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The pursuit of happiness
PRESIDENTIAL
ADDRESS
The Pursuit of Happiness RICHARD
In looking back over the presidential addresses of the New England Surgical Society [I] of the last fifteen years one finds that they fall into three general categories: a discussion of some aspect of surgical care or training as influenced by evolving socioeconomic forces, an imaginative and scholarly escapade into history with current relevance (Mark Hayes’ outstanding offering last year is in this group, and there are also those of Dawson Tyson and Sam Webber in earlier years), and an exposition of a particular interest having broad medical significance (Fritz Sutherland’s delightful talk on the Yale Medical Library is the prototype here). Although the last two items display, perhaps, more talent and are more diverting to the audience, the first category has been the one most commonly selected. The reason is not far to seek. Even though it is the hardest kind of talk to make interesting, the temptation to articulate for oncoming generations the burning problems that one has seen to emerge so clearly throughout one’s career is irresistable. The extraordinary thing is that in the addresses of Bartlett, MacKay, Standish, Dunlop, McKittrick, Taylor, Munro, and Waterman, although the form and illustrations are different, there is, in one area at least, a similarity in content. I refer to a plea for the preservation of the freedom of the surgeon to control his own destiny in the best interests of his patient combined with sacrifices by the profession that we may recapture leadership. But although most of these men have devoted significant parts of their lives to working towards these objectives, a secure formula to accomplish them has eluded the profession as a whole. Indeed, as time passes, proliferating examples are seen of how sacrifices are not being made. Let us take as an example Medicare Plan B. If our profession had not insisted on its inclusion in Plan A (And the real hardship has been hospital costs. It was what nudged the NHS in England into final existence. ) , we would have diminished the unmeetable expenses Presented at the Fiftieth cal Society, Portsmouth.
Vol. 119, April
1970
Annual Meeting New Hampshire,
of
the New September
England 25-27,
Surgi1969.
WARREN,
MD, Boston, Massachusetts
of Medicare, public scolding of physicians for feathering their nests, and strife between hospital staffs and administrators about these fees, and would have made further inroads into our house services that are so important to surgical residency training. Since we are but human, the natural reaction of the profession as a whole to any new source of income for physicians, even though it comes via the Delilah of the Government, is understandably positive. But one thing leads to another. From 1965 to 1967 the average annual rise in the cost of living was 2.8 per cent, the rise in average hourly wage earnings was 4.3 per cent, but the increase in physicians’ income was 7 per cent [2]. There is little wonder that the Secretary of Health, Education, and Welfare refused to raise the $8 premium paid by the Federal Government and the nation’s aged to anticipate a further rise in doctors’ fees. Using as a background, then, the pertinence of a continuing effort to define a balance between justifiable demands and sacrifices I, too, and with humility, will fall to the temptation of selecting a subject in the first category. I will focus on two points: the first, how better surgical care might be served by a specific arrangement of these demands and sacrifices; the second, how far a particular form of medical service, the Veterans Administration, currently goes toward satisfying this balance. The Balance Focus on “Therapeutic” Surgery. The matter of “preventive” medicine (or surgery) is more important to the health of the population than is the treatment of the individual patient. A century ago Henry Jacob Bigelow [3], one of the most flamboyant surgeons of the colorful nineteenth century, wrote : “Do not identify surgery with the knife, with blood and dashing elegance. Distrust surgical intrepidity and boldness. If such epithets have any meaning, they are in bad taste, and tend to give wrong impressions of 357
Presidential
Address
scientific excellence. . . The right subclavian artery and the innominata have been often tied with success. and the patient has always died . . Science never hears of the ten or twenty quiet sufferers who fall victims to the publicity of an exceptional escape from surgical intrepidity. Surgery is not operative surgery. Its province is to save, not to destroy; and an operation is an avowal of its own inadequacy.” Despite similar utterances by other eminent surgeons, we as specialists must bear the burden of being mistakenly considered neglectful of this important aspect of health activity. “To live a full and swift, even though unhealthful, life and be speedily destroyed is better than to live healthily and long and be bored. Overpopulation and increased competition are our worst enemies. It does no harm if epidemics and wars annually take their liberal toll of the population . . . the fanatical champions of public health are fighting for a goal that is too high for my myopic vision. I can admire the struggle but I cannot become interested in it.” That statement was made by