protecting the doctors’ individual freedoms...
...Now most of us have the privilege of viewing medical care not as a constant necessity, but as protection against emergencies...
...In an important new book, Health Care: Can There be Equality?, Odin Anderson concludes that patients in Sweden and England-the two countries whose nationalized health systems are most often cited in criticism of American medicine-echo the American complaint: no matter how many doctors are available, there is always a demand for more...
...But it is clear that some patients are denied the help that they need...
...and Mrs...
...A new generation of medical techniques will expand our ability to postpone the moment of death...
...Unlike many of the medical and public health improvements of the last 50 years, these new developments will be enormously expensive, will demand more of the doctors’ attention rather than economizing on it...
...Florence Nightingale has given way to the Registrar of Deeds as a model for the nurse’s career advancement...
...once the invention is in our hands, to deny its use to anyone is to deliberately choose his death...
...Money rarely poses an ultimate barrier to care: those who are sick enough but can’t pay usually end up in a municipal hospital...
...But anyone who has ever compared the emergency ward of a big-city general hospital with the centers in which paying patients are treated can only be appalled by the disparity...
...In some cases-especially the diagnostic specialties, internal medicine, and general practice-this may require nearly as broad an education as today’s doctor undergoes...
...Administrative expenses for private policies range from Blue Cross’ relatively modest five per cent (of benefits), to 14 per cent for privately issued group policies, to 47 to 79 per cent for individual private policies...
...39 per cent listed “will treat patient regardless of ability to pay...
...Although the GP the sense that one person is taking may not be able to treat every malresponsibility for our care is more ady, when he passes the patient to the basically necessary...
...The variation in physician/patient ratio between different regions of the U. S. is far more dramatic than that between the U. S. and, say, Pakistan...
...We all know people denied the span of years, and the vigor during their years of life, that most of us will enjoy...
...The curtailment would be designed for those students who dispense with considerable course work and training which they never intend to put into practice...
...One is that the rural areas and urban ghettos where the poor generally live are precisely the areas where a doctor is least likely to set up practice...
...and only 36 per cent specified “aware of latest medical developments...
...Thirty million people under the age of 65 have no health insurance whatever, and 35.5 per cent have no protection against surgical expenses...
...The elderly are segregated...
...The P.M.D.s would learn to recognize what they don’t know, to establish the limits beyond which they should refer their patient to a specialist...
...Meanwhile, three other D. C. hospitals were maintaining similar open-heart facilities which are used at less than capacity...
...Yet we realize when we go out to choose a specific doctor what flimsy evidence we have to work on...
...The world has yet to produce a society whose people feel themselves too closely attended by their doctors...
...The opportunities for similar improvements are great: by preventing birth defects, or coping with degenerative diseases, or exploring the origins of cancer, medical research can mitigate some of the tragedies of lives cut short...
...3 Personal Care Dr...
...This shift has taken some of the uncertainty from our lives...
...This may be fortunate, for it will give us time to rethink the fundamentals before everyone starts smelling appropriations...
...and at the University of Colorado they may become “child associates.’’ Laudable though they may be, these programs amount to accelerated versions of the same old thing, not reassessments of how doctors should be certified...
...This is not the specialist’s fault: if he liked general medicine, he would be practicing it...
...To the big, square desks at the end of each ward, where she can reign over a world of paper and machinery instead of providing the patients’ human needs...
...Even so, it does not seem too wild a hope that two or three per cent of the nearly 10,000 doctors who graduate each year would join similar projects...
...Of the $1 5,000 to $20,000 annual cost of medical training, the student pays at...
...Medical education is not an exact parallel...
...While critics have noticed the kind of behavior that open-ended funding induces in defense contractors, the parallels between Lockheed and your neighborhood hospital have not been clearly enough drawn...
...Hospitals’ daily charges have more than doubled since 1966 largely because no one has been in a position to call a ha1 t. Over the last decade, the government’s hospital building programs have left the nation with a greatly expanded supply of hospital beds and an equally expanded need for patients to fill them, since they are nearly as expensive to maintain when empty as occupied...
...Allowing them to concentrate sooner, eliminating training they may never use, and then testing their specific abilities would reduce the cost of training and raise the level of professional skill...
...When lives close to our own are in question, no amount of money seems too much...
...Government figures show that as many as 150,000 deaths each year are from “iatrogenic,” or physician-induced, causes...
...The hospital’s bill at the end was $7.80-for the parents’ meals...
...Several dozen medical schools, among them Johns Hopkins, Stanford, Dartmouth, and Northwestern, have already devised programs to cut the time required for earning an M.D., either by truncating the undergraduate preparation or by allowing students with Ph.D.s in other scientific fields to earn the M.D...
...it raises basic questions of social inequality...
...Most of us would gladly trade a clinic full of crack specialists for a few physicians who would attend to our overall needs, perhaps with less luster but certainly with more old-fashioned sympathy...
...In contrast, Medicare’s administrative costs were only 2.3 per cent in 1967, and experience in Canada suggests that a nationwide program could be run with administrative costs of only about one per cent...
...The immediate climate is hostile to plans as grandiose and costly as serious health reform must be...
...it can lead to the most profound bitterness or a sense of reconciliation...
...How better to remove the stigma than to establish P.M.D.s, like other specialists, as experts in their specific field...
...2 A Guaranteed Right to Care In 1971, The New England Journal of Medicine carried an article by Dr...
...Of the five million who do have private medical insurance, the great majority are only covered for hospital expenses...
...These four elements-competent care, a right to care, personal care, and reasonable care-do not in themselves amount to a detailed outline for a national health care system...
Vol. 5 • October 1973 • No. 8
