by Robin Cook
"Okay," he said finally, in a flat tone.
"Also," I continued, "I'll show you what I know about suturing and tying if you want." Straus didn't say another word.
What a drag, I thought. If he's tired already, he'll have a long, long year. But that was his problem, and his attitude didn't bother me for long; I had too much to do. Dropping my gloves in the bag by the door, I left the OR for the last time as an intern without the slightest feeling of nostalgia. In fact, I was euphoric. I felt I had done my time and was ready to be a resident—very ready. Medical practice was at last within sight. As I walked down the OR corridor, I wondered whether to buy a Mercedes or a Porsche. I'd always wanted a Porsche, but they were, after all, a little impractical. A Cadillac? I'd never own a Cadillac. What an obscene automobile!—although it was a favorite with surgeons. Hercules had one, and Supercharger, too. Anyway, a Mercedes sounded better to me.
The menu called them veal croquettes, but to us they were mystery mounds; ketchup was the antidote. Like that of most hospital cafeterias, the food here required a vivid and willing imagination on the part of the diner. If the menu said veal, it was best to cling tenaciously to the notion of veal, despite evidence to the contrary in taste, texture, and appearance. It was also helpful to suppress any knowledge of slaughterhouse malpractices, to be very hungry, and to be blessed with good conversation.
In fairness, I suppose the cafeteria cuisine in Hawaii was cordon bleu compared to hospital cafeterias I had seen during medical school in New York. Yet even in Hawaii the food service occasionally resorted to mysterious patties of ground meat, and, as if helping me celebrate, they picked this night to serve the veal one of my favorite conversation pieces. Also, I was still on call. Even so, the meal was like a banquet. It was my last night as an intern, and yet I was already a step removed from the battleground. Straus would undoubtedly be the first line of defense if and when trouble started.
The climate in the dining room was pleasant. Crisp, thin shafts of sunlight cut through cracks in and around the blinds on the windows facing the southwest. Specks of dust danced in and out of the golden beams of light, like bacteria under a microscope. Leave it to a doctor to think of such a comparison. One of the drawbacks of concentrated technical training, such as medicine, is that your mind eventually reduces everything to a technical experience. The dust could just as easily have looked like fish in the ocean or birds in the sky. But to me it looked like bacteria in a urinalysis sample.
A group of us were sprawled around one of the large round tables near the window. Straus was on my left, just beyond Jan, who sat next to me. In a social context, away from the terrors of the OR, Straus was anything but quiet and withdrawn, as I had typed him. In fact, he was extremely animated, vocal, and you'd have to say, contentious. He seemed to disagree with every point I made, whether it concerned automobiles, the drug scene, or medicine.
As frequently happened, the conversation had drifted inexorably toward the subject of medical care in the United States. There were six or seven others at the table, besides Straus, Jan, and me, but for one reason or another they had elected early in the meal to listen, rather than participate, and they ate their food and drank their coffee silently, leaving us to jabber on. Their only input involved an occasional incredulous laugh, accompanied by much eye rolling and headshaking, to demonstrate the ridiculousness of what had just been said. Obviously, they weren't going to add anything concrete or relevant. I began to tune them out, concentrating on Straus, who was plunging volubly onward.
"The only way medical care can be equitably distributed so that everybody enjoys the benefits is to restructure the whole delivery system," Straus was saying, alternately lifting his opened palm from the table and lowering it in time with the points he wanted to stress.
"You mean just junk the present system of doctors, hospitals, et cetera, and try something new?" I asked.
"You're damn right. Scrap it. Let’s face it. Medicine is behind the times in the way it organizes and distributes care. Think how much technology has changed over the last fifteen or twenty years. And has medicine changed? No. Sure, we know more science, but that doesn't help the man in the street. The fat cats get the benefit of the newly developed isoenzyme test, round-the-clock handholding, everything and anything new. What about the poor guy in the ghetto? He gets nothing. Did you know that forty million Americans have never even seen a doctor?"
Straus didn't wait for an answer, but kept up his attack, moving closer to the table. It was a good thing he didn't pause, because forty million seemed like a hell of a lot of people, and I wanted to question the figure. Besides, what did the figure mean, anyway, since it was common knowledge that plenty of Americans were literally starving for food? What good was sophisticated medical care when people didn't get enough to eat? But the statistic got lost in the conversation as Straus continued.
"What we have is a bunch of street-vending doctors pushing around handcarts in the space age. And it's the doctors' fault!"
"Now, wait a second," I said. I couldn't let that generality go by. "Things might not be in the best possible shape, but there are a lot of fingers in the pie.
"Right, a lot of rich, greedy fingers. I mean when health care, as lousy as it is, takes seven per cent of your gross national product—that’s about seventy billion dollars a year—there are bound to be a lot of interested parties. But the fact remains that in the United States doctors have made the system, and they run it. They run the hospitals, the med schools, and most of the research. Most important, doctors control the supply of doctors."
"What about the medical-insurance companies and drug firms?"
