PHILADELPHIA REFLECTIONS
Musings of a Philadelphia Physician who has served the community for six decades

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Philadelphia Medicine
Several hundred essays on the history and peculiarities of Medicine in Philadelphia, where most of it started.

Academia, Medical Version

The first hospital in America generated the first medical school, the first medical society, and many of the unique features of American medicine. In modern times, the gusher of federal research funds not only distorted academic medicine, but academia as a whole.

A relatively small proportion of colleges and universities are associated with a medical school, but when one exists, it consumes 50-75% of the university budget. Without knowing anything more about it than that, it is possible to surmise that the rest of the affected university is disrupted somewhat, and the effects even extend to all of the other colleges who are seemingly isolated. There's a famous story of Dean Acheson and Robert Taft, both Yale Trustees, deciding on the trip to New Haven to vote against and thus defeat the motion to disband Yale's very famous medical school. Things had got to the point where a department with 2% of the students was consuming 50% of the university budget. The solution to too much federal money was eventually solved by getting still more federal money. And unfortunately it is also possible to surmise that when buckets of money are flowing in, some individuals will be attracted by the money, and the money alone. The extent of this destabilization was unrecognized for a long period of time, because medical and medical teaching institutions had suffered from nearly two decades of neglect and underfunding during the great depression, World War II, and the Korean War. The buildings all had drastic neglect from deferred maintenance, and the patient population had a huge accumulated backlog of untended chronic illness. There was a huge backlog of deferred research, and even a backlog of unwritten textbooks. There was even a backlog in social attitudes; hospitals were mostly staffed by unpaid student nurses and house physicians until Medicare appeared in 1965, forty percent of hospital beds were in open charity wards, and the the hospital accident room was the normally accepted family doctor for half the population. In the view of the participants, we would never catch up with this backlog. But in fact, we did, by about 1975. The catch-up was greatly assisted by the elimination of vast numbers of diseases. The diseases of urban overcrowding, like tuberculosis and rheumatic fever were going away as urban crowding and pollution declined; and then antibiotics finished the job. But things like duodenal ulcer, once affecting 10% of the population, were essentially eliminated. The biggest event was probably the arrival of statin drugs, causing a 50% decline in the big killers, heart attack and stroke. Among people too young to be covered by Medicare, only the conditions associated with child bearing, the associated and sometimes self-inflicted conditions caused by mental illness, and cancer remained. When cancer is cured, medical care will have been pushed into the arms of Medicare, and much of it will be terminal illness. When cancers disappear, the huge research community will have to justify its cost against a resistance to which it is not accustomed. The directions of changes of this magnitude are too drastic to predict; only the magnitude of the shifting uproar is safely predictable.

The First and Oldest Hospital in America

South East Prospect of 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.


REFERENCES


America's First Hospital: The Pennsylvania Hospital 1751-1841 William Henry Williams Ph.D. ISBN-10: 0910702020 Amazon

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Nation's First Hospital, 1751-2008

{Pennsylvania Hospital}
Pennsylvania Hospital

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.

{Philadelphia Ports}
Philadelphia Ports

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

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July 4, 1776: Patients in the Pennsylvania Hospital on Independence Day

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

Richard Brinkinshire (Admitted 11/15/1775) John Ridgeway (Admitted 12/26/1775)
James Chartier (Admitted 1/6/1776) patient (Admitted 1/6/1776)
patient (Admitted 1/20/1776) patient (Admitted 1/20/1776)
Mary Yell (Admitted 2/7/1776l) John Beckworth (Admitted 2/7/1776)
Bart. McCarty (Admitted 2/10/1776) John King (Admitted 2/10/1776)
Robert Alden (Admitted 2/17/1776) William Patterson (Admitted 3/6/1776)
Elizabeth Hanna (Admitted 3/9/1776) John McMahon (Admitted 3/13/1776)
Mary Burgess (Admitted 3/23/1776) Mary Anderson (Admitted 4/10/1776)
John Hatfield (Admitted 4/15/1776) Eliza Haighn (Admitted 4/17/1776)
Charles Whitford (Admitted 4/24/1776) patient (Admitted 5/8/1776)
Susanna Carrington (Admitted 5/8/1776) patient (Admitted 5/8/1776)
William Johnson (Admitted 5/13/1776) Lazarus Chesterfield (Admitted 5/22/1776)
Mary Spieckel (Admitted 5/22/1776l) William Edwards (Admitted 5/22/1776)
patient (Admitted 5/23/1776, Lunatic) Jane White (Admitted 5/25/1776)
Charles McGillop (Admitted 5/29/1776) ---Fitzgerald (Admitted 6/1/1776)
Michael Rowe (Admitted 6/6/1776) patient (Admitted 6/6/1776)
John Hughes (Admitted 6/12/1776) Joseph Smith (Admitted 6/15/1776)
Esther Munro Lunda (Admitted 6/15/1776) Mathew Coope (Admitted 6/19/1776)
Anne Patterson (Admitted 6/19/1776) Thomas Savoury (Admitted 6/20/1776)
Rebecca Winter (Admitted 6/26/1776) Elizabeth Manning (Admitted 6/26/1776)
Negro (Admitted 6/24/1776) Elex. Scanvay (Admitted 6/24/1776)
Fanny Stewart (Admitted 6/24/1776) Peter Barber (Admitted 6/29/1776)
Catherine Campbell (Admitted 6/29/1776) Ann McGlauklin (Admitted 7/3/1776)
Elizabeth Lindsay (Admitted 7/3/1776) Ann Jones (Admitted 7/3/1776)


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

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A Toast to Doctor Franklin

{Benjamin 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 adequate preparation for potential 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.

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College of Physicians of Philadelphia

{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}
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.

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Cost of Medical Care

{http://www.philadelphia-reflections.com/images/milton_s_hershey.gif}
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."

http://www.philadelphia-reflections.com/blog/514.htm


Flexner Report, Revisited

{http://www.philadelphia-reflections.com/images/CoverphotoCleveland.jpg}
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.

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Charitable Immunity: An Underestimated Revolution

{Percent}
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.

http://www.philadelphia-reflections.com/blog/812.htm


Exit, Pursued by a Bear

{http://www.philadelphia-reflections.com/images/JohnKastor.jpg}
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.

http://www.philadelphia-reflections.com/blog/830.htm


The University City

{University of Pennsylvania}
University of Pennsylvania

In 1920, the University of Pennsylvania graduated 34 students with B.A. degrees, and 134 with M.D. degrees. Today, the campus is a little self-contained city of 50,000 inhabitants. The transformation of the campus during that period is an outward expression of revolutionary expansion of the student body, involving demolitions, restorations, new construction. And nearly constant shortage of parking space.

{David Hollenberg}
David Hollenberg

David Hollenberg, the University Architect, recently gave the Franklin Inn Club an interesting description of the University from the point of view of bricks and mortar. Since almost every building on the campus is undergoing or plans to undergo a major building project, he had a lot of material to cover. The disappearance of the railroad-based industrial area of West Philadelphia has been an economic problem for the city, but of course this abundance of vacant land has created a major opportunity for the University of Pennsylvania. One reflection of this abundance is the opportunity to become the developer for much of the whole region around the campus, working with private developers who wish to be in the University area, and are therefore willing to coordinate their plans with those of the University. It's a remarkable opportunity. Since it comes at the time of a major economic downturn, one can only hope that the University does not impoverish itself taking advantage of this good luck.

{Jonathan E. Rhoads}
Jonathan E. Rhoads

As the graduation statistics illustrate, not so long ago the University was largely a medical school, with appendages. There are rumors of considerable friction from time to time, between the President of the University and the Dean of the Medical School as to who was boss; it is easy to imagine the trustees swinging from one side to the other. The most notable Provost of the University in modern times was Jonathan Rhoads, who also happened to be Professor of Surgery. If you know Quakers, you know that disputes were seldom rancorous. And if you know Jonathan, you know he almost always won the disputes.

