The Health Care Crisis -- One Surgeon's Critical View Stephen D. Leonard, M.D., F.A.C.S. Editor's Introduction An earlier version of this article has become a popular download textfile on Compuserve. When Dr. Leonard replied to my reprint request inquiry, in addition to graciously allowing non-exclusive reprint rights, he added a paragraph that deeply illustrates the depth of his feelings. Dr. Leonard is 47 years old. I've also been given permission to reprint this paragraph, which goes: "As you are obviously aware, everything has gotten much worse since I wrote that article. I finally couldn't stand it any more, and have abandoned vascular surgery. I calculated that if I remained as angry as I was for another ten years or so, I would be dead of a heart attack before age 60. I am now working for a cosmetic hair restoration group in Beverly Hills. It lacks the visceral satisfaction of saving lives, but it is pleasant, low stress, and safe from government intrusion, at least for now." As for the original and subsequent publishings of this article, Dr. Leonard provides the history himself: "As far as its publication history, the reference I have is: Leonard, SD. The health care crisis "One surgeon's critical view." Trends in Health Care, Law and Ethics 8: (3) 55-60. 1993. This is a quarterly journal published by the UMDNJ-Robert Wood Johnson Medical School. The editor, Russell McIntyre, Th.D. [>INTERNET:rmcintyr@UMDNJ.EDU] picked up the article the same way you did --here on CompuServe. It was also published in the monthly journal of some county medical society in South Carolina, but I don't have the reference. The president of the medical society also downloaded it from CompuServe." Steve Leonard The Health Care Crisis -- One Surgeon's Critical View Stephen D. Leonard, M.D., F.A.C.S. August 26, 1993 Updated for ShareDebate International April 4, 1994 Copyright 1993, 1994 Stephen D. Leonard All Rights Reserved Reprinted by permission of the author 8544 Burton Way, Apt. 407 Los Angeles, CA 90048 Compuserve ID: 76260,1663 I am increasingly amazed and discouraged at the tone of the present national discussion of how we are to change our health care system. Even before Hillary Clinton began her labors, there was an escalating fad to slash indiscriminately at both health care costs and physicians' autonomy without regard to the long-term results. With the new Administration, a mob psychology seems to have taken hold. While Mrs. Clinton's secret meetings continue, and as each grandstanding politician, self-righteous bureaucrat, and uninformed "advocate" tries to outdo the pronouncements of the previous one, a climate is developing which is driving today's physicians out of the profession, and will deter bright, motivated, capable, caring young people from entering it in the future. By the time the Administration, the Congress, the plaintiff's bar, the Health Care Financing Administration, the Occupational Safety and Health Administration, the insurance industry and the press are through savaging those of us who have devoted our lives to caring for America's health, the country will be dismayed at what is left of a system that once provided the best care in the world to 85% of the population, and did the best it could for the other 15%. In a few years, not only Medicare patients, but all of society will be unable to find the kind of physicians they have come to consider their "right." As election-year politicians and the new Administration's young zealots have whipped the press into a feeding frenzy over the "crisis in health care," the great majority of Americans still get expert, compassionate, prompt care when they need it. It has, to be sure, gotten very expensive; no one is prepared to settle for less than the very best and latest therapy. Overlooked in all the hysteria is the fact that health care is a service provided by people--doctors, nurses, and an array of support personnel. Whatever system comes out of the current political chaos, it will require doctors to make it work. And those doctors, one can only hope, will continue to be people with a far greater than usual commitment to their work. Despite all the facile comparisons to other government- supplied social services like education, fire and police protection, Medicine is unique. On reflection, I think the vast majority of people will want it to remain that way. Educators, firemen, policemen, all work their shifts and then go home. Doctors must be available 24 hours a day, seven days a week. If I operate on someone in the morning, and he has a problem at midnight, I am the one who needs to be available to take care of him. Quite simply, no one else knows his problem as well. No "next shift" can do it. And, of course, I am available. Despite all the publicity focused on a relatively few doctors who are very rich, arrogant, or unavailable, most of the 500,000 or so of us are not rich, are deeply concerned with the welfare of our patients, and are virtually always available. We dedicate ourselves to our patients in a way asked of no other members of our society. In return, until recently, we had the expectation of making a good living, and being free from pointless, spiteful persecution by small-minded bureaucrats. The kind of care Americans have come to demand can only come from physicians who love their work and feel a dedication to it far beyond most people's. As the attacks on us intensify, that dedication is slowly being beaten out of those of us old enough to have been driven by it; it is being replaced by bitterness, discouragement, and a search for alternative ways to earn a living. As we are driven