The Plight of the U.S. Patient
American medicine is the best in the world.
MOST Americans take this statement as an article of faith--so long as they are in good health. Even when they have a bout of illness they feel, for the most part, that they are getting excellent care. But growing numbers of patients, the consumers of American medicine, are asking questions that range from mildly nagging to openly angry.
When the doctor was first called, why did he refuse to make a house call? Did he take too long in making the right diagnosis? Did he prescribe too many drugs before he knew what the real trouble was? Did he pick the right surgeon to operate? Were all those lab tests necessary? Did the surgeon charge too much? Why does a hospital room cost $60 a day, more than the fanciest resort hotel room? Why doesn't insurance cover more of those bills?
Ingenious and Amazing
These questions are asked each year by many of the 130 million Americans who pay 500 million visits to the doctor. For them, the doctors write a billion prescriptions for a total drug bill of some $3.5 billion. Each year, 27 million Americans go into a general hospital, where they spend an average of 8.2 days and get a bill of $530, about half of which is covered by insurance. The total cost of U.S. medical care is now $53 billion a year--5.9% of the gross national product, or 7.5% of all personal income. These figures are far higher than those for other Western countries with at least equivalent quality of care.
Is the U.S. citizen getting a fair shake for his money? For an estimated 25% of the population, the answer is yes. For another 50%, medical care can be described as passable, but it is certainly not as good as it could and should be. For 25%, care is either inexcusably bad, given in humiliating circumstances, or nonexistent. The breakdown is not simply by social stratum: the rich do not necessarily get the best care, nor the poor the worst. Says Dr. William H. Stewart, Surgeon General of the U.S. Public Health Service: "If even one American doesn't have access to a reasonable level of care, there's something wrong. And when millions don't, there's obviously something wrong."
As befits a huge industry, U.S. medicine has an impressive plant, and many of its facilities are indeed outstanding. In research and medical technology, the U.S. amazes and leads the world. A newborn baby with a defective heart can probably get the best care at Manhattan's Lenox Hill Hospital, which operates an elaborate unit exclusively for pediatric cardiology. For surgery on such a baby's heart, U.S. surgeons are preeminent. So are the surgeons who operate on older patients' arteries. For trouble in the brain's arteries, researchers at Columbia-Presbyterian Medical Center have helped to develop a magnetic probe that will swim through the arterial labyrinth and tell the neurologist what he needs to know. At Harvard, surgeons practice knifeless surgery with a proton gun that destroys overactive tissue deep inside the skull. At Massachusetts Eye and Ear Infirmary, ophthalmic surgeons turn patients upside down to let gravity help them in repositioning a detached retina.
Unhappily, such examples of American medical ingenuity do not make American medicine the world's best. They are available to only a few. The U.S. ranks 13th (behind several West European countries and faraway New Zealand) in infant mortality, and behind most of these countries in maternal mortality and death rates from heart-artery diseases and cirrhosis of the liver. The U.S. averages are pulled down largely by the poor health conditions of the blacks, other minorities and poor Southern whites.
Other comparisons are equally distressing. One involves disparities in the quality of medical care within the U.S., within states, cities, and between cities and rural communities. One man may get optimum care, while another who lives on the same street and enjoys the same access to medical facilities may be handled in wretched fashion. The greatest and least defensible gap of all is, in the words of Dr. Malcolm Peterson, chief of medical services at St. Louis City Hospital, "the wide disparity between the medicine that we know how to give and what we actually give. They're miles apart."
The Non-System
Why has American medicine failed to live up to its wondrous potential? The answer, says Dr. Philip Lee who was, until last week, top man for health in the Department of Health, Education and Welfare, is that the U.S. has no system for the delivery of medical care. To talk of the present system is ridiculous, he says, because it is a "non-system." What the U.S. has, according to Dr. Odin Anderson, of the University of Chicago's Center for Health Administration Studies, is a "pluralistic system" to match its pluralistic society.