{Cira Center}
Cira Center

While today, the dominant change is caused by the Cira Center buildings and the acquisition of the former Post Office building, it is well to keep in mind that the new Cancer Center is a billion-dollar project. A great deal of the medical school expansion is centered on burgeoning research, particularly in molecular biology, largely financed by the National Institutes of Health. While the leaders of the NIH have long struggled with Congress to keep politics out of both the administration and the substance of research, it seems to old-timers that the politicians are slowly winning. Senator Specter's seniority on the Appropriations Committee may have had as much to do with the prosperity of West Philadelphia, as the quality of research, however eminent. We are about to find out, and if things go hard with us in favor of say Chicago, it could be a wrenching experience. Most of those research buildings cost more to heat, air-condition, insure and clean than the entire tuition base of the students; and they wouldn't be good for much if you tried to sell them.

{Map of Section of the City}
Map of the Heart of the City

The University is almost unique in being located on contiguous land, near existing public transportation, and occupying substantial old structures capable of renovation to new purposes. Mr. Hollenberg was asked whether it was cheaper to grow like this within a city, or whether it is cheaper to plant a totally new university in several open corn fields, as we often see happen. While this is a hard question to answer, and depends to some extent on the type of architect in charge, it is his view that big-city restoration is a considerably cheaper way to expand than building from scratch on open land, although if you are starting the institution itself from scratch, there isn't much choice but the corn field.

And then, there is the ancient argument between academics and bricks and mortar. Development officers agree that it is easier to raise donations when you can name a building for the donor; grand visions for new frontiers of teaching are a much harder sell. So a question does hang over this expansion, however exciting, whether the endowment will keep up with the structures, once the excitement of physical expansion dies down. These are definitely things to worry about, but right now you sieze the opportunities as they go past, leaving integration to your successors to figure out.

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http://www.philadelphia-reflections.com/blog/1736.htm


Eakins and Doctors

{http://www.philadelphia-reflections.com/images/grossclinic.jpg}
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.

{http://www.philadelphia-reflections.com/images/mayorstreet.jpg}
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}
Pennsylvania Hospital, Philadelphia

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.

{Amphitheater}
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.

http://www.philadelphia-reflections.com/blog/1163.htm


Community Volunteers in Medicine

{http://www.philadelphia-reflections.com/images/cvim.jpg}
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.

http://www.philadelphia-reflections.com/blog/1250.htm


Picking Up the Usual Suspects

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

{http://www.philadelphia-reflections.com/images/Crains.jpg}
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.

http://www.philadelphia-reflections.com/blog/1265.htm


Why Are Hospital Prices So High?

{http://www.philadelphia-reflections.com/images/inside1-aspirin.jpg}
Aspirin

Cost analysts maintain it really does cost ten dollars to write a simple business letter, so maybe 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 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, these are discounts to insurance companies.

Why do hospitals raise prices, then turn around and discount them? Why do they overcharge, then call it a loss when they write it off?

It's an important question, because it results in confronting patients without insurance with much larger bills than the effective price to insured ones; patients who can't afford to pay are charged more than those who can.

The old-time system of hospital wards to care for people who couldn't pay have been replaced by collection departments and hospitals are very aggressive in pursuing the the very people who can least afford to pay, and who are grossly overcharged in the first place.

Health savings accounts with high deductibles were conceived as a way for people to self insure but they have been thwarted by hospital overcharges. Since HSA deductibles are guaranteed, hospitals perpetuate their present largest source of loss -- unpaid deductibles. So why do hospitals continue to post abusively-high prices for patients without large-insurance-company coverage?

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. The 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?

All current plans for "reforming" health care involve providing government-paid insurance to those without. Will the result be to permanently institutionalize the artificially-high public prices to be paid in full by the government? If so, you can well understand why hospitals support these "reforms".

So hospitals are no better than stores that mark up their prices and then loudly proclaim that they will give you a discount. 200% mark-up, 10% off; terrific.

http://www.philadelphia-reflections.com/blog/793.htm


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.

http://www.philadelphia-reflections.com/blog/789.htm


The American Health Non-system

{Dr. Jock Murray}
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.

http://www.philadelphia-reflections.com/blog/1147.htm


Healthcare Reform: Looking Ahead (2)

{http://www.philadelphia-reflections.com/images/healthcare.jpg}
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?

http://www.philadelphia-reflections.com/blog/1284.htm


Only Three Things Wrong With American Healthcare

Although Congress is offering several thousand pages of proposals for healthcare "reform", none of them even mentions the three main difficulties, to say nothing of fixing them. Let's be terse about this:

1. Health insurance is fine, but if you make it universal, there is no impartial way to determine fair prices. Somebody must haggle with the vendor in order to introduce the issue of what is the service worth? The customer doesn't care what it costs to make, or whether the vendors are being paid fairly. If everyone is insured, no one cares what it costs. Not only do all costs rise, but they rise without coordination, without a sense of what each component is worth, relative to alternatives.

2. Employer-based insurance is fine, but it ends when employment ends. You just can't stretch employment-based insurance because you can't stretch employment.

3. State Medicaid programs are fine, but just about all fifty states are going broke trying to pay for it. Extending it to more people by raising the income limits just makes things worse. Items 2. and 3. are related. Trying to do both -- expand Medicaid as employment shrinks -- during a recession is incomprehensible. Item 1. (price confusion) gets drawn into this because the States try to pay less than it costs, hoping to shift the deficiency through hospital cost-shifting, utterly confounding the information which prices provide. The doctors have no way to tell which is the cheapest approach to a problem, so they don't try. Without control over prices, we can only control volume.

That's really all there is to this mess. Not one word of the current legislation even mentions these problems, so of course the legislation blunders. Even a child can see that compulsory expansion of benefits to universal coverage will fail if you can't pay for what you already have. No one will make sacrifices for a new system if the sacrifices seem futile. They are futile, so leave me alone.

The current administration has been compared with bank robbers who see they are trapped, and decide to shoot their way out. Let's see them try to shoot their way past the first Tuesday after the first Monday in November.

http://www.philadelphia-reflections.com/blog/1754.htm


New Museum of Chemical Heritage

{Arnold Thackray}
Arnold Thackray

Eighty percent of the ethical drug industry is located within a hundred miles of Philadelphia, and the whole chemical industry has had its center here for two centuries. The chemical industry is the region's largest manufacturer, now that locomotives and beer brewing have come and gone, but its profile remains low. In fact, chemists personally have a low profile too, and harbor a smoldering annoyance about it. No one has been more determined to change that nerdy image than Arnold Thackray, the recently retired President of the Chemical Heritage Foundation. He's not only a big idea man, but bubbles with energy and persuasiveness. That largely accounts for the fact that CHF has the second largest endowment among public institutions in Philadelphia, the best library of chemical history in the world, and a growing reputation for fine art concentrated in the field. That's not enough for him, so it came about that a new museum was envisioned, funded and created. But not built; building it was assigned to Miriam Schaefer, a famous go-getter who had the unusual qualification of being squeamish about chemistry. It was her assigned task to find a way to make chemistry exciting to people who were not instinctively excited by it, just exactly because she was the world's authority on that point of view. What was vital was that she was the sort of person who can't resist a challenge, and was capable of thinking, well, big.

With the unlimited backing of Arnold and his board, and their almost unlimited financial support, Miriam set about soliciting big ideas from uninhibited people all over the world, and some of their suggestions were even a little too wild to be acceptable. But since the whole idea was to awaken the enthusiasm of anybody, however sullen, who happens to shuffle through the museum, many outlandish suggestions were forced through the filter of a skeptical, conservative, Philadelphia establishment. The result is a series of pleasant surprises, ranging from fine art with a focus on alchemists trying to make gold out of lead, to astonishing computerized graphic displays of the elements of the periodic table fifty feet high, to depictions of Joseph Priestly known as the father of chemistry, a personal friend of Benjamin Franklin, the founder of the Unitarian Church, and a resident of Philadelphia. There's Arnold Beckman's original Beckman spectrophotometer which made hundreds of millions of dollars, was a major factor in the Twentieth century blossoming of biochemistry, and is here shown to be a clever elaboration of a simple idea. Meanwhile, the museum is housed in a massive old bank building, with its interior reamed out and replaced with as much transparent glass as could support the weight. Inga Safron the architectural critic, more than foamed over with praise in her review of just the structure itself. Don't neglect to notice the stunning portrait of Gay-Lussac, the man who discovered that water is H2O. The pigments of his portrait were mixed with bees wax, and with clever lighting have an astonishing luminosity.

