LETTERS

Let the Patient Pay

Susan Dentzer's article about medical triage ["Dr. Wennberg's Uncertainty Principle," May] was excellent. She described how medical opinion on whether or not to perform certain procedures (such as tonsillectomies) varied gready, and was not based on efficacy but rather physician styles of practice. Doctors expert in a procedure were apt to push it harder than actual cure rates, or unpleasant side effects, might warrant.

The article suggested that enough information exists to prepare a statistical explanation of the outcome of various procedures so that the consumer could make a better choice. A videodisc series was described that explained the actual statistics pro and con of surgery, to make the consumer a betterinformed patient.

But if increasing consumer medical knowledge is half of the story, the other, more important half, is increasing consumer financial power.

If you are covered by any health plan, try to get a doctor to tell you how much his procedure will cost. "Don't worry" is the usual answer. "You're covered completely." Even if you do extract his price, it is absolutely impossible to find out in advance how much the entire hospital stay will cost. When the purchaser of a service is powerless to get a price quote, much less compare prices, he has no ability to control them.

Fortunately, there is an excellent cure. Require that patients pay their own medical bills. Enable them to do so by permitting consumers to invest in their own tax-deductible "medical IRAs" (or have the government do so for the poor) to be drawn upon only to pay for illness.

You can be sure that every consumer would quickly become quite expert in the knowledge of what procedures are useful and which are questionable. Health-advice magazines would spring up by the dozens. Time-Warner would offer the videodiscs. Also, when you have to draw down your own health savings, many of the wasteful, esoteric tests that are performed routinely and merely to shield the doctor against malpractice could be declined by the patient, thus saving him money and protecting the physician.

For so many years the American Medical Association has fought against "socialized medicine," but under current health-insurance policies we have had it all along. Huge government like health insurers "tax" the consumer, fix medical prices, and determine and pay for everything. The consumer is "free" only to choose who performs the unenumerated services but not their costs.

Let us restore the consumer's control over his own medical spending, a capitalistic injection to which the AMA can hardly philosophically object, and overnight medical costs will plummet as fiscal rationality the wisdom of the free market place regains the upper hand.

Concord, Massachusetts

Medicine, Postal-Style

Wennberg is upset to discover variations in medical procedures. He believes the American health-care system will remain fundamentally flawed until it adopts his "outcomes" overview. But where does Wennberg get the authority much less the expertise to dictate the modus operandi in fields as diverse as otorhinolaryngology, urology, and endocrinology? His training in public health invests him with a certain authority in matters pertaining to sewers, vermin, and gonorrhea.

The man is simply not a practical physician. He's been institutionalized all his life in academia and has no sense of how things work in the real world. "More at home with statistics than a stethoscope" pretty well sums it up. He doesn't even understand biological variation, but rather seeks a mythical Gold Standard for treating all patients the same way. This ignores the fact that people don't fit into those neat chisquare patterns he loves so well. For example, there's more diabetes per capita in Wolf Point, Montana, than in Manhattan; more heart disease in Georgetown, South Carolina, than Beverly Hills; and more suicide at Harvard than at Yale.

Wennberg also fails to grasp the significance of market variation. Precisely because doctors do many things differendy, we become the unexpected beneficiaries of new discoveries. Somebody tried propranolol for migraine and found that it worked surprisingly well. But the FDA had only cleared the drug for use in cardiac rhythm disorders and high blood pressure. That's how the field of medicine evolves. And that's how the free market works. But if everybody did everything the same way, i.e., standardized according to Wennberg's Overview, we'd have a health-care system as creative and flexible as the U.S. Postal System.

And because of impractical theoreticians like Wennberg-who prefer the central Statist method over the messiness of free enterprise-we're almost there.

Sherman Oaks, California

The Real Mainstream

The Blue Zoo [May] was indeed magic; it was back in the days when whole lives could be lived in ten weeks. But not all of us considered ourselves fringe—some of us thought, and still believe, that we were the mainstream...