Billroth [4] in the 1870’s, and even making allowances for the military climate in the Austria of those days, it must be considered deplorable in terms of interpreting to the public, which seems all too ready to look on us as disinterested in preventive medicine, the philosophy of our discipline. We as surgeons must lend our prestige and enthusiastic support to meaningful programs to prevent lung cancer, traffic accidents, and obesity and should participate actively in finding new ways of bringing high quality surgical service to people who are not now getting it. But for the present, let us focus on the sick patient seeking surgical help. The Golden Rule, Another preliminary point requires discussion. There is, far more in modern times than in the past, a responsibility concerning which the surgeon has to consult his conscience. I refer to the degree to which his indications for treatment must be colored by the demands he is making on our increasingly complex and expensive medical resources, such as anesthesiology, radiology (particularly cogent now that sophisticated angiography has become generally available), nursing services, equipment, and drugs. We have all questioned whether certain operations, which either have an infinitesimal chance of success or are employed in senile or otherwise incurable patients, had better not have been performed. Once the surgeon has made the decision to attempt to cure or to save the life of such patients, he commits all the elaborate replacement, respiratory, and resuscitative facilities that the modern hospital-juggernaut can provide 358
and, since these cannot be unlimited, hc may by SJ doing deny them to a patient in greater need. His task is made more difficult by younger members of the team who have an enthusiasm for active therapy in the borderline case that exceeds his. The consolation, however, is that once the battle is over, usually the wisdom of the conservative choice will be recognized even by those who pressed for more action in the heat of conflict. The easiest rule here, as has so often been said, is the golden one. The Golden Mean. The traditional concept of the surgical team is that of a combat unit in gowns, gloves, and masks. The team in truth is less dramatic than this but no less disciplined in that it involves combined deliberations as to indications for treatment, pre- and postoperative care, follow-up study, and a responsibility for reporting results. Since good surgical care still means a trained team with a wise surgeon at its head, its implementation requires that the surgeon be kept content. Hence, he is justified in demanding everything that he needs to do his job, but not everything he wants irrespective of financial considerations or demands on resources. He must strive for the “golden mean” [5] Burke [6] in 1791 wrote: “Men are qualified for civil liberty in exact proportion to their disposition to put moral chains upon their own appetites. . . Society cannot exist unless a controlling power upon will and appetite be placed somewhere, and the less of it there is within, the more there must be without. It is ordained in the eternal constitution of things that men of intemperate minds cannot be free. Their passions forge their fetters.” Ten Demands and Nine Sucrifices. Even though each surgeon’s situation differs, I have, in the interests of being specific, prepared a list of justifiable demands and sacrifices that might act as guidelines for a surgeon striving to adjust his balance. These are presented in Tables I and II. These two lists, as are any that deal with specifics in socioeconomic matters, are vulnerable to the criticisms of incompleteness and of inadequate definition of the factors listed. The vaguest item on my list is number 8A on the level of earnings. To state that a surgeon should be paid more than a person in another specialty because he is a surgeon is wrong. But if he works longer hours and takes more responsibility for patients or students, he should be rewarded in proportion. Whether he should be paid more than most hospital administrators is arguable, although I happen to think that he should be. This is not to say that some administrators who carry great loads should not get more than the surgeon. But such positions are rare. The remainder of the items I pass for the moment The
American
Journal
of
Surgery
Presidential TABLE
I
Ten Justifiable
1. Opportunity 2. A hospital
5. 6. 7. 8.
9. 10.
grown to be a force in American medicine as shown by the following figures as of 1968 :
Demands
to focus on one hospital. staff limited so that beds
members. 3. Invulnerability 4. A competent
to compulsory and interested
transfer. hospital
are available
to its
administration
and
governing body, particularly: A. To finance needs and to help with new programs. B. To spare the staff the details of hospital routines. Operating room and surgical care units supplied with sufficient trained help for twenty-four hour coverage. Opportunity for doctor-patient identification. Opportunity for doctor-community identification. Fiscal arrangements along the following guidelines: A. Rewards equal to people of the same degree of training according to the amount of work and responsibilities.* B. Opportunity for further advancement throughout career. C. Pension plan and regular vacations. Teaching and research opportunities. A good community with adequate schools.