The indirect but basic reason for this is that medicine is the only big business in which the ultimate consumer has no control over what he buys. The doctor prescribes the drug, for which the patient must pay, willy-nilly. He orders a hospital admission, and the patient rarely has any choice. The patient has no way of knowing whether he is getting good counsel from his family doctor, good drugs from his friendly pharmacist, good technical performance from his surgeon. For him, there is no Ralph Nader to blow the whistle on unethical practices. There is no ombudsman to represent him before some impartial tribunal. The tightly organized medical profession fends off any and all attacks from the outside, and in cases of complaints against any of its members, sits as prosecutor, judge and jury. It is the rare patient who even tries to protest an obviously excessive doctor's bill.-
Most U.S. physicians do not accept this bleak picture, and point to the undeniable excellence of medicine in many areas. Yet in many ways, the doctors themselves suffer from the lack of more rational organization in American medicine. For the most part dedicated and ingenious, they are usually overworked and harassed. They also have cause to complain of the patient's frequently faulty attitudes toward medical care. Some people, in all social strata, are simply afraid to admit that there is anything wrong with them; they put off seeking care until their disease is far advanced or even incurable. Some, especially among the poor and ill-educated, do not take advantage of care that is available to them. In a single borough of New York City, The Bronx, the infant death rate jumps 100% within five miles, going from north to south. The reason is sad but simple. The southeast Bronx is inhabited mainly by poor blacks and Puerto Ricans. Although excellent clinics are open for predelivery and infant care, it takes several hours and several 200 bus fares for a woman to avail herself of them and, lacking a babysitter, she probably has to drag her other children along with her. The northern Bronx is largely white, Jewish and health-oriented; there, women go routinely to their private physicians for the same services.
Most consumers of medical care--again, regardless of status--are "crisis-oriented," as are most of their doctors, virtually all hospitals, and most insurance plans. Not only does this deny the nation the potential benefits of preventive medicine; it also denies the majority of patients orderly access to the care they need when they need it.
Even for the well-to-do and articulate citizen, getting such care involves an obstacle course. He is, in effect, challenged to take out the right kind of insurance, probably in his 20s or 30s, and certainly years before he expects to need it. Then he is challenged to find the right doctor. For none of these choices are there any reliable buyers' guides. At successive times in his health history, three major components of care--doctors, hospitals and insurance--will be simultaneously involved.
Twin Fetishes
Obviously, it is the doctor who should guide the patient through the bewildering health-care maze. Yet not enough U.S. doctors today are qualified to fill this role well, and the organization of the profession discourages it. With the discoveries of new and potent "wonder drugs"--insulin, the sulfas and antibiotics, new hormones and vaccines--each succeeding decade after the 1920s should have been a golden age of medicine. But medicine needed the understanding and compassion for the patient that had marked the old-style, unscientific family doctor. The American Medical Association, long the champion of improved medical practice, lost sight of the patient. It developed certain obsessions, seeing threats to its own and to every doctor's existence or financial well-being on every side. Among A.M.A. fetishes are "free choice of physician" and "fee for service."
The first means that the patient must not be locked into a system in which he will have a doctor assigned to him. He must have free choice of all the physicians in his area--if he can find one.
There must be no "third party" hiring doctors on salary and then charging patients for their services. For nearly three decades the A.M.A. was almost as strongly opposed to group practice, in which a number of physicians set up shop together and divide the fees collected from all their patients. The A.M.A. feared that this would prove to be a step toward socialized medicine.
The second principle does not mean simply that the doctor must be paid for his services, which is his obvious right. Rather, it means that he must be paid for each individual service, on the basis that U.A.W. President Walter Reuther aptly and contemptuously calls "piecework." It means that no doctor should offer lifetime care to a patient for a flat or annual fee, and thus rules out prepayment by an annual dues system. It means that when a patient goes into a hospital for an operation, he must pay the admitting doctor's bill, a separate surgeon's bill, a separate radiologist's bill for X rays and a separate anesthesiologist's bill.
The G.P.s and the Specialists
The A.M.A. has had only moderate success in choking back group practice and prepayment. Group practice is widespread, prepayment plans are growing, and there are numerous third parties in the medical complex. About 2,300 "multiple-specialty and general practice" groups have been formed, comprising 20,000 doctors, some in big cities, some in remote towns, some in hospitals or other large medical centers, some in a simple suite of doctors' offices.
By far the biggest and most successful group practice is Minnesota's famous Mayo Clinic, with 500 doctor-members. Most groups, with eight to a dozen members, comprise general practitioners or internists, pediatricians, obstetrician-gynecologists, a radiologist, a surgeon, an orthopedist and an ophthalmologist. The mix varies with local demand, but in each group a family doctor, the patient's first and continuing contact with the group, steers him to specialists as needed.
A Lifetime License
Year after year, the U.S. has fewer and fewer family doctors to do the steering. In 1930, G.P.s outnumbered specialists 70 to 30. Today the ratio is more than reversed, 21 to 79. The nation's medical schools have been increasingly geared to train specialists, and few graduates now go from internship into general practice.