"Insurance companies? Well, their hands are not so clean, but, at any rate, they haven't interfered in the doctor-patient relationship—I suppose out of fear of the AMA. I mean if one company pushed too hard, the AMA could conceivably refuse to honor and treat that company's patients."
"Oh, be reasonable, Straus." I looked for support and got no commitment except from Jan, who nodded her head vigorously.
"So you don't think the AMA would do such a thing?" asked Straus.
"I can't imagine it."
"Ho-ho, my friend. Are you aware of the glorious history of the AMA?"
"What do you have in mind? I know some things about the organization." Actually, I was far from being an authority on the subject, both because it had been ignored in medical school and because—well, I just hadn't been very interested in it.
"What do you mean, some things about the AMA? Are you a member?"
"Well, sort of. You know interns and residents can join at a reduced rate. So I did. But I haven't done anything. I mean I haven't gone to any meetings, or voted, or participated in any way."
"There, that's one of the problems. You are a member. You're one of their statistics. They like to think that everybody is a member, only some are more active than others. The AMA claims it represents some two hundred thousand M.D.'s in the country, but do you know what?"
"What?" Straus definitely gave the impression of knowing what he was talking about.
'Their figures are out of whack. In lots of states, it's rigged that in order to get hospital privileges a doctor must join the local medical society, and with it comes automatic and compulsory membership in the AMA. And do you think most of those doctors care or even think about what's going on in the AMA? Well, dream on, because they don't. They say to themselves, I'm too busy; I don't have time. Or perhaps they have a feeling, although they don't examine it very carefully, that the AMA is dirty politics. In that they are correct. But through their apathy the sweet old AMA stands up in Washington and says that it speaks for some two hundred thousand M.D.'s, who never contradict the allegation. To make matters worse, it not only speaks for them, but throws their money around as well. Do you realize the AMA budget is over twenty-five million dollars a year, paid in dues by the doctors who say they haven't the time to find out what’s going on?"
"Okay, okay." I had to interrupt him;
he was getting too excited. Two of the residents on the other side of the table stood up and left, dropping their napkins onto their trays. It was after six, and I had to get to my packing. Yet I couldn't ignore Straus. By now he was leaning toward me, literally in front of Jan, who had to sit bolt upright to accommodate him. I could see his eyes. He was a skinny, intense guy, anyway, and his eyes were burning.
"Straus, I'm not going to defend the AMA, but it is common knowledge that they've lifted the art of medicine out of the chaos it was in the nineteenth century. Before the Flexner report, around 1910, medical training was a joke, and it was the AMA that took on the burden of altering that."
"Yeah, sure they did. But let me ask you, for what end?"
"What do you mean, what end? To rectify a sorry situation."
"Perhaps, but also for their own ends."
"What do you mean by that?"
"Just that they cut the number of medical schools and made them better—that I'll agree to. But at the same time they locked up their control over the accreditation of medical schools. Translated, that means they have control over the supply of MD.'s and control over the curriculum. In other words, they have determined the social path through which potential doctors must pass, and they make damn sure that the students are nicely molded into the system."
"Straus, you are a romantic. Are you sure you want to start an internship?"
"I want to be a doctor, and if there were any other way of getting there, I'd do it. But to change the subject, tell me, Peters, are you aware of the burden of history you're assuming in entering the medical profession in America?"
"What are you driving at?" The last two doctors who had been sitting silently opposite us scraped back their chairs and departed. Only Straus, Jan, and I remained, leaning on a table littered with dirty dishes and soiled trays.
Undaunted, Straus continued. "The AMA has an almost unblemished record of failure in supporting, much less initiating, progressive social changes. For instance, the AMA was against the Public Health Service giving diphtheria shots and setting up V.D. clinics. And against Social Security, voluntary health insurance, and group practice. In fact, in the thirties the AMA labeled medical groups as Soviets!"
I sputtered, trying to say something, but I couldn't get it out.
"A couple more points. Did you know the AMA fought against full-time salaried hospital chiefs, and, closer to home, even against federal low-interest loans to medical students?"
"What was that?" I had started tuning Straus out when he lapsed into his list of grievances, until the words "loans" and "students" connected in my head. I still owed quite a bit of money from my medical-school days. "They were against loans to medical students?"
"You better believe it."
"Why?" That really did surprise me.
"Lord only knows! I guess it opened medicine up to the nonrich. But one of the most pathetic aspects of this scene is that after such reforms have been accepted by society and forced on the AMA, the AMA later tries to take credit for them. Makes you think of Orwell's newspeak in 1984. I mean the whole crummy scene has got to change. I think the government has to do it."
"Okay, Straus. Are you trying to tell me that after going all through those years of study, and all the years you still face, you're going to be willing to work for the federal government? That’s what you seem to be suggesting."
"Not necessarily. All I'm saying is that doctors have had the control, and they've screwed it up. Their responsibility is a lot broader than their solitary practices, treating a succession of individual patients. They've got to consider the totality of health care, including the treatment of the man in Harlem and the family in Appalachia—they're as important as treating a chairman of the board in Harkness Pavilion. If doctors fail again, the government will have to take control and order the medical profession to accomplish what is needed. After all, adequate health care is the right of every citizen."
