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The Medical Triangle.

The Medical Triangle

The Medical Triangle. Eli Ginzberg. Harvard University Press, $27.50. America's health care system seems to be coming apart at the seams. While inflation has hovered between 3 percent and 4 percent in recent years, medical costs have risen at nearly triple that rate. In 1989, total health care spending exceeded $620 billion, or 11.2 percent of the GNP. Credible projections put this figure at about $1 trillion by 1995, or close to 15 percent of the GNP. That compares to just $13.5 billion, or 4.7 percent of the GNP in 1950, when Dr. Marcus Welby was setting up his practice.

More shocking still is what we're not getting for this money: Half our citizens who live in poverty are not covered by Medicaid. An estimated 37 million Americans, most of them members of working families, have no health insurance. Infant mortality in the United States is higher than in at least a dozen other countries, including Chile, Singapore, and Hong Kong.

Many of Eli Ginzberg's observations in this book of essays are hardly new. Most of this material was previously published in medical journals over the past few years, and like many academics who know their subject well, Ginzberg often lapses into jargon ("modalities of treatment") and seldom attempts to enliven his essays with anecdotes or personal observations. Still, those who hunt will find thought-provoking nuggets that raise issues well suited to further journalistic inquiry. Two chapters, "The Politics of Physician Supply" and "The Reform of Medical Education," are particularly good.

Throughout this century, Ginzberg notes, fierce debates have raged within the medical community about the supply of doctors. The infamous Flexner Report of 1910 is known to students of health care policy as a watershed in the "professionalization" of American medicine. It called for much higher standards, to be accomplished by closing a number of substandard medical schools and reducing the number of doctors. The American Medical Association strongly supported the report, and the effect was dramatic: In 1905, 160 medical schools produced 5,606 graduates; by 1922, there were just 81 schools producing 2,529.

In 1932, the AMA-financed Commission on Medical Education noted that the United States still had more physicians per capita than any other country in the world. In urging further reductions in the number of physicians, the report struck a note that sounds surprisingly contemporary: "The present oversupply of physicians in this country is likely to lead to unnecessary services, to a lowering of the quality of medical care, and to excessive costs because people are not able to judge their needs in such a highly technical field as medicine."

But, as Ginzberg details, these efforts at professional birth control did not prevail. After World War II, a series of prestigious commissions warned of an impending "physician gap." Fueled by massive infusions of federal aid, medical school enrollments soared. Thus, 20 years after World War II, officials of the AMA had converted to the new prevailing orthodoxy; the more physicians, the better our medical care.

But in the seventies, another potential crisis suddenly loomed: a projected "surplus" of physicians. In 1980, the Graduate Medical Education National Advisory Committee issued a report concluding that America would have more than 70,000 physicians by 1990 and almost 150,000 by the end of the century. Indeed, if current trends continue, by the year 2000 the number of physicians per capita will be double the total in 1950.

This is more than just an intriguing numbers game. As Ginzberg suggests, the oversupply of physicians cannot help but affect health care costs. He notes, for example, that between 1970 and 1986, America's physician-to-people ratio increased from 146 to 220 per 100,000. Yet physician income, measured in pretax, constant dollars, stayed virtually the same, because, according to Ginzberg, "in most market areas, as in most fields of specialization, established physicians are able to influence both the demand for their services (by encouraging return visits by their patients) and their incomes (by raising their fees)."

Physicians doubtless will respond that this is a gross oversimplification, and there's truth to that. In fairness, there are other factors at work. For example, the fear of malpractice lawsuits has also encouraged the "Call me if you don't feel better" style of practice to give way to the "Come back next week for a check up" approach.

In "The Reform of Medical Education," Ginzberg challenges another orthodoxy: the training of physicians. Notwithstanding the increasing complexity of modern medicine. Ginzberg believes that medical students today spend too much time in academic training. Most of them, he notes, spend three years in medical school, and then at least two more in specialized medical education.

Ginzberg makes a strong case for eliminating a full year of training. At the heart of his argument in his observation that despite a 1:1 faculty-to-student ratio at most medical schools, faculty more and more engage in private practices that provide them and the medical schools with income--but do little to enhance the education of medical students, who therefore get less hands-on instruction in basic practice. The result is increasing specialization. And in general, the longer medical students stay in school, the more debt they incur. This in turn intensifies the trend towards lucrative--and over-subscribed--specialties.

There is one major point in Ginzberg's essays that I strongly dispute. Sophisticated--and increasingly expensive--medical technology is raising difficult questions about who shoudl and shouldn't get medical care. But Ginzberg doesn't believe the public wants difficult choices to be made. He predicts that medical care could consume 15 or even 20 percent of our GNP before public officials confront these dilemmas.

Should we spend $200,000 of our Medicaid funds for a liver transplant with a 20 percent chance of success or invest the same amount of money in prenatal care for 2,000 infants? Like Ginzberg, all of us would rather do both, but too often that's difficult. It's not a question of whether we ration care--we already do that, in subtle, behind-the-scenes ways--but on what basis we should make those decisions.

My own experience suggests these difficult questions are already hard upon us. The Oregon legislature--of which I'm a member--approved a law last year that will probably have the effect of denying certain marginally effective procedures to some Medicaid patients in return to extending scarce Medicaid dollars to 77,000 citizens who now have no health insurance at all. We didn't do this out of indifferences to human life but as an acknowledgement of the cruel reality that resources for health care are truly limited.
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Author:Keisling, Phil
Publication:Washington Monthly
Article Type:Book Review
Date:Apr 1, 1990
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