Membership in a group practice, whether as G.P. or specialist, is no ironclad guarantee that a doctor is outstanding. But at least it ensures that he talks to other doctors regularly and is exposed to some of the ferment in medicine. The 50 states' licensing laws, and the attitude of the A.M.A. and most other professional organizations, offer no such assurance. Theoretically, it would be possible for a man to have graduated from medical school at 25 in 1934, to have been licensed after a year's internship, and to have practiced as a G.P. ever since then without having heard a professional word about most of modern medicine. There is no requirement that he ever read a journal, attend a medical meeting or even talk to another doctor. In practice, of course, the doctor's sense of duty and the growing sophistication (or hypochondria) of the public impel him to keep up. But there is no mandatory continuing education, and there is no reexamination. There is no law limiting his practice to his competence. A G.P. could legally do a heart transplant, if he were foolhardy enough. A license is for life.-Only the American Academy of General Practice (with 31,000 members among the nation's 72,000 G.P.s) expels members who fail to take required refresher courses.
In most smaller cities and towns, virtually every physician is listed as "on the staff" of one or more local hospitals. This does not mean that he is paid by the hospital, and it tells nothing about his qualifications. It does mean that he is a member of the county medical society, has the privilege of admitting his patients to the hospital, and is basically responsible for overall care thereafter. Many a big-city patient is denied this continuing contact with his own doctor. In New York City alone, some 5,000 physicians (close to one-third of the city's total) have no privileges at any voluntary hospital. They can either surrender their patient to the mercies of interns, residents and specialists who have never seen him before, or try to get him into a proprietary hospital, which will turn no one away if it has an empty bed.
Good, bad or indifferent, doctors are doing well financially. Their incomes have skyrocketed and approached escape velocity with the passage of Medicare and, for some states, Medicaid. In 1961, the average doctor, after office and other professional expenses, netted $25,000. By 1965, it was up to $28,000, and last year it reached $34,000. Dr. Martin Cherkasky, the crusading director of New York's Montefiore Hospital, says that doctors have the consumer over a barrel because they are in such short supply and such great demand. The shortage was sedulously fostered by the A.M.A. for 30 years, beginning in the Great Depression and ending only in 1967, when it conceded that something must be done to increase the medical schools' output. "This shortage," Cherkasky says, "makes it impossible for society to deal with the medical profession. You're at their mercy."
Gross Mismanagement
The patient is also at the mercy of the hospitals. Which are the good ones? The nearest thing to a criterion, except for university affiliation, is whether a hospital is accredited by the Joint Commission on Accreditation of Hospitals, set up by the A.M.A., the American College of Surgeons, the American College of Physicians and the American Hospital Association. The U.S. has 5,850 general-care hospitals,-with 645,000 beds for medical and surgical patients, 82,000 for maternity cases. Of the 5,850, only 3,914 have received the cachet of accreditation. Each year there are about 1.5 million admissions to the unaccredited remainder. Worse, in Cher-kasky's opinion, accreditation standards are so low as to be meaningless.
Hospitals are big business. Yet according to Jerome Pollack, professor of medical economics at Harvard Medical School, they are a prime example of gross mismanagement. Hospitals are run by boards of trustees, made up mostly of businessmen, who would never dream of running their own corporations the way they try to operate a hospital.
The first objective of most hospitals is to operate in the black. For generations, U.S. hospitals achieved this by paying little or nothing to interns, residents, student nurses and "nonprofessional" help. Social justice has caught up with the hospitals and found them totally unprepared. They have to pay interns and residents halfway decent salaries ($9,000 to $12,000 in some areas). What has hit them hardest is the demand of scrubwomen, kitchen help and janitors to be paid what is called a living wage. Most U.S. hospitals are grudgingly raising the pay of this nonprofessional help to $1.60 an hour, though in New York and California the rates are nudging $2.50 an hour.
With the reduction in shift hours and the demands of better care, the ratio of hospital personnel to patients has soared from about 145 employees per 100 patients to 260 per 100 in the past 20 years. With mounting labor costs, up go hospital room rates. Hospital administrators stand aghast at this; yet in all too many ways it is their own fault. Dr. Leona Baumgartner, a former health commissioner of New York City who is now at Harvard, can cite chapter and verse to show how hospitals have consistently lagged behind reality and then reacted in a "Who--me?" way. When the baby boom of the late 1940s was aborning, says Dr. Baumgartner, she got calls early every year asking for her forecast of the prospective birth rate-from diaper services, baby-clothing makers and baby-food processors. "Would the hospitals call?" she asks rhetorically. "No! The doctors did nothing, and the hospitals did nothing to meet a predictable demand." It was the same, says Dr. Baumgartner, with the mandated wage increases: "They were caught flatfooted when the minimum-wage law was applied to them."
