The Great White Lie.

I am writing this in Los Angeles, where I arrived yesterday from New York. I am happy to be here, not only because the mid-January temperature is 40 degrees warmer, but (and this is the truth) because Los Angeles is a better place than New York to get sick.

Don't misunderstand. Not only am I not sick, but according to my doctor I am healthier than I deserve to be. Still, I am middle-aged and overweight and lately I have been wondering, as I travel here and there, about what to do if I get run over by a taxi or fall off a hotel balcony or choke on a chicken bone--or if, God forbid, the Big One hits. As I have suspected, and as Walt Bogdanich (*) now confirms, there are some really bad placed in America to get sick. New York is probably the worst. A couple of years ago, as I began to get in touch with my mortality, I asked my friend, a New York doctor, which of that city's many distinguished hospitals I should choose in the event of cardiac arrest. "None of them," she said. "Don't get sick in New York."

She wasn't kidding. Since then, while reporting on AIDS, I have visited a number of New York hospitals in which I would never, under any circumstances, want to be a patient. High on the list is Bellevue, where you'll probably end up if you become cyanotic while choking on a chicken bone, and where you'll discover that the chicken-bone chokers have to get in line behind the hit-and-runs and the heart attacks and the gunshot wounds. There are plenty of New York City hospitals worse than Bellevue, but not many that are better. People who have enough money to buy their own hospitals (the late Shah of Iran comes to mind) seem to like New York Hospital, the teaching adjunct of Cornell Medical School. But as Bogdanich points out, New York Hospital is also where Andy Warhol died, not because of some rare affliction or inoperable complication, but because he was left unattended following a routine operation on his gallbladder (and he had a private nurse).

Here in Los Angeles my chances are better. In Beverly Hills there's the redoubtable Cedars Sinai ("We have plenty of room. Just come on over," said the calm, cheerful emergency-room nursing supervisor when I telephoned the other night to ask how things were going), with the UCLA Med Center a close second. The Los Angeles suburbs also have some first-class hospitals: St. John's in Santa Monica, Pasadena's Huntington, and Valley Presbyterian in the San Fernando Valley. After that the list gets short, and it's even shorter in San Francisco, which hasn't had a truly great hospital since French Hospital closed down. In fact, I'd try to make it to Stanford before I'd check into S.F. General, where employees frequently don't answer the telephone and often seem confused about whether a particular doctor is on the staff. Washington, D.C., where I live, has a couple of well-known hospitals that are OK (and a couple of well-known ones that are less OK), but unless I was bleeding to death I'd head for Johns Hopkins in Baltimore, consistently rated as top in the nation. Anyone wishing to know where not to go may drop me a stamped, self-addressed envelope in care of this magazine. Or buy Bogdanich's book.

The good hospital-bad hospital gamel can be lots of fun--doctors play it all the time--but as the doctors themselves are the first to admit, it's ultimately misleading. The truth is, even at the newest and best-equipped hospitals staffed by the best-trained and most conscientious staff, fatal mistakes are made with some regularity. The best hospital in the world is probably the Cambridge University Hospital in England, where patients are frequently transported from London, 60 miles away. (Tell the ambulance driver you want the "new hospital" or you'll end up at the wrong place; there is more than one hospital in Cambridge.) Even so, I remember having dinner with a group of doctors and nurses there and listening to Dr. X, a truly brilliant young physician in whose hands I would unhesitatingly place myself tomorrow, calmly describe over coffee how he had killed a patient the week before by overprescribing TPA, the anti-coagulant that stops heart attacks in progress (unless you overdo it).

No one wants to end up pushing daisies because somebody like Andy Warhol's nurse wasn't paying attention. On the other hand, doctors are human and it's hard to find one who won't admit, if he knows you well enough, to having killed the odd patient at some point in his career. But Bogdanich, a Wall Street Journal reporter who won a Pulitzer for exposing the sorry state of the medical laboratory business, is trying to tell us about something more important than the inevitability of human error in the practice of medicine. He's saying that no matter what the American Hospital Association and the American Medical Association and all those other associations maintain, the notion that hospitals and doctors are somehow deserving of our complete and unquestioning trust is medicine's great white lie.

Test tube maybes

A tour of Bogdanich's hospital begins at the nurses' station, where perhaps you're expecting to find your fantasy nurse: smart, tireless, dedicated, compassionate, equal parts Albert Schweitzer and Mary Poppins. You might actually find her, since such nurses still exist, although in ever-diminishing numbers and against all reason (considering what nurses get paid for what they have to do). As Bogdanich notes, however, more than half the big-city hospitals in this country employ, or have employed, temporary rent-a-nurses who may 1) have spent less time in that particular hospital than you, the patient; 2) never have been trained in the hospital's fundamental practices and procedures; 3) be on the short end of a 24-hour shift that started in another hospital; or 4) not be a registered nurse at all, but a vocational or practical nurse foisted on the unsuspecting hospital as a certified RN by an unscrupulous nursing agency like the one Bogdanich discovered in Florida. Or maybe Nurse Nancy happens to be a psychopatic killer; after all, a Washington-area RN was recently charged with, although never convicted of, murdering her most bothersome patients by injecting them with potassium chloride.

