Richard Dean Smith, MD

"Requiem for Doctor Edward Browne is appalling; it's heartbreaking. That is not to say its a bad book; it's quite enthralling. It is appalling and heartbreaking because it's about our current health care system, told from a doctor's perspective. Although the book is a novel, the author is a doctor, and this gives the book the ring of truth.

"For the first half of the last century, doctors often worked with patients from birth to death. They made home visits. They sent cards and received presents. They got to know whom they helped. Welcome, managed health care, where doctors don't get to pick their patients, or vice versa, caseloads are often overwhelming, the paperwork load is staggering and patients sometimes have to wait, unless it's an emergency, for months to see a doctor, whoever is assigned to their case.

"Dr. Edward Browne is an old-time doctor modeled on those kinds of physicians. Managed care becomes popular among most practices in his small town. Our hero has one other doctor friend, Dr. Kennes, who stands by him throughout all their attempts to stay independent. Reflects Kennes, 'Blind faith in the wisdom of hospital administrators, the government and the insurance industry is what they want. When the blind lead the blind, both fall into chuck-holes.'

"Not only does the change to managed care affect Dr. Browne's practice, it affects his marriage. He is not willing to join a managed care office, his caseload keeps shrinking, he is unhappy and constantly worried. When his wife is offered work in her field, museum curating, out of town, she takes it. They stay in touch, but he is extremely lonely. Managed care has cost Browne almost everything.

"We hear so much about the patient's side of the health care situation in the U.S., its good to hear from the other important side of the equation. In the end, our hero is a hero, and some good comes of his attempts to preserve pieces of the profession he loves. The novel is engaging but long at 566 pages. The characters are quite well developed, if not a bit stereotypical. The author shows immense knowledge of the painting and museums fields as well."
The US Review of Books

BEGINNING EXCERPT:

Dr. Edward Browne shared an office with another physician, Dr. Meyer Benson, who had been in practice fifteen-or-so years longer than Browne and recruited Browne from a prominent medical residency program in the Mid-West. Their relationship was cordial with few disagreements about how to run their office, such as schedules, personnel, and other greater and lesser matters of everyday operation of a medical office. Browne wondered if their current fairly secure relationship could last with so much adverse publicity towards medicine and warnings of challenges to physicians.
Browne stood somewhat taller than Benson, who was somewhat stooped with age, and rather than trim like Browne, he was slightly endomorphic with a small paunch. Benson had a full head of white hair with a wave that remained from his youth. An aquiline nose showed effects of the sun while fishing, hiking and swimming. Benson had been a hard-driving, competitive physician who mellowed over the years becoming less intense and more personable. He always dressed like a professional man: a dress shirt, bow tie, cuff links, and manicured fingernails. Benson pursued pleasures of opera, theater, food and wine while Browne was satisfied with essentials; his wants did not become needs. “I’m down-market,” Browne said. Practical and down to earth, Browne was not as out-going or social as Benson but developed a loyal following in his medical practice as had Benson. Nor did Browne seek notoriety in his daily professional activities; his medical practice was its own reward.
“One of these days, I’m going to give it up, Edward. I’ve had enough of practice. I’ve been blessed to have a gratifying career here in East Valley. We’ve had a wonderful association over these years, and I want you to know how much I appreciate our partnership. I’ve saved a good sum, and with my retirement plan, I’m able to leave practice comfortably. I will miss being in the office, but I intend to stay active in hospital affairs. All this business of managed care, or whatever it’s called, will be interesting to see how it develops. An insurance crisis of some kind comes along every so often. I’ve seen quite a few in my time.”
“I’m quite a ways from retirement myself, Meyer. I suppose we should look at these health insurance proposals as a challenge. We will surely confront them before I get to the end of my days in medicine.”
“Things seem to work out no matter the criticism and complaining,” Benson said. “In the meantime, it’s turmoil, chaos and crisis-time. One wonders if there is any common sense or judgment left in human affairs, in Washington or executive suites of insurance companies. I’ll start looking for someone to take over for me. I promise I’ll find a compatible replacement. I wanted to let you know.”
Dr. Browne stood erect at six feet tall. His straight back made him appear taller than he actually was, though at times after a long day, round of a scholar’s hump appeared. His hair had thinned on top and grayed along the sides allowing long intervals between haircuts, which appealed to his Scot’s nature. A ruddy tint on his face showed effects of the sun but more often the pallor of a sage who preferred gentle light of libraries to sunlit golf links or tennis courts. He had a straight Celtic nose, thin slightly gray eyebrows and creases aside his cobalt-tinted eyes. He usually wore a white or blue, or striped button-down shirt, a college club-tie, gray or brown trousers, and plain black or brown shoes that he occasionally polished.
If Browne had an enduring interest, passion, or diversion in addition to his occasional outings at pool, it was the writings of Sir Thomas Browne, a seventeenth-century English physician. Like Sir Thomas, Dr. Edward searched through the surface of things. He did not succumb to excited enthusiasms of his day but took a longer view of events. The claims of revolutionary times in the practice of medicine were not new and could not have a lasting influence. Browne was neither fooled by threats from managed care proponents, nor liable to emotional appeals and intimidation from hospital administrators, healthcare planners, economists and consultants since many a strange fire has burned on the altars of medicine.
Newspapers and lay magazines were laden with articles calling for radical changes in medicine, especially by promoting cutthroat, marketplace competition in the form of managed care. Browne kept himself briefed as well as possible, although he could see no justification in the over-all idea of managed care. He was not persuaded that its claims were being presented in an honest, forthright way. Further, Greifter-Kemple, a managed care clinic or HMO, was located in East Valley across town. He wasn’t particularly worried but kept a wary eye on matters related to managed care’s growing sanction.
Criticism of doctors and medicine saturated the media, especially threats to the ability of doctors to survive without managed care. Yet, Browne knew criticism of doctors was not new. Wasn’t Chaucer’s Doctour of Physik excessive in his self-approval and accused of being in league with apothecaries to fleece the public? Wasn’t Flaubert’s Dr. Bovary a problem physician? What about Rosamund and Tertius Lydgate, a young doctor and his wife in Eliot’s Middlemarch? Wasn’t Dr. Lydgate out of step with doctors in the town? Wasn’t Trollope’s Dr. Thorne a poor man living on edge of insolvency?
“Still waters run deep,” Joanna said of her affection for her husband when they courted during his residency-training days. His mellow blue eyes she called deep pools. A ready smile, a flash of warmth made up for his social deficiencies though at times she was concerned he was not more talkative and outgoing. He could not fake interest or manufacture conversation, Sir Thomas Browne says:

Such Silence may be Eloquence, and speak thy worth above the power of Words.

Dr. Browne conducted his practice with an austere simplicity. Pearl Warner, an old time patient, asked, “Why don’t you have papers and journals piled on your desk like other doctors?” His desk was nearly empty with only a few patient instructional handouts neatly arranged. Medical journals were read and discarded the day they arrived.
“What I need in my daily practice,” Browne said, “I must hold in my mind.”
Each morning, Browne entered by the back door, stepped down a short corridor, turned right to his office, removed his jacket and hung it in the closet, donned his white coat with pockets for his pen, penlight, and stethoscope, checked for messages from the previous day, straightened his desk of its few papers, and glanced at his day’s schedule. Squinting into the early morning sunlight, he proceeded quickly across a brick pathway to the Doctor’s Lounge where he occasionally visited. He greeted hospital employees like old friends.
“Hello, Dora,” he said to the housekeeper.
“Mornin to ya, Doctah Browne.”
Dr. Browne discussed matters related to patients in the same concise manner and spare use of language he conducted all of his communications. Browne made his rounds, and as succinctly left with no wasted motion, no gossip and no off-color jokes. The short distance back to his office was a quiet respite from bustle of the hospital and confinement of the office. Sometimes he hurried along a garden route, a path of pea gravel shaded by ginkgo trees and lined with oleanders bordering the parking lot; its black tarmac beat summer heat to his face and absorbed sparse light of winter.
Many physicians disdained their offices preferring the stimulation of the hospital’s bustle, yet Browne handled each with equal interest, although he tended to fret about hospital patients because a trying, demanding diagnostic problem required time to resolve often wore on his patients and their families. Occasionally, when their behavior went beyond what he considered reasonable, he would take control. Pressed for premature judgments, he would reply, “Time will tell. I am not a prophet.”
Dr. Browne may feel a sense of relief and accomplishment upon achieving a diagnostic solution, but relief was sometimes short-lived since the results were not always favorable. When the problem was cancer or another dread disease, Browne suffered along with patient and family. Yet, his experience told him he must maintain a professional, objective and fiduciary role. He could not let his own anxieties and fears enter into decisions on what was to be recommended. “No matter how bad the situation, we can proceed reasonably once we have enough information. Not knowing is the worst. Anything can be faced once we know.”
Dr. Browne stayed in association with Dr. Benson because they were compatible partners, and their office was convenient to East Valley Medical Center. Browne never got the Jewish holidays straight, so each year his partner patiently explained whether it was time for New Year’s wishes or atonement of sins. A few years into their association a third doctor joined them only to discover he disliked medical practice or dealing with patients; he departed after a few months. When last heard of, the doctor had taken a paper handling, functionary position with little stress, safe from rigors of medical practice. The experience soured Browne on expanding into a practice larger than himself and his one associate. Little occurred to disturb Browne’s sense of the future or his satisfaction that his patients appreciated his attention to their medical needs, yet a nagging-uncertainty was ever present.