* This usually means more than nonsurgical specialites and administrators, but does not necessarily mean that he must equate with industrial leaders. without further comment, standing as they admittedly do as the prejudices of one individual. The Veterans Administration
Medical Service
Let us now take a look at the Veterans Administration Medical Service and how far it goes toward satisfying this balance. It often happens that a system of medical care is set up initially for a single purpose and ends in the discovery that in order to survive it must broaden its horizon. As we look about us at specialty hospitals throughout the world and see them languishing, this point becomes even more vivid. The Veterans Administration realized this early and found it had to include veterans with nonservice-connected illnesses to attract staff adequate to care for the service-connected cases, and its adjustments along these lines are by no means at an end, as we shall see. In its modern era, which now covers a period of twenty-three years, it has TABLE
II
Nine Justifiable
Address
166 Number hospitals Number beds 115,782 Fraction of nation’s beds 7% Deans’ Committee hospitals 93 Medical schools represented 79* Fraction of nation’s nursing 13% programs Fraction of nation’s medical residents 10% Inpatients seen per year 750,000 Medical student contact per year 9,677 Table III presents the Veterans Administration’s positive and negative scores in relation to the ten basic demands of a surgeon. The system satisfies all but three of the demands. These and some others bear discussion. The vulnerability to transfer is an insecurity which remains a worry. Since no employee can be removed from Veterans Administration service unless incompetence, immorality, or treason are proved, it is the only mechanism the organization has of allowing new personnel to be brought in to replace previous incumbents when, for instance, a hospital becomes affiliated with a medical school. It is rarely used. Paragraph 4, “Sympathetic administration” and “Simplified hospital routines,” clamors for qualification. The VA clinical records are of high quality and are freely available for research. The insecurity engendered by maneuvers, such as occurred a few years ago when it was decreed to destroy all records of patients who had not been seen for fifteen years, is a fly in the ointment. The prevention of such things requires continued vigilance. Furthermore, there are too many reports that need to be made to the Central Office in Washington. On the whole, however, the hospital rou* There are eighty-five approved medical schools in the country. TABLE
Sacrifices
III
The Veterans Administration Medical and the Ten Justifiable Demands
Service
1. To live near the hospital. 2. To strive for shortened
hospital
Demands
stays.*
3. To work on committees. 4. To take time to teach personnel. 5. TO be selective 6. TO take time responsibility
nurses
in demands
and other nonmedical on res0urces.t
to teach younger surgeons but not “unload” by removing oneself from the patient.
7. To make home visits when indicated phone number freely available.
and to makeone’s
8. To standardize fees, respect the public men along by sharing practice. 9. To keep within
one’s
physical
ability
119,
April
1970
home
till, and help young
and time.
* Often against his and the patient’s convenience. t A useful slogan for house staff to learn is, “Think don’t do it.” Vol.
hospital
of it, but
1. Focus
on one hospital. 2. Adequate beds available by virtue of limited staff. to transfer. 3. Invulnerability 4. (A) Sympathetic administration. (B) Simplified hospital routines. 5. Operating room and surgical care units. 6. Doctor-patient identification. 7. Doctor-community identification. 8. (A) Pay scale. (B) Opportunity for advancement. (C) Retirement and vacation plans. 9. Teaching and research opportunities. 10. Community.
Positive
Negative
X X X X X X X X X X X X X
359
Presidential
Address
tines are logical and not burdensome. Administrators are sympathetic to new programs and to the financing of needs whether it be for an intensive care unit, a surgical secretary, or operating room alterations. They often, however, have difficulty finding funds, and the technic for so doing in the presence of adverse directives is a fine art acquired by only a few of the more talented. The pay level is perhaps the most discussed. There is fiscal parity between surgeons and their brother specialists irrespective of the effort put in and the responsibilities assumed. There is unfavorable comparison with administrative salaries and a ceiling to advancement potential. Limited easements for these matters are available and are being worked out. There is poor identification of the VA doctor with the community. If one item were to be selected as important beyond others in causing disaffection of VA surgeons, particularly in urban community settings, I think this would be it, even though, as I have mentioned, the money is the most discussed. One full time VA surgeon spoke to the point in his annual report: “It becomes clearer as the VA hospital assumes its role in the medical community, that the surgeon should be available for, and have the privilege of, some private practice. It is important that the surgeon can maintain identity and establish his role as a surgeon to small groups of individuals. . .
