I’ve heard but not read much about how the US government limits the number of foreign medical students who are allowed to practice in the United States after graduation. The official line seems to be that foreign doctors would undercut domestic doctors’ salaries. There are exemptions for acquiring the H1 visa for medically underserved and rural areas, but to me this has the feel of protectionism, a bit like a steel tariff. Can you elaborate on this issue and correct any of my incorrect assumptions?

MARK DOLCE
Glenview, IL

Dear Mark,

I truly don’t believe that the number of foreign medical-school graduates allowed to practice is a fixed criterion based on the need to protect jobs for American graduates. The standards may be strict, or even somewhat arbitrary, but I see no evidence of protectionism. I frankly don’t think there is that much concern whether US graduates have jobs or not, though I also don’t think job availability is the major problem right now either. The issue remains more one of quality of care and whether there are enough physicians to go around under the current system.

Many local newspapers have recently published anguished op-eds written by doctors bewailing the heartless cruelty of the huge increases in malpractice insurance costs. The “before” and “after” premium rates are always cited, and then the writers proceed to say they will have to “leave” that particular line of practice. The rest is left to the reader’s imagination.

Curiously, these same doctors never provide the reader with an income statement or a business balance sheet to properly evaluate these claims. And if so many doctors are “leaving the field,” where in the hell have they all gone?

What’s your take on these claims in the overall picture of the ongoing efforts at “tort reform”?

BOB POLWARTH
Des Moines, WA

Dear Bob,

These are not necessarily the same issues. (1) We live in a very litigious society, and doctors are often the target of frivolous lawsuits. At the same time, many doctors do commit malpractice and harm patients. But malpractice is not an effective way to police doctors in any case, hence the need for tort reform. (2) Many doctors are leaving the profession, mostly because of increased stress, responsibility and paperwork, with less and less monetary reward. Having said that, I too think that the majority of doctors still make very decent incomes and shouldn’t spend their time bellyaching. (3) Like any other profession, you shouldn’t be doing it unless you have a passion and an affinity for it. Bottom-line thinking, especially regarding income, may certainly undermine a doctor’s dedication, which further undermines the healthcare system.

I am a retired hospital administrator and am busy promoting universal health insurance.

I am half-way through an excellent book, Dead on Arrival: The Politics of Healthcare in the 20th Century, by Colin Gordon (a history professor at Iowa U), recently published by Princeton University Press. I highly recommend it for anyone interested in the subject.

FREDERICK C. SAGE
Boulder, CO

Dear Frederick,

Thanks for the reference. The inequities in the current system don’t serve many well, and few are happy with the direction our healthcare system has taken. Universal health insurance would be a step in the right direction if it were administered properly. Privatization will lead to waste and further inequities, including exploitation of the have-nots, as I don’t need to tell you.

Can you please clarify for me the difference between a “general practitioner” and an “internist”? I have recently joined an HMO and need to select my primary-care physician. Should she be a GP or internist–and why?

JOANNE STRAKER
Tallahassee, FL

Dear Joanne,

An internist is responsible for a body’s internal organs, including heart, lungs, kidneys, liver, intestines. A general practitioner includes rotations in internal medicine, but also has some experience in OB/GYN, surgery, psychiatry and orthopedics. Usually, a GP functions best in areas where there aren’t a lot of specialists around, whereas internists interconnect well with specialists, at least in the medical arena (cardiologists, gastroenterologists, etc.). Since Tallahassee is a pretty large city, I would lean toward using an internist, unless you have heard good things about a particular GP. As always, personal experience is more important than categories or titles.

I am very worried about mad cow disease. I would like your opinion on this issue because you are a physician and because you possess keen insight on the influence of politics on issues of medicine and health. I believe that the health and safety aspects of mad cow disease are being overshadowed by political actors who are more concerned with protecting the American beef industry than the health of the beef-eating public. Is more caution than that being advocated by the USDA warranted on behalf of beef consumers? The government agencies involved are advocating that beef consumers continue to purchase and consume beef products without exercising any increased level of caution. We are being told to continue eating beef at the same time that reports indicate that this is a much bigger problem than was first believed. Are we being lied to for the benefit of protecting the American beef industry?

JORGE SAAVEDRA
Walnut Creek, CA

Dear Jorge,

There are several important issues here. First, the cattle industry in the United States definitely appears to have been sloppy for many years in terms of what it does to scrutinize cattle. It is not acceptable that downer cows have been used for beef, and little attempt has been made to screen for mad cow disease. Perhaps the recent scare will put more pressure on the beef industry. I certainly hope so, though I have my doubts.

My second point: Prions, the cause of Mad Cow disease, are highly resistant proteins that are very hard to kill. Heat doesn’t kill them, making screening all the more important. At the same time, however, I do believe the incidence in this country remains extremely low; plus, there is an effective interspecies barrier that keeps this disease from infecting humans–for the most part. At it’s peak in Britain, there were 39,000 infected cows, whereas 130 people have gotten the deadly crossover disease (VCJD) in the past fifteen years.

Third, in terms of personal safety, your chances of getting a disease from the beef you eat is astronomically low, especially mad cow disease, which has not been found in the muscle cuts that we generally eat, though it could theoretically be found in meat close to the bone, or in beef potentially containing byproducts, such as hot dogs, an occurrence that would be extremely remote and, to my knowledge, has never been shown to have happened.

No human in the United States has yet to be shown to have acquired this disease from meat eaten here. Although I think our beef, though not adequately screened, is still relatively safe, I would also add that we should certainly be eating less beef in general, as part of a healthier lifestyle. And I also believe that cattle should be fed grass, not parts of chickens (which may themselves be fed potentially prion-infected sheep brains) to fatten them up. Cows are herbivores; they are supposed to eat grass. We’d have a lot less problems with beef if we kept to the natural order of things.