It's Enough to Make You Sick

You would think Bruce Frome, physician, millionaire and chairman of one of America's fastest-growing health-care corporations, would have an easier time finding a good doctor than the rest of us. Well, he doesn't. The head of Los Angeles-based Marvin Health Services has just as much trouble finding reliable physicians as anyone else. Nothing—not his clinical experience, money, stock options nor persuasive manner—seems to give him an advantage on drawing first-rate medical men. This clearly takes the edge off a fine February afternoon for 34-year-old Dr. Frome. After all, he is contractually obligated to serve a mushrooming patient load through his two-year-old medical empire.

At his plastic office inside Marvin's world headquarters on Wilshire Boulevard, he explains just how hard it is to find good doctors these days: "We've gone through a lot of physicians in our first couple of years. Any time you start a new organization like this, you are bound to get drifters. Thirty days after you hire them, you get a report back from the state telling you who they really are. Then you have to turn around and fire them. Employment agencies send over physicians who look good until we find out they are crooks or quacks. Three out of the first 50 doctors we hired turned out to have been indicted for Medicare fraud. Reputations don't even mean much. I was particularly interested in one guy who had been emergency-room chief at a local hospital for three years. We were all set to use him until we checked and found out he had fake medical and narcotics licenses. By the time we phoned up to get his explanation, the guy had disappeared. No one has seen him since. He's probably in another state by now."

Dr. Frome was one of about 100 doctors, nurses, hospital administrators, medical researchers and public-health experts I met during a month-long journey about the country in a protracted effort to answer a simple question: Why is America, blessed with the finest medical schools, the most extensive research facilities, the largest drug laboratories, the best-equipped hospitals and the highest-paid doctors, a "second-rate country" in the distribution of health care? That verdict doesn't come from Ralph Nader. It's the view of the nation's ranking public-health official, Dr. Roger O. Egeberg, Special Assistant to the Secretary for Health Policy of the Department of Health, Education and Welfare. Why do men in 22 other countries have a higher life expectancy than American men? Why do our women rank seventh on the worldwide female longevity scale. Why is America's infant-mortality rate 14th and its maternal-mortality rate 11th? And why—after a generation of health-care breakthroughs that include the conquest of polio and diphtheria, the advent of countless miracle drugs and new lifesaving technology such as open-heart surgery and hemodialysis—has American life expectancy failed to increase since 1961?

No one blames our medical system exclusively for this depressing trend. Rising highway fatalities, urban pollution, high-cholesterol diets, nerve-racking life style and lack of exercise have all contributed. Yet Canada, where environmental pressures and life style are comparable to our own, shows better statistics in both male longevity and infant mortality. Particularly embarrassing is the fact that all of America's impressive medical know-how has failed to keep our male life-expectancy rate equal with that of nations that have considerably lower per-capita incomes, countries like Bulgaria, East Germany and Poland.

Why is this so? My search for answers began in a utilitarian one-bedroom apartment awash in dirty hospital uniforms and copies of the New England Journal of Medicine. Slumped in the middle of' her Levitz sofa, just off night-shift duty at one of the nation's major community hospitals, was the nurse, coughing badly from a cold, compliments of her patients. She was talking about a millionaire surgeon on her hospital staff. This physician, who specialized in diseases of the rich, was adored by his high-society patients. His friends blessed him for finding imaginary breast masses on their wives and then subjecting them to needless mastectomies. Hardly a week went by when he didn't take out a normal stomach or a healthy uterus.

The nurse, still wearing her hospital whites and hacking steadily, went on for several hours about the outrages she had seen performed at the hands of this surgeon. The physician had tried to cure a woman's diarrhea with three totally unrelated surgeries: hysterectomy, thyroidectomy and hemorrhoidectomy. The diarrhea did not abate. Another woman plagued by vaginal bleeding from her I. U. D. ended up with a hysterectomy (when the doctor simply should have removed the I. U. D.). After performing an appendectomy on one man, he closed the patient up before the pus could drain; he was in a hurry to make a baseball game with his son. The patient went downhill and the surgeon returned to pronounce him beyond hope. Several of the nurse's colleagues were so distraught they appealed to the chief of staff, persuading him to bring in other doctors, who drained the pus and saved the man's life.

The nurse's face was red now and her cough was getting worse: "Can you imagine that? Can you imagine a doctor vain enough to let a patient the rather than admit a mistake?"

"How does he get his patients?" I asked.

"Charm and fee splitting."

"Isn't fee splitting illegal?"

"Sure."

"How does he get away with it?"

"The same way he gets away with everything else. Doctors don't have to answer to anyone except the IRS."

After a few more horror stories about the surgeon, it was time for me to go. When the nurse took me to the door, she became engulfed in another coughing fit.

"Hey," she yelled as I walked down to my car, "you got anything for a cold?"

I remember feeling haunted by her stories while I drove home that night. I had read about such outrages in magazines and newspapers but somehow always managed to associate them with poor people who couldn't afford good medical care. Her firsthand accounts of this surgeon's work at the expense of his high-society patients jolted me. Now, dozens of hospitals and clinics later, the surgeon seems like a footnote to what I saw and heard during my travels about America's medical empire. I found:

• Patients denied admission to hospitals who dropped dead on their way home.

• Hospitals that falsify medical-committee-meeting minutes to win accreditation.

• In 1972, the head of California's hospital-licensing division openly admitted that she would not feel safe in some hospitals licensed by her own office.

• A state contracting with medical groups to provide prepaid-health-care services at hospitals specifically disapproved by inspectors from that same state's medical association.

• Hospitals where doctors complain that their patients are constantly disappearing.

• Hospitals that unload their patients on better medical facilities nearby the moment they become seriously ill.

• A surgeon walking out in the middle of a hysterectomy because the nurse said something he didn't like (the anesthetist completed the operation).

• A medical-board-certified cardiovascular surgeon with impeccable medical credentials and a lengthy bibliography who has butchered a number of patients straight into their graves.

• Reputable physicians who can't even remember how many patients they have in the hospital.

• Chiropractors, optometrists and dentists handling emergency-room patients.

• Nurses who can't discriminate between live and dead patients.

What surprised me most during my unguided tour of American medicine was the fact that you can't be assured of adequate care, no matter how much money you spend. Many victims of the malpractice and misfeasance cited above were well off financially. The affluent patient in his $140-a-day private room with wall-to-wall carpeting and color TV is every bit as vulnerable as the welfare patient in an open charity ward. Indeed, many medical charlatans and proprietary (profit-making) hospitals feast off the wealthy. They hospitalize patients for nonexistent diseases, subject them to completely unnecessary lab tests and X rays, hold them for days to increase room and drug charges before finally putting them through needless surgery. Dr. Vincent De Paulo, who runs a prepaid-medical-group practice on the West Side of Los Angeles, told me how this works:

"I know a millionaire g.p. here who caters to a very exclusive clientele, yet he operates out of a tiny office with just one examining room. When I asked him to let me in on his secret, the guy said: 'I don't like to see my patients at the office. It's worth more seeing them at the hospital. I use a place in one of the wealthiest parts of town, so no one feels bad about going there. Generally, I'll keep at least 20 patients in at a time and hit them $25 apiece for my daily visit. That's $500 a day just for making my morning rounds. Throw in some surgery, give 'em a few shots, do some lab work and it really adds up. Especially since I'm part owner of the hospital.' "

• • •

"Operator, this is Mrs. Mitchum over in emergency. Do you have a home number for Dr. Patrick Love? ... L-O-V-E; he's my senior surgical resident tonight and he's five hours late.... Yes, I've.been trying his pager and his room here all evening and there's no answer.... You sure you can't find a home number? ... No, I'm not going to look him up in the (continued on page 120)Enough to make you sick(continued from page 114) phone book, that's too much trouble."

With that, Bertrella Mitchum, supervisor of Cook County Hospital's emergency-room swing shift, gives up on the man I am calling Dr. Love. (With this exception, all the names in this article are accurate.) After 21 years' experience in Chicago's largest medical facility, she is not about to start playing truant officer for senior surgical residents. If the switchboard can't find him, she can't find him. Mrs. Mitchum, a chain-smoking, strong-minded black woman, has tried to reach the night hospital administrator about the problem, but no one knows where he is, either. Since seven a.m., the junior surgical resident, Dr. Miguel Castro, has handled between 24 and 30 surgery cases. Now, at nine p.m., he is too tired to remember the exact number. The young surgeon would simply have to keep his eyes open. It wasn't such a tragedy, really. Dr. Castro could never have picked up this kind of round-the-clock experience back home in the Philippines. And he can be thankful that the X-ray technician is back on tonight. Last night, he disappeared for six hours. Thirteen patients, some of them seriously ill, had to wait until morning for their X-ray reports.

