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Having a foot in both camps: the impact of Kerr White's vision.

It is a pleasure, as one of Dr. White's former students, to provide a brief commentary on his article (White 1995). He spoke eloquendy in that paper of the classic work he performed on the ecology of medical care and the implication of that work for both the field of health services research and clinical care (White, Williams, and Greenberg 1961). It is a message that unfortunately still has not been received in many parts of the academic medical community. The interface between clinical care and public health, and the differences in the quality of care provided at sophisticated referral centers and community-based clinics lie at the very heart ofboth the problems and the prospects confronting managed care. In our new managed care environment, physicians, now more than ever, would do well to heed the content of Dr. White's article. Up until now, medicine has been taught and practiced from the perspective of a "user" mentality; that is, the physician should serve as an advocate for the patient and do everything possible to make the patient well. However, all of a sudden, groups led by physicians, not insurance companies, have been negotiating successfully both for patients and money. In essence, they have acquired, through various governance structures, the power to control both how the budget for healthcare is spent and the population ofpeople forwhom they'll be providing care. For the first time, physicians in real-time medical practice are addressing such questions as: What share of medical resources do I provide to those who visit my office, and what share do I distribute to an outreach program targeting those who are likely to need necessary care? Should I trade off giving the better-contrast material that produces fewer reactions after angiography for a less adequate dye, in exchange for an outreach program thatwould increase the number ofwomen between the ages of 50 and 69 who receive mammography, have their breast cancer detected earlier, and thus live longer? Physicians today must perforce consider the principles embodied in the ecology of medical care described by Dr. White so many years ago (White, Williams, and Greenberg 1961).