1984—Big brother, big government, big business, big problems

Presidential

address

1984-Big brother, big government, big business, big problems Raymond

G. Slavin,

M.D. St. Louis, MO.

The presidential address delivered to the American Academy of Allergy and Immunology has classically been a time for reflection and for a look to the future as the president perceives it. This year I am afforded a particularly unique opportunity solely because I happen to be in this particular position at this particular time. None of my predecessors has spoken at a time when the simple stating of the year evokes so much attention and interest. Of course I am speaking of this particular year, 1984, and the novel of the same name by George Orwell.’ The temptation to make 1984 the theme of this address is simply too great for someone like me who has a bit of a flair for the theatric. Not only are we in 1984 but also we appear to be in some ways heading toward an Orwellian state in the practice of medicine. For that reason I have entitled this presentation “1984-Big brother, big government, big business, big problems. ” I am sure that most of you are familiar with the novel entitled 1984. It is about a society called Oceania. It is ruled by the inner party with the help of a larger outer party of which the hero, Winston Smith and his illicit love, Julia, are working members. Winston and Julia are employed in the Ministry of Truth whose function is to falsify the past in accordance with the needs of present policy. Oceania represents the essence of a totalitarian state in which love, death, work., and every human emotion is subservient to the state, “Big Brother.” Robert C. Tucker,’ writing in the Wilson Quarterly in January of this year, suggeststhat today the totalitarian state appearsjust one of a number of options concerning the way people live. The regimesof North Korea, Vietnam, Cuba, Russia, and China certainly operate in near Orwellian fashion, and the fundamental conception of a totalitarian state appearsso familiar, soordinary, and so plausible today. How doesall this relate to our organization and to our specialty? You cerFrom the Department of Internal Medicine and Microbiology, Louis University Schlool of Medicine, St. Louis, MO. Reprint requests: Raymlond G. Slavin, M.D., 1402 S. Grand, Louis, MO 63104.

St. St.

tainly do not want to read my views of political science and theory, but I would submit to you that some problems facing our specialty relate to 1984 and that someaspectsof the state as envisioned by Orwell are close at hand. These past few years our specialty has been beset by a myriad of outside threats. At times we have felt like a band of pioneerswith wagonsencircled protecting our patients and our turf from the clutches of a variety of external entities. Fig. 1 depicts this phenomenon in a somewhatdifferent fashion in a different time frame. What are the problems we face and from where are they coming? Problems facing the allergist are: (1) government, (2) business, (3) the public, (4) other health-care providers, and (5) ourselves. The first is the increasing intervention of govemment that we all feel. The year 1983 was marked by tremendouschangesin the traditional way we thought about medicine and delivery of health care. Pressure from government and businessto contain the rate of increase in health-care costs mandated changes in hospitalization and ultimately physician reimbursement under the Social Security amendmentof 1983. An over supply of physicians and nonphysician health providers plus a slower growth of the population and the economy have resulted in an extremely cautious climate in American medicine. In 1983the mannerof delivery of medical care underwent its most radical change. We think of the 1965 Social Security amendmentthat included Medicare and Medicaid as being radical. This allowed the aged and the indigent accessto the main stream of medical care that they had not previously enjoyed. However, that amendment did not alter the manner in which physicians and hospitals were reimbursedfor services. The 1983 Social Security amendment marked the beginning of significant changes in the complex interrelationship among physicians, hospitals, patients, employers, third-party payers, and government. This amendment gave us DiagnosisRelated Groups, a program of prospective payment for hospitalized Medicare patients. In essenceit is a preset payment by diagnosis. The 17

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FIG.

1.

hospital receives a sum of money for providing care, and this sum has no relationship to actual cost of care to the patient. The amount of money paid for pneumonia, for example, is the same whether it is an uncomplicated pneumococcal pneumonia in an otherwise healthy., retired 65year-old woman, or a Klebsiella pneumonia in a debilitated, malnourished, alcoholic 80-year-old man. As you know, the recently introduced Kennedy-Gephart bill includes payment to physicians in such a manner. It would appear that the recent suggestion by the American Medical Association that physicians freeze their fees at present levels for 1 yr is at least in part an answer by organized medicine to this proposed legislation. A second threat from without is business, big business. Medical care in America now appears to be in the early stages of a major transformation in its institutional structure comparable to the rise of professional sovereignty at the opening of the 20th century. Corporations have begun to integrate a hitherto decentralized hospital system, enter a variety of other health-care businesses, and consolidate ownership and control in what may eventually become an industry dominated by huge health-care conglomerates. The results already are visible: for-profit hospitals and nursing home chains, urgicenters, emergicenters, dot-in-a-box, and insurance company-sponsored health-maintenance organizations with their attendant gatekeepers. The: great irony is that the opposition of physicians and hospitals to public control of public programs, set in motion entrepreneurial forces that may end up depriving both private medical doctors and local voluntary hospitals of their traditional autonomy. How did this come about? Paul Starr,” a