County's emergency room is the first place approximately 200,000 doctorless Chicago blacks, Puerto Ricans, Mexicans and poor whites turn to when they need medical care. With an average of roughly 900 patients a day streaming into the emergency center, Mrs. Mitchum doesn't have time to worry. Her international physician staff—tonight there is even an American working among the Filipinos, Cubans, Syrians, Rumanians and Indians—barely has time to talk. First priority are gunshot and stabbing victims brought in by the police. They are immediately whisked upstairs to the trauma unit. Next come heart-attack, stroke, O.D. and respiratory emergencies. Third priority are walk-in patients who keel over in the waiting line. After handling these cases, the residents begin taking on two dozen diabetic, asthmatic, epileptic, drug-addict and d.t. cases spread out on gurney carts jamming the corridors.

While doctors work over their patients, Mrs. Mitchum is busy trouble shooting. In one examining room, a rotund old man named Vito fights the nurses as they attempt to remove his new corset. A regular visitor with both heart disease and diabetes, Vito is always making trouble. Mrs. Mitchum and her staff grasp him firmly as an orderly removes his corset. Patients like him seem to be getting more aggressive every day. Just this week, a man jumped Mrs. Mitchum in the corridor because she wouldn't have him admitted to the hospital. It took two guards to pull him off. And that was the third patient to attack her this month. Chicagoans often become desperate at County; they view it as their hospital of last resort.

Vito's clothes are off now, but he refuses to provide a urine sample. The patient's face reddens as he yells: "I rule the world, I rule the world."

"Come on now, Vito," says Mrs. Mitchum, "why don't you give us some urine so we can see if you still rule the world?"

Vito folds his arms over his groin.

Mrs. Mitchum is angry now: "Vito, either you give me some urine this instant or I'm going to catheterize you."

She has uttered the magic word and Vito's bladder promptly empties on a voluntary basis. As the head nurse walks triumphantly out of the room, she notices a pan of stale vomit resting on a counter full of sterilized instruments: "You saving this for someone's breakfast?" she asks an orderly.

It is 9:15 p.m. now, just two hours before Mrs. Mitchum's quitting time; the Saturday-night specials are beginning to roll in steadily. Baseball-bat, stabbing and gunshot victims are taking center stage. After admitting these customary weekend guests, Mrs. Mitchum takes a few minutes to think out loud about her personnel problems. What is going to happen to that nurse over on the women's side who called in two residents to handle a cardiac arrest? When the doctors arrived, they discovered the woman had died of a gunshot wound 15 minutes before reaching the hospital. Both residents were furious about being awakened. You would think the nurse would have taken her pulse.

And what about that Filipino nurse who keeps refusing to answer the phone because her English isn't too good? How can we change doctors who insist on conversing before patients in a foreign tongue, even though they know it's against hospital rules? Why do they think the administration spent $32,000 on a Berlitz course for the 30 interns who flunked the hospital's English-proficiency test?

In between confiscating liquor bottles from patients who consider County a B. Y. O. kind of place, Mrs. Mitchum speaks with an intern anxious to release an ashen-looking old man. The patient is short of breath and Mrs. Mitchum asks about his temperature. "A hundred and four," reports the doctor, "but I'm going to let him go home. We've only got room for sick people in this place."

Mrs. Mitchum nods, then reconsiders the order as soon as the physician turns his back. "Hold him for overnight observation," she tells a nurse. The doctor will probably never know the difference, since it's doubtful he'll ever see the patient again.

Remembering patients is a vital part of Mrs. Mitchum's job. Take the 76-year-old man who came in tonight with a head injury sustained in a fall. X rays turned up negative, which persuaded the resident and the neurosurgeon to release him. Mrs. Mitchum intervenes and when the two doctors try to overrule her, she simply pulls off the man's bandage. There is a deep scalp wound that calls for immediate suturing. The physicians, who had never bothered looking under the bandage put on by a nurse, are beaten. Their patient goes off to surgery for suturing and on up to the neuro ward for observation.

A few minutes later, a call comes down from neuro about another patient who has gone berserk. He is disturbing the ward and neuro's head nurse wants to know if there might be space for him in emergency. Just then, the night hospital administrator makes his first appearance of the evening. He knows Mrs. Mitchum doesn't warn to board this neuro case and tries to work out a compromise: "Why not just bring him down here and put him in the middle of the hall?"

Mrs. Mitchum shakes her head: "Baby, I'm sorry, but we got all the lunatics we can handle."

The administrator mercifully disappears into the night, leaving Mrs. Mitchum with a few minutes to talk about some serious attitude problems among the Indian doctors. Her handsome features stiffen as she explains the difficulty: "Some of the Indians just aren't as concerned about saving lives as we are. We have to yell at them to hurry and save patients before time runs out. They tell me, 'You Americans don't understand how to solve your population explosion. You ought to just let some of them die, the way we do back home.' "

At 11:15 p.m., Mrs. Mitchum turns over her worries to the graveyard shift. She is in a hurry to get home and do some desperate organ practicing for a big lesson tomorrow. Dr. Love never did show up and Dr. Castro is still suturing away. On her way out, the head nurse passes fresh gunshot, coronary and d.t. cases. The examining rooms and corridors are busier than ever. In the waiting room, she notices that the wall clock stopped functioning at 4:55 p.m. Well, now, there's a plus. Maybe some of those people who've been waiting around for almost seven hours think it's still 4:55 p.m.

The head nurse walks briskly on leaving the hospital. She knows not to use County's underground tunnels at night. That's where a lab technician was beaten senseless a year ago. Mrs. Mitchum also refuses to park in lot five. That's where one of the nurses was mugged. The hospital's neighborhood is tough. You really have to watch your step. If you're not careful, you might end up in the hospital.

• • •

Cook County Hospital is the hub of the 305-acre West Side Medical Center, the world's largest medical complex. Surrounded by six other hospitals and four (continued on page 250)Enough to make you sick(continued from page 120) medical schools, it is one of the busiest medical facilities in the nation. County has no room for gift shops selling pink peignoir sets and white-satin eyeshades. There is only a vending machine offering panty hose in ten colors. Circling the complex, I got the impression that County's architect gave up after sticking a few pillars, cherubim and filigrees on the eight-story main building. Unrelieved yellow brick dominates in every direction. Most of the 1600 patient beds are located in structures built between 1909 and 1926. Yet, according to a 1972 analysis, the facility manages to handle 7.2 percent of all Chicago's hospital medical-surgical patients, 15.1 percent of all its pediatric patients, 14.4 percent of all its maternity patients and 30.4 percent of all its emergency patients.

Ghetto patients turn to County because they have no place else to go. In 1970, just 70 of the Chicago area's 7000 physicians handled half of Cook County's 265,000 medical-assistance recipients. Many physicians who used to serve the inner city have fled to affluent North Shore and Gold Coast communities. Pierre de Vise, director of the Chicago Regional Hospital Study, reports that there are more private physicians in a single North Shore medical building than in the entire West Side ghetto of 300,000 blacks. The Near South Side community of ' Kenwood-Oakland had 110 physicians serving 28,000 whites in 1930. Today, five physicians serve 45,500 blacks in the same area. More physicians live in suburban Evanston than in all of south Cook County.

Because many ghetto residents can't find a doctor, they must look to hospitals for primary medical care. Private hospitals in their own neighborhoods cater to middle- and upper-class patients from outlying areas. These facilities don't like to load themselves up with welfare patients, because government reimbursement is slow and inadequate. De Vise found that in 1970 roughly 18,000 emergency cases refused admission to private hospitals were forced to go to County. Hundreds of these transfers were unsafe, resulting in about 50 deaths. Some fatalities occurred because patients were sent cross-town from another hospital without resuscitation. Others transported on their backs simply drowned in their own fluids.

Since they have not had preventive care, County's patients arrive with more advanced medical problems than the general populace. According to De Vise, infant mortality in the poverty areas inhabited by County's patients is double that of the rest of the city. The age-adjusted mortality rate in Chicago's ghettos is twice as high as in the non poverty areas. These statistics are translated into an axiom taught new interns when they arrive at County: "Every one of our patients has three surgically operable diseases. Your job is to find them."

Looking at the hospital today, it is hard to believe that just 25 years ago County was considered one of the best teaching institutions in America. Interns and residents from all over the country took competitive exams to win $15-to-$30-a-month staff positions. County's special facilities became world famous. The hospital developed America's first blood bank and Chicago's first intensive-stroke-care unit. The trauma unit became a model for a state-wide emergency-care system. Hospitals as far away as Latin America sent patients to the superb burn unit.

