MDs give "Needs Improvement" grade to U.S., Canadian and German health systems.

• Position: Physicians

Doctors in the United States, West Germany and Canada believe their health systems all need fundamental reform, according to a survey in the New England Journal of Medicine. The survey indicates that no country has found the panacea for providing affordable, quality health care for its citizens. But U.S. doctors are least satisfied with their health system, citing lack of indigent care as the nation's most pressing health care problem.

* Only 23 percent of the U.S. doctors responding to the survey believe their system works efficiently, compared to 48 percent of West German physicians and 33 percent of Canadian doctors.

* U.S. physicians believe the major problems with our system are lack of access to care by indigent patients (55 percent) and the high cost of care (38 percent). Only 1 percent of Canadian physicians and 5 percent of German doctors mention indigent care as a problem. Canadians are concerned by patient overuse of the health care system (30 percent) and limited access to health care facilities (17 percent). Germans mention the high cost of care (32 percent) and administrative burdens (25 percent) as their top concerns.

* Half of the Canadian respondents are concerned about an inadequate number of well-equipped health care facilities.

* West German doctors are least satisfied with care for the frail elderly. Only 15 percent of them rate these services as excellent or good, compared to 44 percent of U.S. physicians and 36 percent of Canadians.

* More doctors in the United States than in the other two countries believe their patients should seek care earlier.

* A majority of both Canadian and U.S. primary care physicians (66 percent and 60 percent respectively) believe that patient demands for more services than doctors believe...