George R. Fisher, III, M.D.

Obituary

George R. Fisher, III, M.D.

Age: 97 of Philadelphia, formerly of Haddonfield Dr George Fisher III

Dr. George Ross Fisher of Philadelphia died on March 9, 2023, surrounded by his loving family.

Born in 1925 in Erie, Pennsylvania, to two teachers, George and Margaret Fisher, he grew up in Pittsburgh, later attending The Lawrenceville School and Yale University (graduating early because of the war). He was very proud of the fact that he was the only person who ever graduated from Yale with a Bachelor of Science in English Literature. He attended Columbia University’s College of Physicians and Surgeons where he met the love of his life, fellow medical student, and future renowned Philadelphia radiologist Mary Stuart Blakely. While dating, they entertained themselves by dressing up in evening attire and crashing fancy Manhattan weddings. They married in 1950 and were each other’s true loves, mutual admirers, and life partners until Mary Stuart passed away in 2006. A Columbia faculty member wrote of him, “This young man’s personality is way off the beaten track, and cannot be evaluated by the customary methods.”

After training at the Pennsylvania Hospital in Philadelphia where he was Chief Resident in Medicine, and spending a year at the NIH, he opened a practice in Endocrinology on Spruce Street where he practiced for sixty years. He also consulted regularly for the employees of Strawbridge and Clothier as well as the Hospital for the Mentally Retarded at Stockley, Delaware. He was beloved by his patients, his guiding philosophy being the adage, “Listen to your patient – he’s telling you his diagnosis.” His patients also told him their stories which gave him an education in all things Philadelphia, the city he passionately loved and which he went on to chronicle in this online blog. Many of these blogs were adapted into a history-oriented tour book, Philadelphia Revelations: Twenty Tours of the Delaware Valley.

He was a true Renaissance Man, interested in everything and everyone, remembering everything he read or heard in complete detail, and endowed with a penetrating intellect which cut to the heart of whatever was being discussed, whether it be medicine, history, literature, economics, investments, politics, science or even lawn care for his home in Haddonfield, NJ where he and his wife raised their four children. He was an “early adopter.” Memories of his children from the 1960s include being taken to visit his colleagues working on the UNIVAC computer at Penn; the air-mail version of the London Economist on the dining room table; and his work on developing a proprietary medical office software using Fortran. His dedication to patients and to his profession extended to his many years representing Pennsylvania to the American Medical Association.

After retiring from his practice in 2003, he started his pioneering “just-in-time” Ross & Perry publishing company, which printed more than 300 new and reprint titles, ranging from Flight Manual for the SR-71 Blackbird Spy Plane (his best seller!) to Terse Verse, a collection of a hundred mostly humorous haikus. He authored four books. In 2013 at age 88, he ran as a Republican for New Jersey Assemblyman for the 6th district (he lost).

A gregarious extrovert, he loved meeting his fellow Philadelphians well into his nineties at the Shakespeare Society, the Global Interdependence Center, the College of Physicians, the Right Angle Club, the Union League, the Haddonfield 65 Club, and the Franklin Inn. He faithfully attended Quaker Meeting in Haddonfield NJ for over 60 years. Later in life he was fortunate to be joined in his life, travels, and adventures by his dear friend Dr. Janice Gordon.

He passed away peacefully, held in the Light and surrounded by his family as they sang to him and read aloud the love letters that he and his wife penned throughout their courtship. In addition to his children – George, Miriam, Margaret, and Stuart – he leaves his three children-in-law, eight grandchildren, three great-grandchildren, and his younger brother, John.

A memorial service, followed by a reception, will be held at the Friends Meeting in Haddonfield New Jersey on April 1 at one in the afternoon. Memorial contributions may be sent to Haddonfield Friends Meeting, 47 Friends Avenue, Haddonfield, NJ 08033.

Pink Slips for Green Doctors

This little story of discarded pink slips, even after fifty years have elapsed, is on the short list of things I am proud of. I probably remember it so well because it was the forerunner of several other seemingly unrelated matters.