But obsolete facilities, an overwhelming patient load and a fund shortage caught up with County. By 1969, a visitor could find screaming mentally ill patients lashed to their beds in more than half the general wards. Patients slept in their own excrement, with no nurses to change their bed linens. Urine and intravenous fluid puddled on the floors of the open wards, where an average of 50 acutely ill patients lay. Each 60-bed ward was equipped with only one bathtub.

Surgeons were forced to ventilate their non-air-conditioned operating rooms by opening windows, giving rise to the famous cry: "Nurse, scalpel! Forceps! Fly swatter!" The surgeons swallowed salt pills on warm summer days and canceled operations when the humidity became unbearable. Unfortunately, there was nothing anyone could do for stroke patients on 90-degree days; they simply sweated.

Dr. Dean Waldman, who was a medical student at County during this period, found the laboratory particularly tough to deal with: "They would only perform tests specifically related to a diagnosis they understood. So if you wanted to do a series of tests looking for some rare disease they knew nothing about, you had to make up a conventional diagnosis for each piece of lab work. I needed 14 different tests on one 34-year-old patient, so I made up 14 common diseases. According to my lab requests, she had liver failure, hepatitis, infectious mononucleosis, a pulmonary embolism, pancreatitis, a heart attack—she had everything. But at least I got the tests done and found out what was wrong."

Supplies ran out routinely. Dr. Waldman recalls: "At one point, a note went up on the bulletin board listing 25 commonly used items that were not available. Among them were penicillin, oxygen masks, Talwin—an antipain medicine—and toilet paper." A shortage of night nurses often resulted in patients' receiving only emergency medications. And doctors found day-shift nurses frequently reversing their prescriptions unilaterally. Modernization efforts often caused more problems than they solved. Construction of new facilities in the intensive-care unit forced critically ill patients to put up with noise, dust and falling plaster for 15 months.

By 1970, key medical personnel were beginning to quit in disgust and the politicians finally decided it was time to reorganize County under an independent governing commission. This unit's first move was to hire Dr. James Haughton, a handsome black administrator, to take charge.

The Panama-born hospital director came in from New York City at a starting salary of $60,000, making him the highest-paid public servant in Cook County. The hospital's new leader moved decisively, thanks to substantial new funding. He increased the public-relations budget from roughly $20,000 to $113,000 annually. Work crews were sent out to paint the walls and scrub the floors. Air conditioning went into such areas as surgery, trauma, emergency, intensive care and nursery. The radio pager system was doubled, nurses received call buttons, while patients picked up ward curtains and an ample supply of toilet paper. Assuming diffuse powers formerly held by the medical staff, Dr. Haughton cut County beds from an estimated 2300 to 1600. Two buildings were closed, with some patients being transferred to nearby hospitals and others simply sent home early. Today, declares the director, County is no longer a medical dumping ground. Other community hospitals must now begin meeting their obligations to Chicago's poor.

On paper, the plan seems admirable. In practice, it is a disaster. New junior administrators are shutting down wards capriciously and scattering patients all over the hospital. Doctors come to work and find that their patients have literally disappeared: Dr. Nick Rango, president of County's Residents and Interns Association, says recently it has taken three or four days to locate the missing patients. Seriously ill heart patients end up in wards where nurses do not know their names, diseases, medications or attending physicians. Obstetrical-gynecological patients end up in surgery wards. Dermatology patients are shifted to obstetrical-gynecological wards. One night not long ago, the entire rectal-surgery ward disappeared.

The 15 rectal-surgery patients were eventually located in two new wards. But finding patients is only one current challenge facing County's doctors. Equally difficult is admitting patients, because the administration prefers to accept only medical emergencies. Although many doctors oppose this policy, County's officials have ways to win compliance. Tall, high-strung Dr. Rango says the anti-admission posture disturbs patient care: "I recently arranged for one of my clinic outpatients with high blood pressure, obesity and diabetes to be admitted to the hospital. When I went to find out what ward she had been admitted to, I discovered she was transferred to another hospital. No one could tell me which one she went to or who her new doctor was. The whole continuity of care was completely disturbed."

Pressure to turn away patients has some tragic consequences. On March 25, 1972, 45-year-old Sammie Brown was referred to County for "emergency hospitalization" by a private physician. He was taken to the hospital by police. X rays at County showed pneumonia affecting about 80 percent of his lungs; he also suffered from acute diabetes. The foreign resident who examined Brown had been warned earlier that week about admitting too many patients. At 4:35 p.m., he decided to send the man home over the protests of a sister who had accompanied him to the hospital. An hour later, Brown was brought back to County and pronounced dead on arrival. He had suffered a fatal heart attack while waiting for a subway to take him home. The resident subsequently quit the hospital under administrative pressure.

"There is no way to estimate how many County patients have died in similar situations," says Chicago's leading hospital analyst, De Vise. "We figure that five to ten percent of Cook County's patients get tired of waiting for care and leave without being seen. It's impossible to guess how many of these people died for lack of medical attention. And now that County admissions have gone down, that number is bound to increase. Many of these people consider County their doctor; they don't want to go anywhere else. When County turns them down, they just go home."

The departure of six out of ten medical-department heads and 16 senior attending physicians since 1971 has seriously hurt the quality of care at County. Medical director Dr. Quentin Young is gradually finding replacements for most of these jobs. But domestic intern recruiting has been more difficult. Of 128 new interns hired in 1972, 120 came from abroad. This embarrassing situation has prompted some staff members to jokingly suggest that Dr. Hatigliton bring in George Halas to set up a domestic intern draft. Until that happens, serious communications problems will continue between foreign-trained doctors and nurses, who often have trouble understanding one another's English, let alone the unfamiliar dialects of patients. County unit administrators are understandably nervous about being treated amid this confusion. That is why some of them take their personal medical problems to other hospitals.

• • •

Shortly before I left County, one of the facility's most persistent critics told me: "Bad as this place is, I can name you at least 40 hospitals in Chicago that are worse. It's shameful for us to be turning sick patients away. But it's even worse for them to be hospitalizing healthy patients." That's because the overmedicated patient in the suburbs can be exposed to as many risks as the undermedicated one in the ghettos. Doctors who routinely prescribe unnecessary drugs, hospitalization and surgery are exposing their patients to potential iatrogenic—or physician-caused—disease. Nearly every major advance in medical technology has brought new patient complications along with it. Thick medical school texts describe these frightening iatrogenic problems by the hundreds. Cumulatively, these hazards manage to offset much of the progress made by medical science in recent years. Consider:

• Sixty-six hundred patients die each year due to hospital-administered anesthesia.

• An estimated 1000 patients die each year from adverse penicillin reactions.

• A study showing that five to ten percent of all hospital admissions are caused by adverse drug reactions.

• A classic Yale–New Haven Hospital analysis showing that 20 percent of all patients were made ill by medical treatment.

• These complications contributed significantly to ten percent of all Yale–New Haven Hospital deaths.

• Extrapolated out, these conservative figures indicate that iatrogenic disease contributes to the death of 100,000 Americans every year—some experts think the figure is closer to 200,000.

These figures have persuaded many conscientious doctors to begin drastically limiting hospitalization, drugs and surgery. Dr. Waldman, who is now a resident at Chicago's leading pediatric hospital, says: "The other residents call me Old Iron Door, because I'm always the last one to agree to hospilalization. For example, we admit kids with infectious hepatitis only if they are unable to keep liquids down. Otherwise, the child is better off at home, because there is nothing we can do for him here. The minute you let a patient in the door, you are exposing him to at least five new risks. He can be infected by another patient. The staff can administer the wrong medicine or the right medicine in the wrong dose. They can perform the wrong procedure or the right procedure on the wrong patient. Do you know what a common mistake has been in eye surgery? Operating on the wrong eye.

"A lot of our work here," says the 29-year-old resident, "consists of undoing the mistakes of other doctors. We throw out about 80 percent of the medications prescribed by patients' family doctors. Recently we were seeing a number of serious infections started by some doctor who gave kids injections through their pants. He ran a shot mill, where every patient got an injection whether he needed it or not. Apparently, he didn't have time to remove their pants. He was tracked down and persuaded to revise his procedures.

"We have to spend a lot of time teaching mothers that a vast majority of all pediatric illness is self-limiting. The child will usually recover with no special medical treatment at all. When my kid got gastroenteritis, I took her off all solid foods and milk and put her on clear liquids with no medicine. She cleared up fine. Rut many private doctors will prescribe penicillin for gastroenteritis, even though it's completely worthless. The big problem is that we doctors have gotten so good at so many things that the public has come to expect an immediate solution for everything. If one doctor refuses to give the kid a shot, his mother shops around until she finds a doctor who will administer an injection. These physicians do the child a disservice. Ten years ago, kanamycin was commonly prescribed for a kind of sepsis in a newborn. As of five years ago, roughly 75 percent of the organisms were resistant to the drug."