Nonveterans Treated in L’A Hospitais. Public Law 89-785 passed in November 1966 allows for sharing of medical resources in a community. whether VA or other. Although under this law VA facilities have up to now been used for nonveterans only in one transplantation and one heart surgery center, the numbers will increase. The breakthrough in this area has had a salutory psychologic effect on the identification of VA doctors with the community. There have been two other important recommcndations that have been disapproved : 1. Contract relationship with the university. Some universities have suggested that they would take care of the veterans in the VA hospitals and pay the doctors according to a university-determined salary scale, the monies to be procured by contract with the VA. 2. Seven eighths time pay. Currently a “full time” VA doctor (as distinguished from an attending physician or consultant) can have a private practice if he limits his salary to five eighths of the maximum allowed for his qualifications and makes sure that he provides the VA with the service for which he is being paid. It has been suggested that this proportion could be raised to six or seven eighths time. Comments
There is an advantage of the VA system which does not properly find a place in the list in Table III, namely, the freedom of consultation between services. There are no financial considerations in referral channels for consultants and this adds greatly to good patient care. Easements. The administrators in Washington have extensively employed consultative advice from professional leaders throughout the country and have made slow but steady progress toward correcting some of the aforementioned disadvantages. Achievements to date have been to make it possible for full time VA doctors to accept royalties for publications, honoraria for lecturing or teaching,* university salary supplements for teaching,+ and consultation fees.+
The advantages of the easements discussed are that they are a move toward rewarding those who spend more time and take greater responsibility than others. Since control of possible abuses is so difficult under this arrangement, contracting for total care with the medical school is probably a poor idea, but the proposal of seven eighths time pay and allowing practice is attractive and should not be dropped. Behind all these matters, and not yet focused upon, is the bureaucratic superstructure of the VA. Although repugnant to all, it probably can never be totally eliminated. The only real answer is to have top men in a few authoritative positions and pay them enough to make it worth their while to stay. The difficulty, as with any political system, is that tenure at the top is impossible, and budget allowances are vulnerable to political whims. This, with its resulting insecurities about new projects and budgetary matters, remains the biggest ogre. But having had experience with both systems, I, for one, prefer the federal to the municipal ogre. An important point remaining to debate is the need
* Honoraria for teaching or lecturing, approved by the Hospital Director, are permissible up to $200 per episode. There is no limit on episodes. t Full time VA surgeons can accept supplements to their salary for teaching if that teaching is arranged beyond the hours (forty a week) during which his presence in the VA hospital is assumed and provided this is done according to a regular schedule approved by the VA. This is now in operation and is applied to a hundred or more doctors who
are receiving between $500 and $12,.500 annually to supplement their VA salaries. This program needs greater maturation in several areas, particularly in the breadth of its application to ranks below the chiefs of services. t A consultation fee can be provided to a full time VA surgeon if an institution (not an individual) requests that he see a patient in consultation. The VA surgeon cannot maintain an outside office of his own although his name may be on the roster of the University Diagnostic Clinic.
This would enhance the image as a surgeon and teacher that is important community . . .”
in a university
-
The American
Journal
of Surgery
Presidential
for maintaining the current balance between the medical schools and the VA hospitals, so clearly visualized by Elliott Cutler and others twenty-four years ago. Many, of which I am one, fear that if the VA medical establishment or a related federal medical system were to expand to control many times the current fraction of the nation’s hospital beds, the Deans’ Committees would become the creatures of the Federal Government and the balance would be lost. We consider that the Veterans Administration Department of Medicine and Surgery can maintain its quality only if the balance persists, and to offer it in its present image as a prototype for a total federalized medical service would be deceptive. We should, by making sacrifices and working toward the golden mean, try to avoid this eventuality. But if we fail and partial or total capitulation occurs, a good model, American style, exists. In the meantime the VA in its present setting is a good place to work and is getting better.
Vol.
119, April
1970
Address
Summary
A balanced list of justifiable demands and sacrifices is presented whereby the surgeon may travel the golden middle road to his own happiness and thus to the best care of the greatest number of patients needing surgical help. The list of justifiable demands is tested by exploring how a particular system of medical care, the Veterans Administration, satisfies it. References
1. Transactions, New England Surgical Society, 1954-1968. 2. Round the World. Lancet p 367, February 15, 1969. 3. A Memoir of Henry Jacob Bigelow, p 40. Boston, Little Brown, 1900. 4. Billroth T: The Medical Sciences in the German Universities. A Study in the History of Civilization. New York, Macmillan, 1924. 5. Horace. Odes, book II, ode X, lines 5 and 6. 6. Reston J: Black Moderates and Black Militants. New York Times, January 15, 1969.
