THE OPEN MIND
Host: Richard D. Heffner
Guest: Sen. Edward Kennedy with Dr. Malcolm C Dodd, Dr. John Knowles, Dr. Irwin Page, and Dr. Louis Lasagna
Title: “Health Care in America”
Good evening. I’m Richard Heffner, your host on THE OPEN MIND, where today we discuss a subject that most frequently is approached only from a darkly apocalyptic point of view. Indeed, “crisis” seems to be the term of choice in discussing our topic, which is Health Care in America. Perhaps because we Americans revere the healing arts quite so much, perhaps because they give us life and help until the last grim moment of necessity to preserve it, we hold them, medicine and its practitioners, in awe. And perhaps for that very reason we are quite so discomforted to find that the medical machine has its shortcomings and failures, that it does not, cannot work daily miracles in the delivery of health care, and that medical men, alas, have feet of clay even as you or I. The point can, of course, be made that by any standard at all over the past decades we have gone extraordinarily far in developing the principles and practice of health care, and in delivering it to ever-larger numbers of Americans. Diseases that took such a heavy toll of human life and spirit just yesterday seem now like relics of a dim past. In our generation, we have used the term “miracle drugs” for good reason. For pharmaceuticals have performed miracles for so may of us, and hopefully we are providing the conditions for continued research and innovation in this field. Similarly, from preventative medicine to surgery to rehabilitation we have gone further than most utopians could have prophesied or even prayed not long ago. Yet with every medical advance we understandably ask for more, for more and for better, which is, as it must be for the eternally optimistic American, that which may now be posing for us problems we haven’t had to deal with before, and which we may not be able to deal with in traditional ways. Here is the doctor’s dilemma, and to be sure our democratic society’s dilemma. For simply to demand more and better at this stage of our development as a nation may not be enough. A historic, optimistic expansionism that simply assumes that more means better may be unrealistic today. There may now be limits upon what even our miracle men of medicine can do to provide the ever higher quality of medicine we assume is our birthright in the ever greater quantity we demand, and at the same time continue to research for the future. Something may have to give. We may be faced with the tradeoffs that plague mature societies as they plague mature individuals. Unfortunately, too much of the discussion of this quantity/quality dilemma has been emotional and anecdotal. Too much has been aired only in an adversary or political context in the continuing struggle to produce national health legislation. Well, perhaps an open mind can do just a bit better today.
First, for just a few minutes, we’ll report the answers of the President-elect of the American Medical Association, and of Democratic Senator Edward Kennedy of Massachusetts when we asked what they would like us to keep in mind when considering health care in America. Here now is a videotape of Senator Kennedy’s reply:
KENNEDY: Well, first of all, many aspects of the health care that we have in this country is really the best in the world. We’ve won more Nobel Prizes in biomedical research than perhaps any other country in the world. Many of our medical centers provide, I think the best medicine of any place in the world. But we haven’t won any Nobel Prizes for finding ways to deliver this quality health care to all Americans in all different parts of our country, to all Americans whether they’re poor as well as if they’re rich. There are probably too many Americans that are waiting in clinics and hospitals to try and get care for their children. There are too many Americans both in urban areas and rural communities that are unable to get attention at all. And too often there are instances where people can’t really be sure that they’re getting the quality of health care that they think that they’re receiving.
And so what I’m hopeful that we in the Congress can do, working with the medical profession, is to try and develop a health care system which means that we’re going to provide for all Americans quality health care at a price that they can afford to pay. We want to build upon the soundness of the American medical system, but we want to make sure that those Americans who live in our major cities and those that live in our rural communities are going to be able to receive quality health care. In many other different parts of the world, countries have been imaginative and medical associations have been imaginative in trying to develop systems which get people either to hospitals and make sure when they’re at those hospitals that the first question that’s asked to the patient is not what kind of insurance you have but how sick you are or how sick your child is, and can make sure that when a mother has a sick child and takes them to a clinic that they’re going to receive a quick and expeditious treatment and not have to wait for a great deal of time to get a taxi and then pay a good deal to get across to a hospital and then have to wait again for a good many hours.
So this is what I’m hopeful we can achieve: good, quality health care at a price that the American people can afford to pay. That is really the essential part of a quality health care system. We’re going to need the support of the American people in developing the adequate manpower for that system. We’re going to need the support of the American people in developing alternative ways of delivering so that we can have competition in delivery systems so that the best delivery system will survive. We’re going to want to make sure that we’re going to have support of the American people in making sure that we have quality in the delivery as well as quality in the type of medicine that you receive. And we’re going to want the support of the American people in developing a financing mechanism. So it isn’t just the very rich that can afford the very best, but they’re going to need their help and their assistance in developing one system. Not a system for the rich and system for the middle class and a system for the lower middle class and another system for the poor. Because then what that makes is inferior medicine for Americans, and we want to be able to develop the best system for all Americans. So I’m hopeful, as this debate continues in the Congress and the Senate of the United States, that the American people will read about it and study it and indicate to their congressmen or senators that they believe that it’s important that we’re going to provide for American people, working with the medical profession to the extent that we possibly can, quality health care as a matter of right of all Americans.
END OF TAPED EXCERPT
HEFFNER: We also asked the American Medical Association for a videotape statement on health care in America by the AMA’s President-elect, Dr. Malcolm C. Todd of Long Beach, California.
TODD: As a physician engaged in the private practice of medicine, and as a doctor who takes care of people, I would like to discuss health care in its proper perspective. Much has been said, and a great deal has been written about health care in this country over the past several years, and frankly, all of it hasn’t been too accurate. For instance, there certainly is no health care crisis in this country. Our system is not verging on collapse or anything close to it. Every survey and every poll that has been taken among the American people returns the same answer. At least 85 percent of the people are satisfied with the health care they receive. This is all subjective evidence. But there is objective evidence as well.
