The doctor likes to picture himself as a freewheeling individualist. But from the day he enters medical school he must learn—if he wants to succeed—to play ball with a tight bureaucracy. Mr. Chase, who has reported on various aspects of medical economics in other magazines, here explores the anatomy of power in American medicine at the grass-roots level of the county medical society.
Last June a forty-one-year-old obstetrician, Dr. Joseph Garabedian, died on Staten Island, a borough of New York City which is also known as Richmond County. The cause of death was overwork, according to press reports, which stirred a considerable commotion. Dr. Garabedian practiced in a medical group affiliated with the Health Insurance Plan of Greater New York (HIP). It has half a million subscribers, many of them city employees, and 24,000 of them live on Staten Island.
HIP members—with the aid of a contribution from their employers—pay by the year rather than by the visit for their medical care, which they must get from doctors in different specialties who work as partners, sharing expenses and income. Such groups—according to the demonology of organized medicine—are “closed panels”; and the prepayment system flouts the hallowed “fee-for-service” principle. For these heresies, HIP has been anathema to the general run of private practitioners. In the Richmond County Medical Society the local M.D.s found a ruthless champion.
Staten Island is one of the few uncongested areas left in metropolitan New York. Surrounded by the waters of New York harbor, it is within hailing distance of the Statue of Liberty and only a nickel ferry ride from downtown Manhattan. Its population has been growing rapidly in recent years and many of the newcomers have joined HIP. So the local medicos took corrective action. They agreed to deny any new HIP doctors the privilege of treating their patients at Staten Island’s three hospitals. Pediatricians, a surgeon, and other well-qualified specialists were turned down.
For Dr. Garabedian and his HIP colleagues this was an extremely grave matter. Unable to get hospital privileges for an assistant, Garabedian became the sole obstetrician for all HIP babies born in Staten Island hospitals. This would have been a considerahle workload for a healthy man; Dr. Garabedian suffered from a bleeding ulcer. When he died, the outrage of his patients ex- ploded publicly. Protest meetings were staged and the situation was universally deplored by the press. The temperate and judicious New York Times pointed out editorially that the blackball of HIP doctors was not “in the public interest,” adding that hospitals which receive tax exemptions and other largess from government funds are scarcely private concessions.
But despite the public outcry, the hospitals showed no sign of yielding. Whereupon a com- mittee of the New York State Legislature decided to look into the matter.
The hearing took place on a sweltering July day in an atmosphere further heated by TV lights and the passions of witnesses. For those in- terested in the politics of medicine it was a much more enthralling spectacle than the Democratic National Convention which was simultaneously going on in Los Angeles.
As a writer interested in medical economics I was particularly grateful for the candor of Dr. Herbert Berger, past president of the county medical society, who eloquently defended the lockout. His testimony stated in concrete terms the political philosophy of organized medicine as it operates on the grass-roots level of the county society.
At the hearings, both sides—though for opposite reasons—accused each other of obstructionism, unco-operative behavior, and monopolistic practices. An uninitiated observer might have had trouble, at the outset, in judging the merits of the case. But gradually a clear pattern emerged, as the medical society’s witnesses evaded pertinent questions, set up straw men, and adopted diversionary tactics. They argued, for example, that it would be unwise to let all doctors treat their patients in the hospitals. But HIP had made no such requests; it was pleading merely for privileges for those with unimpeachable professional qualifications. Similarly, the island’s three hospitals maintained that their facilities were overtaxed. Yet obviously their beds were the only ones available. Which particular doctors referred Staten Islanders to a hospital had no bearing on the bed supply.
Two fundamental questions were never really raised: Did HIP doctors provide good medical care? And if so, by what right could the ruling clique in their profession exclude them from the hospitals?
Soft-pedaling or side-stepping these issues blandly, Dr. Berger suggested that qualified HIP doctors could, of course, get hospital privileges. All they need do was resign from HIP. Nor did he feel that Dr. Garabedian’s death was traceable to overwork, for he was not only an ulcer victim but “a person of Turkish origin.” Hence “the fall of the Menderes government”—as well as a dozen other provocations—might just as well have brought on his terminal hemorrhage.
“Of all the multitudinous problems that beset him,” Dr. Berger said solicitously, “the one that he could have most easily solved was his association with HIP. He could have resigned.” Certainly the medical society had done its best to drive the point home to this stubborn man. His associates were kept out of the hospitals. They were also, as Dr. Berger put it, subject to “social nonacceptance by their colleagues.”
