Popular Books on Forensic Science and Forensic Medicine: Anil Aggrawal's Internet Journal of Forensic Medicine, Vol.3, No. 2, July

Kill as Few Patients as Possible (and fifty-six other essays on how to be the World's best doctor) by Oscar London, M.D., W.B.D.
Ten Speed Press, Celestial Arts, Tricycle Press, P.O. Box 7123, Berkeley, CA 94707. Phone: (510) 559-1600: Fax: (510) 559-1629: 109 Pages: Publication Date - 1997, ISBN 0-89815-197-X: Price $9.95

In this book - the second by Oscar London to be reviewed by this journal - the Great Medical Humorist comes down heavily upon the HMOs (Health Maintenance Organizations) and Managed care. Of course the main thrust of the book is on some witty advice to fellow doctors on how best to serve their patients (some of this appears to have been given in a lighter vein though). Throughout the essays, one can sense an undercurrent of seething discontentment against the HMOs. As if the author is not content with just this, in his "Afterword" section, he gurgles all his gall explicitly. So impressively does he put his point across, that it does appear HMOs are doing patients more harm than good.

HMOs began mushrooming in 1994. Before the advent of the HMOs, a patient - if he needed a specialist - could happily go to one and get treatment. But now in the days of HMOs, there is a Big Brother sitting above you (the HMO), who decides whether you need to go to the specialists or not. Herein lies the whole point of our good doctor. He asserts that now under the new regime, the doctors can not deliver good medical care at all. Sure enough they can provide economical medical care, but not GOOD medical care. For good medical care often means referring patients to medical specialists. The procedure for referral to a specialist has been made so tough that doctors prefer not to send their patients to them. And of course HMOs do this because they want more profit.

The interference of HMOs is not limited to just this. They would often seem to advice doctors what medicines to prescribe and what not. London gives an interesting example. He once received a tactfully worded letter from an HMO's pharmacy director, asking why he had prescribed Zantac for patients of duodenal ulcers when a much cheaper generic "equivalent" such as cimetidine could easily have been prescribed. Of course the pharmacy director, who is not a medical expert, does not know that Zantac was not given to treat duodenal ulcers but to treat GERD (gastroesophageal reflux disorder).

Kill as Few Patients as Possible - Excerpts

...Medicine used to be about taking care of patients - damn the price! Now it's about making profits for the HMOs - damn the patients!

London is very adept at using puns, spoonerisms and other plays on words to put his point across. Sample some of his bon mots on HMOs and Managed Care:

Medicine used to be about taking care of patients - damn the price! Now it's about making profits for the HMOs - damn the patients!

Managed care, as promoted by the for-profit HMOs, is health care managed by business school M.B.A.s to save bucks and fill their coffers, rather than by medical school M.D.s to save lives and heal their coughers.

These days, your doctor will be happy not to see you. Fee-for-service medicine has been replaced by flee-from-service medicine

Hospitals used to operate like hotels; the more beds filled, the greater the income. Under managed care, hospitals now operate like MASH (Mobile Army Surgical Hospital) units during a battle - the more beds that stand empty, the better the chance of ultimate recovery.

Among the various pieces of advice that London gives to his fellow practitioners are such beauties as "have a lovely office", "if you can't save your patient's life, find someone who can", "Tell an addict to take a walk", "Don't forget to make a cameo appearance at your office daily", "when you make a mistake so horrible it is to die over, don't", "Don't hang mirrors in your waiting room unless your two O'clock Patient enjoys watching himself age visibly by four pm", "Don't try to feel a breast lump over the telephone", "Praise nurses and your patients will live forever or die happy" and so on.

... This book is very strongly recommended to all doctors, medical students, nurses and nursing students. A general reader would also enjoy the book. He can always gift it to his doctor after he is through with it!

Some of these tips may not be immediately apparent to you, but there is a short essay attached to each tip and that makes the point very clear. For instance, one of the advice given by the good doctor is "call in death as a consultant". To me this appeared a very paradoxical advice. But this is what the author has to say in the essay:

I invite death into my office as a consultant on every patient I examine. He sits there, as I see him, in the black uniform and spit-polished boots of an SS Colonel, a white Death's Head insignia perched above the visor of his cap. Through rimless glasses that flash n my examining lights, he studies every move I make. For example, I forget to ask a patient with borderline hypertension to come back in six months to have me recheck his blood pressure. Death, seated at attention, scratches a few words in his black notebook.

Get the idea? The same subtle ideas flow throughout the book. And of course his bon mots too, like this one:

Very strongly recommended to all doctors, medical students, nurses and nursing students. A general reader would also enjoy the book. He can always gift it to his doctor after he is through with it!

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Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology

Volume 3, Number 2, July - December 2002

Book Reviews: Popular Books Section

(Page 4)