Severed Trust: Why American Medicine Hasn't Been Fixed
George D Lundberg with James Stacey
Basic Books, £18.99, pp 336
ISBN 0 465 04291 0
Rating: 4/4
In this magnificent insider's account,
George Lundberg explains how American medicine got into its current mess
and offers suggestions for its resuscitation.
Lundberg has spent 50 years in medicine,
from premed student mopping operating
rooms in a country hospital to editor of the
Journal of the American Medical Association
and now editor in chief of Medscape, a leading internet site.
Trained as a pathologist when medicine
was changing from general practice to
specialisation, he has worked in large and
small hospitals across the United States, as a
doctor in the US army, as head of pathology
at a major teaching hospital, and as a
professor at leading medical schools. For 17
years he edited JAMA, which he raised from
trade journal to member of the international big five.
Lundberg: offering an unusual solution (AP PHOTO/BEBETO MATHEWS)
"Part of a medical editor's job involves
getting into hot water," he writes. He
describes how, under his editorship, JAMA
began theme issues on tobacco, violence,
nuclear warfare risks, and alternative medicine. It published papers on deaths and injuries from medical errors, violence as a public
health issue, gun control, use of illegal drugs,
therapeutic touch, addictions, and the physician's role in easing the death of terminally
ill patients. These peer reviewed papers produced headlines, and anger and praise from
doctors and the public. He was fired for
publishing a paper that showed American
students didn't think oral sex was "real sex,"
during President Clinton's impeachment.
Lundberg explains how American medicine declined from profession to business,
why many doctors have lost joy in their work,
and why the public views them as moneygrubbing white coats who call sick people
"cases." Beginning in the 1950s, medicine
became more sophisticated and expensive.
For employers, health insurance was tax
deductible, and patients paid only a small
amount, so who cared how much it cost?
US legislators expanded the National
Institutes of Health, set up the Veterans
Administration hospital system, provided
funds for hospital construction, and enacted
Medicare for the elderly and Medicaid for
the poor. Lundberg laments that doctors
ended their historic obligation to provide
charity care because someone would prob
ably pay for it. New medical schools opened,
new doctors graduated and - surprise - they
entered specialties, especially those caring
for the elderly. Costs soared. Autopsies, a key
to quality control, fell close to zero.
Procedures such as bone marrow transplants for advanced breast cancer were
demanded without clinical trials proving
whether or not they worked.
To control costs, Lundberg explains,
employers embraced managed care organi
sations that "cherry picked" companies with
young, healthy employees and raised rates
for small firms where one employee had an
expensive illness. They did not pay for clinical trials. Today, 44 million Americans have
no health insurance. All the health insurance industry does "is collect money, keep as
much of it as possible, and dole out as little
as possible," Lundberg writes.
How can this broken system be fixed?
Lundberg has an unusual suggestion not
proposed, as far as I know, by any other US
health expert: the Singapore Solution.
Through a payroll tax, everyone would
receive free preventive care proved by scientific trials: childhood immunisations, cervical
smears, mammograms. Everyone would be
covered for traumatic situations requiring
hospital care. Other care would be optional
and paid for by the patient.
Lundberg calls for national standards
and licensing (which is now state by state),
more public information about doctors'
malpractice and disciplinary histories, and
an independent body (not a doctors' trade
association) to provide leadership. He
suggests the Institute of Medicine of the
National Academy of Sciences. He says all
this will take time. Wish him luck.
Janice Hopkin, Tanne medical journalist, New York
studentBMJ 2001;09:217-260 July ISSN 0966-6494