out, we will be replaced by young doctors who never knew that dedication in the first place. They will put in their 40-hour-week at $24.95 an hour, and then go home. If you happen to come in after hours, or you are in pain, or just terrified of dying well, hey, the next shift should be along soon. Great torrents of blather have been devoted to what is wrong with American health care. Problems are real and serious. Millions of people don't have adequate insurance. Those who do pay dearly for it, or their employers do. A few doctors have been caught egregiously ripping off the system; others are arrogant, uncaring, incompetent or alcoholic; still others overcharge outrageously for procedures that are not as difficult as they once were. Eleven, then twelve, then thirteen percent of our national expenditures go to health care and related expenses (though a quarter of that is administrative costs, having nothing to do with health care). So a great hue and cry have gone up. Business, the insurance industry, the elderly, self-proclaimed experts and "advocates" all insist, the Government must, by God, do something! Led by Mrs. Clinton and Mr. Magaziner, so they will. It hardly seems to matter how destructive or ill- conceived, just so we get "change." Mandatory HMO's, "Managed Competition," DRG's, threaten sanctions against doctors who keep patients in the hospital longer than what is "medically necessary," then fine us for sending them home too soon. Play or pay, national health insurance, single payor, slash fees by 20-30- 40%, encourage "cognitive" medicine, assess fines and civil penalties against doctors who can't understand the bureaubabble spewing over them, better yet trump up antitrust charges and throw them in jail! (Can't we hang a few, to make an example of them?) Change the forms, change the terminology, change the rules, change the codes. Hire more reviewers, previewers, precertifiers, utilization managers, quality managers, administrators, assistant administrators, medical directors. Aha! Now we've got the bastards on the run! But look whom you've got on the run. The huge majority of doctors are decent, compassionate, dedicated, extraordinarily hardworking human beings who sacrifice first their youth, then their family life and free time, and ultimately, often, their own health for their patients. Virtually no one else in our society is routinely expected to give as much. Becoming a physician requires more deliberate sacrifice than perhaps any other peacetime occupation. After graduating from college, my classmates went in all directions. Many went straight into business. Some spent a year or two getting Masters degrees, or three years becoming lawyers. Some very bright, devoted souls spent four or five years getting Ph.D.'s. I decided to become a vascular surgeon, so I spent the next twelve years working sixteen, twenty, sometimes twenty-four hours a day, six or seven days a week, depriving myself of most of the joys of young adulthood, and immersing myself in other people's worst misery. In my twelfth year, as a Fellow in Vascular Surgery, I was even paid $28,000. It never occurred to me to wonder if it was worth the sacrifice--my father, whom I idolized, was a doctor, and I hoped to be like him. I loved the work; I treasured my growing ability to do seemingly impossible things to help people in dire need; I enjoyed the respect accorded even a young surgeon in training; and I looked forward to working as long as I was physically able to do so at a career from which, in return for continued long hours and constant dedication to excellence, I could expect all those benefits and a good income, as well. For it remains an undisputed fact that, in this proudly capitalist country which preaches to the world about the evils of Central Planning, one major inducement to excel remains the hope of being rewarded financially for doing so. When I first entered practice, in 1979, it seemed that my dreams would be realized. I was helping terribly sick people with skills honed during those endless years of training, and had the joy of seeing them get better, and the satisfaction of feeling their gratitude. Those who could afford to, or were well- insured, paid my fees; others couldn't, and didn't. One elderly diabetic, with more pride than money, had her daughters bring me gifts of wonderful, fiery, home- cooked Mexican food, which I treasured. As my practice grew, unlike in my training years, I only rarely worked more than sixteen hours a day, and every couple of months I even took a day, or sometimes a whole weekend off. I also, more than once, canceled long-planned vacations because some patient for whom I felt responsible had developed a new problem, and I felt obliged to be available. As I had hoped, my reward for skill, dedication, compassion, and very hard work, was satisfaction, appreciation, respect, and a good income. Finally, I confess, in 1985, I even bought a BMW. (Nine years later, it has 130,000 miles on it, and I'm still driving it.) Foolish pronouncements about "greedy, rich doctors" notwithstanding, most doctors make a good living, but are not rich by anyone's definition. Rock stars, corporate executives, plaintiff's lawyers and quarterbacks make far, far more than doctors. The average physician in 1992 had a net income of about $140,000 to $160,000 before taxes. In a world where Congressmen have just raised their own salaries to $135,000 a year plus much more than that in "expenses", and heavyweight boxing champions make $472,000 a minute, that doesn't seem excessive. No one gets indignant if a plumber charges $150 to fix a flooded basement on