• U.S.

Medicine: The A.M.A. & the U.S.A.

25 minute read

(See Cover)

U.S. medicine matches any in the world and tops most—a fact that, wholesomely enough, leaves U.S. doctors eager to make it even better. To improve the distribution of good treatment, the organization of medicine is in a state of headlong change, from stressing the general practitioner and his elastic fee to stressing group practice by specialists with most costs prepaid. Last week the American Medical Association, a group not prone to accept change gladly, acknowledged the trend by installing as president a group-practice specialist who says that “medicine cannot be blind to social change.”

Dr. Leonard Winfield Larson, 63, a short, folksy pathologist from Bismarck, N. Dak., will not lead A.M.A. down any radical paths; his denunciations of socialized medicine ring as loud as anyone’s. Yet he is known in the organization for taking a step that a decade ago would have seemed unthinkable to A.M.A. After heading an investigating commission, Larson two years ago got A.M.A. to affirm the economic merits and medical quality of prepaid, closed-panel health-care plans —typically. New York’s Health Insurance Plan (H.I.P.).

Such plans infringe on A.M.A.’s oldest tenets: that doctors should be paid a fee for each service and that patients and doctors should choose each other freely. Fully organized health plans collect from patients on insurance principles, pay their doctors salaries or shares, and assign patients to qualified specialists. A.M.A. fought group plans for years; the surrender was a belated recognition by A.M.A.’s scientific element that these systems can and do give good results. Out of such challenges and accommodations comes 1961’s ferment of change in the relation between doctors and patients.

A Better Buy. The biggest factor in the change is the wholesale advance of medical science that makes modern medi cine more expensive but a better buy, with far more certain diagnoses, routine complex surgery, and virtually sure cures for many ailments. This represents a remarkable change. Harvard’s late Professor Lawrence J. Henderson noted that not until 50 years ago did a random patient taking a random disease to a random doctor have better than a fifty-fifty chance of “benefiting from the encounter.”

Beginning with insulin for diabetes (1922), the benefits from an encounter with the doctor have grown at an ever faster pace. The microbe-killing sulfas came along in time to be dusted into the wounds of hundreds of thousands of servicemen in World War II—and were in turn pushed aside by antibiotics such as penicillin (1945) and tetracycline (1953). Tuberculosis and some forms of pneumonia were brought under control. Virus diseases have resisted cures, but medicine developed effective vaccines that drastically curbed more of them—notably influenza and poliomyelitis.

Perfecting of methods to store blood made transfusions routine and cut the costs. Surgeons learned how to open and repair a blue baby’s heart, use plastic replacement parts—and taught skilled techniques to enough other surgeons so that a doctor like Walter M. Boyd of Greeley, Colo., can say: “I regularly perform operations never heard of 25 years ago. At our little hospital we have four or five men who can handle just about anything that comes along.”

Hard-won knowledge of the body’s complex chemistry has developed the use of hormones such as ACTH and cortisone and their synthetic variants, and has led to life-saving control of a patient’s sodium and potassium during severe illness and surgery. Thanks to new machines (see box), what once seemed impossible and then miraculous is now almost common place. And, notes U.C.L.A.’s Medical Dean Stafford Warren, “More medical research has been published since World War II than in all prior history.”

A Lifter of Standards. In these recent developments, and even more notably in the formative years of U.S. medicine, the A.M.A. has played a promotional role. When 250 doctors from 22 states met in Philadelphia’s Academy of Natural Sciences in 1847 to found the American Medical Association, both the need for it and its aims were clear. In the still raw frontier nation, most doctors were products of dubious diploma mills or outright quacks. The A.M.A. took on the job of raising the standards of medical education to the level of those in Europe, and of driving out the quacks. Success came slowly, but after the famed 1910 Flexner Report (for the Carnegie Foundation), the diploma mills were dramatically shut down. The fight against quackery still goes on; the A.M.A. has called a national conference on the problem, to be held in Washington, D.C., next October.

