Medicine at the Crossroads – The Crisis in Health Care  by Melvin Konner, M.D., Ph.D, Pantheon Books, New York, 1993, xxii, 298 pp. $23; Vintage Books, with updated Prologue and New Epilogue, New York, 1994, xxvii, 318 pp, $12.

Review by Del Meyer, MD

One of our members wrote me a letter some time ago complimenting the departments we added to our journal and suggesting that I review Konner’s book.  I picked up the hard copy from my study table and started reading.  I never got far before other pressing issues distracted me.  I recently saw the Vintage paperback on the bookseller’s shelves and, with renewed interest, pursued it. 

Doctor Konner, a psychiatrist and anthropologist, states in the updated Vintage prologue, “Our nation is embroiled at last in a serious debate about the nature and quality of health care.  I find this debate trivial in comparison with the complexity of the issues; at the risk of sounding heretical, I doubt very much that the 1994 legislative process will have long-term, serious consequences…We are offered unending amusement by politicians as they reveal, day by day, their ignorance about illness and health, and their dismal misapprehension of what it is doctors…do…But America’s health care crisis is so pervasive, and runs so deep, that we will undoubtedly be grappling with it throughout the rest of this millennium…”

Konner tries to figure out why some feel there isn’t a health-care crisis. He gives us the information, he feels, to substantiate that there is a crisis.  He quotes statistical rankings, e.g.,  twenty-third in child health.  He points out the unnecessary C-sections, MRIs, and CABGs we do, and states that  we are ahead in the number of brain-dead patients kept “alive” on ventilators, the amount of venture capital invested in DNA technology, and the number of genes of unknown function sequenced every month.  Konner believes that all the ongoing reforms, including those of the current administration, will only tinker with the system and temporize, but still leave it grotesquely intact.  In his epilogue, Konner explains why he believes it will all eventually end with a single-payer health care system. 

Scanning the chapters briefly, Konner gives us his perspective of (1) “The code of silence” (old stuff with a new presentation); (2) “The temple of science” (his analysis of why a doctor who has saved the life of a hospitalized patient is still unprepared for the day-to-day care required of a primary physician); (3) “The magic bullet” (drug companies glean billions from the world market  and buy some expensive lunches, to be sure, but they pay the salaries of thousands of scientists, their laboratories, discovery of valuable drugs and Nobel Prizes, exceeding the entire budget of the National Institutes of Health.  In fact, we cannot move forward without the profit motive – greed if you like – of investors in pharmaceutical firms around the world trying to develop the “magic bullet”): (4) “Conceiving the future” (Aldous Huxley’s version of the future, which was grotesquely over-organized, but if he were alive today, he might feel we are well on our way into genetic engineering.); (5)  “Disordered states” (late nineteenth century when scientific view of mental illness began to prevail over primitive, religious ones); (6) “Life support” (need we say more?) and (7) Pandemic (a realistic view of AIDS). 

Konner’s chapter (5) on “Random Cuts” (Pantheon and Vintage are Random House subdivisions?) starts off with the story of a surgeon being honored after a long career.  The host asked him what he would do if he won the Florida lottery, which was going to pay $40 million that week.  The honored surgeon thought a while and said, “I suppose I would continue to operate.  But I would only do indicated procedures.”  Konner then discusses second opinions (and third opinions) in tonsillectomies.  Each additional opinion increased the surgical rate, not reduced them as is commonly thought.  As late as 1969, there was still a 13-fold variation in tonsillectomies nationally.  Other regional differences in this country include a 600 percent variation in total knee cap replacement, 1800 percent variation in removal of benign skin growths, and 800 percent variation in repair of an ailing hip.  Significantly, Konner also points out similar variations in countries with single-payer health systems – 900 percent variation within the 44 counties of Ontario, Canada; similar variations occur in England, Norway, and elsewhere, although the overall rate is vastly less than in this country. 

Konner has provided a valuable service by presenting data explaining why he feels a single-payer health system is the inevitable consequence after a number of failed reform attempts.  Others, seeing the same variations in highly structured government programs, would use the same data in support of how health insurance reform would most nearly match these variations with patients’ expectations.  A forum on this very issue is scheduled later this fall.