John Tyndall, Science and Man
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| LEONARD TUSHNET, M.D. THE MEDICINE MEN $2 The Myth of Quality Medical Care in America Today Reprinted in full from the hardcover edition. ~l THE MEDICINE MEN The Myth of Quality Medical Care in America Today LEONARD TUSHNET, M.D. Contents I Mirror, Mirror On the Wall I II The Visitation 7 III The Name of the Rose 9 IV The Sacred Precincts 14 V History and Physical 17 VI The Oracles 18 VII A Commercial Note 24 VIII Members of One Body 25 IX The Pow-Wow 51 x In The Medical Staff Lounge ~3 XI The Bubbling Cauldron 54 XII Advice From an Infidel 60 Copyright 1971 by Leonard Tushnet ALL RIGHTS RESERVED Library of Congress Catalogue #78-166194 Manufactured in the United States of America No part of this book may be reproduced without permission in writing from the publisher. Reprinted by CONSUMER EDUCATION RESEARCH GROUP under special arrangement with St. Martin's Press
Mirror, Mirror on the Wall "It is as fatal as it is cowardly to blink facts because they are not to our taste." -John Tyndall, Science and Man The purpose of this book is to give you a candid look at the practice of medicine and some of its practitioners in America today. It is a view from the inside. Doy~t get the idea, however, that it will be an attack on a Noble Profession. It won't be. Not unless the truth can be construed as an attack. This will not be an expose' of the horrors committed in the name of science-I leave that to the philosophers and the antivivisection societies. Neither will it be a Sickroom Confidential written under an assumed name to protect the guilty-that belongs to Doctors, X Y and Z. Nor will it be the Maria Monkish inside story of what goes on behind the closed doors of the consulting room-that's for the lady novelists and Hollywood. I merely hold the mirror up to nature. De te, fabula -which is a fancy way of saying, "Here you are. Take a good look, and what are you going to do about it?" Because this book is not only about doctors. It's about their patients, too. Without the latter the former couldn't ride around in Cadillacs (or, if they are rich enough and no longer feel the need to impress their patients, in tiny cheap foreign cars). They couldn't afford the long vacations to Europe and the cruises to Bermuda and the expensive country clubs and the private schools for their children and the multiple-carat diamond rings for their wives. The laborer is worthy of his hire and when be works he should get paid, but once in a while his employer might ask himself, "Am I getting my money's worth? Do I really need this guy around? Can't I get along without him?" Sure, he (and you) can-to some extent. It would be a good thing for the doctors, too. They'd spend less time worrying about the stock market and how to cir 2
cumvent government-supervised medicine and they'd have more time to enlarge their souls by contemplating exactly what they're doing-and why. Not that doctors are any more venal than the rest of the population; on the whole they're less so, but they're more conspicuous. I said-to some extent. You can't get along entirely without doctors. You need one when your child has a high fever, when you've broken a leg, when your wife has a bellyache-but you don't need a doctor because it's the style to have one. You need a doctor the same as you need a plumber for stopped-up drains, a roofer for a leaky roof, or a television repair man for snow on the screen. You need him as you need any skilled craftsman. Which means that you don't need one who carries out a mystic ritual in pompous regalia, who hides his mental indolence under the mask of science, who struts like a god amongst mere humans. I'm in a position to talk about doctors, a better position than that of the medical bureaucrats or the social reformers. I had a sound medical education at University and Bellevue Hospital Medical College, and I was a general practitioner, a family doctor who actually made house calls for tli-irty-five years. I started my practice in a typical American working class neighborhood: Germans, Poles, Jews, Ukrainians, Italians and Irish. The neighborhood slowly changed: echt Amerikaners, Negroes, began to move in and the others moved out. My practice changed, too. From treating workingmen and their families I graduated, because the next generation had greater opportunities, to treating white-collar workers and junior executives, and then their bosses. I have had a real millionaire as a patient plus a few semimillionaires. I've been paid by Emergency Relief chits, welfare slips, Medicare forms, good and bad checks, and best of all, by cash. You might say (if you don't mind that eloquent clich6-I've nothing against cliche's because they're great timesavers: they prevent wear and tear on the brain) that my patients ran (puffed, grunted, or wheezed) the gamut from very rich to very poor. One thing they had in common. They were sick, and