The museum is part of an emerging conference center, which should attract audiences of chemists for decades. But that's not entirely the whole idea. The underlying vision is to convince those skeptical, non-chemical bozos that not only are chemists rather richer than the rest of us, and smarter, but clever and fascinating, too. Go visit this museum, before everyone else does.

{Miriam Schaffer}
Miriam Schaffer

http://www.philadelphia-reflections.com/blog/1523.htm


Veterans Hospital

{Philadelphia VA Medical Center Home}
Philadelphia VA Medical Center Home

At a recent meeting of the Right Angle Club, Stephen C. Bennett an administrator, and Alix Esposito a social worker, kindly addressed the club about the Veterans Hospital where they work. The federal government pushes its mass produced products into every city, but gradually a local flavor starts to creep in; how this process works is illustrated by the fact that Steve's grandfather Claude was once the manager of the Bellevue Stratford Hotel. The VA hospital may be a piece of Washington D.C. planted on Philadelphia soil, but Philadelphia will surely absorb it with the passage of enough time. The VA was once a part of the Veterans Administration, but now it is a part of Department of Veterans Affairs, run by a cabinet Secretary, no less. It's the second largest department of the federal government, and since the only bigger department is the Department of Defense, the combination of the two shows you how far we have come from the nation's original opposition to "standing armies". The fact that these two components of our war machine are separate, on the other hand, surely symbolizes some hidden tensions between our regular armed forces and the American Legion, or the hidden frictions between two congressional committees, or else some other mystery of bureaucratic politics.

The Veterans Administration was founded in 1930, the Philadelphia VA Hospital was built in 1950. Originally, it was designated as a Deans Hospital, signifying the intention to confer prestige and lessen friction with the medical schools. Originally, Philadelphia's VA was affiliated with several medical schools, but in time its proximity to the University of Pennsylvania led to the elimination of ties with other schools. Although the bed capacity is growing in reaction to America's successive wars, its open wards converted after 1960 to more semi-private style, and its focus of medical activity shifting with changes in medical science, the VA remains isolated from the rest of the city and the rest of Philadelphia medicine. Part of this is physical; the hospital is confined by the University of Pennsylvania, the parking complex next to the Amtrak line, and the Woodland Cemetery, so there is little room to grow. And comparatively little commonality with the neighbors. There are 2000 employees and a $30 million budget, marooned in a sea of automobile traffic going elsewhere in a big hurry, too big to ignore but too small to influence the local culture.

{Vietnam War}
Vietnam War

The patients are distinctly different from those you find in other hospitals. There is a great deal of chronic mental disorder, a heavy influence of alcohol and substance abuse and rehabilitation, and even some residential apartments for patients. On a national level, between a third and a half of homeless people are veterans, but for some reason in Philadelphia, only a tenth of the homeless are veterans. During the Vietnam War, the system of draft avoidance through educational exemptions resulted in that generation of veterans coming from an unusual concentration of low income and low educational subgroups. The system of government pensions and promotions tend to retain employees in the system for a lifetime. It's true that informal transfer arrangements allow a certain amount of migration to Florida (in the winter), or Maine (in the summer), or California (to see what LaLa land is all about), but those who do this stay within the VA system. Consequently, the interchange of ideas and techniques that professionals carry with them between hospitals is curtailed, confined somewhat to variations within the VA system, conforming to its social norms. An archipelago, although not exactly a gulag archipelago.

{Veteran}
Veteran

But by far the greatest source of distinctiveness in the VA hospitals comes from the byzantine eligibility standards for the patients. The reimbursement systems of Medicare, private insurance -- which more or less copy each other -- changed around 1988 in a way that more or less eliminated psychiatric inpatient care in the community, especially if it lasts more than a month. The VA, on the other hand, was forced by circumstances to increase its attention to this area. Consequently, all social workers everywhere inquire immediately whether an addict or a schizophrenic might be a veteran. A differential sorting process quickly gets under way, with the VA as the preferred place to send such patients if at all possible. Non-veteran victims of the same conditions tend to have a worsened time of it, because the pressure on state and local governments to make some provision, has been relieved.

{Walter Reed Hospital}
Walter Reed Hospital

At the other extreme, the social elite of the armed forces are not admitted, either. President Eisenhower was unquestionably a veteran, but he had his famous hospitalizations at Walter Reed Hospital. There's an income limit for VA admission, which automatically cuts off 20-year veterans above a certain rank, possibly major. And there are overlapping disability classifications for military hospitals and veterans facilities, with considerable latitude available to uniformed boards of three serving officers, only one of whom is a physician. The result is a general perception that if you have any influence at all, you can generally avoid the VA and be treated in a military hospital, probably in a VIP unit. Good for them; I'd take advantage of it if I had a chance, too. But by siphoning off the top brass, a lot of pressure to improve quality is removed as well. If a VA hospital had eight or ten Admirals and Generals as patients, with academy classmates coming to visit, it's safe to assume that courtesy, orderliness and cleanliness would instantly improve. And take it from me, the quality of care would improve, as well.

http://www.philadelphia-reflections.com/blog/1598.htm


Time To Care

Dr. Norman Makous

It sometimes seems as though Medicare has been a standard part of the scene for so long it now needs major reform, but when a doctor has practiced Medicine for sixty years he has seen a lot of contrasts between the old way and the new way, not all of them favorable to the new -- which we are now tired of, and trying to repair. That's particularly true if the doctor practiced at America's first and oldest hospital, because it sustained many traditions from two centuries before, and was among the last to yield to the imperatives of newcomers for the last forty years, their hands grasping for the purse strings. Dr. Norman Makous must either have a remarkable memory or a thick, detailed diary. He tells three hundred pages of fast-reading anecdotes about sixty years of his own medical practice, before summing up in fifty pages of reflection. One by one, he describes the innovations in his field of cardiology and how they affected him and his patients. Thiomerin, one of the first of many easy ways to pump out excess body fluid accumulation, transformed the treatment of congestive heart failure. Synthetic digitalis claimed to but probably did not much improve things over dried digitalis leaves; it certainly raised the cost. Cardiac catheterization, electro-shock resuscitation, ultra sound diagnostics, MRI and CAT scans, cardiac surgery using the heart-lung machine, and finally cardiac transplants -- all started out as headline-news spectaculars, evolved into cutting-edge advances, and then settled down into the Standard of Care that you obtained a plaintiff lawyer to sue about. All in one medical lifetime, supposedly prepared for by one Medical School course, followed by one residency apprenticeship, the specialty of Cardiology was completely transformed at least six times.

{Time to Care}
Time to Care

Meanwhile, the leadership of the medical profession was tenaciously resisted by those who supposedly followed its direction. Hospital admini

http://www.philadelphia-reflections.com/blog/1725.htm


Philadelphia Chromosome

{Dr.Peter Nowell}
The Franklin Institute

Every Spring for the last 185 years, the Franklin Institute has honored the most distinguished scientists alive; Franklin would certainly be proud of the Institute named after him. In recent years, many awards were combined into two categories, the Bower Awards and the Benjamin Franklin gold medals. Unlike the Nobel Prize, the Franklin Institute Medals are not given for eminence in a designated field of science, but rather are given out by a hard working committee of scientists who ask themselves What are the really hottest scientific fields at present, and then ask panels of international referees Who is most eminent in that field? The awards thus effectively avoid fields that are temporarily stale and static, by being unrestricted in advance to particular fields. The approach of searching for the greatest minds rather than greatest achievement may well lead to the same award, but the method of choosing seems more harmonious with the spirit of Benjamin Franklin, who not only excelled in the field of electricity, but actually invented that whole field. The subtle shift in emphasis seems to have been well received; this year's Awards Banquet was over-subscribed before the invitations were printed, and a capacity audience of 800 attended a superb reception, dinner and audio-visualized live ceremony. Actually, the ceremony extends for a whole week, with scientific symposia and in-person meetings with high school students designed to interest them in science.

