"They're pretty good at record keeping in Sweden," returned Straus with a smile.
"Well, then, there are differences in records according to what time during the pregnancy the kid came out — whether it was a stillbirth, dead in utero, or whether it was a case where the kid died when it was really a viable being. It makes a big difference where a country draws the line in amassing statistics on infant mortality."
Straus put up his hands, palms toward me, and slowly lowered them as he continued. "Again, I won't argue about the technical details of the statistics. But the fact remains that the United States is not at the top. And fourteenth is a pretty low position when you consider where we are in most other technological and service fields. Frankly, Sweden makes us look pretty sick."
"Sweden doesn't have our problems," I said sharply. "They deal with a relatively small, homogeneous population, whereas the United States is a pluralistic society. Do you mean to say you feel that a socialistic welfare state like Sweden is the answer to all social ills, and the solution for us?"
"It seems to be better for infant mortality, and children's dental care, and longevity. But I'm not saying that the United States should adopt the Swedish system of government or health care. All I'm trying to say is that there are places where health care in general is better than here. That, translated, means that better health care is possible, and we have to make it happen."
"Well, you can't create a service industry like medicine out of a vacuum, nor can you abruptly legislate it. Changes in social structure occur only through changes in the attitudes of people. These changes are slow, and related to the educational forces organized to deal with them. People are used to the current doctor-patient relationship. I don't think they want it to change."
"For Christ's sake, Peters, forty million people have never even seen a doctor! How can they develop an attitude? Man, that's a vacuous excuse. Yet it's typical, too. You and your buddies can think of a million little irrelevant reasons why the present system should stand without change. That's why the whole structure has to be scrapped. Otherwise, we'll water down the problem by compromises like Medicare and Medicaid."
"So even Medicare and Medicaid are bad. Straus, you're a real bomb thrower. Everything is black from where you sit. I think Medicare and Medicaid are pretty good laws. The only problem I can see with them is that they screw up the graduate teaching system by making it possible for many of the patients we'd been handling to go to private M.D.'s, who don't let the interns and residents in on the case. As a result, we have effectively lost a large population of patients for learning."
"Well, that’s pretty important," said Straus. "And if s indicative of the Band-Aid solution to gigantic social ills. Yet the biggest problem of Medicare and Medicaid is that they have just thrown more money into the hopper, creating more demand. If the demand goes up and the supply stays the same, prices soar."
"Sure, sure." I was getting a little angry now. "What you want is another monolithic government bureaucracy, with millions of file cabinets and typewriters. But this is going to cost a lot of money. Health-care cost would probably go up, not down, with such a bureaucracy. And I suppose you envision all doctors on government salary. That would be interesting! Society is going to be in for a little shock when it finds out how much money it needs to pay those doctors. Financial return would have to go up, as the doctor rapidly learned to compare himself to someone like a unionized airline pilot, who can get about fifty thousand dollars a year for a sixty-five-hour month. How many doctors would it take to man the healthcare system if each one worked sixty-five hours a month? Plus they'll want retirement benefits—"
"That is a—"
"Just let me finish, Straus. Putting all the doctors on salary would have other, more subtle effects. If you are on salary, no matter what you do, it has an effect on your motivation in marginal situations. Look, Straus, when you drag yourself out of bed at 4:00 a.m., you want something for it, something more than the satisfaction it gives you. Lots of times it doesn't give you any satisfaction at all. Quite the reverse.
"After all, the garbage man, the airline pilot, everybody else gets overtime. Well, the doctor is going to want that, too, or he won't crawl out of bed. Let me put it another way. When you work for a salary, you have specific hours. Come five o'clock, and the salaried doctor washes his hands and goes home. I happen to know that, stripped of a lot of mythology, a doctor is a pretty ordinary human being."
"Can I talk now?" asked Straus.
"Please."
"Several things. Number one: a national health service is not the only answer. You're jumping to conclusions. Private prepaid health plans, for instance, work well, plus improving the productivity of individual doctors for a number of reasons. The government's role could be merely to guarantee that everyone is covered, one way or another, with at least a good-quality, basic health-care package. And number two: I don't agree with your views about the sleeping doctor. At the same time, I do believe the doctor will have to be paid in relation to some rational scale that compares favorably with airline pilots, or plumbers, or anybody else, keeping in mind the duration and investment of his training, as well as the long hours he must work. But, on top of that, I believe that the professional pleasure of practicing medicine will carry the doctor over the bumps in his day — especially if he is relieved of the burden of paper work and other piddling tasks that absorb twenty-five per cent of the solo practitioner's time. Besides—"
"Dr. Peters, Dr. Peters." My name suddenly shot out of the page speakers near the ceiling and echoed around the room. Straus went on talking as I moved toward the phone in the corner.
"Besides, in group practice," continued Straus, "there is more chance for peer review. The doctors can keep a good eye on each other and offer advice and criticism when needed. And records. Patients' records would be far better, because they'd be organized and complete whether the patient saw the G.P. or a specialist." Straus was literally shouting by the time I got to the phone and dialed the operator. Then, thank God, he finally shut up.
The operator connected me to the private surgical floor, and then I had to wait while they looked for a particular nurse.
"Dr. Peters."
"Yes."
"We have a patient of Dr. Moda's who's having some breathing difficulty. He wants the intern to see her. Also, I need an order for a laxative on one of Dr. Henry's patients."
"How bad is the breathing problem?"
"Not too bad. She feels okay when she's sitting up."
"Dr. Straus will be up right away."
"Thank you."
Turning around and retracing my steps, I noticed the whole cafeteria was empty except for us. The sun had disappeared, and the illumination in the room had changed from sharp, contrasting light and shadow to a soft, suffused glow. It was a peaceful scene, made more so by my inner joy at knowing that I could send Straus to see the lady with the breathing problem and to handle the constipation case.
"Peters."
"Yeah?" The voice on the other end of the line was familiar.
'This is Straus."
T couldn't have guessed. You certainly do seem to be busy."
"I can't help it. Everybody's going sour," he said. I glanced at my watch. Ten-thirty.
"Well, what’s the current crisis?" I asked.