The success of American medicine is often attributed to the profession’s ability to serve the public on its own terms. Why should doctors care if, from the patient’s point of view, the terms chosen—solo practice and emphasis on the “doctor-patient relationship”—mean that a doctor performs unsupervised services for unregulated fees? What does it matter to them that the poor are outside the system altogether, treated in charity wards or public hospitals which are the medical equivalent of Andrew Carnegie’s libraries, a small concession to charity from an accelerating machine of wealth, power, and influence? In a country proud of its “pluralism” and fearful of “government interference,” a monolithic self-regulating profession is taken as a sign of health. Few people are persuaded that medical care is a fit object of social planning: We have no national health policy and we are mostly proud of it.
It has left us in an extremely unfortunate mess. At its best American medicine may very well be the best in the world, as its practitioners claim, which is why retired English kings and Arabian sheiks turn up regularly in our hospitals. But though excellent treatment is usually available to the very rich, the rest of the population finds even adequate services hard to come by. The charge frequently made by critics that ten countries have lower rates of infant mortality and longer life expectancies does not mean that the Peter Bent Brigham Hospital, for instance, is somewhat sliphod; it means that most people will never set foot in any place half so good.
The situation of the poor is particularly appalling. In Boston, a health survey of a public housing project indicated that among individuals over 65, 25 per cent had chronic bronchitis, 20 per cent had chronic nervous disorders, 12 per cent were blind or had visual defects, and that 40 per cent of these were not receiving treatment. In New York, former Health Commissioner George James has estimated that 13,000 poor people died last year because adequate professional care was not available. The maternal mortality rate for U. S. whites (in 1961) was 2.5 per 10,000 live births. For Mississippi Negroes, it was 15.3, more than six times as high. In a South Carolina county, every tenth Negro child died in the first year of life.
THE POOR ARE NOT wholly without opportunities for medical care. But the public facilities that do exist perpetuate a grotesque circle of personal humiliation and medical lunacy. In many cities a mother cannot take a well baby for a check-up to the same place she must take a sick child for diagnosis or treatment. If she suffers from both migraine headaches and pains in her chest she may have to go to two different clinics herself. Clinics (and emergency rooms) are often far away, in a sometimes unfamiliar “downtown.” For a suburban mother with a car and a maid such problems would be easy to surmount. For the poor mother it is different. Each clinic visit may take a separate trip. Each trip means, if she is working, a day’s lost pay; or, if she customarily cares for her children, an arrangement with neighbors. It means costly taxi fares or time-consuming bus trips. After a long wait in a crowded room arranged like a bus terminal, she may be ordered to go elsewhere or to return another day. She may be asked to undress in the hallways and, thus stripped, to explain her problem to various impersonal functionaries, to what bureaucratic purpose she can hardly be expected to understand. If she sees a doctor at all (no certainty) he will not be the one she saw last time or the one she will see next time. Her medical records may be scattered about the city. She is apt to be submerged in an avalanche of prescriptions and regimens incompletely understood (for there is no one to explain them to her) and often mutually incompatible.
And so the poor, faced with a system that discourages them from seeking care, and beset with other crises that may seem to them more urgent than a nagging cough, have acquired a certain reputation among the professions: They “don’t care” about their health, “don’t keep appointments,” “won’t cooperate,” “don’t do what you tell them,” and even “don’t mind being sick.” The hoariness of this mythology is clear from a recent study of English hospital development by Brian Abel-Smith. He reports that during a government inspection of English pauper hospitals in the 1860s:
At Kensington and Paddington some of the sick were “found washing in their chamber pots.” The inspector was told by one medical officer that the patients preferred to wash in this way but he later established that they did this “against their will and their former habits at home.” Only a few [institutions] provided lavatory paper on the grounds that “a very large proportion of the poor” were not in the habit of using it. There were, however, “numberless instances” of closets being blocked with “old towels, dusters and dish-cloths—and leaves of Holy Scripture…One or more Bibles, and sometimes a Prayer Book, were found in each ward, but in a more or less imperfect and dilapidated state—a circumstance connected with the subject just discussed.”
Even the best of the organized health plans have sometimes had difficulty staffing their units in the ghettoes: Disgust is the other face of charity.