In 1956, I was the Chief Resident Physician of the Pennsylvania Hospital. That position doesn't exist anymore, but most hospitals at the time had a Chief Resident, who was in charge of the house officers, the interns, and residents. The Chief Resident was usually a doctor who had just finished his formal specialty training and was thinking about starting a private practice. He was the father figure to the doctors still in their post-graduate training years, all of them overworked and tense, concentrating on avoiding dangerous mistakes while learning to assume new and difficult responsibilities. He was old enough to carry the weight of authority but young enough so the residents could talk to him frankly, and still call him by his first name. The Chief Resident had his office and secretary near the accident or receiving ward, next to the resident's lounge, which contained mailboxes and coat hangers. The lounge was pretty shabby, as bachelor lounges tend to be, but it was all doctors, all the time, coming and going. If you wanted to know what was going on, this was the place to learn it.

Pink Slip

Tom Paton, the credit manager, had his office further down the hall. In spite of his occupation, he was a jovial, convivial fellow, a former rugby player and soccer referee who fit right in with the lounge crowd. One day, I noticed he was throwing away a large stack of pink slips. He seemed surprisingly eager to tell me all about it. These slips represent the lifeblood of the hospital, sez he, without the flow of cash we would have to close the doors of the institution. Well yes, Tom, but taking care of the sick folk is sort of important, too. After a little explaining, I had to agree that he was talking about an interesting subject.

One of the everlasting problems in any hospital is to have the bill ready at the time the patient goes home. Nowadays, hospitals all have databases and many gigabytes of computing power, but the patient's bill is never ready when the patient is discharged and may take weeks to be sent to them. Hospitals put on a good face, don't you worry about the bill, madam, we trust you and we'll send it to you when you are feeling better. And all that, but the truth is they haven't a clue what your bill is.

All of that drove Tom Paton nearly crazy. The time to collect a bill is when the tears are still hot. Every day you delay the bill costs you a provable fraction of it, and so on. So, the system was devised that the tabulating machines of the hospital would routinely work all night to produce a bill for everybody, every day. If they went home today, they were handed a bill. If they didn't go home, the bills were thrown away. For accounting purposes, a carbon copy of each bill was kept on pink paper. It was an amazingly simple idea, far less expensive than the random-access real-time whatchmacallits that nowadays do a far less effective job, and are out of commission much of the time. Let the record show that in 1956, every single patient at Nation's First Hospital got his bill as he was leaving, any time night or day. IBM charged us eleven hundred dollars a month to rent the machines, which also did the payroll and inventory systems.

An idea occurred to me. If you are only going to throw them away, could I please have the pink-slip copies of the bills of the patients who did not go home? Those patients are still in the hospital, and these slips show how much cost each patient is in the process of running up. So a system was established that my secretary got these pink slips every day, and put them in the mailbox of the doctor taking care of the patients. It was a simple thing to do, but the reaction it got was explosive.

At first, the interns thought I was warning them, or criticizing them, but they soon got over that. We were all appalled at the costs which were being generated and particularly appalled when a patient stayed a little longer than necessary. In those days before Medicare, any unpaid costs had to be made up by contributions and private endowment. The house officers and the student nurses who did most of the work received no salary. The sense of guilt that arose from looking at those bills was very strong, and it was obvious that every one of them went back to the wards to try to speed things up. Since they all left their training to practice in various communities for fifty years, I like to believe that the multiplier effect was significant.

In those days, we had a two-year rotating internship. Every month before rotating to a new service, each intern would summarize the remaining patients on his ward for the benefit of his successor. In doing so, they were able to reflect in retrospect how each case could have been speeded up a little, and therefore wouldn't still be here to require a summary. There is an invisible counter-pressure at work. From a doctor's point of view, most of the heavy work of each admission to the hospital is concentrated in the first couple of days. You get things into motion, and then sort of watch it rolls out. But if your ward is full, you can't get any new admissions, so your day suddenly gets a lot easier. Just let one of them go home, and bingo you have a new one. This little human frailty affects every one of them to some degree, and each one thinks he may have discovered this hidden incentive to slow discharges, except on the last day of the month. It was my job as Chief Resident to keep the system from sludging up. As much as for any other reason, an increased turnover meant more cases per intern, and therefore more training and experience. That's what most of them thought I was up to when I started handing out the pink bill copies. It really wasn't purposeful at all, it was just sort of an accidental discovery of something useful.