Not feeling quite so sanguine about that vision in white who's materialized by your bedside with a hypodermic in hand? Then climb out of bed and come visit the pharmacy, where life-and-death decisions are made every hour by employees who may be the most poorly trained and overworked in the hospital. Upstairs in the operating theater is the surgeonl Bogdanich describes who is preparing to perform coronary bypass surgery on a 33-year-old father of three. During the operation the patient will be kept alive by a heart-and-lung machine while his own heart, temporarily out of action, is bathed in cardioplegic fluid, which the surgeon has asked the pharmacy to send up to the operating room. The operation goes well, but at the last moment the surgeonl discovers that the patient's heart can't be restarted. The man is still alive because of the machine, but not for long. When no transplant can be found, he dies. Instead of cardioplegic solution, which sustains the heart tissue by temporary paralysis, an untrained clerk in the hospital pharmacy--a 19-year-old previously employed as a dry cleaner and an ice-cream store clerk--sent the surgeon plastic bags filled with glucose and water. Her fatal error is mitigated only slightly by the fact that some idiot decided to score the two solutions in the same kind of bag.

Down the corridor from the pharmacy is the hospital's laboratory, where workers just as ill-trained and underpaid as the pharmacy clerk are matching (or mismatching) blood for transfusions, testing (or mixing up) patient samples, and performing (or misreading) complicated diagnostic assays under conditions that may be at best unhygienic and at worst appallingly disorganized and dirty. Only yesterday I visited a well-regarded Southern California medical center to observe a demonstration of a new piece of equipment. On the floor next to my feet was an open container filled to the brim with bloody test tubes, swabs, and latex gloves. "Don't put your hand in there," the lab chief warned me, not that I was about to. "That's stuff from the AIDS tests we did this morning." During the demonstration the lab chief, who claimed to have a master's degree in biochemistry, couldn't seem to remember the difference between "antigen" and "antibody" (there's a big difference). Midway through, he was interrupted by one of his technicians, an unkempt fellow with two days of grey stubble on his beet-red face who might have passed for a homeless person on the street outside the hospital. The reason for the interruption appeared to be some sort of mistake that had taken place earlier that day. "No problem," the lab chief assured the tech. "The doctor gave the injection anyway, so everything's OK." What might have happened had the injection not been given, the lab chief did not say, but he clearly seemed relieved. "Would I ever get on the witness stand and testify that we don't make mistakes?" he said to me after the technician had gone back to work. "No way. But so far we've never been used."

The nursing stations, operating rooms, pharmacies, and labs at the Bogdanich Medical Center are not the only places where problems are waiting to happen. Here in the hospital's billing department, clerks spend their time searching for the precise combination of diagnostic codes for each patient that will bring the hospital the greatest possible reimbursement from Medicare, whether or not those diagnoses accurately reflect the patient's condition. And here is the hospital's discharging office, whose job is to push patients out the door the very moment those reimbursements are cut off by federal cost-containment guidelines, regardless of whether the patients have recovered. (This particular discharge office has a special section that steers such patients to local nursing homes in return for sizable kickbacks.) And here, finaly, is the office of ths hospital's chief administrator, who, rather than waste time searching for ways to improve patient care in the face of static or shrinking revenues, is putting the finishing touches on his latest scheme for "incentive payments" to doctors who send their patients to him rather than to the competing hospital across town.

A nightmare vision to be sure. But isn't the "hospital from hell" exactly what all those state and federal boards and agencies that oversee the health-care system are supposed to prevent? Bogdanic's answer is that while the regulators certainly exist, they often don't do their job. How else can one explain the New London Hospital of Elyria, Ohio, where the chief of surgery had previously lost his medical license for dispensing illegal drugs? Where the chief of staff had been charged with putting out a contract on his former boss? Where the chief administrator was a local real-estate salesman and convicted felon, and his assistant a lapsed Catholic priest who had married a divorced belly dancer named Saudi Arabia on a Mississippi riverboat? Where the resident pyschologist had done hard time for Medicaid fraud? Where the surgeon who headed the hospital's review committee had failed a national licensing exam? Where a staff physician had been charged in another state with having billed a single patient for 288 unnecessary office visits, 285 unnecessary lab procedures, and 597 unnecessary injections? Where unsuspecting patients were often brought by ambulance from hundreds of miles away? Or where, at the time he assumed office, the chairman of the hospital's board was under indictment for grand theft? The good news is that New London was discovered, eventually, for the deadly patient-packing scam it was. The bad news is that the discovery was made not by Ohio's hospital regulators but via a newspaper expose.

