The musings of a physician who served the community for over six decades
367 Topics
Downtown A discussion about downtown area in Philadelphia and connections from today with its historical past.
West of Broad A collection of articles about the area west of Broad Street, Philadelphia, Pennsylvania.
Delaware (State of) Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Religious Philadelphia William Penn wanted a colony with religious freedom. A considerable number, if not the majority, of American religious denominations were founded in this city. The main misconception about religious Philadelphia is that it is Quaker-dominated. But the broader misconception is that it is not Quaker-dominated.
Particular Sights to See:Center City Taxi drivers tell tourists that Center City is a "shining city on a hill". During the Industrial Era, the city almost urbanized out to the county line, and then retreated. Right now, the urban center is surrounded by a semi-deserted ring of former factories.
Philadelphia's Middle Urban Ring Philadelphia grew rapidly for seventy years after the Civil War, then gradually lost population. Skyscrapers drain population upwards, suburbs beckon outwards. The result: a ring around center city, mixed prosperous and dilapidated. Future in doubt.
Historical Motor Excursion North of Philadelphia The narrow waist of New Jersey was the upper border of William Penn's vast land holdings, and the outer edge of Quaker influence. In 1776-77, Lord Howe made this strip the main highway of his attempt to subjugate the Colonies.
Land Tour Around Delaware Bay Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Tourist Trips Around Philadelphia and the Quaker Colonies The states of Pennsylvania, Delaware, and southern New Jersey all belonged to William Penn the Quaker. He was the largest private landholder in American history. Using explicit directions, comprehensive touring of the Quaker Colonies takes seven full days. Local residents would need a couple dozen one-day trips to get up to speed.
Touring Philadelphia's Western Regions Philadelpia County had two hundred farms in 1950, but is now thickly settled in all directions. Western regions along the Schuylkill are still spread out somewhat; with many historic estates.
Up the King's High Way New Jersey has a narrow waistline, with New York harbor at one end, and Delaware Bay on the other. Traffic and history travelled the Kings Highway along this path between New York and Philadelphia.
Arch Street: from Sixth to Second When the large meeting house at Fourth and Arch was built, many Quakers moved their houses to the area. At that time, "North of Market" implied the Quaker region of town.
Up Market Street to Sixth and Walnut Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
Sixth and Walnut over to Broad and Sansom In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Montgomery and Bucks Counties The Philadelphia metropolitan region has five Pennsylvania counties, four New Jersey counties, one northern county in the state of Delaware. Here are the four Pennsylvania suburban ones.
Northern Overland Escape Path of the Philadelphia Tories 1 of 1 (16) Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
City Hall to Chestnut Hill There are lots of ways to go from City Hall to Chestnut Hill, including the train from Suburban Station, or from 11th and Market. This tour imagines your driving your car out the Ben Franklin Parkway to Kelly Drive, and then up the Wissahickon.
Philadelphia Reflections is a history of the area around Philadelphia, PA
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Philadelphia Revelations
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George R. Fisher, III, M.D.
Obituary
George R. Fisher, III, M.D.
Age: 97 of Philadelphia, formerly of Haddonfield
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.
Around 1970, the American Medical Association offered a supplemental health insurance policy to its members. It was a $25,000 deductible policy, costing $100 a year. That is, it offered insurance against the worst possible health disasters, and its cost was negligible. Even then, the marketing department struggled with a catchy name for it, and finally produced terms like "excess major medical coverage." Right away, you know the marketing department wasn't terribly anxious to sell it.
Nevertheless, the major difference in cost between catastrophic coverage, which I needed, and Blue Cross/Shield which I didn't particularly need because of my employer, was the germ of the Health Savings Account idea. It snapped into place when John McClaughry of Vermont told me that Senator Roth of Delaware was preparing to offer IRAs as a tax-exempt savings idea. Linking the two together, you got Health Savings Accounts, which the Texans Bill Archer and John Goodman finally got enacted. A third component was the cross-product of my son and an old surgery professor of considerable renown. One day, he leaned over to me and muttered, "The only reason to have health insurance is to keep the hospital from fleecing you."