BUT THE MEDICAL SYSTEM has not only failed the poor: It is also cheating the middle class. There is a joke popular with medical students: “What are the indications for a hysterectomy?—Two children, a Blue Cross card, and a uterus.” Unfortunately, it is no joke. Every review of the quality of medical care has found a high rate of unnecessary and incompetent surgery, of faulty and delayed diagnosis, of sins not only against medical science but against common sense. A famous study by Columbia University’s School of Public Health and Administrative Medicine of the medical care of a group of Teamsters and their families in New York City a few years ago concluded that one fifth of the hospital admissions were unnecessary and one fifth of the surgery was “poor.” (1)
More than a third of the hysterectomies and more than half the Caesareans were held unnecessary. A study sponsored by the Rockefeller Foundation and the University of North Carolina Division of Health Affairs of North Carolina general practitioners in the 1950s found that 44 per cent were failing to take medical histories, using unsterile instruments, conducting incomplete examinations without using laboratory aids and without having patients undress or lie down, or prescribing irrelevant drugs. “The physicians studied came from many medical schools and had exhibited all degrees of academic success,” the report stated, “so there is no reason to assume an adverse selection. It can…be stated with considerable assurance that in terms of medical education and training the physicians who participated in this study are not evidently different from general practitioners at large.” (2)
Ethical controls are as lax as the medical ones. Denunciations of fee-splitting issue periodically from the professional associations. But doctors combine to buy pharmacies in medical buildings; take payments for journal articles they have not written endorsing drugs they have not tested; conduct medical and surgical experiments on their patients without telling them; cheat on insurance; and, like the GE executive who went to jail, they retain an honored place among their colleagues and within their communities. (3)
Middle-class medicine is facing a crisis in costs as well as quality. Hospital rates now average over $40 per day and insurance rates have taken off like a rocket. To a certain extent this is the price of technological achievement: A heart-lung machine, for instance, and a cobalt machine for treating cancer may cost in the vicinity of $100,000 each, and each requires a small army of skilled technicians for its upkeep. It also reflects the inroads of unionization on hospital pay scales. Salaries have been so low that in New York, for example, some hospital employees were recently receiving public welfare while holding down full-time jobs. But to a large extent the doctors themselves are responsible for the inflation: An electrocardiograph standing idle for thirty-five hours a week in the private office of a Park Avenue internist is an exceedingly costly instrument, and the costs are reflected in his bills. The inflationary pattern of solo practice is reinforced by the pattern of insurance plans. Nearly 150 million Americans have some, but it covers on the average only 30 per cent of a family’s regular medical bills. Hospitalization insurance is easy enough to obtain, but it is hard to buy policies that cover office or home visits, drugs, outpatient diagnostic tests, or psychiatric or nursing care. The payment system common to insurance—so much for a hernia, so much for a tonsillectomy—supports the ideology of solo practice in another way. It encourages both doctors and patients to think of health negatively, as a series of episodic battles against discrete afflictions. In this system the concept of “comprehensive” or preventive care has little place.
THE RESULT IS POOR MEDICINE and poor policy. It is poor policy because it leaves both doctors and patients dependent on hospitalization—the patient, in order to pay his bills, the doctor to collect his fees—and obstructs development of more rational and humane outpatient, home, and nursing services that could be more cheaply arranged. The present dilemma of the hospitals—shortages of services in some areas and underutilization in others—has additional causes: administrative rigidity, regional competition, desultory Federal supervision, and technological leapfrogging that has left many small institutions unable to perform modern services adequately. But hospital-oriented insurance has played a major role not only in overcrowding many hospitals but in deflecting attention from their defects. In addition, the system leads to poor medicine because it subsidizes the costs of catastrophe, not the preventive care that might minimize catastrophe, and it is flourishing at a time when medical victories over many acute diseases and the growing proportion of old people have made arrangements for preventive and long-term care all the more essential. Illness is simply more flexible than insurance. As Anne Somers pointed out in a recent paper:
The corollary of this shift [to an aging population] is increasing need for long-term preventive, rehabilitative, semi-custodial, and medical social services. Most chronic diseases are months or years in developing and require early diagnosis if they are to be handled effectively. The period of treatment is, by definition, extensive. If “cure” is achieved, there is often required a long “post-cure” rehabilitation. Generally, the most optimistic solution is stabilization—for example, in diabetes or glaucoma—under continuous life-time medical supervision. With such changes in morbidity and disability patterns, the distinction between health and illness becomes blurred, and the concept of medical need increasingly difficult to pinpoint in space or time. Rather there is a continuous spectrum with varying degrees of emphasis. It begins before we are actually ill; it does not cease when we are discharged from the hospital. Continuity and comprehensiveness have become indispensable aspects of effective medical care. (4)