Some busy suburban doctors obligingly hospitalize children in behalf of overwrought parents. One afternoon I drove out to Evanston Hospital, a first-class facility equipped with chapel, public cafeteria, gift shop and hordes of eager volunteers. The hospital is so well staffed that nurses actually have free time to keep up with their knitting. Dr. Joel Schwab, a pediatric resident, showed me patient after patient who had no business being there. On a tour of the pediatric ward, he told me: "Some of our admissions are of the 'get the mother off my back' variety. We get things like 'stomachaches to observe,' with the family doctor showing up once a day to write orders for eggnog."

Among the patients in the ward was a young girl recovering from a bunionectomy, another with a mild urinary infection and a third with laryngitis. A teenager, who could have been handled as an outpatient, was present because her parents' insurance covered only inpatient treatment of her muscular disorder. "I think we should be discouraging many of these admissions," Dr. Schwab told me. "Hospitalizing a child is a very heavy thing. I wish we could get the parents to understand these kids are safer at home."

• • •

"Eleven pounds of organic pork!"

Dr. Wallace H. Livingston looked at the Boulder, Colorado, allergist's bill a second time and blinked. He turned to his secretary and asked: "Is this right? This physician is billing his bronchial-asthma patient $13.20 for 11 pounds of organic pork?" She nodded and Dr. Livingston broke out laughing.

The Denver internist had spent a long, hard morning going over insurance claims on behalf of the Metropolitan Denver Foundation for Medical Care. As chairman of the foundation's peer-review committee, Dr. Livingston had been busy knocking down the bogus claims of the shot doctors, fat doctors, rubber-stamp doctors, whiplash doctors and other local charlatans preying on defenseless patients. He had seen the normal run of nonsense diagnoses like "cellular metabolic insufficiency" and "prehypoglycemia." The doctor had winced at charges for urine cultures that had no applicability to the patient's ailment. And he had blown up over totally unjustifiable steroid and antibiotic injections. But this allergist was really dreaming.

When Dr. Livingston stopped laughing, he looked out over the conference table full of insurance claims and said: "Doctors are my worst enemy. They are mean, ornery prima donnas who like to run around playing God. They are arrogant, stubborn and slow to change their ways. But this is the first one I ever heard of who tried to run a butdier shop on the side." Turning to his secretary, lie declared: "Disallow the pork charge and see that this guy appears before the regional review committee."

Traditionally, doctors have been able to escape meaningful quality controls. Unlike airline pilots, who must go through semiannual physicals, regular retraining and check flights, most medical men are home free after they take their degree, complete internship and receive state licensure. That explains why ambitious general practitioners across the nation perform difficult surgeries without the benefit of specialty training. It also explains why an elderly Santa Clara County, California, physician could be found using arsenic on his venereal-disease patients in 1972. He just hadn't realized his colleagues had been using penicillin for V. D. over the past few decades.

Of course, most hospitals have peer-review committees designed to make sure, for example, that surgeons aren't taking out too many healthy appendixes. But even when a hospital takes the radical step of kicking an unscrupulous physician off its staff, no warning letter goes out to his patients. The doctor merely moves to another hospital. In California, I learned of one doctor suspended from two hospitals for malpractice who simply went out and started his own hospital.

Many doctors believe this lack of quality control is the most serious problem in American medicine. After all, they reason, an airline is only as good as its worst pilot; a hospital is only as good as its worst doctor. Good physicians worry about their inability to drum bad men out of the profession. During my trip, I met numerous doctors who told me about flagrant malpractice cases they wanted to see brought to justice. In Chicago, a pediatrician discussed a doctor who had failed to do a routine blood transfusion on a kernicterus case (jaundice of the newborn). The jaundice got into the infant's brain, leaving him severely retarded. In Denver, a cardiologist told me about a cardiovascular surgeon who wrote brilliant articles on surgical technique. Yet when he went into the operating room, this man butchered patients to death. The surgeon simply could not handle a scalpel. Both physicians who told me about these cases said they had thought of giving the victims' relatives the truth so they could sue for malpractice. Neither did.

Although doctors have no way to run these bad actors out of business, new economic controls are beginning to curb some of the most outrageous chicanery. Denver is a case in point. Four years ago, the California-based Kaiser Medical Foundation moved into town and set up shop. Kaiser, a prepaid group practice, uses peer review to drastically reduce expenses for 2,500,000 members concentrated in the West. Because its doctors all work on salary, there is no incentive to overmedicate. Well-structured review mechanisms eliminate needless treatment. Thus, Kaiser patients end up with 50 percent less surgery and 30 percent less hospitalization than the national average. These cost savings enable Kaiser's doctors, hospitals and clinics to offer full inpatient and outpatient coverage for 25 percent less than the services cost on the private medical market. Naturally, the cost savings enable Kaiser to offer attractive rates to employees for group health insurance.

When Kaiser arrived in Denver, physicians realized they would begin losing patients to the economical prepaid plan unless they began cutting down on excess costs. In self-defense, they organized the Metropolitan Denver Foundation for Medical Care, one of 89 such groups across the country. The foundation oversees claims on 180,000 patients who acquire health insurance through conventional plans paid for by their employers. Cooperating health-insurance carriers write policies giving foundation patients broad coverage at a discounted rate. In return for this discount, the foundation agrees to establish fee ceilings and to police insurance claims of 1050 member doctors.

I spent some time in the foundation's busy office watching hundreds of claims go through the processing mill. Clerks scan all physician bills, pulling out those that look imaginative. They keep an eye peeled for claims from about 50 M.D.s on the foundation's "watch list." This highly confidential record carries the names of men who persistently hospitalize, operate, medicate and charge excessively. Some of them have enormous practices and most cater to affluent patients.

During my visit, Dr. Livingston showed me some of the clay's claims. One came from a g.p. who had performed tonsillectomies on three children from the same family in the same week. Discharge summaries indicated no history of tonsillitis for any of the children. The tonsillectomy is America's favorite operation. About 1,100,000 are done annually and most of them are unnecessary. Between 200 and 300 children die each year because of tonsillectomy complications. Nearly all of the deaths are needless, because informed medical opinion views the operation as a useless cure for a non-disease—or a self-limiting condition at worst. Scores of medical-journal articles as far back as 1885 document the case against tonsillectomy and respected doctors nationwide have given up the operation.

These are some of the reasons Dr. Livingston disallowed the entire $433 bill for this tonsil triple-header. Neither the doctor nor the hospital received a penny. "This is one of our biggest problems," he told me. "One out of four tonsillectomy claims involves a second member of the family. The doctor says it's time for one kid's tonsils to come out and the mother figures she might as well have the whole brood taken care of at the same time. At least the kids can keep one another company in the hospital. A number of doctors encourage this, because that's the way they make their living."

Dr. Livingston showed me another bill from a doctor who favored a handful of diagnoses that he always stamped on claim forms. This particular bill covered a husband-and-wife team afflicted by "endocrine dysfunction with obesity": "Here we have a stamp doctor who treats all his patients with four bogus therapies and charges them all $367.50. We routinely knock all his claims down to $114.50. I'm thinking of rejecting his claims with a stamp of my own." The utilization review chairman turned to another form: "Every one of these guys seems to have a favorite diagnosis. Here's one who always comes in with 'menopausal syndrome and bronchitis.' It seems like every one of his female patients comes down with these two things simultaneously.

"We also have a great deal of trouble with shot doctors. Look at this claim: $562 for a yearlong series of 250 vitamin shots for a patient with 'cellular metabolic insufficiency.' That isn't a diagnosis, it's just a catchall, it's just garbage. There's no justification for treatment at all. Generally, we frown on injections when things can be given cheaper and safer orally. A lot of doctors are putting their kids through school with bogus injections."

When I finished talking with Dr. Livingston, I spoke with one of the claims clerks. She told me: "Working at a place like this sure changes your ideas about doctors. Let me show you this bill from a neurosurgeon who performed four craniotomies on the same patient. He had some technical difficulties the first time around and had to go back in three times to clean things up. We're disallowing three out of the four surgery charges, which will cost the doctor about $1500. He wrote us a long letter defending himself. It was really incriminating. If the patient could see it, she'd have a good malpractice case against him."

Later, the foundation's operations director, Dean Russman, quantified what his co-workers had been showing me: "From our analysis here, we figure about five percent of the doctors in this community are practicing bad medicine. It would be helpful if consumers would do a little investigation on a new doctor like they do when they buy a new car. Of course, there's no way we could warn people about bad doctors without legal reprisal. But even if we did, many patients would keep going to the quacks. People choose doctors for their personality, not for their ability. We can dock the bad guys financially. But as long as the public remains medically ignorant, they'll have all the business they can handle."