The A.M.A. was a leader in urging the compulsory registration of births and deaths, and saw this battle won everywhere by 1933. As early as 1874. the A.M.A. began to promote laws to prevent the spread of syphilis, and it was a prompt advocate of premarital examinations, which became general by 1937. Sample resolution in 1910: “The American Medical Association, through its House of Delegates, hereby presents for the instruction and protection of the lay public the unqualified declaration that illicit sexual intercourse is not only unnecessary to health, but that its direct consequences in terms of infectious disease constitute a grave menace to the physical integrity of the individual and of the nation.”

Still pursued with vigor is the crackdown on quack remedies, now under the Department of Investigation. This office does original investigations, cooperates with federal watchdog agencies, and often provides the evidence to get convictions.

Great Mouthpiece. It was this department, says the association itself, “that gave the A.M.A. stature with the public.” But A.M.A.’s best remembered stature giver was a rasp-voiced, acid-penned doctor named Morris Fishbein, who became editor of the A.M.A. Journal in 1924.* Editor Fishbein had opinions on everything even remotely medical and expressed them unhesitatingly, often without a by-your-leave to A.M.A.’s top officers and trustees. He crusaded against anything “socialistic,” by which he meant virtually any proposal to alter medical practice or payment procedures.

In 1932 a committee on the costs of medical care reported that quality would be improved, and care would be made more widely available, if doctors practiced as groups in hospitals—an idea not unlike incoming President Larson’s. “Savors of Communism!” cried Dr. Fishbein in the Journal, though the committee chairman was no less stalwart a Republican than Physician Ray Lyman Wilbur, then Herbert Hoover’s Secretary of the Interior. Such bluntness cost Fishbein his job in 1949, but not until this year did the A.M.A. Journal admit that the criticism of Wilbur had been false.

Membership & Budget. In its 114th year, the A.M.A. is an organization that enrolls 177,337 of the country’s 253,233 doctors (149,086 pay dues), and sets its cap to 1) make them better physicians by spreading medical-scientific news, 2) police ethics and uphold standards, and 3) protect their economic interests as doggedly as any trade union does.

Toward the goal of information, A.M.A. publishes eleven professional journals, a monthly magazine for laymen and a weekly newspaper. Most notable: the big (averaging 240 pages, 180,000 circulation) weekly Journal of the American Medical Association. Toward the goal of ethics, President Larson only last week promised a renewed drive to scourge from A.M.A. ranks the abortionists, drug addicts, mental and professional incompetents, over-chargers, fee splitters and rebaters. To protect its interests, A.M.A. runs an effective propaganda plant and Washington lobby. Member doctors pay dues of $25 a year, but the bulk of A.M.A.’s annual income of $16 million comes from advertising in its publications, mainly by drug and medical appliance makers.

Federacy. “It is unfortunate,” says Dr. Richard L. Meiling, dean of Ohio State University’s College of Medicine, “that many people don’t realize that A.M.A. is probably the most democratic organization in the U.S.” A.M.A. defines itself as “a federacy of its constituent associations”—the state medical societies that in turn are associations of county and district societies. For the U.S.’s 3,131 counties and equivalent divisions, there are 1,901 county or district societies, many covering two or more counties with few doctors.

Nearly all physicians in private practice belong to county societies; they must, to qualify for their most important prerogatives, notably putting their patients into hospitals and treating them there. All members may vote for county officers, in eluding delegates to state conventions. These delegates elect state society officers, plus a quota of delegates to sit in the A.M.A. House of Delegates. The House elects the national board of trustees, the president and all top officers. Thus the individual doctor’s influence is two removes from national headquarters and national policy.

It is a special breed of physician who works his way up the county-state-A.M.A. ladder. He gladly pays his own expenses to attend meetings. In most cases he is old enough to have his practice so organized that he can arrange time off. This is easiest if he is a specialist in a small town. “Medical organization is less efficient in the larger cities,” says a top A.M.A. official. “There is greater participation in the rural societies, and they furnish us relatively more delegates.”

The High Command. Critics of A.M.A., including many members, charge that this ponderous machinery keeps A.M.A. from reflecting the varied and open-minded attitudes of doctors themselves and gives rise to the common complaint that “we are respected as individuals but looked down on as a group.” Yet no poll of medical opinion uncovers much dissent. Kansas Pathologist William Reals says, “It’s the only voice the doctors have.” His general-practitioner neighbor Walter Reazin adds: “I think its basic principles are right.” If somewhat glacially, the House of Delegates does represent doctors. Yet A.M.A.’s week-to-week affairs must be left in the hands of the staff at headquarters in Chicago. Thus the public picture of A.M.A. is often formed by only four men:

¶ Dr. Francis James Levi (“Bing”) Blasingame, 54, Arkansas-born and Texas-reared, a private practitioner (surgeon) for 20 years, is executive vice president and senior administrative officer.