Americans generally have been growing healthier with each passing generation. In fact, with each passing year. We are living longer and longer. A record of 71.2 years at the present time. Our infant mortality rate has dropped 27 percent in the last decade. And we’re no longer plagued by epidemics of measles, smallpox, and polio. I cite these figures not in a sense of complacency, but to give perspective. A crisis atmosphere creates distortion. Crisis psychology encourages solutions that often do more harm than good. Well, we do indeed have unmet needs in our health care system in the United States. Some very serious ones, in fact. But the health care system generally works, and the quality of care is the highest in the world. Whatever we do to improve things ought to begin from those two things.
What then are our problems that we must address ourselves? It is true that some Americans do not receive the care that they should, because it is out of reach financially or geographically. There is a misconception that various laws or legislation or health care systems can make health care cheaper. But costs in health care are like costs in anything. They are simply a reflection of expenses. Costs of medical care have gone up for a multitude of reasons. Take general inflation, sophisticated medical equipment and facilities, even better pay for nurses and hospital personnel that was so necessary. And yet, the cost momentum created by federal programs of Medicare and Medicaid have all been responsible. Unfortunately, the illusion is sometimes created that government health care is free health care.
There is also no such thing as cheap health care unless you want to accept poor care. We really can do very little to reduce the cost of care without reducing the quality of care. What we can do is to keep costs of care from being a barrier, and we just see that it is unnecessary that the costs that arise are avoided if possible. To eliminate the financial barrier, some type of a national heath insurance program should be enacted. The question really is what type. Some of the insurance plans now being considered in Congress could in themselves become terribly expensive. Some of them try to be all things to all people. But some income levels and some physical conditions are more in need of national health insurance than others are.
According to the AMA’s own national health insurance proposal, called Medicredit, it is scaled to need. Americans would buy this coverage largely through income tax credits instead of paying new taxes or more taxes.
Next, how can unnecessary costs be avoided? A major answer is to end the needless hospitalization that results from lack of insurance coverage for home health services. Therefore, any national health insurance program that is adopted should cover home care.
I mentioned lack of physical access to care, and there are ways to relieve that too. More family physicians are being produced, particularly since 1969 when family practice became a specialty. Such doctors, working in multi-specialty group practices in neighborhood health centers and regional health systems will do much to bring more care to more people. In addition, the AMA has a bill before Congress to establish patterns for world heath care delivery.
So, I repeat, let us see the health care situation in perspective. I urge this to clarify the solutions. And believe me, there are practical solutions that will serve both the quality and the quantity of care without hurting you, the patient, or his alter ego, the taxpayer.
END OF TAPED EXCERPT
HEFFNER: Now let me introduce my guests who are here in the studio to discuss health care in America. First, Dr. John Knowles, formerly Director of the prestigious Massachusetts General Hospital, and now President of the Rockefeller Foundation. Dr. Irwin Page, world-renowned cardiologist, editor of Modern Medicine, and senior consultant at the Cleveland Clinic. And Dr. Louis Lasagna, Chairman of the Department of Pharmacology and Toxicology at the University of Rochester’s School of Medicine.
Gentlemen, suppose I begin by picking up Harry Schwartz’ book, The Case for American Medicine, not one without its biases, but who is. And he begins by quoting Ambrose Bearce’s Devil’s Dictionary, defining a physician as “One upon whom we set our hopes when ill, and our dogs when well”. And Dr. Page, as a senior physician, medical man, I wonder how you’d comment on that cute remark.
PAGE: Well, I think this is not an unreasonable thing. It’s always been so, though. People, when they’re desperately sick, naturally they turn to other people for help. Then they want the very best. Nothing is too good for them. Until they get well. And as soon as they get well, I think you’ll agree, you’re a nice fellow, but your bill is too high and, after all, a doctor’s got a lot of troubles and so forth, rather than saying, “Well, you know, you still are a good guy”. And I think this is where the trouble comes.
HEFFNER: Do you think that plays a role in the present debate over national medical legislation?
PAGE: I doubt it really. I think that that is not the major difficulty. To my way of thinking, perhaps the major difficulty is that we have – I hate that dreadful word – escalated the whole problem up into the idea that somehow we’re in desperate shape. I think you mentioned that we’re in a crisis psychology. Well, actually we’ve all been taken along doing pretty well. We know we’ve got weaknesses. Sure we’ve got feet of clay, but just as good clay as anybody else’s. So I’m not convinced that this is all that desperate. What I personally want to see is, not that we in any way become smug. Heaven knows, with John Knowles and myself I don’t think we’re ever going to become smug. At least our friends say this is right. But that we improve things as we go along and recognize that we have a wonderful heritage that we must keep alive. I think, I’ve lived quite a long time in medicine, and as I look back on it and realize that when I was an intern for instance, at Bellevue here in New York, that what we treated was typhoid fever, pneumonia, arasyphillis, syphilis, tuberculosis, things which today the youngsters never even heard of. They think that we’re making this up. And the first disease that we learned about in Osler was typhoid fever, because he thought that was the most important, I assume. So just in my relatively short lifetime we’ve changed enormously, and for all the good.
HEFFNER: Well, I wonder then, Dr. Page, if I may, I had read Dr. Knowles’, the reprint of Dr. Knowles’ piece on the quantity and quality of medical manpower. And I wonder, Dr. Knowles, whether you are quite as sanguine concerning our situation today and the delivery of health care.
KNOWLES: Well, I think at the outset, let me say, that all of us who are in the field are at times desperately interested in improving it. If we give speeches about, which I could very easily give, the latest Harris poll shows that the physician still enjoys the highest respect of anybody in American life. Now, that’s when they were all well when they took that poll, too.
PAGE: And you mentioned who was the lowest, too.