• • •

Three years ago, a delegation of Richmond, Indiana, physicians got in touch with the town fathers of nearby Liberty (population 1814) to ask if they could do something about that horrible sign in the village square: This town needs a Doctor. It was downright unethical, they said, for a town to advertise like that. The Richmond men promised to find Liberty a doctor if the community removed the sign. Liberty's leaders thought it over and decided to comply. Unfortunately, they've never heard another word out of the Richmond delegation.

Few, if any, of America's doctorless towns have searched longer and harder for a physician than have the people of Liberty. Over the past six years, residents of this prosperous community, situated in prime eastern Indiana hog-farming country, have done everything short of kidnaping a doctor. They have raised $40,000 for a clinic, traveled to such cities as Cleveland, Cincinnati, Dayton, Indianapolis and St. Louis, while making hundreds of long-distance phone calls in pursuit of an M.D.

Liberty's problem is one that afflicts nearly every rural sector of America. It is rooted in the nationwide doctor shortage. Our country has 345,000 physicians, or one for every 589 potential patients. This ratio actually puts us behind such nations as the Soviet Union, where the doctor-patient ratio is one to 420. Federal authorities want one doctor for every 500 patients, which means we are short about 61,000 physicians. Aggravating the shortage is the fact that M.D.s tend to concentrate in big urban centers like Boston, Chicago, Denver and Los Angeles, where the best hospitals, medical schools and cultural opportunities are located. Thus, rural counties with fewer than 10,000 residents average only one doctor per 2000 patients. About 500 communities with populations between 750 and 2500 have no physician.

Actually, Liberty's residents are better off than they would be in most other doctorless towns. Those who take sick between seven p.m. and nine p.m. Monday through Thursday can visit a temporary clinic. It's run by a moonlighting physician who goes there after finishing his daytime duties at the Philco-Ford plant in Connersville. Unfortunately, he is unable to accept cases involving hospitalization. Some elderly Liberty residents get periodic attention from a 77-year-old semiretired physician living in town. This man doesn't take hospital cases, either.

Since few residents can get treatment in town, they drive a cumulative total of 173,000 miles annually to visit doctors in Richmond, Connersville and Oxford, Ohio. Many have no regular doctor and end up paying $50 for a routine emergency-room visit. Elderly residents who don't drive must spend $25 for an ambulance ride to the hospital. Even filling a prescription means an out-of-town drive, because Liberty's only drugstore closed in 1968.

Residents of the town's handsome white frame houses, fronted with broad porches and shaded by towering maples, tend to put off their medical needs. In the spring of 1972, Mrs. Thomas Lawson, a local sixth-grade teacher, was hit by a bad cold: "I didn't have a family physician, so I figured I'd doctor myself. On the last day of school, I was so sick I could barely walk without losing my breath. A couple of days later, I woke up and found I couldn't breathe. So I got on the phone and collapsed. When I came to, I told the operator to send an ambulance to the post office, which is located across from my house. I went out and sat on the curb at 5:30 a.m. until the ambulance arrived and ran me in to the Richmond hospital. When I got to the hospital, the emergency-room physician asked who my doctor was. I told him: 'My doctor died three years ago, you be my doctor.' So they admitted me for respiratory failure, pulmonary congestion and a heart condition. I spent five weeks in the hospital, including two on oxygen.

"My former Liberty doctor would have caught the whole thing in time if he'd been alive. The poor guy, we worked him to death. The town tried to find another doctor to help him out after his first heart attack in 1967. He practiced with a pacemaker for his last three years. Sick as he was, that man saw patients right up to the weekend of his fatal heart attack."

Mrs. Elaine Stubb, a nurse who operates the Park Manor Nursing Home with her husband, told me about some of the special problems of caring for geriatrics in a doctorless town. Pajama-clad patients wandered past her office door as she talked. "There are times when we can't find any doctors willing to drive over and see our critically ill patients. I can't tell you how many might have been saved by a local doctor with a defibrillator and medications to keep them out of shock. It's more patients than I care to think about.

"We end up taking patients to the hospital at great expense for conditions any local physician could treat on the spot. The emergency rooms become unable to lake care of real emergencies, because their facilities are crowded with patients who should have been seen in a doctor's office. The hospitals get down on us about this. Recently, I was certain one of our patients had suffered a stroke, so I called McCtillogh-Hyde Memorial Hospital in Oxford. They told me not to bring her in, because they were full. I look her in anyway and they finally accepted her. Hospitals really aren't interested in elderly patients like ours. They feel it's better to let them die. So now I don't call ahead on patients like that. I just take them in."

At the nearby trust department of Union County National Bank, Ted Montgomery, Liberty's handsome young chamber-of-commcrce president, offered an economic analysis: "It's the damnedest monopoly you ever saw. If any company had a strangle hold on a market the way doctors do on medical care, every politician in the country would be out to break it up. You know, most self-employed physicians in this country average $42,000 a year. With that kind of income, it's not hard to see why none of them want to move to a place like this. They'll probably have to work harder for the same money. But there ought to be one doctor willing to sacrifice a bit. Life here has advantages you can't put on a ledger. Frankly, I can't understand why a community that supports seven attorneys is unable to support one doctor. Twenty years ago, Liberty had three doctors who made house calls. Today, it's nearly impossible to get a doctor in to check us out."

Despite the frustrations, townspeople continue searching diligently for a doctor. Not long ago, the Ernest Millers drove to Indianapolis during the annual state medical exams. They took a two-room suite at Howard Johnson's, where many examinees were staying during the tests. State examiners promised to send over 10 to 15 doctors for interviews. Signs soliciting candidates were posted around the motel. The Millers fiddled patiently about their expensive suite for two days. Unfortunately, a motel mix-up on the Millers' room number kept away doctors seeking them out. Not a single interview took place. The couple returned to Liberty furious and filed a long letter of protest with Howard Johnson's. The motel never replied.

• • •

When the doctor returned to his office from morning rounds at Houston's Hermann Hospital, a letter awaited him on the desk. Opening it, he read of his temporary suspension from Hermann's staff for failing to keep patient records up to date. Then the young physician tossed the communication into his waste-basket.

"Nothing to get upset about. I get suspended all the time. It's routine. Whenever a doctor gets behind on three patient records, they do this. It's impossible to keep up. To tell you the truth, I'm not even sure how many patients I have in the hospital right now. I don't have as much time to devote to patients as Marcus Welby. I'll just admit patients under another doctor's name until I get my records cleaned up."

The doctor, a cancer specialist, keeps so busy he's not even sure how many cases are under his care: "It's somewhere between 2000 and 3000." At any given time, he lias 15 to 20 patients in nonprofit Hermann and ten-story Diagnostic Center Hospital. The latter is a proprietary facility linked by a parking ramp with the eight-story Diagnostic Clinic of Houston. This clinic, a partnership of 45 physicians, is his home base.

What distinguishes this slim, fast-talking M.D. from his colleagues is a complete lack of bedside manner. He regularly runs through the wards at a rate of ten patients per hour. His brusque manner disturbs many who expect the kind of compassion dispensed by TV doctors. Just today, a patient's relatives fired him for his coldhearted attitude. The doctor, whose brown hair is thinning noticeably after six years of practice, recognizes the problem but refuses to change his ways: "Good doctors don't have time to take a personal interest in their patients these days. I'm seeing a lot of really sick people. There are days when two or three of my patients die on me. I don't have the patience to sit around holding hands, telling jokes and giving needless shots for psychosomatic problems.

"Some guys limit their practice so they can have more time for each patient. I'm never going to do that. This place is like a bank. We're open for business every day of the week. Anyone who can afford us can come here. Our clinic doesn't exclude anyone except gypsies. They just run up too many bad debts."

Diagnostic Clinic and Center bask in the international reputation of Texas Medical Center across the street. Thanks to air conditioning, this 210-acre site has surmounted Houston's Liberianlike climate to become America's fastest-growing health-care complex. The mélange of buildings in half-a-dozen clashing architectural styles houses a scene that would drive Liberty, Indiana, visitors wild with envy. Over 900 physicians work at seven hospitals, three research-and-rehabilitation institutes and two medical schools. Other units include a nursing school, a dental school and a religious institute, where chaplains learn how to comfort the grieved. Nearby, the city's reigning surgical superstars, Drs. Michael DeBakey and Denton Cooley, run their open-heart assembly lines.

Largely because Diagnostic's men are associated with this prestigious medical center, 500 new patients a week flock to the modernistic beige-brick clinic and hospital. Patients from 25 nations on five continents visit the flourishing group practice. Among them are the vice-president of Guatemala, the head of the Mexican secret police, bishops, generals, Congress-women and numerous Texas millionaires. "You have to be very careful how you judge new patients around here," the doctor says. "Guys worth $40,000,000 or $50.000,000 show up in jeans and work shirts."