SOURCES AND SUGGESTED READING:

ART

Edmund Burke. A Philosophical Enquiry into the Origin of our Ideas of the Sublime and Beautiful. (1757) Adam Phillips, editor. Oxford: Oxford University Press, 1990.

Matthew Arnold. Culture and Anarchy. (1869) J. Dover Wilson, editor. Cambridge and New York: Cambridge University Press, 1981.

Laurence E. Schmeckebier, John Steuart Curry’s Pageant of America. New York: American Artists Group, 1943.

James Johnson Sweeney. Stuart Davis. New York: Museum of Modern Art, 1945.

E.H. Gombrick. The Story of Art. Greenwich, CT: Phaidon, 1962.

John Rothenstein and Martin Butlin. Turner. New York: George Braziller, 1964.

Thomas Hart Benton. An American in Art: A Professional and Technical Autobiography. Lawrence, Kansas: University of Kansas Press, 1969.

Stuart Davis. Edited by Diane Kelder. New York, Washington, London: Praeger 1971.

Robert Hewison. John Ruskin: the argument of the eye. London: Thames and Hudson, 1976.

Cynthia Mines. For the Sake of Art. McPherson, Kansas: The McPherson Foundation, 1979.

Robert Hewison. New Approaches to Ruskin. London, Boston and Henley: Routeledge & Kegan Paul, 1981.

M. Sue Kendall. Rethinking Regionalism: John Steuart Curry and the Kansas Mural Controversy. Washington, DC and London: Smithsonian Institution Press, 1986.

Robert Hewison. Too Much. London: Methuen, 1986.

Ruskin on Turner. Edited by Dinah Birch. Boston, Toronto, London: Bulfinch Press, Little, Brown and Co., 1990.

Gerhard Richter. Sean Rainbird and Judith Severne editors. Millbank, London: Tate Gallery, 1991.

John Ruskin. Modern Painters. Abridged and edited by David Barrie, London: Pilkington Press, 1987, revised edition 2000.

Mary Acton. Learning to Look at Paintings. Abingdon, Oxon, Routledge, 1997.

Patricia Junker. John Steuart Curry: Inventing the Middle West. New York: Hudson Hills Press, 1998.

Simon Schama. Rembrandt’s Eyes. New York: A.E. Knopf, 1999.

Dinah Birch. Ruskin and the Dawn of the Modern. Oxford: Oxford University Press, 1999.

John Drury. Painting the Word. Christian Pictures and Their Meaning. New Haven and London: Yale University Press, 1999.

Sarah Quill. Ruskin’s Venice: The Stones Revisited. Aldershot, England: Ashgate, 2000.

Walter Sickert. The Complete Writings on Art. Edited by Anna Creutzner Robins. Oxford: Oxford University Press, 2000.

Robert Hewison. Ruskin’s Artists: Studies in the Victorian Visual Economy. Papers from the Ruskin Programme, Lancaster University. Robert Hewison, Editor. Aldershot, England: Ashgate, 2000.

Francis O’Gorman. Late Ruskin: New Contexts. Aldershot, England: Ashgate, 2001.

M. Therese Southgate. “Thomas Hart Benton.” JAMA 287 (2002) 2185.

Robert Storr. Gerhard Richter: Forty Years of Painting. New York: Museum of Modern Art, 2002.

ECONOMICS

Thomas Carlyle. Past and Present. (1843) Houghlin Mifflin. Richard D. Altick, editor. The Gotham Library. New York: New York University Press, 1965.

Charles Dickens. Hard Times. (1854). Introduction by Jane Jacobs. New York: Modern Library, 2001.

Charles Dickens. Little Dorrit. (1855-57).

John Ruskin. Sesames and Lilies. (1865) from The Works of John Ruskin. 39 vols. Editors Cook and Wedderburn, London: G. Allen, 1903.

J.A. Hobson. John Ruskin: Social Reformer. 2nd edition. London: James Nisbet & Co., 1899.

John Ruskin. Time and Tide, by Weare and Tyne in The Complete Works of John Ruskin Edited by E.T. Cook and Alexander Wedderburn, London: George Allen, 1905.

Richard H. Tawney. The Acquisitive Society. New York: Harcourt, Brace, and Howe, 1920.