¶ Dr. Ernest Bertram Howard, 51, graduate of Harvard College and Boston University School of Medicine and a former director of VD control for Massachusetts, is assistant executive vice president.

¶ Clarence Joseph Stetler, 44, graduate of Catholic University, who worked for the U.S. Civil Service Commission and Social Security Administration before joining A.M.A. in 1951, is general counsel, director of the legal and socio-economic division, and director of a special commission on the cost of medical care.

¶ Leo Emerson Brown, 48, from Clarion State Teachers College, former teacher, athletics coach, public relations secretary for the Pennsylvania Medical Society, is director of public relations.

Insiders nominate Bert Howard as the single most powerful individual. Though technically assistant to Bing Blasingame, he dominates policymaking, chairs the “legislative task force” that keeps a hawk-eyed watch on federal legislation, and swoops in to fight bills that run counter to A.M.A. principles. The headquarters’ permanent staff inevitably wields great power. No one-year president, such as Larson, can dislodge it. A front runner for next year’s presidency, who showed an itch to get the reins in his own hands, was shunted aside last week.

Lobby with a Weapon. The A.M.A. Washington lobby may not be, as Health, Education and Welfare Secretary Abraham Ribicoff charges, “the most powerful in America,” but it commands the profound respect of beefier, louder-talking outfits. The A.M.A. lobby, has only 13 people in its Washington office. It picks its legislative targets knowingly and concentrates its fire, and it is the envy of other lobbies because it has a secret weapon: the Congressman’s personal physician.

As soon as an A.M.A. lobbyist learns that a Congressman is inclined to vote against the A.M.A. line and seems immune to Washington persuaders, he sends the word back to A.M.A. headquarters in Chicago. From there it is relayed through the Congressman’s state and county society to his personal physician. This doctor usually does what he is asked: he phones or wires the Congressman. The legislator is far more likely to heed a trusted, intimate adviser than any number of relative strangers. This technique works poorly with Senators and some big-city Congressmen, but it has proved to be magic with small-town and rural members of the House.

The lobby has lost many a battle. It fought Blue Cross hospital insurance (a “half-baked scheme” that would result in “mechanization of medical practice”), the American Red Cross Blood Bank, federal aid to medical schools (“a backdoor route” to socialized medicine), federal aid to states to reduce infant and maternal death rates, disability payments under social security. All are now in effect. But in the greatest of all contests, the 1949-51 battle over the Truman-Ewing national health insurance plan, A.M.A. scored a smashing win. Through the 19403, opinion polls had shown that a majority of the U.S. electorate—74% in a FORTUNE poll—favored such a plan. Ewing’s idea was to levy a 4% payroll tax (to yield $4.5 billion as of 1950), toss in a couple of billions from general revenues, and cover hospital and medical care for 85% of the population. Patients would have free choice of physician. Doctors would be free to join the plan or not; those in it would decide whether they wanted to be paid by fee for service, a per capita rate, or (in group practice) salary. Though the A.M.A. had powerful allies, it was the biggest single force in squelching the plan so thoroughly that it has never been revived.

K.M. v. K.-A. As the A.M.A. met last week in Manhattan for its uoth convention, the House of Delegates lined up against what seemed to them—unanimously—to be the newest federal threat: the Kennedy Administration’s bill to make the hospital and nursing-home costs of Americans over 65 a responsibility of social security. For consistency’s sake, they also turned down a proposal backed by 51% in a poll of U.S. doctors, that would put them into the social security system for old-age pensions. (Doctors get “courtesy medical care” from their colleagues for themselves and families, both while in practice and during retirement.)

The Administration bill, sponsored by New Mexico’s Senator Clinton Anderson and California’s Congressman Cecil R. King, would not pay doctors’ fees, but the A.M.A. argues that it would be only the first step toward “socializing” all U.S. medicine. New York’s Dr. Gerald D. Dorman, an A.M.A. trustee, points out: “Why 65? That’s an arbitrary retirement age set up by Bismarck in the last century. Why not 60—or 50?”

