A Toast to Doctor Franklin

Benjamin Franklin

Benjamin Franklin's formal education ended with the second grade, but he must now be acknowledged as one of the most erudite men of his age. He liked to be called Doctor Franklin, although he had no medical training. He was given an honorary degree of Master of Arts by Harvard and Yale, and honorary doctorates by St.Andrew and Oxford. It is unfortunate that in our day, an honorary degree has degraded to something colleges give to wealthy alumni, or visiting politicians, or some celebrity who will fill the seats at an otherwise boring commencement ceremony. In Franklin's day, an honorary degree was awarded for significant achievements. It was far more prestigious than an earned degree, which merely signified preparation for later achievement.

And then, there is another subtlety of academic jostling. Physicians generally want to be addressed as Doctor, as a way of emphasizing that theirs is the older of the two learned professions. A good many PhDs respond by rejecting the title, as a way of sniffing they have no need to be impostors. In England, moreover, surgeons deliberately renounce the title, for reasons they will have to explain themselves. Franklin turned this credential foolishness on its head. Having gone no further than the second grade, he invented bifocal glasses. He invented the rubber catheter. He founded the first hospital in the country, the Pennsylvania Hospital, and he donated the books for it to create the first medical library in the country. Until the Civil war, that particular library was the largest medical library in America. Franklin wrote extensively about the gout, the causes of lead poisoning and the origins of the common cold. By inventing bar soap, it could be claimed he saved more lives from infectious disease than antibiotics have. It would be hard to find anyone with either an M.D. degree or a PhD. degree, then or now, who displayed such impressive scientific medical credentials, without earning -- any credentials at all.

The First and Oldest Hospital in America

Pennsylvania Hospital

There is a painting of the region around 8th and Spruce Streets in the 1750s, depicting a pasture, with cows, and three or four buildings between 8th and 13th Streets. When the Pennsylvania Hospital moved there in 1755 from its temporary location in a house located a block from Independence Hall, there were complaints that it was now located so far out in the woods that it was difficult and dangerous to go there. Still another description of the area is evoked by the provision which the Penn family placed in the deed of gift of the land, strictly forbidding the use of the land as a tannery. Tanneries have always been notorious for giving off noxious odors, so most people wanted them to be somewhere else, anywhere else. In any event, the main activity of Penn's "green country town" at that time was concentrated closer to the Delaware River, and the nation's first hospital was definitely placed in the outskirts. Two blocks further West the almshouse was already in place, but not much else. We are told that Benjamin Franklin had flown his Famous Kite at 9th and Chestnut, using a barn there to store his materials. It might be recalled that the population of Philadelphia, although the second largest English-speaking city in the world, was only about twenty-five thousand inhabitants at the time of the Revolution, and in 1751 was even smaller.

In any event, the first and oldest hospital in America was built on 8th Street between Spruce and Pine, and the Eighteenth Century buildings on Pine Street still present a breathtaking view at any season, but particularly in May when the azaleas are in bloom, and fragrance from the flowering magnolias fills the evening atmosphere for blocks around. Although some people today mistake the Pennsylvania Hospital for a state hospital, it was founded in the reign of George II, decades before there was such a thing as a State of Pennsylvania. The Cornerstone was laid by Benjamin Franklin, with full Masonic rites. Most doctors regard a hospital as a mere workshop, but the affection with which many Pennsylvania physicians regarded their special hospital is indicated by the number who have requested that their ashes be buried in the garden.

For two hundred years, beginning with the first American resident physician Jacob Ehrenzeller, the interns and residents were paid no salary, so they had to live on the grounds. An Interne was just that, interned within the four walls for at least two years. Because the resident physicians had no money, they stayed in the hospital at night and on weekends, playing cards and swapping stories. The hospital was home for them, as it was for the student nurses, likewise unpaid but more strictly confined and supervised. This penury seemed acceptable because the patients were mostly charity ward patients, otherwise unable to pay for their own care. Ehrenzeller finished his medical apprenticeship and went to practice for many decades in the farm country of Chester County, but gradually upper-class Philadelphia moved from 4th Street westward to and beyond the hospital, and two of the richest men in American history, Morris and Biddle, had houses within a block of the hospital, although Morris never lived in his house, having more pressing matters in debtor's prison. Therefore, later resident physicians at the hospital had the potential of setting up private practice in the area and becoming society doctors as well as academically prominent ones. Being a charity hospital in a rich neighborhood created the potential for volunteer work by the town aristocrats, and large bequests for charity. The British housed their wounded in the hospital during the Revolutionary War, and shot deserters against the red brick wall of the small cemetery to the north. A century later, there were a couple dozen rooms for private patients in the hospital for the convenience of the doctors and the neighbors, but everyone else was a charity patient. And a century after that, the hospital still did not have an accounting department to collect bills, and tended to regard people who asked for a bill as a nuisance. Benjamin Franklin is regarded as the Founder of the hospital, and his autobiography famously describes how he fast-talked the legislature into matching the donations of the public, not mentioning to them that he had already collected enough promises to see the project through. This seems in character; Franklin's biographer Edmond Morgan summed up that,"Franklin doesn't tell us everything, but what he does tell us, is straight." The idea for the hospital was that of Dr. Thomas Bond, whose house is now a bed and breakfast on Second Street, , but it was characteristic of Franklin to be the secretary of the first board of managers of the hospital. In Quaker tradition, the clerk of a meeting is the person who really runs the show. It thus comes about that the minutes of the founding board were recorded in Franklin's own handwriting, among them the purpose of the institution, which is to care for the Sick Poor, and if there is room, for Those Who can pay. This tradition and this method of operation continued until the advent in 1965 of Medicare, when charity care was displaced by concepts which the nation had decided were better. The Pennsylvania Hospital was not only the first hospital, but for many decades it was the only hospital in America. Its traditions, sometimes quaint and sometimes glorious, cast a long shadow on American medicine.

Nation's First Hospital, 1751-2008

As commonly stated in medical history circles, the history of the Pennsylvania Hospital is the history of American medicine. The beautiful old original building, with additions attached, still stands where it did in 1755, a great credit to Samuel Rhoads the builder and designer of it. The colonial building on Pine Street stopped housing 150 patients around 1980, supposedly at the demand of the Fire Marshall, although its perpetual fire insurance policy still owes the hospital several thousand dollars a year as unspent premium dividend. There may have been one small fire during two centuries of use, but its true fire hazard would be difficult to assert. It was just out of date. The original patient areas consisted of long open wards, with forty or so beds lined up behind fluted columns, in four sections on two floors. The pharmacy was on the first floor, the lunatics in the basement, and the operating rooms on the third floor under a domed skylight. It was entirely serviceable in 1948, when I arrived as an intern doctor. Individual privacy was limited to what a curtain between the beds would provide, but on the other hand it was possible for one nurse to stand at the end of a ward and recognize any distress among forty patients immediately. In this trade-off between delicacy and utility, utility was certain to be preferred by the Quaker founders. Visitors were essentially excluded, and if a patient recovered enough to be unnaturally curious about neighboring patients, well, he had probably recovered enough to go home.

