Looking Back, Looking Forward Straight Talk About U.S. Medicine

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Looking Back, Looking Forward: Straight Talk About U.S. MedicineFitzhugh Mullan and Lundberg

[Health Affairs 19(1):117-123, 2000. © 2000 Project HOPE -- The People-to-People Health Foundation, Inc.]

Fitzhugh Mullan: Let's begin by talking about the state of medicine in the United States. We live amid reports of growing longevity and fabulous progress in under- standing the human genome, set against disgruntled doctors retiring early and the number of uninsured Americans increasing monthly. Are we living in the best of medical times -- or the worst?

Lundberg: Medicine in America has never been better -- if you can afford it, if you can get to the right places, and if you have good insurance. Medicine has been a lot worse, even in the twentieth century. One of the advantages of being older and still having your marbles is that you remember how things were when there was no Medicare or Medicaid, and there was a shortage of doctors and hospitals. People who don't remember what it was like when nobody had insurance may think things are awful now. But it was a lot worse then. Mullan: Many physicians say, "I wouldn't tell my kids to go into medicine today." Is this an unhappy few, or do you sense this sentiment sweeping through medicine? Lundberg: A lot of doctors say that, but a huge number of kids of doctors go into medicine today, just as they always have. The media pick up on doctors who say that because it makes good copy. But the number of people applying to medical school in this country now is close to an all-time high. Mullan: I was raising that as a potential marker for trouble in the profession. Do you thin that physicians are demoralized, as some in the profession and in the press proclaim? Lundberg:I think a lot of physicians are unhappy, even demoralized, mostly by the hassle factor. One attraction of medicine has been the potential of being an independent professional, not needing someone looking over your shoulder. So, traditionally, independent-minded people have come into medicine. But now, in many settings, physicians are not able to be as independent as they were. Other physicians, accountants, and all kinds of people are looking over doctors' shoulders. Doctors don't like that. Younger physicians who are now coming into the field in the era of managed care have different expectations than their older colleagues and aren't as unhappy because this is what they expected. We may attract a different kind of person into medicine in the future than we did thirty years ago --people who may be comfortable with not being as independent as their predecessors were, people who understand that efficiency and quality assurance matter. These newer doctors will do population-based medicine in addition to individual-based medicine, and that's good.

Commercialism And Managed Care

Mullan: One indisputable change in recent years has been the rise of commercialism in medicine. Medicine has always been commercial in its way, but the past two decades have seen business enterprise show up in all aspects of medical practice. A popular adage is that American medicine was so busy guarding against socialism, it got blindsided by capitalism. As you have watched commercialism move into medicine, do you think these changes are pernicious or simply the American way of life? Lundberg: Medicine has always been both a business and a profession. Chaucer wrote about it. Commercialization in medicine by small-money interests and by individual doctors and doctor groups has been around for a very long time. But the degree of commercialization by big-money interests is new; so is the presence of Wall Street, venture capital, stockholders, and quarterly reports on earnings. These changes are troubling because of the possibility of the loss of professionalism in medicine, which worries me a lot. On the other hand, the efficiencies that will come from being scrutinized on a business level can be beneficial --if they don't squeeze out quality and professionalism. Mullan: The rise of managed care has been a prominent feature of these changes. Was it inevitable?Is it a Jekyll, or is it a Hyde? Lundberg: Something like managed care had to happen because the percentage of our gross national product spent on health care in the middle and late 1980s was rising at an unsustainable rate. Managed care was already here as a model that, in theory, would constrain costs through competition. But I don't think that the purchasers of health care in this country have really gotten serious about competition. If they had, health care costs would drop. I'm talking about the buyers who still pay far more than they need to pay for an acceptable product. We have far too many doctors, far too many hospital beds, far too many pharmaceutical products, and far too many everything else. In such a surplus-supply mar et, costs should be forced down. But because medicine in America remains so pluralistic and doctors are very smart, they can avoid or bend almost every restraint put in the system. And because the economy's good, companies aren't worrying that much about health care costs right now. Mullan: And yet there is plenty of complaint about managed care and about the quality and the availability of services, in particular. Are these complaints fair, or are they a hyperreaction on the part of certain patients or certain interest groups? Lundberg: I like to think of quality in terms of outcomes and patients' health status, not just in terms of patient satisfaction. In general, patients aren't equipped to evaluate the actual quality of care given. It also depends on who's complaining. For example, registered nurses in California complain bitterly about the quality of nursing care in investor-owned hospitals, where the number of nurses per patient has been cut. Although that complaint makes intuitive sense, a drop in quality of care has yet to be documented as a real problem in any peer-reviewed article I've seen anywhere. So here again, we're talking anecdote, we're talking about impressions, we're talking about people with their own biases and their own axes to grind. Mullan: Could organized medicine have done anything to prevent the massive commercialization of recent years? Lundberg: Costs did not have to go out of control. Inefficiencies did not have to abound. These problems could have been handled better, but we would have needed to start by funding health insurance for everyone. Without doing that, we have had care funded in nebulous ways for the uninsured, driving up costs and justifying cost shifting. We have had a massive amount of overcharging in which the health insurance industry has been totally complicit. And we have had a cost- plus environment in which purchasers have said, "Whatever your expenses are, that's what we're going to pay. " What on earth is that? In the 1970s and 1980s new procedure-driven doctors, such as surgeons, entering into practice set fees as high as possible so that incomes would continue to inflate with every new arrival in a community. That practice was considered reasonable and customary, and neither the Federal Trade Commission nor anyone else did anything about it. Professionalism includes not ripping people off. Yet organized medicine just watched and enjoyed the money. Relevance Of Organized Medicine