Census Bureau figures show that of the 15 million Americans aged 65 and over, 55% have cash incomes of less than $1,000, whereas 23% have $1,000 to $2,000, and 22% have $2,000 or more. The figures include social security payments but do not indicate how many oldsters are taking cash handouts from their children. HEW also finds that the over-65s use 2½ times as much hospital service as the U.S. average. Recognizing that old people indeed have a serious problem, the A.M.A. backs a law that Congress passed last year in the heat of the presidential campaign.

Under the Kerr-Mills program, the Federal Government matches state funds —a little more than 3 to 1—for hospital, nursing and some doctors’ care for those oldsters willing to declare themselves “medically indigent”—that is, possessed of enough resources to live, but not enough for stiff medical bills. There is wide variation among the states’ requirements: some set limits on cash reserves as low as $300, can require the liquidation of other assets such as cars, can require homeowners to mortgage their houses to the state, the title to change after the death of both spouses. Kerr-Mills critics find the means test demeaning, and the lien unjust, but A.M.A.’s Larson maintains that “there’s nothing wrong with taking it after they’re dead.”

To get the system working, each state must pass enabling legislation and vote its share of the money. Eight have done so: Kentucky, Massachusetts, Michigan, Oklahoma. Washington, West Virginia, Maryland and New York, plus the Virgin Islands and Puerto Rico. Kerr-Mills back ers say the law will eventually cover 2,500,000 old persons, cost the Federal Government $200 million a year.

The King-Anderson bill, which is basically the same bill that Kennedy sponsored last year as a Senator, would cost $1.5 billion a year, to come from a ¼% increase in social security contributions by both employee and employer (currently, contributions are 3% of salary, up to $4,800, from each). Beginning Oct. 1, 1962, it would cover 14 million aged people drawing social security or railroad retirement benefits—and skip 2,000,000 not so covered. As the A.M.A. points out, King-Anderson would help some people who might not need help, and would not cover others whom Kerr-Mills helps. King-Anderson proponents reply, rather weakly, that they, too, rely on Kerr-Mills to plug some gaps. (About 2,500,000 are drawing old-age assistance and getting medical care “on the county.” In addition, most states give some medical aid to non-indigent aged. Many of these are being switched to Kerr-Mills plans so the states can get the federal funds.)

Hard Sell. The King-Anderson bill may not even come up in Congress this year. If it does, it is likely to be in a watered-down version, largely because the A.M.A. has decided to wage an all-out fight, and its Washington lobby has been in fine fettle. In addition, leaflets have been printed, 7,500,000 at a time, and sent in batches of 50 to 150,000 doctors, to be put in waiting rooms. Though the King-Anderson bill forbids Government abridgment of the patient’s free choice of his doctor, the pamphlets, going on the first-step-to-socialism hypothesis, cry: “Your freedom is at stake!” A.M.A. commercials on more than a dozen radio stations have quoted a housewife (“When I think how good it is to choose your own doctor, I can’t bear the thought of socialized medicine”), a druggist and a doctor denouncing the bill and urging listeners to “write your Congressman—tell him to vote against it.” Public reaction was so unfavorable that some stations, including the New York Times’s WQXR, canceled the five-week contract after a few days.

As it raced toward adjournment, the House of Delegates approved a Washington state resolution urging all local, state and national officers, and as many as possible of the 23,000 rank-and-file packed into Manhattan, to go home by way of Washington. D.C.. to demonstrate to their Congressmen “that there is no necessity for the King-Anderson bill, and to vote against it.”

This campaign has A.M.A.’s opponents fuming. Says Ribicoff: “The A.M.A. is riding for a fall. Any organized pressure group that tries to frustrate a basic need of the people will find that no matter how powerful it is, it comes out on the losing end.” Less to be expected, a sizable fraction of doctors have found A.M.A.’s hard sell a bit overdone.

