Born in Chicago, educated at Harvard and St. Louis's Washington University Medical School, 47-year-old Knowles is a Boston Brahmin by adoption. He commutes by air from his New York office to spend each weekend with wife Edith and their six children in their suburban home near the Country Club in Brookline.
Lee Wohlfert of PEOPLE met with Dr. Knowles at the Rockefeller Foundation to talk with him about himself and current issues in health care.
What do you feel is wrong with American medicine today?
Well, one thing is that a certain segment of specialists—some surgeons, radiologists, pathologists and anesthesiologists—are making up to $170,000 a year, which is exorbitant! When you couple this with the fact that doctors have the highest median salary—$60,000—of any profession in the country, it's clear things are getting out of hand.
This is due to a general inflation of income following Medicare, the skyrocketing volume of patients—and the amount of unnecessary surgery. Since I began to criticize doctors for "making a killing" the government has passed the Health Maintenance Organization Bill to encourage group practice, which improves medical care for less cost.
In what ways?
It tackles the three major issues in medicine or any other service which improves life—cost, quality and accessibility. It's been shown time and time again that when you group physicians together, both generalists and specialists, their work improves.
Under group practice, the doctors are salaried; their salaries come from contracts with large groups of consumers. With group practice you can decrease the amount of unnecessary surgery—and therefore hospitalization—by as much as 50%, in comparison with doctors who are paid on a fee for service basis.
What do you mean by unnecessary surgery?
I mean the unnecessary removal of tonsils, uteruses and discs in the back, hemorrhoidectomies, knee operations, operations for low back pain. In many cases, if you examine the organs that have been removed you find they are perfectly normal. The patient has complained only of vague symptoms and not intolerable pain, and conservative therapy should have been tried and wasn't.
Why would doctors practice unnecessary surgery?
Often out of expediency or ignorance—if they work by themselves instead of in a group where advice and consultation are readily available, or out of avarice. Working on a margin, a doctor can somehow rationalize having to do the surgery because he is building a home out in the country, or his wife needs a new car. In our time, far more people have been harmed by unnecessary hospitalization and surgery than have been harmed by not having enough.
What should be done?
We have studiously avoided the prevention of disease or the maintenance of health. We spend $94 billion a year—the largest percentage of the Gross National Product of any country in the world—on health, and you look at our health statistics and wonder what is wrong.
I feel that the health services in this country have got to be structured so that the patient prepays a flat, per capita annual rate and is guaranteed comprehensive treatment by groups of physicians. Some such health maintenance organizations are already operating very successfully.
What do you think of the various national health care plans now before Congress?
I think the new Nixon bill and the Kennedy-Mills proposals are desirable, both good. They both go in the right direction of reducing financial costs and putting more emphasis on standards of quality.
What about the notion of policing doctors?
I think it's too bad, but it's necessary if they can't do it themselves. The Professional Standards Review Organizations, recently authorized by Congress, look at medical quality on a regional basis. It's a bureaucratic attempt to improve that quality.
How does it work?
The program is organized and administered by physicians to evaluate medical care in their area under federal programs. There also are advisory groups of citizens to convey the layman's point of view.
Why lay people on these review boards?
Well, as Aristotle said, "The guest will judge better of the feast than the cook." While physicians still dominate, I'd agree with British socialist Harold Laski—"The expert should always be on tap—but never on top."
Organized medicine was unalterably opposed to PSRO, madder than hell. But the people of this country can't and shouldn't tolerate uneven quality and costs going up.
What can the average patient do now if he feels a doctor is charging too much, or is guilty of malpractice?
Right now, he can't do a hell of a lot about it except appeal to the hospital director. If he's going to a private doctor he can appeal to the state medical society, which rarely results in much satisfaction. He can also appeal to his state's department of health to look into the doctor's practices. Or he can hire a lawyer, which is damned expensive. Under the PSRO, hopefully, he'll be able to get a much more rapid answer to his grievance, but I wouldn't hold my breath on it. I just say: if someone recommends surgery on you—get a second opinion. That reduces surgery by 20% in many communities.
Where does the American Medical Association stand?
They are very powerful and have almost consistently lobbied against things that were needed by the people—the public health program and Medicare, which they fought for 30 years. They lobbied against the group practice mechanism hammer-and-tongs. Every major piece of legislation or social change in this country which has benefitted the people has been steadfastly fought by the AMA. I think they are a relatively humorless bunch of merchants and that's it.
But they are the far right keeping the far left honest, and so I think they do perform a function, because their counterpart, the far left, is equally doctrinaire and ideologically frozen.
You were nearly appointed Assistant Secretary for Health and Scientific Affairs in 1969. What happened?
The American Medical Association effectively blocked it, primarily through Ehrlichman and Haldeman. They told the President not to make the appointment and told then Secretary of HEW Robert Finch to get someone else.
Why did the AMA do that?
The AMA said, "Gee, this guy is a flaming liberal, and we don't like him." The hell I was! I kept browbeating the AMA to do something themselves to show the people of this country that a private voluntary organization could set priorities and live up to them. How the hell could organized medicine say that I was a flaming liberal when I was running a voluntary private hospital of which there are few better in this country.
What has the Rockefeller Foundation done for health since you have taken over?
In this country we have focused primarily on the problems of population, size of the family, ways of achieving population stabilization—all of which relates to the health of the family and the community. We have set up study centers at such places as the University of California, Yale, Harvard and the University of North Carolina.
Before you decided to head up the Rockefeller Foundation you considered running for governor of Massachusetts. Would you again?
When I came here the trustees said, "How do we know you aren't going to run for political office? You could be using this as a platform." I said, "I've never used a job to go looking beyond. When I go to Washington I don't call up the big boys and pay my respects." Generally speaking, I'm not terribly popular with politicians. How many of them are responsible for allocating $45 million a year, as I am, with the only charge being to promote the well-being of mankind throughout the world?
From his days as the youngest director ever appointed to the huge Massachusetts General Hospital in Boston to his presidency since 1972 of the influential Rockefeller Foundation, Dr. John Knowles has established himself as something of a consumer advocate in medicine.