California once had a Governor who felt there should be vertical mobility in the health care field. He stated that if a nurses aid wants to become a doctor, there should be a training program to get there… Aren’t those determinants essentially fixed when two gametes become a zygote?

Arnold S. Relman, M.D., Editor NEJM since 1967, and Editor-in-Chief Emeritus since 1991, spoke at the California Health Forum recently. This was his first venture to Sacramento. He was introduced by Richard Ikeda, MD, MPA, the Chief Medical Consultant at the Medical Board of California and Executive Director, Health For All. Dr “Bud” Relman (Cornell 1946) said that in his 48 years in medicine, there have never been more turbulent times than these. He quoted Yogi Berra, “When you come to the cross-roads, you’ve got to take ’em…” Change is in the wind. President Clinton could relent (he won’t) and congress could go home (dream on); but health care reform would continue. People who say there is no crises in health care either don’t understand the issues or are unaware of them. Our best health care is clearly the best in the world. American doctors on the average are better than any place else. Unless we understand how we got to where we are, we won’t understand where we’re going. We have to find an American solution to our problem. Dr. Relman outlined: 1) The Era of Expansion: since WWII we doubled the number of medical students; patients paid in cash, those that couldn’t were charity; wages were frozen and employers on their own began to pay health insurance benefits; LBJ implemented Medicare by promising not to interfere in the practice of medicine, paid the UCR fees, essentially saying, “Here’s the key to the treasury–just leave a note stating what you did with the money.” 2) Rise of the Medical Industrial Complex in the 1970’s: The best investment was the health care industry, inflation proof, and a continuous Bull Market. Our health care budget grew to exceed the entire budget of nearly every country in the world. 3) Revolt of the Payors: this began with Richard Nixon although the first HMO was actually started by the Boston Dispensary in 1790. 4) Outcome Evaluation & Quality Control: We began to show what services are useful and what facilities are needed. 5) We are now in the Reorganization Phase of the Health Care Delivery System with a decline in fee for service and private practice, increasing networks, managed care, and prospective pricing all unrelated to Clinton’s program… During the Q & A session Relman stated “it is not if managed care will continue, but who will control managed care.” However, he did not predict a disappearance of fee for service or that indemnification insurance will disappear. Auto salesmen will sell you a car even if you don’t need one. We cannot do that in Medicine. He says he is against socialized medicine. “We’re talking about a delivery system under private control.” But he felt government would be required. Semantics? Relman said just pay him the 14% of the GDP and he would design an excellent system.

According to a report in the SFChron, in Italy the national health care has been a showcase of corruption, fraud and waste. Even with local control exorbitant expense has driven the cost of health care to 11% of their GNP–the highest in Europe.

Overheard: an Amway distributor asked a physical therapist, “How would you like to make a quarter million a year?” He answered, “I already do.” That quote is a little dated, but it occurred when a large medical group had a top salary structure for physicians of about $60,000 per year or one-fourth of an allied health specialist.

Speaking of Governor Moonbeam’s vertical health care integration, he reduced nursing standards by having two year colleges produce RN’s, the same as the four year colleges. We missed a golden opportunity to give all the three year hospital nursing programs an academic back ground by affiliation with junior colleges and maintaining the third clinical year. What if he had been governor long enough to shorten medical training. Maybe he could have also shortened medical school to three or even two years and also shortened the residencies. Just think, a family neurosurgeon in four years after college? Imagine what he could have done for Medicine nationally if the electorate in other states had taken him as seriously as the majority of the voters in this state did… We could work a few years as a hospital orderly, progress to a LPN, and then on to nursing school to become an RN. After a few years of burn out, psychology would look interesting, especially if they are successful in getting hospital privileges and the license to prescribe tranquilizers. But not liking to play second fiddle to psychiatrists we could switch over to become a podiatrist so that we could prescribe any drug. After paying over $1500 a year for Podiatric society dues which never got us above the ankle, we could take an orthopedic residency which had been shortened to three years (Moonbeam felt nothing could be more complicated nor take longer than law school) and then become a practicing orthopedist. At that time we’d realize that the political hostilities to MD’s aren’t worth the effort, and physical therapy would look very appealing, especially since we’d make those big bucks between 8 and 5, Mon thru Fri. And what perks: exercise equipment and swimming pool right outside the consultation room.

Psychology Today begins a new column, “Ask Dr. Frank” (Pittman,M.D. author of Man Enough: Fathers, Sons, and the Search for Masculinity, and Private Lies. The questions seem to be the same ones we observe in practice. In the same issue (27-2), Susan Baxter gives us the last word on Gender Differences. “Once upon a time, men were men and women were women, and anyone who rocked the boat got eaten by sharks… Fast forward to a time of fax machines and heart transplants, when real men change diapers and real women carry guns… A time when it’s not always easy to pin point what traits are strictly male or female. So today how should we differentiate between sex (innate, physiological) and gender (socialized, learned) differences?” She quotes Mark Twain, “There are three kinds of lies–lies, damn lies, and statistics,” as she takes us through all kinds of “intellectual and statistical rubbish.” She concludes that “if there are neuropsychological sex differences, clearly, we don’t know what they are or what causes them. Don’t bet real money on ever predicting who’ll be the better nurse or engineer. Because however much we yearn for simple truths, there aren’t any here.”

Researchers at the University of Indiana state that physicians who use computers to order drugs and tests for hospital patients can significantly reduce medical costs. In a study of 5,000 patients at an Indianapolis hospital, the researchers found that charges to patients treated by computer-using doctors were nearly 13% lower, a savings of $900 per admission. This was the result of doctors immediately seeing the cost of tests and treatments as they are ordered. They noted that when a doctor ordered a heavily promoted antibiotic and the cost seemed high, it would promptly be changed to a less costly and equally effective antibiotic. The computer work stations may also have improved quality of care by immediately flagging allergies, cross reactivity to other drugs and possible adverse effects immediately compared with patients diagnosis… Information is always the first step to changing behavior which then becomes automatic without laws which have the side effect of making us criminals. Physicians can’t begin to evaluate the cost-benefit analysis until the costs are available. Maybe if we computerized our office and hospital medical charts, with a 13% reduction which would put health care at 12% of GNP, (which is close to Italy & Canada) the whole national health care cost debate would evaporate. These costs are certainly being hidden from us now. When I asked a therapist assisting me in a bronchoscopy what were the hospital charges for the endoscopy room and his assisting me, I was told not to worry because the hospital worries about such details. But the patients complain to me about the bill, not mine but the one that is ten or twenty times mine.

Congratulations to the twenty-two faculty members across town who have been named to the 1994 edition of The Best Doctors in America. Four volunteer faculty were also included.

The AMA states that 33% of doctors’ offices fail to cover their staff with health insurance. However, 77% offer their employees health insurance. Some have spouses with health insurance and therefore decline coverage. The AMA states that still is three times as high as other small businesses with 25 or fewer workers.

At a surgery conference in SF, my surgeon reporter roaming across the hall, states that the speaker told his audience that a chiropractic office practice is inefficient if it’s not grossing at least a million dollars a year. So the epitome of a varied vertical mobile medical career after physical therapy could then be to become a chiropractor, reduce one’s working hours to 40 hours per week, (isn’t that close to retiring after a lifetime of 60-80 hours per week) and enjoy the golden years without significant malpractice premiums, no night or weekend call, and yearly international vacations. But physicians, who are used to living on much less, would only need to work three months a year, take a nine month annual vacation, and still make twice as much as the average doctor. Too bad it took 30 years to figure this one out.