Located between two large rivers, South Philadelphia up to ten blocks away was essentially a swamp until the Civil War. So, there were seasonal epidemics of malaria, yellow fever, typhoid and poliomyelitis at the hospital until the early twentieth century. Philadelphia was a port city, so sailors brought in cases of venereal disease, scurvy, even an occasional case of anthrax or leprosy. During the Industrial Revolution of the nineteenth century, tuberculosis, rheumatic fever and diphtheria were part of clinical practice. But underlying the ebb and flow of environmental effects, there was a steady population of illness which did not change a great deal from 1776 to 1948. These patients were all poor, because the rules in Benjamin Franklin's handwriting restricted service to the "sick poor, and only if there is room, for those who can pay." In 1948 there was a poor box for those who might feel grateful, but no credit manager or official payment office. The matter had been considered, but the cost of collection was considered greater than the likely revenue. When Mr. Daniel Gill was offered the position as the hospital's first credit manager, it was suggested that he be given a tenth of what he collected. To his lifelong regret, Dan Gill regretted that he refused an offer that he had felt he could not afford to accept.

So, the wards were filled with victims of the diseases of poverty, punctuated by occasional epidemics of whatever was prevalent. And a second constant feature of the patients was their medical condition forced them to be housed in bed. For centuries, physicians dreaded the news that a new patient was being admitted with "dead legs". Mental and neurological diseases presented a second major imperative for admission; such patients either couldn't walk or couldn't be trusted to walk alone. Coma or raging fever was another category of mandatory admission.

Therefore, the roster of patients who were in the Pennsylvania Hospital on July 4, 1776 was not substantially different from those who were present on July 1, 1948. The turnover was greater, because antibiotics made it easier to treat the disabling diseases of the poor, but the causes of admission were essentially unchanged. Instead of treating five dead legs a month, a modern physician might treat twenty, but after you have seen and smelled one dead leg, you have seen and smelled them all. Under the circumstances one Pennsylvania Hospital surgeon, Dr. C. Alexander Hatfield, became an internationally famous expert on the management of this class of conditions. But although scientific rigor was much elevated in the meantime, both Benjamin Rush and his distant descendant Alexander Rush undoubtedly experienced the same sights and smells when dead leg patients were wheeled into that same ward. The nurses curiously almost seemed to welcome such cases. They had been told exactly how to spring into action, and within an hour the odor and slime had disappeared; the nurses were very visibly proud of their accomplishment. It was a miracle only they knew how to conjure up; you could tell from their beaming faces that they had accomplished a triumph. We today can be fairly sure the patients in the hospital paid scarcely any attention to the commotion in Independence Hall on July 4, 1776 four blocks away. Just as the patients in the same beds were later unaware and unconcerned about the explosion of an atom bomb in Hiroshima, their focus was much more pointed. What was surely overpowering to both groups was the unbearable summer heat in Philadelphia before air conditioning. Modern physicians are astonished to learn what was then a commonplace: during a heat wave, almost every patient runs a fever. No one was taking their temperature, but it seems possible the doctors and nurses were running a fever as well.

Venereal disease is a constant among the poor. At present, the most prevalent condition is HIV/AIDS, but syphilis was a regularly fatal condition until it disappeared within a few years of the introduction of penicillin. About a sixth of the patients in the old Pennsylvania were suffering from syphilis on the day the Declaration of Independence was nailed to a post. Two hundred years later, a survey of the Philadelphia General Hospital revealed one Wasserman test in six was positive. Prostitution was supposed to be the underlying source. One thing was more or less unique. Other hospitals serving the poor reported a great deal of drug addiction, now delicately called substance abuse, but Philadelphia had remarkably little of it. In another essay, we have speculated on the likely cause of this anomaly, although in more recent days there is far less reason to remark about it. Gunshot wounds, then and now, provided evidence of the interactions between criminals and police; these fierce combatants seem universally meek and humbled when the medical establishment gets to see them.

For two centuries, the more things changed, the more they stayed the same. And then, in 1965, the heavens opened and Lyndon Johnson rained money in all directions. It took a few years for a mistrustful system to adjust to the idea that things had changed forever. A doctor could really do anything he knew to do, without concern about cost. The nursing school, the heart of the hospital, was not only unnecessary as a source of free labor, but actually an impediment to full Federal reimbursement of costs. Not long afterward, the resident physicians were actually paid a reasonable wage, after two centuries of being paid nothing at all. The large open wards were eliminated and replaced with semi private rooms, as insurance regulations insisted. The definition of poverty was changed to include people whose circumstances would have been considered luxurious before Medicare, so there are still thought to be poor people in the hospital. But the diseases of poverty are hard to find among all those people who would once have been expected to be treated in their homes. The floor space tells a story. Up until 1965, patients would have occupied 90% of the floor space of the institution, now they scarcely occupy 15%. The presence of patients, the reason for the institution after all, is far less dominant; doctors and nurses are a comparatively small proportion of the thousands of employees. That makes a big psychological difference. At one time, there was hardly anyone present except patients, doctors and nurses. Today, the other members of the medical industry predominate within these walls. There are many more computers than patients. But what is ultimately most puzzling is that so much more money is being spent on so much less disease. Life expectancy has increased by thirty years, several dozen diseases have disappeared, the disorders of 1776 which took months to treat are now cured in three days. It's all a very good thing, but it is puzzling.

July 4, 1776

According to the records of the Pennsylvania Hospital, the following 48 persons were patients in the hospital on July 4, 1776:

The records indicate the following diseases were the reason for admission of those patients. Although in Colonial times there was no medical delicacy to avoid offending readers, present privacy standards require that we strip the diagnoses from the name of the patient and list them independently. There is some overlap, sometimes making it difficult to judge which disorder caused the admission.

• Sore, poisoned or ulcerated legs: 16 cases
• Lunacy, mind or head disorders: 10 cases
• Syphilis: 7 cases
• Fever and Rheumatic fever: 7 cases
• Dropsy: 5 cases
• Gunshot: 4 cases
• Diabetes: 1
• Blindness with clear pupil: 1
• Spitting blood: 1 case
• Dislocated arm: 1 case
• Inflammation of face: 1 case
• Scurvy: 1 case
• broken arm: 1 case

The following physicians were elected at the Managers Meeting dated 5/13/1776:

• Dr. Thomas Bond
• Dr. Thomas Cadwalader
• Dr. John Redman
• Dr. William Shippen
• Dr. Adam Kuhn
• Dr. John Morgan

College of Physicians of Philadelphia

College of Physicians of Philadelphia

The College of Physicians of Philadelphia is the oldest medical organization in America, or even the Western Hemisphere, having been founded in 1787, the year of the Constitutional Convention. The CPP, located on 22nd Street near Market, is not to be confused with the American College of Physicians (a much more recent organization, formed in 1923 and located at Fifth and Arch Streets). The term "Physician" was then much more specific, and Philip Syng Physick, now known as the father of American Surgery was not considered eligible for membership because he was a surgeon, not a physician.

The general idea of the founding of the College seems to have been to focus on the physicians who had attended medical school (usually in Edinburgh), as distinguished from the general run of physician at the time, who had merely served an apprenticeship. The first medical school, at the University of Pennsylvania (then at Ninth and Walnut Streets, but now at 36th and Spruce) caused the College of Physicians to turn away from pedagogy to the direction of setting standards and providing a forum for the "better sort" of the profession to be self-governing. At one point, there was even a real possibility that the College of Physicians of Philadelphia would become the credentialing agency for the whole country, but licensing took the direction of state boards during the Nineteenth Century. Every book and journal must have a Library of Congress number. The Transactions of the College of Physicians of Philadelphia has a Library of Congress number, all right. Number one. Jonathan Rhoads, the giant of 20th Century surgery and the only person to be president of the College twice, once remarked that being first may not be terribly important in the greater scheme of things, but -- it's awfully hard to imitate.