Actually, Brad Fanestil, the one with the waffle-filled cheeks in the middle of the picture, is also a doctor. And, yes, he too works for a free clinic. "Don't get me going on my job," he advises. "I love my work. That's what we're all after, isn't it?" Brad also has the proud distinction of being one of three people in Los Angeles who walk to work.

San Francisco, California

John H. Writes In

I have just received with great pleasure your reference to Johns Hopkins University ("Dartmouth's Future: Now for the Hard Part," February). I would quarrel with all your assertions about Hopkins save one.

"Massive"? Larger than Dartmouth certainly, but we are no mega-university. In fact, the full-time undergraduate enrollment of our schools of Arts and Sciences and Engineering was 2,986 last fall, significantly less than the Dartmouth undergraduate enrollment cited a few pages after your exercise in Hopkins bashing.

"Financial crisis"? The universitywide bottom line at Hopkins had been and remains healthy. There have been, to be sure, particular problems, but those problems are being addressed by a careful reallocation of resources within and across divisional lines. Prudent management, yes. A crisis atmosphere? I have not detected it.

"Cutbacks in federal aid"? I'm not sure what this refers to, but the university's funding for federally sponsored research has risen an average of 11.3 percent over the past dozen years, slightly more than that in the past six.

"Increasing costs of administering research"? In fact, the administration components of Hopkins' overall indirect cost rate—the research overhead reimbursement we negotiate with the federal government—have declined over the past five years. Both are below average for our peer universities.

"Departments are being slashed"? Reductions in the School of Arts and Sciences have been accomplished through attrition, not through anything I would describe as slashing. In fact, some departments have increased in size following a thorough review of academic priorities. The size of the school's faculty is now established at a level significantly above what was projected less than three years ago.

"Undergraduate programs are in dan- ger"? No majors have been cut; we have, in fact, added new majors and minors in areas such as the environment, ancient law and women's studies, and are designing more.

The one point you got right: the spelling of our name. As we are constandy afflicted with references to "John Hopkins," we consider that no small achievement.

Director, News and Information Services The Johns Hopkins University Baltimore, Maryland

Untouched Squash

The April "Dr. Wheelock's Journal" made brief mention of the somewhat thin seasons enjoyed (endured?) by most winter sports teams. You highlighted two exceptions, and I think you might have added a third: men's squash, which ranked fifth in the country—one of the highest rankings in some time.

Rye, New York

Choice Gut

In the April issue you ran an article entitled, "Could You Get into Dartmouth Today?"

Based on the current state of the institution, the title "Should You Get into Dartmouth Today?" seems more appropriate!

Atlanta, Georgia

Grand Mannerisms

I enjoyed your article in April, "Teachers in the Grand Manner," very much, and found it lacking in only one respect.

Doubtlessly, many recent alums will write in, astonished that you have overlooked their favorite professor, and I will not disappoint you in this regard. While all of die professors you highlighted certainly were deserving of the special recognition, I feel it unfortunate that you did not include History Professor Heide Whelan.

No one who has experienced her passionate and picturesque lectures on the Battle of Borodino, Napoleon's retreat from Russia, or the abdication of Czar Nicholas II can help but hear the bullets whiz, feel the biting frost, and experience the drama of history unfolding. It is a rare professor indeed who can make students feel as though they have experienced time travel during an early morning winter-term class.

Professor Whelan's courses are ones that I will never forget, and she certainly deserves recognition as well for her outstanding talent as a teacher and a lecturer.

Burbank, California

Thank you for the credit given to six of Dartmouth's outstanding professors. As a graduate student, in the MALS Program, I was fortunate to spend time in the classrooms of several of these outstanding educators.

As a young history teacher myself, it was great to see "master teachers" at work. One of the best memories of my summers spent at Dartmouth were those days I spent listening, enraptured, to Mary Kelley as she led us through pre-Civil War intellectual history.

