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The Coming Medical War

Certainly the reasons for the Carnegie Commission’s concern may be less devious than my reading of the report suggests; as they may have been in 1910: the academic medical elite may be interested not only in power and prestige but in the nation’s health. That of course is the claim and doubtless many well-intentioned doctors sincerely believe it. Perhaps it is true that placing control of health facilities and resources in the hands of a narrow, powerful group of “experts” is the best way to make people healthy, although the evidence gathered in The American Health Empire would seem to contradict that claim. However, the university doctors and their supporters are not culpable simply because they are advocating the formation of a new elite. They are guilty of hypocrisy and manipulation precisely because they have not taken such a position openly.

If, as the Carnegie Commission suggests, we need “to provide more health personnel of the right kinds” and “to achieve a better geographic distribution,” “to provide more appropriate training,” and “to relate health care education more effectively to health care delivery,” then we will also need to decide some very difficult and important questions: what is “right”? What is “more appropriate”? What is “effective”? Will the new medical elite make these decisions because it alone has the information and the expertise to do so? Modern medicine is, after all, very complicated, so complicated that the G.P. trained ten years ago can’t keep up (if we are to believe the academics).

But what is good medicine? Who defines it? Will patients, consumers, citizens make decisions about health and doctors? Or will such people pretend to make medical policy while in fact the medical elite makes it (as, for example, we make military policy with the help and advice of the Pentagon)? These cannot be trivial questions. But the liberal medical establishment has been unable to raise them because it has refused to acknowledge openly what it is doing. (“As to the honor and conscience of doctors,” Shaw warned, “they have as much as any other class of men, no more and no less.”)

So we must attempt to understand what these doctors are doing and to raise questions about their work. Selig Greenberg, a medical reporter for many years and author of the excellent The Troubled Calling, might have been expected to do this. But in his new book The Quality of Mercy, he has seen only what the doctors he interviewed intended him to see—not what hospitals really are like. Mr. Greenberg is infatuated with the academic medical profession. The university hospital has evolved, he writes, into “the nexus of medical care.”

With the growing complexity of medicine and the consequent need for a concentration of specialized skills and sophisticated equipment, the hospital has increasingly become the place where the latest benefits of science can best be obtained. Here the emotion-charged struggle between life and death is a daily occurrence and new weapons of healing are forged.

This is where the exploration of the grim terrain of disease presents the great intellectual challenge and where apprentice physicians are trained to shift the balance in favor of the prolongation of life and vigor.

With equal fervor he concentrates upon Beth Israel Hospital, one of the Harvard “family,” which “has a notable history of service, education, research and innovation” and which is “a germinative center of both men and ideas.” The chief of surgery at Beth Israel is “a dedicated perfectionist”; the chief of psychiatry frequently voices “passionate concern” about things and is “level-headed”; and the man who edits the prestigious New England Journal of Medicine (“one of the brightest jewels in the diadem of Boston medicine…widely regarded as the best medical publication in the United States and probably in the world…a unique blend of passionate zeal and the cool poise of the Boston Brahmin”) is “a robust, hearty, articulate and endlessly inquisitive man…and a prominent gastro-enterologist.” There is no unfavorable portrait of an academic physician in this book.

Unfortunately, not only has Mr. Greenberg been misled, but he is also in a position to mislead others:

In the meantime a ceaseless battle against death was being waged in the medical and respiratory-surgical intensive-care units set aside for acutely ill patients requiring close monitoring of vital signs and constant care by physicians and nurses…. It is generally believed that use of the monitors can reduce deaths from initial heart attacks by at least half.

That statement, like many others in the book, requires closer scrutiny. The battle may be ceaseless, but it soon ends: even if a patient recovers from the “initial” heart attack (and the statistic here is questionable and offered without documentation), a second cardiac arrest often follows soon after. Those of us who have worked on an intensive care unit know how difficult it can be to “bring back” a cardiac patient two or three or four times in the course of a few days, only to “lose” him to another attack that no amount of intracardiac epinephrine and bicarbonate and chest pounding could dissuade. The cost is $200 per day—if it can be measured in money.

Moreover, while Greenberg reports that these units are “set aside for acutely ill patients,” in fact they are as often used to prolong the life of chronically ill patients in the terminal stages of their disease (as were two of the three patients Greenberg describes as being on the unit at Beth Israel). These chronic patients merely die a bit more slowly and painfully on the unit than they would elsewhere; and there is significant evidence of “ICU psychosis.” Intensive, expensive care has some advantages, but many fewer than Mr. Greenberg and the doctors he spoke to would have us believe.13

Mr. Greenberg refers to “the grasping self-interest of the medical profession”—the other medical profession, that is:

For purely selfish reasons, the AMA for more than 30 years sedulously fostered a shortage of doctors through its monopolistic stranglehold on the standards and admissions procedures of the nation’s medical schools….