Between 1971 and 1972, Diagnostic's hospital census and surgeries went up more than ten percent. Profitability of the hospital (owned by Hospital Corporation of America) is enhanced by its failure to offer maternity and major emergency-room services, both of which lose money. The success of similar ventures nearby is the main reason four major hospital corporations are building or expanding facilities in Houston. Biggest of these will be Doctors Center, a $200,000,000 complex dominated by a 26-story professional building. This one is a joint venture between Hilton Hotels and Bud Adams, owner of the Houston Oilers.

Services at these new medical facilities aren't cheap. At Diagnostic, basic consultations are $50. Physicals average $250 and can run to $500. With computerized multiphasic screening, 40 patients a day can be given complete checkups. Results from E.K.G.s, urinalyses, hearing tests, eye exams, blood-pressure readings, blood-sugar checks, etc., feed directly into the clinic computer. The lab has highly automated machines that can perform 12 blood tests in just eight minutes. Radiologists can punch X-ray results directly into patient records via computer link. The president of a Houston-based oil company was so impressed by his recent Diagnostic physical that 250 other executives of the firm subsequently went there for checkups of their own.

"What we are doing here," the doctor says during a guided tour, "is gearing up for socialized medicine. The Government will throw out the best of what we have and keep the worst. Federally sponsored clinics will treat people like they are V. A.-hospital patients, forcing them to wait all day to see a doctor. Pretty soon everyone who can afford it will be running back to places like ours. That's why doctors and private corporations are building these proprietary hospitals and affiliated clinics. We're going to clean up, and I'm not ashamed of it. I was 31 years old before I started making a decent salary and I deserve every penny of it. Actually, doctors like me are really underpaid. Insurance companies won't pay us what we're worth, so we have to make it up on lab and X-ray charges. You know, this is a business, just like anything else. I'm in the black and that's all I care about."

He had underscored this point the night before in the room of a breast-cancer patient hospitalized at Hermann. A sunburned visitor paying his respects told the physician about his wife's bleeding ulcer: "I want her to come in and see you, but we can't afford it."

The doctor thought about that for a second while examining his cancer patient: "Don't you have insurance coverage?"

"She's a substitute teacher and ineligible for the school board's group plan."

"Well, you should dig up the money somewhere, friend. If you don't bring her in soon, she's really going to bust loose one of these days. Then it will cost you a whole lot more to fix her up."

"I know; sure wish we could afford you."

Later, as the doctor jumped into his Buick to rush home for a P. T. A. meeting, he reflected on the couple's problem: "People are really careless about their health. If you don't have your health, you don't have anything."

This physician doesn't lose much sleep over people who refuse to take care of themselves: "Sooner or later, they'll have to come see us. We're like food and booze, everyone needs us." Today, for example, the doctor is one of the busiest men in the clinic. His patients are backed up in the waiting room. New ones can catch a rare glimpse of him standing still. A full-color portrait shows him posing at home. Similar pictures of his colleagues line the reception-area walls.

The doctor is moving faster than usual this Friday morning, because he plans to take off early for a weekend of R & R in San Antonio with his wife. "We'll get a big room at the St. Anthony, listen to some jazz down at The Landing, carry a bottle back to the hotel and unwind," he says wistfully. "No phone, no kids and no patients."

Right now, though, he must examine a middle-aged oil-company mechanic with terrible pains in his left leg. For the past seven months, this man has been going to the M. D. Anderson Hospital and Tumor Institute down the street. At Anderson, one of America's leading cancer-research-and-treatment centers, the problem was diagnosed as bursitis and treated with an ami-inflammatory agent. Unimproved by Anderson's treatment, he had come to the doctor, who immediately ordered a xerogram and an arteriogram (two sophisticated X-ray procedures involving xerography and dyes).

Next he examines an elderly woman, discovering a fistula (hollow area) between the bowel and the colon. The internist orders her hospitalized immediately at Diagnostic and rushes back to his office to phone a surgeon: "She is big and old and fat and you are going to have one hell of a selling job on the colostomy." As the M.D. hangs up, a nurse comes in with a fresh E.K.G. He glances at the report and dials another number: "Dr. ——here. Just wanted to tell you your E.K.G. looks OK. Now, when did I tell you to come back—in six weeks or six months?"

Then the physician dictates a letter to a Mexican doctor about a breast-cancer patient who had flown up for consultation. On signing off, he boasts: "We do $1,000,000 worth of business with Mexican patients alone." After looking in on several other cases, the doctor heads for lunch in the staff dining area–lounge. While he nibbles at a chili dog, a colleague wheels in a patient allergic to his own red blood cells. The medical men all put down their food to cluster around the patient for a closer look.

In the afternoon, the doctor's first patient is an amputee. He recently underwent a modified hemipelvectomy, severing of the right leg at his pelvis, to remove a sarcoma. Aside from some difficulty sitting on his stump and swollen testicles, the elderly patient has no complaints. The internist couldn't be more pleased: "For a while there, we didn't think you were going to make it. When that artery broke loose from the suture, you lost 17,000 c.c.s of fluid, went into shock, heart failure, kidney failure and pneumonia. If those nurses hadn't kept a careful eye on you after the surgery, you wouldn't be here today. You know, we used the best man in Houston doing that surgery, Dick Martin. Afterward, he told me that was the first time anything like that had happened in over 100 patients. Dick felt awful, because that was his first surgery at Hermann and he was trying to make a good impression."

After examination of half-a-dozen other clinic visitors, the doctor walks through the parking ramp to reach Diagnostic. After authorizing the release of one patient who suffered a temporary memory loss following a bad fall, he returns to the nurses' station and phones central records. First he dictates a discharge summary with a final diagnosis of "transient ischemic attack." Then he dictates an admission summary on the same patient with an entering diagnosis of "transient ischemic attack." As we walk over to sec a kidney-stone patient, the internist laughs. "You come out looking pretty smart when you do it that way."

When he finishes examining his kidney case and seven cancer victims, the physician heads over to radiology for a look at the mechanic's leg X rays. A quick check shows he has a sarcoma in the left hip. The doctor quietly tells the radiologist: "Looks like he's going to be my second modified hemipelvectomy. Guess I'll bring in Dick Martin to ruin his career as a mechanic." Just before walking out, he laughingly asks the radiologist: "What else can you do for me today?"

As he heads down to break the bad news to his newest cancer patient, the doctor sounds proud of himself: "That's the fastest consult I've ever done. I found that sarcoma in six hours. Boy, wait until they hear about this one back over at Anderson; bursitis, my ass. He was probably seen by one of the junior men who didn't give a shit. I guess this is going to be one of their notable misses. Heads are really going to roll. The irony is that the surgeon who will chop off his leg is based at Anderson."

When he emerges from the mechanic's room, the doctor says: "I told him he had a tumor, that we needed more tests and that it may involve radical surgery. I didn't lie, I just understated the facts to get him thinking about it. That way, he'll be psychologically ready for amputation by the time we're set to cut. If I had told him the truth, I wouldn't be able to go to San Antonio this weekend. I'd have to stick around, keeping an eye on him, to prevent a psychotic break. It's what we doctors call patient management."

Rushing back to his office after rounds, the physician cleans up a few pieces of paperwork. Then he changes into a brown-hopsack sports coat and heads off for the long weekend. Unfortunately, the M.D.'s path is blocked by his nurse, who has a form for him: "I need your autograph, Dr. ——."

He signs it quickly, hands back the form and tells her: "Hang on to that signature. Someday it will be worth $1000."

(Six weeks later, I checked in with the doctor to see how his second modified hemipelvectomy had gone. "Well," he told me, "that turned into a real interesting case. The surgeon reviewed the X rays and agreed it was a sarcoma necessitating amputation. We broke the bad news to the mechanic, who went home for two weeks to quit his job, which involved oil-company work world wide. After his affairs were in order, he checked into Anderson for surgery. But a biopsy showed no sarcoma. He simply had recurrence of a testicular seminoma, a germinal tumor that had been taken out in 1971. We canceled the operation and knocked the cancer out with X-ray therapy. The mechanic is back on the job. You just can't be sure of anything in this business.")

• • •

"We don't care about the kind of patients we get," says Dr. Donald Kelly. "With the law of large numbers, we can take care of any populace anywhere—California, France, India, you name it."

The 40-year-old leader of Los Angeles–based HMO International, a mushrooming prepaid-group-health plan, hasn't begun negotiations in Calcutta yet. But his firm does have 110,000 California patients and is talking with French health leaders about a contract that would cover 30,000 to 40,000 Parisians. Dr. Kelly believes his company and others like it offer the final solution to America's health-care crisis. With the help of foreign governments, he dreams of revolutionizing medical treatment in the slums of Rio as well as in the streets of San Francisco—all at a reasonable profit.