CLIN. IMMUNOL. JULY 1984

Harvard University sociologist, has written a brilliant book entitled The Social Transformation of American Medicine. He divides his history of American medicine into two sections. The first deals with the rise of professional sovereignty, i.e., how the profession arrived at the enviable position of power that it has enjoyed. The second concerns itself with the transform,ation of medicine into an industry and the growing, though still unsettled, roles of corporation and state. In his last chapter entitled “The Coming of the Corporation, ” that I would suggest as “must” reading for all of us, Starr writes, “Unless there is a radical turnabout in economic conditions and American politics, the last decades of the 20th century are likely to be a time of diminished resources and autonomy for many physicians, voluntary hospitals, and medical schools. Two immediate circumstances cast shadows over their future: the rapidly increasing supply of physicians and the continued search by government and employers for control over the growth of medical expenditures. They may prepare the way for acceleration of the third development: the rise of corporate enterprise in the health services.” One direct outcome of this in our own field will be the turning of more and more allergists to salaried positions in health-maintenance organizations or hospitals. A third source of problems is posed by the public, the consumers of our services. It is a public that is rightfully concerned about rising medical costs, maldistribution of medical care, assurance of professional competence, and increased specialization with an associated decline in the ties between physician and patient. It is a public that wrongly or rightly has lost confidence in physicians as a group. It is a wellknown sociologic principle that if things are perceived as real, they are real in their consequences. From a point years ago when we could do no wrong, physicians as a group have slipped in 1984 according to several polls to a rank just above used-car salesmen. A fourth distinct threat comes from other healthcare providers. I do not need to discuss in great deal the competition that has arisen from other physician groups vying for the patients that we consider our “own;” the otolaryngologist and his involvement with allergic rhinitis, the pulmonologist caring for the asthmatic patient, the dermatologist treating u&aria, atopic dermatitis, and contact dermatitis, and the “dabbler” that is the primary-care physician who attends a weekend course and begins to do skin tests, RAST., and carry out immunotherapy on everyone and anyone. Add to that the clinical ecologist who believes that most of us are allergic to the 20th century, and the cytotoxicist who encourages, first, in-

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1984-Big

vestors via an advertisement of a few months ago, and second, patients to avail themselves of this test and to manage a variety of medical conditions as observed in a number of recent newspaper advertisements:

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cialization has diminished the scope of the relationship between doctor and patient. One reason that health-maintenance organizations have developed so rapidly and so successfully is that the ties between physician and private patients are so much weaker today than in the past. The samereasonis presented

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The fifth and final threat does not come from without, rather it is from ourselves. The immortal words of Walt Kelly’s Pogo come to mind, “We have met the enemy and they are us.” I believe that we all know of instances in which accepted sound medical practice is ignored by board-qualified and boardcertified allergists. These include the marketing of mail order allergy whereby therapeutic decisions are made without personal contact with the patient, the abuse of skin tests and RAST, and the institution of immunotherapy for non-IgE mediated conditions that in some instances is continued for 20 to 30 yr. Two other practices are often discussed privately but seldom discussed in public. At the risk of offending some, I believe that they are worthy of mention now. The first concerns itself with the increasingly common trend of turning over sick patients, particularly sick asthmatic patients to intensive-care physicians or

pulmonologists

who are hospital based. I believe this

practice, often referred to as “turfing, ” is extremely

damaging to our specialty. It is often said that spe-

for the rise in malpractice suits. In our own specialty, the turning over of sick asthmatic patients to other physicians puts allergists and clinical immunologists in an extremely poor light. I simply do not believe that this is what the original referring physician ex-

pects, nor do I think that the sick asthmatic patient should expect to have a totally different physician treat his illness in the hospital.

