College and Research Libraries


Book Reviews 

Ayres, Stephen M. Health Care in the 
United States: The Facts and the Choices 

· (The Last Quarter Century: A Guide 
to the Issues and the Literature, no. 
4). Chicago: American Library Asso-
ciation, 1996. 275p. $38. (ISBN 0-8389-
0663-X.) 

Despite the failure of national legislation 
for health care reform, the restructuring 
of America's health care delivery system 
is under way. The trend away from spe-
cialist, inpatient health care toward gen-
eralist, outpatient care has created frac-
tures in well-established models of health 
sciences education and practice. Educa-
tors are redesigning the curriculum, and 
administrators are seeking new ways to 
support students and reward preceptors. 
Also, the nature of office-based practice 
in a managed care environment demands 
that practitioners change their behaviors. 
They must learn to compute disease 
probabilities for the populations they 
serve, to follow externally defined prac-
tice guidelines, to treat problems that 
were once referred to colleagues, and to 
involve patients actively in their own 
care. 

The political, social, and economic fac-
tors that are causing these . changes are 
complex and interrelated. In this volume, 
Stephen M. Ayres, M.D., former dean of 
the School of Medicine, Medical College 
of Virginia, attempts to help the general 
reader understand both the current U.S. 
health care system and recent attempts 
at its reform. Specifically, the book "ex-
plores the general health of Americans, 
the current American medical enter-
prise's contribution to good health, 
changes that could improve the public 
health, and the failure of elected leaders 
to change the system when the public so 
clearly supports reform." 

The volume begins with a brief his-
tory of the growth of scientific medical 

579 

practice, provides an over-
view of concepts of health 
and disease, and reviews the 
current professional training 
of doctors and nurses. Then, 
the author summarizes the 
economic and political struc-
tures that have developed around pro-
fessional practice and health care deliv-
ery. After exploring the problems with 
the current system, he concludes with a 
review of President Clinton's failed 
health reform initiative and a proposal 
for change. 

Detailed footnotes and an annotated 
bibliography follow each chapter. Books 
dominate the bibliographies, and book 
titles and authors are listed in the index. 
Periodical literature is referenced in the 
footnotes of most chapters; index access 
to those citations is limited to author 
names that point to the original text ref-
erence. The index also includes subjects 
and some essay titles. An appendix of 
selected resources for research on health 
care is included at the end of the volume. 
Written by Claire Hoffman, a librarian at 
the Tompkins-McCaw Library, the guide 
suggests a general research approach and 
recommended starting points. Examples 
of print and electronic resources are 
listed, as are the names and addresses of 
fifteen public policy organizations. 

Ayres provides a useful overview of 
the many sociologic and economic fac-
tors affecting health care. He cares deeply 
about the issues, does not hide his views 
about the need for reform, and offers a 
proposal for reform that is "understand-
able, workable and cost-effective." His 
writing style wavers between academic 
and conversational: some sections are 
carefully annotated and some are not, 
some are carefully neutral in tone and 
some are not. The author draws heavily 
upon a core set of published medical 



580 College & Research Libraries 

sociologies, particularly Paul Starr's The 
Transformation of American Medicine, Vic-
tor Fuchs's Future of Health Policy, and a 
1977 issue of Daedalus devoted to Ameri-
can health care. 

Two major flaws detract from the over-
all success of this book. First, the final 
editing was inadequate: there are numer-
ous errors of typography (e.g., Stark in-
stead of Starr in the index, Harry & Louis 
in the text) and style ["Older men (and 
they were almost always male) ... "].The 
data in the columns labeled "Developed 
& Developing" in figure 2-2 seem to be 
reversed, given assertions made in the ac-
companying text. Concepts are often in-
troduced without explanation (e.g., 
'overbedded hospitals'), and unsup-
ported assertions abound (e.g., "Unfor-
tunately, the use of discounted fees and 
the employment of thousands of new 
people ... have destabilized the health 
care system"). The same sentence ("One 
physician bucked the tide of medical ob-
struction ... . ") appears on page 131 and 
again on page 177; it also contains an 
unreferenced quote. Though often merely 
a nuisance, preventable errors such as 
these detract from the authority of the 
text. 

The second flaw relates to the integra-
tion of concepts across chapters. The 
chapters seem to have been written to 
serve as self-contained units. This can be 
disconcerting for those readers who at-
tempt to read the book from cover to 
cover. For example, the same statistics are 
reported in several different places, and 
some concepts (and some reference 
works) are introduced and explained sev-
eral times, each time as if they were new 
to the reader. Frequently referenced 
books (such as those by Paul Starr) ap-
pear in several chapter bibliographies, 
sometimes with a different annotation. 
More important, introducing only that 
piece of a concept which relates to the 
theme of the chapter makes complex top-
ics such as managed competition and the 
role of third -party insurers difficult to 

November 1996 

follow and synthesize. This approach 
may leave readers of a single chapter 
with the false impression that they know 
everything the author has to say about a 
given issue. 

In short, the volume is a mixed bless-
ing. For careful general readers, it ex-
plains some of the health care reform is-
sues that appear daily in newscasts and 
newspapers. Via footnotes and bibliog-
raphy, it suggests some beginning points 
for those who want to explore a topic in 
more depth. It is probably most appro-
priate for a public, high school, or com-
munity college library, but I would not 
recommend it for an academic health sci-
ences library.-Valerie Florance, University 
of Rochester Medical Center. 

Greening the College Curriculum: A Gu.ide 
to Environmental Teaching in the Liberal 
Arts. Eds. Jonathan Collett and 
Stephen Karakashian. Washington, 
D.C.: Island Pr., 1996. 328p. $40 cloth 
(ISBN 1-55963-421-9); $22 paper (ISBN 
1-55963-422-7.) LC 95-39225. 

Published as a project of the Rainforest 
Alliance, Greening the College Curriculum 
was purportedly prepared to mainstream 
environmental education in academe. 
Although intended for the use of faculty 
members interested in integrating envi-
ronmental teaching into their discipline-
based courses, faculty to whom this con-
cept may be new, administrators, and 
trustees also might benefit from perus-
ing this volume for the thoughtful and 
thought-provoking ideas it explores. 

The core of the work comprises ten 
discipline-specific chapters. Covered are 
anthropology, biology, economics, geog-
raphy, history, literature, media and jour-
nalism, philosophy, political science, and 
religion. Each chapter is written or 
cowritten by a professor or professor 
emeritus of the discipline under review. 
The editors acknowledge lapses in cover-
age and suggest that other areas may be 
treated in a second edition. They also state 
that sociology was deliberately omitted