“No one denies,” he added, “that this can be a devastating experience. But they have made the mistake of isolating themselves from the rest of the profession. This can be readily rectified by resigning. Many of them do just this. More than half of the [HIP] physicians who came to this community have done so.” Others, it seems, moved away. The one substantive charge against HIP doctors, that they were “disputatious” and “transients,” thus stood revealed as the consequence, quite intended, of the county society’s campaign of ostracism.
At this writing the Staten Island controversy appears to be approaching resolution. The repeated demands at the hearing for legislation prohibiting discrimination against doctors because they choose to practice in groups financed by prepayment will likely go unheeded. But at the instigation of the state legislative committee, the hospitals have been forced to accept three new HIP doctors. HIP has interpreted this as “an interim agreement” hopefully pointing the way to “further steps necessary for an adequate solution.” In fact, it amounts to a considerable victory for HIP and one more of the increasing number of instances in which organized medicine has had to bow to public opinion.
Belatedly the county society has shifted its ground. It claims now (1) that the whole altercation could have been avoided if only city employees had a choice of alternate health-insurance plans and (2) that the Staten Island doctors were motivated all along by solicitude for them. A multiple choice may in fact be a good idea. But it is hypocrisy for the society to say at the eleventh hour that this is what’s been troubling it. As Dr. Berger stated in an astonishing exchange with the legislative committee chairman, State Senator George R. Metcalf: “Sincerely, this is a personal and social matter, not a medical one. I have no question about the medical competency of these [HIP] doctors.”
Senator Metcalf: “It is a medical problem.”
Dr. Berger: “No sir, it is not, not in my eyes.”
Senator Metcalf: “That is quite an admission.”
To date the hospital spokesmen have shown no misgivings as to the propriety of their ways or the probity of their motives. Their self-righteous unction seems impermeable. Doctors, in truth, are not given to arguing it out with the laity. They have been running their own show for centuries.
the mighty guilds
In ancient Greece, medical knowledge was a holy secret shared only by a few families claiming descent from Aesculapius, who became the god of medicine after his death. Hippocrates devised his oath to regulate the admission of new physicians into guilds, which the ruling families tightly controlled. These guilds of antiquity looked after the professional and economic interests of medicine. This remains the prime purpose of their successors, the medical societies. One of their chief concerns, as with business trade associations, is to help the membership make money, substantial money.
The modern guilds are run by the top practitioners—in income and prestige—in each community. Like their Greek forebears they have seen to it that there are not too many doctors and that those who are admitted to the fraternity abide by the rules. In theory this is not a sinister function—it is fitting and necessary that those of highest competence set and maintain professional standards. But in practice the system controls a good deal more than medical excellence. How it operates has been perceptively analyzed by Oswald Hall, Ph.D., now professor of sociology at the University of Toronto. For his most important essay, “The Stages of a Medical Career,” he conducted confidential interviews with physicians in the United States about intern appointments, hospital department assignments, and the problem of establishing a successful practice. (This study was reprinted in 1958 in Patients, Physicians, and Illness, edited by E. G. Jaco and published by the Free Press.)
As Hall describes it, the “inner fraternity” of medicine uses informal but potent mechanisms to “incorporate the new doctor into the profession, to repel the intruder (i.e., the ethnically undesirable or the idiosyncratic), to minimize mobility, and to control competition.” The medical bureaucracy run by this “inner fraternity” stabilizes the profession by controlling the flow of recruits and by allocating the coveted positions, especially in hospitals.
The process starts the moment a young man tells his family he is going to be a doctor and files his application with a medical school. A physician’s career is constructed brick by brick, and at each level an appropriate echelon of the medical hierarchy stands guard. A hint by one of its members can be an invaluable lever in gaining admission to one of the major medical schools. The “right” medical school provides its students not only with fine training but with a label which will materially help his professional ascent. (This is not to say that every young man’s career will be blighted if he is trained at an undistinguished—or even a foreign—medical school. But he may need extraordinary ability to surmount the handicap.)
Upon leaving medical school the young M.D. takes a step which usually is decisive for his career. He must spend several years as a hospital intern and resident. The prestige of the institutions where he serves will have a crucial effect throughout his life on his associations and opportunities as a practicing doctor.
The most admired hospitals tend to pick a large proportion of their interns and residents from the “top” medical schools. Many other factors also influence their choice. Professor Hall’s interviews with physicians reveal, among hospital staffs in charge of assignments, dismaying prejudice and judgment by trivia of the kind which I associate with college eating clubs and fraternities. Anti-Semitism, for example, survives in hospital administrations in many parts of the country. (Discrimination against other minority groups has been, on the whole, an academic question. Only a very few Negroes, for instance, have any hope of getting the kind of pre-medical or medical education that would qualify them professionally for first-rate internships.)