In a Madison Avenue spirit, hospitals play games with words. Blue Cross and most other insurers pay for a semiprivate room. In many hospitals, this may turn out to be a room with four beds, making it a demi-semiprivate room.
Occupancy rates are as important to hospitals as to hotels. Counting the overhead, it may cost the hospital upwards of $40 a day to maintain a semiprivate bed even when it is empty. It costs only about $3 to $5 a day more when the bed is occupied--that being the charge for the patient's meals. But an empty bed earns nothing, while an occupied bed earns dollars. Therefore, while virtually no surgery is performed on weekends, it is common practice to admit surgery patients on Friday. That keeps the bed filled, profitably for the hospital, until Sunday, when the patient gets his first dose of medicine to prepare him for Monday's workup in preparation for Tuesday's operation.
Much more that is done to the patient in the hospital is scheduled with no consideration for him. What the medical staff intends as superefficiency seems, by the time it explodes around the patient, merely frenetic, and is highly discomforting. "They woke me up to give me a sleeping pill" may be an apocryphal com plaint. But it is still common practice to awaken a patient at 4 a.m. in order to feed him one of his countless, multicolored pills, and perhaps again an hour or two later for a thermometer reading or a hypodermic shot. These universal complaints, though seemingly petty, are symptomatic of the depersonalized atmosphere of too many hospitals. Equally distressing is the noise, which makes sleep or even rest far too difficult.
Motels Motels and and Half-Half-Way Way Houses Houses
With rare exceptions, every commu nity medical hospital and is an surgical empire staffs in itself. demand -- Its and get -- costly equipment and facilities for their exclusive use, regardless of whether another hospital down the block already has them lying idle two-thirds of the time. In Miami, the VA hospital has a $100,000 linear accelerator for the radiation treatment of cancer, but Cedars of Lebanon Hospital is installing its own. Neither will be used at any ners" where in near Los capacity. Angeles, At on North "hospital cor Ver mont Avenue and Sunset and Beverly Boulevards, are four cobalt-60 radiation units, also for cancer, where one, or at most two, would do.
Hospital planners have been arguing for years that the crisis-care hospital for the acutely ill patient is only one part of the complex that is needed.
There should be, they say, a motel-type unit to which a man can drive his own car when he goes in for a checkup, where he can live like a healthy human being and go to the cafeteria for his meals, merely following his doctor's diet instructions. At the other end of the line, there should be a halfway house for patients not quite ready to go home, who still need some, but not 24-hour, nursing care, and who can fend for them selves in a dining room. The planners have not proved very persuasive. Hos pital administrators give lip service to the idea, but little more.
Countless hospitals have been and still are being built in the wrong places for the wrong reasons. Under the Hill-Burton Act of 1946, any hamlet could raise hospital of matching 20 to funds 30 to get beds -- itself and a too tiny many did. These are not only uneco nomic but bad for medicine, says New Orleans Surgeon Alton Ochsner: no hospital with fewer than 100 beds is medically viable, and he suggests that none should have more than 600.
A basic trouble with today's hospitals is that, like today's doctors, they have been geared to crisis care. In fact, says Palo Alto's grand old man, Dr. Russel V. Lee (father of Philip and other M.D. Lees), 30% of the patients in a hospital at any one time should not be there. Either they have been admitted for what are really diagnostic procedures, to gain insurance coverage, or they are past the acute stage of their illness and should be in some sort of convalescent or other extended-care facility, in which the costs would be 40% or 50% less.
Singing the Blues
When the idea of voluntary health insurance for the U.S. germinated in the 1930s, the actuaries insisted that whatever was covered must be quantifiable, so that it could be priced. They hit upon hospitalization as a tangible item, and Blue Cross was born. But definitions of hospital costs are so complex that ever since, while it has expanded into 45 states, Blue Cross has been involved in haggles with state insurance departments over rates.
What Blue Cross will reimburse varies from state to state, and within states, according to what plan the subscribing group has chosen. Some Blue Cross plans in the West cover in-hospital doctors' bills, a function generally reserved in the East for Blue Shield. Whatever its limitations, Blue Cross was such a success that commercial insurance companies soon tried to emulate it.