KNOWLES: Yes, indeed. And the latest poll shows that the senators and the folks in the White House and the congressmen were at the lowest end of the stick, along with American business. There’s an all-time low.
PAGE: And used car dealers.
KNOWLES: Yeah, but it’s true. Now, I’m not, I do see major defects. The major defects are the social issues of the cost of needed care, the quality of that care, and the accessibility of that care. And we’re all interested in trying to meet those major social issues. Now, let me say at the outset, conceptually that’s also the problem with education, with transportation, with defense, with any sort of human service. You can go into restaurants here in New York. Cost, quality, accessibility. Now, in terms of cost, we are spending about 83 billion, 7.6 percent of the gross national product, or roughly 450 bucks per capita per year for health in America. And that’s fine. It’s about the highest absolute as well as relative amount of any country in the world. And yet, still in all, if you balance that against our health statistics, we don’t rank first in health statistics. Now, this may have nothing to do with the medical field, by the way. It may have something else to do with the habits of Americans, their lack of exercise, they eat wrong, they’re malnourished in terms of being overweight and so on. But within that money we spend 32 billion on hospitals, 16 billion on doctors, 7 billion on drugs, and 5 billion on dentists.
Now, there have been definite studies to show, for example, this medical manpower review I made, in prepaid groups where doctors are salaried and give comprehensive services to defined consumer groups, as contrasted with solo fee for service, those prepaid groups need about seven surgeons per 100,000 population. The average in the United States is just double that: 13 per 100,000. Number two, you can show that you can reduce hospitalization and surgery by as much as 50 percent when you compare prepaid groups with fee-for-service groups. That’s why even a republican administration passed the so-called Health Maintenance Organization bill, which was to stimulate prepayment and contractual basis. May I say at the outset that I think salaried physicians are fine, but I think they need incentives just like anybody else does. If they do a better job they should be paid more. But we don’t have to get into that argument.
Now, in terms of quality. There was a study done here 12 years ago – this is just anecdotal – 12 years ago 30 percent of the uteruses removed on Teamsters’ wives were unnecessary. That’s a lot of hysterectomies, unnecessary removal of female uterus. When I was in Massachusetts the department, and sitting on the council of Public health, the State Public Health Council, there were five times as many tonsillectomies done in one part of the state as another on comparable population groups of youngsters. Now, that means one of two things: either too many in one part or too few in the other. Whichever it is, it’s not good.
Now, in the case of unnecessary hysterectomies and unnecessary tonsillectomies, nothing has been done, except the so-called Bennett Amendment to the Social Security Act which established the so-called professional standards review organizations or mandated it through federal legislation. Many of us think that it’s going to take three or four years to get those things going, and everybody’s upset about it, and I’m not so sure what it’s going to prove anyway. But the fact…Now if you get to accessibility, you get people still living in rural areas, and both Senator Kennedy and the new president of the AMA both agree that there is a problem of accessibility, both in inner cities as well as rural areas. Now, certainly that doesn’t mean that any of us think that we’re going to hell in this country. I think our health services are fine for the majority of the population. But there are defects in cost containment, quality, and accessibility. And there are plenty of things that can be done. When you get up to this expenditure of money, it’s all very good to extol the virtues of 70 or 80 percent of what we do, but those of us in the field – and this is not a measure of age, by the way. Dr. Page raises just as much hell as Dr. Lasagna or me –
KNOWLES: And even more. But we’re all anxious to improve it. Any professional group is.
HEFFNER: What is the common denominator in the business with hysterectomies and tonsillectomies? Prepaid medical insurance?
KNOWLES: In some of the Kaiser Permanetti studies, which is a form of prepayment, and also the federal employees’ health benefit plan, it isn’t just the Kaiser plan; it’s been shown under the federal employees’ health benefit plan, the Puget Sound group. In addition, a number of groups have shown in comparable population groups that surgery and hospitalization are reduced significantly.
Let me make another point. It’s been shown in some studies that if you get a second consultation before recommended surgery to you or me, if we ask for a second consultation, you would reduce in comparable population groups the incidence of surgery by about 20 percent.
HEFFNER: What does that say about your profession, Dr. Knowles?
KNOWLES: It says a number of things. As far as I’m concerned, it still says that as professional groups go we’re doing well, far above average, but we’ve got a long way to go. And in the case of unnecessary surgery and hospitalization, quite frankly, it means that there are three problems. And it isn’t all just money-grubbing, by any means. Avarice is the root of part of it. Ignorance is the second root, which is almost worse than avarice, because it can do more harm. And the third one is expediency. If you do what you can with a patient in an inaccessible area you may have to go ahead and remove something that you’re not sure of. So it’s a combination of all three. And many of our efforts, whether it’s in continuing education, the use of two-way television…Graduate courses. Do you know the medical profession, as far as I know, is the only professional group in this country that’s even mentioned the business of relicensing themselves in the public interest? I think that’s a plus. They haven’t done it yet, but I think it’s a great plus. The legal profession ought to do it. We won’t get started on the American Bar Association.
HEFFNER: (Laughter) Not on this program.
KNOWLES: A lousy lawyer can do just as much harm in some ways as a lousy doctor.
HEFFNER: You mean there’s going to be a competition to see who can do the most harm?
KNOWLES: I think we’ve got lots to do to improve ourselves in the public interest.
HEFFNER: Well, let me ask Dr. Lasagna. Dr. Lasagna, you wrote a book some years ago called The Doctors’ Dilemmas. And if we made this quantity/quality matter a major dilemma, where do you come out on it? What’s your won point of view about where we go fro here, indeed, where we are?