they reacted to sickness in the same way, not even mutatis mutandis, which I'm not going to bother to translate. Look it up if you want to. You might as well learn some Latin so you'll be one up on your doctor. Contrary to common opinion, he knows little of that classic language. I have lived through the days when pneumonia was treated by serum when it was available, and when it was not, by the liberal use of mustard plasters, expectorants, and prayers to St. Jude. Plus diligent watching, of course. You remember that Sir Luke Fildes painting, "The Doctor"? You've probably seen a steel engraving of it in your doctor's office. It shows a sentimental scene: a bearded doctor N,,ith top liat and wing couar is holding his chin in contemplation of a sleeping (or dying) child lying on an inipron-ised I)ed made of two chairs, while the father looks %-acantly hopeful at the doctor and pats his wife's shoulder. I have often wondered what the doctor is thinking about. Certainly not about the comfort of the child restiiig on those backbreaking chairs. Nor about the %-altie of the medicine he's just given, because if the child has diphtheria or pneumonia or any other likeln- illness, he knows the medicine didn't do any goocl. 1'%-e come to the conclusion that the doctor is just -,%-atcliiiig, watching being standard in Victorian medical rittial. I was on the scene when sulfanilamide turned pa,tients blue, antibiotics gave them uncontrollable diarrhea, and cortisone changed skiiiii-,- N-.-omen into florid elephants. I have observed plastic surgery become respectable and syphilis mentionable. I have seen appendectomies go out of style, titerine suspensions frowned on, and focal infections poohpoohed, and I have seen new fads take their place: hysterectomies, lumbar sympathectomies for the treatment of high blood pressure, and heart val,~,e stirger,%-. So what does all that prove? That I lived a long time? That as a result of delivering babies, N,,riting prescriptioiis for nervous stomachs, and opening boils I have become a I)eiiign Old Doc willing to gin-e the benefit of his experience to a bunch of opeiiniotithed neophytes (patiei)ts as well as doctors)? No. The great patliologist Virchow once said that some doctors make the saiite mistake for twenty years and call that experience. Not me. You get along the best N-,-aN- you can. All I'm trying to do in this book is tell %-oti the facts. The rest is lip to you. Don't get the idea that I'm a disgruntled hack who couldn't make a living in the practice of medicine and who now hollers that the grapes NN-ere sotir and who wanted them aiix,waN~? Not at all. I have retired (amidst the tears of my patients) to live on an adequate income derin,ed from my practice. A little whisper-my fees slowly climbed from two dollars for an office visit to a magnificent fi\,e, and from three dollars to six for house calls (I made them!). I am a living demonstration that a doctor can get rich according to the laws of classical economics when a huge demand exceeds a very limited supply. There's very little advice in this book. It is strictly .%I fryL'Pf At irror on the %%'all infoc-,iti,-,tial, the information having been distilled n% and .-otir, blood, sweat, tears, urine, sputum ~-Aher more or less unmentionable exereta. My hope -on %, ttlat % -ill use the information to become an educ.ated consumer, to become less credulous of what doctors sa%-. and to become a disbeliever in the doctrine of medical infallibility. 1-,x)k iii the niirror of medical practice. See what's there Niax-I)e the next time your hand gets the itch to ,-otir pet phvsician you'll put calamine lotion on .t iTi(! (to something more excitiiag, like makii-ig love or (liml)iniz a mountain. Maybe the next time you visit N otir (I(x:tor, %-ou'll look at him with eyes unclouded bv Afft-t tioii and with the skepticism of one who no loi-iger !wlie%es in magic you'll think about what he proposes to do No scieiitific discussion would be complete without (IiNtr,t(.-tiiig footnotes. Those you'll find in this I)ook are ;,-)r the iiidiniduals who can't possibly believe the refleetioii in the mirror. There are also digressions, mostly for fun. And a number of anecdotes. Doctors love aiiecdotes. Some are sad, some are hilarious, but always, always they're true. -Now i)roceed to your medical educatioi-i. 2. First let's take a very broad view of what medical practice is supposed to do, then zoom in on what it actually does, and then look at close-ups of what happens when you're sick. Because, after all, you are not a statistic. You are a human being with hands, organs, dimensions, senses, affections, passions. You want to know what's the best that can be done for you and %%-bo's going to do that best. As a citizen of the richest democracy in the world, yoi-i're entitled to know that. Regardless of your wishes, from the remote vantage point of the demographer you are part of his statistics. So--let's see how you fare