Often today, as I struggle to enlighten young minds about the Puritans, the Jacksonian era, the early women's movement, I have thought of that class, and the wonderful job done by Professor Kelley.

It is not often enough that we, as students, fellow educators, or alumni, applaud those who have inspired us through their unique ability to inspire young minds.

Northfield, Massachusetts

Nostalgia Binge

The March "Special Issue of Unabashed Memory" is a timely tonic. Well done.

Oslo, Norway

It is unfortunate that the President of the College did not contribute more to the nostalgia binge featured in the March issue by offering memorable encounters relating to Dartmouth instead of to Yale.

Kailua, Hawaii

Who Wore the Knickers?

The March issue photo of the softball game, in which I appear in "whistlebritches" knickers, has caused some alumni confusion. As a scout for the Woodsmen's Weekend Team, I was checking out a batter who was said to swing "like he was chopping wood."

He never made the team, and I never got to second base!

Plymouth, Massachusetts

My octogenarian mother (with the aid of a magnifying glass) says that's her boy Raymond out there pitching. Daughters three agree (the hair's the same, they say). I say that sure looks like Al Davis '52 at the plate and the backside of my classmate, roommate, and four-year batterymate Neil Kelsey behind the plate (I believe the same pants lasted four seasons—one Topliff, three Theta Chi).

You sure that kid in knickers wasn't superimposed?

Storrs, Connecticut

I enjoyed the letters in the May issue from Ted Mortimer '44 and Alan Davis '52, who each identified themselves and their contemporaries as the players in the picture of the softball game on the Green.

To resolve who was on the playing field the umpire should make the call. I was the umpire, the person in the middle of the picture, and I've got to give the nod to Alan Davis.

New Canaan, Connecticut

She Was a Brother

Rarely am I moved to action to write your excellent magazine. In this case, there was a significant oversight which demands correction.

Your article on the Tanzi Brothers [March] was nostalgic and on target with one exception—there was no mention of the fourth Tanzi "brother," Harriet Tanzi. Harriet was as important as Harry, Leon, or Francis. She, like them, was a friend to all. My four years in Hanover were richer by far for having known them. Tens of thousands will attest to this.

Riverside, California

PC'ing Hoppy

The April issue has been thrown out with the trash so I don't have your "interview" with Ernest Martin Hopkins in front of me. It doesn't matter. The article left enough of an impression that I will write and make my point anyway.

The article was utter pap. It was a terribly amateurish attempt to enlist alumni support for college efforts aimed at achieving your "politically correct" agenda. Alumni are more aware of and concerned about important issues than you give us credit for—we just don't all agree with the liberal elite's solutions. And I speak for many when I tell you we are growing weary of the suggestion that we are somehow less worthy because we don't.

More than most, you should know that to construct an argument from remarks taken out of context is fallacious. It's also unbecoming of an institution that purports to pride itself on its integrity. There's no excuse for this. You get a failing grade on form as well as on substance.

I don't know who your boss is or against what standards your perfor- mance is measured. But this article calls into serious question your professional competence. You should be reprimanded for it and told to improve your work in the future or go. Dartmouth and the alumni deserve much better.

Menlo Park, California

808 NUTT '49 REPLIES: Mr. Wood's familiar "out-of-context" complaint really doesn't apply in the case of our Hopkins interview, since we were clearly providing a contemporary context for Mr. Hopkins's well stated and remarkably timeless beliefs. One of those beliefs was that the College's purpose is to teach students how to think. We think most Dartmouth alumni fully capable of entertaining without cavil the pros and cons of Hoppy's views presented in our formal interview format. Unfortunately Mr. Wood does not make clear where and how he differs with our eminent former president.

As for the magazine's "boss," the role is filled by an editorial board consisting almost entirely of alumni.

Overcharging

I was embarrassed to read in the May 10,1991, Washington Post the following under the headline, "U.S. Probe of Research Billing Wdens to Include 20 Colleges."

"Dartmouth also charged $2,459 last fiscal year for the chauffeuring of its president, James Oliver Freedman, the aides said."