The College was a very strong guiding force in the development of a system of medical ethics for the profession. A curious false turn was taken in the direction of Lambda Chi, a secret society of physicians for the purpose of invisibly policing medical conduct, but the College soon recognized this was the wrong direction to take, and eventually it assumed the lead in forming the American Medical Association in 1848. The portrait of Chapman, the first President of the AMA, hangs above the mantle in the fellows' reception room, the original minutes and rolls of the delegates are found in the library. Half a dozen presidents of the College were also presidents of the AMA, but for some curious reason the College never became the local branch of the AMA, reserving that for the State and Pennsylvania County Medical Societies.

Mutter Museum

Every year a number of the most distinguished physicians in the world address the College, and an annual lecture by a Nobel Prize winner has been established. The College had the largest medical library in the country until recently, and it is still one of the largest. The present building is a Carnegie Library, in a sense. Andrew Carnegie was a patient of S. Weir Mitchell at the time Mitchell was president of the College, and donated a large sum for a new building. The present elegant marble and walnut paneled structure was built in 1905, fairly recent by Philadelphia standards but nevertheless a national landmark.

With all this dignity, history and tradition, it likely comes as a surprise to learn that the College building has sixty thousand paid visitors each year. The source of this popularity is a combination of medical exhibits for the public, and the Mutter Museum. In the late Nineteenth Century Thomas Dent Mutter gave his large personal collection of anatomical specimens to the College for a museum in the style of the medieval European medical schools, where the students could learn from specimens on display because anatomical dissection was discouraged if not forbidden, and Kodachrome slides had not been invented. Mutter's collection is a combination of believe-it-or-not "freaks", anthropological studies of human variations, and a museum of medical history. The former curator, Gretchen Worden, has produced an illustrated book of the exhibits which quickly sold out and must be reprinted, and a yearly illustrated calendar which is quite popular. The doctors are a little bemused by the popularity of this material with the public, but tolerant.

Among the odd features of this collection is the brain of Sir William Osler, the giant of modern medical education. Osler belonged to a club of people who had such a high opinion of their own genius they pledged to donate their brains after death to the collection of specimens, in the hope that eventually science would be able to determine the anatomical source of their talents. Most people today are a little staggered at the arrogance of such an idea, so widely at variance with the concept that all men are created equal. Albert Einstein is another acknowledged genius whose brain is still floating in a pickle jar, waiting for its unique properties to be discerned. Presumably, time will eventually tell whether even the greatest intellects suffer from unconquerable hubris, or whether the envious rest of us must adapt to the consensus of political correctness, just to avoid facing the reality of our own inferiority.

Eakins and Doctors

The Gross Clinic

A Christmas visitor from New York announced he read in the New York newspapers that Philadelphia's mayor had just rescued a painting called The Gross Clinic, for the city of Philadelphia. The Philadelphia physicians who heard this version of events from an outsider reacted frostily, grumpily, and in stone silence. To them, the mayor was just grandstanding again, and whatever the New York newspaper reporters may have thought they were saying was anybody's conjecture.

Mayor John Street

Thomas Eakins is known to have painted the portraits of eighteen Philadelphia physicians. Several of these portraits have been highly praised and richly appraised, seen in the art world as part of a larger depiction of Philadelphia itself in the days of its Nineteenth century eminence. That's quite different from its colonial eminence, with George Washington, Ben Franklin, the Declaration and all that. And of course entirely different from its present overshadowed status, compared with that overpriced Disneyland eighty miles to the North. Eakins depicted the rowers on the Schuylkill, and the respectable folks of the professions, every scene reeking with Victorian reminders. It's a little hard to imagine any big-city mayor of the present century in that environment. Indeed, it is hard to imagine most contemporary Americans in a Victorian environment -- except in Philadelphia, Boston, and perhaps Baltimore. So, Mayor Street can be forgiven for not knowing exactly what stance to take, and was not alone in that condition.

Pennsylvania Hospital

Philadelphia had the first hospital and the first medical school in America, but its greatest medical fame was a result of the Civil War. Anesthesia had been invented in 1840, the railroads made Philadelphia the nearest medical center to the Civil War battlefields, and the battles dumped hideously large numbers of devastating injuries on the city. Using temporary additions, Philadelphia General Hospital alone housed seven thousand patients. Enabled by ether anesthesia, there was nothing for it but to have the surgeons improvise new techniques. The death toll was appalling, but there was nothing unusual about that in the medical environment up until that time; those boys were surely going to die anyway, unless the surgeons invented something to help them. It was not merely surgeons, of course.

S. Weir Mitchell

S. Weir Mitchell, for example, became known as the father of neurology as a result of his studies and descriptions of wartime nerve injuries. But the repair of injuries is a surgical art, and many novel procedures were invented and even perfected, many textbooks were written. Amphitheaters were constructed around the operating tables, for students and medical visitors to watch the famous masters at work.

In The Gross Clinic, we see the flamboyant surgeon in the pit of his amphitheater at Jefferson Hospital, in the background we see anesthesia being administered. Up until the invention of anesthesia, the most prized quality in a surgeon was speed. With whiskey for the patient and several attendants to hold him down, the surgeon had one or two minutes to do his job; no patient could stand much more than that. After the introduction of anesthesia, it might overwhelm newcomers to observe leisurely nonchalance, but in truth the patient felt nothing, so the surgeon could safely pause and lecture to his nauseated admirers.

Operating Amphitheater

What made an operation dangerous was not its duration, but the subsequent complications of wound infection. By 1876, Eakins could have had no idea that Pasteur and Lister were going to address that issue in four or five years, making operations safe as well as painless. But his depiction of a surgeon with bloody bare hands, standing in Victorian formal street clothes, gives the most dramatic possible emphasis in the painting to the two most important scientific advances of the century. Modern medical students spend days or weeks learning the ceremonial of the five-minute scrubbing of hands with a stiff and somewhat painful brush, the elaborate robing of the high priest in a sterile gown by a nurse attendant, hands held high. The rubber gloves, the mystery of a face mask and cap. In some schools, the drill is to cover the hands of a neophyte with charcoal dust, blindfold him, and insist that he scrub off every speck of dirt that he cannot see, before he is admitted to the operating theater for the first time. If he brushes some object in passing, he is banished to the scrub room to start over. So the Gross Clinic has an impact on everyone who sees the surgeon in street clothes, but it is trivial compared with the impact that painting has on every medical student who has been forced to learn the stern modern ritual. For at least fifty years, that painting hung on the wall facing the main entrance to the medical school, where every student had to pass it every day. To every graduate, the lack of clean surgical technique by the famous man was a wrenching sermon on every doctor's risk of trying his utmost to do his best, but doing the wrong thing.

That painting, hanging quite high, was rather cleverly displayed to the public through a large window above the door. With clever lighting, every layman who walked along busy Walnut Street could see it, too, and it became a part of Philadelphia. That was a feature the medical community barely noticed, but it was probably the main reason for public uproar when a billionaire heiress offered the school $68 million to take the painting to Arkansas. The painting was not just an icon for the medical profession, it had become a central part of Philadelphia. Philadelphia wanted to keep that painting for a variety of reasons, and one of the main ones was probably a sense of shame that we were so poor we had to sell our family heirlooms to hill-billies.

