Winter 2017 - Vol. 12, No. 4

Who Speaks for Physicians?
We All Do. Each One of Us.

For most of the 20th century, physicians weighed in about political issues mainly when their medical practices or their ability to deliver health care were affected, and they usually let the American Medical Association speak for them on such matters. At mid-century, about 75% of practicing physicians were members of the AMA, so it could legitimately claim that role.

When it had begun in the 1840s, the AMA had been a progressive organization whose founders championed scientific medicine, and supported strict requirements for medical education and licensure. When early members were active politically, it was primarily to persuade their state legislatures to pass such requirements.¹ As the 20th century unfolded, however, the AMA became increasingly vocal at the national level, with a rightward political slant that reflected a preoccupation with preserving the independence and income of physicians. For much of the 20th century, the AMA opposed expansion of medical education and immigration of foreign physicians, effectively suppressing the supply of physicians despite a growing U.S. population. The AMA opposed health insurance when it first appeared, and until the 1950s, many county medical societies excluded physicians who belonged to HMOs.

In the early 1960s, the AMA opposed legislation that inaugurated Medicare, and, later, Medicaid. At that time, the position statements of the AMA, which reflected the general attitude of the medical profession, consistently opposed government involvement in health care. Such an intrusion was viewed as a threat to the independence of physicians, who preferred to be self-employed, and who then practiced predominantly in solo practices or in small groups. Fear of “Socialized Medicine” even outweighed the potential for increased revenue from government payments for the needy.

This fear was promoted to the public, and during the Cold War it was easy to portray Medicare as the vanguard of a communist takeover of the United States. The federal government had to be shut out completely, it was suggested, because any government involvement would be the camel’s nose that would lead to total government control of the entire health care system. Never mind that the federal government lacked the resources to do so. (Subsequent events have demonstrated, of course, that even the relatively straightforward task of making Medicare payments must be largely accomplished through private health insurers.)

Popular literature also reflected the fear of government involvement. The best seller “That None Should Die,” first published in 1941 and never out of print, was the first novel by the late Frank G. Slaughter, M.D., a graduate of John Hopkins Medical School who abandoned his surgical practice for a career as a prolific author. Though now mostly forgotten, from the 1940s to the 1980s he published 56 books that sold over 60 million copies and were translated into every major language. Clearly, he was a skilled storyteller with an endless supply of creative plots, so it is telling that for his first novel he chose to describe the disruptions and scandals that would be caused (he assumed) by socialized medicine – a total federal takeover of health care.

Times and attitudes change! When the U.S. Postal Service first started carrying packages, it was viewed as a challenge to private enterprise and a quasi-socialist/communist enterprise, but FedEx and UPS have no reason to worry now. Similarly, physicians’ historic objection to a government role in health care has rapidly waned for a variety of reasons.

As the population has aged, Medicare has become the source of more than half the revenue in most adult medical practices. Medicare’s lower but more reliable payments are often a favorable alternative to those of private insurers, who use imaginative strategies to delay, reduce, or even deny payments. A steadily increasing percentage of doctors have become employees of hospital systems or large multi-specialty clinics, and they don’t value independence the way solo practitioners once did. Lastly, the specialty societies have assumed a growing role in lobbying government directly for their interests, rather than relying on the AMA to represent them.

Only 15% of America’s physicians now belong to the AMA, and those paltry numbers limit the AMA’s influence when it purports to speak for physicians. What voice is left for individual physicians concerned about public health issues that command our attention, such as environmental pollution? Dr. Alan Peterson has discussed one such problem in JLGH – the health hazards of methane from fossil fuel production.² Its adverse effects on infant brain development, the respiratory tract, and the cardiovascular system occur through contamination of both the air and the water supply, but it is also a leading cause of climate change. The health dangers of global warming have been discussed by Dr. Joseph Kontra in JLGH, and they range from an increase in tropical diseases transmitted by proliferating insects, to disease epidemics unleashed from the corpses of diseased animals exposed by melting permafrost.³ But fossil fuel has powerful defenders, and those who raise these red flags must be prepared to be abused and falsely derided by the fossil fuel industry.

Whether as individuals, or as members of interest groups, we must speak up for both our patients and for our profession, because our interests coincide. For the vast majority of physicians, the greatest satisfaction comes from our ability to heal the sick. That’s why many of our medical staff spend time each year working as physicians in developing countries, usually in Africa or South America, providing state-of-the art care, and teaching local medical personnel.

But we can’t all travel abroad to do those things, and though we can do so vicariously by supporting Doctors Without Borders, for example, there is much more we can and must do here at home. We must ensure that everyone has access to health care, and we must strive to counter the dangerous anti-science bias that has gained alarming strength and respectability in America.

As individuals, we can write letters to our representatives and to the newspapers, but the internet abounds with opportunities to act in concert with other physicians by joining and supporting organizations that are focused on a healthier, more peaceful, and more cooperative world. Physicians for Social Responsibility is probably the largest physician-led organization in the U.S. working to prevent nuclear war and proliferation and to counter global warming and toxic degradation of the environment, but it is only one of many such beneficent nonprofits. There are physician groups that work for women’s rights, or to prevent nuclear war or gun violence. Take your pick.

But equally important is the imperative to get engaged politically, even if you never did so in the past, for these are perilous times for health care. Support and work for candidates who understand health care issues and are working to improve the American system of health care so that it is accessible and affordable for everyone.

Stand up and be heard from.

And last but not least: Vote.

REFERENCES
1. Greenwald HP. Health Care in the United States: Organization, Management, and Policy. John Wiley & Sons, 2010. pp 147-149
2. Peterson AS. Shale gas (methane) extraction and public health: Why doctors should be concerned. J Lanc Gen Hosp. 2017; 12 (3): 88-89.
3. Kontra JM. Zombie Infections and Other Infectious Disease Complications of Global Warming. J Lanc Gen Hosp. 2017; 12 (1):12-16.