The government has signed a contract to pay $850,000 for development of "practice guidelines" and "protocols" to tell doctors how to treat an ear infection, a $20 problem. If the Clinton administration has its way, there will be protocols for the treatment of virtually every ailment. Yet there is no evidence that protocols save money or improve quality. Nurses, for instance, outperform protocols in deciding how to treat abdominal pain.

So why aren't doctors raising a cry of alarm? Many have been browbeaten into submission, or have discovered that it's easier to play the game than to buck the system. But also, a different type of person is entering medical practice these days. Although the evidence is largely anecdotal, Dr. Orient says that the best students are avoiding medical schools and the schools are lowering their standards. (In 1990, 16% of medical graduates flunked the national boards, compared with 9% in 1984.)

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