a weekend. Why is everyone so furious at me for charging $120 (the maximum allowed by law), for getting up and going to the Emergency Room at 3:00 in the morning to evaluate someone's life-threatening illness? Nine years ago, the regulatory juggernaut began in earnest the crusade to bring the health care system to heel. In that time, my reimbursement for most of what I do has been forcibly decreased by about 40%, while my costs for everything from office rent and salaries to liability insurance have, on average, doubled. Perhaps worse, I now have an army of vindictive bureaucrats and largely untrained reviewers nipping at my heels, and must waste many hours a week defending myself against their overwhelmingly wrongheaded second-guessing of my clinical decisions. Last year, a man came to our emergency room after suddenly going blind in one eye. The ophthalmologist and neurologist, who saw him first, identified his carotid arteries, which are the principal blood supply to the brain, as the source of the trouble and called me. An arteriogram revealed both of his carotid arteries to be over 95% blocked. His eye was irretrievably damaged, but there was a massive stroke just waiting to happen. I operated on him, and fixed both carotid arteries, and he left the hospital in a week. The local peer review agency decreed that the hospitalization and both operations were "not medically necessary," and told the patient so! We got the decision reversed after wasting many hours writing angry letters, but the patient, who had received the best possible care and had done well, had his confidence badly shaken. I could find much better things to do with my time than argue with idiots. Yet this happens day in and day out, not because there is anything wrong with the care that I and most other physicians deliver, but because the only politically acceptable way the government and insurance industry have been able to save money is by threatening and browbeating doctors. In the spring of 1972, just when it seemed it couldn't get much worse, OSHA landed on us with an astonishing--and entirely irrational--set of rules governing "biohazards." The rules are convoluted and incomprehensible, as always, but one can glean the general tone from the fact that if a soiled bandage, or a used tampon, that anyone could throw away at home, turns up in my office trash, I can be fined up to $70,000! I have not met a single physician (and we do know about health hazards, after all) who thinks that anyone's health will be safeguarded by these rules. But by OSHA's own (very low) estimate of a cost of $1200 per physician per year, they have just added nearly a billion dollars a year to our national health care bill. The corresponding regulations for hospitals, clinics, and school and industrial health offices will cost tens of billions more. Recently, an attorney I know told me that the favorite name for physicians among attorneys and government regulators is, "Wildebeest." As we've all seen on TV, the wildebeest is the large, benign, juicy animal that all large predators love to feed on. After years of having jackals and hyenas tearing at me, it is increasingly hard to focus on the lofty ideals that made me want to be a surgeon in the first place. One- on-one with my patients, if I can put the big picture out of my head, I still savor everything I hoped to enjoy about being a surgeon. But overall, I hate it. I am 46 years old, and only survive by promising myself that I will retire as soon as I can afford to. Unfortunately, that day gets farther and farther away with each turn of the federal screw. I expect derisive comments from some quarters about spoiled doctors getting our comeuppance. I am not soliciting sympathy, but rather offering a serious warning. If present trends and policies continue, no young person with the combination of qualities you would hope someday to find in your doctor, will go to medical school. All that attracted some of the best of my generation to become doctors--intellectual challenge, freedom to do the very best we knew how for people desperately in need, based on our best understanding of science and humanity, rewarded by trust, respect and, yes, financial security--is being taken from us. Indeed, applications to medical schools have dropped over the last ten years. (There has been a slight rebound in the past three years, mainly young people from tormented Asian countries, newly come to this country.) There is no reason why a smart college student should make the enormous sacrifices necessary to become a surgeon to live the way surgeons can expect to live fifteen years from now. As the word gets out, smart college kids won't even consider it. Maybe the biggest irony in all of this is that the heaviest burden of current policies is borne by exactly those physicians whom most people would select as the best our profession has to offer. Since the Federal Trade Commission, backed up ultimately by the Supreme Court, decreed that doctors could not be prohibited from advertising, a class of slickly packaged doctors has appeared, filling magazines and telephone books with expensive self-promotion unheard of since the snake-oil salesmen were banned at the turn of the last century. As the Health Care Financing Administration cuts, and cuts, and cuts reimbursement, they include further reductions to account for the cheating which they assume will follow. They then add threats of truly draconian penalties to keep us "crooked doctors" in line. Those of us who remain scrupulously honest must swallow the insult along with the reduction in fees. The more entrepreneurial of my colleagues