Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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Personal Reminiscences
One of the features of aging past ninety is accumulating many stories to tell. Perhaps fewer are left alive to challenge insignificant details.

The Philadelphia Delegation to he Pennsylvania Medical Society I


George Ross Fisher, Chairman

Barbara Shelton, Vice Chairman

During the 1988 meeting of PMS at the Adams Mark Hotel, the Philadelphia delegation directed its chairman to write articles for Philadelphia Medicine, describing delegation activities. Many members of the society do seem to have relatively little idea of the activities of their elected representatives, and perhaps need to know more.

The Republic of Medicine

The best way to describe the medical society "system" is to see it through the eyes of a member who, for whatever reason, becomes actively involved in social activities after a variable time as a relatively passive member. Most newcomers to active participation in "organized medicine" are surprised and pleased by flood of insight into the unexpected brilliance of the creators of the system. The central ideas of organized medicine came from two main two sources, the creators of the national constitution in 1787, and the physician group of 1847 who adapted the national constitutional process into a republic of physicians. Both groups met and conducted their work in Philadelphia. No doubt the similarities between the national constitutional system and the Republic of medicine were increased by meeting in the same city, sometimes in the same buildings. Undoubtedly, successive generations of newcomers to organized medicine are able to navigate its complexities by encountering familiar landmarks of national civics. Conversely, it is frequently a source of continuing pleasure to activists in organized medicine to encounter personal experiences which evoke the enduring insights of the founding fathers of 1787.

The Electoral System

Organized medicine, like the United States of America, is not a democracy, it is a republic. What does that mean? It means that all the voting members of county medical societies are periodically asked to select colleagues to represent them. Once elected, those representatives are trusted to make decisions about specific issues on behalf of the members, and those decisions are subsequently binding on society. The general membership generally selects representatives of their own style of thinking, and eventually replace representative's who prove disappointing. The membership makes their views known to their representative is fully delegated to hear the debate and use his best judgment on behalf of those who elected him. In Pennsylvania, delegates each represent about a hundred members of the county society, although in New Jersey there is a delegate for every ten members. In California, local groupings of physicians select their own specific representatives. In Pennsylvania by contrast, the members of each county-wide vote. Collectively, those delegates become the Pennsylvania Medical Society House of Delegates collectively select about one-tenth of their number to become delegates to the American Medical Society. Since few medical issues markedly separate Pennsylvania's viewpoint from that of the rest of the country, delegates originating in Pennsylvania are representative of the profession as a whole more than they are agents of local faction. Similarly, few issues before the Pennsylvania House of Delegates evoke a special Philadelphia viewpoint.

From this overview it can be seen that any physician who wants to be presidents of the American Medical Association need only persuade a few of his friends to vote for him as a delegate to the State Society, then persuade about a hundred of his fellow delegates to make him a AMA delegate, and subsequently persuade 201 of the other AMA delegates to elect him president. Many doctors from Philadelphia have climbed this ladder, and every doctor who reads this article could potentially do so. Of course, it turns out to be a more difficult path to follow than to describe, but perhaps this oversimplified description will serve to illustrate the vital essence of a republic: selection of representatives at each step is always in the hands of a small group of electors with opportunity to know the qualities of candidates intimately. No television "sound bites", newspaper posturing, or demagoguery from a podium will elect someone well known to the small group of peers who cast the ballots. No candidate within such small groups can long conceal major personality flaws or biases from the group. Sometimes someone claims the leadership of medicine does not reflect the viewpoint of the rank and file; it is hard to see why that should ever be so.

The Republic of organized medicine derives from elegant design, but it contains one potentially serious flaw at the very beginning step of the process of election. The individual physician members of many country societies mostly do not cast their ballots. From many conversations with members, it is clear that the main source of failure to cast votes s not indifference or inertia, but rather a fear that lack of information will inadvertently lead to a vote for the wrong candidate. A system which was consciously designed to assure that voters really knew the delegates for whom they were voting can thus sometimes fail because a high conservation electorate fears that its information is inadequate. All information is only partial, but the individual physician's assessment of the fellow members of his hospital staff or neighborhood is surely superior to the knowledge available to voters in any other sort of election it is possible to name. The society can be positively assured that the scrutiny of candidates once they become active in organized medicine is intense, but it is entirely up to the membership to be serious about choosing local captains.

