Medical Problems

To the Editors:

…One hesitates to criticize Mr. Bazell too harshly, for his heart is obviously in the right place [NYR, November 2]. His selections for review are quite appropriate, and I particularly like his highlighting Away With All Pests, which has inspired a growing number of US health workers. However, he has not really criticized the books, and his conclusions show an alarming lack of knowledge of the literature. There are a number of “experts” on the area of health care delivery who could have done justice both to the books and to the subject.

For example, Mr. Bazell makes a complete hash of the question of payment of the physician. This question is complex enough that entire books have been written on it (Paying the Doctor, William A. Glaser, The Johns Hopkins Press, 1970). Mr. Bazell leaves the impression that physicians in HMOs will be on salary. In fact, in the prototype HMOs, Kaiser and HIP, physicians are paid by capitation. Traditional physicians resist this mode of payment perhaps more strenuously than they do salaries, but it certainly seems to encourage development of a close relationship between doctor and patient. The quote from Dr. Cook, cited by Mr. Bazell, concerning reversing the usual economics of medical care, refers to capitation payment. The physician is prepaid to take care of an enrolled person, not an illness, and his interest, financial and otherwise, is in keeping the person well. Whether this is in fact true may be debated. The point is that your readers should not be left with the impression that only two methods of payment, both clearly with major problems, can be used.

Another example of Mr. Bazell’s missing the point is in his equation of HMOs to large organizations. Large organizations such as hospitals do seem to promote a lack of humanity and concern. However, one must consider a spectrum of possibilities. An ideal size medical group seems to be about thirty physicians serving 30,000 persons. This can be personal, close to the place of residence of the patients, and can offer the services of all specialists, as well as family physicians. One would like to know the source for Mr. Bazell’s assertion that in Kaiser “you may have a hard time when you need to see a doctor.” One may wait weeks for a routine consultation in Kaiser, but those who need to see a physician can see one that day, either by appointment or by walking in. I am personally familiar with Group Health Cooperative of Puget Sound (Seattle) and the Kaiser-Permanente Group in Portland, and I can testify that service is both personal and of high quality.

Mr. Bazell devotes quite a lot of attention to prevention, but sees no relation between this area and the organization of health care. I find it difficult, however, to conceive of a system which deals with prevention effectively which does not have a defined or enrolled population. Such innovations as multiphasic screening require an approach to a population group. One of the strengths of prepaid group practice is that the system has responsibility for the health of its “consumers.” Health education then becomes a priority. How many physicians carry out this function effectively? Every group of HIP has a full-time health educator.

Mr. Bazell quotes Dr. Halberstam with approbation as to the advantages of solo, fee-for-service practice. I think the opposite argument should be made. Dr. Halberstam will be a good physician in any system. But how do we control the marginal practitioners, insisting on continuing education and some level of quality of care? I believe this requires an organizational framework.

Finally, the question of why physicians seem more concerned with money than with patients’ needs is much more complex than Mr. Bazell indicates. Someone commented that if one wishes humanist-doctors, one does not choose scientists for training, one chooses humanists. Yet medical schools positively select out students who are not tops in science. The training process itself does little to instill humanism. The medical system needs changing, but so do many aspects of medical education.

In closing, let me say that I do not intend to attack Mr. Bazell personally. However, I deplore the “instant expert” syndrome so prevalent in medicine today. The field of health care delivery has its own scientists, critics, and philosophers. I hope in the future you will pay us the same courtesy as to those in other fields.

H. David Banta, MD

Department of Community Medicine

Mount Sinai School of Medicine

New York City

Robert Bazell replies:

It was not my intention to undertake a comprehensive discussion of the reform of health care delivery in the United States.

Rather, I tried to point out some general considerations which I believe have been overlooked in the nitpicking over the details of reform that has been going on for years now in departments of community medicine and other bastions of the liberal health establishment.

As for leaving all statements on the subject to the “experts,” I think the history of American medicine is a perfect example of what can happen when a service, vital to everyone’s life, is left to the experts.