The doctors didn't pay much attention to that. They were mad, plenty mad, that a Philadelphia board of trustees would appoint a president from elsewhere who would give any consideration at all to such an impertinent offer.

Cost of Medical Care

Milton S. Hershey

On several occasions, Richard A. Kern M.D. (1891-1982) told the story of his part in the founding of the Hershey School of Medicine. Dick Kern was a distinguished professor of Medicine at Temple University, well known for his contributions in the field of asthma and allergy, a past president of the College of Physicians of Philadelphia, and a former Grand Master of Pennsylvania Freemasonry. The Milton S. Hershey School was considering the creation of a medical school and needed advice.

Milton Hershey had been a strict Mennonite, which is closely related to Quakerism, and had accumulated a huge fortune making chocolate candy. He left generous trusts to endow a theater and various other public services in the town of Hershey, but his ownership shares in the chocolate company had been left to the Hershey School for orphans. The value of the shares had far outgrown the ability of the school to employ them usefully, and they were considering a medical school. In 1963, as at present, everybody else was wondering how to get out from under the crushing cost of running a medical school. The sudden inquiry from a donor both willing and able to start a whole new medical school from scratch was an opportunity not likely to appear again soon. Kern carefully considered the options, including the danger of scaring off the naive potential donors with too high a price. Finally, he screwed up his courage and suggested a price to the trustees, of fifty million. The prompt answer was, done, you've got your medical school.

In due course, Kern found himself on the platform at the inaugural ceremonies of the school, sitting next to the guest of honor, that man who had made such an instant decision. Chatting amiably, Kern mentioned that he had always wondered how high the Hershey Foundation would have been willing to go. The answer was just as prompt as the original one. "Hundred-twenty."

Charitable Immunity: An Underestimated Revolution

Percent

Until 1939, there was a legal doctrine of Charitable Immunity, which universally shielded hospitals and other charitable institutions from negligence lawsuits. No doubt the underlying reasoning was that charities possess limited funds for unlimited demands, and must be forgiven for imperfect compromises in the face of scarcity. To threaten them in court for falling short of perfection might drive charitable efforts away entirely. Since many professionals donated their services to the common effort, there was some spill-over protection for individual professionals, but this centuries old doctrine applied to institutions more than individuals. There can be little doubt that improved financing of hospitals by health insurance and government programs resulted in both higher standards and lessened public tolerance for imperfection. One might say that twentieth century America decided it could afford better care, supplied the money for it, and expected to see results. It might also be commented that Medicare and Medicaid were significantly over funded at first, but with time have become painfully underfunded, particularly by Medicaid.

The New Hampshire Supreme Court, against all prevailing doctrine of the time, held in 1939 that hospitals in that state should no longer be broadly shielded from liability by the doctrine of charitable immunity. By 1991, this new legal view had extended to the point where the Pennsylvania Supreme Court felt a need to define Corporate Negligence, emphasizing a hospital's duty to ensure a patient's safety while in the hospital. The court specified the duty to provide safe facilities, to select and retain only competent physicians, to oversee all persons who practice medicine within the walls, and to formulate and enforce adequate rules of behavior. Looking back, legal scholars point to two particularly significant intervening court decisions. In 1957, eight years before Medicare, the New York Court of Appeals declared that to say the doctor is the captain of the ship, acting on his own responsibility, no longer fits the facts. The court bore down hard on the existence of salaried physicians, and the illuminating fact that hospitals were openly sending out bills for medical services. In 1973, the Superior Court of Delaware deliberately and consciously extended the New York doctrine from salaried physicians to independent contractors working within the hospital. But independent contractors are still working for pay; the courts have been more hesitant to extend the idea of corporate control to volunteers who work without pay of any sort. But the movement is in that direction, so it is increasingly difficult to find anyone to volunteer. The American instinct to volunteer is still very great, as the response in 2005 to the South Asian tidal wave demonstrated, with relief agencies forced to send out appeals for the flood of volunteers please to stay home. But the central fact remains that the original premise was limited resources for unlimited needs; Medicare and Medicaid temporarily made it seem resources would be infinite, so why should an injured patient forgive a volunteer. As it becomes increasingly evident that the 1965 federal promises of infinite support are unsustainable, the invalidation of charitable immunity deserves to be re-examined.

The 1973 date of the Delaware decision is probably significant, because that was a time of abandonment of malpractice coverage by insurance companies. If you couldn't sue doctors, and you feel you must sue somebody, plaintiffs were in effect told to sue the hospitals. With charitable immunity, hospitals didn't carry insurance, but they immediately searched for it. And thus, a bigger, far juicier deep pocket was created. Physician malpractice premiums, outside of California, were approximately $100 a year. Those rates proved to be far too low. The temporary collapse and disappearance of malpractice insurance companies took place in 1975. It is very hard to blame the actuaries of a malpractice company in say, California, for failing to take fully into account a decision by the Superior Court of Delaware in their premium-setting.

Before this revolutionary upheaval, a volunteer chief of medical staff was (nominally) in charge of every mistake made by any employee, and that was pretty unfair if he got sued. The captain of the ship idea devolved to department heads, or perhaps just the responsible surgeon in the operating room. If the scrub nurse counted sponges wrong and left one behind in the patient, the responsibility passed upward to one of these captains or sub captains. The manifest unfairness of demanding damages from someone six or more steps removed from the incident, particularly one who had a largely honorary title and no real control, exercised a restraint of sorts on lawsuits. Once the blame was shifted to a nebulous legal entity known as the corporation, blameless blame transformed into corporate financial liability. The average size of awards against institutions escalated upward, raising the size of claims for similar injuries against individual physicians. Add to that the growing fact that hospital revenues are almost exclusively derived from insurance third parties, and thus the premiums for hospital insurance could only come from insurance as an automatic pass-through. Disaster looms if the intermediate parties have nothing to lose, and the public pays all the cost through health insurance or taxes. None of this adversary system, including the whole tort system and the whole malpractice insurance system, was designed to cope with a financially pain-free defense posture. One paradox of the situation is that the admirers of the plaintiff viewpoint are typically also sympathizers with universal health insurance. The two are utterly incompatible under any set of proposals, so far offered.

If matters had stopped at that point, well, it's only money. But obviously the counter pressure on health insurers to hold down these costs was inevitable. Hospitals were practically under court order to make rules (the hospital associations would be happy to construct a model set of rules) and enforce them on their attending physicians, to pay professionals salaries wherever possible as a time-tested means of encouraging obedience, and to reorganize themselves as corporations practicing medicine rather than hotels providing space and services. (There are legal barriers, of course. Numerous state constitutions awkwardly state "No person may practice medicine in this state without a license so to do.") Needless to say, physicians resisted this trend toward the corporate practice of medicine, even though its early forms only took the shape of placing the hospital lawyer in charge of conferences about "risk" prevention. Since the lawyer knew very little about the topic, the discussion tends to focus on horror stories of suits that were lost or are in litigation.