From that, I developed an interest in efficient use of hospitals, a subject we called utilization review. Through the County Medical Society, I formed a club of other doctors at other hospitals who had the same interest. When Senator Bennett of Utah got a law enacted, this organization turned into the Philadelphia Professional Standards Review Organization, which became part of the Pennsylvania PSRO, and eventually a national one whose name has changed several times. We had some interesting battles at the AMA House of Delegates, which dissolved into insignificance when the national business organizations took matters into their own hands and used their control of employer health insurance to push HMOs, Health Maintenance Organizations, onto the hapless public. Public outrage about HMOs put egg permanently on the face of national business, but the matter is now worse, not better.

What I got out of all this was an enduring interest in computers, which has served me well for half a century. And a sense of outrage bordering on apoplexy whenever some well-meaning activist declares that the doctors are responsible for pushing up hospital prices to enrich themselves in some way.

ACA Synopsis, July 4, 2014

The Affordable Care Act, commonly called Obamacare, contains two clashing provisions. Although the public may believe the Act provides for Universal Mandatory Health Insurance for all Americans, it actually only sets standards for minimum coverage. Because of later Supreme Court decision, the applicable section was renamed Section 5000A of. In the same section, it delays applying these standards to employees of big business and exempts about thirty million others entirely. (Section c). In an independent section of the same law, Section 1251 clearly states that people satisfied with existing coverage may keep it. Even after millions of Americans nevertheless received cancellation notices, President Obama repeated on television that no satisfied person would be required to drop existing coverage. Even disregarding mere verbal assurances, the two written sections did follow the rules for enactment and were signed by the President. just how are they simultaneously possible, to say nothing of workable?

A quick answer would be that the first sentence of the first Article of the Constitution vests sole power to create legislation in a Legislative Branch composed of a Senate and House of Representatives; thereby requiring the agreement of both, for a law to be a product of the entire Legislative Branch. It did not take long before a Conference Committee system was established, where the two Legislative Houses could negotiate any differences. When one party has voting control of both Houses, however, it is occasionally able to create identical language, eliminating the need for reconciliation. According to a book by an intimate, the Clinton administration planned to take this process a little further in their own Health Plan of 1992, including undesired provisions when that was useful to obtain a wavering vote, or otherwise to obscure the true direction of the legislation for extra time. Having complete control of the process, the party in power would later be able to delete undesirable provisions. The true nature of the legislation might thus only emerge at the last possible moment when timing could be manipulated to make it difficult to object. It is not possible to know whether this strategy has been used in other legislation, but circumstances strongly suggest it was partially implemented in both Clintoncare and Obamacare, and by many of the same people.

In any event, Clintoncare was withdrawn by its sponsors, before a floor vote, and for undisclosed reasons. Obamacare was enacted by the Senate, but the death of Senator Kennedy and his replacement by a Republican Scott Brown made it impossible to survive a filibuster on its return for final Senate adoption. To avoid this outcome, the Senate bill was forced through the House of Representative's word for word, and the Senate bill then became the final law, even though it was known to include booby traps. Largely as a result of public outrage, a strong Republican majority was returned to office, and the possibility of the further amendment was ended. So that's why we are essentially where we are.

What happens next is much more uncertain, because more actors have an opportunity to initiate events. Setting aside international adventures and financial crises, Congress could lose control of events by failing to negotiate a solution. After that, it is probably up to the electorate of seven states with tight Senate races, if not the United States Supreme Court, which has its own private agenda. All of these potentials put pressure on Congress and the President to negotiate a compromise. I suggest a simple first step would be to see if the entire section 1251 could become an amendment by addition to section 5000A, That would have the effect of adding a fourth class of exemption (people who don't want to change) to Illegal immigrants, incarcerated persons, and those with religious objections. Alternatively, they could be added to employees of big business as "temporarily" delayed. A case could be made to the Democrats that a smaller initial transition group could be more readily implemented. And a case to the Republicans would essentially be that "nothing is so permanent as the temporary". In both cases, the November Senate races would suggest what the public will support.

The public tends to believe the central agitating issue is health care, but more likely the central issue is state versus national regulation of health insurance. Health care was universally regarded as a local or state issue for three hundred years, and the issues were all technical and peaceful until pre-paid insurance began to be the dominant method of paying for it. No one seems to be noticing that ERISA has peacefully solved almost all of the problems of interstate mobility, which is what agitates interstate health insurance. Essentially, my position is that healthcare regulation can safely return to state control, at least during the period when the techniques and insights of ERISA are copied and experimented with, for health insurance. The public actually has very little interest in the interstate regulation of health insurance, so fifty years of agitation have essentially been over nothing.