The trouble with all the early coverage, by both "the Blues" and the commercials, was that it was not health insurance, although it was widely misrepresented as such. It was, and to a great extent remains, sickness insurance. Far from putting a premium on preventive medicine and the maintenance of good health, it puts a premium on sickness. Until recently, most Blue Cross plans covered no care outside a hospital, and specifically excluded diagnostic procedures. The result has been connivance to defraud the insurers. Often if a woman needs a diagnostic pelvic examination that might better--but need not necessarily--be done in a hospital, her doctor enters some meaningless diagnosis such as leucorrhea or dysmenorrhea (which practically every woman has now and then) and plunks her in the hospital for two days. The insurance pays virtually all the hospital bill and, if the family has coverage of the Blue Shield type, the doctor's bill as well. To Mark Berke, director of San Francisco's Mount Zion Hospital, the system "puts a premium on being a horizontal rather than a vertical patient." Says Surgeon General Stewart: "For episodic care of the middle-income class, the Blues do a reasonably good job. But there simply aren't enough benefits --for office visits, for drugs outside the hospital, for a lot of things. Overall, the Blues still pay only about 35% of an insured's medical expenses. And for chronic illnesses, even the fully insured subscriber is in trouble."
However broad the Blues and commercial health-insurance companies may become, they are still likely to suffer by comparison with prepaid group-practice plans on two key issues: hospitalization and surgery. In 1966, the Blues tallied 876 patient-days in the hospital per 1,000 subscribers (excluding maternity cases), while the group-practice plans had only 408. Blue Shield subscribers had 73 surgical procedures per 1,000, while the groups' subscribers had 31. For tonsils and adenoids the disparity was still greater: 8.4 v. 1.9.
Now both the Blues and the commercials are being crowded by Medicare. Despite the long years of angry controversy that preceded its enactment, Medicare has caused no upheavals in medicine generally. Hospital admissions of oldsters have increased, in most areas, by no more than 5%. True, hospitals that used to do much charity work--and treated their patients as charity cases--are losing these patients to voluntary hospitals. For the first time, they have a choice.
Physician's Assistants
Less than two years ago, the A.M.A.'s then president, Dr. Milford O. Rouse of Dallas, sputtered against what he considered the heresy of regarding medical care as a right rather than a privilege. "Today," says Walter McNerney, president of the national Blue Cross Association, "it is firmly accepted that no one is going to be without care who needs it. That battle is over." The questions then are: How shall it be delivered? How will it be paid for? And how good will it be?
There is a growing consensus that the best method for delivery is "the satellite system." At the center of each system would be a university medical school with its affiliated hospitals, or some medical center like the Mayo Clinic, which may not be part of a medical school but has equal standing. The first ring of satellites would be community hospitals. The second ring would be community health centers, some along the lines of the Office of Economic Opportunity centers now operating in such disparate places as Boston, Mass., and Mound Bayou, Miss. (TIME, Nov. 29). These centers could have their own satellites; in areas where distances are great and people are few, they might be manned by a "physician's assistant," a new breed of paramedical personnel with skills and training equivalent to those of medical corpsmen in the Armed Forces.
To get satellite systems into their proper orbits, regional planning is a necessity. A few areas have voluntarily begun such planning. For the rest, says Houston Surgeon Michael E. DeBakey, it may be necessary for the Federal Government to set rules and enforce them. One area plan has been started by the University of Oklahoma without such prodding and will cover the state. Its clinics, like one now operating in Wakita, will have three doctors: a general physician, a pediatrician, and one for obstetrics and gynecology. With three men on duty, one of them can always get away for vacation or refresher courses. They will have ready access to the medical center's battery of specialists. The three doctors agree to stay for a specified number of years. The citizens of Wakita and surrounding Grant County put up $500,000 for a 27-bed clinic and a 24-bed nursing home.
Staffing the satellites remains a problem, and the "physician's assistants" are probably the best solution. These men and women can replace doctors in some areas, and everywhere they can relieve doctors of time-consuming detail work. Much of this work, from filling out case histories to drawing blood specimens, they can actually do better than many a doctor. Duke University is the pioneer in training physician's assistants. It has 31 in its current two-year class, and will soon enroll 50. Three other schools have followed suit, and 50 are getting ready to do so. The numbers are still small, but if the experiment works, they can be rapidly expanded.