So the allocation of internships—and of medicine’s other patronage plums—is determined only in part by technical distinction. A vital factor also is what Hall calls “institutional acceptability.” “The cut of a man’s jib” said Dr. Berger in the course of his testimony on the Staten Island case, can make or break him, quite apart from his professional attainments. This means that those familiar yardsticks of organization life—”personableness” and evidence that a man “fits in”—weigh heavily in hospital appointments.
Hall’s observations were made more than a decade ago, before the present critical scarcity of doctors. But there has been little or no change, according to the many administrators I have questioned. And indeed the increasing dominance of the hospital as the center of medical practice has if anything fortified Hall’s thesis. It is only in the average hospital that the would-be intern enjoys a seller’s market for his services. For the most coveted appointments there are still about ten times as many applicants as openings.
To be sure, the applicant’s competence is always pertinent. The written and the unwritten rules of the profession demand that the doctor pass muster throughout his career. Nor can a neophyte skip over the successive stages of his apprenticeship. He must climb up the ladder step by step. And on each rung he can be given an upward or a downward push by the controlling elite—department heads, hospital administrators, medical boards, outstanding specialists—and their lay allies, the hospital trustees.
His own progress within the hospital system will heavily influence not only his status but his earnings. Specialists who are on the visiting staff of the same hospital quite naturally refer private patients to each other for consultations and surgery.
“If a man gets to the top in a hospital in one of the more lucrative specialties,” my own doctor said recently, “he’s also got it made in his private practice.”
The trappings of prestige impress not merely the doctor’s peers but also the wealthiest, best-informed people in the community. It is convenient and flattering to be treated by a physician or surgeon who can always command a fine private room for his patients while others stand in line on waiting lists—or by a surgeon whose mere name inspires a magical deference from other doctors’ receptionists, nurses’ registries, convalescent homes, and even pharmacies. The physician’s prestige, in other words, contributes materially to his success in delivering medical services.
As a result medicine, to a far greater degree than any other profession, imposes upon the doctor the need for endless adjustments to an intricate bureaucratic structure in which powerful political controls are strikingly prevalent. With rare exceptions, only by succeeding within “the system” can he hope to become a leader in his field, let alone a mover in its power apparatus. Success in the system is essential for either “informal” political power, wielded within the hospital, or for formal political power in the county, state, or national medical urganizations. An interlocking directorate prevails, since the brass in the hospital and the brass in the societies gen- erally (but not always) tend to overlap.
As he works his way upward the doctor with political interests will have his reliability tested by appointment to various committees of his county society. In due course, if he proves himself, he may sit on its governing body. From the ranks of this august and dependable group the county society chooses its presidents, in a succession tidily arranged for several years in advance. The progression upward to the state society is automatic for those with time and taste for the medical organization life. The doctor who scales these heights is well schooled in the political and economic orientation of his colleagues. Doubtless he has served on his county’s two most im- portant committees—legislation and public relations. He has been well insulated from any dissenting viewpoints, for his associates—in the hospital, in “the professional building, and at the country club—are almost entirely fellow members of the same “inner fraternity.” He is ready now to contribute his own wisdom—too often a pecul- iar brand of bumbling provincialism—to the supreme guild of his profession: The American Medical Association.
the bursting dam
One hundred seventy-eight thousand—about 80 per cent of the nation’s practicing physicians—are members of the AMA’s 1,911 county and district societies and its fifty-three state and territorial associations. The AMA is the largest medical organization and perhaps the most powerful trade association in the world. Membership at the county level is virtually compulsory, for otherwise the doctor’s license to practice is inconsequential. Without it he is unlikely to get staff privileges at most hospitals. As a result he may even have trouble in gaining the approval of the governing boards which pass on the qualifications of specialists. In his day-to-day work, too, he is dependent on his county society for many services—such as the battery of seasoned attorneys and experts it commands to defend its members in malpractice suits (a growing menace among today’s litigious patients); the “grievance committee” which contrives to keep a good many customers’ complaints out of court; its amiable intervention when police officers are overzealous in distributing parking tickets to doctors’ cars. And for his dues he also becomes a subscriber to the chief professional journals. A large proportion of doctors, however, stay away frum their societies’ meetings and conventions in droves. They trust their leaders, and with sound reason; these have shown, over the years, an unshakable belief that what’s good for the doctor—financially—is good for the country.
