The American Thoracic Society composed of 13,000 pulmonologists and physicians with related interests, met in San Diego for their annual scientific meeting. For the last 7 years, this has become an international conference with 16,000 attending this year, including 6,000 from the international community. All fifty states were represented as well as nearly 50 foreign countries including Washington, DC. I use this opportunity to discuss practice issues with as many colleagues from overseas as possible. It’s the best opportunity that I have to obtain a perspective on health care around the world as seen “from the trenches.” However, even pulmonologists from the same country sometimes vary widely in their perspectives of the prevailing practice. Perhaps this is more like medicine as seen from “fox holes.”

The high point pervading the meeting was the impending divorce of the ATS from the American Lung Association. In 1905 the medical arm of the TB Association was known as the American Sanitorium Association. In 1939 it became the American Trudeau Society and in 1960 the ATS as the TB & Health Association became the American Lung Association. The physician organization was completely owned by the Lung Association, and the relationship has been somewhat stormy for decades. I was on the Board of Directors of the TB & Health Association of Sacramento Emigrant Trails in the 1970s for six years and it was during my term as president that we changed the name to the Sacramento Lung Association. It was later changed to the American Lung Association of Sacramento. I thought this made about as much sense as changing CMA to the AMA in California or changing SEDMS to AMA in Sacramento.

Doctor Julius Comroe, the Director of the UCSF Cardiovascular Research Institute, and author of the definitive textbook, THE LUNG, told me about 1980 that he’d love to sue the ALA if only someone would cure his back pain. Unfortunately, it was progressively fatal. Comroe, however, epitomized the feeling of much of academia against the ALA which has been a topic at the last several conferences. This year we became separately incorporated and the split will be final on January 1, 2000. We will be paying the ALA a half million dollars a year for the next 15 years for the rights to our name, the ATS, our international conference, our two world class journals, and our dues and membership list. These items had an averaged appraised value of around $15 million. If one considered this “community property,” the “alimony” was reasonable. This past year the divorce became more amicable and more like a legal separation. We will probably continue to share resources, but on a more equitable basis. One of the ALA staffers who is now an ATS employee, told me they tried to get the local lung associations to forward up to 25% of the donated dollar to lung research to get on par with the American Cancer Society and the American Heart Association, but had to settle for 10%.

The conference was of the usual high caliber type with 18-24 concurrent sessions going from 7 am sunrise to the 7-9 pm evening sessions. Most of the senior members were content to follow the 8:15 am to 6:30 pm schedule. The fellows in training and the practitioners from some of the developing countries were so thirsty for knowledge that it was always interesting to see them run ahead on the escalators trying to rush from a lecture in one hall to a lecture in another hall rather than sit out a three-hour symposium. Asthma continues to increase, and roach dust may be more important in the homes of the urban poor than dust mites. Tuberculosis continues to increase bringing us back to our roots. Research on lung reduction surgery is moving forward, but slowly. It seems some patients are concerned that they will receive the placebo.

The between session discussions with practitioners from around the world that took place in the halls, on escalators, elevators, walking the street between centers, and while having lunch was quite rewarding. The United Kingdom had their usual 900 pulmonologists. Belgium had 100 which they said was one-third of the country’s pulmonologists. Taiwan had 30. Japan had many hundreds. While waiting for one luncheon conference, I found myself at a table with pulmonologists from Canada, Scotland, Columbia, Japan, and Belgium. Medical practice seems to be government operated or socialized in essentially all countries. Private practice is allowed in most of these countries with financial restrictions rather than medical restrictions with criminal repercussions as in our country’s socialized medicine for the elderly known as Medicare. These financial restrictions effectively discourage private practice. For example, in the National Health Service of UK, the physician income peaks at £57,000 (about $90,000). If they make more than 10% or £5,700 gross from private practice, they will lose 1/11 or £5,282 of their income. However, private patients are unwilling to pay for their care while being seen with the masses in the clinic. Therefore, the doctor has to have a small privately staffed office. The cost of this is usually greater than the amount he/she makes from the private fees minus the forfeiture of governmental subsidies and thus a great disincentive. If they make £57,000 from private practice, then 10/11 will be lost and £5282 will be their entire government “subsidy.” But with a 50% overhead, they will only net one-half of their private income, which, to come out ahead, would have to be twice their governmental income. But that is a pittance in comparison with the United States where you will lose 100% of the income from your Medicare patients for a two-year period for treating even one as a private pay patient. Although there may be instances, I was unable to find any country where the government makes every patient a federal case as in the USA.

In no country could I find that pulmonologists would even consider a simple charitable goal of hanging out their shingle and providing service to sick people and just take their chances. Everyone had to have a primary anchor, an appointment in a hospital, a medical center, a medical school, or a research center.

One professor asked a European pulmonologist if the waiting times in his country were really up to the two years as we had been led to believe? He agreed they were and that, of course, was a political problem. The political system had to put enough drag in obtaining health-care so that many, maybe up to a half of the patients that wanted to see a doctor, were unable to do so in a timely manner or even during the course of the illness in question. But if and when a patient gained access to the system, they felt they received good care–maybe not CTs or MRIs, but what the patient really needed.

Is the AMA, the CMA, and the SEDMS listening? In some countries, universal access really means reduced access, sometimes only 50% access to an inferior system which is far less than a free market system provides. Do we really want to snuff out the last bastion of freedom in health-care which provides the highest quality of care the world has ever seen? Are we on the government’s side of power, politics, and perverse incentives or on our patient’s side of their health-care needs? Can we get our priorities in order before it’s too late?