This year eleven scientists, the most prominent of whom were Bill Gates and Peter Nowell, received the medals. We'll get to Bill Gates in a while; for the present, let's concentrate on Peter Nowell, who invented the Philadelphia Chromosome. What's that?

{The Philadelphia Chromosome}
The Philadelphia Chromosome

Well, from 1921 to 1955, it was generally held that people, members of the human race, contained 48 chromosomes in every cell in their bodies. The chromosomes were thought to contain the genetic code governing our biological construction, explaining the difference between us and fruit flies, which for example only have four chromosomes per cell. After painstakingly examining the appearance of the chromosomes in different people and in cancer cells, it was then generally held that cancers never seemed to have any genetic abnormality. After all, the chromosomes of cancer cells looked exactly like those in normal tissue: Forty eight chromosomes, never differing in cancers, so go look somewhere else for the cause of cancer. Unfortunately, the state of scientific development fifty years ago can be summarized by noting that about that time it then became established we really only had 46 chromosomes, not 48. As for cancer, the M.D. pathologist Peter Nowell, then noticed in 1956 that a patient with chronic myelogenous leukemia had an extra translocation on one particular chromosome, giving it a funny shape. This translocation was furthermore present in every single other leukemic cell, suggesting that one cell had somehow undergone a single mutant change, and all the rest were its descendants. At least in CML (chronic myelogenous leukemia), it suddenly looked as though the cause had been found, since further study revealed the same was true of just about everyone who had CML. At first it was felt that while maybe the cause of this particular type of cancer had been found, every other cancer might still be caused by something else. Not so. From believing no cancers were genetic in origin, Peter Nowell started us on the path of now being confident all cancers have a genetic cause.

{Dr. Peter Nowell}
Dr. Peter Nowell

How could we all have been so wrong; can't scientists even count up to 46? No, as a matter of fact, in 1955 it was pretty hard. If we couldn't even tell how many of them were there, it's obvious the comment they all looked alike wasn't worth very much. As Peter shyly admits, his discovery was a result of being trained as a physician rather than as a life scientist; he knew what leukemia looked like, but at that time he didn't know very much about chromosomes. It happens chromosomes spend most of their lives expanded into tiny filaments too small to examine under the microscope. But as they enter the stage of cell division called metaphase, those filaments shorten and thicken up, becoming a lot easier to examine. As a pathologist, Peter didn't bother to stain his slides in dilute salt solution, but just washed them in tap water. The tap water had caused the cells to swell up and burst; those that happened to be in metaphase dumped their stubby chromosomes out where they could be stained and looked at. Simple. Doesn't everyone wash slides in tap water?

So fifty years ago, the general question of what causes cancer finally narrowed down to the right sort of specific question. Thousands of scientists, spending billions of dollars from the National Institutes of Health, sharpened the focus of their search considerably. It certainly looks as though someone is going to carry the search the final step, pretty soon. However, the fact that fifty years of intensive study still hasn't quite found the answer is an illustration of how fiendishly difficult the search really is. Each year that might have been spent futilely avoiding genetic searches would have added one year more before the answer was finally found. By the way, why is it called the Philadelphia Chromosome? In 1955 it had been decided by the scientific community that every genetic abnormality would be named after the city in which it was discovered. Dr. Peter C. Nowell of the University of Pennsylvania and the late Dr. David Hungerford of the Fox Chase Cancer Center were the joint discoverers, so obviously it was entirely a Philadelphia discovery; at that time it had been made a custom that genetic abnormalities were named after the city where they had been first found.

It would be a mistake to conclude that nothing new has been discovered in half a century of research. It has been established that not only Myelocytic Leukemia, but essentially every cancer starts with some genetic abnormality, which triggers the expression of "mini RNA". These abnormalities then apparently express a cancer-producing action by triggering an abnormal factor in the cell signalling system, called tyrosine kinase. Drugs with the effect of paralyzing that enzyme have been found to be curative in 95% of cases of chronic myelogenous leukemia, and some other forms of lymphoma. We're certainly getting closer, step by unexpected step, to the answer. In fact, we may be getting even closer to a point where drug research can jump to seeking cures without precisely defining how the cancer was caused. After all, if cancer is caused by a chain of cellular events, it may not matter where you break the chain. That realization appeared with, first aspirin and then the statin drugs, for treating heart attacks and strokes, even though we are still not completely clear about how atherosclerosis is produced. Meanwhile, the death rate from hardened arteries has dropped by half.

It wouldn't be right to omit mention of Peter Nowell's Quaker heritage. Although he isn't a Quaker, his mother was a Matlack, a direct descendant of Timothy Matlack, the Haddonfield Quaker who was the scribe for the first writing of the Declaration of Independence. Sitting in silent Quaker meeting, polishing and simplifying one's message before delivering it, is very good training for a habit of simple, direct thought. As Dr. Nowell phrases it, he is a chronic "lumper" of ideas, when so many scientists are content to be "splitters". Splitting complexity into its essential components is a useful approach. But somewhere, someone has to get to the heart of the matter.

http://www.philadelphia-reflections.com/blog/1809.htm


Lumpers In Constant Combat With Splitters

{James Boswell's Book}
James Boswell's Book

Some colleges produce managers by teaching management theory, but in certain Ivy League colleges it is thought to be more useful to teach how to dominate a committee, eventually perhaps a board of directors, or a board of trustees. The handbook of instruction is James Boswell's Life of Johnson which is a rather large book of verbatim notes that Boswell took of his many lunches at a London club in the 18th Century. Boswell was a quiet mouse privileged to sit in the company of the great Dr. Samuel Johnson, surrounded by the most eminent intellects of the Enlightenment. Boswell carefully manages the background of each episode, describing the issue and the various arguments, and then -- Sam Johnson's booming voice settles the matter. After he speaks, the meeting is over.

{Dr. Samuel Johnson}
Dr. Samuel Johnson

"Why, sir", says Johnson, and then look out for the one-liner to follow. We get the impression that Dr. Johnson used that "Sir" signal to indicate he had enough of these dumb arguments, and soon would come the growled epigram that scatters any token resistance. Boswell may have neglected to record instances where the great Johnson was defeated in debate, who knows. We are left with the distinct impression that if you engaged in lunch table conversation with Sam, you were almost certain to lose. So that's what Ivy League students are being taught: how to win a debate at a committee meeting, in the expectation they would spend much of their lives in committees, boards, and even cabinets. That's how the English-speaking world gets its work done and its decisions made. That's what lunches at the Franklin Inn Club, or the club tables of the Union League, are trying to do for the education of neophytes.

{Chauncy Brewster Tinker}
Chauncy Brewster Tinker

As the goggle-eyed student of the great Chauncey Tinker, who gave young Pottle his start in life, it was an awesome performance for me to watch. But the rules of this game never became entirely clear to me, I'm afraid, until the other evening when I listened to Peter Nowell describe in a half-dozen brief paragraphs how he had revolutionized prevailing theories of the cause of cancer. The Franklin Institute then followed the award ceremony by putting on an all-day symposium of notables who run elaborate enterprises in cancer research, essentially funded by the National Institutes of Health, your tax dollars at work again. Last year, the NIH dispensed thirty billion -- you heard me -- dollars in research grants to internationally known research entrepreneurs, and if you can stay awake during their talks, there must be something the matter with you. So far as I could see, they were painstakingly describing every grain of sand on the beach, whereas Peter Nowell made the whole beach electric and clear in ten minutes. Essentially, he was saying that each patient's cancer is caused by a long chain of events, starting with a single mutation within a single cell. All the other cancer cells of a patient are descendants of that first one, which triggered the cascade of chemical events now repeated by the descendants. To stop the process, you probably only have to find a way to break the chain at one vulnerable point. Then you have a cure, without necessarily understanding every other link in the chain.