My son gave real substance to this reasoning by telling me a famous Boston hospital had sent him a bill, charging $12,000 for a screening colonoscopy. I responded I thought it was far too much, worth at a guess $500. So he called his insurance carrier, who got him a revised bill for $1000. Overcome with gratitude, he immediately sent a check for $1000 to the hospital because he had just saved eleven times that much. Any $500 overpricing seemed trivial compared with saving a much larger surcharge. And this particular insurance company had been clever enough to notice it was this larger surcharge they were really selling protection against, not some minor markup from audited costs.
But let's get back to the catastrophic insurance, which under the name of "excess major Medical" had started this whole train of thought, decades earlier. The insurance pattern followed by excess major medical was the model of maritime insurance of Lloyds of London, one of the oldest and best-established forms of insurance. Maritime insurance made handsome profits using combined deductibles plus catastrophic coverage with a "cap". That is, the top limit to the liability was definable because by an act of Parliament it was the value of the hull. The English treasure their juries, but the Common Law knew better than to leave the upper limit of any liability, up to a jury to decide. Why then, couldn't health insurance follow the same pattern of defining liability limits? Malpractice liability is the case in mind, but it might be any disputed issue.
One suspects that hospitals in 1955 had a virtual bed surplus created by better home environments and transportation. But in 1965, Medicare and Medicaid really created an actual surplus of (40-person) ward beds, by offering to pay for semi-private accommodations. Given a choice of paying for insurance or accepting a 40-bed assignment, enough of the public chose ward beds rather than pay for extra insurance, so insurance patterns became fixed around the reality; an invisible ceiling was created over what they would provide for in pre-payment health insurance. The illusion of employer payment and the politically consequent tax exemption promoted the continuation of this obsolete pattern of two beds in a room. The substitution of "service benefits" for indemnity was, among other factors, a concession to the primitive hospital accounting systems, once again a holdover from the glory days of private charity. When you have no idea what something costs, you guess.
That continues to be true. The struggling hospital industry responded slowly to the implications of Payment by Diagnosis in the 1980s, and only recently began to shift inpatient care to outpatient care in satellite clinics. Up until that time, outpatient care in doctors' offices had been markedly cheaper, but hospitals began to imagine that free-standing physician practices were a threat to their business plan. For twenty years, this friendly competition expanded into a life-and-death struggle, which physicians largely lost. It was a fairly slow process, held back by the ability of physicians' offices to raise prices, even in spite of differential reimbursement for the same services, often by the same doctors inside hospital walls. After 2000, a new carnivore entered the gladiator ring: the parent university of university-owned hospitals. Innocent new entrants into a competitive situation often over-react by adopting aggressive behavior they eventually come to regret.
Doctors in teaching hospitals were put on salaries where that was possible, but the bulk of the public had individual preferences for certain physician practices and resisted enlistment into hospital clinics, which had a welfare sound to them. Some patients preferred a hybrid: large group practices, many of them controlled by physicians or physician organizations. For the most part, the finances of such group clinics can be stated as paying generous salaries to "feeder" physicians, subsidized by procedural surgeons who could still generate, and share with the hospital, rather large surpluses from a large volume of surgical procedures which the feeders could provide to them. The public has difficulty estimating the quality of its surgeons, but when they can, or when the group's aura suggests it, they will willingly pay extra for procedures which are dangerous or painful, or both. Innumerable entrepreneurs in the hospital industry have broken their lances against this irresistible force of human nature because the public has so far drawn a red line in the sand around a matter affecting their own personal well-being.
Not all universities have medical schools, but current agitation about doctor shortages is colored by the wish of many universities to catch up with those who do have such schools. Since the central function of most university presidents is to raise money, it has not escaped their attention that the budgets of many universities of international rank are heavily lopsided toward their medical schools. Or that the revenues of most medical schools are heavily weighted toward research grants with 70% "indirect overhead" allowances. Or that the captive teaching hospitals only generate a 2% profit on inpatients (suppressed by the DRG payment method), but a 15% profit on emergency care, and a 30% profit on satellite clinics. Tuition and other medical student revenue can run $50,000 a year, for which the students go heavily into debt, but which the parent university can often easily do without. Transfers from medical student revenue to non-medical student costs of the rest of the university are a closely guarded secret, and very few people are in a position to speak of them. But it would be a very strange world if long-haired undergraduate students in the arts, much given to demonstrations about "rich doctors", were not, in fact, subsidized by medical students carrying quarter-million-dollar educational debts. One might even conjecture that some of the multi-million dollar salaries of university presidents are enhanced by trickles from this same stream, although I have no proof of it, and perhaps this is too crude a formulation. The fact is, these prestigious universities do contain some very attractive honey-pots of medical revenue, and also contain a few egregious salaries for administrators in a position to decide how the surplus, or excess, revenue should be spent.