361
ADDRESS
The Pursuit of Happiness RICHARD
In looking back over the presidential addresses of the New England Surgical Society [I] of the last fifteen years one finds that they fall into three general categories: a discussion of some aspect of surgical care or training as influenced by evolving socioeconomic forces, an imaginative and scholarly escapade into history with current relevance (Mark Hayes’ outstanding offering last year is in this group, and there are also those of Dawson Tyson and Sam Webber in earlier years), and an exposition of a particular interest having broad medical significance (Fritz Sutherland’s delightful talk on the Yale Medical Library is the prototype here). Although the last two items display, perhaps, more talent and are more diverting to the audience, the first category has been the one most commonly selected. The reason is not far to seek. Even though it is the hardest kind of talk to make interesting, the temptation to articulate for oncoming generations the burning problems that one has seen to emerge so clearly throughout one’s career is irresistable. The extraordinary thing is that in the addresses of Bartlett, MacKay, Standish, Dunlop, McKittrick, Taylor, Munro, and Waterman, although the form and illustrations are different, there is, in one area at least, a similarity in content. I refer to a plea for the preservation of the freedom of the surgeon to control his own destiny in the best interests of his patient combined with sacrifices by the profession that we may recapture leadership. But although most of these men have devoted significant parts of their lives to working towards these objectives, a secure formula to accomplish them has eluded the profession as a whole. Indeed, as time passes, proliferating examples are seen of how sacrifices are not being made. Let us take as an example Medicare Plan B. If our profession had not insisted on its inclusion in Plan A (And the real hardship has been hospital costs. It was what nudged the NHS in England into final existence. ) , we would have diminished the unmeetable expenses Presented at the Fiftieth cal Society, Portsmouth.
Vol. 119, April
1970
Annual Meeting New Hampshire,
of
the New September
England 25-27,
Surgi1969.
WARREN,
MD, Boston, Massachusetts
of Medicare, public scolding of physicians for feathering their nests, and strife between hospital staffs and administrators about these fees, and would have made further inroads into our house services that are so important to surgical residency training. Since we are but human, the natural reaction of the profession as a whole to any new source of income for physicians, even though it comes via the Delilah of the Government, is understandably positive. But one thing leads to another. From 1965 to 1967 the average annual rise in the cost of living was 2.8 per cent, the rise in average hourly wage earnings was 4.3 per cent, but the increase in physicians’ income was 7 per cent [2]. There is little wonder that the Secretary of Health, Education, and Welfare refused to raise the $8 premium paid by the Federal Government and the nation’s aged to anticipate a further rise in doctors’ fees. Using as a background, then, the pertinence of a continuing effort to define a balance between justifiable demands and sacrifices I, too, and with humility, will fall to the temptation of selecting a subject in the first category. I will focus on two points: the first, how better surgical care might be served by a specific arrangement of these demands and sacrifices; the second, how far a particular form of medical service, the Veterans Administration, currently goes toward satisfying this balance. The Balance Focus on “Therapeutic” Surgery. The matter of “preventive” medicine (or surgery) is more important to the health of the population than is the treatment of the individual patient. A century ago Henry Jacob Bigelow [3], one of the most flamboyant surgeons of the colorful nineteenth century, wrote : “Do not identify surgery with the knife, with blood and dashing elegance. Distrust surgical intrepidity and boldness. If such epithets have any meaning, they are in bad taste, and tend to give wrong impressions of 357
Presidential
Address
scientific excellence. . . The right subclavian artery and the innominata have been often tied with success. and the patient has always died . . Science never hears of the ten or twenty quiet sufferers who fall victims to the publicity of an exceptional escape from surgical intrepidity. Surgery is not operative surgery. Its province is to save, not to destroy; and an operation is an avowal of its own inadequacy.” Despite similar utterances by other eminent surgeons, we as specialists must bear the burden of being mistakenly considered neglectful of this important aspect of health activity. “To live a full and swift, even though unhealthful, life and be speedily destroyed is better than to live healthily and long and be bored. Overpopulation and increased competition are our worst enemies. It does no harm if epidemics and wars annually take their liberal toll of the population . . . the fanatical champions of public health are fighting for a goal that is too high for my myopic vision. I can admire the struggle but I cannot become interested in it.” That statement was made by Billroth [4] in the 1870’s, and even making