With regard to health insurance, I believe we are working with the wrong design. Young working people accumulate savings, and old retired people spend it. Lengthened longevity has created the potential for enormous savings from compound investment income generated by working people, but such savings have been frittered away by using a "pay as you go" payment system. If we created portable systems for saving and investing income during the working years (the Health Savings Account), we could almost dispense with health insurance of the present model until people reach fifty or sixty years of age. Lifetime health insurance would be one approach, but all that is really necessary is lifetime savings accounts. Dispensing money from a fund could be quite adequately managed with a debit card, leaving only the problem of disciplining the fees of investment managers. But the details of such saving, investing and disbursing are of only secondary interest to the public, probably best left to the industry itself, because the industry will be very interested, indeed. As for reducing the cost of health care, we have stumbled along, letting the scientists eliminate disease costs by eliminating disease itself. They still have worms in Africa, and Asia could use some sanitation, But we have reached the point where our fastest-growing age group is over 100, and out biggest unsolved health problem is not dying too soon; it is living beyond our savings.

The Grand Plan for HRSA Networks, Very Briefly

So, we discover Health Savings Accounts are not snake-oil, a quick-fix solution to every healthcare problem ever complained about. No good idea is improved by such exaggeration. What is offered here is a long-term plan for greatly reducing the cost of healthcare, conceivably cutting it in half. It has some features which would show quick results, and we must devise a transition plan which puts them first. But it might take fifty years to achieve it all, and much can happen to upset plans in fifty years. The plan of this book is to suggest what should be done, in more or less the order of when to do it. But first to sketch in -- very briefly -- the final goals for doing any of it.

What Have You Done for Me, Lately? What I propose is a healthcare network of existing systems, linked together one by one with the retirement and investment incentives of Health (and Retirement) Savings Accounts. The short term value of the network is to create a unified transfer system to the more distant goals, providing some time to reach them. The HSA will be tempted to wander from its mission but should remain as simple as possible -- a gussied-up transfer vehicle for healthcare funds. Most of the elements are in place for this, although some enabling amendments might be suggested. Meanwhile, the option must persist for using HRSAs by themselves as total lifetime coverage, since transitional changes may leave some people without suitable alternatives. But repairing existing programs rather than replacing them--Medicare, in particular--usually offers the advantage of shortening the transition time. The long transition period is certainly what people will find hardest to accept.

With the framework in place, the institutions attached to it should be gradually coaxed into externalizing their surpluses (dividends or their equivalent) instead of re-investing them, allowing surplus to flow between low-cost and high-cost eras of consumers' lives within the network, ultimately ending up as individual retirement financing in the private sector. That last part may be hard for people working in the public sector to accept because it removes the government as the insurer of last resort for pensions. But for reasons too obscure to describe here, that was never possible as long as Congress controlled the extension of the national debt. And that, in turn, was driven by the conviction the private sector was a superior creator of wealth, not an unlimited source of taxes. Ultimately, our model is the goose that laid golden eggs.

An easy early step would be to create following-year bonuses for low expenditures within the "pearls" on this string. Much will depend on intervening national politics, and it is intended to avoid including ACA or employer-based insurance until the direction clarifies. Meanwhile, everyone might have the option of adopting an HRSA fully, plus Medicare, plus the childhood transfer mechanism. The ultimate unified vehicle would be an accordion-structured First and Last Years of Life Reinsurance (see below), although if several variants emerge, that would be fine.

The final step, integrating the ACA and present employer-based systems is left entirely out of the project for the first few years. But driving it onward, posing the threat of retirement destitution if you don't, would be the availability of retirement financing from every penny you legitimately save from healthcare, from the day of birth to the day of death. Since no one wants to die, and very few enjoy living in poverty, restraining this vast incentive must rest with its health beneficiaries, since everyone is its ultimate beneficiary. When scientists finally do cure the worst diseases cheaply, the retirement folks may be permitted to start to win the healthcare vs. retirement pension competition.