Frank H. Knight. The Ethics of Competition and Other Essays. New York and London: Harper & Brothers, 1935.

Jacob Burckhardt. The Civilization of the Renaissance in Italy. Vol. 1. New York and London: Harper Colophon, 1958.

The Chicago School of Political Economy. Warren J. Samuels, Editor. East Lansing: Michigan State University Press, 1976.

Simon Schama. The Embarrassment of Riches: An Interpretation of Dutch Culture in the Golden Age. London: Collins, 1988.

Terry Burke, Angela Genn-Bash, and Brian Haines, Competition in Theory and Practice. London & New York: Routledge, 1991.

John Stuart Mill. “On Liberty.” In On Liberty and Other Essays. John Gray, editor. Oxford and New York: Oxford University Press, 1991

Robert H. Frank and Philip J. Cook. The Winner Take-All Society. New York and London: The Free Press, 1995.

Donald Winch. Riches and Poverty: An intellectual history of political economy in Britain, 1750-1834. Cambridge: Cambridge University Press, 1996.

John Ruskin. Fors Clavigera: letters to the workmen and laborers of Great Britain. Edited by Dinah Birch. Edinburgh: Edinburgh University Press, 2000.

David Hawkes. Idols of the Marketplace: Idolatry and Commodity Fetishism in English Literature, 1580-1680. Houndmills, Basingstoke, Hampshire, England: Palgrave, 2001.

Larry Elliott and Dan Atkinson. The Gods that Failed: How Blind Faith in Markets Has Cost Us Our Future. London: The Bodley Head, 2008.

LITERATURE

Sir Thomas Browne. Sir Thomas Browne’s Religio Medici, Letter to a Friend, and Christian Morals. W.A. Greenhill, editor. Peru, IL: Sherwood, Sudgen, & Co., 1881, reprint 1990.

Thomas Hobbes. Leviathan: Parts I and II. (1651) Introduction Herbert W. Schneider. Indianapolis, IN: Bobbs-Merrill, 1958.

William M. Thackeray. Vanity Fair. (1847-1848).

Herman Melville. Moby-Dick or The Whale. (1851) Evanston and Chicago: Northwestern-Newberry Press, 1988.

Anthony Trollope. The Way We Live Now. (1875) London and New York: Penguin, 1993.

George Gissing. New Grub Street. (1891) New York: Modern Library, 2002.

C.S. Lewis. The Screwtape Letters. (1959) reprint. New York: Macmillan, 1980.

Dashiell Hammett. The Maltese Falcon. New York: Alfred A. Knopf, 1929. Reprint. Random House, 1972.

Wesley A. Kort. C.S. Lewis Then and Now. Oxford: Oxford University Press, 2001.

MANAGED CARE

Lawrence D. Brown. Politics and HealthCare Organization: HMOs as Federal Policy. Washington, DC: The Brookings Institution, 1983.

Beyond the Crisis: Preserving the Capacity for Excellence in Health Care and Medical Science. Henry M. Greenberg and Susan U. Raymond, editors. Annals of the New York Academy of the Sciences, 1994.

The Flight from Science and Reason. Paul R. Gross, Norman Levitt, and Martin W. Lewis, editors. Annals of the New York Academy of the Sciences, 1996.

Richard D. Smith. Managed Care: Anatomy of a Mass Medical Movement. The Rhodes-Fulbright Library Series. Bristol, IN: Wyndham Hall Press, 2000.

Richard Dean Smith. Rise and Fall of Managed Care: History of the Mass Medical Movement. New York: Nova Science Publishers, 2002.

Justices Ginsberg and Breyer, Concurring. Aetna Health, U.S. HealthCare v. Davilla. Certiorari to US Court of Appeals for Fifth Circuit. 21 June 2004.

Jan Gregoire Coombs. The Rise and Fall of HMOs: An American Health Care Revolution. Madison, WI: University of Wisconsin Press, 2005.

MEDICAL QUACKERY

James Harvey Young. American Health Quackery: Collected Essays. Princeton: Princeton University Press, 1992.

R. Alton Lee. The Bizarre Careers of [Dr.] John R. Brinkley. Lexington, KY: The University Press of Kentucky, 2002.

MASS MOVEMENTS

J.S. Mill. On Liberty (1859) in On Liberty and Other Essays. John Gray, ed. Oxford: Oxford University Press, Oxford and New York, 1991.

Gustave Le Bon. The Crowd: A Study of the Popular Mind. transl. La Psychologie des Foules. (1895) Atlanta, GA: Cherokee Publishing, 1982.