One is Palo Alto’s Dr. Philip R. Lee, 37, who has formed a Bay Area committee, including doctors, to buck the A.M.A. (he belongs) and fight for the King-Anderson bill. Lee says: “I don’t favor socialized medicine, but we should experiment in providing better methods of care. If social security helped pay the cost of hospitalization, I wouldn’t hesitate to put my older patients in the hospital if they needed it. They would come to me earlier if they were not afraid of catastrophic hospital bills.” And under the noses of A.M.A. bigwigs, Chicago’s Dr. Roland Cross was organizing the Independent Physicians of Illinois to bring together “physicians who are concerned for the public welfare.”

Other doctors, less crusading, simply worried about medicine’s good name. Atlanta’s Dr. A. Hamblin Letton, public relations chairman for the Fulton County Medical Society, grumbled that the A.M.A. “is always against something.” Dr. Ian Macdonald, secretary-treasurer of the Los Angeles County Medical Association, stresses that “the most urgent medical problem in the country is the care of the elderly.”

The New President. But both the proper care of the aged and the A.M.A.’s concern over the threat to U.S. medicine may well turn out to be vanishing problems. The answer for both could lie in the growth of private prepayment plans, usually combined with group practice. Communities, counties and corporations are hard at work all over the U.S. spreading such plans, and the recent benison of the A.M.A. is certain to allay the objections of many balky doctors. Therein lies the significance of Leonard Larson, a man who can look at all the ferment calmly.

Larson got into medicine through the drugstore: his Norwegian immigrant father owned a pharmacy in Clarkfield. Minn. As a boy, he toiled in the store with steadily diminishing enthusiasm. “After working until midnight one Christmas Eve and then doing inventory the day after Christmas, I’d had it,” he recalls. Then he fell under the influence of a “wonderful old country doctor.” Now Specialist Larson concedes that “no doubt he was more wonderful as an unforgettable character than as a doctor. He used to take me hunting prairie chickens, and I’d tag along on his calls in the country. His prescriptions were marvelous concoctions of eight to ten ingredients.”

At the University of Minnesota Medical School, Larson did best in bacteriology but decided, upon graduation, to get experience in general practice. He settled in Northwood, Iowa, and did not like it. largely because there was no hospital. “I spent too much time traveling to and from patients. I didn’t feel that I was making the most of myself. After six months. I went back to Minnesota and went into clinical pathology.”

Many pathologists never see a live patient; instead, they peer through a microscope at an excised piece of him. Larson is too social-minded for that sort of remoteness. Hired in 1924 to work at the Quain & Ramstad Clinic in Bismarck, he was North Dakota’s only private-practice pathologist. He made his professional mark in diagnosing tumors, but felt that “pathologists should get out of the basement and see patients and examine them if necessary. They should be real consultants.” A.M.A. duties keep him away from Bismarck more and more, but Dr. Larson still takes pride in a sharp piece of clinical pathological diagnosis.

Though Dr. Larson had been active in arranging scientific programs for his district society, it was less ambition than recruitment that started him on the way to A.M.A. leadership. A senior partner in Quain & Ramstad was the state medical society’s legislative watchdog. When he retired, he put the arm on Larson. “I volunteered by means of appointment,” says Larson. In the Bismarck statehouse, Dr. Larson learned the bitter way about politics: the M.D.s took a crushing defeat when they tried to keep out osteopaths and chiropractors by legislation.

Dr. Larson was first named to A.M.A.’s House of Delegates in 1940. Ten years later, he made the board of trustees, and in 1958 became its chairman. He was already chairman of the commission that had been studying group-practice panels for 2½ years. When he presented its unanimous 15-man report on them in 1959, he did so from a position of great strength: A.M.A. mossbacks did not openly oppose the man who seemed headed for the presidency. In a massive report covering all forms of group practice and sparing none of their shortcomings, the Larson commission paid tribute to the principle of free choice of physician. But it held that this principle is not violated if the patient has free choice between an inde pendent physician and a panel.

If Dr. Larson sounded rigidly traditional in his attacks on King-Anderson last week, he is actually quite flexible on other issues in the provision of medical care. As a group practitioner, he naturally favors group practice, and Quain & Ramstad makes no bones about the fact that it pays salaries to 32 of its doctors, though it charges patients on a fee-for-service basis. Moreover, Dr. Larson believes that “if we’re going to keep Government out of the practice of medicine, we’re going to have to provide more coverage through prepayment plans—and, if possible, at lower cost.”