Special projects and program outliers, such as prison inmates, mentally and physically disabled, and illegal immigrants, are left for us to find solutions more tailored to their needs, and here are not dealt with further. This proposal deals with the great majority of Americans who are not in poverty, not handicapped, and not poorly treated. Surely they should have a voice in such a vital topic, which from their perspective could be considerably cheaper, and rather easily improved over present uncertainties. Along the way, if they themselves could devise something beyond golf, bridge, gardening, and travel to occupy thirty years, it would be an enhancement to the community. Arguments can be made for regulating immigration, but not ones for providing servants for a rentier society.

We begin integration with the big gorilla, Medicare. In the first place, the program is bleeding money. The first step in saving money should be to stop losing so much of it, and that definitely won't be easy as long as serious illness keeps migrating into the Medicare age group. Furthermore, it contains the most expensive item of all, terminal care. The transfer of terminal care out of Medicare by the Last Four Years of Life transfer, should facilitate this decision. Other programs may get financially healthier if we do nothing. If we do nothing about Medicare, it probably will only get into deeper trouble.

At the moment, our best dream is the scientists will find something as cheap as aspirin, which will cure something as expensive as cancer. A century ago and roughly simultaneously, scientists discovered cures for pernicious anemia and type I diabetes, both fatal conditions. Pernicious anemia has virtually disappeared with occasional injections of a vitamin, while diabetes has grown to be about as expensive as anything, despite lifesaving injections of insulin. Unless you want to gamble on similar mixed outcomes in the future, read on.

The Election is Over; The Work is Just Beginning

We knew this election was coming; we didn't know who was going to win it. Whether Hillary Clinton would replace the Affordable Care Act with her own plan, or whether Donald Trump would replace the ACA with a different plan, was far less certain. In either case, the many flaws in the Affordable Care Act would be addressed. One thing seems certain: the Affordable Care Act will start off 2017 with a bigger deficit than was expected. My previous four books on the subject were forced to assume the ACA was cost-neutral, offering proposals for lifetime health finance for every age group except age 26 to 65, the working years of life. This book mostly concentrates on that gap.

Cheaper. The core of this lifetime proposal is the Health Savings Account. It was devised by me and John McClaughry of Vermont in 1981, when John was Senior Policy Advisor in Ronald Reagan's White House and I was a Delegate to the American Medical Association's House of Delegates. It flourished after John Goodman of Texas wrote a book about it, Bill Archer of Texas pushed it through Congress, the American Academy of Actuaries found it saved 20-30% of the cost of more usual Health Insurance, the AMA endorsed it, and thirty million accounts were established by June 2015. It consisted of two ideas welded together: a high-deductible catastrophic health insurance policy, and a double tax-exempt Savings Account, acting as a sort of Christmas Savings Account for the deductible. It wasn't free, but it helped a poor man get coverage as cheaply as we could devise it. The individual patient or client owned his own account, so it had no "job lock" to hinder changing jobs. In that sense, it was patterned after Senator Bill Roth's IRA or Individual Retirement Account. A significant improvement followed the question of what to do with an unspent surplus which remained in the HSA (Health Savings Account) if you turned 65 after being healthy and then got Medicare. The Law was changed to turn such surplus into an IRA.

Retirement Funding. In correcting this oversight, the right thing was done for the wrong reason. Before anyone really understood Medicare was 50% underfunded, a retirement fund had been created. Since increased longevity was an inevitable consequence of better healthcare, it seemed natural for this "Medicare money" to pay for the extended retirement. It soon became apparent that retirement came at the same time as Medicare, and Medicare was thus underfunded. Even though the $3400 annual limit to Health Savings Account deposits was not enough to pay for soaring Medicare costs, it was not needed for that purpose for up to forty years. So augmented funds became available for healthcare at age 26 but had to be invested for fifty years or more until sickness made its appearance later in life. Emergencies might come up before then, but the Catastrophic health insurance took care of them. After many state laws mandating small-cost expenditures were amended, the high-deductible product took off, particularly in California and New York. Millions of policies were issued before anyone took the trouble to count them. When the Affordable Care Act made high-deductible insurance widely mandatory, Health Savings Plans took off like pursuit planes.

