THE AMERICAN WAY OF HEALTH - How Medicine is Changing and What it Means to You by Janice Castro, Back Bay Books, (Little, Brown, & Company), Boston, 1994, x & 282 pages, including glossary, notes, & index, $9.95, Paperback.

Review by Del Meyer, MD

Janice Castro, senior health-care correspondent at TIME who interviews professionals, patients, and others, opens with "Ask most people what they think about the state of American medicine, and they will tell you about their own doctors, or about something that happened to them during an illness. Chances are, if they see a need for health-care change, it will be very specific, based on personal experience. On the other hand, listen to American leaders discussing health-care reform. They speak of providers. Access. Alliances. Competition. Mandates... The concepts seem impossibly complicated and remote from the experience of one sick person needing help."

She continues, "This book will help the general reader understand how the American health system works, why it costs so much... Medicine is too important, too personal, to be left to economists and politicians... After all, the health-care debate is really about life and death. It is about those times when people need help and about whether it will be there, about one sick patient at a time and the doctor or nurse who provides care... It is fundamentally a moral problem. Viewed in that light, the challenge... begins to come more clearly into focus. It is not really that complicated. We know what we need to do. We need to take care of old people... Children should see doctors and dentists. A pregnant woman should be able to check in with a doctor as the baby grows. People should not be dying in the street... Families shouldn't lose their home over the cost of coping with medical disasters. Breadwinners should not quit good jobs in order to qualify for poor people's insurance... People should take responsibility for their own health and for their family's. Children should not be having children..."

And, "If we are going to ensure that every American has access to decent health care, while also controlling the burgeoning costs, all of us must curb our medical greed. All of us must stop pretending that someone else is paying the bills. 'What do you think most people would say if one of their parents called up and said they needed a hundred and twenty-five thousand dollars for an operation?' asks one economist. 'Do you think that son or daughter would think twice and wonder whether that operation was really necessary? Of course they would. But none of us think we pay for medical care. And of course we all do.' All of us must pay our share..."

Castro then takes us on a tour de force of health-care about our country. She starts at Kaiser Walnut Creek's two delivery rooms where 4,000 infants, mostly delivered by midwives, take their first breath each year. She interviews a midwife who feels that midwives can deliver most women in tents, a practice which is prevented by organized medicine. She then takes us inside the delivery room where the midwife has a complication with a stuck shoulder. Within seconds, an obstetrician and pediatrician come through the delivery room doors and deliver a healthy infant two minutes later. Castro feels it was fortunate this baby was not born in a tent and that the pediatric ICU is only twenty steps from the delivery room.

In the next chapter, "Condition Critical," Castro guides us on a tour of hospital care. There are 827,000 Americans in hospitals each day spending $2.7 billion which is about $3,000 average cost per day. To name a few, she notes a 400% variation in hospital charges for the same care; 35% of Medicare spending is on futile care; it may take 750 tests to find one abnormal value; up to $100 billion per year is spent on unnecessary medical procedures with new ones coming along all the time and used immediately before their true value are known; charges of up to $5 per aspirin tablet. Touring through a dozen chapters including "Jackson Hole," "Why Doctors, Hospitals, and Drugs Cost So Much," "Bean Counters: Insurance and Managed care," Castro ends with the final chapter, "All the King's Horses," subcaptioned "Command economics didn't work in Russia, and it won't work here," concluding by quoting Dr. Brent James who believes that American medicine is on the cusp of change so vast that it will rival the dawning of the space age. He says, "We stand at the cross roads. We can redefine medicine and turn American health care into something the world hasn't even imagined in terms of how good it can be. We can redefine what it means to serve and what it means to be a nurse or a physician. We can achieve a level of care that has never been seen before. But if we mess it up, we can destroy this whole system... And we are at the point of decision. What we're talking about here is the profession of medicine." "It is up to all of us," she says... This book has a wealth of relevant information for us in a format that our patients can also understand.

Del Meyer, MD