"That’s easy enough to say, but I'm not so sure. After all, when someone is bothered by a headache at 4:30 a.m., and he gets a doctor out of bed because health care is his right, what about the rights of that doctor? I mean how much can you impose on one person for the rights of another? Surely the doctor has rights, too.
"And besides, if somebody's kidneys give out, but all the artificial-kidney machines are in use, whom does the patient sue? Society can't have an artificial-kidney machine sitting in the corner for every citizen. The fact of the matter is, health care is a service industry provided by highly trained people and sophisticated equipment, both of which are always in short supply. You can't promise health care to all when you have limited resources."
"I'm not going to argue that point, Peters. The federal government has clearly defined health care as a right of its citizens by passage of the Medicare and Medicaid laws."
"Well, Straus, I'd like to talk to you again after you finish your internship. Up until now you've been a student, and let’s face it, if things got too bad you could just walk out and leave somebody else with the responsibility. I wonder if you'll feel the same after this year is over."
Jan had been listening quietly, more, or less on my side, I thought. Now she chimed in. "There might be some problems with health-care distribution, but we do have the best medicine in the world, Straus. Everybody knows that."
"Nonsense," retorted Straus. 'Take infant mortality. The United States ranks fourteenth in prevention of infant mortality, eighteenth in projected male life span, and twelfth—"
"Hold on a minute, Straus," I said, refusing to listen to another statistic.
"Only fourteenth in infant mortality?" asked Jan. Straus had really gotten to her.
"Jan, dear, don't be misled by statistics. You can prove almost anything with statistics if you deal with different sample populations. It can be a kind of mathematical gerrymandering. Straus, being fourteenth or whatever we are in infant mortality probably has more to do with the fact that we keep such accurate records in this country. Lots of countries record only the births in hospitals. All others go unrecorded."
"They're pretty good at record keeping in Sweden," returned Straus with a smile.
"Well, then, there are differences in records according to what time during the pregnancy the kid came out—whether it was a stillbirth, dead in utero, or whether it was a case where the kid died when it was really a viable being. It makes a big difference where a country draws the line in amassing statistics on infant mortality."
Straus put up his hands, palms toward me, and slowly lowered them as he continued. "Again, I won't argue about the technical details of the statistics. But the fact remains that the United States is not at the top. And fourteenth is a pretty low position when you consider where we are in most other technological and service fields. Frankly, Sweden makes us look pretty sick."
"Sweden doesn't have our problems," I said sharply. "They deal with a relatively small, homogeneous population, whereas the United States is a pluralistic society. Do you mean to say you feel that a socialistic welfare state like Sweden is the answer to all social ills, and the solution for us?"
"It seems to be better for infant mortality, and children's dental care, and longevity. But I'm not saying that the United States should adopt the Swedish system of government or health care. All I'm trying to say is that there are places where health care in general is better than here. That, translated, means that better health care is possible, and we have to make it happen."
"Well, you can't create a service industry like medicine out of a vacuum, nor can you abruptly legislate it. Changes in social structure occur only through changes in the attitudes of people. These changes are slow, and related to the educational forces organized to deal with them. People are used to the current doctor-patient relationship. I don't think they want it to change."
"For Christ's sake, Peters, forty million people have never even seen a doctor! How can they develop an attitude? Man, that's a vacuous excuse. Yet it's typical, too. You and your buddies can think
of a million little irrelevant reasons why the present system should stand without change. That's why the whole structure has to be scrapped. Otherwise, we'll water down the problem by compromises like Medicare and Medicaid."
"So even Medicare and Medicaid are bad. Straus, you're a real bomb thrower. Everything is black from where you sit. I think Medicare and Medicaid are pretty good laws. The only problem I can see with them is that they screw up the graduate teaching system by making it possible for many of the patients we'd been handling to go to private M.D.'s, who don't let the interns and residents in on the case. As a result, we have effectively lost a large population of patients for learning."
"Well, that’s pretty important," said Straus. "And if s indicative of the Band-Aid solution to gigantic social ills. Yet the biggest problem of Medicare and Medicaid is that they have just thrown more money into the hopper, creating more demand. If the demand goes up and the supply stays the same, prices soar."
"Sure, sure." I was getting a little angry now. "What you want is another monolithic government bureaucracy, with millions of file cabinets and typewriters. But this is going to cost a lot of money. Health-care cost would probably go up, not down, with such a bureaucracy. And I suppose you envision all doctors on government salary. That would be interesting! Society is going to be in for a little shock when it finds out how much money it needs to pay those doctors. Financial return would have to go up, as the doctor rapidly learned to compare himself to someone like a unionized airline pilot, who can get about fifty thousand dollars a year for a sixty-five-hour month. How many doctors would it take to man the healthcare system if each one worked sixty-five hours a month? Plus they'll want retirement benefits—"