So, when competitive plans -- like HMOs, Preferred Provider Plans, First-dollar Coverage, Employer-sponsored plans, and a host of others -- started to encounter criticism, Health Savings Accounts became much more popular. Their flaws, instead of provoking consumer resistance, provoked demand for legislative relief. It was a mistake to limit ownership to people who were employed, or who were age 26 to 65; what good purpose did those age and employment restrictions serve? The advent of DRG payment limits to hospitalization and debit-card payment for outpatient services raised a question of the usefulness of insurance claims processing, which was certainly expensive. Prohibiting the HSA from purchasing the required catastrophic health insurance seemed to hamper unnecessarily a tax deduction which its competitors widely enjoyed. One or two amendments were all that would be needed to enhance sales considerably. People change jobs a lot; why would anyone want to prohibit dual coverage if someone wanted to pay for it, for his own personal reasons? The changes needed to enhance Health Savings Accounts were short and simple and could be enacted over a weekend. Why wait?

Improved Investment. Changes in the HSA Law to permit higher returns on invested deposits, are certain to provoke resistance but should be addressed very soon. If you are serious about replacing the old with the new, there are some zero-sum tradeoffs, especially within the finance industry. Go to the library or the internet, and look up the graphs of Professor Ibbotson of Yale about the performance of stocks and bonds for the past century. You will surely find the total stock market has risen at 9-11% for the past century, and what people describe as crashes and disasters seem like small wiggles in the line -- in retrospect. Some opportunities are better than others, but the main determinate of investing is the year you happen to have been born. In spite of these retrospective results, you will find very few investors who received half of that, but John Bogle and Burton Malkiel have demonstrated that random selection of stocks in a total market index fund beats expert active investors more than half the time, at a hundredth the cost. Bogle has something like 3 trillion dollars invested in his funds, and they have grown so fast he has trouble satisfying the demand. The average investor should be getting 5% on his money over the long run, and regulatory changes ought to aim for 7%. Money invested at 7% tax-free will double every ten years. With an average life expectancy approaching 90 years, that's ten doublings, or 512 times the initial investment in 90 years. And it still leaves 9-12% minus 7% (2-5%) for the finance industry.

But that's only half the problem. If you invest massive amounts of money for 90 years, there are plenty of cheerful brigands out there. Inflation is the main one -- it averages 3% a year -- because governments issue bonds, and enjoy low-interest rates. Federal Reserve and other central bankers are the nicest people in the whole world, mandated to preserve independence from the rest of the government. But they read newspapers and know who appoints whom. Bankers and brokers are also nice people, overvaluing rigidity because counterparties cheat when vigilance gets relaxed. One way or another, spreads should be narrowed.

The present system, plus stronger management, plus a few simple legislative amendments, would suffice to get us started with something workable, while we immediately roll up our sleeves and plan for a revolutionary future, better, system.

What's The AMA all About?

The American Medical Association feels unappreciated and misunderstood, and that is indeed a pretty accurate appraisal of things. In 1976, when I was offered an opportunity to be nominated to the AMA House of Delegates, I naturally was flattered to represent a thousand physicians. But I must admit that an extra incentive was the opportunity to learn what the AMA was all about. Since that is not exactly a superior qualification for election. I kept it quiet until now, but I can tell you that it is a very common feeling among new delegates. Even up to the time of being invited to give this lecture, my thoughts were formless or subliminal, and it is actually a welcome opportunity for me finally to coagulate my thoughts in order to say something useful to you tonight. Some would say, it is about time I made up my mind.

It seems helpful to begin with a broad historical perspective. Most of you know that the AMA was founded in Philadelphia in 1847 and that this Philadelphia County Medical Society is older than the AMA, and older than the Pennsylvania Medical Society. That was entirely natural, since Abraham Lincoln was then a small child in a log cabin in the forests of Illinois, whereas Spruce Street was lined with mansions, and the Pennsylvania Hospital was one of less than a dozen hospitals in the whole country. Things changed dramatically during the Nineteenth Century, but it would be important for you to recognize that by the year 1900, only seven percent of American physicians were members of the AMA. The AMA was founded as an elite brotherhood, adhering to a Hippocratic Code of Ethics, protected by stringent entrance restrictions, and internally disciplined by active boards of censors. If you were a member of the AMA and had not yet been thrown out, the public could be assured that you pledged active allegiance to Code of Ethics.

Well, as you know, the news media now jeer, and the AMA now despairs, that membership has declined to slightly less than half of all practicing physicians, a fact which is probably correctly attributed mostly to the rather high dues. Again, you should know that at the peak of membership in the 1930s, when it is fair to say that almost every physician was a member, the dues were free.