LASAGNA: Well, I would hope that we are moving not just towards equality of health care. Sometimes own gets the impression that there are some folks who, if everyone got the same level of quality regardless of how good that care was, that that would somehow be a wonderful achievement. Well, I admit that would satisfy some people, but if we achieve equality of care at the expense of quality, then I think we’re moving in a backwards direction. As far as what the public wants to achieve in this area, it’s clear to me that, as in all other aspects of life, we’ve got to engage in cost benefit analyses. And this is something that the public has to end up doing, and not the profession. It’s the public that has to decide. Often they are not given the choice of deciding. But it’s the public that ought to be deciding, for example, whether we have grade crossing or not. If you want to avoid deaths at grade crossing, you have railroad crossings that go over highways instead of crossing them. You know that there’s a certain number of deaths that occur each year from that kind of corner-cutting. Now, there’s an expense involved in that. There are lives that are lost whenever you put up a skyscraper, but society has made the decision that the cost benefit analysis is in favor of putting up skyscrapers. And I think the same thing applies to health care. We cannot do everything we want as a society. We have to select our order of priorities. And I hope in selecting those priorities that we don’t lose sight of the fact that one of the things we badly need to make headway on this quality end of the equation is research at all levels. I’m not talking just about fundamental basic research, trying to accumulate the building blocks for progress, although God knows we need those very badly in so many areas of health where the diseases, the mechanisms of the diseases elude us. But we also need to do research on the quality of health care. Just what is it we are delivering? Where are we deficient? Why are we deficient? How can we correct that? That’s why these suggestions that people are making now about monitoring the quality of health care, evaluating it at, where the action is, I think are highly to be commended, and I only hope that they are done in a sensible way without getting either paranoid or hysterical about it without trying to create a great crunch overnight.
Many of these things that are being done suboptimally are a result of pressures of various kinds on the physician, for example. If a doctor is averaging 15 minutes a visit in his office, and someone comes to him with a psychosomatic disorder, I think it’s somewhat perverse to suggest that extensive psychotherapy be picked, even if it had been demonstrated that that worked better than drugs, that that is to be preferred over the prescription of a psychotropic drug of some sort. I’m afraid often people fall into this trap of saying, “Well, if we don’t do it the perfect way, then let’s avoid any approach to it”. And that might be called the bite the bullet school of therapeutic neglect in regard to providing a drug to the public. I think actually the compromise often turns out to be not all that bad. If psychotherapy at an extensive level isn’t available, for example, for treating the multiple psychosomatic complaints that come into a doctor’s office, the proper use of drugs that are reasonably effective and reasonably safe, I think, is not a bad compromise.
HEFFNER: Yeah, but the strange dialogue that seems to go on continues to be whether one does it one way or the other, whether one goes one on one in psychotherapy or uses drugs. Are you suggesting instead that no way can we meet the psychological problems of our time or the psychiatric disorders with a one-on-one approach?
LASAGNA: Oh, I think it’s extremely difficult at this moment in history for a one-on-one approach to psychiatric illness. There’s just too much emotional stress in the population. It’s not clear to me exactly how one would go about on a one-on-one basis dealing with the stresses of everyday life, for example. Sometimes one feels the answer to that would be, change the world, that would be the answer, not so much a psychiatrist or a physician doling our psychotherapy or advice that can’t be heeded anyway, like “Go to Florida, change your wife, change your job, change your life”.
KNOWLES: Well, that’s true, Louie, but one of the classic studies was Redlich and Hollingshead, which showed that social and economic class determined whether you got put on the couch an hour a day, five days a week for five years, or whether you got a pat on the back and a few tranquilizers. If you were poor, you get that, if you were rich, you get put on the couch. Now, you and I know there’s no scientific evidence that says either one of those methods are better than the other.
KNOWLES: So the point there is some people know they get the pat on the back and the tranquilizer, the other guy says, “I’ve been on the couch for five years on Park Avenue” or something. So the public then gets confused. Well, where there’s no science, there’s mischief. And one thing we need is much more rigorous scientific research in this whole field of mental illness. And a lot of this isn’t mental illness; it’s social disease generated by the Watergate, by the Vietnams, by the lousy housing, the transportation, the unemployment, inflation, the interdependence of the work, nuclear warheads, the misuse of the mass media, and so on. Things that are massive social issues which I think today if you could resolve all those you’d probably do more to extend the happy lives of Americans than any doctor will ever be able to do.
PAGE: But how do you think we ever got tarred and feathered with this? The thing that bothers me is that I have to agree with everything you say except that, not really. The point is that we banter or we toss around all these ideas about the use of behavioral sciences, the psychiatric approach and the couch and this and that and the other, and yet when you try to get it down to reality, what are you really going to do about a patient when you’ve got maybe ten minutes to see him because you’re got 40 people you’ve got to see? Are you going to say, “Well, we’re going to have 40 doctors see these people”? Another approach that’s promised is that we’re going to have a team see them. You know, we’re going to have a psychiatrist, an anthropologist, an economist and so forth, they’re all going to see them. Now, will you tell me how in the world, if you had a team seeing all these people that you really have to take care of…
PAGE: And they don’t want a team to look at them; they want the doctor to look at them. That’s all they came to see; not a team.
KNOWLES: Well, that’s true, Irwin. But you know, there have been studies showing how much unnecessary, almost non-medical work a given doctor’s doing. There are experiments not…
PAGE: I think there’s no question of that.
KNOWLES: …to try to screen that out…
PAGE: I think there is, but…
KNOWLES: Other types of so-called paramedical people see them…
KNOWLES: …or the use of questionnaires…
PAGE: That’s right.
KNOWLES: …and screening, and they get to you and you and the patient can do what you’re supposed to be doing…
PAGE: No, I’m not, I agree with you. I think the use of paramedical, that is, to find ways of increasing the effectiveness and efficiency of a doctor. So I think there’s no question that that is desirable if you can do it without getting into trouble with the law, the malpractice problems.