in that role. Since we are the richest nation in the world, it fol1,)\N-s that the United States of America should have the fii-iest technology and the most advanced sciences. We should be able to afford the best of everything, no matter %%-hat the cost. We should have the best medical men in the world. It certainly looks that way. Foreign graduates in medicine flock to our hospitals and to our training centers to learn the latest techniques of diagnosis and treatment. Our pharmaceutical companies have branches all over the globe. With all the advan 3 tages money can buy we should be the healthiest nation in the world. Right? Wrong! Truth is stranger than fiction, but not so popular. We're spending the money, all right. In 1937 the budget of the National Institute of Health included less than $150,000 for subsidies of biomedical research in university hospitals. Ten years later that figure rose to a million dollars. In 1965 more than a billion dollars was distributed in support of medical research. From 1937 to 1967 the cost of the intramural research program of the National Institute of Health alone rose from about $350,000 to ninety million dollars. Besides that, nonfederal support of medical research increased ten times since the end of World War 11. The total consumer spending on health care soared from $19.1 billion in 1960 to $31.3 billion in 1966. It went up to $42.6 billion in 1969, according to the Office of Business Economics of the U.S. Department of Commerce. As a nation we're not stingy-that's for sure-when it comes to laying out money for our health. What have we got to show for all that cash? Not too much. For the past two decades there has been a steady leveling off in actual health progress, maybe even a slight deterioration in comparison with the rest of the world. The life expectancy at birth for niales was 66.6 years in 1959; in 1970 it was 67.0 years. Ditring those eleven years we dropped from thirteenth to twenty-second on the world Est. Norway's rate went tip to 71.4 in the same time, and Canada's from 67.4 to 68.4. In this country the life expectancy of females rose from 72.7 years to 74.2, but women did 13etter throughout the rest of the world; we barely managed to hold on to seventh place. Actually, a man of forty can expect to live only about four years longer than did his grandfather in 1900; a man of sixty can anticipate only an added year and a half over what he coul(I have lived in 1900. Furthermore, there is no way of de --rmining how much of even this small gain is due to better medical care or to improvement in housing, sanitation, and general living standards. A mathematical paradox is hidden in the statistics. The saving of infants from exhausting diarrhea and the prevention of death from diphtheria in small children will add years to a longevity table but not to the life of a grown man. For example, a male child born today has a chance of living 191,/, years longer than if he were born in 1900, but a man of forty today might live only eight years longer than if he were forty in 1900. The World Health Organization of the United Nations gives the death rate per 100,000 persons (from 4
disease only) in the United States as 85.8 in 1965, an increase over the 83.7 in 1963. We lag behind Japan, Northern Ireland, Yugoslavia and Greece-all not very rich countries-but at least we're ahead of Colombia and the Philippines. If we take one disease by itselfcancer of the skin, for example-in England the rate per 100,000 persons dropped from 21.4 to 19.3, but in the United States it rose from 22.1 to 23.5 in the same period (1955 to 1964). And if we look at how we are caring for our mentally ill children, the picture is even worse. The National Institute of Health reports that in the year 1966 (the last year for which accurate reports are available) 1,400,000 children needed psychiatric care, but fewer than 500,000-about a thirdreceived it. That's enough for statistics. If you want more or want to check on mine, I refer you to Dr. David M. Rutstein's book, The Coming Revolution in Medicine, Cambridge, 1967. What does a little sober reflection demonstrate? For one thing, maybe it's not the amount of money the country spends on health that's important. The Pharoahs poured gold and silver into the building of the pyramids, and their engineering feats were marvelous, but to what end? In 1910, a medical joke (?) goes, a patient had a fifty-fifty chance of benefiting by seeing a doctor. Is he much better off today? The tools of the medical trade are finer, the conjurations more logical and the herbs tastier, but the approach of death seems to be about as fast. In this country the majority of men do not reach even the Biblical three-score-and-ten. Maybe it's time to see if we're getting full value for our money. Maybe we ought to get rid of our comfortable misconceptions about how well our doctors treat us. First, let's get rid of some of our nationalistic arrogance. Wealth