Dr. Quentin Young discusses his work at Cook County Hospital
BROADCAST: Aug. 20, 1974 | DURATION: 00:52:39
Dr. Young talks about his policy about addictive medications at Cook County Hospital, and about the financially driven connections between pharmaceutical companies and doctors.
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Studs Terkel One of the most often discussed topics when people meet is the doctor: the relationship of patient to the doctor. It's the one that's least written about too; the doctor's [attitude to a?] patient and the other way around. Another subject often discussed, perhaps [it's one or two subjects?], the matter of drugs. Not simply the young kids taking drugs: psychedelic, heroin, LSD; just drugs generally. People taking drugs. You hear this on buses, whether it be Seconal, or aspirins, or what. I think it's all related, perhaps, to something happening in our society that may be narcoticized. Perhaps a narcoticized society. Dr. Quentin Young is quite a singular position, he's the Chairman of the Department of Medicine at Cook County Hospital, recently came through with a memorandum that is precedent shattering and may alter a good deal of the conversations we hear these days and perhaps offer us new insights. Before we hear from Dr. Young, who is my guest this morning, who I've known for a good number of years, perhaps about his background, too, as we go along through this conversation, we should hear Mike and Elaine. Mike Nichols, Elaine May, and one of their celebrated conversations. It's titled, "Calling Dr. Marks". I think it tells us a good deal:
Studs Terkel Dr. Young, you know. And you, sir, are a doctor.
Dr. Quentin Young Yes.
Studs Terkel And thoughts on hearing Mike & Elaine?
Dr. Quentin Young Well, I must say I've always enjoyed that one because they really capture some of--in a very satiric way--some of the realities of our present arrangements in dealing with patients. That sort of epitomized the, what I guess is a growing sense of patients, about accessibility to doctors and the really ludicrous way they characterize the doctor--not really knowing whom he was dealing with. Of course, it's a very sobering thing. And in many respects you could reduce much of the discussion about health care to two questions. And this, I would argue, involves all people of all social class except maybe the very rich and I'm not sure about that. And it's the question of accessibility and cost. And accessibility, Elaine and Mike very vividly dramatized. Of course, it also means once there, that the elements of caring and accountability--
Studs Terkel Isn't that then related to a recent memorandum you issued involving drugs? You're at Cook County Hospital. To begin with, you were not too long ago selected as Chairman of the Department of Medicine at Cook County Hospital, which is a public hospital where very poor people go, mostly black.
Dr. Quentin Young Well, County is, is indeed as you characterize it. It's interesting to note that the patient population is no longer exclusively poor people although the bulk of our responsibility is to the poor. And, indeed, nor is it exclusively a black group although the overwhelming majority of our patients are black. One of the interesting things of late is that we think we detect selection of County Hospital by people who have somewhat more choice and this has served to mean that we have the beginnings of more than just the very poor and certainly there's--
Studs Terkel Yeah. What I'm thinking is, is that memorandum. Perhaps you talk about this that you've recently issued that seems to be rather explosive in what its implications might be because you've heard from some of Ralph Nader's colleagues, too, about this. Is that it came from a poor people's hospital.
Dr. Quentin Young Yes.
Studs Terkel And obviously this is happening in hospitals that have more affluent patients, too. Suppose you speak of the background of the memorandum--well, the
Dr. Quentin Young It tells how far we've come as a society when a memorandum would be explosive. In other days, I guess, pamphlets by Paine and maybe declarations of independence but so much are we imbued with the bureaucracy that now we speak of the explosive memorandum. This one, maybe, passes
Studs Terkel [You simply?] say, "To all Physicians in the Department", "From Dr. Quentin Young, Chairman of the Department. Prescribing", subject, "Prescribing in the General Medicine clinic".
Dr. Quentin Young That's the memorandum. Well, the background is this, Studs: I have been at County now for two years and I knew this, of course, before I came that both--in all sectors of medical practice--in the private office, in the clinics, in the university hospitals; the overwhelming evidence of the growth of the use of drugs--medications--as an alternate to communicating with the patients. Every graph of drug usage is startling. The figure that sticks in my mind is that last year there were 1.5 billion prescriptions written in this country. That's 8 for every man, woman, and child in the whole society. And, of course, many of these have provision for refills so it's an incredible number. And, of course, it says something. As a practicing physician, which
Studs Terkel Pardon me, just, this says something--we just heard Mike and Elaine on their comic skit.
Dr. Quentin Young Yes.
Studs Terkel The impersonal aspect of it. And so, the solution for a doctor who's removed from a patient is a drug?
Dr. Quentin Young Yeah. Well, they did very well with that: a doctor who was so busy, and certainly Mike looks like many busy doctors, he just dealt with the patient in terms of the medication and the response to
Studs Terkel But the drug being the surrogate for his own personal
Dr. Quentin Young Exactly. That's a very important point. It was clear almost in all walks of life this subornation of patient and doctor as there were the outburst of drugs, roughly speaking, since World War II. We've had a whole series of drugs, some of which are of enormous use. The antibiotics have changed the whole outlook for a patient who gets an infection. I always like to use this example, and I don't know whether it dramatizes how old I am or how recent modern medicine is but, in any case, with students I describe how pneumonia--very common, very important illness--was treated eight years before I became an intern at Cook County Hospital and have them guess the year. The point of the story is, and the answer to the question is that eight years before I became an intern, pneumonia was treated in Cook County
Studs Terkel How long ago would this be?