I do not know whether I am angrier at the fact that the once proud name of Dartmouth has again been disgraced by our current president by cheating the government or the fact that he was being chauffeured in the first place.

It is ironic that the Washington Post article coincided with the arrival of the Alumni Magazine with an article by President Freedman entitled "The Concept of Heroism."

If there was ever a case when actions speak louder than words it is this condoning of criminal conduct while writing about "a deep longing for genuine heroes."

If he will not submit his resignation then at least he should apologize to the entire Dartmouth community.

Round Hill, Virginia

Except for two almost-identical newspaper articles concerning the federal eral funding claims by Dartmouth and a May 13 editorial in the Wall Street Journal, I have neither read nor heard additional comments about this supposed questionable conduct on the part of the College.

What is the fall story of this alleged misconduct?

Wilmington, North Carolina

See this month's "On the Hill."

Interest Groups

In response to the letters published in the May issue under the heading, "Gays Denied," I submit the following:

We should appreciate the good work of the Dartmouth Gay and Lesbian Alumni Association (D-GALA) in bringing back to the Dartmouth community those graduates who may have felt less-than-welcome over the years. Nonetheless, the issue should not be whether the College offers "official recognition" (whatever that is) to D-GALA but whether the College welcomes, respects, and appreciates the gay and lesbian members of the College community. A simple statement from an appropriate official of the College on the following substantive issues would far outweigh the importance of the "official" status of D-GALA:

1. Does the College protect its applicants, students, staff, and faculty against discrimination based on sexual orientation in admissions, educational programs, and employment?

2. Does the College welcome the full participation of its students, faculty, staff, and graduates in all of its programs without regard to sexual orientation?

In my opinion, if an appropriate official of the College will respond clearly to these issues, then there will be less need to argue about the "official" status of D-GALA. If the College is unwilling to make this affirmation, that would raise serious concerns.

Los Angeles, California

In regard to the decision not to grant official recognition to Dartmouth Gay and Lesbian Alums, Michael Choukas, director of Alumni Affairs, says DGALA will still have access to certain services. In the abstract, I understand that the College does not want alumni fragmented into special groups, and I understand his reasoning.

On an intimate level, though, personal experience indicates otherwise. The environmentalists who sought recognition most likely responded to denial by saying, "OK, just thought we'd ask." To a minority group that has been told for decades to "keep quiet and we'll see what we can do," however, his response seems like one more deliberate impediment in a chain stretching back years—whether that is the intention or not.

My connections to the College are three-fold: friends still in Hanover, generic College mailings, and D-GALA. The first group is rapidly shrinking, while the second is usually of minimal interest. D-GALA represents the ideal marriage of the two: information in which I am interested from people with whom I share a bond.

Such alumni groups can only serve to increase alumni interest in the College at a time when the College can ill afford to alienate its graduates.

Berkeley, California

D-GALA and the Dartmouth adminis-tration seem to have settled the matter. InJune, Director of Alumni Affairs MichaelChoukas released a statement that D-GALA had recognition "as a bona fide or-ganization working in the best interest ofthe College." Choukas's office will not pro-vide staff to the group, however.

J J OX'An equal-opportunity statement adoptedby the Board of Trustees in June appears togive a positive answer to at least one of Mr.Saltzman's questions. It lists sexual orien-tation as one of the characteristics againstwhich Dartmouth will not discriminate.

Wheelock Corrects

We have been trying for some time to atone for our error, last April, in confusing the names of the architects responsible for certain new campus buildings. The recent honorary degree awarded by Dartmouth to American Institute of Architects gold-medal winner I.M. Pei reminds us. Stuart White of Banwell White Arnold Hemberger & Partners should have been given credit for the boathouse on the Connecticut. We also failed to mention in that paragraph of A.I.A. medalists the name of Pier Luigi Nervi, Dartmouth's twoarena man (Leverone and Thompson).

A curefor our medical ills will be found whenpatients bold the purse, says one reader.