have hired expensive consultants to find the loopholes in the ever-more-bewildering regulations, to maximize their incomes; again, those of us who choose simply to do the right thing for our patients are the ones who suffer a further reduction in income. A whole new class of "managers" has appeared, trying to teach us to think of our patients as "clients" or "customers," and to market our "product lines" accordingly. Those of us who simply want to sustain the healthy and heal the sick are increasingly treated as obsolete relics of a bygone age. A quarter of our staggering health care bill pays not for health care, but for "administrative" functions--bureaucrats and opportunistic businessmen who contribute nothing to solving the problems of the sick, but siphon off a huge chunk of the resources, as they cry crocodile tears over the size of the bill. Mrs. Clinton and the present government-business- "consumer" coalition certainly have the power to continue to abuse and humble physicians, be it for sport, profit, or out of dog-in-the-manger resentment. But if they do, they will find themselves with a health care system that, as someone predicted, will combine the compassion of the IRS, the efficiency of the post office, and the cost-cutting skills of the Pentagon. Solutions to the very real problems in health care must be found. It is vital that we find ways to address the spiraling costs and the problems of access, and do whatever we can as a profession and as a society to be sure that the care we provide is expert, appropriate, and compassionate. I do not claim to have all the answers, but would offer these suggestions as a beginning, or a basis for a rational dialog to replace the current hysteria: 1. Before we hack away at doctors and hospitals, look at the totality of health care expenditures, and trim the part that does no one any good. It is essential to differentiate between those areas within the "global budget" that have already been cut as far as they can without impacting quality, and those areas where there is still fat to trim. I submit that most doctors have experienced cuts in the last few years, deep enough to discourage them from providing the level of care that we, as a nation, want. Further decreases in their reimbursement will begin to do real damage to physicians, and to their ability, as individuals, to do what we need them to do, at all hours of the day or night. If we want an excellent health care system to emerge from the present process, we must ensure that the rewards of providing health care go to the providers--not to an array of middlemen who really contribute nothing. Though the President wants physicians to "sacrifice," a strong case can be made that we have already done so. William Hsiao, Ph.D., is the Harvard economist whose work on a "Resource-Based Relative Value System" formed the basis for Medicare's 1990 assault on physicians' incomes. In a recent, lengthy analysis of the results of that "reform," Dr. Hsiao concluded, "The current Medicare fee schedule yields too little net income to most physicians. In the long run, the Medicare level of payments would not attract an adequate supply of qualified people to medical careers unless private insurers continued to subsidize the services used by Medicare beneficiaries. It is clear that legislation is needed to correct these deficiencies." God knows nurses have never been paid half of what they are worth, and they have been fleeing clinical nursing in droves; cutting the funds available to pay them would lead to a real catastrophe. Even hospitals have done a fairly good job of reducing waste in the actual delivery of care. Where hospitals waste vast amounts of money is on the salaries and machinations of bureaucrats whose presence is mandated in one way or another by the myriad of agencies with authority to dictate how hospitals are run, from innumerable Federal and State financing agencies, to OSHA, to the EEOC, to the American Cancer Society, to the Joint Commission on Accreditation of Healthcare Organizations. That 28% of the total health care cost that goes to administration is an obscenity. Cutting that only in half would reduce health care from 13% to 11.2% of GNP without depriving any patient of anything. The government spends $300 million annually paying "peer review organizations" to scrutinize Medicare charts for quality of care. After the almost panicky response of seniors to the 1984 cut in hospital reimbursement, Congress was thrashing around to make it look as if cutting expenses would not impact on care. They hit on a scheme of vindictive nit-picking of doctors, which has little or no benefit in terms of assuring quality of care, and is horribly expensive, but does allow them to say, "See, we're getting tough with doctors who try to practice substandard medicine." In practice, hospital records are reviewed either by non-practicing nurses or by clerical personnel, and are screened against big checklists for "variations" or "quality issues." When such are identified, the physician is sent a threatening letter, giving him 30 days to prove there was no "mismanagement" or face demerits. Too many points can result in a fine or exclusion from caring for Medicare patients. To the totally uninitiated, it doesn't sound unreasonable, except that the alleged "mismanagement" usually means only that the clinical problem was complex enough that the reviewer didn't understand it. The "charges" are usually discarded after the physician wastes hours and hours educating the reviewer as to what was going on. Actually, there is a system of verifying quality of care, already in