Dear Al,

I apologize for the delay in answering your letter,
but I have been playing with my grandchildren, as well
as pamphleteering on the Healthre List in an exchange with
Bob Fink. I hope you will have a chance to read it and
give me your candid advice. I need well-intentioned friends
like yourself to keep me out of mischief and trouble.

It is kind of you to ask me for my opinion and my advice.
However, there is so much that I don't know and and that
I don't understand, so when I talk, I remind myself of old
Polonius in Shakespeare's Hamlet who mouthed platitudes,
blind to the turmoil and chaos of the world to which he
spoke.

Fifteen years ago or so, when my son Klemens was choosing
a career, I explained to him that of all the professions,
medicine was closest to the realities of our lives, because
it concerned our bodies and minds, whereas the law occupied
itself largely with fictions concocted from fear and selfish-
ness. I still feel that way, and would cherish my profession
even if it never earned me a dollar. But I would rather dig
ditches than work for an HMO. Klemens became a nephrologist
and now directs the dialysis unit at Tufts New England Medical
Center.  He has made a tenuous peace with the new state of
things, and flies regularly to Washington to advise NIH about
the needs of his patients.

I think it is our ages, I will be 65 in June, which make you
and myself so averse to the new order in medicine. We know that
we are too old to make a fresh start. We will not be given the
time necessary to adapt to managed care and such things; and the
old order, with which we had come to terms, is gone. But I am 
not a reactionary; I always wanted to be my brother's keeper,
and my profession never supported me. So I am pleased that things
are changing, although I fear it is for the worse.

Tell your daughter to be of good cheer. Her children, if she is
fortunate enough to have them, will surely think she is the world's
greatest pediatrician, and I think that is all that matters.
I see a close analogy between contemporary developments in medicine
and the state of our public schools, whose teachers have about as
little freedom to be themselves as do physicians in the HMO's.
And yet there are very many dedicated and effective teachers,
even in the most dismal of public schools.

Besides, our country is so wonderfully free. What one can do is
limited only by ones imagination, intelligence and energy. On my
agenda are writing a second novel, building with my own hands,
a house on some vacant farmland in New Hampshire, organizing a
peer review project to make the HMO's behave, transcribing into
computer files, the keyboard works of J.S. Bach, and most important
of all, practicing what I have tried to tell my patients, looking
forward with courage and confidence, and perhaps a little bit of joy,
to the end of things.