Dr. Quentin Young Well, that's the point of the story. Let me unfold it. At Cook County Hospital, which was in the forefront then, as now, in the therapeutics of this country--in those days I fear it was much more of a research on human subjects than, happily, it is today--but at that time whatever was new was being tried at County. But, yet, eight years before I got there, pneumonia--a very common disease with 50 percent mortality--was treated as follows: you put on a pneumonia jacket, which was a canvas jacket, which is a euphemism for something to keep the temperature high. Gave the patient quinine, which is kind of in that usage an analgesic to relieve aches and pains and reduce fever, and wait for the crisis. Which is a euphemism for waiting to see whether the patient lived or died. I would argue that Hippocrates 3000 years before probably had a better set of treatment. But eight years before I came to County, and I'm answering your question as to when, something very important--a turning point in modern medicine took place. The first of the chemotherapeutic agents, sulfonamides--the Germans had developed this from the aniline dyes--and that set the whole stream going from sulfa to the antibiotics and all the variety of drugs which are extremely useful. That was one stream. Some years later we got into the psychotropic drugs, the variety of mood changing drugs. And then we got into drugs that work on enzyme systems. And each of these in turn has been heralded by the Varietys of the drug industry as the answer. And the enormous pressures--and I think we could well spend some time discussing the marketing of these drugs and how unique the marketing arrangements are that guarantee the proliferation of the use of these drugs in this society. Well, that memo you read which says, in effect, that there will be no more hypnotics, sedatives, tranquilizers, certain analgesics; drugs that are used by the tens of thousands in County and elsewhere and that have costs associated with them in the hundreds of thousands, indeed, the millions, are essentially banned by that memorandum. Your
Studs Terkel Your memo says, "No hypnotics or sedatives should be prescribed in the clinic".
Dr. Quentin Young Yes.
Studs Terkel Now, this is--what was the reaction to this?
Dr. Quentin Young Well, the amazing thing is--I braced myself because I was doing by sheer authority something I'm loath to do. Something that did violence on one hand to the doctors' established practices, even though these are young doctors; they're already going down that road of 'give me a symptom and I'll give you a pill'. And, of course, equally important: the patient's conditioning and, often, dependence on these medications. I expected a storm. And what I'm pleased to report to you--what I consider a reasonable period--after five weeks and literally thousands of patients later, there has been no reaction except a calm acceptance. The rest of the memorandum, of course, encourages the doctor insist that he explain to the patient the reason for these new arrangements, make certain that social work or psychological support is arranged for the patient who must have it, but tries to begin that patient education in the direction of the addictive and potential harm of the chronic use of these medications. And because I anticipated the whirlwind, I made extraordinary efforts to make sure that, what the true response of both the practitioners and the patients is. And I'm really pleased to tell you: none. None.
Studs Terkel Let's go over this very slowly, now. You said, "No hypnotics or sedative be prescribed". So a patient who has a difficult time sleeping, nervous. You're saying no
Dr. Quentin Young That's right. Not then--
Studs Terkel What--
Dr. Quentin Young What do we do for that sleepless patient?
Dr. Quentin Young We have a tiny escape clause in there because there obviously are moments and there are times when these drugs have utility. I would insist that with some important but very small, circumscribed, well-defined exceptions, this utility should be for an acute problem: you learn of the death of a loved one, or you have some other grave personal crisis. No question that calmative medication will get you through a bad few days; you have a similar stress that requires sedation and you're getting restless from lack of sleep, people under great stress. But this is not the day to day condition. What happens with the patients who get these chronically is they, indeed, become dependent on them and they confuse their sleeplessness with their addiction. In other words, they can't sleep because they didn't get the Seconal, not because they're restless. And, of course, this demands a much more adult and serious approach to the problems of stress. Now the patients, particularly at County as you might guess, are under enormous stress. We're dealing with the underclass or the poor people, the people who have the everyday problems of getting enough to eat, and rent, and hustling, and hassling, and we're not unaware of it. And this is no cavalier statement from on high, you know: "Sweat it out". On the contrary, we're attempting to deal with the fact that these drugs can further corrupt their lives, further enslave them. And it's widely bruited in medical circles, in those areas dedicated to solving problems of drug use, how--what a key role the physician often plays in his looseness in the prescribing of drugs and the progressive steps from getting some medication to relieve tension and go to sleep easy, to a dependency state, then moving into using drugs from multiple physicians unknown one to the other, then the street drugs, the parents setting the example for the kids who are seeing mama take a sedative to go to bed and some Dexedrine to stay awake and this to calm her nerves and that to relieve tension. What I'm saying is that the model is there and it's been said many times--it's almost a cliche--and yet, I think there's something to it in dealing with young drug users, sometimes even addicts: they are almost thrust at you. The fact that the adults set the example with their particular set of addictions, not to get into the other addictions of booze, and cigarette smoking which in their way are devastating, perhaps, even more than the drugs. But the idea that we have to break this cycle was behind that memo and I'm gratified in the extreme at the way at which both patients and doctors have accepted this new responsibility to begin to deal with their problems.