Gustave Le Bon. The Psychology of Revolutions. tranl. La Psychologie des Révolutions. (1912) Burlington, VT: Fraser Publishing, 1968

Adolph Hitler. Mein Kampf (1925-1927) translated by Ralph Manheim. Boston: Houghton Mifflin, 1943.

Eric Hoffer. The True Believer: Thoughts on the Nature of Mass Movements. (1951). New York: Harper & Row, 1966.

Charles P. Kindleberger. Manias, Panics, and Crashes: A History of Financial Crises. New York, Chichester, Brisbane, Tronoto, and Singapore: Wiley, 3rd edition, 1996.

Edward Chancellor. Devil Take the Hindmost: A History of Financial Speculation. New York: Farrar, Straus, Giroux, 1999.

Anne Goldgar. Tulipmania: Money, honor and knowledge in the Dutch golden age. Chicago: University of Chicago Press, 2007.

FOLLY

Adam Smith. The Theory of Moral Sentiments. (1759). Great Books in Philosophy. Amherst, NY: Prometheus Books, 2000.

Sydney Smith. “Bentham on Fallacies.” (1825) from the Edinburgh Review, in The Works of the Rev. Sydney Smith. New York: D. Appleton and Co., 1864.

Institute for Propaganda Analysis. "How to Detect Propaganda." from Propaganda Analysis, vol. 1, no. 2 (1937) in Propaganda edited by Robert Jackall. New York: New York University Press, 1995.

F.A. Hayek. The Road to Serfdom. Fiftieth Anniversary Edition. Introduction by Milton Friedman. Chicago: University of Chicago Press, 1944.

Sandra Billington. A Social History of the Fool. Sussex: The Harvester Press, 1984.

Barbara W. Tuckman. The March of Folly: From Troy to Vietnam. New York: Ballatine, 1984.

Joseph E. Stevens. Hoover Dam: An American Adventure. Norman and London: University of Oklahoma Press, 1988.

Robin M. Dawes and Richard H. Thaler, “Anomalies: Cooperation.” J. of Economic Perspectives 2 (1988) 187-197.

Mark S. Foster. Henry J. Kaiser: Builder in the Modern American West. Austin: University of Texas Press, 1989.

Jane J. Mansbridge. Beyond Self-Interest. edited by Jane J. Mansbridge. Chicago: University of Chicago Press, 1990.

Jon Elster. “Selfishness and Altruism.” Chapter 3, in Mansbridge, Jane J. Beyond Self-Interest. edited by Jane J. Mansbridge. Chicago: University of Chicago Press, 1990, pp. 44-52.

Terry Burke, Angela Genn-Bash, and Brian Haines. Competition in Theory and Practice. London & New York: Routledge, 1991.

John Henry Newman: Theology and Reform. Edited by Michael E. Allsopp and Ronald R. Burke. New York and London: Garland, 1992.

Matthew Rabin. “Incorporating Fairness into Game Theory and Economics.” American Economic Review 83 (1993) 1281-1302.

Paul R. Gross and Norman Levitt. Higher Superstition: The Academic Left and Its Quarrels with Science. Baltimore and London: The Johns Hopkins University Press, 1994.

Charles J. Stewart, Craig Allen Smith, Robert E. Denton, Jr. "The Persuasive Function of Slogans." from Charles J. Stewart, Craig Allen Smith, Robert E. Denton, Jr. Persuasion in Social Movements. 2nd edition. Prospect Heights, Ill.: Waveland Press, 1989, in Propaganda edited by Robert Jackall. New York: New York University Press, 1995.

Stephen B. Adams. Mr. Kaiser Goes to Washington: The Rise of a Government Entrepreneur. Chapel Hill & London: University of North Carolina Press, 1997.

Matthew Rabin. “Psychology and Economics.” Journal of Economic Literature 36 (1998) 11-46.

Robert H. Frank What Price the Moral High Ground: Ethical Dilemmas in Competitive Environments. Princeton and Oxford: Princeton University Press, 2004.

Mitchell Zuckoff. Ponzi’s Scheme: The True Story of a Financial Legend. Random House, 2005.

Richard Dean Smith. The Circus of Medicine. The Rhodes-Fulbright Library Series. Lima, OH: Wyndham Hall Press, 2005.

OTHER

Stewart E. Perry. San Francisco Scavengers: Dirty Work and the Pride of Ownership. Berkeley, Los Angeles and London: University of California Press, 1978.

Alex Boese. The Museum of Hoaxes. A Collection of Pranks, Stunts, Deceptions, and Other Wonderful Stories Contrived for the Public from the Middle Ages to the New Millennium. New York: Dutton, 2002.

Kitazawa Seed Co. Catalog, Oakland, CA, 2008.