His primary focus and major challenge right now is the American market. How does he plan to turn around a sickness-oriented health-care-delivery system that eschews preventive medicine in favor of last-minute technological solutions? Can he adequately handle new patients who lack medical histories because the nation has no central patient-file system? Will he be able to find new physicians to handle doctorless inner-city patients victimized by the absence of comprehensive national health planning? Is there a way to curb M.D.s who overmedicate? Can he establish effective peer-review mechanisms for doctors who have traditionally been able to enjoy life tenure from the day they completed their internships?

"With the law of large numbers, we can do anything," says Dr. Kelly in his 15th-floor Century City suite. His lawyer and public-relations man nod. They are sitting on his maroon-corduroy couch beneath the crescent-shaped mirrors framed by English griffins. The president, who likes to go barefoot about his office in jeans and sport shirts, is wearing his three-piece pinstripe suit from Chipp of New York. The doctor privately calls it his "stockholder's suit."

This actuarial axiom Dr. Kelly has been spouting from his English partner's antique desk is vital to the company's success. It is largely why HMO's subsidiary, California Medical Group (CMG), has been able to profitably enroll 50,000 Medi-Cal (public-aid-recipient) patients during the past year. Under this plan, CMG contracts with the state to provide complete medical services for each Medi-Cal case at a fixed fee of around $20 a month.

Dr. Kelly, sunburned from a recent ski trip, says that these poor patients' acute medical needs are offset by their underutilization of certain costly services: "Take physical exams, for example. Our coverage includes free checkups. It every one of our Medi-Cal patients came in for an annual physical, we would be out of business. But, in reality, only about 20 percent actually come in for complete checkups each year, so we're OK. That's the law of large numbers. Out of any patient population, only a fraction is going to use any given medical service. With our prior patient experience, we can set up an actuarial basis for determining costs and fees. You take the number of patients times the estimated annual cost of service per patient, divide by 12 and there's your monthly premium. Using this formula, we can provide prepaid health coverage for any group in the world."

With CMG's patients, Dr. Kelly can work out the medical economics that will carry HMO across the country and around the world: "The key to our business is keeping people out of the hospital. The average hospitalization stay in the U. S. is eight days. Kaiser is six and we are four. Every one of our hospitalizations requires approval from supervisory personnel. We can do many things like biopsies, tonsillectomies, dilatation and curettage without overnight hospitalization. We've got a fine surgeon who can do some hernia repairs under local anesthetic. When our hernia patients do have to go to the hospital, they come out in two days. Most other places, it's four or five."

CMG's mellifluous medical director, Dr. Toby Freedman. who has just joined the conversation, says: "We encourage our doctors to be a little more imaginative, a little freer. They know they are supposed to transfer patients out as soon as they can. If someone doesn't have anyone at home to take care of him, that's his problem, not ours. We have very efficient doctors. Recently, Don had a lipoma on his back that looked like it could be malignant. We decided to take it off. The growth was very deep, but not malignant. The doctor sewed him up and Don was out playing tennis the next afternoon. Isn't that right, Don?"

"You bet," says Dr. Kelly.

Finding good doctors is crucial to the future of Dr. Kelly's organization. An assistant medical director says: "The challenge is getting the best men. Our salary is no problem. We start out many of our specialists at $50,000. They all like coming to work for an outfit that has a 40-hour week. Everyone looks forward to having a month off for vacation and medical leave each year. All of them are interested in joining the company's taxshelter plan. But you know what really sells them? The car; we throw in a free car. They get their choice of a Cadillac or a Mercedes. That's really our most potent recruiting weapon; we always hold it out for last. There've been a number of doctors right on the fence who completely flipped out when we told them about the Cadillac or the Mercedes. As soon as they heard that, they were totally sold on our kind of medicine. You see, a lot of doctors won't treat themselves to the things they deserve. Many doctors would love to drive a Cadillac or a Mercedes, but they won't indulge themselves. However, if the car is shoved in their face, they'll say shit, why not? Of course, they don't have to take a Cadillac or a Mercedes. They can have another luxury car. such as a Porsche, if they want one. But that costs us more, because we don't get the volume discount we enjoy on the Cadillac and the Mercedes. For a Porsche, they have to chip in $20 a month out of their salary. Hell. I mean, we're not made of gold or anything."

Dr. Kelly's corporation is only one of half-a-dozen Los Angeles group-health organizations with eyes on the national market. All these companies are among the 25 contractors recently selected by California to enroll up to 464,000 Medi-Cal patients on a prepaid basis. State costs are expected to run ten percent less than the old fee-for-service reimbursement system. In a desperate effort to sign up Medi-Cal patients, the contractors (located primarily in Southern California) began bombarding ghetto communities with letters and solicitors during the summer of 1972. With contractors footing the bill, the state obligingly mailed out official-looking envelopes to Medi-Cal recipients eligible for the new prepaid program. On the outside was a Sacramento postmark and this announcement: Important Medical Bulletin enclosed. On the inside was sales literature. One enterprising contractor sent recruiters wearing white nurses' uniforms into prospective neighborhoods. Some aggressive solicitors signed up patients 10 to 15 miles from their medical group's nearest clinic. Recruiters representing different contractors competed with one another block by block, sometimes door by door.

Local doctors and pharmacies were understandably dismayed about losing patients and customers to these prepaid groups. Physicians began posting signs in their waiting rooms telling Medi-Cal patients not to sign with contractors. Pharmacists put similar notices in with their prescriptions. And doctors across Southern California began flooding the Los Angeles County Medical Association with documentation on numerous cases of patient mistreatment at the hands of their new prepaid competitors. In an unprecedented display of candor, the medical association made about 100 of these stories public.

The state stood by all contractors but one, Comprehensive Health Services. This group was supposed to provide full coverage for 20,000 Medi-Cal patients in Orange County. Several exposés by Robert Fairbanks of the Los Angeles Times revealed how this company actually started out in the discount-wine business. Two state legislators enjoying direct financial relationships with Comprehensive had done the company big favors. One helped nudge a special bill through the legislature that permitted wine companies to own hospitals. The other helped set up the firm's Medi-Cal contract. State officials tried to ignore these revelations until it was disclosed that one of Comprehensive's hospitals, Broadway General in Anaheim, was substandard. This facility had been disapproved by both the California Medical Association and the Joint Commission on Hospital Accreditation. This meant the state had violated its own rule requiring contractors to send Medi-Cal patients to hospitals that had been approved by at least one of the two groups. The Comprehensive contract was canceled in January of this year. In February, the firm filed for bankruptcy and was hit by a $47,860 IRS tax lien.

No one feels worse about the bad publicity than Dr. Bruce Frome at Marvin Health Services. Here he is, working 14-hour days in his Los Angeles office, taking a red-eye flight to the East Coast for meetings and then catching another sleepless flight back to work on Wilshire Boulevard. Here he is, peddling prepaid group-health care in New Jersey, Indiana, Michigan, Illinois and several other states. Here he is, hoping to push business up tenfold to $100,000,000 annually in one year and the clowns are messing things up.

"Changing America's health-care-delivery system is not an easy job," the boyish-looking doctor tells me. "There are bound to be growing pains for companies like ours. I knew that from the beginning. Making money in prepaid health care is a real challenge. To tell you the truth, I didn't even want to get into this business. In the old days, I rose in Bel Air and drove down to the largest practice in Watts. There I was running the Marvin Clinic with two other doctors, working hard and making a fortune. But when the state announced it was going to enroll Medi-Cal patients in this prepaid program, I realized my kind of practice was through. Sure I could move, but in five years this prepaid thing will be all over the country. That meant starting Marvin Health Services or losing all my patients to someone else's group plan. I decided to form the company and get the state contract for up to 30,000 Medi-Cal patients."

Dr. Frome pauses and reaches into his office desk for a cigar. "Sure I ran into recruiting problems at first. I was idealistic, my first inclination was to hire 20 of my welfare patients and let them do solicitation. Naturally, I expected them to go next door and enroll their neighbors. Instead, they hung around the office all day and just signed up my regular patients. In the first two weeks, they enrolled 1576 patients. Of course, those were the sick and pregnant ones. God, in the first month we had to deliver six babies under the prepaid plan. We'd gotten only $21 from the state for each of these women and they were hitting us with $400 deliveries. It was terrible. We just got killed that first month."

Cigar smoke clouds the room as Marvin's leader continues: "We decided to shift to a professional enrollment organization that sent 300 people out door to door. Well, you can imagine any time you have 300 people going door to door selling anything on commission, there is going to be a certain amount of misrepresentation. Especially when they are competing with other companies. I'm sure some people were confused when they signed up for Marvin. Some of them probably thought they were signing petitions to recall Governor Reagan."