Studs Terkel You know, for the hospital not to be a drug pusher, you're saying.
Dr. Quentin Young Exactly. Exactly. At this point these are rules, were promulgated and, you know, after proper discussion and agreement by all the people who are going to be affected by it on the professional side, in the clinic. Now what does that mean? I thought it was wisest to start in a place where the doctor has some ongoing rapport with the patient. Clinic is the setting where the patient, as an ambulatory outpatient, comes back and we take extraordinary pains to make sure that, these days in Cook County, the patient is seen by the same doctor. It may surprise you to know that we have an appointment system, that our patients are seen, I fear, more promptly than I was able to see patients in my own office when I used to practice. We have this appointment system; they do have a card--regular card, the kind you used to get from your doctor--indicating the doctor's name, his--how he can be reached by phone. And the amazing thing is we're beginning to create this kind of union of the patient with his practitioner. And this was a precondition it seemed to me to introduce this because if you merely say to a patient who sees a different doctor every time and who has come to say, "Well, if there's nothing else I can get there, it's a little relief," a little "Balm in Gilead", as you might say, "from that pill or the other". And the doctor solving his problem of not seeing the patient ever again and not having seen him before by repeating the last prescription. You can see what you've got there: you've got a huge drug [market?]. Well, that, I feel, is behind us at County and preconditions was to create personal relations between the doctor and his patients. Now we've asked the colleagues in Surgery, Obstetrics, Peds, to consider the same move and I have every reason to believe they're going to give it a try because they saw how easily and how successfully it worked out in Medicine. Same time, we now have to look at our outpatient service. I'm sure you know that the newest, biggest thing in medicine is not the rising cost--that's been with us a long time--not even what we're talking about today, the sharp rise in drug use under professional auspices; but it's the shift of the action of medical care into the emergency room. The scarcity that Mike and Elaine were parodizing [sic] has resulted in the emergency room becoming the place where people seek primary care. Not, you know, the broken leg, or the gunshot wound, or the perforated peptic ulcer, which the emergency room was designed to take care of when you couldn't instantly get the care you needed with great risk to life and limb if there's any delay. But the place where the patient goes when they have a headache, an ingrown toenail, a cough; it's become the primary physician and that's--there's something a little bit robot-like there. But that's happened, that's an accomplished fact: the sharp rise in the ER, the emergency room being used as the primary physician. And there the temptation to give a pill or a number of different kinds of pill is even more intense because they haven't seen a person they know. They're looking at a strange new face that they'll never see again. Now all this, of course, has been lubricated, exacerbated, stimulated by the drug industry. And the drug industry is something special in this country. It's interesting to note it, first of all, it's a 10 to 12 billion dollar a year industry--I'm speaking of the so-called "ethical" drug company. And these institutions have had a kind of a shady relationship to medical--medicine, particularly organized medicine in the past. I'm pleased to say that that is in the past but up until a decade or so ago it took federal intervention to separate the American Medical Association from the subsidies involved in drug advertising in its journals. And the obvious conflict of interest led happily to a complete cleansing of that.
Studs Terkel You know, a question has come to my mind: visiting a doctor--
Dr. Quentin Young Yeah.
Studs Terkel Any doctor. And in his office are these various magazines and invariably these drug ads are there. And also he gets all these samples, too, doesn't he?
Dr. Quentin Young Yeah. That is the point. This 10 to 12 billion dollar industry spends 25 percent of its sales--25 percent--on what they call detailing or merchandising. An inordinate proportion. And this amounts, mind you, to $4500 per physician, per year, in pushing the product. And, you know, therein hangs a tale because not everybody can arrange for you to get medication. A pharmacist can. To get medication you have to get a prescription and not everybody writes prescriptions. For example, in my profession surgeons write relatively few prescriptions; they're busy cutting. Likewise, other specialties, particularly the super-specialized people, with some exceptions--dermatology and eye doctors--they write a lot of prescriptions but the person who pushes that pen is the internist--the guy who specializes in internal medicine--and the general practitioner, and the pediatrician. So the experts have instructed the drug companies wisely: pour it all on them. And the concentration of personal service, gifts, education, magazines is spectacular. Every practicing physician gets at least a dozen very high-cost--high cost to produce--and high quality in terms of artwork, medical journals free of charge, of course, which are full of blandishments to use this drug over
Studs Terkel Of course, we're talking about several things now: We're talking about medicine. We're talking about commerce.
Dr. Quentin Young Yes.
Studs Terkel Aren't we? We're talking about public relations.
Dr. Quentin Young Yeah.
Studs Terkel We're also talking about--to come back to Mike and Elaine again, if we can talk about it--all this becomes the surrogate for the personal relationship with the patient--
Dr. Quentin Young That's correct.