It was not always thus. The AMA was founded in 1847 to improve medical education and combat quackery. Over the years it has been a powerful force in raising the level of practice by enforcing standards in education, specialist practice, medical ethics, and in communicating scientific knowledge to physicians through its publications, exhibits, and meetings. It has battled successfully against the commercial solicitation of patients by doctors and against such miscellaneous menaces as fake “cancer cures” and worthless patent medicines. Even today, in the realm of strictly medical matters, few would quarrel with the AMA. But as it has faced complex modern social problems, it has been an increasingly ineffective and even negative factor in meeting the nation’s health needs. Its dismaying political performance has been recorded in rich—and now repetitive—detail by its critics.For documentation, the student of AMA political history is referred to Richard Carter’s The Doctor Business, New York, Doubleday, 1959; “The American Medical Association: Power, Purpose, and Politics,” in the Yale Law Journal, Vol. 63, No. 7 (May 1954); James Howard Means’ Doctors, People, and Government, Boston, Atlantic-Little, Brown, 1953; Oliver Garceau’s The Political Life of the American Medical Association, Cambridge, Harvard University Press, 1941.
One of the doughtiest was the late Bernard DeVoto. Thirteen years ago in this magazine he likened the attitude of the AMA toward government participation in medicine to that of a town which has learned that a dam up the valley has burst and a flood is on the way.
“The dam burst long ago,” he wrote, “and year by year the AMA has prepared to meet the flood by saying that it must not get here, that the Hood waters are Communistic, that we shall all be lost if they reach the city limits.”
In this fashion the AMA led by Dr. Morris Fishbein (with an assist from Whitaker and Baxter, California’s publicity wizards) stilled the clamor for national health insurance that was heard in the wake of the depression of the 1930s. Though Dr. Fishbein’s successors in the AMA have not altered their basic position, they have been forced to yield some ground.
For times have changed. The long-forgotten Wagner-Murray-Dingell Bill never had many supporters outside of liberal New Deal and labor circles. To most Americans it was a partisan—even a “radical” or “foreign” notion. And the pressure then brought to bear on organized medicine was a mere spring freshet compared with the deluge it now faces.
Thanks to medicine’s own triumphs, people expect great things of doctors, And with the meteoric spread of voluntary health insurance, the average American has come to rank modern medical care along with food, clothing, and shelter as a basic social right. Most insistent in their demands at the moment are the sixteen million Americans who are over sixty-five years old. So self-evident is their need that the principle of federal aid in medical care for the aged has been accepted this year for the first time by both the Republican and Democratic parties. But the AMA fights on. Old people, it argues, are generally fussy, preoccupied with their troubles, and never lack care if they really need it. And they should get all the medical care they need simply by using up their own savings and their families’ or through public assistance, the pauper’s choice.
Dr. Berger of Staten Island developed this theme when he testified in Washington last year against the Forand Bill. Unwittingly he invoked the ghost of DeVoto.
“Does it not seem inconsistent,” he asked the House Ways and Means Committee, “that we should be fighting Communism [abroad] while introducing legislation to support it in Washington?”
When gentle Representative Aime Forand of Rhode Island protested against this characterization of his bill, Dr. Berger retreated strategically. “Economics,” he conceded, “is not my forte.”
no time to read
The same may be said of most physicians. One expert who has been exposed to the socioeconomic opinions of doctors is Mr. John Steinle, consultant to the New York State legislative committee on health insurance. In his opinion, the doctor may be a learned man in his own field. Rut in general knowledge he is the worst-educated of our professional men. This widely-noted deficiency stems in part from his narrow training in the natural sciences and the all-absorbing nature of his work. Eternally busy with individuals and their private troubles, he seldom participates in civic problems. Nor does he have time to read much more than medical journals—a uniquely unenlightening brand of literature in social, economic, and political affairs. There are many publications, of course, which stick to the job of communicating scientific information. But those that discuss political and economic matters (whether sponsored by medical societies or by the pharmaceutical houses, which need the AMA’s blessing to sell their wares) are consistently AMA propaganda media. With the single exception of the New England Journal of Medicine there is no medical publication in this country remotely comparable to the British Lancet in literary quality, sophistication, or objectivity.
This deficiency was recently impressed on a young doctor’s wife. Agitated by a discussion of the Forand Bill at a medical dinner party, she decided to write to her Congressman about it. Being a conscientious Radcliffe girl, she set about doing her homework first. The handiest source of information seemed to be the stack of medical periodicals on her husband’s desk. Thumbing through them she found in each a banner headline and a savage editorial denouncing the bill in nearly identical words. These were embedded in tender testimonials to doctors from their blissfully aging clientele. Nowhere, however, could she discover the facts that seemed essential to her naive mind. Just how would the bill work, who would administer it, what would it cost, what benefits would it give?