Mullan: Let's talk about the American Medical Association (AMA), an organization you served for seventeen years. Membership has dropped below half of American physicians and is continuing to fall. The AMA's leadership seems to have a penchant for the high- profile faux pas. Is organized medicine on the way to extinction? Lundberg: The membership problem is a lot worse than that. The newest data from late 1998 had AMA membership at one-third of eligible American physicians and declining rapidly. Organized medicine in America, meaning the AMA and state and county medical societies, is in deep trouble. Average doctors see many such organizations as marginalized and irrelevant. Three recent debacles in a short period of time have accelerated the decline. First was the Sunbeam endorsement mess, which merely culminated years of AMA commercialization that finally went off the cliff. Second was the dreadful decision by the board of trustees in 1998 to invite the federal government into the doctor/patient relationship by supporting the Republican legislative proposal to ban late-term pregnancy terminations. Third was the decision to dismiss me in the manner in which it was done and the huge backlash that followed. Most doctors do belong to their specialty societies, which for the most part will do fine because they offer something that the doctors want and need and that the AMA seems not to have offered recently. Academic Health Centers and Medical Education

Mullan: Academic health centers (AHCs) face their own set of challenges today. They frequently speak in terms of what they do for the "public good." "What is your view of the role they have played in recent years? Lundberg: They play a very positive role in providing high-quality education, research, and patient care. But AHCs have often developed a life of their own that is somewhat divorced from the populations they serve. They have tended to be unresponsive to the needs of public health. When he was dean of the University of Michigan Medical School, Bill Hubbard said that an academic medical center is the most effective resource-trapping device ever created. I think he was right. I'm a great fan of AHCs. I'm a product of them. When I'm sick, I want to be cared for in one. But generally they're very inefficient. Managed care --especially investor-owned, single- disease or single-organ hospitals doing mass volume --is going to put a real squeeze on AHCs in the near future. Mullan: What about medical education? Are we producing too many physicians, or too few? Is the problem at the medical school or at the residency level? Lundberg: The main problem with the workforce has to do with the concept of the United States being a country of immigrants. As long as we continue to import about half as many physicians each year as we graduate from our own medical schools, it's silly to talk about limiting the number of doctors we're educating in our medical schools. Getting control of this situation requires congressional action, and no Congress to this point has had the guts to do it or the ability to figure out how to do it. But until the number of international medical graduates entering the country is limited, I don't think we should change our medical school enrollment situation at all. Mullan: With the number of nonphysician professionals (advanced practice nurses, physician assistants, podiatrists, psychologists, and so on)expanding rapidly, what will the increasingly crowded provider marketplace look like ten to fifteen years down the line? Will the battles over scopes of practice become increasingly nasty and political --a sort of health professions demolition derby --or will some pan-professional alliance produce a new kind of caregiver who is defined differently? Lundberg: More the former than the latter, although there will be efforts at the latter by professionals trying to work together. But when the spoils are not as bountiful as they once were and more people are scraping for them, the likelihood of humans reverting to a more base model is pretty high. A Controversial Career in Journalism