Studs Terkel And his--doctor and patient.
Dr. Quentin Young Yeah. After a lot of years of practice I've come to embrace the critique of professionalism that goes beyond medicine but certainly is never truer than when talking about medicine and healthcare. And that is the removal of power of self-control, of self-activation, from the subject, from the patient, from the client. All these words are used. And that is, of course, I would say, that is the treason of the industrial technologic epoch which is very new. I tried to dramatize it by indicating when sulfa came in. Since World War II people have become so conditioned by the media that they can't have a headache without dealing with a doctor or, worse, getting a pill to relieve it. What I'm saying to you is that there's been a kind of a mindless conspiracy. I doubt very much that anybody sat down and figured it out but under the twin thrusts of profit seeking in the drug side, the physician getting more and more pressed by the turning of the patient to him because that's a very good concept. You know that picture? The AMA picture of the obviously distinguished, bearded doctor sitting at the patient bedside?
Studs Terkel That's the old picture in old-time drug stores.
Dr. Quentin Young Exactly.
Studs Terkel And that glass is there--
Dr. Quentin Young Yeah.
Studs Terkel With the green liquid in
Dr. Quentin Young And now, you know, there have been--medical students have fun--they always get that and they write their own titles. It's an untitled--I think it's called "The Doctor". But they've--I've heard such titles as, "What the hell is the diagnosis?" But my favorite is, "How much do you think the bill should be?" It shows the doctor really kind of [to blame?] but that's cynical. That picture really captures an epoch. We--
Studs Terkel That's the old GP.
Dr. Quentin Young That's right. We have to recognize that he was very much--in fact, he was literally the extension of the witch doctor, the doctor priest, which every culture, not just ours, has had to generate. And he was the counselor, the friend of the family, the wise person grown wise by people turning to him, having very little to offer. Very little.
Studs Terkel Dr. Quentin Young is my guest and we'll take a slight break now, which leads, of course, to the question, we'll open with a question of how can there be that personal general practitioner or family doctor in this highly technological age. Cities overwhelmingly crowded, they are, the tremendous number of people there are. Plus the tremendous growth of the drug industry itself, the matter of junkies, and the matter of commercials. And your memorandum--back to that again, in a moment after we pause for this message. [pause in recording] Resuming the conversation with Dr. Quentin Young, whom I have known--
Studs Terkel In many dimensions, in many ways, and many years, who was a couple of years ago appointed Chairman, Department of Medicine at Cook County Hospital. And before that, aside from being a doctor--"That man is a doctor!"
Dr. Quentin Young Yeah, that's
Studs Terkel And we'll talk about that matter, "That man is a doctor!", too, perhaps. There's a Dr. Kissinger.
Dr. Quentin Young Yeah.
Studs Terkel A Dr. Willis as well as--
Dr. Quentin Young Dr.
Studs Terkel [Dr. So & So?], Dr. Strangelove. But the matter of you're also involved with a group called the Medical Committee for Human Rights. We'll come to that, too. It's all related, isn't it, really?
Dr. Quentin Young Well, I'd like to think so. Certainly [because?] it's part of what I go through every time we explore these questions. I was stressing that we tend, even in the profession, to sort of mock the old GP. We have all sorts of derogatory terms in the medical history: the term LMD means local M.D., local medical doctor and this is, in the medical students' mind, some kind of subhuman, quasi-qualified person. But that picture, again, which is--I ridiculed myself moments ago--does grasp the priestly service, friend, supporter, adviser role that, I argue, was central to the health care experience, the health care transaction which became superseded in the flood of technology. And what has happened is, to borrow a line from the poet, "We've given our souls away, a sordid boon." This wonderful place, the consultation room where patients are open in a world that's closed, their patients feel safe in a world that's threatening, suddenly becomes a drug center. Not exclusively. And I don't mean to imply that important diagnoses aren't being made and lives saved and illnesses healed but I'm suggesting the opposite. Along with that, simultaneously there's this doling out of a medication to meet a symptom which clearly becomes a way of removing people's capability of solving and dealing with their own lives. And that phenomena is now getting to such catastrophic proportions that it's been a cause for alarm, depending on the discipline that's looking at it: the sociologist, the drug people, and so on.
Studs Terkel There's a paradox involved before you, we come back to how can there be the general practitioner, the family doctor today. The paradox is the drugs, whether it be penicillin or the others that, indeed, have helped--
Dr. Quentin Young Yes.
