BOOK REVIEW: 'The Doctor Crisis': Improving Health Care on Grassroots Level

Reviewed by David M. Kinchen
BOOK REVIEW: 'The Doctor Crisis': Improving Health Care on Grassroots Level

Rick: How can you close me up? On what grounds? 

Captain Renault: I'm shocked, shocked to find that gambling is going on in here! -- "Casablanca", 1942, directed by Michael Curtiz, with Humphrey Bogart as Rick Blaine and Claude Rains as Renault.

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Many people -- especially those not involved in the inner workings of America's health care industry -- will be as "shocked" as Captain Renault to find that everything is not even close to perfection in that sector.

But after reading "The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care" (PublicAffairs Books, 240 pages,  $23.99, also available as an ebook) by Jack Cochran, M.D., and  Charles Kenney, those same people might be even more shocked to learn how bad things really are.

In a superb example on contrast and compare, the authors describe how a multispecialist team of medical professionals successfully separated two newborn conjoined (Siamese, in popular parlance) twin girls, providing them with normal lives.

Contrasting with this example of the best of the U.S. health care system, they go on to describe how Denver-based  Kaiser Permanente Colorado -- the same organization that provided such a successful result in 2001 and the following years for the daughters of Jim and Emily Stark -- was in the mid-1990s was "a period rich with lessons for improvement."

That may be the understatement of the year!

During this time, the authors write, KP Colorado was beset by problems: Patients experienced great frustration in simply trying to make an appointment or get advice from a nurse.  After being placed on hold for a long time, many patients were unable to get the appointment with the doctor they wanted. The problems extended beyond the call center: KP Colorado experienced significant membership losses, with 12,000 members leaving the system, contributing to major financial problems. Not only potential patients left, the authors write: physician satisfaction rates plunged and many doctors abandoned KP Colorado.

Fundamental flaws in the US health care system make it more difficult and less rewarding than ever to be a doctor, Cochran and Kenney write. They don't specifically lay the blame at "American exceptionalism"  -- the belief that our health care system is the best in the world -- but they come close.

In a book I reviewed more than two years ago, "The New Health Age" ( authors David Houle and Jonathan Fleece point out that honor belongs to France: We're dismal No. 37, despite the vast expenditures we make in health care.

Much of that money is wasted -- an amount  "approaching $750 billion of health care money every year, Cochran and Kenney write -- blaming much of the waste on unnecessary medical procedures and tests.

In my review of "The New Health Age" I referenced an outstanding book on health care by T.R. Reid, "The Healing of America." My review:  Reid says one reason France ranks at the top of the health care pyramid is their computerized "smart card," the "carte vitale." In my review of "The New Health Age" I wrote:

"We don't even have computerized health care cards like the French do. My Medicare card is a piece of flimsy cardboard, unlike the French "smart"card -- called the "carte vitale" -- which is encoded with the holder's health care information, making diagnoses much easier when there's an emergency."

Why the world leader in technology, the U.S., not have an equivalent "smart card" testifies to the fragmented nature of health care in this country, in my view. OK, I'm just a simple B.A., but it doesn't take an M.D. to make sense of this mess!

More from my review of "The New Health Age" which equally to "The Doctor Crisis":

"Newsweek  referenced Reid's outstanding book -- I recommend it without reservation -- in a February 2010 article, which I found on the Daily Beast site:   

"When veteran foreign correspondent T. R. Reid set out to write about France's health-care system for his recently published book, what impressed him most was not the country's universal coverage. Nor was it the system's low prices and wide-ranging benefits. Instead, as he explains in The Healing of America, the defining element of the French health-care system is a small green card that each patient carries: the carte vitale. The plastic credit card carries all the essentials of health care: medical records, insurance information, prescriptions, and reimbursements. It is used to check in, identify the patient, and provide the doctor with a complete background on the patient. "For me," Reid explains, "the carte vitale ... became a symbol of what the French have achieved in designing a health-care system to treat the nation's 61 million residents." In fact, the only picture that Reid includes in his 277-page book is one of the carte vitale.     

"Quoting from my 2009 review of Reid's book -- which I once again recommend to everybody:   

"Washington Post correspondent Reid traveled to about a dozen countries in his quest to fix his aching right shoulder and -- more importantly -- to find out which system would work to fix our ragged, patchwork quilt health care delivery system. "The numbers tell the story: All the other developed industrial nations spend far less on health care than the U.S., which spends a whopping 15.3 percent of its GDP on health care (in's closer to 17 percent now) and have greater longevity, lower infant mortality and better recovery rates from major diseases than Americans, Reid says, and backs up these statements with statistics from the World Health Organization (WHO) and other agencies."   

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Speaking of degrees, Cochran and Kenney deal with something many people have experienced at one time or another: The arrogance of people with M.D.s. This arrogance alienates other health care professionals, especially nurses, they write, to the point where KP Colorado experienced a strike by nurses. KP Colorado's nurses probably struck for higher salaries, but the authors point out (Page 97) that a study by the Veterans Administration -- an organization currently under fire for problems similar that experienced two decades ago by KP Colorado -- showed that "when asked whether they had ever experienced abusive behavior by a physician toward a nurse, 96 percent of nurses said yes."                        

Cochran and Kenney write that many factors prevent primary care and specialty physicians from doing what they most want to do: Put their patients first at every step in the care process every time. Barriers include regulation, bureaucracy, the liability burden, reduced reimbursements, and much more. Physicians must accept the responsibility for guiding our nation toward a better health care delivery system, but the pathway forward—amidst jarring changes in our health care system—is not always clear.


"The Doctor Crisis" shows how Cochran and others fixed the problems at KP Colorado, showing how other organizations can do the same. But I'm still pessimistic about the monetary and human waste engendered by our fragmented health care system. At the very least, we should copy the French and put in place our very own "carte vitale."

About the authors

Jack Cochran, MD, FACS, is the executive director of The Permanente Federation, headquartered in Oakland, Calif. Prior to his appointment to The Permanente Federation in October 2007, Dr. Cochran served as executive medical director, president and chairman of the board of the Colorado Permanente Medical Group for Kaiser Permanente. Dr. Cochran serves as a member of the board of directors of the Alliance of Community Health Plans and the UCSF Global Health Group Advisory Board. Dr. Cochran is also a past president of the Consortium for Community Centered Comprehensive Child Care (C6), a foundation that has built hospitals in East Africa. He is a vocal advocate for nurses and oversees the Lois and John Cochran Education Award, an annual scholarship given to oncology nurses at Lutheran Medical Center in Denver. Dr. Cochran earned his medical degree from the University of Colorado and served residencies at Stanford University Medical Center and the University of Wisconsin Hospital. He is board certified in otolaryngology (head and neck surgery) and in plastic and reconstructive surgery.

Charles Kenney is the author of many books including The Best Practice: How the New Quality Movement Is Transforming Medicine. He formerly worked as a reporter and editor at the Boston Globe.

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