Mullan: Let's talk about your career in journalism. How do you feel about your years at the Journal of the American Medical Association (JAMA)? Lundberg: I feel enormously blessed by having had seventeen years and thirteen days of happy service as the editor-in-chief for AMA scientific publications and JAMA , in particular. It was a fantastic job, a great opportunity and honor, and a great responsibility. Mullan: Your reputation over those years was distinguished for being independent and to the left of what was perceived as the center of the AMA. How did that affect your relations with the AMA? Lundberg: I took the view early on that the journal's role was to move things forward and that we needed to try to figure out what "forward " meant. To me, it meant better quality and quantity of life for people --better-quality patient care and better public health. In 1982 we established a set of goals, got them approved by management, published them , and tried to live by them. They were updated every five years and became our basic marching orders. When we began to emphasize the public health model and to move forward on social issues as well as strict medical issues, objections were raised, but people always object to change. When I was hired , I was informed that I had editorial independence and could publish what I wished, but that I should be aware of three particularly sensitive issues. The first issue was nuclear war. Therese Southgate, deputy editor of JAMA in 1982, and I had the idea to do a cover of JAMA commemorating Hiroshima. We were concerned that we might offend Japanese doctors, so I went to Tokyo to see Taro Takemi, a physician who had been president of the Japan Medical Association for twenty-five years. He endorsed the idea and offered to describe how he had diagnosed the atomic bomb at Hiroshima. JAMA's issue of 5 August 1983 had a picture of Hiroshima on the cover and carried Takemi's article, several others on nuclear subjects, and an editorial by me about Hiroshima. The theme was the prevention of nuclear war. Annually thereafter JAMA stayed on that theme, broadening it to the prevention of chemical and biological warfare and later to refugees, rape as a method of warfare in Serbia, and related topics. This experience solidified our plan to publish thematic issues. The second sensitive subject was tobacco, so we started doing thematic issues on this soon after the Hiroshima issue. With good authors and good reviewers, JAMA has been able to change middle-class Americans' attitudes toward tobacco. In 1990 we published Fisher's piece on "Mickey Mouse, Disney, and Joe Camel. "It was the first time that anybody had shown that the tobacco companies were getting into the heads of three-and four-year- olds. The most famous JAMA of all was the July 1995 tobacco issue, which carried the Brown and on papers. These revealed that the company had known about tobacco hazards long before the scientific community raised these same issues. Because JAMA published them, information in the journal has been used in court in every major trial about the tobacco industry since 1995. The Fisher work and the Brown and on papers were the key publications in the campaign against tobacco. Tobacco had been on the "don't touch "list because for many years the AMA had an unwritten agreement with politicians in tobacco-growing states that if doctors didn't bother tobacco, politicians would be friendly to doctors. The third sensitive issue was abortion, which I consider to be a private issue between a woman and her physician, not the courts, Congress, or the police. We published both clinical and public health articles on this subject. In August 1998 we carried several articles about late-term pregnancy termination, trying to present a balanced position (without taking an editorial stance)on that procedure. Mullan: Why weren't you fired earlier? Lundberg: The main reason was that I was doing what I was supposed to be doing: publishing a lively, well-read scientific journal. Second, we had made the journal enormously successful. The AMA publications became the number-one revenue source for the organization, and it's hard to stay mad at your best cash cow. Finally, JAMA gave the AMA the best publicity it ever got, week in and week out, in all of the leading media. We were successful every- where you looked. Why would anyone want to screw that up? Mullan: My sense is that JAMA is nearly a household name to- day, whereas it would not have been in 1975. JAMA and other leading medical journals are cited daily by both the scientific and the general press. Has there been a change in public interest or a change in what JAMA and other publications are doing? Lundberg: The public today is very interested in its health. Everybody wants a healthy life and wants to live a long time. The growth of public media covering health has been extraordinary. In my earlier academic career I had observed the prevailing adversarial relationship between physicians and scientists, on the one hand, and public media reporters, on the other. So soon after joining the AMA I tried to emphasize good relations between JAMA and the media. For instance, we ran an annual science reporters' conference so that reporters could learn how to write better for the public. We provided reporters with embargoed advance copies of articles so that they had plenty of time to work on them to get the story right and nobody could scoop anybody else. We worked to make JAMA relevant, interesting, and very available to the public as well as to doctors. We looked at ourselves as journalists as well as physicians. Mullan: Pressure on editors from commercial interests is considerable. How do you stay faithful to your journalistic imperative when you've got folks underwriting you who want you to say certain things --or not say certain things --about their products? Lundberg: Primary-source, peer-reviewed medical journals must have absolute church- and-state separation. Editorial staff opinions must not influence advertising, and advertising must not influence the editorial side. Commercial interests attempt to infringe on that separation all the time by paying ghost authors or hiring guest authors and not disclosing financial interests. That kind of thing is common. Journal editors become keenly aware of it and should smell it coming down the hall. Mullan: Besides commercial interests, are there other kinds of pressure groups that are particularly prominent or problematic? Lundberg: The radical right. The gun-toting doctors, the "war is good "doctors, the "limited nuclear war is okay "doctors. The doctors who say that motorcyclists shouldn't have to wear helmets because it's their brains and if they want to scramble them, it's their problem. Because we too a public health approach on almost all of these things, these people were on our case constantly. Their power wasn't leveraged through money but through membership -- they would threaten to cancel their AMA membership because of something on the cover of JAMA they didn't like. This went on all the time. Medical Information and the Future

