AMERICAN MEDICAL QUANDARIES
The United States is mired in a profound, expensive, divisive, paradoxical medical swamp—and has been, with increasing malign consequences, for at least fifty years. Despite spending an average of $4,270 on medical care for every man, woman, and child in the United States each year—55 percent more than the next most munificent nation (Switzerland) and a full 3.4 percent more of our gross national product than the next most medically committed nation (Germany)[1]—we get undistinguished (some would argue terrible) results for our investment. A recent global comparison of health systems conducted by the World Health Organization rated the United States as number 37 overall, behind virtually all Western European nations, Canada, Colombia, and Morocco.[2] The U.S. system's levels of responsiveness as scored by the WHO did not offset its very low ratings on costs and fairness, confirming many transnational and domestic studies that document high degrees of frustration with the medical care in this country. Most troubling, the United States does not receive good outcomes for its prodigious expenditures,
The WHO document analyzes global data, but its findings are in no way contrary to multiple surveys, studies, and consensus documents published over the years in this country. Fifteen percent of our population has no health insurance. Infant mortality and longevity figures lag well behind countries that spend much less on health care but enjoy more comprehensive systems. In a businessdriven campaign to control medical costs, many whose insurance is provided through employers have been moved into systems of managed care, which many think limit patient choice and compromise quality. Despite this widespread phenomenon, medical costs are again rising, led by pharmaceuticals, which are now aggressively marketed to the public as well as to physicians. Medicare (government-mediated health insurance for the elderly) remains an extremely popular but expensive program that, despite its lack of coverage for drugs and nursing homes, is headed for insolvency in the future. Medical information is everywhere—in newspapers and magazines, and now on the Web—but the consumer, newly rich in data and opinion, has a new problem of sifting and evaluating this proliferation of advice. Despite the resplendency of our medical technology and the monumental outlay that we make for health care, we are not doing well in outcomes, satisfaction, or fairness.
A national primary care system of robust quality is a necessary prerequisite to draining our national health care swamp. This generalist ideal is a concept that flourished in earlier times, when, to be sure, medical knowledge was far more limited and an individual doctor could “own” a significant portion of it. The proliferation of knowledge in the twentieth century spawned and promoted specialism, but has led to the current situation in which specialty physicians in the United States outnumber generalists two to one, are paid at substantially higher rates, and enjoy far more prestige than their generalist colleagues. These circumstances and the general gusto with which American medicine has adopted the specialty ideal are at the heart of the quandary in which we find ourselves. Not coincidentally, primary care physicians play more central roles in virtually all of the national systems that rate ahead of the United States in satisfaction and quality. Quantities of evidence demonstrate the ability of generalist physicians to manage medical care more cost-effectively than highly compartmentalized specialists. Primary care must be the basis of any future strategy to extend care to all of the American population as well as all of the current “safety net” efforts to provide
Many questions came immediately to mind when I considered the status of big doctoring at the end of the twentieth century. The physician with a horse and buggy faithfully traveling the countryside to treat patients at all hours and in all seasons is a powerful but dated American image. The house call and the cradle-to-grave care are important national lore but these images, too, tend to come from the past. Marcus Welby was celebrated on TV, but that was forty years ago. Who are the generalists of today, women and men, rural and urban, physicians and, in fact, nonphysicians? How are they trained? What are their practices like? How do they balance their work and their personal lives? How do they see the changing medical world in which they live? How do patients regard them, given the specialist bent of our society? What do they think about managed care and their prominent role in it? How do they feel about keeping current given the continued growth of clinical science? What about the tedium of routine care and the hassle factor of dealing with a dizzying array of billing codes and insurance forms … and the future?