With added personnel, the U.S. annual bill for medical care will continue to go up, but more care will be delivered in return. How to pay for it will remain a problem at all levels. "All or virtually all Americans are now medically indigent," says Economist Pollack. "Health insurance for all has become a necessity." Dr. Philip Lee says: "The Federal Government will have to fill in the chinks of the private system. Private insurance does fine during the years when people are employed, but it doesn't do well for the aged or the unemployed. The Government must fill those needs." Before last November's election, Lee's former boss, ex-HEW Secretary Wilbur Cohen, had on his desk a plan to extend Medicare to provide "crisis care" for all Americans. Some suggest extending it to children, to the handicapped, and perhaps to all the indigent (Medicaid having proved to be no more effective than a bread poultice in most states). McNerney is pressing all Blue Cross plans to broaden their coverage. A practical man, he notes that merely shortening the average patient's hospital stay by one day would save well over $1 billion.
From Passive to Active
U.A.W.'s Reuther, once reviled but now widely lauded for boosting health insurance by building it into union contracts, keeps saying that he will soon announce plans for nationwide health insurance, but has offered no details. Senator Edward Kennedy is on record as favoring, in principle, some such proposal. No serious student of the U.S. medical scene believes that the nation is ready for--or would accept in the foreseeable future--a system like the British National Health Service. All current proposals envision the perpetuation of free enterprise in medical care--but a more responsible free enterprise system, with which the Federal Government and the states could enter into mutually profitable partnerships.
The voluntary programs are expected to predominate. There is increasing clamor from consumers for release from their passive, captive role and for an active voice. One who will support them is San Francisco's Berke, president-elect of the A.H.A. The association, he says, will soon set up a national consumer forum, and Berke would like to have it include not only representatives of con sumer groups like labor unions, but housewives and other individuals who have been through the medical mill as both patient and parent.
One of the most hopeful signs of change on the medical-care horizon comes from the young men and women who, three or four years from now, will be supplying much of that care as interns and residents. Across the continent, New York's Cherkasky declares, there is now "a substantial number of medical stu dents who don't put economics above everything else. These young people want to find in their profession a social commitment as well as a decent living. These kids are marvelous. They're even beginning to force changes in the curriculum.
They don't think that molecular biology is more important than people."
Family Medicine Men
Another promising development was announced last week in Chicago. For years the American Academy of Gen eral Practice has been campaigning to have its branch of the profession rec ognized as a specialty -- despite the con tradiction in terms. Now, after many commissions and conferences, the A.M.A.'s Council on Medical Education and the Advisory Board for Medical Specialties have granted the G.P.'s plea and agreed to let the generalist become a specialist in "family medicine." The A.A.G.P.'s president, Chicagoan Dr.
Maynard Shapiro, made it clear that no G.P. will get the exalted rank with out earning it. There will be no grand father clause for automatic certification of present members. Each G.P. will have to put in at least 300 hours of ac credited postgraduate study to earn it.
Said Shapiro: "The new family phy sician will be a family counselor in sick ness and in health. He'll be trained in both the art and science of medicine.
He'll have training in psychiatry, psy chology, sociology, cultural anthropol ogy and economics in order to deal with lems." all Added aspects of Shapiro: the the patient's family med prob icine man will bring back "the com passion of the oldtime family doctor."
Doctors are given to claiming that medicine is both an art and a science.
The fact is that until a half-century ago it was virtually all art with scarce ly a modicum of science. Recently it has become virtually all science, and whatever art remains has often been ob scured by materialism and poor orga nization. Today not only disgruntled pa tients but also a growing body of opin ion makers and activists in public life and in medicine itself recognize its short comings -- and know that they can be remedied. It will take time for the emer gence of a better-organized system for the delivery of medical care. It will take even more time for the new types of family physicians and medical grad uates to make their mark on the na tionwide practice of medicine. When they do, U.S. medicine may yet, in fact as well as in cliche, become the world's best.
-In an average year, patients bring 150 complaints of fee gouging against the 7,200 members of the New York County (Manhattan) Medical Society, and 25% of them win remission or reduction of the fee. -Only 31 states reported revocation of license proceedings for 1967. These states had 469 cases in which 208 licenses were revoked. No fewer than 148 revocations were for nonpayment of license fees. Violation of the narcotics laws, including self-addiction, with 13 cases, and abortion, with ten cases, were the only causes relating to medical practice. -About 5,100 of them are operated as nonprofit institutions and awkwardly called "voluntary"; the rest, concentrated in California, New York and Texas, are proprietary hospitals, frankly operated for profit. Excluded from these figures are all psychiatric and federally supported institutions.
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