From the first horror story to the last, The Great White Lie is a truly terrifying book, a portrait of a health-care delivery system where the patients check in but don't check out. The question it inevitably raises is not whether the stories are true (Bogdanich's facts are documented and he is a careful reporter) but whether they paint a representative picture. Every day, after all, thousands of Americans are discharged from hospitals cured of whatever ailed them (I myself have been hospitalized for surgey three times and have survived to write this review). So it's possible that this is less a systemic indictment than simply a shocking collection of worst possible cases, tales from the crypt. In attempting to give the reader perspective, Bogdanich offers a few statistical extrapolations: In New York state in a single year, he writes, poor medical care "figured in the deaths of nearly 7,000 patients," from which he deduces that "poor medical care may be linked to 80,000 deaths a year" nationwide. Such assessments, of course, are so imprecise they are meaningless. (What constitutes "poor medical care"? What exactly does "linked to" mean, or "figured in"?) On the other hand, such factors may be impossible to measure in the aggregate, and Bogdanich points out that numbers define only one dimension of the problem.

Also in his favor is the fact that he is hardly the first to have sounded an alarm about the quality, availability, and affordability of health care. Sidney Wolfe, head of the Public Citizen Health Research Group, has been doing so for years, and so have successive squadrons of congressional investigators. Anyone who spends much time around doctors and hospitals, as I do, can't have any doubt that the health-care industry is in some kind of trouble. Finally, and perhaps most convincingly, it is harder now than ever to find someone who's recently been hospitalized, or even someone whose friend or relative has been in the hospital, who doesn't have a scary story about unattended nursing stations or understaffed emergency rooms or unwatched monitors or misprescribed medications.

While the precise extent of such failings remains unknown, one of the most disturbing aspects of Bogdanich's book is the lengths to which the health-care providers and regulators, and, of course, those who represent them, will go to keep the rest of us from becoming informed consumers of the services they provide--not just by covering up suspicious deaths and protecting incompetent practitioners, but by making it nearly impossible for a prospective patient to play the odds based on hospitals' track records. The essence of the "great white lie," after all, is the industry's denial that the odds even exist. Bogdanich writes:

Overall, hospital care remains a crapshoot for most American families. Most patients lack the research tools, for example, to learn that three open-heart units in northwest Indiana had mortality rates in the late eighties two to three times greater than some hospitals an hour away in Chicago. The federal government could provide that information to the public. It could put it in every public library. But neither President Reagan nor President Bush has done so. The same stonewalling characterized Congress's 1986 decision to deny patients access to a national data bank that collects records of malpractice judgments and disciplinary actions against doctors.

It should be obvious that the nexus of all this trouble is money. Maniacally overbuilt in response to the promise of guaranteed Medicare revenues, then left with excess capacity in the wake of mandated cost controls, hospitals are now struggling to make up the difference by fighting one another for patients and by pushing high-end elective surgeries and contrived substance abuse and "health-enhancement" programs, while discharging nonessential staff and overworking and underpaying those who remain--not the indicators of an industry in good shape. (One of the few scams Bogdanich doesn't mention is the overtransfusion of blood, which costs the patient $400 a unit. It's a hard one to spot, because nobody can fault the surgeon for transfusing a couple of extra units on the ground that "I had to keep the patient's vascular volume up." But human blood, which is perishable, comes to hospitals on a "use it or lose it" basis, and those units, which were donated for free by civic-minded citizens, represent pure profit for the hospitals and the blood bankers.)

Health to pay

So doesn't it follow that the solution to the healthcare mess is simply more money? Yes, because anyone can see that more resources are urgently required, even though it's not clear how or on what that money should be spent. Although the book he has written leads there inevitably, the question of how the health-care problem might be solved is not addressed by Bogdanich except in passing, as when he suggests replacing the current conglomeration of competing and conflicting health-care policies with one coherent national policy.

But why should Bogdanich have a solution to offer when no one else does? It seems quite enough that he has provided us with an illumination of the problem. The health-care crisis is only going to compound itself as my generation of baby-boomers moves along the wellness curve toward coronary artery disease and colon cancer. Perhaps there is no solution. Perhaps we will have to accept that, just as the drug epidemic and other problems appear to be insoluble, we simply will have to become accustomed to living in a nation where decent health care is available only to the very, very rich. But it does seem unfortunate that the nation that has the best physician training in the world and is the clear world leader in biomedical research should be unable to translate those accomplishments into affordable, first-rate health care for all of its citizens.