{Peter Nowell}
Peter Nowell

Peter Nowell described himself as a "lumper", admitting that most scientists are "splitters". A splitter quite reasonably attacks a complex problem by isolating one small piece of it at a time; that's really a pretty good way to address overwhelming complexity when you encounter it. But you can be sure that people of that mindset should not be found in a President's cabinet, deciding how to save the world from impending disaster. Whether by their own genetic predisposition or as a result of peer pressure in their profession, they are habitual splitters. And it suddenly occurred to me why Sam Johnson's one-liners always won the argument; he was a lumper. Usually right, sometimes wrong, never in doubt. Witty as a Frenchman, but as quick as a rattlesnake. Cordial, perhaps, unless you disagreed with him.

We need more lumpers. If they get that way from the likes of Chauncey Tinker, we need to print more copies of The Life of Johnson. If they are born that way, maybe we need a breeding farm for lumpers, which is what the Assembly Ball amounts to. But don't get me wrong, we need more splitters, too. They just have to learn their place at the table.

http://www.philadelphia-reflections.com/blog/1810.htm


Atlantic City, Brigantine and the N.I.H.

{Steel Pier}
Dr. William Osler

It would only be honest to say that Atlantic City was a rundown mess after World War II, cheap, sleasey and dispirited. But for academic medicine during a period of thirty or forty years, one small nook of A.C. was the most exciting place in the whole world. Only during several days at the beginning of May, however. The reason it was so attractive to scientists was that beach hotels were cheap and dilapidated; Atlantic City probably contained the worst on the East Coast. The Haddon Hall was an exception, rather elegant and far too expensive for most physicians in training; research is a young doctor's game. The medical profession's annual beauty contest for medical research was headquartered in Haddon Hall next door to the Steel Pier, surrounded by hundreds of cheap lesser hotels. The professors all stayed at Haddon Hall, but few others could afford it. Indeed, resident physicians from Philadelphia mostly found it cheaper to commute from home for ninety minutes than to stay overnight, residents and fellows from more distant cities stayed in the dumpy hotels. Nobody in that age group had much money to spend, so the commuting Philadelphians didn't miss out on much night life at the shore by going home every night.

{Atlantic City Skyline}
New Atlantic City Skyline

Before the spring meetings got popular after World War II, the hundred members of the most elite society of academic research professors on the East Coast assembled in Haddon Hall, all of them quite able to afford to stay in the headquarters hotel. This had been going on since William Osler founded it in 1885, at first in Washington, and then migrating to Atlantic City. As medical research began to flourish, the society grew a little, but at a pace too slow to keep up with the growth of medical scientists, so a second group of "Young Turks" formed a competitive society which met the next day, and ultimately a third group, the "Young Squirts", felt excluded by the old has-beens, and met on the third day of what eventually turned into a week-long parade of scientific presentations, each ten or twelve minutes long, starting before normal breakfast time, lasting until 10 PM, with occasional breaks. That is to say, the medical papers that everybody wanted to hear grew from thirty or forty a year to nearly a thousand. If a young fellow did well, the older professors would notice, and he would get employment offers. That kept the eminent older doctors around for the whole session, and provided an informal ranking of the worth of the program. Everybody wanted to advance up the ranks of prestige, and this system roughly sorted them out. However, it was an exhausting experience just to sit through all that and listen; the old professors tended to drop out and go home a little early. No matter how many outstanding papers were clamoring to be heard, no one could endure more than a week of straining for attention. It was strictly forbidden to present a paper which had been published or presented anywhere else, so it was usually difficult to guess in advance whether a paper was likely to be exciting. You could go home early if you wanted to, but at the risk of missing the real block-buster of the year, tucked away on the program with a bewildering scientific title. The younger wise-apples had a formula, that if one paper in three was outstanding, you were having a good meeting; you just had to grit your teeth and try to stay awake during the other two-thirds. Still, that got to mean that the reward for pursuing this grinding ordeal was to go home after learning about three hundred outstanding scientific advances that no one else knew about; knowing three hundred cutting-edge things that other doctors didn't know really did put you well ahead of the pack. Keep that up for ten or twenty years, and notable differences among colleagues would relentlessly emerge.

{Steel Pier}
Old Steel Pier

From the lounge of the Haddon Hall, with non-members forced to stand in the back, the meeting moved to the 2000-seat movie theater in the Steel Pier, at about 1950. Things then came to an equilibrium; the movie theater was never completely full. We were told there were seven or eight even larger auditoriums on the Steel Pier, but it was never necessary to move to them. The first four years I attended these sessions I was being paid no salary at all, and most of my contemporaries were only getting token amounts beyond room and board. The eminent professors who were real members of the top society would find their way to front-row seats where they could ask questions, having had a chat with colleagues at breakfast in the Haddon Hall. But they had once been impecunious, too, and wore their brand-new Ivy League plaid jackets rather uncomfortably. Doctors who (gasp) worked for drug companies also gave signs of affluence, but they tended to drift over to the barber shop and have a shoeshine, where they picked up the gossip for their employers. Over a period of fifty years, I can recall first hearing of the wonders of several new antibiotics, a strange chemical called cortisone which seemed to cure rheumatoid arthritis, the introduction of the birth-control pill, the introduction of polio vaccine, the first drugs in the treatment of tuberculosis, and a vast array of novel explanations for disease phenomena that had seemed mysterious for centuries. In those days, a year without a new medical miracle was a very lean year, indeed. During this interval, the basis for curing at least thirty common diseases was first presented at the Spring Meetings in A.C., and since then medical practice looks nothing like it did in 1947.

{Jitney}
Ten Passenger Jitney

Gradually the audience changed, too. At first, the people presenting papers came from at most ten medical schools, and mutterings of discrimination could be heard. In fact, it was plainly true, because only about ten schools had any extra money to fund research. When this news reached the U.S. Senators from the Mid and Far West, federal research money started to be spread around more evenly, just like the distribution of Senators. It was the appointment of one of the members of the original small nest of clubs to the Directorship of the N.I.H., the National Institutes of Health in Bethesda, Maryland, which really got the research spigot to flow. The point man was James Shannon, who knew what was what in cutting-edge research, and he sat there in the audience making up his mind who was who. For all the time of his directorship and for long afterwards, he enforced, really enforced, the rule of "no political influence in research grants". Lots of congressmen came to the N.I.H. with the news that their relatives had such-and-such a disease, and so they thought more money should be diverted to research in that area. Nothing doing. Shannon held the keys to the kingdom, and he knew it. He had a deft feel for how much money the research industry could usefully absorb, and then he went to Congress and demanded it. The purity of this process has frayed at the edges somewhat as the amounts of money grew to what is now thirty billions of dollars a year. Most experiments unfortunately fumble or fail, so a lot of money gets spent on blind alleys before someone gets it right. It takes a tough-as-nails idealist like Jim Shannon to survive the temptations of an N.I.H. Director, and among the temptations is just to give up and give out money indiscriminately to people who want to count all the grains of sand on the beach. If your idea was a good one, you got all the money you could possibly spend; if the idea was mediocre, in those days you got nothing at all. On the other hand, the estimation of overhead costs is something other mortals can quibble about. Shannon demanded and got about a third of the grant money to be given to the medical school administrations. That was barely enough in a research establishment emerging from the Depression of the 30s, and the World War. However, now that the pipeline is filled, it is increasingly doubtful that ten billion a year needs to go to administrators; the bean-counters took over, and the results are more open to criticism. After all, after someone finds a cheap cure for cancer, some disadvantages of perpetuating an aging retiree population start to emerge, and may outweigh the arguments for spending quite so much doing it. That may well be what the advisors to President Obama are growling at, but for now the example of his nose poked into the hornet's nest of favoring research for certain population (voter?) groups will restrain others who were once inclined to agree. After cancer is cured, perhaps then everything will seem different.