place, and it's free! As a prerequisite for certification, each hospital is required to have a complex quality assurance plan, which the medical staff must submit for review no less than every three years. As possible problems are identified, they are brought to the attention of departmental committees, usually consisting of the involved doctor's colleagues and competitors, where they are studied. Many can be disposed of, but if there is a problem, the physician involved will be brought before the committee and questioned, cautioned, or even have his privileges reduced, depending on the severity of the problem. This is done without the stupid vindictiveness of the PRO system, but it is far more effective. And, to repeat, it is free!JDoctors donate their time. The only serious impediment to the effectiveness of this system comes from the government: federal antitrust law has been interpreted to allow doctors who have been disciplined by review committees acting in good faith, to sue for monetary damages by alleging anticompetitive activities by the reviewers. Eliminating the PRO's, and strengthening the free, in- house peer review process would provide improved quality assurance, and save a third of a billion dollars in one fell swoop. There are dozens of similar examples. 2. The thing our government has been worst at doing, since the dawn of regulation, has been controlling those who break the rules without punishing the larger number who really try to live by them. Yet it is crucial that new regulations aimed at eliminating "unnecessary" tests, medication, and procedures, not place such a heavy burden on physicians that necessary care cannot be administered. Those doctors who are doing exactly what we as a society want them to do should be encouraged, not threatened and punished. The astonishing vindictiveness of the Health Care Financing Administration towards physicians has served only to demoralize us and drive a wedge between us and the people we serve. Somehow, the decency and humanity of the majority of physicians must not be ignored or trampled when government makes policy. 3. Establish a central government agency that must approve all government regulations impacting on health care issuing from the dozens of executive branch agencies. Give this new Health Policy Coordinating Agency the power to alter or reject any regulations that conflict with more pressing policy directives from the Congress or other agencies. Too often, we are whipsawed between competing bureaucratic entities; each, like the proverbial blind man and the elephant, only perceives a tiny piece of the picture and, thinking it understands the whole thing, promulgates regulations that cause terrible damage in some area its proponents never considered (or, when informed, don't care about). Thus, the recent sweeping, ludicrously excessive, OSHA regulations concerning medical waste, which will probably cost a billion dollars a year to implement in doctors' offices, and ten times that in hospitals, would be balanced against the demand for cost reduction. They might well be reduced in scope or discarded entirely. 4. Encourage an honestJdialog regarding health priorities, as only Oregon is attempting to do. If dollars are limited, the question of whether an indigent care program should pay a million dollars for a bone marrow transplant for a sad, big-eyed, dying child, should be made on the basis of intelligent prioritizing, and not tear-jerking TV shows or lawsuits. Society as a whole may decide that it does or does not want to tax itself to pay for this, or for coronary artery bypasses for ninety-year-olds, or experimental drugs for AIDS patients. But these decisions to use more or less taxpayers' money (there is no other kind) should come from legislatures with the full advice and consent of the American people, and not from dark courtrooms or TV studios. The recent suggestions that Oregon's plan cannot be implemented because it might conflict with the Americans With Disabilities Act must be eliminated by prompt corrective legislation clarifying the ADA. 5. Once we have determined what minimum level of care we, as a society, want to provide for every American, resist the impulse to decree, in the name of "fairness," that no one may purchase a higher level of care if he has the means to do so. Our egalitarian impulses are often at odds with our devotion to free enterprise, and with common sense. It would be as foolish to ban those who could afford to purchase health care beyond the universal minimum from doing so, as it would be to tell successful individuals that they were prohibited from spending their money to eat in better restaurants, live in nicer homes, drive nicer cars, or take fancier vacations, than the poorest person in the country. The best we can do in the name of fairness is provide everyone an equal opportunity to excel. Having a level playing field cannot mean assessing a six point penalty against a team any time it scores a touchdown. Philosophical considerations aside, the high end of any industry drives technological progress, and provides the engine that leads to new discoveries. If those who can afford to purchase additional health care are prevented from doing so, advances that can benefit everyone will be impeded. 