— Emerson Hospital staff, influence of administrator Pat Snow
— Impact of government on health care
— Group practice and Health Maintenance Organizations
— Dr. Reginald Fulton Johnston, house calls
— Malpractice Insurance
— Physicians for Social Responsibility
— Right to die-living will. issue
— Formation of the Middlesex Central District Medical Society
— Efforts for medical care of prisoners in Concord
Perspective on primary care medicine.
I came from North Carolina where I had grown up in Charlotte and had gone to Duke University, both to undergraduate and to medical school. I came to this area in 1954 to the Peter Bent Brigham Hospital in Boston where I was an intern and subsequently did residency training. I had a fellowship in cardiology in London, and in 1960 I went into practice in this area as an internist.
My wife Anne and I had taken all of our free weekends to go around New England to methodically search out what we thought was the best place to live and to practice, and Concord seemed to be that place. We never found anything we liked better, so we came to Concord. It had a good hospital, good schools, and was a wonderful place to live, we felt then and still do.
At the Brigham the training was aimed mainly at producing doctors for academic medicine, and I was really the exception in my group there because I was not aiming at academic medicine. From the very beginning I had the avowed intention of going into private practice, and that, at least at the Brigham, was a bit of an oddity at that time. When I came out here in 1960, there weren't very many specialists. The practice of medicine had been largely that of general practice, and the few specialists that had come before me were mainly surgeons. I was in the early part of a wave of specialists that came to Concord over a period of 10 years and participated in the transformation of the hospital from a cottage hospital that probably was not terribly good in the 1940's and 1950's but in the 1960's became really an excellent first-rate community hospital.
Pat Snow -- she was Emerson Hospital. She very much was the soul of the hospital. She was the administrator. These days we call the head the "chief executive officer" or the "president," but then she was called the administrator. There is no doubt however that she was in charge. She was a little bit like a mother hen with all of her brood. We didn't always agree with her but there wasn't anyone on the staff that didn't feel comfortable talking to her. She was a wonderful leader. I think she was able to sense problems ahead of time and head them off. She always had her pulse on what was going on in the hospital. For instance, every Friday morning when we had our medical meetings -- these were not business meetings but were educational meetings at which we discussed medical topics -- she would always sit to the side with her knitting, always. Knitting was part of Pat Snow. She absorbed the feel of what the hospital was going through and consequently was, I think, a wonderful leader. She also was a person who was able to change with the times. When she came, which was quite a few years before I did, the hospital was very definitely a cottage hospital, and she led in the trans- formation of the hospital from that sort of an institution to a first-class, excellent, modern, community hospital. Most people can take an organization part of the way and then, when the character of the institution changes, they have to let somebody else take over, but Pat Snow was different in that she was able to change with the times; every five years that went by, she adapted, for twenty-two years, I believe. She was a wonderful person.
In the '60's when I came, I was number 25 on the active staff, and anything that went on in the hospital that had any importance was decided in their weekly business meeting. Everything was discussed there. We expressed all of our feelings and hammered out whatever had to be decided. If there were problems with one another personally, I think we all sensed it and could be supportive to one another. So, we were colleagues then, the active staff, and that continued for awhile; but as the years went by the numbers became larger and now have reached 160 on the active staff, I believe. You can't decide things as a committee with 160 people, and you certainly can't give any sort of moral support or sensitivity towards one another's personal problems in a group of 160. So, the staff is no longer the source of support that we all look for in one way or another. We all have had to go in different directions to get emotional and psychological support as we practice medicine. I think that's inevitable, but it has meant the creation of different factions. These factions have gone in very different ways because of the external pressures, and it isn't the way it used to be. I used to know everybody in the hospital, all of the laboratory staff and, of course, all the active staff. Now there are just many, many people in the hospital, and none of us knows who everybody is -- it's big -- it's different.
There is a lot of pressure from both the government and big business, both of which pay for a lot of medical care. The government and large corporations clearly foot the bill for much of medicine now, and as they have seen costs go up and up, they have quite rightly said that you have got to control these costs -- we can't keep on paying more and more all the time, so they put the pressure on. They expect and really demand that we do more for less. I think one can do that to a certain extent, but over the last six or eight years that this has been going on in a really hard way we have gotten most of the fat out of the system. It's gotten to the point now where it is an increasing crunch from the doctor's point of view to continue to provide more for less. It is very difficult, and this has led to other ways of providing the medical product, that is, the care of the patient.
Increasingly, care has gone from the individual practitioner to the group setting. We can see the rise of the HMO in the last decade. It is now a very important part of the scene of private practice -- the HMO, Health Maintenance Organization. In this setting the care of patient, the things we do for the patient, the tests we order, the money we spend is all very carefully managed, and everything is scrutinized. If it isn't really necessary, then it is denied. The group that I am in is finding that the HMO requirements of cost containment, trying to do more for less, has become the tail that is wagging the dog now and really is very, very important in everything we do. We talk about this all the time, although we shouldn't be emphasizing it to the exclusion of other things. We ought to be talking about the medicine that we practice rather than the methods we use, but we have been increasingly caught up in the way we produce this medical product -- the mechanics of it. We receive a certain amount of money to care for the patient no matter what is wrong with him. That means, therefore, that we are very much trying to hold down consultant costs. We try to negotiate contracts with our consultants so that they will provide care to our patients for reduced rates, and that is difficult. We are talking to our colleagues about the money that they are going to receive. They, in turn, are beset with similar sorts of pressures on them from all directions including increasing malpractice costs. For instance, the orthopedic surgeons, to take one example -- two of the surgeons in our area are having to pay $100 per hour for their malpractice insurance. They have to earn $100 an hour just to pay for insurance. That is before anything else is paid for, it translates into around $50,000 or $60,000 a year. Now, when they have that sort of pressure on them, and we go to them to say you have got to do more for less because we have got the pressures on us, then you can see that this is really a very difficult situation. They get mad at us, and we are uncomfortable. It is hard.
