Changing the American system will confront us with far more difficult decisions than how much doctors or lawyers or drug companies are paid. The real battleground will be over coverage-what treatments the system will pay for, and under what circumstances. This in turn will bring to the fore all the ethical issues created by modern medicine in this century. Here especially we will need the expertise of physicians. It is unfortunate that the most recent tendency among politicians has been to exclude physicians and other health-care workers from planning the new system. One can only imagine this is a temporary phase, similar to the temporary phase when Detroit tried to design better cars without the help of workers on the line. That didn't succeed for automobiles, and it is unlikely that the current strategies in Washington will succeed any better for health care. There are signs that the public is disenchanted with politicians, and as our national debate continues, we can at least hope for a system that controls costs while preserving the innovation, vitality, and excitement that has always characterized American medicine.

M.C.

Foreword

there has recently been a lot of fool-ish talk about something called "the new medicine." To the extent that it implies a distinction from some form of old medicine, the phrase has no meaning at all. Medicine has crossed no watershed; there has been no triumphant breakthrough, no quantum jump in science or technology or social application.

Yet there is, within medicine itself, a sense that things are different. It is difficult to define, for it is not the consequence of change, but rather the fact of change itself.

The first time I began to look at the Massachusetts General Hospital in the spring of 1969 I had the uneasy feeling there was too much flux, too much instability in the system. I felt a little like an interviewer who has come upon his subject at a bad time. Only later did I realize that there would never be a "good" time, and that change is a constant feature of the hospital environment. The true figurehead of modern medicine is not Hippocrates but Heraclitus.