Fellow patients!

A few months ago --

because I had to take a leave of absence to finish another writing job -- I ended the first seven months of this experiment.

More exactly, this column, The Patient's Advocate.

The Patient's Advocate is an attempt to give patients -- myself and others -- some ways of navigating modern medical care, some help in coping with the complications and frustrations of the doctor's office, the busy hospital, the many new health plans.

In the apt phrase of the editor who wrote the headline for the first of these columns last October, it is an attempt to provide some guidance in "mastering the medical maze."

There may be more than one way to do this, but the way of this column is mainly to share ideas rather than present perfect solutions.

This way has apparently given one reader a very large pain. When my editors announced that I would be on a brief leave, she wrote them: "From the looks of his columns, he needed it."

Her most serious complaint, in a long list, was that I was "dancing on a tightrope between trying to be a 'patient's advocate' and trying not to antagonize the medical community."

Trying not to antagonize the medical community?

Very possibly so to an extent, but far from completely so.

Let me explain.

As a reporter and as a citizen, I believe in subjecting the medical community -- doctors, hospital administrators and workers, everyone else who gives us our care -- to the same kind of criticism that every other element of society, including journalism, ought to get.

I believe doctors who deserve it should be criticized for arrogance, incompetence, greed and fraud. I believe the whole health community should be criticized, even castigated, for helping create or tolerate a system that lavishes care on the affluent and, increasingly in the past few years, gives shorter shrift to the poor.

I believe the American Medical Association and most of the rest of the health establishment deserve scathing criticism for the way they have had to be pushed, kicking and screaming, into taking any really bold actions to hold down the often disgracefully high cost of health care.

I abhor a system in which we pay some doctors hundreds of thousands of dollars a year -- yes, there are some earning such incomes -- for caring for patients, while we scratch for enough money to hire decent doctors and stock enough drugs at a semi-starved public hospital like D.C. General and many others.

But I also believe two other things.

First, I believe we all deserve a share of the blame for all these scandals.

This month four medical scholars at Boston hospitals and Harvard University reported on Boston death rates in infancy, childhood and adolescence in blacks compared with whites and the poor compared with the more affluent.

Boston is probably the most hospitaled and doctored big city in the United States. It has almost a plethora of medical centers, hospitals and clinics with doors open to the poor as well as the rich. In the language of this study, Boston children have "unusually high access to tertiary health services," that is, the most advanced care as well as family clinics.

In other words, high quality medical care is available in unusual degree in Boston to the poor and minorities. Yet, these scholars found, poor children and black children had significantly higher death rates from cause after cause. As infants, they died of prematurity, low birth weight and all the illnesses that go with these conditions. As children, they died of respiratory diseases, mainly pneumonia, among other illnesses, and they also died in inordinate numbers in fires and other accidents and, as they became adolescents, of shootings and stabbings.

Few of these differences in death rates, if any, had to do with differences in the availability of medical care. "Equitable access to all forms of medical care must remain an essential goal," these authors concluded. But these differences in deaths mainly "reflect the profound inequities that seem to shape their social environment."

In short, we can't blame all these dead children on doctors or the medical community. We had better blame ourselves.

This is not to say that in some American communities today there is not rampant "patient dumping": closing hospital doors to those who can't pay and shunting them to often inferior medical facilities. But most of this policy-making is in the hands of administrators and finance officers -- who, after all, have to pay their bills to keep their doors open at all -- and not doctors. Flaying the AMA won't help a bit.

Second, in reply to my reader-critic, I may sometimes still flay the AMA and organized medicine and individual doctors for their sins. But when I as a patient, or you as a patient, go to the doctor or hospital, our goal at that point should be getting well, not social reform. Getting well and keeping well in an often difficult system is the topic of this column most of the time, though I promise that it won't shun social reform.

When I go to the doctor's for care, it won't help at all and may very well hurt me if I go in with a chip on my shoulder about my doctor's occasional lapses or the AMA's failures. What I need to understand to get well is that I must bear a great deal of the responsibilty for my own care. I need to learn how to get the best out of doctors and nurses. I need to understand that doctors are human. Most are not villains.

Not every doctor but most are indeed caring, concerned people who are subject to many pressures and are therefore sometimes curt and unhelpful. I need not always take this in silence. I need not endure coldness or bad care. I have a right to speak up and complain if I think I'm being shoved around.

I can also walk out of my doctor's office and go elsewhere, and in today's increasingly competitive medical world, there are plenty of elsewheres where most paying patients can go -- though fewer, once again, for the non-paying.

There is a lot more we need to know in today's complex medical world. But doctor-bashing -- going into doctors' offices with chips on our shoulders or blaming doctors for all of society's sickness and death -- is not, in my opinion, the road to either personal health or social progress.

So I will continue, in my reader-critic's words, to try to dance "on a tightrope" between being a patient's advocate and "trying not to antagonize the medical community." But I will do so, I might add, only where antagonizing is simply inappropriate. Where criticizing is necessary and antagonizing is the price, so be it.

My reader-critic also says that month by month I became "increasingly inconsistent" and "illogical." I'll leave the decision on "illogical" to you, but as for inconsistency, well, that's a little more complicated.

She points out, for example, that in one instance I wrote "the chart is not the patient" and advocated better, more thorough communication between doctor and patient.

And elsewhere I said "good doctors are busy doctors with other sick patients," and there are times when a "two-minute glance at you may reveal all that's needed" -- when you're in the hospital, say, and the doctor, if conscientious, has spent some minutes reading the notes on your chart, looking at your X-rays and tests and possibly consulting about you with the nurses and even other doctors.

Well, all these things are true. Sometimes my doctor gives me a lot of time. Other times he's obviously in a hurry. Sometimes I'm satisfied, sometimes not. I'd certainly scream if I never got more than a few minutes. It's all a matter of balance, and, if I sometimes seem inconsistent, it is partly at least because the same advice does not hold at all times and different situations call for different tactics and tolerances.

And let's face it -- we're all inconsistent sometimes.