What happened to the ama was the Flexner Report in 1914. At that point, the AMA enlarged its traditional posture of self-discipline in a naughty world to active involvement in the processes by which medical excellence is produced. The Flexner report was devoted to examining the scientific content of the medical educational process and membership in the AMA came to stand for scientific as well as ethical excellence. Without intending for it to happen, the AMA had stumbled on the real secret of medical prestige, and after that, the AMA had no problems with attracting membership.

Throughout the Nineteenth Century, the major accomplishment of the AMA had been to establish the state licensing process. As a result of its formative activity in lobbying legislatures to create state boards of medical licensure, and it's later spectacular success in specifying the best medical educational process, the AMA has long played an influential, indeed dominant role in both areas. The Joint Commission on Accreditation of Hospitals was another AMA project, and so was Blue Shield. None of these secondary power centers (now dominant in licensing, education, hospital regulation, and health insurance) was established as an AMA vassal,but their formats were established from the beginning using the AMA model, their early leaders were all AMA leaders, and to this day, the AMA is certainly where to be if you want to learn the ropes. It must surely be frustrating to the enemies of the AMA to see how fruitless it has been to resist the power of the AMA in these areas, because so much intangible power rests in the experience, savvy, and contacts of the AMA in these areas, because so much intangible power rests in the experience, savvy, and contacts of the AMA leadership. They know where the bodies are buried, and they know all about the personalities and politics of the process. You could spend three lifetimes as an outsider just trying to learn what is going on. By the time you learned, the situation would have shifted just enough so the information wouldn't do you any good.

So, you can see that in some ways the AMA is an object lesson in the way that society often gives power to idealistic leaders, and then Idealism struggles to check the corrupting pressures of Power. The ancient Greeks thought it was a good idea to have philosopher kings, but history teaches us that even they acted more like kings than philosophers. Since this seems to be the universal nature of human behavior, it is vital that we search for self-regulating mechanisms in our institutions. The one I suggest for the AMA is the very unpopular suggestion that we be careful how we lower the dues, and we must never achieve automatic membership of the entire physician community. We must be cautious of defining success in the Morris Fishbein sense of getting rid of all dues because then the staff and leadership won't need to solicit membership. When we stop scratching and scrabbling for members, the members lose their ultimate power to impose their wishes on the organization. No one now needs to sign a petition or make a speech, and it is definitely counterproductive to threaten the leadership that you are going to resign. Rather, the invisible hand of the perceived wishes of the membership is raised in every vote at every Trustee meeting we must care of this or that, we must be careful of our image, else the membership might not like it. The paradox is that the AMA is now much more representative of members than it ever was in its heyday. When Morris Fishbein was coining a fortune in cigarettes advertising in the JAMA, the wishes of the membership be damned.

The thought I would next pursue is that the bumper stickers, paraphrased as "If you don't like the AMA just try to practice medicine without it." The . AMA is the largest medical publisher in the world, and while New England Journal has more prestige at the moment, it wouldn't take a charismatic editor more than five years to put the JAMA back on top of the prestige heap. The AMA News is by far the best medical newspaper in the world, and it supplies an absolutely unique information role.

The AMA has a program in the health care within our prisons which has almost no visibility, but which I can assure you is something you can be very proud of as a humanitarian effort conducted for its own sake. The AMA is extremely active in such abstruse but vital projects as creating medical nomenclature coding, uniform insurance billing forms, medical manpower surveys, health economics monitoring, and clearinghouses for personal exchanges. Whenever we have had a war or physicians draft, the AMA has been the only organization capable of coordinating the civilian and Military medical needs of the country. The AMA seems to be the only organizations which give a hoot about the Veterans Administration or military medicine. There is a very large building in Chicago filled with a thousand salaried people doing many other very necessary things, and doing them quite creditably, without getting very much public credit for it.

The United States of America is a republic, not a democracy as we sometimes tend to say. The American Medical Association is a much purer form of a republic, and its retention of some republican forms which the National government has lost has been a very useful political education for me. I take my seat in the House of Delegates by presenting a little yellow card, signed by the current president of the Pennsylvania Medical Society. If I have the card, I am seated; no card, no card. The cards are given to the State societies in the proportion of one card for every thousand AMA members. The AMA sees to it that the State Society Presidents are in person at the meeting to adjudicate credentials disputes. States may elect their delegates in any way they like and there are several methods. In Pennsylvania, the election is made by the Pennsylvania Medical Society House of Delegates, where membership is roughly one for every hundred members, sitting by countries. Philadelphia County has 30 delegates, and three AMA delegates, although there is nothing official about that.