allowances for the military climate in the Austria of those days, it must be considered deplorable in terms of interpreting to the public, which seems all too ready to look on us as disinterested in preventive medicine, the philosophy of our discipline. We as surgeons must lend our prestige and enthusiastic support to meaningful programs to prevent lung cancer, traffic accidents, and obesity and should participate actively in finding new ways of bringing high quality surgical service to people who are not now getting it. But for the present, let us focus on the sick patient seeking surgical help. The Golden Rule, Another preliminary point requires discussion. There is, far more in modern times than in the past, a responsibility concerning which the surgeon has to consult his conscience. I refer to the degree to which his indications for treatment must be colored by the demands he is making on our increasingly complex and expensive medical resources, such as anesthesiology, radiology (particularly cogent now that sophisticated angiography has become generally available), nursing services, equipment, and drugs. We have all questioned whether certain operations, which either have an infinitesimal chance of success or are employed in senile or otherwise incurable patients, had better not have been performed. Once the surgeon has made the decision to attempt to cure or to save the life of such patients, he commits all the elaborate replacement, respiratory, and resuscitative facilities that the modern hospital-juggernaut can provide 358
and, since these cannot be unlimited, hc may by SJ doing deny them to a patient in greater need. His task is made more difficult by younger members of the team who have an enthusiasm for active therapy in the borderline case that exceeds his. The consolation, however, is that once the battle is over, usually the wisdom of the conservative choice will be recognized even by those who pressed for more action in the heat of conflict. The easiest rule here, as has so often been said, is the golden one. The Golden Mean. The traditional concept of the surgical team is that of a combat unit in gowns, gloves, and masks. The team in truth is less dramatic than this but no less disciplined in that it involves combined deliberations as to indications for treatment, pre- and postoperative care, follow-up study, and a responsibility for reporting results. Since good surgical care still means a trained team with a wise surgeon at its head, its implementation requires that the surgeon be kept content. Hence, he is justified in demanding everything that he needs to do his job, but not everything he wants irrespective of financial considerations or demands on resources. He must strive for the “golden mean” [5] Burke [6] in 1791 wrote: “Men are qualified for civil liberty in exact proportion to their disposition to put moral chains upon their own appetites. . . Society cannot exist unless a controlling power upon will and appetite be placed somewhere, and the less of it there is within, the more there must be without. It is ordained in the eternal constitution of things that men of intemperate minds cannot be free. Their passions forge their fetters.” Ten Demands and Nine Sucrifices. Even though each surgeon’s situation differs, I have, in the interests of being specific, prepared a list of justifiable demands and sacrifices that might act as guidelines for a surgeon striving to adjust his balance. These are presented in Tables I and II. These two lists, as are any that deal with specifics in socioeconomic matters, are vulnerable to the criticisms of incompleteness and of inadequate definition of the factors listed. The vaguest item on my list is number 8A on the level of earnings. To state that a surgeon should be paid more than a person in another specialty because he is a surgeon is wrong. But if he works longer hours and takes more responsibility for patients or students, he should be rewarded in proportion. Whether he should be paid more than most hospital administrators is arguable, although I happen to think that he should be. This is not to say that some administrators who carry great loads should not get more than the surgeon. But such positions are rare. The remainder of the items I pass for the moment The
American
Journal
of
Surgery
Presidential TABLE
I
Ten Justifiable
1. Opportunity 2. A hospital
5. 6. 7. 8.
9. 10.
grown to be a force in American medicine as shown by the following figures as of 1968 :
Demands
to focus on one hospital. staff limited so that beds
members. 3. Invulnerability 4. A competent
to compulsory and interested
transfer. hospital
are available
to its
administration
and
governing body, particularly: A. To finance needs and to help with new programs. B. To spare the staff the details of hospital routines. Operating room and surgical care units supplied with sufficient trained help for twenty-four hour coverage. Opportunity for doctor-patient identification. Opportunity for doctor-community identification. Fiscal arrangements along the following guidelines: A. Rewards equal to people of the same degree of training according to the amount of work and responsibilities.* B. Opportunity for further advancement throughout career. C. Pension plan and regular vacations. Teaching and research opportunities. A good community with adequate schools.
