Taking the Pulse of UHS

"It seems to me that one of the single biggest problems with medical care is the maze that must be navigated in order to gain access to it. A singular virtue of our health services, I think, is that it is small enough to be manageable, to make sense. That also means it is small enough to get to the bottom of something, small enough for one person to have an impact on it, small enough to change.

Over the span of two years, University Health Services has changed markedly--to the credit of a lot of different people. Since Dr. Wacker became director in July 1971, everything has opened up. Things are more honest, people are more accessible, there's a lot more input from a variety of people. It was Dr. Wacker who accepted my proposal to create a position of ombudsman, a gesture of good faith on his part in the consumer population. It was more or less giving official status to an infiltrator.

I came as 100 per cent consumer, feeling the Health Services was facing a crisis in terms of responsiveness and credibility. My basic ideology revolved around the premise that in a prepaid health plan the consumer should be informed, involved and influential. At that time there were almost no sources of information about services, policies, or staff; there were no established channels for feedback, grievances or consumer input into planning; there were no mechanisms to reach out into the community and actively involve its members in the workings of their health service. As I saw it, it was "us" against "them," consumers and providers working at odds rather than together.

My premises remain essentially the same. My perspective has altered significantly. Basically two things have happened: 1) I've tried to fill all the gaps, and been forced into a more realistic time perspective; and 2) I've seen the "other side."

A naive approach has advantages--freshness and freedom from preconceptions of what is possible, can spur an institution into considering old issues in new ways. On the other hand, such an approach is highly susceptible to impatience and frustration as things and people seem to balk over and over again at the thought of change. Naivete brings with it a certain detachment that makes things seem quite straightforward by considering only the issues and not the people involved in them. Experience shown--fast--that no matter how sound the ideology, no matter how appropriate the policy, the implementation of it rests with the people who actually compose the institution. (Institutions are only faceless from a distance.) Neither directives from on high nor revolutionary takeovers can really effect change, especially in a system so complexly interrelated as the delivery of medical care. Both are arbitrary, and can, I suppose, deal with some relatively cut-and-dry issues of economics--but assigning all the money in the world doesn't come near to attacking the basic problems of dehumanization of care.

Most of the complaints and problems I have tried to deal with stem in some way, usually quite directly, from very human issues in health care. The remedies to these kinds of problems lie only in changed attitudes, changed patterns of interaction, changed expectations from the people involved.

My naivete ended when I realized that neither side, neither providers nor consumers, was solely responsible for the problems. Walking the delicate balance line of intermediary, trying to bring the sides together in some profitable dialogue, I heard, each time, both sides of an incident or an issue. And had to somehow cope with the realization that both sides made sense, both positions were consonant with the context of those who held them, but that those contexts were worlds apart.

Perhaps the best way to illustrate the two sides that are always present is to point out what I have come to feel are the most important rights of the consumer of medical care, and the inseparability of the responsibilities that go with those rights.

The consumer has a right to information: about services available, about the personnel he turns to, about costs and procedures, about his health problems and the treatment prescribed. The student guide to the Health Services; attempts to encourage doctors to go to the Houses and to set up meetings with students and with tutors; beginnings at having UHS take an active role in educating consumers about health; my appointment as a person concerned with answering questions, solving problems, and helping people to get the care they need--all these efforts are directed at a greater exchange of information. But people mostly don't pay attention to information until they are in need of it, and by then it may be long gone. The consumer must meet the information-givers halfway, by listening, by attending, by saving relevant material...and by asking questions. After working the past two years to make sure that UHS has one of the best possible procedures for helping people with unwanted pregnancies, our current survey on abortion is showing that a significant number of people still don't know that the Health Services arranges abortions. That's like a slap in the face when you've been working intensively on something. Maybe for those people who don't know, it hasn't been relevant. I hope so.

Implicit in an improved interaction between providers and consumers of medical care is the right to respect. Medicine is a profession of service, but to many people it seems to serve only itself. Patients fall at the bottom of the hierarchy. To change this, we have to bring providers and consumers together outside of the treatment area, and get them to talk to one another. Both sides need consciousness-raising. No changes are made by putting one side or the other consistently on the defensive. Starting to talk over issues of importance, as our Consumer's Council has begun to do, is a slow process, because the two sides start so far apart, and have so little experience in really communicating. But the evolving respect has to go both ways. Consumers must respect the situation the doctor or nurse is in, the perspective they have, and the particular constraints they face. Mutual respect would alleviate a lot of anger that stems from an inability to understand where the other person is "coming from."

Finally, consumers must have substantial input and influence on the functioning of a health care facility. If we are to accomplish this, consumers must prove that they are responsible, reachable, willing to work to achieve their goals, and determined to make their opinions heard and responded to. Haphazard, halfway efforts only convince professionals that consumers can't really become involved in the issues that matter. And all too often that's all we come up with.

I really believe in these goals. I also believe that channels are open now at UHS, and that change is possible. The first big changes have been the opening of the channels. The impetus for further change must come from the consumer population. A person in my role can only pave the way and help to make things possible. Initiative for change, and direction for the goals of change, must come from a responsible community, willing to participate, not only to make demands.

The problems with health care in this community are not acute. There are adequate resources, competent people, accessible administrators. Issues to mobilize around are hard to find. But it is the fact that so much is "given" that affords us the opportunity to focus on the more subtle, but all-pervasive issues in the structure of medical care, the issues that really affect our chances for achieving the goals I outlined above. There is a lot to do here. I'm leaving because one person can only stay in the middle for so long. I'll cast my lot with the doctors for a while, and then try for a private resolution of the two sides.

Margaret S. McKenna '70, assistant to the director of UHS, is off to Harvard Medical School next year.