Newsday - March 19, 2000
Laurie Garrett

EVERY POLICY WONK shares this fantasy: Foundations shower money upon you for the research and production of your definitive book. The book, which calls for profound and large-scale policy changes, receives warm reviews but doesn't fly off the bookstore shelves. Nevertheless, a steamroller effect ensues as leaders in the field one by one stand up and loudly declare your book the answer to society's burning question.

It's a terrific daydream, rarely realized by any author.

But Kenneth Ludmerer isn't just "any author," he is America's leading expert on the history of our often chaotic system of medicine, having previously penned the best available accounts of pre- 1900 medical training in this country.

Now Ludmerer's "Time to Heal" provides two desperately needed services. First, he tells us how medicine developed in the 20th Century, only to reach the sorry state of contentious managed care that we now face. And, second, he sounds a deafeningly loud alarm about the future of medical education.

Back to that steamroller effect: Ludmerer's book was released late last year, having been underwritten by five large medical foundations. Since its release, the nation's most prestigious physicians and medical societies have sung its praises, now sounding a laudatory chorus. Only the general public seems unaware of "Time to Heal," though its writing is sufficiently riveting and its message important enough to capture any reader.

The tale Ludmerer tells is of the professionalization of doctors in America through establishment of rigorous medical education and testing programs, largely created during the early part of the just-ended century. American training acquired a unique flavor that, unlike that in Europe at the time, placed heavy emphasis on sound undergraduate scientific schooling, followed by years of both scientific and clinical apprenticeship. Key to that training were the nation's medical-school hospitals, where, by mid-century, patients were drawn from all over the world, lured by high cure rates for diseases and conditions that were elsewhere considered hopeless. Senior physicians - the stars in this picture - taught their students hands-on medicine, spending hours on individual patients and wards.

But greed is an ugly thing. American hospitals, Ludmerer argues, devoured dollars during the latter 20th Century as they transformed themselves from teaching centers to gargantuan, high-technology medical complexes. In the 1970s, America's terrible decades-long struggle with double-digit annual medical inflation was driven predominantly by hospital costs. And the costliest of all hospitals were those attached to medical schools. The Nixon, Carter, Reagan, Bush and Clinton administrations all sought ways to control medical inflation, putting caps on reimbursement rates for federally funded treatment: Medicare and Medicaid. By the 1980s insurance companies, too, were trying to force-feed low-cost care down the esophagi of the nation's hospitals.

Enter the era of managed care. All across America in the '90s, hospital chains consolidated, cut costs and set tough restrictions on both doctors' practices and time. The former limitation meant few tests could be ordered, less elective surgery could be executed and doctors - once godlike figures - had to beg permission from untrained insurance clerks to treat their patients as they saw fit.

The latter restriction is the one Ludmerer finds most dangerous: time. Commercial managed-care companies commanded their physicians to spend less time with each patient, thus managing to squeeze more billings into a single day. Eight minutes, by 1995, constituted a long patient visit.

To compete - indeed, to survive - medical schools adopted the same strategies, forming conglomerates that swallowed up neighboring clinics and hospitals, instituting managed care and grossly reducing the amount of time physicians could spend with their patients. The result, Ludmerer clearly demonstrates, has been a radical reduction in the amount of time medical schools' star physicians can spend with their students. Poorly supervised, the students are left to learn on their own, often making terrible - indeed, tragic - mistakes in patient care.

American medical schools, Ludmerer says, were in "a race to the bottom" in the 1990s, eager to grab pieces of medicine's profit pie by any means necessary. Students, once treated as society's valuable apprentices and revered future doctors, were now little more than medical factory workers. Worse, really: The students actually paid tuition for the privilege of serving as hospital slave labor.

Meanwhile, America is embarking upon what advocates claim will be the boldest medical revolution since the invention of antibiotics: genomic medicine. As scientists finish deciphering the entire human genome, pharmaceutical companies are eagerly developing products that promise to alter individual genetic fate. Complex concoctions may render all cancer truly treatable, even preventable. Heart disease, psychiatric ailments and most forms of chronic disease will be treated completely differently in 2010 from how they are today.

America desperately needs young doctors who are prepared for this new reality. Instead, Ludmerer insists, the country is producing undertrained physicians completely lacking in bedside manner or humanity, but well schooled in cost control and personal time management.

"If the United States is to retain its leadership in medicine, an understanding of the history of American medical education during the past century reveals the principles that must be followed," Ludmerer writes. "The key lies in restoring the tattered social contract between medicine and society. The medical profession must remember that it exists to serve; society must remember that it will not have good health care unless it provides the needed financial and moral support."

Before you or your loved one checks into an American teaching hospital for critical care, read this book.

ILLUSTRATION/PHOTO: Photo by Andrew R. Newmann - Kenneth Ludmerer

Laurie Garrett's new book, "Betrayal of Trust: The Collapse of Global Public Health,'' will be out this summer. She won a 1996 Pulitzer Prize for her Newsday coverage of Zaire's Ebola epidemic

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