An Editor's Diagnosis

Severed Trust: Why American Medicine Hasn't Been Fixed, by Dr. George D. Lundberg, M.D., with James Stacey. Basic Books, 371 pages, $26.00.

"Remember, the job of a medical journal editor is to shed light, ... to be the conscience of the profession." Dr. George Lundberg got this kind of advice from fellow medical editors and medical school deans when he assumed the editorship of the Journal of the American Medical Association (JAMA) in 1982. "In other words," he concluded, adding his own spin, "an editor who is doing his or her job correctly is getting into trouble all the time." Aware that all but one of his predecessors had been fired or otherwise pressured to leave, he nevertheless used his powerful perch for 17 years to publish rigorous, peer-reviewed studies exploring the breadth and depth of America's health care system--looking at costs, quality, and access, as well as more unusual subjects, such as boxing, Joe Camel, and ancient Chinese healing practices.

Lundberg was brought down in January 1999 after publishing a scientific study in the midst of President Bill Clinton's impeachment trial showing that 59 percent of college students did not regard engaging in oral sex as "having sex." This was seen as an improper interjection of the journal into partisan politics. Ironically, he notes, "the Monica Lewinsky affair resulted in the loss of my job, but not Bill Clinton's."

While we may regret that the results were not the reverse, we can appreciate Lundberg's accomplishments in Severed Trust, a "medical memoir" that seeks to diagnose our health care system's key ailments while taking readers on a fascinating ride through his own medical career and editorship.

Lundberg succinctly addresses the question of "why American medicine hasn't been fixed" in his title for the first chapter: "The Enemy Is Us." Insurers and HMOs, pharmaceutical giants, hospital administrators, government officials, patients, and detached employers--"all played equally malign and benign roles... . Everyone wanted the best, but unhappily everyone's self-interest led them on to the worst."

Higher health care costs have been one result. "Each group not only contributed to this wild skyrocket ride, but often did so with the best of intentions... . The bottom line is that no one has been accountable for managing the cost of care," Lundberg notes. His first three chapters provide a sweeping survey of the tripartite problems of costs, quality, and access--a useful account even though at times it rambles and sways with shaky generalizations. For example, he blames the rising prices of pharmaceuticals solely on direct-to-consumer advertising by drug firms--but the run-up in drug costs began well before the 1997 loosening of Food and Drug Administration restrictions and can be pegged at least as much to the broadening of insurance coverage for prescription drugs and the hugely increased use of such drugs over the past decade.

Lundberg's key target, though, is the physician community in general and his former employer, the American Medical Association, in particular. His proposed remedies focus first and foremost on physician behavior. He urges a return to professional autonomy and responsibility, in which doctors are more attentive to patients. Yet at times, this seems naive in light of his own characterizations of physician behavior: "Why do people think that too many doctors are in it only for the money, and that their idea of self-regulation is to charge as much as they can get away with? Unhappily, these perceptions exist because too often they are true... . When the American Medical Association talks about quality, what it really means is letting doctors do and order whatever they wish, and thereby letting them make as much money as they can." What to do about it? Lundberg is short on specifics. He urges his colleagues to forgo physician-owned labs, for instance, but he doesn't say how they are to be persuaded to surrender this lucrative sideline.

Lundberg also makes a case for "national standards based on scientific knowledge and expertise" that would lead to "my dream scenario, [in which] the government would pay for all scientifically proven preventive medical services." But agreement with that admirable principle is treacherous in implementation--witness the near-death experience of the Agency for Healthcare Research and Quality by Congress in 1995. Orthopedic surgeons blasted the agency for producing guidelines discouraging surgery for acute lower back pain; in return for its survival, the agency abandoned efforts to design such strict practice protocols.

Beyond the need for better physician practices and national standards, Lundberg's prescriptions are familiar: rein in the business of medicine, ban direct-to-consumer drug advertising, and eliminate for-profit health insurance companies. And beyond that, he seems to retain the same hope in historical inevitability that he expressed in his well-publicized 1991 JAMA editorial "National Health Care Reform: An Aura of Inevitability Is Upon Us." His current forecast is similar: "The probable scenario is that a government program, similar to Medicare, will be established for all U.S. residents within a decade of two. The push will come not from liberal legislators but either from the flame-out of insurance companies or from employer support for such a national system." Those who subscribe to inevitability theories will be pleased; the rest of us will be hungry for more.

While his overall survey and recommendations may not quite succeed, Lundberg offers plenty of cogent and compelling observations to satisfy experts and nonexperts alike. The middle chapters explore controversies about alternative medicine, the role of the Internet (Lundberg now runs Medscape, a leading Internet medical source), boxing, assisted suicide, medical errors, and tobacco (Lundberg published the study showing that more kids could identify Joe Camel than could identify Mickey Mouse).

Particularly powerful is his indictment of the medical system for abandoning autopsies. As a pathologist, Lundberg speaks on this issue from an authoritative position. In the 1950s and 1960s, between 50 percent and 70 percent of hospital deaths resulted in autopsies; today's rate is about 10 percent--and zero at many hospitals. "Lack of autopsy is the ultimate cover-up in medicine, and the signature of poor quality care," he asserts, noting a discordance of 40 percent between what physicians diagnose as causes of death and what postmortem investigations reveal.

One of the signature features of our pluralistic U.S. health care system is that no one is in charge. More than any other advanced society, we use and abuse a system with "no controlling legal authority," to borrow Al Gore's famous phrase. If we could choose ourselves a health care czar, I would nominate Dr. Lundberg. His values, compassion, and humanity are refreshing and vitally needed. In the meantime, his book deserves a respectful reading; too many with stepped-on toes will avoid his candid and valuable perspectives and advice. ยค