Studs Terkel Solve so many of the ills to which man is heir to, does not cure them. This is the paradox, isn't
Dr. Quentin Young Of course and why, indeed, are people turning whence all these pressures? Doctors don't advertise. I mean, you could argue that most TV shows are advertisements for doctoring and, indeed, they are in the cultural sense. It happened because--my theory is, my explanation--is that the public has been enormously educated, and there's no tongue in cheek. Since World War II the media, both the boob tube and the radio, and I wouldn't sell short the linear media, have done a spectacular job of bringing enormous amounts of information to the public. Thus, in my professional lifetime, at the outset--which really overlaps this period--the typical patient, regardless of their educational background, was passive. The slogan was, "You're the doctor". There was a reluctance, certainly no insistence, on discussing the illness process, the outlook. That's all changed now. The typical patient, be he, university professor, or she, welfare mother, well, like as not come in with an article from the paper, want to discuss the disease, interested. And, of course, this is wholesome. This is the good side. But with it has come this other phenomenon, this kind of modern technologized side and we're at a crossroads. You can't, to use a simile, push the tube, the toothpaste back in the tube. We're not going back to that old day. The task before the society, believe it or not, Studs, is not how to finance medical care. That's awfully important. But if, for example, all we do is guarantee payment to hospitals and to doctors we're going to have the same disastrous inflation that we've experienced as we have in the past, what, 12 to 15 years. The answer lies in changing the arrangements between those people we dub professionals, health care providers, all that jargon, and the patient. Which is people. And this means to me an enormous shift in the question of reliance and accountability and moving away, backing off, from the use of drugs.
Studs Terkel Well, how can this come about, see? We'll return to your memorandum in a moment again but how--return again, that's redundant--but return to it, certainly. How can we, how can there be this change in relationship? Not going back, as you say, but certainly capturing that which was good, that personal aspect in a highly technological age, in a highly 'city-ized' society which was once primarily rural and small town.
Dr. Quentin Young Well, I give you my diagnosis where the answer lies and you may be surprised at whom I identify as the culprit. The culprit in this is not the drug companies per se because they're doing what drug companies are expected to do: trying to sell drugs. Nor, indeed--
Studs Terkel At quite a profit.
Dr. Quentin Young Yes. That's their motivation, you can count on that. You know, you can put--some wag said--you can put a steak in front of an anteater and he won't touch it but give him a plate of ants and he'll eat it. Anteaters eat ants and corporations move for profits. So that's, as the poet says, is a given. But nor, indeed, is it the doctors because they, as such, because there's a process that takes place when that starry-eyed, altruistic medical student enters the great school. And something happens to him in that process when he comes out and what's not completed during that medical school gets finished in the hospital setting when he's churned out to become the highly specialized, technologized, scientific-oriented person. And I'm hinting at the culprit. The culprit in my mind is our educational processes. The way we train, acculturate, socialize our doctors--using that last word in a different sense. And we do a spectacular job. We give them peer models who are scientists. People who, by definition, didn't--preferred not to practice and chose the academic life. But academic life in medicine is slightly different from academic life in the college and the university, even. It's usually somebody who has, often as not for good reason, fled practice: a person who is preoccupied with research, a person who enjoys teaching but who by definition usually does not have a practice proclivity. In a word, does not deal with people.
Studs Terkel By the way, not too removed--if I can just interpose a comment--I don't think what you're saying is too removed from the non-medical academician, too; removed from life, or the street, perhaps.
Dr. Quentin Young Maybe.
Studs Terkel In a way, perhaps--sorry.
Dr. Quentin Young Well, I accept the observation. It just becomes much more serious in the question of medical care because there's--all of the volition is gone. I would say something approaching 100 percent of the population at one time or another wants and seeks medical care. But, you know, those kind of options aren't there in terms of the historian, or the engineer, even, and what have you. So since it's a universal it takes on some of the quality, if you please, of a public utility. And the public's concern, the commonweal concept, is not unimportant. And this, I mean, this is the legitimizing, it seems to me, for dealing with this subject on the airwaves. It strikes me that this is a matter of the highest public interest. The what's happening to that enormous industry, the health care industry, which affects every one of our lives and particularly when it seems to be counterproductive. It--
Studs Terkel By the way, you used the word "industry".
Dr. Quentin Young Yeah.
Studs Terkel The health care "industry".
Dr. Quentin Young That's the word.
Studs Terkel The word "industry" is interesting, isn't it?
Dr. Quentin Young Yes. It is an industry by every standard. I've mentioned the drug component. I remind you of the medical equipment thing which has had this spectacular rise as we go into gadgets. And, again, the false economics of the arrangement with the government and other agencies picking up the check on a cost-plus basis has stimulated the proliferation of costly gadgets and often is not on the most planless way. Hospitals, you know, across the street from one another purchasing really high-cost equipment, underutilizing it. This has been one of the scandals within the profession, of planlessness. And, of course, there have been. what I would say, very halting, and at this point very incomplete, and to date unsuccessful, efforts at comprehensive health planning and regional planning. But, in any case, you have the drug industry; we've talked about them. The medical equipment industry; mentioned them in passing. You have the insurance industry and that's another one in the rogues gallery. To meet the public's understandable anxiety about the big hit, you know, when you go into the hospital, that multi-thousand dollar thing that few families can absorb, we have the growth of health insurance policies. The principle is excellent: share the risk and then if you have the bad luck of needing a large amount of medical care you're protected. But that has been so corrupted by the same motivation. The so-called "ethical" companies do such things as "experience rate". That's a nice sounding word. What it means is if a given company or a different set of people by age or geography have a high usage they raise their rate. The logic is this is to help those that aren't using it as much and give them lower rates. Very appealing but it immediately destroys the insurance principle. What it did was price all old people out of the market and that was when Medicare was born. Fine. But then you give all the high-risk people to the federal government. And here, again, prudence in the most elementary economic sense was thrown out the window. They just said to the hospitals, "Here's the patients. Cost- plus". And you saw such a proliferation of tests and utilization that has made a crisis. There are many ways to define the crisis in healthcare, not the least of which is the fiscal crisis caused by excessive use by hospitals and doctors of services when there's somebody guaranteeing the
Studs Terkel Well, how can this dilemma be, how can we escape from this dilemma?