is not a necessary companion of wisdom. American biologists did not discover penicillin-an Englishman did. American engineers did not develop the artificial kidney-a Dutchman did. American chemists did not synthesize the phenothiazines-a Frenchman did. I have no desire to denigrate the accomplishments of American science. I merely state the facts. Necessity may be the mother of invention, but money is certainly no relation. Millions of dollars are raised here(not counting the tax money spent for the same purpose) for research, prevention and treatment of a dozen or more diseases by private foundations. Of the oldest, the National Tuberculosis Association, one weH known doctor has noted that "the sad fact remains that the National Tuberculosis Association has contributed relatively lit tle to the fight against tuberculosis."' According to him, the public is deluded when it thinks that its massive contributions have any substantial effect on the control or alleviation of muscular dystrophy, cystic fibrosis, or any of the other diseases used for fund raising. The full details, for example, of the Salk vaccine fiasco can be found in Dr. LaSagna's book on page 150. After the general use of the Sabin vaccine and the virtual disappearance of poliomyelitis from the United States, did the polio foundation fold up? No, sir. It changed its name and its purpose-to research in arthritis and birth defects. Old foundations evidently don't die; they merely metamorphose themselves. The amount of money the foundations collect and spend is far out of proportion to the good they do. To ask for more money is to make the assumption that lack of funds is the only bottleneck in research. That is not trite. It is the dearth of fruitful ideas that's the trouble. And remember that the heavy hand of entrenched blireatieracy is strengthened by the lifting of moneybags. For example, the possibility of a viral cause for cancer was pooh-poohed for years because of the bias of pathologists that cancer was a single disease sui generis. Since pathologists, the doctors who -make microscopic studies of tissues, were the final arbiters in the sttidy of cancer, it took a long time to overcome their influence. Today most researchers into cancer have come to agree that the answer to the cancer problem may lie in the field of immunization to that dread disease. Pouring money into specific areas of research is not necessarily the way to stay healthy. Witness the cool response of responsible scientists to President Nixon's proposal for a Manhattan Project against cancer. Another wasteful expenditure is the proliferation of highly specialized medical agencies. Hyperbaric chambers, cardiac surgery teams, and radioactive isotope laboratories are only a few of the many services that spring up in communities where the need for such services is very limited and where modern transportation has done away with isolation. Although doctors are the advisors and pushers of such projects, they are not always the originators thereof. Citizens filled with civic pride and hospital trustees seeking glory are partners in the crime of building and equipping structures when similar facilities exist only a few miles down the highway. And then, of course, it becomes necessary to in I Dr. Louis LaSagna, The Doctor's Dilemma, Harper & Bros., New York, 1962, p. 154. Mirror, Mirror on the Wall form the ,-,-orld (or at least the neighbors) about the forNN-ard-looking hospital administration, a sure winner in the medical one-upmanship game. So-public relations firms are hired, publicitv campaigns are started, and ever so ethically the peopie are informed about the wonders being performed daily at St. Moses General Hospital. If connections are good enough, maybe a Senator or a President's wife will come for treatment -at no cost to them, of course. The cost will be borne by the taxpayers and the other patients. Actually the need for such facilities is sharply limited, as low as one to a citn-, a county or even a state, in some cases. Too much research and too much overbuilding ii.crease the costs of medical care but do not improve the quality of what is delivered to you. That final stage , the direct jol) of the doctor. But a liealer implies a patieiit to be bealed, and the relationship is dialectic, oi-ie reactiiig on the other. I'm going to tell you about the doctors, but that means that I'll be talking about patients, too. It takes two to tango. Americans are used to the concepts of rapid progress and equally rapid obsolescence. If it's new it must be better. That's why the medical reporter is so breathless. He tries to be first w-ith the drama of every suppo, d breakthrough (horrible word!) in the cure and pre-,,eiition of disease. He I)tiilds t-ip folk heroes like Dr. Salk and Dr. Barnard. Patients come to the doctor's office clutching their clippiiigs and demanding the latest treatnieiit. "I can pay," they say, and pay they do. Patients have