This struggle between physicians and administrators for control of the hospital, using malpractice as a debating point, is bad enough. Far worse is the slanting of the system of actual medical organization of the staff. Hospitals now often have thousands of nurses and hundreds of doctors, each reporting upward within two guild structures. You would think the chief of surgery would have a lot to say about the selection of the nursing supervisor in the operating room, but heaven forbid. Nurses are hired and fired through the nursing hierarchy, not the department hierarchy which would cross guild lines. It's sometimes hard to say who is on which side of this issue, and probably everybody is on both sides, sufficient to paralyze rational discussion. Everybody involved wants to diffuse blame for an error through the whole organization, and so resists having responsibility conferred in any consistent way. The chief of surgery, for example, is ambivalent about whether he wants nursing errors legally passed back to him, and thus tends to retreat from asserting himself. It can sometimes be hard to specify the ways this chaos expresses itself in poor quality or higher costs, but it would certainly be remarkable if it didn't.

Flexner Report, Revisited

Specialty Care In The Era Of Managed Care

Book Review

Specialty Care In The Era Of Managed Care

Cleveland Clinic versus University Hospitals of Cleveland
John A. Kastor, M.D.
0-8018-8174-9
The Johns Hopkins University Press

Abraham Flexner's 1910 Report practically canonized the notion that medical schools must be owned by universities. Forty years later, Dwight Eisenhower firmly disagreed. Asked why ever would he give up the pleasant life of Columbia University president to get into the nastiness of national politics, he replied, "The White House doesn't run a medical school." During the same era, Secretary of State Dean Acheson and Senator Robert Taft, political enemies but personal friends, were riding to New Haven together to a Yale trustee meeting. The two agreed it was unfair for 40% of university budget to be spent on 1% of the student body, and decided Yale should get rid of its medical school. Their subsequent motion failed by only one vote at the meeting. And as a final Flexner footnote, Princeton University which shrewdly never owned a medical school, is now nonetheless in the news over the central underlying discordance -- managing huge sums which, either by contract or donor restriction, are inflexibly assigned to a single department, thus substituting the donor's priorities for those of the University president. Medical school ownership of teaching hospitals raises the same issue except in reverse. It is politically impossible to treat an affiliate as a cash cow without learning the harsh reality of the Golden Rule: the affiliate with the gold will promptly remake the rules.

Understanding these issues but seldom emphasizing them, John A. Kastor has done us all a great favor by studying and publishing the unseemly disorders which result, in many cities and institutions. His particular focus in this book is on Cleveland, where all that matters medically is the prospering Cleveland Clinic and its struggling rival, Case Western Reserve. The book is mainly focused on a particular question: under managed care, should teaching hospitals adopt the Cleveland Clinic's style and organization, in order to prosper as they do? In the end, he cannot quite bring himself to recommend it. Essentially, the Clinic is run by doctors, for doctors. The clinic pays salaries, but (so far) bills fee-for-service. The over-reimbursed procedural specialties such as surgery subsidize the under-reimbursed cognitive specialties (prompting East Coast colleagues to sneer at "organized fee-splitting".) Cleveland's Clinic, like all group practices, must devise strategies to a)induce acquiescence to the subsidy of internists by surgeons, b)discourage physicians from starting competitive practices in the neighborhood or c)turning their salaried incentive into an instant 40-hour week. Not everyone will submit to what is between the lines, most notably at the Clinic's Florida satellite. But since the alternative is to hire non-physicians with concealed animosities to doctors to run hospitals and medical schools, all physicians who actually treat patients must give the physician-run group practice model some thought based on experience with its alternative.

We all have an unfortunate tendency to assume that weakness of character is the main cause of the executive misbehavior so widely observable in all corporate environments. In the medical world, a much more powerful force is generated by shifting quirks of reimbursement. Once the pecking order is established between hospital and school, medical school and university, it gets violently upended by the underdog suddenly getting riches from the Senate Finance Committee, then upended again by Ways and Means a few years later. Or bureaucrats in Rockville, in Baltimore, or the Executive Office Building. Eisenhower was wrong, the White House does run medical schools and hospitals, when they would very likely be better run by physicians. In fact, Flexner's offhand interposition of the University into this dogfight seems a little quaint. Just to mention the indirect residency reimbursement program, the institutional research overhead allowance, the old cost-plus reimbursement of hospitals, the institutional patent revisions, is to start a list which can get to be quite long. In most of these cases, an institutional component which needed to be subsidized in the past has now become prosperous and is asked to return the subsidy. The chief executive is then caught between duty to his institution, the threat of investigation if funds shifting is suspected, and his own sense of fairness. That these upheavals are so frequently pacified without serious harm to the patients, is a credit too seldom given.

Dr. Kastor's writing is somewhat hampered by a need to footnote, document and defend everything he says. Nevertheless, the book will be read by physicians like a novel with a great many villains. It's encouraged reading. One hopes that the next book in the Kastor series will examine the Florida satellite clinics of the Cleveland Clinic and of the Mayo Clinic, one making money and the other losing money. Maybe some basic issues of effective medical organization can be resolved by making different comparisons.

But don't expect permanent axioms to emerge; Medicare Risk contracts are coming. Under capitated systems, administrative incentives are slanted to discourage expense, especially expensive surgical procedures. Perhaps group practices will soon face a need to have their internists subsidize their surgeons, reversing the traditional arrangement. The threat to colleagiality, so evident in this book, is destined to continue.

Exit, Pursued by a Bear

John Kastor

Everybody ends up getting fired in a recent book by John Kastor about recent events at the University of Pennsylvania just like everybody ending up dead in an Elizabethan play. The vital difference, of course, is that the dramatis personae at Penn can still relate to a bewildered audience their own versions of those grand events. To protect himself, the author peppers his book with more footnotes than a PhD. thesis. And thousands of stakeholders at the University can now realize that during those eventful times they were as clueless as Rosencranz and Guildenstern.

One basic fact about that institution is that the medical school spends three quarters of the entire university budget. That leads to grudges in the little law school, the little engineering school, and the little president's office, as they knuckle under to the Golden Rule. The department chairman with the gold, makes the rules. Since most of that gold comes from research grants, hence ultimately from the federal government, the medical students and the teaching faculty don't have the same power they had during the Vietnam War era, either. Although medical school tuition imposes a crushing burden on the students and their families, leading to debts close to a quarter of a million dollars apiece, the tuition money doesn't amount to much in the university scheme of things, either. In some schools, tuition amounts to two percent of the medical school budget. You could eliminate the students entirely and not see much difference in the "school".

Unfortunately, when you become dependent on government grants, you find they can suddenly be terminated, or awarded without funding, or held up for several months by Congressional bickering. Meanwhile, there are salaries to pay, contracts to fulfill. Even if you can furlough some of the staff, it's not easy to see what you do about a thirty-year mortgage on a research building when there is a lull in its research funding. If you try to save money, the granting agency will try to get it back; they aren't authorized to make grants to be squirreled away. If you shift money to unauthorized uses, you risk going to jail. And yet, if you don't do something along those lines, the whole enterprise can collapse.

Having said that much to be fair, it is still uncomfortable to see the financial transparency of our most valued nonprofit institutions vanish behind a Byzantine fog of secrecy, out of which arise the magnificent towers of new buildings, and in front of which an occasional limousine is to be observed. No wonder the research scientists feel the constant pressure to produce. A Nobel Prize every ten years, or so, would go a long way toward quieting envious remarks from the liberal arts faculty.