My second concern involves the participation of physicians, in this case allergists, in the flourishing private-for-profit corporate form of medicine. Dr. Arnold S. Relmaq4 editor of the New England Journal of Medicine, puts it bluntly: “The publicgivesdoctorsspecialadvantages andprivileges in exchangefor a commitmentto put the public’sinterests aheadof any personaleconomicgain. Ipso facto involvementof practicingphysiciansasinvestorsor entrepreneurs in the ‘newmedical-industrial complex’raisesseriousdoubt aboutthiscommitment.Physiciansshouldbe fiduciariesor representatives for their patientsin evaluatingandselecting the servicesofferedby the health-careindustry;theycannot ethically servein that capacity if they alsohave financial interestsin that industry.”

For example, if a physician owns or has a financial interest in a dialysis center, he may be more interested in keeping that center full than in turning over the

responsibility

of self-treatment in the home to the

uremic patient. By the sametoken, the ability of an allergist to be completely objective about diagnostic testing may be compromised when he or she has a significant financial interest in a RAST-testing laboratory to which their patient’s serum samples are sent. There we have it. Threats and problems from five different sources:government, big business,the public, other health-care providers, and, yes, in some instanceseven ourselves. How can we approachthese problems? Can in fact something be done? Are we headed inexorably to a 1984 Orwellian existence in the practice of medicine?Those of you who know me well are aware that I am an incorrigible optimist. More than that I have tremendous faith and confidence in our specialty and in our organization. There are approaches.There are answers, and what I would

like to do now is to outline a plan of action and a blueprint for success,first, as far asindividual actions are concerned and then, the stancethat our Academy should take.

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Slavin

Let us consider initially what we can do as individuals. First, we must reinforce our commitment and dedication to scientifically proved, state of the art, cost-effective practice. We must continue to regard patients as people who need appropriate, individualized attention not as annuities providing a secure income. We must continue to deplore and avoid the useless skin tests, the useless RAST, and the useless immunotherapy that never ends. We must establish and maintain close ties with our patients and that includes actively following them not only in our offices but also in the hospital, if necessary. Finally, we must continue to be health advocates for our patients and commit ourselves to put their interest ahead of any personal economic gain. In short, ladies and gentlemen, we must be the leaders in demanding and assuring quality standards of allergy practice whether we are in private practice, in a health-maintenance organization, or a hospital. This brings me to the next item and that is our accountability to patients and to fellow physicians. Sheldon Siegel5 in 1975 reminded us that physicians have traditionally enjoyed the confidence of the public and independence from regulation because we professed the ability to promote and guarantee the quality of our members’ performance. Despite the Hippocratic Oath, state licensure, national board and speciality examinations, and accreditation of training programs, the public, as I pointed out earlier, has become dissatisfied and is seeking other means of regulating the quality of health-care delivery. In 1969 the American Medical Association commissioned a citizens committee on graduatse medical education. It was called the Millis Commission,‘j and a particularly meaningful passage from that report is as follows, “For any learned profession, there are but two alternatives for establishing standards of practice and education. Responsibility can be assured by society as a whole operating through government or can be assumed by the organized profession through voluntary self-discipline. There are no alternatives for if the profession does not take the responsibility, society will surely demand that the vacuum be filled and that the government assume the responsibility.” Stated simply, my friends, if we do not assume the responsibility of quality assurance to society and to our patients, then surely someone else will do it, and chances are that if someone else does it, it will not be as well done as if we did it ourselves. We must therefore be as active as possible in pursuing continuing medical education, and we must participate in the recertification process. Next, we must assume more and more the role of teachers. We are after all by definition teachers. The