The Caucus System

Historians relate that the founding fathers of the American Republic did not anticipate the development of the party system, which was largely the creation of Martin Van Buren. That is, the founding fathers did not anticipate that coalitions would form among voters with enduring special interests related to geography. The Republic of medicine has never developed a party system, presumably because the members of a single profession have fewer reasons to polarize for more than a vote or two. Coalitions definitely do form, but seldom endure for more than a year or two before some other issue causes new coalitions to reorganize. However, the large volume of business creates a need for small discussion groups, and group efforts are required to promote the election of officers of a profession which unite and inflame the passions of a geographical locality against some other region or locality. Mostly, however, state and regional caucuses are study and discussion groups, social clubs, and mechanisms for promoting the election of members who are wise enough to know that intense personal ambition is not a highly regarded quality. Although passionate love of your hometown is a faintly ridiculous component of a professional scientific society, there can be little doubt that the local caucuses operate to the advantage of the profession by identifying and encouraging useful leaders who might otherwise be too diffident or awkward to succeed on their own. By promoting its obligated members to leadership positions, the caucus puts its stamp on policy; the reelection process then ensures that those in leadership positions will return to their grassroots with information about "inside" activity. Caucuses provide instruction for newcomers, an opportunity for young delegates to select informal mentors at the breakfast tables. And caucuses give some entertaining parties, which greatly relieve the tedium of a great volume of detailed professional business.

The Reference Committee System

Reference Committee are a particular invention of organized medicine. They are not to be found in the United States Congress, or in Thomas Jefferson's American modification of the rules of the British Parliament, or in the famous rules of order written by General Roberts. The inventor of reference committees at some early House of Delegates of the American Medical Association is apparently not discoverable, but the high priestess of parliamentary process today within organized medicine is Mrs. Sturgis. Her book describes the process of the speaker of the House convening select member committees to review privately the complexities and merits of business before the House, capsulize their opinion, and present it before the fully assembled House as respected advice for general consideration in the debate. Her book also leads the parliamentarian or the speaker around most of the traps and inconsistencies which have surfaced during decades of use, setting sensible rules which mainly allow the assemblage to avoid entanglement in its own processes.

The reference committee system is essential if we are to preserve the right of every member to submit his complaints, suggestions, and resolutions to any meeting of the House of Delegates. The system makes it possible for any member of the society or invited guest to deliver written testimony, or to speak before a microphone without any time limitation. At the same time, the reference committee system makes it possible for a House of Delegates to vote as a whole on several hundred issues in a session, and to be satisfied that their votes were informed ones.

Different speakers have different views about the composition of a reference committee; and different houses of delegates have differing traditions. Currently, the American Medical Association follows the traditions of assigning each member of the House to reference committee in rotation, a system which places a member on a reference committee every eight or ten sessions. An effort is made to assign members to a committee covering subject material with which he is not strongly identified, and hence is likely to give neutral impartial opinion. At the Pennsylvania Medical Society House of Delegates, there has been a tendency to pick reference committee members with a great deal of expertise in the subject under discussion. There is something positive to be said about both approaches. There is nothing sacred about the opinions of the reference committee, and many of their recommendations are swept aside by the House. Consequently, a reference committee chairman quickly develops the goal of providing advice which he believes the House will accept, thereby avoiding the embarrassment of a snub. The reference committee system is to some extent an elegant mechanism for harnessing the egotism of the committee members to the goal of reducing unnecessary floor discussion and quickly achieving the will of the House. Those who are ignorant of Mrs. Sturgis' rules quickly find the pace of business leaves them and their favorite projects behind.

The AMA has the perfect vehicle for defining the quality of care in a particular situation, the PRO system has the people on the front line, observing the gray areas and problem areas. The overlap delegates Weeks, Pierson, Eberle should hustle up the others to forward a stream of requests to AMA to study particular areas. The outcome should be that the collected works of CSA would become the de facto standard for quality.

Subject: Washington Fellowships for Doctors

The Robert Wood Johnson Foundation supports six fellows in health care each year; Allen Hyman was one. The PMS or AMA ought to establish an office for locating suitable candidates and finding fellowships for them. Roger Egeberg suggested as his person. Cost limited to the expense of putting the deal together; the fellowship money to come from foundations. White House fellows, Johnson fellows, Pew fellows, etc.

Lay Oversight of Physician Orders in Intermediate Care Facilities

Whereas, federal regulations concerning intermediate care facilities (400.150) specify (E),(2) that drugs for the control of inappropriate behavior must be approved by the interdisciplinary team.

And Whereas, regulations (483.440) specify that (C),(1) each "client" must have an individual program plan developed by an interdisciplinary team which represents the "professions, disciplines or service area which are relevant".

And Whereas, the statute and regulations (1801) declare that "Federal interference with the practice of medicine is prohibited".

Therefore be it resolved that the AMA study all sections of the Social Security Act which utilize the word "client" in a medical setting where the term "patient" might equally apply, seeking to determine whether some regulatory provisions promote interference with the practice of medicine.

Originally published: Monday, August 27, 2018; most-recently modified: Tuesday, July 16, 2019