Suddenly, Dr. Frome is compulsively shoving a stack of private-investigation reports off his desk into my arms. "Check some of these out. We discovered so many employees with drug convictions and felony arrests we had to turn to this. Look at some of these people who want to work for us." I see that several applicants have police records two and three pages long. "Half the girls who apply for pharmacy work have been arrested on pushing charges.

"Pioneering is tough. In December 1971, at the old Marvin Clinic in Watts, someone put a bullet hole in my Cadillac's windshield. One of the doctors working there had his throat slit when he walked out the door a couple of weeks later. He lived, but things like that would never have happened before this corporation got going."

Dr. Frome firmly believes the future of his company, the burgeoning prepaid-health-care business and American medicine itself lies in keeping patients well: "We have 20,000 people enrolled right now and 85 percent don't bother us much. The problem is that the other 15 percent are monopolizing our 29 clinics and emergency centers. Obviously, the trick is to keep that 15 percent away. We're doing that now with our computer. It's kicking out the name of every patient who uses more than $500 worth of medical services in 90 days. In a few months, we hope to put each of them through a behavioral-adjustment system designed to keep hypochondriacs away. The whole thing is really very simple. These patients are isolated in booths and bombarded with unintelligible sounds for 20 minutes. This noise shuts down their central cortex, making them brainwashable. Then all we have to do is feed in a cassette full of suggestions: Stop drinking, sleep more, stop worrying, eat right, take your pills, stop visiting the doctor. We can do patient recruiting simultaneously by telling them to bring friends in to enroll. Thus, we get rid of expensive patients and attract new members at no cost. Obviously, a system like this could be dangerous in the wrong hands, but we know what we're doing."

Six weeks later, I checked in on Dr. Frome and found that Marvin Health Services was doing fine but that he had run into trouble. One of his consultants in Chicago had attempted to sell the Marvin concept to Teamster president Frank Fitzsimmons through an intermediary. "Everything was going fine," says Dr. Frome, "until one morning in late February, when two FBI agents picked me up outside my office.

"They took me across the street to a Nibblers restaurant and told me this intermediary was connected with a Mafia front. I was shocked, of course, and we cut off talks with the Teamsters right away. But the state Department of Health Care Services panicked when they heard the story. They were frightened about bad publicity that might come from public disclosure of the fact that one of their prime Medi-Cal contractors had been dealing with Mafia types. We got the message that unless there was a big shake-up in my company, they might not renew our Medi-Cal contracts."

Dr. Frome resigned from Marvin Health Services in March and resumed private practice and work at the Marvin Clinic in Watts. He figures to lose roughly $250,000 due to his untimely resignation from the company. "That's life; sometimes you get bumped off," says Dr. Frome philosophically. "Well, at least I got a free Nibblers breakfast out of the FBI."

• • •

When I returned home from my odyssey through America's medical empire, a large packet awaited me from Gilbert Martin of the A.M.A.'s magazine-relations division. Handsomely laid out books, pamphlets, brochures and surveys in purples, oranges, blues and greens popped out at me. There was even a 185-page guide to the A.M.A.'s stand on 250 issues of the day, ranging from accident prevention (pro) to zoonoses (con).

I was particularly taken by a summary of a recent Harris Poll measuring confidence in the leadership of 16 national organizations. Medicine ranked first; the press was 13th. Had Martin slipped that in as a hint, I wondered? Was that supposed to be fair warning to fourth-estate members who might try to shake public faith in American medicine?

Sensing a threat, I decided to scan the A.M.A. literature, looking hard for the bright side. Here is a taste of the good news the A.M.A. has for those who think something might be amiss with America's health-care-delivery system:

• Only 311,000 Americans suffered medical injuries due to drug, surgical and hospital treatment in 1968.

• Of these victims, a mere 2872 died because of "medical or surgical complications or misadventures."

• Fewer than 50 percent of all adverse incidents occurring in hospital patient treatment now result in malpractice claims.

• A mere 6160 doctors lost malpractice suits in 1970.

The A.M.A., which represents 60 percent of the nation's doctors, is also quick to point out that medical men don't make as much as everyone thinks. That average yearly salary of $42,000 is based on a typical 62-hour work week. Scaled down to a .standard 40-hour week, that works out to about a paltry $27,000 annually. If the A.M.A. sounds a little defensive here, that's understandable. After all, this is the organization that persuaded medical schools to reduce their class size during the Depression due to an imaginary over-supply of physicians. The association promoted the view that America had 25,000 more physicians than it needed. Prospective medical students were warned that the profession was overcrowded. This policy wasn't reversed until 1951, and the public is still paying for it in terms of today's doctor shortage and consequent inflation of fees.

Today's A.M.A. fights hard to retain doctor control of the nation's health-care system. But when defects of this system are pointed out, organized medicine absolves itself of responsibility. Dr. Max H. Parrott, chairman in 1971 of the A.M.A.'s board of trustees, speaks for his profession when he claims: "No matter how drastic a change is made in our medical-care system, no matter how massive a program of national health insurance is undertaken, no matter what sort of system evolves, many of the really significant causes of ill-health will remain largely unaffected. We should keep in mind that medicine is relatively powerless before many of the major health concerns that trouble us all."

I thought about this professed inability of the medical profession to improve public health one night while leafing through copies of Rx Sports and Travel, a handsome leisure magazine sent free to physicians. It's the kind of publication you probably won't find lying around in your doctor's waiting room. That's because it gives such a vivid view of the tortures today's M.D.s are subjected to. Looking through the magazine, you see all the terrible decisions he is forced to make. How shall he do the Caribbean this year? Should he go "posh" at $3600 per week on a 72-foot ketch or economize on a "first-class" 41-footer at a mere $968 weekly? What about this American Revolution bicentennial-collection chess set with each piece a different symbol of liberty? Should he spend $1440 for the sterling-silver edition or spring $19,200 for the 14-kt.-gold set? Perhaps he would be better off with a $1500 porcelain bobolink sculpture or a $2000 reproduction of the 1873 trap-door Springfield used exclusively by members of the Seventh Cavalry at Custer's last stand.

Surveying the ads for the $350,000 Colorado ranches and the articles on physicians building private water-skiing lakes, I got the feeling that doctors have taken better care of themselves than of their patients. I found it hard.to believe that the same men who had made medicine the most affluent profession in the country were "relatively powerless" when it came to improving the nation's healthcare system.

It seems to me that they are about as powerless as the auto makers who boast of their superb engineering ability until the Government asks them to put effective pollution-control devices on their cars. They remain powerless by choice—not wanting to break up a monopolistic medical empire oriented toward their own financial health, not their patients' well-being. While perpetuating America's second-rate health-care-delivery system, physicians use the A.M.A. and the rest of organized medicine to spout lip service about the need for such things as better preventive medicine and patient education. But in day-to-day practice, they work against these much-needed reforms.

Solid economic reasons lie behind this strategy. Preventive medicine is very time-consuming for the doctor and not particularly lucrative. Why should he devote half an hour to teaching a patient how to avoid illness when he can give six sore-throat patients penicillin shots in the same amount of time? No matter that the injections are worthless because none of the patients has a positive strep-throat culture. The physician still comes out ahead financially.

M.D.s prefer keeping their patients in substantial ignorance about medical practice for similar reasons. Educated patients can cost them money. Consider just a few of the countless examples. Over the past decade, the Roswell-Park Research Institute in Buffalo has conclusively established that postoperative radiation treatments for breast-cancer patients are of no lifesaving value and may actually be injurious. Yet radiologists nationwide continue irradiating women following breast surgery. If these cancer victims knew about the Roswell-Park work and refused to accept treatment, radiologists would lose a major source of business. Similarly, surgeons would be substantially deprived of their largest single supply of patients if parents knew about the dubious value of most children's tonsil-lectomies. If informed patients began consulting the Physicians' Desk Reference to weigh a proposed injection series' side effects against its benefits, they might cancel treatment.

Certainly, there are some conscientious doctors who do place proper emphasis on preventive medicine and patient education. But most of them are not treating the patients who need them most. In Chicago, for example, most of the top specialists are not devoting their careers lo the multiple-disease problems rampant among ghetto residents. Instead, they are out in middle- and upper-income areas, tending to overmedicate a much healthier populace. Modern American medical technology is simply not being effectively applied where it is most desperately needed. Instead, it is being overutilized among patients who often do not need it—sometimes with iatrogenic problems the result. Neither the rich nor the poor get the balanced care they need. The results are evident in our stagnant mortality statistics that put us behind many less advanced nations. But there is no point in being discouraged by the fact that we rank 23rd in male life expectancy, seventh in female life expectancy, 11th in maternal mortality and 14th in infant mortality. After all, American doctors continue to rank first in per-capita income.

what's wrong with american medicine? not much, except that in a few places there's too much, in others there's none at all and in the rest there's the wrong kind