Your Doctor Is Not In was written by an internist in solo private practice who is also executive director of the Association of American Physicians and Surgeons. Dr. Jane M. Orient is a gifted writer and a prominent figure in the health care reform discussion, who here addresses many of the problems with our health care system and offers solutions.

In 18 chapters, the author discusses why national health programs don't help the poor, what the politicians really mean when they say you have a right to medical care, why the private doctor is an endangered species, why you probably don't know what the Hippocratic oath really says, why every fee under Medicare's relative value scale (the RBRVS) is wrong, and why the public accepts the idea of slavery for physicians.

The author argues that access for all means access to nothing, that the purpose of managed care is to prevent medical care (and save money for third parties or the government), that practice guidelines are not the answer to cost and quality, and that the cost of government regulation is measured in lives as well as in dollars. Finally, she discusses the free-market changes needed to allow Americans' health care to remain the best in the world.

Dr. Orient reminds us that in a college debate, the affirmative always has the burden of proof. Regarding national health care, she suggests that we "ask the advocates of socialized medicine...to point to a socialized system elsewhere that is fiscally sound, not plagued by waiting lines, and not experiencing a crisis in its own perception." As she notes, all bureaucratic systems have the same problems: power tends to corrupt, and central planning doesn't work. A central committee cannot make good decisions for individuals. Central planning of health care has failed miserably in the Soviet Union, China, Sweden, Great Britain, and Canada.

For example, she evaluates the "free," universal, compulsory Canadian system (now rapidly "disintegrating," according to Canada's own news media). It is the second most expensive system in the world, which is paid for through inflation, high taxes, and a huge national debt. The health care portion of the provincial budgets is one third and is steadily rising. According to Canadian politicians, "health care spending is on a collision course with economic realities." Moreover, she cites the estimation that some 250,000 Canadians are on waiting lists for major surgery. Canada's Native American infant mortality rate is twice as high as ours, and their patients with cancer, heart disease, and chronic renal failure have a shorter life expectancy than ours. Finally, Canadian health care is two-tiered, with the (smaller) uppermost tier coming to the United States for care.

Turning to our own system, Dr. Orient comments on politicians, Medicare ("essentially bankrupt"), RBRVS (a "fundamentally bad idea from the beginning"), managed care, the Clinical Laboratories Improvement Act, and the Food and Drug Administration.

As Dr. Orient points out, the cost of ensuring safety through government regulation is enormous. For example, ...the fifty-three-volume Code of Federal Regulations has grown from 16,502 pages in 1954 to 200,000 pages in 1990, following an exponential growth curve with a doubling time of approximately ten years....To enforce these regulations, there are about 122,000 federal bureaucrats costing each American household at least $4,000 to $5,000 per year, or about 20% of its average after-tax income.

Excessive government regulation raises the already high cost of medical care in our system, thus preventing access to that care by the patient.

To reverse these effects, the author calls for a return to "individual responsibility, the protection of property rights, the supremacy of the rule of law (as opposed to arbitrary police actions), and the accountability of the government." She also calls for a revision of the tax laws, giving preference to employee-based health insurance. Believing that people will respond to incentives, she would change these incentives through medical savings accounts. She also would repeal expensive insurance mandates imposed by the states and reform the Medicare program.

Your Doctor Is Not In offers rare insight, from a clinician involved in direct patient care, into many of the problems that beset our health care system. The author relies on experiences from her medical training, work in the Veterans Affairs system, and medical practice. Her solutions, based on the primacy of individual rights and relying on the power of free-market principles, would allow health care once again to be based on the time-honored patient-doctor relationship, free from third-party interference. This book fills an important void in the literature of health care reform and provides valuable information for patients, nonclinical physicians, and health policy analysts.