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Severed Trust: Why American Medicine Hasn't Been Fixed

BMJ 2001; 322 doi: (Published 19 May 2001) Cite this as: BMJ 2001;322:1253
  1. Janice Hopkins Tanne, medical journalist
  1. New York

    George D Lundberg with James Stacey

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    Basic Books, £18.99, pp 336 ISBN 0 465 04291 0

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    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 pre-med 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.

    “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.

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    Lundberg: offering an unusual solution


    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 money-grubbing 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 probably 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 organisations 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 proven 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.

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