KNOWLES: That’s true. That is true.
PAGE: It’s a very complicated…People say it’s an easy way, but it isn’t easy, because for instance, when you have a helper, you’ve got to remember that you are legally responsible for what that helper does. And that creates possibilities of malpractice. Then that leads, of course, to so-called defensive medicine, where you do everything in order to defend yourself against possible suit. And that’s no way to approach medicine at all. In constant fear of a lawyer. As far as I’m concerned, if I had to practice medicine in fear of a lawyer, I’d let the lawyer practice it.
Now, a second problem that bothers me is that we would like to turn a lot of these problems over to the public. And yet, when you say, “Who is the public?” Well, they say that’s a person who is a consumer. Well, they consume health, which is one of the neater tricks of the week, I should say, consuming it. But the thing that bothers me is that we really don’t know who the public is. Is it somebody that happens to be put on a committee as a representative of the consumer? Is that person somehow supposed to represent all of us who are in the public? I don’t see how you decide who the public is. The public is just a sort of an amorphous group, and if you use the term, particularly if they agree with you, then you say the public demands that such and such is the case.
LASAGNA: Irwin, a lot of the reasons that we’re in trouble, that we are expected to give more than we can possibly deliver seems to be that we…
PAGE: Yeah, I think this is.
LASAGNA: …engage in holding actions…
LASAGNA: …and the surgeons cure some people and the infectious disease people cure an occasional person. Most of the time we’re engaged in making people more comfortable, and as I say, engaging in holding actions, because there’s nothing more than that we can do given the available information we have.
PAGE: Sure. But that’s, I think, the function of all of us who are in research, is to provide and provide better means of doing things, and if they’d let the research people alone for a while so that they could do their research, not worry about politics all the time, they’d be a lot happier and they’d get a lot more work done.
KNOWLES: Absolutely. Now, let me try another on you, Irvin, because I know your own interest in the field. In the last several years we decided we’d pass federal legislation for the exorbitant costs of, and realistically so, of renal dialysis. In other words, when your kidneys go back on you you have to get on a machine and get the blood washed constantly and it costs 20, 30, 60,000 dollars and so on a year or every two years. Now, at the same time, for years, at least I was taught, and you correct me, recent evidence shows that if you detect high blood pressure in its incipiency, early on before it gets too advanced, before it affects your kidneys and your kidneys go bad, at which point you get into the hospital and get on the machine for $20,000 a year, if you detect that and you have exercise and weight reduction and salt restriction in your diet and some of the newer drugs that you can definitely reduce the morbidity and mortality due to high blood pressure.
KNOWLES: Now, right here in New York City there’s over a million black people, and high blood pressure is particularly common in black people. There was an estimate here by the Department of Public health that as many as 30 percent of those black people might have high blood pressure. Now, the thing that disturbs me a little is that so many of our decisions have been after the fact acute curative. And we do very well with that. And I ran an acute curative institution and proud of it. But here is an example of passing legislation to take care of the end result of a disease, one type of disease, where you might have spent even less money to do health surveys to detect high blood pressure on some mass-screening basis. Am I right or wrong?
PAGE: Well, I think you’re reasonable. You’re not wrong. I think you have to put the whole business in its proper perspective. You remember the time when hypertension and arteriosclerosis, hypertension was considered a good thing for people. That is to say that your blood pressure was elevated in order to pump blood through thickened blood vessels. Now, that was a great idea, because we didn’t know how to lower it. So that settled that problem.
PAGE: The problem of arteriosclerosis was the problem of senescence, of old age. And everybody said, well, you had to get old, you had to die from something. Now, believe it or not, when I went through medical school at Cornell, we did not see a heart attack. And fortunately my generation didn’t have heart attacks in those days. Very nice. And yet, Harold Pardee was our professor of electrocardiography, and I never saw a heart attack. And people don’t believe that I used to have lunch with Dr. Harrick at the Drake Hotel who first described a heart attack. Now, you realize that, so my life has subtended both arteriosclerosis, heart attacks, and hypertension. And I struggled along. To begin with, nobody wanted to study hypertension. That’s the reason there was nothing. Fortunately we got the cures or the treatment for hypertension long before we knew what it was all about. I mean, what causes it.
KNOWLES: But Irvin, do you agree that there could be more emphasis for the future if we’re worried about cost, for example, more emphasis on early detection, prevention, and some forth of health education?
PAGE: Sure. Now, this is what they’re trying to do now, is the government is involved. The problem is that when you take on such a massive program of literally something like 21 million…people are candidates for treatment. Now, the question I’ve been asking all along is: Who’s going to treat 21 million people?
HEFFNER: What’s your answer, Dr. Knowles?
KNOWLES: Well, in the first place, I think that within certain limits you can set a certain pattern of care for large numbers of people with a little elevation of blood pressure.
PAGE: Right. And this is what you’re doing in dialysis. You see, there you’re coming up against, as you mentioned, this very expensive business both in human endeavor, to run our dialysis clinic takes an awful lot of expensive people.
HEFFNER: But I wondered whether Dr. Knowles was asking the question: Do we do this? Do we use a preventative approach instead of concern…
PAGE: Can we let people die with…
HEFFNER: I’m not following through. I’m asking Dr. Knowles what the alternative…
KNOWLES: Well, I don’t think any of us would take the alternative. I…
PAGE: No, no, I don’t think anybody’s going to do that…
HEFFNER: Can we do both?
KNOWLES: Yeah. I think we can…well, actually, in many ways we are doing both with large segments of the population now. But the thing that disturbs me still and all is the high priority put on terminal, degenerative diseases in our society. And philosophically we are guilty, you know, life at any cost in the United States, vitalism, salubrism and so on. There’s been some good articles about the American way of death in recent times which points out our whole culture just won’t contend with the issue. As Irvin Page says, you save everybody from what’s going on now, they’ve got to die sometime of something.
