There is nobody in the medical field in this state with a better reputation than Dr. John Eckstein at the Mayo Clinic in Scottsdale.

Having been thoroughly confused by what everyone tells me about President Clinton's health plan, I decided to seek out Dr. Eckstein the other day for his opinion.

He had just finished a morning jog when I arrived at his home. He was wearing shorts and drinking a tall glass of water. It was the first time I had ever seen him without a jacket and tie.

Eckstein is not a celebrity doctor. Now middle-aged, he does not appear in advertisements promising to clean out your arteries or fix your eyes so you will no longer have to wear glasses. He has never owned a sports franchise.

And yet, when the Mayo Clinic recently decided to do an institutional campaign aimed at gaining trust, it was Dr. Eckstein it chose to illustrate as its typical doctor.

He specializes in internal medicine. If you are not certain what's ailing you, Eckstein will sit down and talk to you for what seems like a long time. You always wonder why he seems to have so much time. Then he will see to it you get the right tests. Later on, he will explain thoroughly how he has come to the decision he thinks is right for your case.

Word of mouth on John Eckstein among his patients is that he is terrific. Ask those who have been treated by him and you always get the same answers. Women say, "He's wonderful." Men say, "He's smart and I trust him."

Eckstein became a doctor because he admired his father, Albert, now 85, who was also a doctor.

"The apple doesn't fall far from the tree," he says, chuckling. "He is a really good man, a caring and compassionate doctor. I watched him practice medicine from an office at Ninth Street and McDowell here in town as I grew up."
He tells a story about his father, who is now retired.
"When he arrived in this country from Hungary with his seven brothers," Eckstein says, "the authorities decided that the youngest brother was too frail to be admitted. They held him at Ellis Island. My father decided to stay with his brother. If his brother wasn't going to be admitted, he would go back to Europe with him. Five days later, they were both admitted."
Eckstein's father made excellent grades at the University of Pittsburgh in the late 1920s, but was not admitted to the medical school because of a Jewish quota that then existed.

So Albert Eckstein went to Frankfurt, Germany, to the Johann Wolfgang von Goethe medical school. While Albert was studying anatomy, Adolf Hitler became Germany's chancellor. Only because he was an American citizen was Albert allowed to finish medical school.

John Eckstein smiles at the irony of the tale.
"When I was growing up," he says, "it turned out that I got good grades in science. So I went to medical school at the University of California in San Francisco and then did my residency at the Mayo Clinic in Rochester, Minnesota."
He has been a dedicated student of medicine ever since.
"There is no question changes must be made," he says in discussing the health plan. "We can't continue drifting this way. We'll go broke as a country and there will eventually be a revolt among the people."
He thinks the future calls for hard choices.
"What kind of care are we going to provide?" he asks. "There are some ethical choices in medicine that must be addressed."
For one thing, Eckstein points out that if the millions of people who are currently uninsured are given cards for free medical care, there will not be enough doctors to handle them all.

He stresses that there is already a shortage of doctors who specialize in primary care. Many doctors run up tuition loans of $100,000 during medical school and thus gravitate to specialty fields in which pay is much higher.

"When I was in medical school, the internist was much admired as someone whose breadth of knowledge in the field was so wide," he says. "If we are going to get doctors back to practicing general medicine again, we must make it seem more attractive."
Eckstein wonders how the Clinton health plan will view some procedures that now receive great amounts of publicity.

How will we treat young children? He cites the example of the expensive surgery that was recently employed to separate Siamese twins who had only one heart.

"We ought to say that an operation like that is research and that it must be paid for by the government because there is a lot of knowledge to be gained.

"But in a world of finite resources, should we spend $2 million for that operation or should we use those funds to perform 20,000 immunizations on indigent schoolkids?"
Eckstein hesitates.
"Spending money like this is a decision that society should make, not doctors. We shouldn't be making societal decisions. Once you do that, we are all heading down a slippery slope."
He fears we will reach a situation in which some surgeries won't be performed because it will be decided we can't afford them.

"The decisions to operate must be made on medical decisions and not on the fact that the family has no insurance. Doctors should not be put in that situation."
He cites a recent case in which a young child was born without a brain. The child was kept alive on life supports and the mother refused to remove them. She said it was God's will to keep the child alive.

"Do we spend $3,000 a day to keep this child alive? Do we keep people alive who have had massive strokes and will never again be able to have a decent quality of life?"
Eckstein points out that in England, if you are past the age of 60, you do not get a kidney machine. If you are 70, you don't get coronary bypass surgery.

He wonders whether the new system will approve things like bone-marrow transplants for breast cancer. Can we afford to spend this money on one person when there are so many other patients to be treated?

There are other concerns. Eckstein points out that the government promises to simplify the filling out of forms. A great deal of hospital costs is now tied up in clerical work.

"I don't underestimate that," he says, "but I get a little leery when the government says they can simplify things. I've never seen that happen before."
Eckstein worries, too, about an insidious form of pressure that might weigh upon doctors in making their decisions.

"The doctor plays the major role in deciding what gets done," he says. "If we say don't operate or we say let's treat this with medication, the decision has been made. No one questions what the doctor does."
But Eckstein realizes that there is a wide spectrum of decisions made by doctors. Some, he says, are very good. Some are poor.

"American doctors have not lived with uncertainty. Our drive is to get the final answer. So we order the extra test. Sometimes these decisions are defensive and driven by a threat of litigation. I would hope I never make a decision based on the fear of litigation."
Eckstein has concerns, too, that the new system might place the doctor in the role of a gatekeeper--the man who says no treatment can either be provided or is needed.

Some doctors might get the feeling they are being pressured to cut costs.
"Those messages get through to the doctor," he says. "The word filters down. Maybe you should stop doing this procedure. Maybe you should back off. Don't order so many tests."
He believes there is often a legitimate controversy about how to treat patients.

Sometimes an expensive surgery is cheaper in the long run. The medical problem is solved quickly. You don't have to see the patient so many times.

He cites the question about when to order expensive magnetic resonance imaging tests that cost about $1,000.

"The patient is a 28-year-old woman. She is a wife and mother of three young children. She also has a full-time, pressure-filled job as a junior executive, as well as her full-time home responsibilities.

"She comes to me for chronic headaches of eight years' duration which began shortly after she jumped on this incredible treadmill which she is on. After a thorough history and physical examination, I conclude that her headaches are classical for stress-type headaches. I also learn that she had a completely normal MRI scan of the brain two years ago for these same headaches.

"Nevertheless, she asks me, 'Doctor, don't you think another MRI of the brain is necessary, just to make sure I don't have a slow-growing brain tumor?' Without hesitation, I say, 'Absolutely not. What you need is some time-management counseling and, better yet, a realistic solution to your overworked and overloaded life.'

"Now, was that the right decision not to order another MRI of the brain? In my view, of course it was. Some doctors would not agree. But in my view, they are either poor medical decision makers, or they are excellent profit-motivated decision makers because they have a financial interest in their MRI machine. The cost savings in health-care dollars for not ordering the MRI--$1,454."
And yet, Eckstein realizes there is a fine line between becoming a gatekeeper who emphasizes only the saving of medical costs and a doctor who employs the best methods for each case.

"The problem," he says, "is that the gate can too easily turn into a wall.


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