This brief excursion into the "inside baseball" of medical economics is meant to be convincing about one central point: this is all getting to be too complex to survive. Instead of responding to complexity with more complexity, we must simplify. We have tried little dictatorships; they don't simplify, they make more rules. We have tried virtual finance, substituting concepts and abstractions for a cash transaction. We have tried subsidies, interjecting moral principles and elaborate circumvention into the simple process of just doing a few things free of charge. We have stopped firing people for incompetence and sloth, we must re-educate them. We even are considering a raise in the minimum wage, in order to keep welfare payments from exceeding the labor market. Eventually, this must come to an end, so let's start with paying for medical care.
Let's start with paying for it in cash; indemnity insurance rather than service benefits, debit cards instead of claims forms. But let's also be realistic; when people are helpless in a hospital bed, they need a financial surrogate, or at least a payment system that does not require personal judgments. The DRG system needs to be calculated with a computer, not a table look-up, and therefore made much more precise.
Let's save for lifetime medical costs within a highly mobile real lifetime, by allowing the patient to identify the state which regulates his policies as he moves around, but transfer between policies by establishing a medical exchange on the pattern of the stock exchange. Direct-pay from patient to insurance should be permitted but phased involuntarily. It will be noticed that this system eases out the employer as a middle-man, but permits it to continue when it is mutually agreeable. And let's devise a scheme for a maximum safe investment of the savings between those of healthy youth and a sickness-prone retirement. And that means, not merely guaranteed renewal, but lifetime policies. All of that seems to be a Health Savings Account, but notice what it doesn't include. It definitely isn't one insurance for 80%, second insurance for 20%, a third, major medical, for outliers. Nor is it one insurance for hospitals, another for drugs, another for doctors, and eventually as many insurance components as there are medical components. It's, like, simple. Cash or cash equivalents. And for a mobile society, an end to state monopolies, by the expedient of national exchanges for sales transactions while administrative regulation remains true to the Tenth Amendment, largely state-regulated.
The final simplification is -- that's enough for now. The managers know perfectly well there is more to be done, but they deliberately don't do it, out of respect for getting started and seeing how it goes. However, some future projects can be foreseen, so as you go along, you try not to make things harder to do in the future. And one thing that can be done is to foresee that we must start thinking about paying for a lifetime of healthcare, not just healthcare for next year. Why should I pay insurance including care for appendicitis, when my appendix has already been removed? Why should I join interest groups and carry placards to include my condition (whatever it is), when I have plenty of money in my HSA to pay for it? And why can't I have guaranteed insurance renewal after decades of paying my premiums?
In short, we must try our best to devise a system of life insurance to supplement, if not replace, the year at a time term insurance we now have. Its advantages are numerous and there are no natural opponents. The hesitation all relates to getting the mechanics of it right, or right enough to get started. Since working age people ultimately pay for all of it, we need a system for young people to borrow from themselves when they get older, and another system for old folks to pay for themselves when they earned the money earlier in life. We need a way to dispose of unintended surpluses, and a way to subsidize the poor. We need a way for the individual to own his own policy, but pool his investments to reduce administrative costs. Someone must monitor the system, to notice changes in the environment, suggest mid-course changes, but have the integrity not to warp the system to his own advantage. It is possible to see ways to accomplish all of these things, but some things are easier than others, and doing almost any of it for 300 million people is a daunting prospect. We, therefore, propose that we go ahead with the relatively simple structure outlined in Chapter FOUR, but start talking right now about how much we could add, and how gradually we could add it, in the rest of this Chapter FIVE. My preliminary advice is we start with a monitoring system.