{Diving Horse}
Dr. James Augustine Shannon

Well, let's tell one story out of many that could be told. Around 1965 there were two competitive polio vaccines rumored to be in the pipeline. Jonas Salk had an injection method, and Albert Sabin had an oral vaccine. Anyone who had watched children run shrieking from a needle knew that Sabin had the preferred method, but Salk got to Atlantic City two years earlier than Sabin. The auditorium was filled with rumors of very dubious precision to the effect that Salk had used unfair methods to get to the stage of public announcement. For example, it was growled he gave the vaccine to the Russians to test, but they were afraid of it and gave it to the Poles. Regardless of such scurrilous gossip, which is here repeated only to show how hysteria can occasionally agitate even scientists, when Salk gave his paper at the Steel Pier, the standing ovation was thunderous. And so, as the meeting broke for dinner the crowds migrated over to a huge seafood restaurant named Hackney's and watched the new scientific hero get a little tipsy in public. That seemed to revive the rumors which became even less factual. But there is no doubt that by the time Sabin stood at the same podium and gave his presentation of the oral vaccine, the crowd had switched to his side, the ovations were unlike anything the scientists had ever heard. Anyway, as emotions now settle down in retrospection, we are all pretty happy that polio is nearly eradicated from all but a few corners of the earth, and these two men are both responsible for it. But so is Jim Shannon responsible for it, and he never got the ovations he deserved.

{Mr. Peanut}
Mr. Peanut

When the gambling casinos came to A.C. the cheap boarding houses were swept away, doctors in research were incidentally better paid, and the Spring Meetings migrated back to Washington. The dumps on the beach have been replaced by gleaming multistory hotels, the place looks much more prosperous. Doctors are in a position to know about the drug and alcohol addiction, the venereal disease and crime among the casino employees, and the personal tragedies among the gamblers. But anybody can see the new buildings and the clean streets. When a group of eight of us took a nostalgic trip to revisit the place, no doctor even mentioned the idea of going in to drink and gamble -- even the suggestion was preposterous. So we wandered over to Brigantine where there appears to be a large retirement community, where gambling and drinking seem equally unlikely. The elementary school in which we heard a talk about the old days was splendid beyond anything I remember in an elementary school. Among the audience the questions revealed there were many former employees of the old A.C., people who ran shops to sell salt water taffy, fudge and the like to crowds on the boardwalk. Some of them may have once driven Jitney buses, or pushed sightseeing wheelchairs. But not one of them showed the slightest sign of recognizing that on the first weekend in May, every year, a crowd of nerdy-looking serious fellows would move into familiar boarding houses for a few days, remaining mostly invisible during daylight hours. That was the academic doctor crowd, if anyone had bothered to ask, pouring into the Steel Pier movie theater, having the time of their lives listening to medical history being made. After a week they all went home, and nobody in A.C., later Brigantine, paid any attention to any of it. After all, A.C. is about salt water taffy, right?

http://www.philadelphia-reflections.com/blog/1818.htm


Cataracts and Deference to Seniors

Last week I had a cataract extraction; it went well. I now see like an eagle, there was no pain at any time, and it only interrupted my life for about six hours, including travel time. While I suppose there is a chance of complications during the next month after surgery, I'm an optimist and statistics are on my side. As they say in South Philadelphia, fageddabout it.

{Cataract Extraction}
Cataract Extraction

Those were of course not the serene thoughts I had in advance of the surgery, which carries certain risks. Persons with myopia like me often have a mismatch in the size of their eyeball and the size of the retina inside, so the retina can tear or detach during the first few days after the eyeball's integrity has been pierced. The lens can get stuck and break apart as it is being removed, hemorrhage can occur. The surgeon's hand can slip; he can sneeze at the wrong moment. So, bad things could have happened to me, making my twinge of anxiety entirely justified. But that's all behind me now; I even forgot to ask the surgeon what type of lens he intended to implant, so I could argue with him. Let the Captain run the ship. I was surrendering my fate to the largest eye hospital in the country. They perform between fifty and a hundred of these procedures every day, and my surgeon is the chief of the cataract department.

And yet, and yet, I have a few grumbles, leading to some generalizations about health care for the elderly. In the first place, I was told by an administrator who sounded terribly fierce that I had to be there at 8:15 AM, in the company of the person who would drive me home, or they wouldn't do my surgery. I told her I doubted that, so we got off to a poor start. The procedure ought to take less than ten minutes to perform, perhaps twenty if you count the formalities. Furthermore, I was a consultant to that hospital once, and still had a certain amount of standing in the Philadelphia medical community, having once been a trustee of almost everything you can be a trustee of. Sure enough, when my driver and I arrived at 8:15, there were more than fifty others waiting. They finally called my name at 1:30 in the afternoon, and by roughly 2 o'clock I was out of there. I was by no means the last one waiting to be called, and it sort of felt as though we were all treated like logs of wood. While I was inside the operating room, a couple of nurses were chattering, and one said she much preferred to work on weekends, because there were no administrators around. I could see what she meant.

To keep this essay from sounding like constant whining, let me tell a little of the history of this operation. Until perhaps twenty years ago, a cataract extraction involved keeping the patient in the hospital after the operation with the head in sandbags, for two full weeks. Now, it takes ten or twenty minutes, and you are free to have lunch with a friend in an hour, unless you give in to your driver who has been waiting five hours and wants to go home.The results are far superior, and you don't have to wear glasses that look like the bottom of Coke bottles afterwards; in fact, I already see pretty well without any glasses before a week is up. In the past, the great fear was a complication known as sympathetic ophthalmitis, in which disturbing the lens of one eye would set up a sort of allergy which could also make you blind in the other, good, eye.

{Spitfire}
Spitfire

In the famous Battle of Britain in the Second World War, the British pilots to whom so many owe so much were covered with a plexiglass canopy in a fighter plane called the Spitfire. Enemy machine gun fire would often shatter this canopy, and among a lot of other damages, shards of plexiglass got lodged in the eyeballs of the pilots. For the most part it was left in place because other injuries needed tending more urgently. Long after the Battle, it finally dawned on a British ophthalmologist that this wasn't supposed to happen, it was supposed to cause sympathetic ophthalmitis and the pilots were supposed to go blind. From this it was finally deduced that plexiglass was safe to use as a lens implant, a so-called "hard implant". You can still see people walking about with these lenses, recognizable because their eyes seem to glow when the light shines into them, like crocodiles along the Amazon at night.

The second step in the migration to modern cataract surgery was the insight that soft pliable forms of plastic retain a memory of the shape they were moulded into. So, the old lens can be scooped, lasered or sucked out of place, and a squeezed-down soft lens can be shoved into the vacated space. Retaining its shape-memory, it springs back into the correct shape for a lens, and you are all set.

And finally, there was the stitch. If you cut into the side of the cornea, you have to stitch it up after you are through. And then later you have to remove the stitch. An eye surgeon who should be more famous if he were more popular then invented a form of curved incision which did not requite a stitch because the pressure within the eye held it closed. It was a simple and brilliant idea, which took scarcely a few extra seconds but eliminated one of those sources of complications which dogged the statistics. There was only one problem. This surgeon decided to apply for a patent for his invention, and the medical world had a fit; not only did he patent the curved incision, he sent bills for royalties to every eye surgeon he could prove was using it. I happened to be seated the the House of Delegates of the American Medical Association when this matter came up, and the uproar was considerable, including some ribald limericks which were read the House "as a matter of personal privilege". Shortly afterwards the courts did the right thing and disallowed the patent.

So that pretty well summarizes how cataract surgery became a modern miracle, with a great many elderly people now playing demon bridge when they would otherwise be fed with a spoon. Somehow, the national gratitude is not quite equal to its obligations, and we hear people grumble that eye surgeons make too much money. When the achievements of politicians match those of the average eye surgeon, perhaps they will have a point. But not sooner.

But I'm allowed to complain, and perhaps obliged to issue a warning to my fellow elders about the true source of our discontent. It seems to start with eye drops, but it's more than that. There's a simple technique for instilling eye drops, which involves pulling down the lower lid, creating a pocket, and putting the drop in the pocket, after which the subject blinks his eye and spreads the drop around. Works slick, takes no extra time, and little trouble. And while a half-dozen nurses put drops in my eye, and must put fifty drops in fifty eyes every day, not one of them did it right. The drops were spattered on the eyelids and eyelashes, much of them running down my cheek. One extra-large nurse with an attitude put her thumb on my upper eyelid and spread the lids so painfully apart that I cried out in protest. It's supposed to hurt, was the unwelcome answer. I resolved then, and soon carried out the threat to scold the surgeon and the Physician-in-Chief about the responsibilities of supervision, but there are two other more serious issues behind this indignity.