* This usually means more than nonsurgical specialites and administrators, but does not necessarily mean that he must equate with industrial leaders. without further comment, standing as they admittedly do as the prejudices of one individual. The Veterans Administration
Medical Service
Let us now take a look at the Veterans Administration Medical Service and how far it goes toward satisfying this balance. It often happens that a system of medical care is set up initially for a single purpose and ends in the discovery that in order to survive it must broaden its horizon. As we look about us at specialty hospitals throughout the world and see them languishing, this point becomes even more vivid. The Veterans Administration realized this early and found it had to include veterans with nonservice-connected illnesses to attract staff adequate to care for the service-connected cases, and its adjustments along these lines are by no means at an end, as we shall see. In its modern era, which now covers a period of twenty-three years, it has TABLE
II
Nine Justifiable
Address
166 Number hospitals Number beds 115,782 Fraction of nation’s beds 7% Deans’ Committee hospitals 93 Medical schools represented 79* Fraction of nation’s nursing 13% programs Fraction of nation’s medical residents 10% Inpatients seen per year 750,000 Medical student contact per year 9,677 Table III presents the Veterans Administration’s positive and negative scores in relation to the ten basic demands of a surgeon. The system satisfies all but three of the demands. These and some others bear discussion. The vulnerability to transfer is an insecurity which remains a worry. Since no employee can be removed from Veterans Administration service unless incompetence, immorality, or treason are proved, it is the only mechanism the organization has of allowing new personnel to be brought in to replace previous incumbents when, for instance, a hospital becomes affiliated with a medical school. It is rarely used. Paragraph 4, “Sympathetic administration” and “Simplified hospital routines,” clamors for qualification. The VA clinical records are of high quality and are freely available for research. The insecurity engendered by maneuvers, such as occurred a few years ago when it was decreed to destroy all records of patients who had not been seen for fifteen years, is a fly in the ointment. The prevention of such things requires continued vigilance. Furthermore, there are too many reports that need to be made to the Central Office in Washington. On the whole, however, the hospital rou* There are eighty-five approved medical schools in the country. TABLE
Sacrifices
III
The Veterans Administration Medical and the Ten Justifiable Demands
Service
1. To live near the hospital. 2. To strive for shortened
hospital
Demands
stays.*
3. To work on committees. 4. To take time to teach personnel. 5. TO be selective 6. TO take time responsibility
nurses
in demands
and other nonmedical on res0urces.t
to teach younger surgeons but not “unload” by removing oneself from the patient.
7. To make home visits when indicated phone number freely available.
and to makeone’s
8. To standardize fees, respect the public men along by sharing practice. 9. To keep within
one’s
physical
ability
119,
April
1970
home
till, and help young
and time.
* Often against his and the patient’s convenience. t A useful slogan for house staff to learn is, “Think don’t do it.” Vol.
hospital
of it, but
1. Focus
on one hospital. 2. Adequate beds available by virtue of limited staff. to transfer. 3. Invulnerability 4. (A) Sympathetic administration. (B) Simplified hospital routines. 5. Operating room and surgical care units. 6. Doctor-patient identification. 7. Doctor-community identification. 8. (A) Pay scale. (B) Opportunity for advancement. (C) Retirement and vacation plans. 9. Teaching and research opportunities. 10. Community.
Positive
Negative
X X X X X X X X X X X X X
359
Presidential
Address
tines are logical and not burdensome. Administrators are sympathetic to new programs and to the financing of needs whether it be for an intensive care unit, a surgical secretary, or operating room alterations. They often, however, have difficulty finding funds, and the technic for so doing in the presence of adverse directives is a fine art acquired by only a few of the more talented. The pay level is perhaps the most discussed. There is fiscal parity between surgeons and their brother specialists irrespective of the effort put in and the responsibilities assumed. There is unfavorable comparison with administrative salaries and a ceiling to advancement potential. Limited easements for these matters are available and are being worked out. There is poor identification of the VA doctor with the community. If one item were to be selected as important beyond others in causing disaffection of VA surgeons, particularly in urban community settings, I think this would be it, even though, as I have mentioned, the money is the most discussed. One full time VA surgeon spoke to the point in his annual report: “It becomes clearer as the VA hospital assumes its role in the medical community, that the surgeon should be available for, and have the privilege of, some private practice. It is important that the surgeon can maintain identity and establish his role as a surgeon to small groups of individuals. . .