Housed in those ivy towers are three institutions, the teaching hospital, the medical school, and the university, with three boards of trustees, and at least three ruling potentates. At irregular intervals, congressional committees do things to the Budget Reconciliation Act which enrich one of the three components of the institution, or suddenly impoverish another, or both. Integration of the three under one governance sounds plausible until you notice how radically different is the mission of each one. You can take a big building away from one component and rent it back to them, and things like that; but you can't do it without starting whispers about Enron. You can gather up surplus funds from one of them during the decade of the eighties, but you have trouble giving it back twenty years later. Officials at Blue Cross come snooping to see if health insurance premiums are passing through this shell game, ultimately paying salaries in the department of English Literature. Everybody distrusts everybody else, somebody sasses somebody, and everybody gets fired.

Nothing unusual about that. It happens at every medical school.

Picking Up the Usual Suspects

The federal government directly controls about half of health care spending, and makes rules affecting most of the rest.

Claude Rain

Every group or business which receives some of this money is alert not to lose it. Many other groups are alert for openings to get more of it. All employ sentries in Washington. False alarms are frequent, stealth attacks are a constant threat, constituents paying the bills demand immediate reassurances. Members of Congress seldom initiate a disturbance unless someone from inside an industry brings it to them. Consequently, when proposals do surface, and seem to be serious, the question to be immediately answered is -- who's behind this? If you know who starts something, you can readily imagine the motive, assess the political strength, decide how to respond. With what little was generally known about the Clinton Health Care Plan of 1993, it was easy to imagine a host of people with some motive, but very hard to say who was actually pushing one. Must be a Democrat, obviously, but not immediately obvious which of several possibilities was the real agitator.

Health insurance companies would always seem likely to have proposals about national health insurance. Blue Cross dominates the market in large geographical markets, mainly East Coast, and would seem fearful to lose that dominance in a major upheaval. But other market areas of the country are dominated by commercial insurance companies who might seek to upend the Blue Cross monopoly, but whose form of business would be even more seriously threatened by health insurance innovations. Most commercial health insurance was written by large life insurance companies who regard health insurance as a small sideline for the convenience of their industrial customers. Blue Cross was somewhat more comfortable with government work, particularly since the 1965 Medicare and Medicaid programs were patterned after them. However, Blue Cross was non-profit, thus lacking in incentives, and historically controlled by health care providers. That is, Blue Cross was formed by and dominated by the hospital associations, and Blue Shield was formed by and dominated by medical societies. Since doctors and hospitals were very prompt in announcing their deep concerns and uncertainties about the Clinton Plan, Blue Organizations seemed unlikely to make daring proposals so likely to provoke trouble at home.

Not that some doctors and some hospitals didn't try to see what might be made of this opportunity. At the American Medical Association, certain leaders known to have Blue Shield involvement offered conciliatory remarks about waiting for further details before taking a stance, but were abruptly halted by a general opinion that things had apparently already gone too far for substantive negotiation. Much the same thing occurred at the Hospital Association; the winners had too much to lose, the losers had too little influence to matter, and nobody stepped up to claim an inside track. Hospital trustees didn't know what was going on, strongly suspected something was going on, and didn't like either situation. If the doctors got mad enough at a hospital, they could ruin it, and if hospitals got mad enough at Blue Cross, it too was ruined. The main strength behind the Blue Cross monopoly position was the secret discount provided to them by hospitals, which was refused to competitor insurance companies, but could easily be extended in the interest of fairness. If need be. The commercial competitors wanted that discount much more than they wanted new insurance models.

There is one subset of doctors and hospitals that might be suspected of generating a sweeping revision of the medical system -- academia. Medical schools think of themselves as the appropriate source of vision about the profession they are training, and they run large prestigious hospitals. Their heavy dependence on government research grants, teaching subsidies, and tuition support programs puts them in constant contact with Washington bureaucracy and politics; propinquity is a great match-maker. Their style of salaried faculty creates estrangement from making a living by being paid fees for specified services, and they are reasonably comfortable with the flaws and techniques of professional promotion within a large organization. So, a slogan which has been attributed to Wilbur Cohen himself does not greatly jar on their ears. The author of the Medicare Act is said to have announced that the entire medical system of America could be accommodated by thirty or forty Mayo Clinics. Twist that just a little, and you are imagining he said forty or fifty medical school teaching hospitals. The briefest contemplation and rebuttal will knock down that proposal, such as pointing out that we have several times that many teaching hospitals at present without achieving anything like the nation-wide coverage envisioned. After absorbing the administrative chaos of readjusting to that model, you would confront the old repeated history of grossly overestimating, and then grossly underestimating, the future manpower needs of a medical system in the process of constant scientific turmoil. Supppose you built the fifty Mayo Clinics and found you needed two hundred? Suppose you built two hundred and found you needed seventy? And then, finally, remember that each big city could expect to contain one of these organizations, but the fewer of them there are, the longer the distance everyone else would have to travel to get to them. No one has even ventured to speculate how you could go about doing such a thing, let alone doing it three or four times to get it right. But, but. The infeasibility of academia at the center of medical care delivery does not eliminate the possibility that the idea underlying the Clinton Health Plan may have originated in academia, or that academia might support some similar proposal with something else at its center.

Since it was soon clear that the traditional "players" in the health policy arena were unlikely to be sponsoring some self-serving policy that might masquerade as the Clinton Health Plan, the search went on. There were a number of professional groups within the medical community who had traditionally chafed at domination of the hierarchy by physician leadership. Nurses, hospital administrators, pharmaceutical companies, druggists, corporate human resources officers, public health officials, social workers, biology teachers all represented groups who derived status with the public by displaying inside knowledge of medicine. But all of them fell silent when a physician entered the room, and tended to shift their emphasis to faults of the "system" or the "industry". Their Washington representatives placed their emphasis on changes in the existing system which might elevate the prestige and income of the members, and were particularly vigilant for system modifications intended for other purposes which might nevertheless create advantageous loopholes for the members. All of this is normal striving in the good ole' American way, a polite variant of the mixture of bellicosity and restraint usually seen in the Union movement. These people wanted to improve their income and working conditions, but were ultimately quite hesitant about radical proposals that might sink the ship. A quick survey showed they were not supporting any particular reform project, even though they could be counted on to support any reform project. Furthermore, they consistently injured their political strength by extending beyond economic goals to issues like radical feminism in the case of nurses, or direct advertising to the public as in the case of the drug companies, or practicing medicine without a license in the case of limited-license practitioners. These people had votes, influence and lobbyists, but they did not have a national project for health care reform of their own devising, and they surely were not the people behind the Clinton Plan.

During the six months before The Plan was presented to Congress and the Public, a White House task force said to consist of five hundred secret members was meeting under the direction of President Clinton's wife Hillary. No doubt part of their purpose was to give Hillary a public platform on which to show her stuff, with the idea of someday succeeding her husband as President sort of in the back of her mind. But most of it was also quite practical; somebody had to figure out what this proposal was going to be, and newly elected Bill had to spend most of his time learning how to run the rest of the country. Buried in here was an efficiency principle too; the staff members of every important congressman and senator were involved in the process, making the deals and surfacing the political angles before things had to come down to votes and filibusters. Meanwhile, the rest of the country had to wait outside closed doors, fed by rumors and spin.

