The State Of Medical Care, 1984


Much, much tougher—and the decisions are often more important. But with our advances has come yet another tricky problem. We have largely lost the ability to prognosticate—to tell you what is going to happen to you. That was not so difficult when the physician’s world was dominated by all the infectious diseases that were both acute and self-limiting. If you came to me with pneumococcal pneumonia in the old days, I could say, “You’ve got a Type 3 pneumococcus infection, and your chance of dying is 30 percent. If you do die, you’ll do so in a week, but if not you will recover completely and have no lasting effects. ” But now we’ve skimmed off all those diseases and are left with a huge burden of chronic diseases that have such infuriatingly variable courses. Take hypertension, which we mentioned earlier. If you are sixty and have hypertension, I know that for every hundred of you with high blood pressure, fourteen will get into trouble. But eighty-six will not. So how do I know whether to treat you? I have to make an educated guess—and it’s a very tough one. It is also likely to be an expensive one: the tests are costly, but so is the medication if you end up getting it. So there is an enormous amount of time and money going into the management of problems where we’re almost flying blind.

On top of that, I gather from what you have written in the past that you feel doctors often don’t follow up with their patients to make sure the patient returns to leading an effective life.

I call it paying more attention to the functional outcome of an illness. Say you’ve had a heart attack and it’s a minor one. We treat you and you go home and then we tend to let you go it alone. That’s not acceptable, to my mind. Because months later you may be still sitting at home, scared to go out on the golf course, even scared to have intercourse. You are a functional cripple, because of our not having followed up fully and satisfactorily. We’ve got to get you back to work so that you are not a loss to society. Which leads to another point: One of medicine’s problems is that it legitimizes a lot of illness that perhaps should not be legitimized.

We have about 150,000 too many hospital beds in the U.S. But trying to close a hospital generates a raft of political and social problems.

What do you mean by that?

Well, let’s say you and I each have a cold. We both know what it is. You are a highly motivated person and you decide to live right through it, so you keep on working. But I go to the doctor and tell him I feel awful. He says, “You’d better take three days off, stay home, drink lots of fluids, and take aspirin.” He has legitimized my being disabled with something that really is not a disabling illness at all. A related problem, while we’re on that subject, and an extremely serious matter, is that we are an overbedded nation.

You mean our hospital capacity is too great?

Yes, And it is very hard to close a hospital. Now there is no question that we built all those hospitals for the right reasons. After World War II we had a serious need for them. So the government passed the Hill-Burton Act, which made it possible for communities to get matching funds for new hospitals. Then two things happened. One, we overshot the mark and built too many. Two, technological developments reduced the need for such capacity. For example, we had all those beds for tuberculosis patients, but isoniazid came along and knocked all the projections out of the ball park. Similarly, we had perfectly reasonable projections of the need for mental hospitals, whereupon along came the psychoactive drugs, and instantly there were too many mental hospitals. Today the estimate is that we have a hundred and fifty thousand too many hospital beds in this country. But trying to close down a hospital generates a raft of political and social problems.

Is that because community leaders, congressmen, and so on, get into the act?

Yes, it’s worse than trying to move a cemetery. Even though your community is ten minutes from another hospital, your particular hospital is a great source of community pride, the local doctors are all connected with it, the annual fund-raising drive is a neighborhood fixture—it’s like having your own fire department. On top of that, and sometimes most importantly, it’s a matter of losing jobs. But there’s no doubt we’ve got lots of excess hospital-bed capacity.

Isn’t there any recourse other than closing them?

As I see it, our great need now is not for acute-care beds but for more humane, effective, well-monitored nursing homes or chronic-care beds. Some communities have already converted portions of their hospitals into special sections in which people can take care of themselves—where they have their own dining room and other facilities—and sometimes the funding can be arranged to make it pay. This is welcome news, because most nursing homes are out of the mainstream of national supervision. Right now we are just warehousing too many of our older population, and it’s a national scandal. The frail or dependent elderly need to be in places where qualified doctors can watch over them.

Teaching hospitals cannot give up their traditional mission of providing care for poor people, who have the toughest time getting it.