Medicine: The Plight of the U.S. Patient

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takes several hours and several 200 bus fares for a woman to avail herself of them and, lacking a babysitter, she probably has to drag her other children along with her. The northern Bronx is largely white, Jewish and health-oriented; there, women go routinely to their private physicians for the same services.

Most consumers of medical care—again, regardless of status—are "crisis-oriented," as are most of their doctors, virtually all hospitals, and most insurance plans. Not only does this deny the nation the potential benefits of preventive medicine; it also denies the majority of patients orderly access to the care they need when they need it.

Even for the well-to-do and articulate citizen, getting such care involves an obstacle course. He is, in effect, challenged to take out the right kind of insurance, probably in his 20s or 30s, and certainly years before he expects to need it. Then he is challenged to find the right doctor. For none of these choices are there any reliable buyers' guides. At successive times in his health history, three major components of care—doctors, hospitals and insurance—will be simultaneously involved.

Twin Fetishes

Obviously, it is the doctor who should guide the patient through the bewildering health-care maze. Yet not enough U.S. doctors today are qualified to fill this role well, and the organization of the profession discourages it. With the discoveries of new and potent "wonder drugs"—insulin, the sulfas and antibiotics, new hormones and vaccines—each succeeding decade after the 1920s should have been a golden age of medicine. But medicine needed the understanding and compassion for the patient that had marked the old-style, unscientific family doctor. The American Medical Association, long the champion of improved medical practice, lost sight of the patient. It developed certain obsessions, seeing threats to its own and to every doctor's existence or financial well-being on every side. Among A.M.A. fetishes are "free choice of physician" and "fee for service."

The first means that the patient must not be locked into a system in which he will have a doctor assigned to him. He must have free choice of all the physicians in his area—if he can find one.

There must be no "third party" hiring doctors on salary and then charging patients for their services. For nearly three decades the A.M.A. was almost as strongly opposed to group practice, in which a number of physicians set up shop together and divide the fees collected from all their patients. The A.M.A. feared that this would prove to be a step toward socialized medicine.

The second principle does not mean simply that the doctor must be paid for his services, which is his obvious right. Rather, it means that he must be paid for each individual service, on the basis that U.A.W. President Walter Reuther aptly and contemptuously calls "piecework." It means that no doctor should offer lifetime care to a patient for a flat or annual fee, and thus rules out prepayment by an annual dues system. It means that when a patient goes into a hospital for an operation, he must pay the admitting doctor's bill, a separate surgeon's bill, a separate radiologist's bill for X rays and a separate anesthesiologist's bill.

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