How well I remember one public seminar on the subject during this period of suspense. The audience was filled with people thought to be influential with the public, the usual suspects in that sense, too. Representatives of various interest groups were seated up front at a table, and for some reason I had been picked to represent doctors. Next to me was a druggist who had made a billion dollars starting an HMO; it was intriguing to watch how many well-dressed women with no interest in health care paraded up to the table to show their stuff to the billionaire, while we waited for the meeting to begin. All of the usual suspects of Philadelphia medical care were at the table, each of us wondering what the other was going to say. When some last Very Important Person had wandered in and taken a seat, it was time to begin. The moderator told a funny story or two, and then asked each one of us what we thought of the Clinton Health Plan. One by one, to the utter amazement of us all, we each explained how we were opposed to it.

So obviously this proposal was not coming from the usual agitators. But, remember, somebody was surely behind it. Before we take a stab at that mystery, let's humanize the usual suspects by describing a few of them.

Why Are Hospital Prices So Artificially High?

Aspirin

Cost analysts maintain it really costs ten dollars to write a simple business letter, so it's no surprise when hospitals charge ten dollars to administer an aspirin tablet. But there's also another form of hospital overcharging. Mark-ups of prices (publicly listed, at least) of several hundred percent over audited costs are routine in hospital bills. These are not hidden cross-subsidies, either; they emerge on the yearly audit as multi-million dollar "losses", neatly balanced by "contractual allowances". Translated, they are discounts to insurance companies. My daughter, armed with several accounting degrees, spoke out recently at a hospital board meeting, "Why do you do this? Why do you raise prices, then turn around and discount them? Why do you overcharge, then call it a loss when you write it off?" The replies to her question, she recalls, were mumbles.

Until hospital officials come forward with a coherent defense of their practices, outsiders can only guess at motives. Start with the old legal approach of "Cui bono?" (Who might have a motive?) and divide the answers into those with a motive and those with the means (but no visible motive.) The police line-up will then consist of hospitals, insurance companies, limited-license practitioners, and the state government. Limited licensees, acupuncturists and the like, surely must hate high-deductible health insurance because their fees mainly fall below the two or three thousand annual deductible. Old-line health insurance companies also have plenty of motive to keep out competitors, fearing antitrust action if they get too obvious. That leaves the state government.

States have ample power over hospitals. Substantial annual payments are negotiated with hospitals for Medicaid services, charity care, and educational grants and subsidies. Tax exemptions are repeatedly challenged and re-negotiated, and overall non-profit corporations are entirely creations of the state legislature. So, unless it is a violation of federal law, state government has the means to compel hospitals to do anything. Power, yes, but where is the incentive for states to wish for exorbitant hospital prices? Or confer monopoly status on certain insurance vendors by according them sweetheart discounts?

The Blue Cross Discount (6)

Blue Cross Blue Shield

Since I've alluded to the two basic problems in health financing today, perhaps I need to explain them. What's known in hospital circles as the Blue Cross discount refers to the wide disparity between what the hospital will accept from an insurance company and what they will demand in payment from someone who has no insurance. It's often double the price. It's a tragedy that forty million Americans don't have health insurance, all right, because it costs them twice as much. It's a punishment for the terrible crime of not buying insurance, to call a spade a spade.

That sounds like a pretty easy problem to fix, doesn't it? Stop overcharging them, and half of the problem of the uninsured would go away.

Furthermore, most of the people who do have health insurance are effectively able to buy it at seventy cents on the dollar, because they don't pay income tax on the money that goes for "health benefits" which is to say health insurance premiums.

Taken together, most people thus pay seventy cents for health care which will cost uninsured people two dollars. Most people would suppose that we ought to give a break to some poor devil who can't afford insurance, but in fact we skin him alive financially. It's impossible to name any other necessity of life that's treated this way, and it's hard to think of any other problem that would be so easy to solve -- just charge everybody the same amount. If you are really bighearted, charge poor people just a little less,

Now, I refuse to get drawn into a history of the origin of these egregious situations. It has to do with price controls during World War II and the fact that investment capital for the health system was impossible to raise during the depression of the 1930s. But it doesn't matter in the slightest how this came about. What matters is how to make it go away.

The American Health Non-system

Dr. Jock Murray

Dr. Jock Murray has recently been Chairman of the American College of Physicians. He is also a Canadian. Recently, he was invited to address the College of Physicians of Philadelphia on an evaluation of the lessons to be learned from comparing the health systems of the two neighboring nations. It was an excellent, fair, and well-balanced address. The man who introduced him referred jokingly to the American non-system, and Dr. Murray emphasized two epigrams about national systems in general. No nation on earth can afford to fill all of the health demands of all its people. So, all nations confront the three main demands, to deliver everything, to deliver it to everyone, and to do so immediately (ie without waiting lists). Fulfilling any two of these three demands is possible, but to deliver all three is impossible. Comparison of health systems in various countries amounts to identifying which two of the three they have chosen to have, which one they choose to surrender. I hope and believe Dr. Murray would mostly agree to this caricature of his remarks.

As a member of his audience, it does seem to me fair to acknowledge we have a non-system, and probably even fair to go further and observe we fundamentally resist those irksome constraints implicit in having a planned system. No organized system, and proud of it. But we do have something else. Let's call it a vision.

Without formally stating it, or even widely acknowledging it, Americans seem to have embraced a dream that we can indeed have everything for everybody right away. Yes, we can. The method available is to gamble that research can eliminate disease. We hope, although we know it is not certain, that cancer, schizophrenia and Alzheimer's disease will reduce the cost of care. Our model exists in Rheumatic Fever and poliomyelitis, for which there are essentially no remaining treatment costs. We know that everyone ultimately dies of something; we assume we are already paying everybody's terminal costs. Eliminating diseases postpones terminal costs, but surely does not add to them.

We have knowingly and recklessly embarked on a program of pouring huge amounts of money into medical research. I believe the public mostly suspects that much of our present high cost of health insurance eventually finds its way into supporting research, and the public mostly acquiesces in whatever cost-shfting is involved. The people who devote their lives to research in turn vaguely recognize that we might reach a point where the country cannot afford this gamble any longer, and they could have half-wasted a career. We all vaguely understand it's a gamble; major elimination of disease might not be just over the horizon, and might lead us on to indefinite postponement of a foolish dream.

But those are the chances you take; we seem resolved to take them. We are going to give it a go. If we can, we are going to spend whatever it takes to give everything to everybody, right away. We are going to eliminate diseases, on the unproved but plausible assumption that doing so will eventually bring costs down.

Healthcare Reform: Looking Ahead (2)

health care

The Industrial Revolution crowded people together into smoky, draughty unhealthy places to live and work, and thus created ideal conditions for the spread of smallpox, tuberculosis, plague, poliomyelitis and many other infectious diseases. With better sanitation and hygiene, those diseases declined steadily for two centuries. Meanwhile, medical science developed a steady stream of expensive enhancements to health like removing an inflamed appendix, inserting pins into broken bones, utilizing CAT scans and artificial kidneys. These things each made life more comfortable and extended it a little longer, but steadily increased the cost of care. Here and there major leaps forward occurred, like the discovery of antibiotics and the prevention of arteriosclerosis, but it seldom seemed that medical care was stamping out disease, it was just making it more complicated and expensive. But if you stopping plodding forward for a moment and looked backward, the aggregate progress was astounding. Dozens of diseases either disappeared entirely or are well on the way to disappearing, like polio, smallpox, tuberculosis, syphilis, rheumatic fever, and what have you. Life expectancy for Americans at birth, which had been 47 years in 1900, was approaching 80 years in 2000. When I started as an attending physician in 1955, I was in charge of a 40-bed ward continuously full of diabetic amputees; during the last fifteen years of my practice, however, I did not attend a single diabetic amputation. At some point in this amazing medical pilgrimage I can remember realizing that for really important purposes, there were only two diseases left. Arteriosclerosis and cancer; and now arteriosclerosis mortality has declined fifty percent in ten years.

