The American Thoracic Society meetings are being held in Boston this week. I’m writing this on a Macintosh while learning the “Mac” at my daughter Julie’s apartment a short distance from the Hynes Convention Center. The 11,000 registrants represent 4000 international guests including three air bus loads from the UK. Many countries in Europe, Asia, S. America, Africa, Australia, as well as Canada and Mexico were represented. The ATS membership of 11,500 includes Pulmonary Internists, PhD’s doing research in lung disease, Pulmonary Pediatricians, Pulmonary Surgeons, Pulmonary Allergists, Environmental and Occupational Medicine Specialists, Pulmonary Nurses, as well as Pulmonary Veterinarians. In addition there are 1200 fellows in training. This was the largest pulmonary meeting in history, even exceeded last years meetings in SF by a thousand.

Over heard at Lindburg Field after a research seminar in San Diego: The really wealthy rich man died and opened his eyes and found that he was in Abraham’s bosom. He saw Moses afar off and walked down the diamond studded gold lined velvet path towards him and said, “There must be some mistake. I was a health care CEO. I wasn’t a very honest man. In fact, I made life quite miserable, not only for the doctors, but also for the patients. I subverted much of their premium dollar to my personal fortune.”

Moses said, “Let me look for your name in the Book Of Life.”

The extraordinarily rich CEO said “I know you won’t be able to find it. I kept the doctors so busy getting pre-authorizations that they didn’t even have enough time to write down everything they did for the patient.”

As Moses kept scanning, he said, “Here’s your name.”

“I really can’t believe that,” the filthy rich CEO said. “The doctors even got investigated by MediCal and MediCare and were charged with fraud because the records couldn’t substantiate their charges. I found some doctors that testified that `if it isn’t written down, it wasn’t done.‘ What a travesty. I’m the one who should be felon.”

“Well you may be partially right,” Moses said, “I see you are authorized a three day stay here, and then you will spend the next three eons with Lucifer in the fiery furnace.”

The noticeable difference in meetings these days seems to be the number of sessions devoted to health care reform. Of the eight concurrent sessions at the ATS meetings, one always seemed to be devoted to political/practice issues. The other new wrinkle is the emphasis on practice guidelines, a necessary requirement as the government takes over the purse strings of our practices. One evaluation is that this poses no medical legal liability as long as one follows the guidelines. However, it is not clear what happens if you don’t. Some felt that departure from guidelines makes one automatically guilty of malpractice, because the evidence confirms that there was a departure from the standards of care. Hence, no trial is needed except to assess damages. Others felt that it could cause automatic loss of hospital privileges and/or licensure for incompetence… In another session, National Jewish, a TB & Resp tertiary center, reviewed their treatment of TB for the past decade. This revealed that there was an 80% departure from standards of treatment and an average of 4 errors per case. If the superspecialist still make errors, will the malpractice attorneys and juries as well as state medical boards and hospital peer review committees be persuaded that there are huge variations in practice patterns and deviations from standards of care that don’t reflect malpractice or incompetence?

The pages of the Boston Globe are filled with the passing of Jackie Kennedy Onassis. She was indeed a saint according to all local reports. She was the epitome of grace, charm, grandeur, and culture. She didn’t redecorate the White House, she restored it. President Clinton stated, “She seemed always to do the right thing, in the right way.” Bill Buckley recalled when asking her to do ten minutes for the Sistine Chapel, her negative was charmingly delivered, “Bill, the only time I ever appeared on television was when I took the camera around the White House after the renovations. I was so awful I decided never to do it again.” The Globe editorial that caught my eye was, “She taught us how to live.” To which I would add, “She taught us how to die.” When the medically related quality of life (MRQL-a frequent topic at this conference also) was no longer acceptable, Mrs. Kennedy bade her doctors and nurses good-bye, asked to be taken home so she could die with her family and friends, with only her personal nurse to attend to her physical needs and comforts.