HEFFNER: Well, what’s the alternative?
KNOWLES: The alternative is to put more stress on prevention and health education, whether it’s in research or whether it’s in health services, in the structuring of them.
HEFFNER: Now, may I ask this follow-up of this question, because I need to be clear in my own mind. Are you suggesting that this be done in addition to the massive efforts that we make to preserve the lives of people who are suffering in this way, or are you suggesting that we have to shift the priorities because we really, when you really get down to it, we can’t be in two places at the same time?
KNOWLES: Okay. I’ll give you a good answer to that. It’ll never happen. You know, we spend about 85 billion on health in this country. We spend 85 billion on education, public and private, and we spend 85 billion on defense. The world spends 250 billion on defense. I’d say let’s take 3 billion out of the defense budget and give it to health for prevention on top of what we’re doing now.
HEFFNER: Okay. Then the next question that I would ask, and I would ask…
KNOWLES: I can find it elsewhere too. I could raise the sales tax around the country by half a cent. I’ll also give you the figures on booze, liquor, and movies and so on.
HEFFNER: Okay. But isn’t this part of that same optimistic notion on the part of the American people that by gosh, if we would just shift our priorities just a quarter of an inch we could do this and that? And I had the feeling earlier in this program that you gentlemen were suggesting that perhaps we can’t do that, perhaps there’s a limit, given the numbers of physicians, given the medical resources. And I’d like to ask…
PAGE: Well, I think you touched a point that we all recognize. That is, there is a limit to what people will take. For instance, it’s all very well to prescribe. But when doctors proscribe they start forbidding things, and they usually proscribe when they don’t know what to do. In other words, if they don’t know the cure for a disease, they give it a fancy name, they call it essential hypertension. And then they say, “Well, you shouldn’t eat too much red meat”. And you say, “Why?” “Well, I don’t know why, but you just shouldn’t”. Now, this is the kind of foolishness that did go on. This fortunately, I think we’re gradually getting over it. I think thought we do have to face a cultural situation, and that is that people still feel very strongly about letting anybody die. I’ve just been reading Stuart Alsop’s book. And when you realize what an enormous human effort has been spent in treating just one man. Now, he’s a fine man; I’m not criticizing that. But I’m just thinking of the enormous expense, since he’s an NIH patient, is just in the preservation of this one man’s life. We’ve got the same thing in renal dialysis. This is a tremendous expense. And yet we can’t come to the point where we just simply say there’s a law that says we can’t treat more than this many people. So what are you going to do about it?
LASAGNA: But we can’t put all of our money on prevention, because even in the field of hypertension, where we now know, I think, that the adequate use of drugs, if the patient is diagnoses early enough, will delay certain kinds of vascular complications, will not prevent all of the complications of hypertension. There’s not much evidence that coronary disease, for example, is ameliorated or prevented by such drugs. Furthermore, in treating hypertension you have the problem that if the patient is early in the course and essentially asymptomatic, the patient isn’t sick until he starts treatment. Then he’s taking a drug which makes him dopey or makes him feel faint or makes him impotent. And the doctor is happy because the blood pressure cuff shows that the blood pressure has come down. So the sphygmomanometer, the blood pressure cuff, is in great shape, but the patient is complaining. And sooner or later many of these patients stop taking their medications and drop out of view. So there’s a human failure which no amount of money, no amount of professional beefing-up of personnel is going to solve.
HEFFNER: Would it be unfair…
KNOWLES: But that applies to some of them, but not all of them. And if you and I were running around with a blood pressure of 160/120 and feeling great, I personally would want to take the chance of all these things that could happen.
LASAGNA: Sure. I would too. But a lot of people don’t make that judgment.
KNOWLES: Well, that’s true. But let’s get back on this business of hospitals and doctors and unnecessary hospitalization and surgery, a part of which is due to the lack, for example, of extended care facilities, chronic hospitals, and appropriate facilities for people in this country. If you can reduce hospitalization and surgery by five or ten percent, you’re talking about a saving on what is now $50 billion of three or $4 billion. Now, I know from my experience in hospitals that that can be done if the facilities and extended care are available to people. We’ve spent, we estimated three-quarters of a million dollars a year on Medicare patients. We had to keep them in the hospital because we had no place to send them, no chronic hospital…
PAGE: Why have people been so reluctant to accept the halfway house type of thing? The only thing I can think of is that the city fathers usually refuse to allow you to use a motel. Now, we’ve just had a clinic inn built. And we wanted it first for the patients’ families so that we could get them out of the hospital. And then after we began putting more and more patients in there the city said, “No, you can’t use that”.
KNOWLES: Well, part of it is because everything that was acute and interesting was arrogated to acute hospitals in the private sector, and everything that was chronic and dismal and uninteresting was left either to proprietary interests, profit-making nursing homes, or to state facilities, chronic hospitals. In Massachusetts the taxpayers wouldn’t build any more chronic hospitals.
The other thing, in answer to our question, it is complicated, but there are definite savings within this system where you could allocate more money for the necessary research and detection and prevention, to say nothing of some forms of health education programs. Where’s another area? The school health system of this country is abysmal.
HEFFNER: You mean medical education?
KNOWLES: The school system, from…
HEFFNER: I see. Excuse me.
KNOWLES: …from the first day they get there. Usually the powers have appointed some crony of theirs who passes through five minutes a week and pays no attention to anything. There are areas there where improvements can be made. You see, it takes a lot of these changes to save that money to use it more…
PAGE: A lot of these are political, they’re semi-political things. For instance, the school system, to try to change that is almost impossible, if you’ve ever tried. Just try if your own children…
HEFFNER: I, again, I thought you gentlemen were both talking about medical education.