So now it is possible to have the luxury of asking: what will happen when we finally cure cancer? Oh sure, there is Alzheimers Disease, HIV/AIDS, schizophrenia and childbirth, plus an apparently endless variety of ways to produce self-inflicted conditions. Everyone will eventually die of something, so doctors will keep busy. It is not necessary to predict the end of medical care to see that some important social transformations are likely. For example, if we cure cancer around the time of financial chaos caused by the retirement of baby boomers, it is going to be hard to resist the demand that we reduce spending on medical research. Every tedious word of the impending debate on the topic could be written right now to save time, because it is a very strong probability that spending on medical research will decline, once an effective cure for cancer is behind us.

Let's, however, continue our march into the future of healthcare reform. When employers became self-insured for employee health costs, they came into possession of data about what they were buying. It didn't look adequate to them to explain the sums of money they were spending, so they concluded they were being hoodwinked by hospital cost shifting, with consequences summed up as the Clinton Health Plan. Now put yourself in their shoes when the Wall Street Journal tells you cancer has been conquered. Michael De Bakey once pressured Lyndon Johnson to start a crusade against Heart Disease, Stroke and Cancer, and now even cancer is gone. A significant number of C.E.O.s are likely at that point to decide that since Far Eastern competitors don't have this cost to contend with, perhaps it is time to declare that you have been fleeced long enough. Give the employees some money, and tell them to buy their own health insurance.

There are even some more legitimate arguments for doing so. Individually owned and selected health insurance would be portable, putting an end to "job lock", the fear of changing jobs for fear of losing health coverage in the process. Employee divorces create a different twist to job lock, and inequities jump out at you from the tangle of arguments about dual coverage for working couples. Add same-sex marriages to this issue and employers are driven to despair. Individual policies would simplify all of these issues, and open the door to life-long coverages, which we will discuss in a later section.

If medical progress makes just the right progress in the impending time interval before doomsday, it is even possible to start talking about eliminating health insurance in a practical way. If there is no threat of medical expense, why buy insurance against it? Since everybody will die of something, it is hard to envision a time without insurance. But maybe Medicare is enough. Senator Edward Kennedy (D, Massachusetts) will finally have his universal single payer system -- by default.

What we have here are the daydreams of a corporate C.E.O., struggling to make his numbers for the next quarter, and they are pretty strong stuff. But who can doubt the power of these concepts to move the system away from an employer-based formulation?

Baruch Blumberg, Renaissance Man

College of Physicians

Baruch Blumberg may be an octogenarian, but he radiates vigor and good health; his current intellectual interests are invariably on the cutting edge. He currently serves as the president of the American Philosophical Society, was for five years the Master of Balliol College at Oxford, was the Director of Astrobiology at NASA -- all of them after he had won the Nobel Prize in Medicine, and retired from his laboratory. He likes to run and bicycle, with a long history of disconcerting the populace of China, India and Africa with early morning forays. His undergraduate major was physics, with graduate work in mathematics. He went to medical school at his father's suggestion.

Hepatitis B

The Nobel Prize was awarded for the discovery of the Hepatitis B virus, for which he developed a highly successful vaccine. It has been estimated that there are 375 million people in the world infected with this virus, and it leads in time to liver cancer, the most common form of cancer in Asia. If you set about to stamp out disease and save lives, it's advantageous to do it with an extremely prevalent disease. And then there are some surprising side-benefits. For some reason, women who are infected with Hepatitis B produce a disproportionately large number of male offspring, so that vast immunization programs in Asia are now starting to result in a larger proportion of females in the population. The lack of female children in Asian families has long been attributed to selective abortion, so it's satisfying to see an abatement of that particular slander.

Baruch Blumberg

Blumberg has twice been invited to deliver a lecture to the College of Physicians of Philadelphia. The first was a description of the problems of space travel. The second was a discussion of current trends in medical genetics. It seems that gene mutations only occasionally cause disease directly. The much more important genetic factor in disease affects the ability of some people to resist particular diseases, and makes others more likely to be a victim. Hepatitis B? Well, that's so yesterday.

Community Volunteers in Medicine

Comm Volu In Medicine

Mary Wirshup has a very different medical background from mine, but she's my kind of doctor. I couldn't help wishing, as she addressed our urban luncheon club, there could be thousands more like her, even while understanding more fully than she seems to, the reasons why doctors are driven from her behavior model. As we parted, it felt like saying a last goodbye to the Spartans marching to Thermopylae.

As 46,000 medically uninsured persons in Chester County get sickness and injuries, they know that a Federal Law prohibits a hospital accident room from refusing to see them, so ways are found to shunt patients to the CVIM free clinic, run by volunteers. This law is in turn a response to a government-created situation where a hospital which "accepts" patients must keep them. Any economics teacher can tell you that supply/demand issues are best addressed by price adjustment, so price controls in whatever guise lead to shortages. I must say I have little sympathy with the devious strategies which hospitals often employ to disguise their rejection of uninsured patients. At the same time, I know a lifeboat will sink if too many climb aboard. Nevertheless, the semantic switch from lack of insurance to lack of care implies that only more insurance can surmount the barriers to care, which is absurd. For one thing, I know too many hospital administrators who are paid a million dollars a year, and one who is paid two million. And at least two health insurance executives are in the newspapers with net worth over a billion -- yes, that's billion with a b. We have reached a point where reducing all physician income to zero would only reduce "healthcare" costs by 10%. As I look at Dr. Wirshup's modest clothing I can only surmise she plans to continue her modest living until she is 80 years old, after which her savings might see her out. Squeezing physician reimbursement is not intended to save significant money, nor intended to restore physician incomes to more equitable levels. It is intended to address the oversupply of physicians without confronting either the universities or the foreign trained lobby.

The elite tranche of medical schools do their part to relieve physician oversupply without reducing class size, through the encouragement of their students to go into research. I was well along at the National Institutes of Health before I finally decided I had not gone into medical school with that goal, and returned to teaching and patient care in a more satisfying model not too different from CVIM's obviously Pennsylvania Dutch spirit. The Amish at the far western end of Chester County reject the whole idea of insurance; their most characteristic statement is "Don't send me no bills." That attitude is rather a contrast with the shiny housing and automobiles in the Silicon Valley developments of Southern Chester County, or even with some rather bewildered Quaker farm families scattered over the rest of the county next to the horsey set. Chester County is America.

On Second Street in Society Hill, next to the park where William Penn's house stood and a few feet from Bookbinders, is the house of Dr. Thomas Bond. Bond conceived the idea of building the first hospital in America and with Franklin's publicity machine succeeded in getting it built, to care for the "sick poor". Dr. Bond started a second enduring tradition as well. When the Legislature expressed doubt that the institution was sustainable, he pledged to convince the local medical profession to serve the poor without charge. Some of the legislators who voted for the measure did so in the belief that charity care would never appear, so the gesture would be without cost. The physicians did indeed come forward, in sufficient numbers to run many institutions for two hundred years. In 1965 health insurance made its national appearance, and has regarded the benchmark low costs of charity care as a threat, ever since.