YOUR DOCTOR IS NOT IN - Healthy Skepticism about National Health Care, by Jane M. Orient, MD, Crown Publishers, Inc. New York, 1994, xii & 176 pages. $23.
Dr. Orient, a practicing internist, teacher, and administrator for the Association of American Physicians and Surgeons, has a clear vision of where medicine is heading and where we should be heading. Without fanfare or even a preface, she opens with a glossary. These five pages define terms and gives examples so there is no question or dispute of her message. Capitation (Kopfausschale) is payment by the head regardless of how much service the physician does (or does not) provide. In agriculture, the same thing would be achieved by paying a farmer by the acre no matter how much corn he grew (rather than payment for not producing). Practice guidelines: instructions on how to manage certain medical problems in ways approved by the government or some other authoritative body; the AMA's solution to high costs and variable quality.
Chapter I: "What to expect from this book" would otherwise be labeled a preface. Dr. Orient says this book explains where we are, how we got there, and where we ought to go; it is a road map, not a panacea. The main point of the book, she says is, "I cannot and will not prescribe a detailed 'plan.'" She proceeds to define principles, but does not tell people exactly what to do, "without becoming little tyrants. That's how the free market that I advocate is so different from other proposals. It just sets up some basic ground rules and lets the players determine their own strategies for the game. For example, I will advise people to buy true (catastrophic) insurance, but I will not try to define a basic package."
Orient does not agree with Congress that medical training programs should produce a specified 50% proportion of "primary care" physicians. We don't know how many of each specialist we need, but neither does anybody else. As an internist she says she used to be called a diagnostician. Patients may ask internists for a prescription after telling their complaint. However, a competent physician first makes a diagnosis. And to do that, we must first take a history and do a physical examination. She feels that most of the books on medical care and the bills passed by the legislature, offer dangerous treatment based on faulty diagnosis. Sometimes an internist actually learns more from examining the patients shopping bag of medicines than from examining the chest. We may be suffering from the side effects of prior treatment, according to her.
Orient defines the heart of medicine is the relationship of one doctor to one patient. In medicine, as opposed to a "health care delivery system," the training and experience of the physician are placed at the service of a sick person, under conditions agreeable to both. In medicine, the patient is at the center of the universe. The hospital, the CT scanner, the pharmaceutical industry, all the appurtenances of modern diagnosis and therapy, should revolve around the patient, not around the heads of the "system." Why should we be subordinate to and ruled by a giant national monolith? Maybe decentralization is our strength, not our weakness. She does not pretend to show that a free market in medicine would be a utopia. There is no utopia. She only maintains that a free market is the best of the available alternatives and the one that does the least harm. Free market does not mean anarchy or lawlessness. Quite the contrary. Free enterprise is governed by the laws of economics. Like the law of gravity, and unlike acts of Congress, the law of supply and demand cannot be repealed, she says.
Dr. Orient covers a lot of topics in 18 chapters including practice guidelines, medical policing, regulations, and what is a doctor worth. Her attitude can best be summed up as she recounts how her colleagues are cynical and bitter by saying, "Don't feel sorry for me, because I am very fortunate__it's the patients you should worry about." She says we must return power to its rightful holder, the patients; create true, not "managed," competition; and restore the primacy of the physician_patient relationship.
Maybe she's for medicine what Allan Bloom was for education. Instead of back to basics, maybe we should move forward to basics. It's certainly must reading for any physician who feels helpless and hopeless.