Nonveterans Treated in L’A Hospitais. Public Law 89-785 passed in November 1966 allows for sharing of medical resources in a community. whether VA or other. Although under this law VA facilities have up to now been used for nonveterans only in one transplantation and one heart surgery center, the numbers will increase. The breakthrough in this area has had a salutory psychologic effect on the identification of VA doctors with the community. There have been two other important recommcndations that have been disapproved : 1. Contract relationship with the university. Some universities have suggested that they would take care of the veterans in the VA hospitals and pay the doctors according to a university-determined salary scale, the monies to be procured by contract with the VA. 2. Seven eighths time pay. Currently a “full time” VA doctor (as distinguished from an attending physician or consultant) can have a private practice if he limits his salary to five eighths of the maximum allowed for his qualifications and makes sure that he provides the VA with the service for which he is being paid. It has been suggested that this proportion could be raised to six or seven eighths time. Comments
There is an advantage of the VA system which does not properly find a place in the list in Table III, namely, the freedom of consultation between services. There are no financial considerations in referral channels for consultants and this adds greatly to good patient care. Easements. The administrators in Washington have extensively employed consultative advice from professional leaders throughout the country and have made slow but steady progress toward correcting some of the aforementioned disadvantages. Achievements to date have been to make it possible for full time VA doctors to accept royalties for publications, honoraria for lecturing or teaching,* university salary supplements for teaching,+ and consultation fees.+
The advantages of the easements discussed are that they are a move toward rewarding those who spend more time and take greater responsibility than others. Since control of possible abuses is so difficult under this arrangement, contracting for total care with the medical school is probably a poor idea, but the proposal of seven eighths time pay and allowing practice is attractive and should not be dropped. Behind all these matters, and not yet focused upon, is the bureaucratic superstructure of the VA. Although repugnant to all, it probably can never be totally eliminated. The only real answer is to have top men in a few authoritative positions and pay them enough to make it worth their while to stay. The difficulty, as with any political system, is that tenure at the top is impossible, and budget allowances are vulnerable to political whims. This, with its resulting insecurities about new projects and budgetary matters, remains the biggest ogre. But having had experience with both systems, I, for one, prefer the federal to the municipal ogre. An important point remaining to debate is the need
* Honoraria for teaching or lecturing, approved by the Hospital Director, are permissible up to $200 per episode. There is no limit on episodes. t Full time VA surgeons can accept supplements to their salary for teaching if that teaching is arranged beyond the hours (forty a week) during which his presence in the VA hospital is assumed and provided this is done according to a regular schedule approved by the VA. This is now in operation and is applied to a hundred or more doctors who
are receiving between $500 and $12,.500 annually to supplement their VA salaries. This program needs greater maturation in several areas, particularly in the breadth of its application to ranks below the chiefs of services. t A consultation fee can be provided to a full time VA surgeon if an institution (not an individual) requests that he see a patient in consultation. The VA surgeon cannot maintain an outside office of his own although his name may be on the roster of the University Diagnostic Clinic.
This would enhance the image as a surgeon and teacher that is important community . . .”
in a university
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The American
Journal
of Surgery
Presidential
for maintaining the current balance between the medical schools and the VA hospitals, so clearly visualized by Elliott Cutler and others twenty-four years ago. Many, of which I am one, fear that if the VA medical establishment or a related federal medical system were to expand to control many times the current fraction of the nation’s hospital beds, the Deans’ Committees would become the creatures of the Federal Government and the balance would be lost. We consider that the Veterans Administration Department of Medicine and Surgery can maintain its quality only if the balance persists, and to offer it in its present image as a prototype for a total federalized medical service would be deceptive. We should, by making sacrifices and working toward the golden mean, try to avoid this eventuality. But if we fail and partial or total capitulation occurs, a good model, American style, exists. In the meantime the VA in its present setting is a good place to work and is getting better.
Vol.
119, April
1970
Address
Summary
A balanced list of justifiable demands and sacrifices is presented whereby the surgeon may travel the golden middle road to his own happiness and thus to the best care of the greatest number of patients needing surgical help. The list of justifiable demands is tested by exploring how a particular system of medical care, the Veterans Administration, satisfies it. References
1. Transactions, New England Surgical Society, 1954-1968. 2. Round the World. Lancet p 367, February 15, 1969. 3. A Memoir of Henry Jacob Bigelow, p 40. Boston, Little Brown, 1900. 4. Billroth T: The Medical Sciences in the German Universities. A Study in the History of Civilization. New York, Macmillan, 1924. 5. Horace. Odes, book II, ode X, lines 5 and 6. 6. Reston J: Black Moderates and Black Militants. New York Times, January 15, 1969.
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