In the first place, the reimbursement mechanisms were modified so that hospitals were no longer paid for maintaining a school of nursing. Within a few years, all hospitals had trimmed this expense, and nurses went to college to be trained in nursing, miles away from the nearest hospital, and eventually trained by other nurses who had themselves had scant experience with patients. Although it is boasted that they now have batchelors's degrees instead of mere diplomas, their skill with patient care is far inferior to that of the generations which went before them. Instead of being well trained, they are rule ridden.

The other underlying issue lies with us, the patients. In France people retire at fifty I hear, and in this country we retire at sixty-five. But we sit around, essentially quite healthy, until eighty-five or later. Everybody knows we have nothing important to do, so they waste our time. Or rather, whenever there is a choice of wasting a minute of working-person's time, or an hour of a retired person's, it is the retired person who is dumped on, and it's only going to get much worse with time. Hey, folks, it's degrading to be so useless. Go to work and accomplish something. Don't let the younger generation treat you like logs of wood.

http://www.philadelphia-reflections.com/blog/1967.htm


Medical Generation Gap

{Miriam Schaffer}
Miriam Schaefer

To understand the dynamics of the following medical anecdote, the reader should understand the thrust of Miriam's First Rule of Management. Miriam is my oldest daughter, with long experience managing many firms, large and small. Her rule is that when an employee starts misbehaving for no good reason, eliminate the position. Invariably, well almost invariably, an employee who starts acting out doesn't have enough work to do. If you are managing a large organization, you should also consider firing the supervisor of that person, on the grounds the supervisor should have noticed there was not enough work for the employee to do, and is probably covering up.

My anecdote concerns a session at the 2006 annual meeting of the American College of Physicians, ostensibly devoted to conflict between generations of doctors. It didn't take long before the meeting turned into an uproar about the new work rules which prohibit a resident physician from working more than 80 hours a week. That's supposed to protect patients against mistakes of sleepy doctors, although some suspect it is mainly an outgrowth of a gap between what they do and what they expected to do. From the time they entered high school, future doctors have been taught to expect workaholic employment conditions, and while more normal people haven't been taught that message, that's irrelevant. The situation is aggravated by the increased admission of women to the profession, who for their part have been taught to expect a breathless race between finishing their work and getting home to relieve the baby-sitter. Perhaps in time the newly invented specialty of "hospitalists" will get established and accepted, along with accident room work as another harrowing occupation which abruptly ends its day by the clock rather than the backlogs. At the moment the pioneers must overcome the suspicion, only partly fair, that Miriam's First Rule applies to them.

{Medical Care}
Medical Care

If not, that Rule clearly does apply to the youngsters who now must go home to spend quality time with their families, because they are not allowed to exceed the new work rules. At the ACP meeting, a dozen of us Civil War veterans were treated to an appalling amount of teenage mumbo jumbo apparently emanating from unsuspected warfare between Generation X and the Baby Boomers, their supervisors, mentors, and colleagues. All of us Civil War veterans held the private opinion that Baby Boomers were a little self-indulgent, but in the eyes of Gen Xers the boomers are workaholic fanatics, incapable of relaxing even for a moment in order to enjoy the life of the good, the true and the beautiful.

As we passed out of the room at the end of the session, one of the silent gentlemen with white hair came over to me. We didn't know each other, but we recognized the signs of a silent shared opinion. The old doctor leaned over to me and muttered, "They offer nothing, but they want everything." I smiled, and we parted. I guess I might have told him about Miriam's First Rule, but it would have taken too much explaining.

http://www.philadelphia-reflections.com/blog/823.htm


Nanoparticles: The Dwarfs are Coming

{Professor Shyamelendu Bose}
Professor Shyamelendu Bose

Professor Shyamelendu Bose of Drexel University recently addressed the Right Angle Club of Philadelphia about the astounding changes which take place when particles are made small enough, a new scientific field called nanotechnology. In one sense, the word "nano" comes from the Latin and Greek for "dwarf". In a modern scientific sense, the nano prefix indicates a billionth of something, as in a nanometer, which is a billionth of a meter. Or nanotubes, or nanocalcium, or nano anything you please. Nanometer is likely to be the dominant reference, because it is around this width that particles begin to act strangely.

{Nanoparticles}
Nanoparticles

At this width, normally opaque copper particles become transparent, cloth becomes stain-resistant, and bacteria begin to emit clothing odor. Because the retina is peculiarly sensitive to this wave length, colors assume an unusual brilliance, as in the colors of a peacock's tail. Stable aluminum powder becomes combustible. Normally insoluble substances such as gold become soluble at this size, malleable metals become tough and dent-proof, and straight particles assume a curved shape. Damascus steel is unusually strong because of the induction of nanotubes of nanometer width, and the brilliance of ancient stain-glass colors is apparently created by repeated grinding of the colored particles.

{Richard Feynman of Cal Tech}
Richard Feynman of Cal Tech

Practical exploitation of these properties has almost instantly transformed older technologies, and suggests the underlying explanation for others. International trade in materials made with nanotechnology has grown from a few billion dollars a year to $2.6 trillion in a decade, particularly through remaking common articles of clothing which were easily bent or soiled, into those which are stain and water resistant. Scientists with an interest in computer chips almost immediately seized upon the idea, since many more transistors can be packed together in more powerful arrangements. Richard Feynman of Cal Tech seems to be acknowledged as the main leader of this whole astounding field, which promises to devise new methods of drug delivery to disease sites through rolling metal nanosheets into nanotubes, then filling the tubes with drug for delivery to formerly unreachable sites. Or making nanowires into various shapes for the creation of nanoprostheses.

{Cal Tech on Los Angeles}
Cal Tech on Los Angeles

And on, and on. At the moment, the limitations of this field are the limitations only of imagination about what to do with it. For some reason, carbon is unusually subject to modification by nanotechnology. It brings to mind that the whole field of "organic" chemistry is based on the uniquenesses of the carbon atom, suggesting the two properties are the same or closely related. For a city with such a concentration of the chemical industry as Philadelphia has, it is especially exciting to contemplate the possibilities. And heartening to see Drexel take the lead in it. There has long been a concern that Drexel's emphasis on helping poor boys rise in the social scale has diverted its attention from helping the surrounding neighborhoods exploit the practical advances of science. The impact of Cal Tech on Los Angeles, or M.I.T on Boston, Carnegie Mellon on Pittsburgh, and the science triangle of Durham on North Carolina seems absent or attenuated in Philadelphia. We once let the whole computer industry get away from us by our lawyers diverting us into the patent-infringement industry, and that sad story has a hundred other parallels in Philadelphia industrial history. Let's see Drexel go for the gold cup in this one -- forget about basketball, please.

http://www.philadelphia-reflections.com/blog/2193.htm


Wistar Institute, Spelled With an "A"

{Dr. Russel Kaufman}
Dr. Russel Kaufman

The Right Angle Club was recently honored by hosting a speech by Dr. Russel Kaufman, the CEO of the Wistar Institute. Dr. Russel is a charming person, accustomed to talking on Public Broadcasting. But Russel with one "L" ? How come? Well, sez Dr. Kaufman, that was my idea. "When I was a child, I asked my parents whether the word was pronounced any differently with one or two "Ls", and the answer was, No. So if I lived to a ripe old age, just think how much time and effort would be wasted by using that second "L". In eighty years, I might spend a whole week putting useless "Ls" on the end of Russel. I pestered my parents about it to the point where they just gave up and let me change my name". That's the kind of guy he is.

{The Wistar Institute}
The Wistar Institute

The Wistar Institute is surrounded by the University of Pennsylvania, but officially has nothing to do with it. It owns its own land and buildings, has its own trustees and endowment, and goes its own academic way. That isn't the way you hear it from numerous Penn people, but since it was so stated publicly by its CEO, that has to be taken as the last word. It's going to be an important fact pretty soon, since the Wistar Institute is soon going to embark on a major fund-raising campaign, designed to increase the number of laboratories from thirty to fifty. The Wistar performs basic research in the scientific underpinnings of medical advances, often making discoveries which lead to medical advances, but usually not engaging in direct clinical research itself. This is a very appealing approach for the many drug manufacturers in the Philadelphia region, since there can be many squabbles and tanges about patents and copyrights when the commercial applications make an appearance. All of that can be minimized when fundamental research and applied research are undertaken sequentially. Philadelphia ought to remember better than it does, that it once lost the whole computer industry when the computer inventors and the institutions which supported them got into a hopeless tangle over who had the rights to what. The results in that historic case visibly annoyed the judge about the way the patent infringement industry seemingly interfered with the manufacture of the greatest invention of the Twentieth century.