Largely because of such a “stranglehold,” the book suggests, in cities like Boston there is now “the gross divergence between the bright technological potential and the grim reality” in medical care. We do not learn why the guilt is not shared by the “brilliant activists in important positions in the medical schools and teaching hospitals” who have never served the urban—generally ghetto—communities that are literally at their doorsteps. Nor are we told that the staffs of such hospitals have physically ejected black and poor people from their emergency rooms. We learn merely that these “activists” have “innovative ideas” and are “glimmers of hope in the ferment.”

Where precisely is the academic medical elite headed? What will happen when the “bright technological potential” is realized? First, Greenberg says, the doctors will have to stay in control because “much of this research is far too arcane for the untutored layman even to attempt to understand.” “But,” he adds, “all of it is aimed at alleviating pain and warding off premature death.” This is not true. There is little current medical research of which the essentials cannot be understood by anyone capable of reading Scientific American. Much of this research is aimed more at alleviating pressures to publish and rise in the profession than at alleviating pain.

Second, we learn that in the new and more “rational” health care delivery system, “The proper role for the great medical center…is to serve as the pinnacle of the pyramid…a sort of umbrella under which all the other parts function.” At the pinnacle, the university physician will “act as captain of the health team while aides working under his supervision assume some of the duties he is now performing.” It becomes clear that to Greenberg and to the leaders of the profession the primary obligation of the patient will be to recognize his own inadequacy and to follow, as always, the doctor’s orders.

Here the Orwellian implications of the plan become clear. “Much of the pleading for a resuscitation of general practice,” Mr. Greenberg tells us, speaking for the doctors, “is little more than a nostalgic harking back to the legendary old doc of yesteryear.” But that day “is gone forever,” and our hopes are a product of “our atavistic longing for personal attention,” a failure to recognize that “the pressures for change are relentless, and doctors as well as patients will eventually have to bow to them.”

…now there are diagnostic procedures which can penetrate the core of the body’s processes and yield evidence that makes the patient’s feelings superfluous…. Patients will have to be educated to a more realistic perception of quality.

What’s the good of free choice to a patient who is unable to make the proper choice?” a prominent medical spokesman wants to know. If ICU nurses become depressed over a dying patient being kept temporarily (and sometimes unwillingly) alive by machines, a staff psychiatrist can be “called in to give them an opportunity to talk out their pity and concern.” If patients feel neglected in the modern hospital, that is simply because, Mr. Greenberg assures us, “The patient often regresses to an infantile, egocentric dependence in which he tends to invest his doctor with omniscient ability and at the same time to fret that he is not getting enough attention.” In other words, stop complaining! As one doctor put it, “Which would you rather have—warm compassionate care to usher you into the next world or cool scientific care to pull you back into this one?”

The difficulty is that “scientific care” may pull very few people back into this world for long, and can pull no one back permanently. Here a distinction should be drawn between certain advances—antibiotics, insulin, diuretics, and some others—which by no means need to be administered impersonally, and care which is more detached and machinelike by its very nature. In fact, a great deal of expensive, “cool” medical technology causes as much suffering as it prevents, kills or hurts as many people as it “saves.”

Heart transplantation, which costs some $40,000 per patient, is a case in point. In a period of two years since the first operation, over 150 transplants were performed: 80 percent of the patients died within four months; the rest lived limited, uncomfortable, fearful lives; and, in view of the imprecision of diagnostic techniques, it is likely that many of these patients would have lived longer with no operation at all, lived in less agony and with less expense to their families and society.

Mr. Greenberg and his academic sources admit as much, but they fail to admit that a similar, if less immediately apparent, case can be made against the efficacy and humanity of many of the most widely publicized medical “advances” upon which their claims of superiority rest: intensive care units, hyperbaric chambers, expensive diagnostic, surgical, and laboratory procedures (some of them unnecessarily painful), esoteric and useless research. There is the serious question, too, of priorities. Even if hyperbaric chambers were of great therapeutic value, which is doubtful, they are still of limited utility and immensely expensive. A chamber costs about three-quarters of a million dollars and some $600,000 each year to operate. In its five years of operation the unit at Mt. Sinai Hospital in New York, according to the authors of The American Health Empire, has been used for fewer than 900 patients.

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    In addition to exaggerating the efficiency of the new medical practitioner and his complex tools, the academics are conspicuously unfair to their colleagues outside the university hospitals. “There is evidence to suggest,” according to one physician cited by Greenberg, “that the actual medical performance of a significant number of American physicians is, within a few years of their departure from medical school and postgraduate training, grossly unscientific and dangerously close to ineptitude and incompetence.”

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