Dr. Quentin Young Well, my prescription, my recipe, if you please, is that not to chase any false gods. For example, although I welcome the fact that the nation is debating new financial arrangements and everybody's talking about the inevitability of some form of national health insurance before another year is gone, as soon as the impeachment unpleasantness stops jamming the Congress--and that's probably true--and as a person who's looked forward to beginning of rationalization of payment, I have to welcome it. You know, it was Shaw, after all, who said--roughly, I can't give it exactly--that he intuitively mistrusts the system of health care that charges more for removing a man's leg than his toe. And he absolutely despaired of political man having learned that it pays to give a baker an interest in the baking of bread goes on to give a doctor such an interest in the cutting off of your leg. Well, that's Shavian satire. He wrote it in 1909 and, of course, we have every reason to believe it's as right today. Indeed, every country in the world, virtually, has now moved to get medical care out of the commodity market. And that's the point: the question isn't who'll pay the bill once the event has taken place. But how about making arrangements that do several things; one, that give the doctor an interest where the patient's interests--in the patient, maintaining the patient's health, rather than in the contradictory role of dealing with the patient's illness. I'm reminded of the straightforward GP who, when asked by an old-time patient who came into his office, "Doc, I want you to get me well," he says, "Get out of the office. Death and health are my enemies. We thrive on illness here more than [health?]."
Studs Terkel "Death and health are my enemies. We thrive on illness".
Dr. Quentin Young Yes.
Studs Terkel It's the in between.
Dr. Quentin Young Yeah. But the point is that you mustn't have the health worker, doctor, nurse, what have you, have his interest in disease. He should be interested in eliminating or preventing or minimizing disease and view his achievement in terms of maintaining health. All right. Nothing in the health insurance arrangements have that. Sure, they speak about preventive health measures and the old Kennedy bill--the one he abandoned--and they speak of group practices and--
Studs Terkel The one he abandoned?
Dr. Quentin Young Yes. he joined
Studs Terkel Kennedy?
Dr. Quentin Young Yeah. He joined with Mr. Mills to get a watered down version on the notion that--and Mr. Mills' bill, now the Kennedy-Mills
Studs Terkel bill-- This is Wilbur Mills.
Dr. Quentin Young Is very close to what Mr. Nixon himself was proposing. Again, dealing with the public's fear of the big hit so they have a catastrophic feature. And they have the beginnings of covering, you know, your day to day illnesses. But if Medicare has taught us anything, and certainly Medicare brought a lot of health to old folks--health care--nevertheless, it has to be stated: at what a price? It inflated the system out of sight, jammed the hospital, every abuse of the system. So what I'm suggesting, and I'm still answering your question, Studs, I'm suggesting we need to revamp our system which--probably the first thing: everything goes. Which restores to the patient a sense of ability to cope with his or her own life. That should be the test of everything we do. This means we have to end the dependent, infantilized state which takes in one hand, constant going to the doctor, on the other, a constant reliance on medication; on the part of both the physician and the patient. If we can achieve that. Now that assumes--not that we blink our eyes at disease, you know. Cancer, for example, that important and growing cause of tragedy in our society is dependent upon early detection and using the doctor promptly. So what am I saying? You have to couple this with an enormous amount of health education. And we have to recognize that not only the doctor can do these things. That there are all kinds of
Studs Terkel Yeah. But as we we're talking, daily, on television--radio, too--but television more dramatically, since the added dimension of sight is there, the commercials: beginning with the legal drugs. You know, continuously we speak of the drug problem. The law and order guys speak of getting those hippies, etc. and the marijuana smokers. That became an issue in the campaign, too.
Dr. Quentin Young Yes.
Studs Terkel Well, we think of drugs that are pushed daily on television.
Dr. Quentin Young Yes.
Studs Terkel Scores of times, perhaps, hundreds of times a day.
Dr. Quentin Young Yes. Of course, it's ironic: I got to believe you're aware of the comparison studies, say, with such a simple thing as aspirin where they find differences which are of no therapeutic significance or are touted and used as justification for charging 10, 12, 20 times what the drug can be bought at in its generic form.
Studs Terkel I was thinking of aspirin, by
Dr. Quentin Young Yeah.
Studs Terkel It's comic but sad at the same time. Euell Gibbons, who's seen very often on television--
Dr. Quentin Young Poor
Studs Terkel Health food apostle, has now got an ulcer and he ascribes it not to health but to aspirins that he's taken so often.