The case of King v. Burwell was argued before the United States Supreme Court March 4, 2015, and the decision was reported June 26, 2015. In a clear victory for President Obama, the Court held that it was not the intent of Congress that a phrase in the statute, even though repeated six times, should be the final meaning of the law. Someday a participant in the writing of the law will come forward and tell the story of how the words got into the statute in the first place, but at the moment all we know is the words are there, and the law is unworkable if they remain. Just about everyone would agree these two statements are true. Furthermore, it is clear only Congress could change them, and Congress has changed parties since they were originally written; so they probably cannot be changed at all before new elections are held, unless the President agrees with Congress to do it. There is a third possibility: Congress and the President could make private agreements about what they would compromise on and present a friendly adjustment. Whether that was tried and failed, or whether it was not tried at all, is unclear. So, the Supreme Court did what it never wants to do, it changed the law.
Since millions of citizens had watched (on C-Span) the legislation, dropped on the desks of astounded Congressmen, with no opportunity permitted to debate or amend it. Indeed, even to read most of it before it was voted on, the public is inclined to take the Court's word for it, that...
"The Affordable Care Act contains more than a few examples of inartful drafting".
Whether the clause in question was accidental or not, is a matter of opinion. The clause in dispute reads, and is repeated six times, as
Tax credits "shall be allowed" for any "applicable taxpayer", but only if the taxpayer has been enrolled in an insurance plan through"an Exchange established by the State under [42 U/S.C., pp18031]" pp36B(b)-(c)
Some idea of the Court's historic position is given in a few quotes:
"In a democracy, the power to make the law rests with those chosen by the people. Our role is more confined--"to say what the law is."--Marbury v. Madison, 1 Cranch 137, 177 (1803)
"Oftentimes the meaning--or ambiguity--of certain words or phrases may only become evident when placed in context."--Brown and Williamson, 529 U.S. at 132.
"Reliance on context and structure in statutory interpretation is a 'subtle business, calling for great wariness lest what professes to be mere rendering becomes creation and attempted interpretation of legislation becomes legislation itself.'-- Palmer v. Massachusetts U.S. 79,83 (1939)
In the end, three conservative Justices, Scalia, Thomas, and Alito found there was no reason to change the language of the statute as ambiguous, and four liberal Justices, Ginsburg, Breyer, Sotomayer, and Kagan found there was. The two swing Justices, Kennedy and Roberts, joined the liberals in finding the statute ambiguous, for a final vote of 6-3.
Judging from the global circumstances, it is probably fair to conclude that ambiguity was probably not the only issue involved, and it was probably inartful for the Court to establish a precedent that such a restructured role for the Court was either necessary or desirable. The history of Canada's use of this device to coerce provinces into joining the national health system was well known in Canada at the time. And the McCarran Ferguson Act has restricted insurance administration to a State level for seventy years. Both of these examples would seem to have provided a sounder basis for the Court to interfere in what really seems like pretty clear language in the law.
That results in no small effort, however, because our focus programs require a transfer of at least 68% of healthcare costs from people who are not seriously sick, to the places where costs more naturally concentrate. It's the case for every broad-based plan ever proposed, but this is the first one to concentrate on nothing else because we are blocked from diluting them with the costs of well people. Since we cannot force well people to agree to funds transfer, we merely relieve them of the need to pay the costs and expect they will take advantage of the opportunity. Similarly, we cannot force sick people to make use of the program, so we must rely on their recognizing the advantages.
First Year and Last Year of Life Coverage. We start with the simplest case. Everybody gets born, everyone dies; there are no exceptions. Furthermore, these two years are the most expensive ones, and likely to remain so. Medical advances of the future may raise the costs of terminal care, but even that is uncertain, and the costs may go down. And it is likely to remain true that just about everybody who dies, dies at the expense of Medicare, so we start with firm data, readily available. To simplify boundary disputes, using the calendar dates of the first year and the last year eliminates that particular fuzziness. Furthermore, obstetrics and terminal care contain elements found in no other age groups, concentrating the scientific issues. When I first presented the idea to a medical audience, one wit rose to the microphone and recalled a town in Pennsylvania that passed a law stating: "Every fireplug in the town must be painted white, ten days before a fire." He was, of course, quizzing me how you knew when the last year of life began. The answer is, you wait until the person dies and count backward, and you get the cost data from Medicare. Since everyone knows how imprecise hospital costs may be, it is probably better to reimburse average terminal care costs for the year and the region. If the patient retains Medicare coverage, a simple funds transfer to Medicare simplifies both administration and coverage disputes.