Working Plans. Group practice and the increased specialization that goes with it are already well along in the U.S.; 16,000 doctors practice in 1,151 groups; and the proportion of specialists (27 varieties) is steadily rising. To make prepayment possible, pioneering groups all across the U.S. have worked out an interesting assortment of ways to get medicine to people on a local, private basis. Examples:

¶ New York’s H.I.P., covering 620,000 people under 200,000 subscribers’ contracts, for premiums ranging from $3.56 a month (single man) to $10.68 (family) now runs 32 centers with 1,100 physicians (two-thirds of them specialists). Emphasizing the benefits of preventive medicine, H.I.P. subscribers have a hospital admission rate 20% lower than other New Yorkers.

¶ Washington’s Group Health Association, set up in 1937, covers 47,000 individuals, has spread in monthly rates from $7.25 (standard, single) to $24.20 (de luxe family), covers both hospital and medical costs. In 1939, G.H.A. doctors were barred from Washington hospitals until the District Medical Society and A.M.A. were convicted of violating the Sherman Antitrust Act.

¶ United Mine Workers of America, a massive operation in 26 states, financed entirely by a royalty of 40¢ on every ton of coal mined. It runs ten hospitals in three states, gives miners and their families little choice of physician. It has closed its panels against physicians and surgeons whom it accuses of doing unnecessary services and padding fees.

¶ Henry J. Kaiser’s Foundation Medical Care Program, with eleven hospitals, 800 doctors and 800,000 subscribers in the Pacific Coast states and Hawaii, offers womb-to-tomb care, hospital and medical (including psychiatry), for $15.55 a month for family.

¶ Palo Alto Clinic. It runs several plans, including one open to Stanford University students and faculty, makes money with enough left over for experiments. It is now starting a pilot plan for 500 over-65 couples, offering full medical, surgical and hospital care for $20 a month.

That physicians can do it themselves, with no third party intervening or insurance company overriding, is shown by a bold experiment that has been running for 23 years in Oregon. This is an attempt to combine solo practice (which many A.M.A. members still prefer), fee for service, free choice of physician and full prepayment. Sponsor of the plan is the Physicians’ Association of Clackamas County (pop. 113,000), adjoining Portland. Every physician practicing in the county is eligible to join, and all have done so. Every resident is eligible, at $7.50 a month, to receive whatever medical and surgical services he needs. He chooses his own doctor. When he gets treatment, the doctor sends the bill to the P.A.C.C. If illness has been running at average rates, the doctor gets his full fee, according to a set schedule. If there has been a lot of illness, so that charges outstrip premiums collected, the doctors take a proportionate cut.

A major objection to panel practice is that the traditional, one-to-one patient-doctor relationship may be weakened. Yet, says Atlanta’s Dr. Arthur P. Richardson, a doctor in a group can have just as much interest in his patients as any other: “The corner grocery store is gone, but people in supermarkets can be friendly too.” Says Dr. Joseph C. Hinsey, director of the giant New York Hospital-Cornell Medical Center: “Group practice is the most efficient type in the long run.” New York University’s Dr. Howard A. Rusk goes farther: “Solo practice is outdated, as outdated as fee-for-service. You have to have groups. No one doctor is smart enough to know enough about the entire skin and all that it covers.”

Ingenious plans, flowing out of the American sense of compassion and justice, seem certain to spread in the U.S., probably holding the expansion of Government-run medicine to the role of filling in a dignified way the needs of those who are not otherwise covered. The A.M.A. will undoubtedly continue to promote medicine of the highest standards, and it may also learn to accept changes in the doctor’s economic status with more grace. At its May meeting, the dynamic California Medical Association urged A.M.A. to take the lead in efforts to make prepaid medical care available to all U.S. citizens. President Larson, in his inaugural address last week, said: “The professional spirit emphasizes conformity to the principles of scientific truth and ethical conduct. It also recognizes the rights and potentialities of the rebel or maverick who may have a new idea, a different method, a fresh viewpoint.”

*And in 1923, was TIME’S first medical consultant; 72 this month, he is now a prolific medical columnist and editorialist, and editor of Medical World News.

More Must-Reads from TIME

Contact us at letters@time.com