Dr. Quentin Young He's right, of course. I mean, I believe that's the right diagnosis as I read the, read it in the--aspirin is a primary irritant. It's a very useful drug and ironically has, although poor Euell apparently has gastritis from it and it's not without its risks, it's no question it's a fine drug. It's relative therapeutic--
Studs Terkel So we have a question of paradox or whatever it is, or excess, or modera--or whatever we're talking about, aren't we? We're talking about drugs that have a certain value.
Dr. Quentin Young Yes.
Studs Terkel Medicinally, as far as health. At the same time the overwhelming use of it--
Dr. Quentin Young That's correct.
Studs Terkel For another purpose entirely.
Dr. Quentin Young That's right. As a substitute in the case of seeing a physician, of the human transaction. And in the case of facing life, the alternate to solving life's problems and dealing with them.
Studs Terkel I was thinking--so, your--is your memorandum that forbids hypnotics--hypnotics, by the way, I didn't know this: is hypnosis been used a great? What is hypnotics?
Dr. Quentin Young No, no, hypnotic is a technical term,
Dr. Quentin Young I'm sorry, you were reading--
Studs Terkel I misunderstood.
Dr. Quentin Young Well, it's an innocent thing. Hypnotics is a category of drugs.
Dr. Quentin Young Which have certain soporific
Studs Terkel And so, no sedatives means Seconals unless, you speak of certain special emergency situations
Dr. Quentin Young Right. We banned all tranquilizers,
Studs Terkel Studs. And Talwin and Darvon--what are those?
Dr. Quentin Young Well, Talwin is a drug resembling opiates and is used, I thought, was being used excessively to relieve pain where aspirin itself would go. Darvon is a trademark drug which has the analgesic pain relieving qualities of aspirin. It costs about 20 times as much. Comes in about six or eight different
Studs Terkel Yeah. But on that subject, you know, Citizen Actions Program, a group I happen to admire very much, the credo of which--Marge Person, one of the older people there and she's battling on behalf of generic drugs--
Dr. Quentin Young That's
Studs Terkel [So you've got some company
Dr. Quentin Young It's interesting, if I may say, that from all places Mr. Nixon's director of HEW, Caspar Weinberger, who is not my favorite person normally, seemingly is pushing through the decisions of a blue ribbon task force that federal monies, which are increasingly the whole ballgame in this country, will be paid only for drugs at the level of the generic equivalent. What that means is the generic, which is the kind of basic chemical name, and is often, as I said, a fraction of the cost of the trademark drug, is being touted as an enormous saving to any agency that has to pay and I agree with that. There is, it's worth mentioning because it tends to come up now, the issue of bioequivalency. Bioequivalency means, okay, you take ten milligrams of drug A and drug B, they're both supposed to be--let us say, aspirin--but what arrives in the blood stream is different. This is a real issue but it's in a very circumscribed group of drugs. And as the Weinberger decision sort of stresses, this is not guaranteed by our present arrangements. It's one thing to say you don't know what's in drug A but, by the same token, you don't know what's in drug B. So the synthesis of that is that the government, with its regulatory agencies, will take responsibility for measuring bioequivalency so that when you take 10 milligrams of a particular drug you can be sure of a blood level. And that's the happy solution. And he stressed, and it's important because this will become increasingly a drug industry issue and they will try and scare the public, I think, that the bioequivalency thing can be easily controlled and should never be used as the basis for resisting an insistence on generic drug prescribing.
Studs Terkel By the way, in this memorandum of yours that proscribes, not prescribes, but forbids hypnotics or sedatives in the clinic--has this been taken up by the hospitals? This memo just recently came out, is
Dr. Quentin Young We just started it; to best of my knowledge there's no equivalent decision elsewhere. I felt we had to go this route and I've already commented I'm very pleased at the initial results. I can tell you what the results are going to be in the long pole. First of all I think it is a model. I think it's an example to the rest of the hospitals when a place as big as County can do this with a certain amount of physician education being achieved and the doctors having to rely more on their interaction with the patient rather than, "Okay, take this and everything will be okay". Then that's an important step forward in the training of doctors. It just creates conditions where they've got to get to know one another, patient and doctor. How about that notion. And then the other thing is, and this shouldn't be--it has never been our motivation but it certainly is a byproduct that's well worth mentioning, is the enormous costs that will be saved that can be put into medical programs, you know, that have much more of a yield. And that's exciting.
Studs Terkel You know, I'm thinking of, in the brief time that remains talking to Dr. Quentin Young, who is Chairman, Department of Medicine at Cook County Hospital. But also one of the founders of the Medical Committee for Human Rights. The big question now is young medical students today, and medicine, and [lo the?] Hippocrates. Is there for--during the 60s, the fervent years that Harry Truman described the 30s as, and now the 60s--fervent years. Many young medical students [don't seem to be interested in?] poor people's medicine, for want of a better phrase. And that wasn't, since the [base?] Of the Medical Committee of Human Rights. Is there a change now on the campuses, the premed students? I've heard that there's more of a status quo aspect and make-out artist aspect.