Conceivably, the editorial writers didn’t know themselves. It is, in any event, a safe guess that the average physician is magnificently Iree of precise knowledge about government medical proposals, let alone the social and economic facts that prompt them. Ignorance is the most charitable explanation of the lag between events and organized medicine’s political stance. A less benign interpretation might attribute it to the determination of a profession, corroded by the ideology of business, to hang onto lucrative privileges. After their long, penurious apprenticeship, doctors are naturally anxious about money and suffer more than most of us from great expectations. Till now, they have succeeded in maintaining their preserve largely unmodified by the lay world. But as medical care has become life’s fourth social right, the doctors’ archaic socio-economic philosophy has plunged the profession into intense public controversies.
In a simpler age the “inner fraternity” could manage their communities’ health affairs with reasonable efficiency. The top specialists attached to the major hospitals provided a rough coordination of services. They referred cases to each other and thus saw to it that the patient was not tossed into a chaotic bazaar but was passed along until he eventually ended up in the right hands—either as a private patient or as a charity ward case. This plan worked well enough when relatively few people expected to be treated by specialists or to be tended in hospitals. But today a semi-private bed is regarded as a minimum prerogative by nearly everyone. The hospital is the essential workshop for the doctor who tries to dispense modern medical care, and patients in vast numbers are insisting on the quality of service that only a hospital can give. “A huge new problem faces the medical profession,” Dr. Dean Clark, Director of Massachusetts Cencral Hospital, told me, “the distribution of medicine on a mass basis. This has never been accomplished before. The whole question is new and difficult.”
Dr. Clark, who is also Clinical Professor of Preventive Medicine at Harvard Medical School, puts his students on notice that it is the public, not they, who will determine the institutional framework of medicine in the future.
“They’re always surprised and indignant to hear this,” he said.
Dr. Clark is a member of the medical intelligentsia which accepts political and economic realities and is far from happy with the political antics of the AMA and its component societies. With the increasing scientific complexity of medicine, the ranks of “academic medicine” and salaried doctors in research are growing. These men are relatively free from the pressures of the market place. Most of them, however, are completely absorbed in the world of teaching and research. Some observers believe that these intellectuals, while oblivious to the alarums and excursions of organized medicine, none the less by their example and by their occasional contacts with active practitioners will gradually influence medicine’s policy for the better. At this juncture, though, the intellectuals seem as detached from the politics of their profession as, for instance, a legal scholar in New York is from the machinations of Tammany Hall.
a new breed
There is, however, a new kind of doctor making his appearance within the earthy sphere of day-to-day medical practice. His changed point of view is the direct result of the enormous pressure by the public to get better mileage out of its medical dollar. Owing to the ever more expensive technology of the healing arts, the costs of medicine cannot go down. So the system for distributing medical services is undergoing a revolution to cope with this new technolugy and with the new mass demand for comprehensive care. It is this pressure that is creating turmoil within the profession.
The new kind of physician may be practicing in an HIP prepayment group (there are now a thousand participating M.D.s). Or he may be affiliated with the largest group-practice plan of all—with over 600,000 subscribers on the West Coast and Hawaii—sponsored by the Kaiser Foundation; it has actually built its own hospitals to avoid the discrimination HIP has encountered. Or the doctor may be a member of one of the small number of enlightened county medical society plans, in which the physicians co-operate among themselves and with the community in supervising fees and sticking to a fee schedule. (This is solo rather than group practice. The plan operated by the San Joaquin County Medical Society in Stockton, California, is the best known example.) Or he may be a salaried doctor within the Veterans Administration, practicing in one of its 170 hospitals which serve some 114,000 patients daily with medical care of a high order. Or he may be a member of the hospital chain of John L. Lewis’s United Mine Workers Welfare and Retirement Fund, which has performed a miracle for the impoverished coal miners of West Virginia, Virginia, and Kentucky by bringing them superior hospital and medical care where previously they had virtually none.
These doctors of the new breed are being exposed day in and day out to the economics of medical practice in terms far broader than their own pocketbooks. And through the boards of their organizations, they are in contact with the kinds of laymen who have, so far, coerced organized medicine into modifying its stand on a variety of issues, It also seems likely that the rising demands by labor and other consumer groups for greater participation in the policy decisions of Blue Cross and of our community hospitals will confront the doctors with facts and viewpoints from which they have hitherto been insulated. Conceivably in the years ahead the doctors practicing in group prepayment plans or on a salary will no longer be merely intransigent minorities within their county organizations. If so, the squall on Staten Island may grow into a national tornado.
But that day is not immediately at hand. At mid-century, the politics of organized medicine must still be reckoned as a major obstacle to the reforms so urgently needed in our health services and institutions.