{Vitamin-D}
Vitamin-D

Patents are a tricky issue, particularly since the medical profession has traditionally been violently opposed to allowing physicians to patent their discoveries, and for that matter, Dr. Benjamin Franklin never patented any of his many famous inventions. But the University of Wisconsin set things in a new direction with the patenting of Vitamin D, leading to a major funding stream for additional University of Wisconsin research. Ways can indeed be devised to serve the various ethical issues involved, since "grub-staking" is an ancient and honorable American tradition, one which has rescued other far rougher industries from debilitating quarrels over intellectual property. You can easily see why the Wistar Institute badly needs a charming leader like Russel, to mediate the forward progress of our most important local activity. From these efforts in the past have emerged the Rabies and Measles vaccines, and the fundamental progress which made the polio vaccine possible.

It was a great relief to have it explained that there is essentially no difference at all between Wisters with an "E" and Wistars with an "A". There were two brothers who got tired of the constant confusion between them, see, and agreed to spell their names differently. When the Wistar Institute gathered a couple hundred members of the family for a dinner, the grand dame of the family declared in a menacing way that there is no difference in how they are pronounced, either. It's Wister, folks, no matter how it is spelled. Since not a soul at the dinner dared to challenge her, that's the way it's always going to be.

http://www.philadelphia-reflections.com/blog/2393.htm


Psychiatry: Last Cow in Philadelphia

The present problem with PSYCHIATRY can be summarized as follows: At the suggestion of the American Hospital Association, Congress introduced the DRG system of paying for inpatients by diagnosis, rather than itemized services. It worked well except for psychiatry, where the diagnosis usually implies little relation to the later costs it generates, so an exception was made. The dual system of payment created loopholes which unfortunately overpaid psychiatric hospitals and were described as exploitation. Congress over-reacted in a way that was unsustainable, and essentially all of the psychiatric hospitals of the nation were forced to close. This is not a history for anyone to be proud of, and the lack of outcry is also a disappointment. However, after twenty years without reform, evidently nothing is going to be done without an outcry.

CONVENE BLUE RIBBON COMMISSION TO REPAIR PSYCHIATRIC INPATIENT CARE. The 1983 BRA switched hospital inpatient reimbursement to payment by diagnosis (DRG). Abuse of the psychiatric exclusion then led to "corrective" legislation which has essentially reduced American's psychiatric inpatient care to an underfunded national disappointment. The problem is not an easy one, so a commission should devise a workable methodology for psychiatric hospitals, relying neither on present approaches, nor on DRG. But overpayment is a better outcome than no care at all. Homeless people sleeping in cardboard boxes on downtown steam grates are the consequence any visitor to the area can observe at night after the commuters go home. Psychiatric social workers readily recognize their daytime patients in the boxes.

* * * * *

Daniel Blain, M.D. (1898-1981) was just about the most important psychiatrist in America. He was the Physician in Chief of the Institute of the Pennsylvania Hospital at 49th and Market, the first and in many ways the most prestigious psychiatric hospital before it was closed. Before that, he was the first Medical Director of the American Psychiatric Association, itself the first (1844) medical society in America. His fame rested on organizing the disorganized psychiatry of the Veteran's Administration into a chain of advanced "Dean's Hospitals", a huge and very important achievement. Before that, he had achieved considerable fame as the man who took the dilapidated State Psychiatric Hospitals with a reputation as "snake pits" and made them a respectable part of the medical community. And before that, he had been born in China as the son of missionaries. As a matter of fact, even before that he was a descendant of General Mercer of Revolutionary War fame.

Dan was an outstanding example of the peculiar fact that Psychiatry was dominated by social upper crust psychiatrists in Philadelphia for a very long time. In fact, Benjamin Rush of the 8th Street branch of the Pennsylvania Hospital is known in some circles as the "Father of Psychiatry", while in other circles he is known for signing the Declaration of Independence. That isn't true in other cities, and it definitely isn't true in New York City, where the psychoanalytic school of Sigmund Freud took that city by storm, and essentially drove every other school of psychiatric thought out of town, out of medical schools, out of psychiatric hospitals. The famous sixteen year psychoanalysis of Woody Allen is an example of the extremes of that fad. Every profession has petty civil wars of that sort, best left undiscussed in public. But in the case of psychiatry, it was indirectly a material contributor to the present disappearance of inpatient psychiatry, and the related appearance of lots of homeless people on steam grates. Let me give a biased view of what is a massive human tragedy, which someone else can "rectify" if he chooses.

It starts with a Budget Reconciliation Act of the 1980s, which brought us the DRG (Diagnosis-related) system of paying for hospitalized patients. The idea was that appendicitis resulted in essentially 7 days in the hospital, give or take a couple of days, and the bills for an admission for appendectomy were for more or less the same amount. If you had fifty or a hundred cases a year in your hospital, the high bills balanced the low bills, and the overall hospital reimbursement was essentially the same without itemizing the bandages and whatnot. Congress bought this package, and after it got going, just about all hospital bills were reimbursed at one of three hundred prices, the cost to the government was the same, and there was a whole lot less bookkeeping and accounting cost. It was a success, except for a few cases where the costs did not closely line up with the diagnosis, and psychiatric hospitals were where they concentrated. So, psychiatric hospitals were excluded, and psychiatric bills skyrocketed. This experience has been carelessly cited as an example of the evils of payment by service ("fee for service"), when in fact the duration of psychiatric hospitalization is related to features of the condition, like a danger of suicide, rather than the diagnosis itself. Psychiatric leadership at the time contained many in a subset of physicians who did not think much of inpatient psychiatry in the first place, and even less of lobbying, and they underestimated the severity of the assault on the specialty. Apparently, no workable formula for pricing inpatient psychiatry has since been brought forward to be approved by a Congress which is more accustomed to getting its lobbying in the form of one-liners. And would you believe it, psychiatric inpatient care soon disappeared.

That's right, if someone in your family needs psychiatric hospitalization, I wouldn't know where to tell them to get it -- at any price. From considerably overpaying for psychiatry inpatients, to paying scarcely anything for them, this little change of the regulations caused every psychiatric hospital I know of by name, to close. It helped balance some state budgets, but it also was a considerable factor in filling the steam grates of American cities with people who sleep on cardboard boxes. And what it illustrates is that this is what political society always seemed to do, before Dan Blain and a small group of upper-crust psychiatrists were temporarily able to shame them into something better. In fact, if there is any tattered remnant of good inpatient psychiatric care left in America today, it is in the Veterans Hospitals that Dan was able to straighten out.

Dan Blain will probably eventually be bypassed as a curiosity, like his wife. She was a Wister Logan Blain, descended from families who ruled Philadelphia a hundred years before even General Mercer came along. So the Blain couple lived on an enormous farm plot, centered at 20th and Olney right next to LaSalle University, which is built on their property. It also contains the Peale House, where Charles Willson Peale lived as the elected president of the rebel faction of the American Revolution. Peale didn't know what he was supposed to do, so he resigned and painted portraits of people. The Blains enjoyed keeping a cow on their land, the last cow in Philadelphia, and the LaSalle students enjoyed stealing the cow and leaving it on the top floor of a dormitory, for laughs. Meanwhile, the Blain couple had cocktail parties on their front porch for visiting dignitaries. They usually wore blue jeans, and Mrs. Blain, the absolute Queen of Philadelphia society, was occasionally observed to pour vodka into her glass of beer. That sort of background may well have been useful when psychiatry needed to be built up and humanized, but it became a liability when the rest of inpatient psychiatry failed to appreciate what was knocking on its door.

http://www.philadelphia-reflections.com/blog/2564.htm



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