PAGE: (Laughter) That’s in pretty good shape.
KNOWLES: Well, now, this is just…
LASAGNA: Well, the question is…
HEFFNER: Excuse me. Dr. Lasagna?
LASAGNA: The question is whether medical, how much medical education you can give kids. I don’t really know. I sometimes wonder. You know, when you see the dreadful things they eat, all these snacks and butter and the whole kit and caboodle, it’s unbelievable when you look at it from the point of view of nutrition and from the point of view of their ultimate coronary disease.
KNOWLES: But Irving, even if they were told that…
PAGE: I don’t think they’d pay any attention to you.
KNOWLES: Well, we can at least try…But nobody’s told them what you’ve just said. All they hear is Madison Avenue beaming 16 different kinds of lousy food at them all day long.
PAGE: Every time I tell them, John, I find I’m telling them in a dairy state, and I get run out practically on a rail.
HEFFNER: I’m going to come back a third time and make a pass at medical education.
PAGE: At medical education itself.
HEFFNER: Yeah, I meant in the medical schools.
PAGE: In the medical schools, yeah.
HEFFNER: Satisfied? Dr. Page, if you were emperor, you ran the zoo, what would you do? In fact, that’s the question that I would like to put to each of you. Here we’re dealing with what is proclaimed a crisis, or it always will be, you said, Dr. Page, and it probably will.
PAGE: Always will be.
HEFFNER: All right. Crisis or no crisis, there are things you must want to see done. And if you did run the zoo, what would you do in this whole area of health care?
PAGE: Now, you’re talking about just the medical schools?
HEFFNER: Start there. Very briefly, what reforms, changes – “reform” is a poor word – changes would you see take place in health care in this country?
PAGE: Well, now wait a minute. We have to tighten it down a little bit. If I were to go to medical school, what I would do – and I think both these gentlemen are going to die when I say this – but I really think what should be emphasized is much more about the humanist approach to medicine for the average practicing doctor, so that he behaves himself as a human being and as a figure that people can turn to in trouble. That’s one thing. I think the second thing I’d like to do would be to get a good deal of the professional research out of the medical school and into professional research organizations, and that makes all deans absolutely livid with rage. But I think really it does belong there. And as a longtime research worker, I feel strongly, that research can get along perfectly well without medical teaching, not that it’s necessarily desirable. But I think there comes a point when medical research begins to clutter the process of teaching of teaching doctors. And I cite as an example the Rockefeller Institute as a prime example where there was not teaching at one time. For the record, I looked at the record…there is no institution in the world that has a record…that the Rockefeller Institute…which had no teaching in it. It’s a university now. And if I can live 30 years longer I’d like to compare the record today with what it ws 30 years ago. The point I’m making is that the medical course could be changed around a bit to bring out certain things that at least in my experience are the things that patients want.
HEFFNER: Dr. Lasagna, how do you feel about that?
LASAGNA: Well, I would hate to see research institutes take over research completely.
PAGE: Not completely. No, no.
LASAGNA: There’s a place for them. I feel that a good teaching hospital needs the patient care, needs the teaching, needs the research. As far as the training of the young doctor, I think the young medical student is today much more interested than he ever was in the past in matters about relating to medical ethics, in humanism and so forth. And I think, at Rochester at least, we turn out a pretty good product in that regard. I’m not too unhappy about the product that we turn out at the end of four years in terms of having the basic wherewithal to start practicing. I am quite unhappy about what happens after that point. I’m quite unhappy about the fact that we can turn out students who are very good at giving you a lecture on digitalis, but don’t necessarily know how to use it optimally.
KNOWLES: Well, isn’t that too much science in the medical school?
PAGE: Well, I think the answer to that is going to come not from less science in the medical school, but from more monitoring of the actual performance of medicine in its natural habitat. I think there’s a limit to what you can do in the classroom. And what we need is an attempt to teach the doctor and continue to teach him right on the firing line. See what he’s doing, congratulate him for what he’s doing properly, criticize him for what he’s doing badly, and try to get him to do better. I think that’s where the action is going to have to be in the future in terms of education.
(KNOWLES?): Yeah, but you see, I think we’re talking pretty much the same thing, but different emphasis. I have a feeling that we have gotten…Remember that at one time, certainly when I started, research ws nothing in the medical school. They didn’t have any. And anybody who did research did it at his own peril. Then it went too far the other way when the NIH, National Institutes of Health stepped in, provided huge amounts of money. Then you couldn’t be a professor of medicine unless you were a research worker, and the emphasis was too much that way. I think we’ve got to spring back now and not bring a red herring across by saying you want to abolish research. You don’t want to abolish research. I’m simply saying you want to abolish the hegemony of research in a medical atmosphere, so that the people who practice medicine needn’t feel inferior with a research worker.
HEFFNER: Well, may I quote you, Dr. Knowles, in a speech you gave late last year? “Whatever the reasons professors of medicine have by their contemporary motto downplayed the art and science of clinical medicine and the important community health measures while stressing the role of super-specialized technocrats.”
PAGE: It’s true.
KNOWLES: You see, I think he’s, I really do feel that. And all of us have sat on ad hoc committees trying to find what used to be the very symbol of everything good in medicine, the professor of medicine. He could go to the bedside, he could diagnose anything, he was a human being, and he was a scientist. And then we began to shave it, so all we could find was super-specialized idiot savants who could take care of one organ, but if they saw somebody wit a swollen knee they’d ask somebody else to see him. And so the students and the practitioners get the idea that there is nothing but idiots practicing general medicine. As a matter of fact, I used to practice general medicine, and I can still do it and would love to do it. Maybe that’s what I ought to be doing. But there is that problem. And I don’t think they’re incompatible. I think you can still not be anti-science, anti-intellectual, or anti-knowledge, while you rejuvenate the idea, clinical medicine as a scientific form of humanism. And so I do agree with, I agree with both of them. And I don’t think they’re antithetical, quite frankly.