6. Refrain from fatuous sloganeering about health care. Health care is not a "right," it is a valuable service provided by highly skilled people. In this free society, at least since the Emancipation Proclamation, no one has a "right" to someone else's labor. Food and housing are even more urgently necessary than health care, and they cost more than health care. In all three cases we must formulate policy to assure that they remain available in sufficient quality and quantity to meet the needs of our population, and we must then be prepared to pay for them. We must not constantly punish the people we rely on to provide them simply to cover up society's inability to plan or prioritize intelligently, or Congress' inability to accept responsibility for the results of its actions. 7. Merge Workers' Compensation coverage with general health insurance wherever both are provided by an employer. It is absurd for an employer to have to pay two competing insurance bureaucracies to fight with each other over which of them should pay for an injured worker's care. State Industrial Commissions routinely spend $20,000, and several years, on lawyers, second- and third- and fourth opinions, hearings and administrative reviews to get out of spending $1,500 on an operation that could have gotten the worker better and back to his job in six weeks. Employers should be encouraged to opt out of Workers' Compensation by purchasing a single, complete insurance package that covers employees' health problems wherever they happen to occur. 8. Severely restrict the multibillion-dollar malpractice lawsuit industry. Directly and indirectly, the threat of lawsuits adds greatly to the cost of health care. Insurance premiums alone, at an average of $15,000 per doctor (lower for some, much higher for others) cost over $7 billion per year. But it is impossible to estimate the number of times every doctor says to himself, "I'm 99% sure I already know what this scan will show, and I could just as well do without it, but I'll be damned if I'm going to stand in court and be asked, 'Doctor, did it ever occur to you to get an MRI scan?'" So another thousand-dollar test gets ordered (no, the doctor who orders it doesn't get the thousand dollars), and everyone's bills go up a little more. If it can be shown that a doctor was incompetent, or impaired by drugs or alcohol, or driven by malice, or attempted something for which he was unqualified, then it makes sense for him to have to make restitution to his injured patient. But lawsuits over bad outcomes (everyone has one, in the end, after all) are sucking health care--and the rest of the economy--dry. "Pain and suffering" awards should simply be eliminated. They can't undo the pain, and too often are simply a way to make bad luck profitable. Punitive damage awards should be eliminated as well. In the extraordinary case where a physician's behavior is so bad as to warrant punishment beyond being forced to pay restitution to an injured patient, any monetary penalty exacted should go into a general health care fund, not into the pockets of plaintiffs and their attorneys. Most importantly, all malpractice claims should be heard before permanent, expert arbitration panels, not the circus of our court system. A full-blown trial can easily cost half a million dollars by the time it's over; arbitration before a panel of experts can hear the same evidence and give a more intelligent verdict for one tenth that amount. 9. If insurance companies are to be given any role in the new health care system, restrict it to necessary management of the flow of payments to providers. Their role in the present system is patently dishonest and exploitative, and their second-guessing obstructionism is the single biggest thorn in doctors' sides. If we have resolved as a nation to spend less on health care, as close as possible to 100% of that lessened expenditure must buy actual health care. There can be no possible excuse for squandering any of it on insurance companies. 10. Except in urgent situations (AIDS research, perhaps?) direct the Food and Drug Administration to license new technology only after its efficacy has been demonstrated in studies in university medical centers, and it has been accepted by recognized professional specialty organizations. Until recently, virtually all research came out of the relatively pure intellectual environment of the major universities. In the last decade, hugely expensive technologies have been developed by corporate venture capital, with input from private physicians, with virtually no balanced, scientific studies of their effectiveness. They have been brought to market over the objections or at least the reservations of the nationwide specialty organizations, been snapped up at enormous expense by hospitals not wanting to be left behind their competitors, and only later been shown to be ineffective. (Endovascular lasers are but one noteworthy example in my own field.) We can, as a nation, provide expert, compassionate health care to all of our citizens. It will never be cheap, but we can make sure it is affordable if we approach the problem thoughtfully. The vindictive, meat-axe approach that has characterized recent policymaking can only decrease our effectiveness, divert to wholly unproductive bureaucrats money that could be saved or spent on real health care, and drive away from medicine the very people we should be trying to attract into it. It is crucial that the Clinton Administration and the Congress, in trying to redesign the system, take an entirely different tack, and provide some encouragement and reward, not to the innumerable parasites around the periphery of the health care system, but to those of us who are trying to do our best at an enormously difficult job. Those making policy today, and all the rest of us, will need caring, dedicated, expert physicians someday. How we reshape our health care system will determine whether or not they will be there when we need them. # # #