Dr. Quentin Young Yes. The medical student, after all, is yesterday's undergraduate. And he does reflect--he and she--does reflect the mores of the campus. And it's been written about recently, and I certainly feel it's true, that the disillusionment that assaulted the so-called student movement after Kent State is, as you might expect four or five years later, expressing itself among medical students. But it's not--happily it's not the privatism that goes for making it, making out, doing those things that will guarantee a big buck. I think it's a kind of a sober reflection and has both the good and the bad effects, as I see it, of looking into themselves and trying to solve problems in terms of their individual evolution as human beings. On one plane that's desirable; it's a thoughtfulness that would be--fit anybody, particularly a physician. On the other hand it can be counterproductive if it shades off into hedonism because the rewards for doctors in our society are so enormous and so ubiquitous. You know, any young doctor with the license can almost at will go into any emergency room and say "I'm ready to work" and be paid a very handsome figure per hour and, you know, have no ongoing responsibility. They'll let him work 6, 8, 12 hours a day twice a week and he can live comfortably on that and not a few are choosing that route and I, for one, don't find it that attractive. But I think I can report with confidence that--the direction of your question that what's the mood of the newly trained medic, doctor--I think there's still a very wholesome, very strong searching. We talked about the decline of the general doctor and the rise of the specialist. Well, that's being reversed. One of the most exciting things is the burst of interest in family practice and pediatrics
Studs Terkel Well, there is that, go on, yeah.
Dr. Quentin Young Fantastic switch, Studs. And these programs are burgeoning under the hammer of the student demand and under the anvil, if you please, of public need. But that's happening. That's big. Now what we're trying to do at a place like County, and obviously this explosive memorandum is just one expression of it, is to see if we can't channel those decent impulses, which are almost universally present when young people enter med school, and give them an opportunity to serve. It's one thing to say "Serve the poor" and "Bring health care to the masses" and all those wonderful slogans. It's another thing to create the conditions for that to take place. And these conditions have to meet standards, I think we'll all agree, for the patient's sake as well as the doctor: standards of quality, standards of reasonable remuneration, at least in some way meet the competition but never hope to meet the exorbitant kind of rewards that the private sector can make. And then capture some of the exciting, basic impulse of doctors, of working together, of serving, of helping. That's something very important. I, for one, think this industry that we've become, and [unintelligible] a minute ago, may well be the place where this society can regain its decency and morality. I really feel that.
Studs Terkel You know, it's funny, as we're talking, began talking, the memorandum and, also Mike and Elaine's skit--that funny and hilarious as it is based on an obvious truth.
Dr. Quentin Young Yes.
Studs Terkel This block, this impersonal air of the doctor to the patient. And the idea that the drug becomes the surrogate, you know.
Dr. Quentin Young That's
Studs Terkel If you take that then you won't have to see me, I won't have to see you, no matter what it is.
Dr. Quentin Young It's distancing.
Studs Terkel And so, we come back to distancing, of people one from the other. And in this metaphor, the [unintelligible] of doctor patient relations, so dramatic.
Dr. Quentin Young Yes.
Studs Terkel And your memo, indeed, your memorandum [assigning?] all sorts of implications to it.
Dr. Quentin Young Well, my goal, insofar as I'm responsible for the training and the delivery of care at County, is to--if I may use a metaphor--to have the physician embrace the patient; not hand them a pill or hand them a prescription that will get a pill. If they can do that I'm sure everything
Studs Terkel Well, what makes it even more dramatic is it happened at a poor people's hospital, you see.
Dr. Quentin Young Right.
Studs Terkel You would think that memo would occur in a hospital where the patients are more affluent and are more accessible to personal contact with the doctor. But it happened in a poor people's hospital which makes it
Dr. Quentin Young Well, obviously we have to come up with the opposite--if we're not going to give them pills--to ease their pain. We have to give them the medical care, the solidity, the human experience that they are entitled to. We're working very hard at that. I think the atmosphere at County is conducive to it. A lot of different eyes are upon us because if we can succeed here, there are lessons to be learned throughout this society.
Studs Terkel Any other thought that occurs to you? Any other base that we haven't touched before we say goodbye for now? Dr. Quentin Young--my doctor, by the way! Dr. Quentin Young, who is Chairman, Department of Medicine of the University of--University!--of Cook County Hospital.
Dr. Quentin Young Yes.
Studs Terkel Any thought, last thought for the moment?
Dr. Quentin Young Well, the thought, if I have to have a concluding thought, is a reiteration: I believe that everybody in this society has to begin to look hard at themselves and their sense of self-reliance. I think our institutions have, indeed, increasingly controlled us and the use of drugs is just a dramatic, universal, dangerous example of it. I'm hopeful that in the short time we have before the apocalypse that we can make the turnaround. I really believe that it can happen and there would be no more appropriate place for the taking place in the so-called health care industry.
Studs Terkel I trust to avoid the apocalypse.
Studs Terkel Quentin Young, doctor. "That man is a doctor!" Thank you very much.