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word doctor is derived from the latin “dot” meaning to teach. The suffix “tor” means an agent or one who performs the act of teaching, in other words a teacher. A myriad of opportunities exist. We must take advantage of th,em by educating other physicians and perhaps, more importantly, by educating the public. A marvelous vehicle to do this is through the Asthma and Allergy Foundation of America. I firmly believe that the integrity of our specialty depends on the continued strengthening of the lay organization to which we are now so closely entwined. The Foundation can educate the public to the advantages of trained quality care in a nonself-serving fashion that we cannot do. The Foundation has the potential of becoming a dominant force in our national health scene if we nurture it and support it with our money, our time, and our expertise. Our continued existence as a strong medical specialty depends on an equally strong and viable lay organization. Finally, it is obvious, I hope, to everyone that continued support of our own Academy is absolutely necessary. We serve as the most respected voice today in American allergy and clinical immunology. What :should our Academy be doing in this year of 1984 and in the years ahead? Our constitution defines us as a largely educational organization. In this respect we must continue our efforts to improve our meetings in an attempt to provide you, the membership, with the most up-to-date, state of the art information. An expanded series of workshops, luncheon seminars, and a learning resource center at our annual meeting plus a self-education addition to THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY and our first ever fall clinical meeting leaves no question as to our commitment to the education of our membership. In terms of other educational efforts, I disagree heartily with those who argue that we should stop our efforts in educating other physicians. I have received a number of letters from Academy members who characterize our efforts at continuing medical education of primary-care physicians as “training the competition. ” I simply cannot believe that the excellent courses our Continuing Medical Education committee plans will prompt any significant number of phy:sicians to begin their own allergy practice. Rather, I believe it acquaints the primary-care physician with the true nature of the allergic patient and emphasizes the importance of prompt and proper referral . Is there a responsibility of our organization beyond education? As Charlie Reed7 pointed out 10 yr ago, we can no longer be a purely education-oriented organization. Dr. Reed emphasized the need to become

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involved in the practical socioeconomic issues of the day as they relate to improving quality care and controlling utilization of health services. One way we can do this is to continue to support our Washington presence. We must continue to speak out in support of such issues as the Health Care Financing Administration’s exclusion of medicare coverage for scientifically unfounded techniques and in opposition to the current administration’s decision to eliminate the Food and Drug 14dministration panel on allergenic extracts. Finally, we have a responsibility to educate legislators, third party payers, other health-care providers, and the public to the talents and scientific expertise we bring to our specialty. Our Academy hasembarkedon an intensive campaignto do just that through a patient information brochure and public service announcementsfor radio and television. To be surewe must be in the forefront of the challenging encountersaheadin immunology, but we also owe the very best in diagnosis and treatment to 35 million allergy sufferers, and we cannot abrogatethis responsibility. If we truly believe we can offer something more to allergic patients than other health-care providers, we must tell them. We must be honest, we must be accurate, and we must be forceful. Are we inexorably headed toward the 1984 existence of which Orwell wrote? Will we find ourselves in a situation in which every decision is made by and every emotion subservientto “Big Brother”? Orwell himself said “I do not believe that the kind of society I describe necessarily will arrive, but I believe that somethingresembling it could arrive. ” Paul Gray” in Time magazine wrote, “Orwell’s greatest accomplishment was to remind people that they could think for themselves at a time when humanity seems to prefer taking marching orders. His whole message is that if men would behave decently the world would be decent. Orwell had an abiding almost pious faith in the ability of the fragile querulous species, humankind, to correct its deficiencies by the most radical process of allthinking. The author’s name is not a synonym for totalitari-

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anism. It is in fact the spirit that fights the worst tendencies in politics and society by using a fundamental sense of decency. ”

So too is it with us in the field of allergy and immunology. We cannot sit on the sidelineswringing our handsand beating our chests. We can make a positive contribution toward correcting the deficiencies and problems in the medical world about us but not without effort. We can do it by continuing to be true in our practice of allergy to the scientifically proved even though voices clamor for compromiseand profitability. But we must do more than simply put our own house in order. We must lead the way and enlist the support of all concerned to protect quality health care for all consumersof our services and the services of all physicians dedicated to quality health care. It is not enough to decry the DiagnosisRelated Groups and various alternative health-care systemsas being unfair to hospitals and doctors. To make an impact on congress, big business, the public, and other health-care providers, we must speakout positively, aggressively, and forcefully but always in a scientifically sound and accurate manner. We must be equal to this task for we owe nothing less to ourselves, to our profession, and most of all, to our patients. REFERENCES

1. Orwell G: 1984. New York, 1948, Harcourt Brace Jovanovich IIIC

2. Tucker RC: Does big brother really exist? Wilson Quarterly 8:IO6, 1984 3. Starr P: The social transformation of American medicine. New York, 1982, Basic Books Inc 4. Relmau AS: The future of medical practice. Health Affairs 2: 1983 5. Siegel SC: Quality assurance. J ALLERGY CLIN IMMUNOL 55: 161, 1975 (presidential address) 6. Millis JS: The graduate education of physicians. The report of the Ctizens Committee on Graduate Medical Education. Commissioned by the American Medical Association, 1966 7. Reed CE: The quest for excellence-who is responsible? J ALLER~GY CLIN IMMUNOL 53:257, 1974 (presidential address) 8. Gray P: In Time magazine. November 28, 1983, page 56