The big problem is the long transition unless Medicare and the Administration should agree to prime the pump. Therefore, the program must remain voluntary, and may even have waiting lists at times, depending on its popularity. Certain tricks known to financial managers may help to shorten the transition to self-sufficiency. For example, CSS reports the first year of life absorbs 3% of healthcare costs, and the last year about 6%. That is, $10,000 should be more than ample for the first year and $20,000 for the last year of life. By externally supplementing the first, the surplus after ten years can be applied to accelerating the funding of the last year. But even doing that could take twenty-five years to complete the process. Funds could be borrowed with a bond issue, of course, but eventually, that would raise costs and prolong the transition. "Sweet spots" can be found, but at the best, the transition is a long one, certainly spanning several turnovers of political power. Nevertheless, at the end of it, these pivotal medical coverages would acquire a major funding source, and other programs could experience a major reduction, up to 9%, in cost duplication.
In this, as in other parts of the book, we round off investment returns to 7% when we really expect only 6.5%. Using the old adage that money doubles in ten years at 7%, the reader can verify approximate accuracy by doing the sums in his head as he reads.
The Rest of Childhood, Seniority, and Permanent Unemployability. So that was the first Proposal 21: , to which the second one is a natural extension. All children are dependents of their parents, and the heavy costs of obstetrics (magnified by the unusual concentration of malpractice claims) make it impossible to devise pre-funding schemes. Young parents are often strapped for funds, so the lack of pre-funding is a growing problem in a Society uncertain of its family structures. Therefore, we have devised the grandparent roll-over. Tort reform would improve but not eliminate this workaround. Therefore children are lumped with senior citizen costs, and hence to a buy-out of Medicare.
The permanently unemployable are included by using surplus funds from the other two, mainly because there is no way to establish eligibility except by starting a program and seeing what it costs if you monitor it. Those may not seem like adequate reasons to lump them together, but it will be seen the details feel congenial, to do so. That is always a good sign in new proposals.
Multiple Programs in Multiple Years. The transition problem is always vexing in a new program, but reaches some sort of new limit when the ambition is to work toward uniformity and maximum patient control, across the entire nation; fragmentation always sounds easier. The temptation is always there to order and threaten to use force, but it must be resisted. Furthermore, enormous cost savings are readily available if programs are multi-year, and the cost is a paramount issue, here. It's hard to beat compound interest, the longer the better.
We explain the reasoning of the grandpa transfer in the next section. It's simple (one grandchild's worth of costs per person), it uses surplus cash after a grandpa has no further use for it, and it comes at an optimum time on the compound interest curve. It greatly stretches the lifetime for compounding, but it is readily suited for a limitation on perpetuity. It even follows established family patterns, although families are under considerable stress, these days. True, it jumps over a new barrier for the first time, but it doubles the duration of compounding, skips over the issue of leaving a dark hole around Obamacare, skips over the issue of pre-funding obstetrics, simplifying a host of unnecessary red tape obstacles. And it reduces costs by half.
No Employer Involvement, No Obamacare Contributions. At first, it seems like a relief not to have to deal with the two thorniest issues of the past, but in fact, it doesn't quite do that. If the patient has duplicate coverage, there must be cordial negotiations to see which coverage should be dropped. And while significant savings can be readily demonstrated, there will be some residual revenues which have to be transferred along with the patient, or the new program will starve. The complicated systems we have evolved to facilitate cost-shifting will probably invalidate old statistics, and perhaps some old ideas. Transferring six percent of the gross domestic product is by definition a tedious, difficult task, even if you reduce it to four percent in the process. Everyone is hesitant to name the individuals who will lose their jobs, or their pensions or their seniority if the program shifts significantly. But if the savings aren't significant, what good are they?
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.
109 Volumes
Philadephia: America's Capital, 1774-1800 The Continental Congress met in Philadelphia from 1774 to 1788. Next, the new republic had its capital here from 1790 to 1800. Thoroughly Quaker Philadelphia was in the center of the founding twenty-five years when, and where, the enduring political institutions of America emerged.
Philadelphia: Decline and Fall (1900-2060) The world's richest industrial city in 1900, was defeated and dejected by 1950. Why? Digby Baltzell blamed it on the Quakers. Others blame the Erie Canal, and Andrew Jackson, or maybe Martin van Buren. Some say the city-county consolidation of 1858. Others blame the unions. We rather favor the decline of family business and the rise of the modern corporation in its place.
Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