Mullan: Patients and the public have much greater access to print and electronic information than ever before. People visit their doctor armed with a Web-site printout or USA Today article quoting this week's New England Journal of Medicine or JAMA. How do you feel about this democratization of information? Lundberg: We have a literate populace that wants to read about its health, and we have patient autonomy coming on big-time to challenge the doctor. It's no longer "the doctor knows best." This is a cultural phenomenon that goes way beyond the journals. The personal computer is driving this movement at the moment, but it is only the latest stage in an ongoing information explosion fueled in large part by electronics --first the radio, then broadcast television, cable television, and now the Internet and the World Wide Web. We are going to see more patients, not fewer, empowered by the electronic age, and physicians will have to adapt to this. Mullan: Your belief in the importance of the electronic future seems to be borne out by your new career. Tell me about it. Lundberg: Leaving the AMA in early 1999 allowed me to focus for the first time on electronic publishing. I was familiar with an excellent Web site for doctors called Medscape. It was one of several groups that came after me when I left JAMA. signed on and took the job as Medscape's editor-in-chief one month to the day after the AMA fired me. I've had a lot of good jobs, but I've never been in a place where I can do so much so fast with such good support. The current entrepreneurial world of the Internet is unprecedented -- with the possible exception of the California gold rush. The Internet is the most significant advance in human communications since the printing press. It's going to change the face of how humans interact in almost every realm, including the way medicine is practiced. Mullan: Tell me about Medscape as you envision it and about your new electronic journal, Medscape General Medicine (MedGenMed). Lundberg: Medscape is a broad and deep medical information supersite that is four years old. Its focus is clinical information arranged in a simple, quick, easy-to-use format designed for practicing doctors. MedGenMed is a new, primary-source, peer-reviewed, fully electronic general medical journal --the first of its kind. Other solely electronic journals exist, but not general medical journals. All articles must be submitted electronically, all reviews must be done electronically, all editing must be electronic, and all publishing is electronic. We now have Medscape for physicians, nurses, pharmacists, medical students, and patients/consumers via CBSHealthWatch. Our information is available free of charge and is used by more than 1. 5 million people in 230 countries. Mullan: As you look down the road of electronic publishing, what do you see? What will happen to hard-copy journals? Lundberg: In 1995, 3 percent of American physicians used the Internet. Today more than 80 percent do. The growth is fantastic. Today's twenty-year-olds will be more and more into electronic information and less and less into print publications, although I don't believe that electronic journals will replace print journals. Electronic reviewing and "printing "will put a lot of pressure on print journals to move faster than they do now. And I think that doctors will grow more and more computer dependent, and more regular in their reading and information-retrieval habits, because the electronic age pushes one to stay current. My strategy is to use Medscape and CBSHealthWatch as the fulcrum for improving physician/patient communication through a common database. The patient and the doctor could use Medscape to look at each other's information and compare notes. Medscape is our prescribed antidote to managed care. Mullan: Whatever else it does, electronic information seems to contribute to the ever-increasing pace of life. Are these new sources of information going to drive doctors nuts or overcrowd the medical information marketplace? Lundberg: Both doctors and patients will have to pick and choose where they go for information, to avoid information overload. Print journals have always competed for readers' time. The Internet is simply another way to compete for readers. But we can get more value per minute using the Internet because of the ease of search and the sheer volume of information available. It's an exciting time; it's a compressed time; it's Internet time.

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