The AMA House of Delegates meets twice a year for a week. Since you cannot retain your seat without tending to the political fences, a delegate must also attend the state and local meetings. A delegate must thus expect to devote four full weeks a year to the experience, and he need not expect to be influential at the AMA until he has been there at least five years. The AMA delegates feel very strongly about personal commitment; you can be tolerated if you are pretty eccentric, but if you don't come to a meeting, you are instantly ostracised, and probably will be quickly replaced.

The delegates have two main duties. They are an electoral college and they are a legislative body. The House of Delegates elects the President of the AMA and the Trustees, who run the organization between meetings of the House. The House also elects the members of four Councils, who are the specialists in matters of science, legislation, medical practice, and governance. The 70 officers, trustees, and councilors are the leadership, the Curia so to speak, and House of Delegates meetings are highly charged with the politics of these elections as well as the shadow of elections coming in future years. I am inclined to think the candidates take the elections too seriously and the delegates do not take them seriously enough, but it is a matter about which you cannot be entirely certain. There is absolutely no doubt that every delegate has ample opportunity to know every candidate very well, and it is likely that the House makes relatively few mistakes in its choices.

Acting in its legislative role, the House of Delegates usually receives a very thick handbook of agenda, two weeks before every meeting. Most newcomers are overwhelmed by the unexpected volume of detail and are quite unprepared for the ensuing experience of holding up their hands and voting on two or three hundred issues in the course of a week. There is a knack to mastering the process, of course, but mostly the knack comes from making the awful acknowledgment that you really must spend all evening studying the handbook, every evening for the two weeks before each meeting. You don't have to do it, of course, and some members are obviously bluffing. But if you expect to be effective you must do it, and if you want to get effective you must do it, and if you want to get effective you must do it, and if you want to get promoted you have to be seen to be effective. Business starts at 7 AM sharp, often in a city where you must cope with three hours of jet lag, and it goes straight through to midnight. The fact that you are eating breakfast o at a reception does not change the business nature of the day. Only a profession of workaholics could produce three hundred delegates and three hundred alternates, the majority of whom will put up with this grind for ten or fifteen years. Some of our decisions may be wrong, but we sure try hard to make them right.

In closing, I think I should say something about the AMA lobbyists. The AMA is rightly known as having the most effective lobby in Washington, but you ought to know what that means. Since we are a national organization, and every congressman has a doctor, and every congressman lives where there is a county medical society, it is possible to create an organization which can influence the entire Congress, but only with a massive organizational effort. Congressmen too are overload with work and live in a constantly confusing environment. Just to be able to get them to listen to your story is an achievement, and it is necessary to work very hard at repairing this network of contracts. AMPAC raises campaign contributions, and this is one way of reaching some congressmen. Knowing who is on what committee, how he leans, who can influence him, and when the timing is right is an enormous organizational job. Sometimes extraordinary measures are needed, was true in April 1984 when mandatory assignment of Medicare benefits looked as though it might pass. The AMA flew in 125 state medical society presidents and other key contracts and led each one up to the appropriate doors at the critical moment. As you know, the effort was successful.

Most lobbying, however, is far less dramatic. The Federal Register is published weekly and averages seventy thousand pages a year. Perhaps a twentieth of that fine print pertains to medicine in some way, and it must be culled out, studied, decided about, and lobbied with the staff assistants and bureaucrats who are producing it. here are no major victories in this sort of work and you lose a lot of arguments. But there is little doubt that the steady pressure, the constant alertness, and the presentation of superior information have the effect of pushing this avalanche of legislation in directions which are much more favorable to medicine than if the effort were not undertaken.

And fellows, it all takes money. We can raise money by forming captive malpractice insurance companies, or getting advertising in our journals, or charging for computer networks, or speculating in real estate. But who pays the piper calls the tune. In the long run, the member will only control their society if the society remains heavily dependent on their dues. You really must choose between three alternatives. You can have no one represent the profession in an era when everyone else is represented. You can be represented by a bureaucracy which constantly reflects your wishes because it constantly hungers for your dues. The decision is yours and you can expect, in the long run, to get what you pay for.

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