“Lenin Untombed” by Gorov & Mashberg of the Globe staff cerebrate on what to do with “The Body, the Mummy forever young.” Devoid of his brain and his internal organs, they make a number of suggestions for the use of Lenin, the Mummy. Number six stated, “Long sucked dry of all things living, he’s an ideal spokesman for a 1996 Dukakis for president campaign–or the perfect chairman of a Senate committee–any Senate committee.” Rostenkowski, a former ward boss from Chicago who leased to Congress unused space in an office building he owned, and put on payroll friends who never had to report for work, was indicted and lost the Chair of the House Ways and Means. Could we propose a House committee chair in charge of the Clinton health care reform as a perfect fit for Lenin out of the tomb?

I met the former Medical Director of Tuberculosis for Chicago at the ATS Harvard Club reception. He supported Mayor Washington in the elections and when Mayor Daley took over after Washington’s death, the doctors were told that the Mayor would like his own doctors in office. However, doctors can’t be fired for political reasons, and since he didn’t resign, he was transferred to a small TB office in the highest homicidal area of Chicago. He still continued to work. He was then told he would report to a “facilities manager,” a new position to which they appointed the custodian of the building. The next time he went to meet his consultant at O’Hare, he was cited for leaving the “facilities” without permission which could cause “great jeopardy to the citizens of Chicago.” When he told the “facilities manager” that he had told the nurse he would be absent to pick up a consultant, he was told she was not in the administrative hierarchy. He was brought to full hearing and suspended without pay for two weeks for not following the rules and regulations of the city of Chicago. After eight years of public service, he reported to work after the two weeks, resigned the following day, collected his vacation and benefits and returned to the practice of pulmonology.

Also at the Harvard Club reception, a Pulmonologist from Japan, stated that he thought Japan’s socialized medicine was the best in the world. When asked for the reason, he stated that currently the government is flushed with money and the doctors are doing well. He recognized that it would change with a change in financial winds… A pulmonologist from the UK stated that with all the cost cutting by the British government, the doctors would probably do better. So many benefits were being eliminated by the government’s financial crunch that patients would probably pay physicians cash outside of the National Health Service for these lost benefits. Doctor’s welfare improves with black market medicine? Most pulmonologists that I was able to talk with from other European countries seem to repeat the UK experience… With the financial crunch of the USA, deficit spending, trade deficit, national debt increasing by almost a quarter trillion per year and may exceed our GNP and national assets by the end of this decade, haven’t we left our senses to even consider placing the one trillion dollar health industry into the federal system, even if sneaked “off budget?” Especially when there are health insurance reforms that would achieve essentially more with no direct federal costs or controls. A History professor once told us that those that can’t be objective about history in the making because they emotionally can’t handle it, are destined to repeat the mistakes. Or the UK physician stating, “As we try desperately to privatize and you are trying to nationalize, we’ll probably meet somewhere in mid Atlantic and both drown.”

Dr. Sylvester, president of the ATS reported that our lay organization, the American Lung Association, has essentially agreed to allocate 10% of their contributions for lung research. This increase he stated would essentially double the support to fight lung disease. The membership gave a round of applause.

The 50th anniversary of the chemotherapy of TB was celebrated with the reading by Jason Robards from Dr. Ryan’s book, THE FORGOTTEN PLAGUE, How the Battle Against Tuberculosis was Won and Lost. He then joined a panel of the great phthisiologists of our day as he recited personal experiences from his military service days when he encountered TB. It was a real pleasure to listen to H Corwin Hinshaw, albeit on video. Dr. Hinshaw went from Oakland to Weimar for their Chest Conferences for many years.

Before leaving Boston we saw Isaac Bashevis Singer’s Shlemiel, the First at the American Repertory Theater. Spreading wisdom is hard work for Shlemiels as they are cautioned to “Just tell the truth, it’s the best swindle.”

Returning to Sacramento, we saw Moliere’s The Imaginary Invalid which was playing at the Sacramento Theater Company. Mark Cuddy, the Artistic Director, did an excellent job of adapting and directing. He also added a modern epilogue which included Dr. Elder, Dr. Koop, Hillary, and Willie Clinton. The protagonist of The Imaginary Invalid believes, as the title implies, that he is critically ill, when in fact he is quite well. This was Moliere’s last play, and he himself often acted the role of the protagonist. During this time, he believed himself to be healthy, but was actually dying and indeed hemoptysized to death from his tuberculosis after a performance.