Written by two reporters, this book contains a wealth of information about the history and inner workings of the American Medical Association since its founding in 1847. It is divided into two parts. The first covers how the AMA is organized, the history of its development, its ongoing battle against compulsory health insurance, a description of its political action committee (AMPAC), and a discussion of its support for the business ethic. The second covers the AMA's response to health issues including alternative medicine, the tobacco problem, abortion, and the AIDS epidemic.
Several liberal authors·, politicians and physicians are quoted at length, including sociologist Paul Starr, Hillary Rodham Clinton, physician-editor Dr. Arnold Reiman, and activist-physician Dr. Sidney Wolfe. The authors' objective is to allow the reader to "see through the imagery and mythology to discover the reality of the AMA."(1) Along the way, however, they promote a fair amount of imagery and mythology of their own. For example, the authors state:
* ...the health of Americans lags behind that in many other industrialized countries.(2)
* One reason our system is in trouble is because the AMA historically has seen health-care as a privilege rather than a fundamental right for Americans....(3)
* Galen ran away from the plague. (See Footnote below)
* Regarding nurses providing primary care: It is unlikely that patients will suffer at the hands of highly trained nurses.(4)
Moreover, the following points are presented as factual: That Medicare recipients now are paying as much out of pocket as they did before Medicare because the doctors' Medicare pay is too high(5); that the rapid rise in Medicare costs is because of the failure to limit physicians' "reasonable charges," and to physicians abusing the program; that the American College of Surgeons' Board of Regents represented its 55,000 members in 1994 when it supported a single-payer Canadian-style system(6); and that Mrs. Clinton did not include the AMA or any other special-interest groups among the 538 members of her Health-Care Task Force.(7)
These statements reflect the authors' bias that government intervention is the solution to, rather than the cause of, our health-care problems. Many of us would disagree that patients have a fundamental right to health care, that fee-for-service medicine is bad, that the business ethic "ought to be antithetical to healers," or that the state should control doctors because they have the potential to "exploit their patients financially."(8)
The authors assume that the role of healer conflicts with the role of "businessman and profiteer."(9) For most physicians, however, medicine is a 'calling,' an all-consuming lifestyle, a profession(10), which is guided by a code of ethics that has developed over the past 2,500 years, and that places the patient's welfare first. In all other occupations, the business ethic places profit first. So it is difficult for persons such as insurance or managed care executives, politicians, or even medical ethicists (and especially liberal reporters), who are not trained in medicine, to understand that patient advocacy overrides all other interests.
A prerequisite for this advocacy, however, is that the patientphysician relationship remains 'intact. Problems arise when it is severed by the interposition of thirdparties such as insurance, the government (Medicare), or the advocacy of group or societal interests ahead of those of the patient (such as with managed-care schemes). The egalitarians who advocate "universal access," "quality of care," and "cost containment," who would place the "public interest" and the "good of society" ahead of that of the individual, are usually serving their own interest, which is putting themselves in control of the system.
In 1964, under its greatest spokesman Dr. Edward R. Annis, the AMA was perhaps at the peak of its power and efficiency, with its largest membership ever. Even so, the year after, the AMA lost the battle against Medicare. Ever since that time, the effectiveness of its strategy in support of physicians and patients has steadily declined, along with membership. Dr. James S. Todd, the AMA's executive vicepresident, tells us why: "You know that perception in this world is reality. You need to use the terms and fit your action to what is going on at that particular time."(11) This pragmatism has resulted in an inconsistent philosophy which has prevented the AMA from attaining its goals. Many of its moves are made for PR, to allow it to negotiate collectively with third-party payers, or as an attempt to be given a larger role by the government in health-care reform.
Many in the AMA hierarchy believe it should "serve the public interest" and help devise a "health care system that meets the public's need."(12) In addition, its new ethical guidelines on self-referral are based on "anecdotal evidence of excessive profits" and the "national priority of cost control." It is not surprising that many of the AMA's policies "send such mixed signals that it angers people on both sides of the debate." For example, in dealing with the smoking problem, the AMA down played the 1964 Surgeon General's report. "Smoke if you feel you should, but be moderate."(13) Regarding the abortion problem, Dr. Todd observed, "We can't win no matter what we do. And on this subject I think the less the AMA says the better."(14) Rachael Pine, of the Center for Reproductive Law and Policy, observed: "If they really want to be neutral, they would stay out of it."(15)
Regarding physicians dispensing drugs, the authors are critical of the AMA's ethical stand because it "left doctors in charge of deciding just exactly what is the patient's best interest. "(16) They even are critical of the AMA's name, which they consider to be "pretentious and misleading...the equivalent of the American Bar Association calling itself the American Justice Association. The AMA...should be called the "American Doctors' Association."(17) ([here is no suggestion that the American Bar Association call themselves the "American Lawyers' Association.")
Commenting on changes the AMA should make, the authors are correct: The AMA "ought to start acting like a group of doctors concerned about its patients instead of like medical politicians."(18) If ever it does, many of us who have long ago dropped out will rejoin, and it then might justify its claim, made to Hillary Clinton in 1993, that it represented 90% of the doctors and 100% of the patients, a claim which the authors (to their credit) point out was far from accurate. Unfortunately, if past history is any guide, two questions posed by the authors will continue to haunt the organization: "Who does the AMA really represent? And does anybody --- doctors, the public --- need the AMA anymore?"(19)
The Serpent on the Staff provides a fascinating look at various activities of the AMA since the mid-1800s, and of the various movements for health-care reform since that time. Along with this, it documents the AMA's failure to attain many of its goals, largely because it has followed the same liberal philosophy the authors themselves espouse, (but for reasons opposite of what the authors claim.) As with most liberal writing, many of the "facts" really aren't facts, and many of the basic assumptions aren't true. Liberals will love it, since its inconsistencies will not be a problem for them, and its egalitarian philosophy will be music to their ears; but conservatives will have a more difficult time accepting many of its liberal premises and statist/authoritarian solutions.
* Dr. Joseph Walsh, as quoted in Faria's Vandals at the Gates of Medicine, p. 181: "He [Galen] left Rome, where the epidemic had not yet begun and no one expected it, and actually went into the regions where it was already a menace."
1. Wolinsky H and Brune T. The Serpent on the Staff: The Unhealthy Politics of the American Medical Association, G. P. Putnam's Sons, New York, NY. 1994, p. XVII.
2. Ibid , p. 15
3, Ibid., p. 5
4. Ibid., p. 143
5. Ibid., p. 62
6. Ibid., pp. 42-43
7. Ibid., p. 40
8. Ibid., p. 120
9. Ibid., p. 194
10. Blome DP. Can business and medicine coexist? Jaggard Society Meeting, Akron, Ohio, April 28,1996.
11. Wolinsky and Brune, op. cit., p. 221
12. Ibid., p. 120
13. Ibid., p. 152
14. Ibid., p. 194
15. Ibid., p. 191
16. Ibid., p. 107
17. Ibid., p. 3
18. Ibid., p. 194
19. Ibid., p. IX
Reviewed by Jerome C. Arnett, Jr., MD
Dr. Arnett is a pulmonologist in Elkins, West Virginia, and a member of the Editorial Board of the Medical Sentinel.
Originally published in the Medical Sentinel 1996;1(2): 36-37. Copyright©1996Association of American Physicians and Surgeons (AAPS)
(The Serpent on the Staff: The Unhealthy Politics of the American Medical Association by Howard Wolinsky and Tom Brune. 267 pp., $24.95, ISBN: 0-87477-800-X, G.P. Putnam's Sons, New York, NY, 1994.)