the illusion that doctors are beneficent purveyors of the best that science can offer to maintain health and cure disease. We live in a democracy wheretheoretically all men are equal and equally entitled to life and happiness. If there's a drug or treatment available for a tycoon, it should be available for a tire salesman. I remember vividly a young girl who came to me with her teenager magazine folded to the page describing the virtues of skin abrasion for acne. The article told how painless was the treatment, how deft were the operators and how miraculous the results. Nothing I could say could convince her that her acne was insignificant and didn't warrant such drastic therapy. The four pimples on her chin and the solitary pitted mark near her right ear loomed up to her like the landscape of the moon. Then I showed her the medical journal in which the treatment was described in detail, together with all the coiitraindicatioiis and possible complications. She shook her head. "Doctor, mv Aiiiit Cecelia loaiied me four hundred dollars. What I want to know is-do you think that will be enough?" Do you think that the treat- ment changed the poor self-image she had of herself? Not on your life! Worse are the pathetic souls who have been nursing a relative with terminal cancer. "I read in the papers that at the Mayo Ciiiiic (or the Lahey Clinic or New York Memorial Hospital) they foui-id a new medicine that's injected into the ve~ITs and it cures the cancer." They haven't read that at all. They've wanted to read it and they've misinterpreted a sometimes none-toocautious comment about current research. They borrow money, they impoverish their families, they plague their astors until tliev'x-e gathered together enough p cash to make the long trip to certain disappointment. They forget tl-lat in i-iiediciiie there are no secrets, that a new and useful therapy is immediately adopted everywhere, that experimeiitatioi-i is not treatment. When I was ,~oung in practice I used to get angry when I saw people squander their savings on a will-o'-the-wisp. I thought they were stupid. As I got older I realized that they were merely human, willing to grasp at a straw, hoping (not really believing) that the straw was att~telied to a strong rope that would baul them to safety. And honesty compels me to say that now I have reached the age when I fear I bear the beating of the ,,~.-iiigs of the Angel of Death and I would probably do the same as they did. The doctors themselves have fostered the illusion that they have unbounded competeiice. They have not applied their intelligence to the education of the public -nor to themselves. They're remiss, and not because they're moiiey-grubbers. Most of them make so much iiioiiev now that they fall into very high income tax brac,kets and have no need to make more. They have failed because they have come to believe ii-i their %-atinted magical powers. They agree with the layman whose Dative optimism takes on pathos when he enlarges on the tremendous power of medical science to do away with pain and disease, to prolong life and to niake newer and better drugs. The doctors see in themselves not masked medicine men treading a mystic round, but panoplied knights standing triumphantly on the bodies of the dragons of disease and death. It's too bad that on a close look they resemble the knights of King Arthur's court as seen by Sir Boss: intellectual innocents. Witeb doctors, too, bonestly believe in their healing powers. So do their patients. What happens where ,6
witch doctors ply their art? Someone falls ill. The frightened family sends a messenger entreating the witch doctor to call. A bronze, black or yellow man in a devil mask or a feathered headdress comes carrying the tools of his trade in a bag (called, surprisingly enough, by the anthropologists a 11 medicine bag"). The witch doctor is a highly respected member of the community. He has attained his exalted position by long years of study and apprenticeship. He knows all about diseases, those caused by supernatural malevolent forces and those caused by the patient's own bad deeds. First, he takes a history. "Did you break any taboos? Have you had any bad dreams? Were you fighting with your kinfolk?" While he is so engaged, his eyes wander around the hut or the clearing to determine how many goats or cooking utensils or turqouise bracelets the family has so that his fee will be commensurate with its status. Directory: 2013 2013 -> Annual InStructional unit plan 2013 -> The Ministry of Education and Science of Ukraine 2013 -> #1 a lifesafer of virginia inc 2013 -> Name(s): your name here team or Group #(if applicable): Professor’s name 2013 -> Alcott Local School Council (lcs) Meeting Minutes 2013 -> Table Of Contents introduction 2 2013 -> Supplemental demographic information 2013 -> 【Education&Working Experience】 Download 468.23 Kb. Share with your friends:
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