Why have these improvements in doctors' training not significantly upgraded the overall care of patients? Three recent examples:

• A pregnant woman goes into premature labor and is bounced from one emergency room to another until she starts hemorrhaging and is admitted, comatose.
• A young woman faints in the heat and is brought to a large city hospital where the resident does blood tests and gets a CAT scan -- all because of the hospital policy to practice "defensive medicine" and avoid lawsuit.
• An alcoholic, at the end of his three days of insurance coverage in Boston, tells the claims person -- a teenager in Topeka -- that he's afraid to leave and asks: "What am I gonna do?"

  "Go out and get drunk," she says, "and we'll readmit you for another three."

These examples reflect the larger picture. None is cost-efficient or an example of good care. Preventive care is not valued. Hospitals are less available -- in the past several years approximately 1,000 hospitals (of a total of 6,000) closed their doors. The ones still in business are overwhelmed, cutting costs. Because of cost cutting and insurance industry pressure, the time a resident can spend per visit with any one patient is severely limited. The hospital stay is dangerously foreshortened, so the resident never really gets to know the patient well, never gets to use these new humanistic skills. Paperwork and defensive tests consume the resident -- about 25 percent of the $1.66 trillion per year health budget goes to administrative costs -- $399.4 billion a year for pushing paper instead of patient care. Because of all this, mistakes are rising: Your chance of being a victim of a mistake during your hospital stay is over 50 percent.

The reason doctors can't provide good care is that the American health care system prevents it. Doctors can't give the care they aspire to; patients feel the limited care.