PAGE: No, I don’t think we are either.
KNOWLES: And I’ll tell you, when you try to find them, it’s pretty darn tough.
PAGE: Well, we all know that.
HEFFNER: You say they’re not antithetical points of view. But so often during this hour there’s been this kind of general agreement. And it usually comes back to that we can really pull it all together. And I wonder again here whether there isn’t some wishful thinking going on. My assumption has been, from what I’ve heard from my fellow, former students who have become doctors, that there isn’t room for one bit more in the medical curriculum. Maybe you say that’s not true. But to the degree that it’s true, how are you going to meld these things together? We don’t necessarily need to agree here at this table. If there is a conflict on any level to any degree between the approaches that Dr. Page suggested and Dr. Lasagna suggested, then I think it ought to be faced.
PAGE: Well, I don’t think this is, again, you see, this is the crisis psychology. I think this is just an ongoing operation. And I’m not really concerned. I don’t think we’re going to blow up. We’re going to have excesses where one school becomes too scientific and too much, and they’re going to see the error of their ways and they’re going to come back the other way. So we’re going along.
KNOWLES: But the other, certainly when you and I get sick we want that super-specialist, and let’s make that clear.
KNOWLES: And if we want it, that’s what we want for the rest of the people. But there has been a drive in recent times, because of an overabundance of super-specialists, to try to find some kind of generalist who you and I could go to so he can get us to the right person or handle it himself. Now, medical schools are starting to be more interested in the production of generalists…
PAGE: Sure they are.
KNOWLES: …and family practitioners and what-have-you.
HEFFNER: Gentlemen, do you think that any of the other countries in the world have an edge on us? And I think particularly of Sweden and England. The Times did that series on Swedish…
KNOWLES: No, no. No.
HEFFNER: No? Why not?
KNOWLES: If you look at the cost, the quality, the accessibility…
LASAGNA: That’s right.
KNOWLES: If you look at the relative amounts per capita that they’re expending, I don’t think you see it much better than what we got. I know you don’t.
HEFFNER: Presumably, no individual Swede goes bankrupt because if his medical bills. Is that a fair statement? Maybe the whole nation will, but presumably no individual Swede will.
PAGE: Well, I know that in Sweden they’re complaining bitterly about going bankrupt as a result of this.
KNOWLES: That’s true.
PAGE: And you talk to many of the knowledgeable Swedish physicians and they will tell you that the way they’re going just can’t go on this way. They are really heading for a crisis.
LASAGNA: The Swedes have a more manageable problem in the sense that it’s a smaller country.
KNOWLES: Heterogeneous culture.
LASAGNA: They’ve lopped off the extremes socioeconomically. You don’t have quite as many rich people as we have, and…
KNOWLES: Or the distances.
LASAGNA: …you don’t have quite as many poor people.
HEFFNER: Well, Dr. Lasagna, going back to something you said earlier, do you think it’s possible to avoid this equation of equality with quality? This is an old American theme and…
LASAGNA: Well, I think the only way we can avoid losing the quality is for people to keep fighting and reminding folks that just giving everybody the same degree of lousy care is not what we ought to be aiming for. I’m all for those who say that the poor person should not suffer in the kind of care he gets. But I don’t want the rich person just to get as poor care as the poorest patient who lives in an inaccessible area gets. That’s to be avoided at all costs. And I think the medical profession has the responsibility to the public – not to itself – to keep hammering away at not losing the quality and not getting ourselves bogged down in massive efforts that will really not get us towards that goal.
HEFFNER: Do you think in any way in your own field or other medical fields that drive toward – poor word – socialization, equalization, is hampering what perhaps a decade ago was a more vital form of medical research, medical activity?
LASAGNA: I don’t really think so, at least not in my own environment, because I’m fundamentally an elitist at heart. I tell my medical students that I have no sympathy with those who want pass/fail courses. I expect every one of them to do as well as he possibly can. I’d like all of them to get honors in pharmacology when I teach it. So I don’t compromise with quality.
PAGE: I think one of the difficulties that has been introduced is this constant threat of federalization. This is being held over. Everything that’s being said now is the threat of government intervention. “If you fellows don’t do this, we’re going to do that”. Now, I personally, I think government has its place. But I must say that when government really gets into the business of trying to decide what dosage you’re going to have, how you’re going to treat every patient, and they’re going to provide the priorities and the guidelines, as you hear spoken almost every day in the Congress today, the statements about “We’re going to do this or we’re going to do that unless you do such and such”. Then I think that the federal government is doing things which it should not do. And I’m scared of this.
HEFFNER: Hasn’t that been said though to mobilize the doctors, not in their own defense, but to do the things they should have been doing a long time ago?
PAGE: No, because I think they really are beginning to get into the point where it’s getting dangerously close, not to socialization, that’s just a lot of words. What bothers me is the increasing paperwork, the increasing guidelines, the threat that if you give two-tenths of a gram of digitalis or you give three-tenths that’s too much because the book says you can’t do that, and that sort of thing, now, this is where I see real trouble ahead.
HEFFNER: And it’s on that note, I’m afraid, that I have to end the program. But thank you very much, gentlemen, Dr. John Knowles, President of the Rockefeller Foundation, Dr. Louis Lasagna, who is Chairman of the Department of Pharmacology and Toxicology at the University of Rochester Medical School, Dr. Irwin Page, Editor of Modern Medicine, Senior Consultant to the Cleveland Clinic. Thank you, gentlemen, for joining me today.
And thanks too, to you in the audience. I hope that you will join me again on THE OPEN MIND. Meanwhile, as an old friend used to say, “Good night and good luck”.