As an internist, I have to orchestrate the different specialists that deal with my patients. We are what is called the primary physicians or the gatekeepers to the health care system. All of the things that go on with an HMO patient come across our desk and either get our approval or not. If we approve too much and too freely, then the HMO gets after us, and if we deny too much, then we have our colleagues mad at us, and the patients don't like it and they feel they are being deprived of care. The bottom line of all of this is trying to keep up the quality of care and at the same time to reduce the cost, and it is something we talk about all the time. I do think we are doing it, but it is a serious conflict.
I am a member of the Concord Hillside Medical Associates. We have eight internists, three pediatricians, and a part-time radiologist. There are, I think, around (at the last count) 40,000 patients that we had on our rolls. These are not all on-going patients. This includes just about everybody that has ever walked in the door once in the last five years, but we do have a large practice. I don't know how we compare to Acton Medical in terms of numbers, but between the two of us we clearly care for the biggest segment of patients in the area. Acton Medical Associates is the other group in the area, and they have a lot of similar problems.
Clearly, medicine has become a very competitive business, and Emerson Hospital has to work hard to beat out the next hospital, it seems. The hospitals never really used to compete, but now they are, and there are pressures on the hospitals in the same way there are on physicians. The hospitals are getting less money and they are having to cut some programs, and yet at the same time are trying to keep up patient volume because to keep up patient volume is the only way that their financial bottom line is going to be acceptable. Hospitals that are not extremely efficient probably in the long run are just not going to make the grade. Either you have got to be highly efficient and do things cost effectively, or you won't make it. Overall, there is an excess of beds in the state, so the people that run the public health policy say, and I think rightly so, that the hospital industry and the medical industry as a whole must perform efficiently because we can't afford to have empty beds sitting around. They want more and more regionalization, cooperation, and closing of inefficient units. It definitely pits one hospital against another and creates a different atmosphere. The word "marketing" was never heard in medicine before, but now "marketing" you hear all the time from the groups and from the hospitals.
Charlie Duston was a real medical entrepreneur. He was a general practitioner who was very smart. He had the ability in treating patients to have very good sense of what was wrong. He made rapid decisions and was, I think, a very good doctor. He did a lot by what he just felt about the patient, and it was usually accurate. He had a tremendous practice. He did many operations and just worked at full steam all the time. He would not do well in today's environment because he was a loner; he wanted to do things this minute the way he wanted to do it, and get on with it, and he would have rebelled tremendously at papers and forms.
When I arrived, doctors were still making house calls. The person who sent me many of my patients when he retired was Dr. Reginald Fulton Johnston. He loved to make house calls. He would have a good part of every day that was devoted to this. For many years he had Meniere's disease which made him dizzy, so for a long time before he reached retirement age he needed a driver, and he and his driver would go around making house calls. Then when he did retire and sent me many patients, the expectation was of course that I would come around on a house call. I did so but not nearly to the extent that he did. I had a little retraining to do of patients in my practice as to the fact that many times we could do things better in the office, but I have continued to the present to make house calls. I suspect I make more house calls now then, well probably, anybody on the staff. I'll make one, two, or three a week, something like that. These calls are usually for elderly patients. I feel very keenly that old people really ought to be seen, if possible, at home if they are really sick and unable to come in. The tendency in modern practice is, if you can't come in to the office, then some sort of ambulance or chaircar transportation is called and you are taken to the outpatient or brought to the office. That is fine except that it probably costs $250 or $300 to do a round trip that way, and it is not good, I think. I still make house calls and urge my colleagues to do so, although not all do.
Today, all doctors live under a cloud of the malpractice suit. As I explained, how malpractice insurance is a very keen cost that we have to cope with. It is a cloud. It has become one of the all-prevailing forces in the way we operate nowadays -- this threat of suit. I think that in the early years of my practice I was aware that, if I made some negligent mistake, I was liable and I might be sued; but that was certainly not something that was on my mind much of the time, and I think for most of us who have tried to practice well and to do things the right way as best we could, it just was not a concern. But that is not true now. I think our society has gotten extremely litigious and everybody is suing everybody else, and in particular people are suing the medical profession. If something happens that is a bad outcome, but not negligence, then people tend to think about suing. That is all wrong I think. I mean there are many things that are going to have a bad outcome. We can't treat patients and have it turn out perfectly all the time. People do die, and mistakes are made but that are not negligence. There are many things that you would like to do in retrospect differently from the way you did do them. But, it seems that no matter what happens, if anything goes the least bit wrong, even if everything is done all according to best methods and no negligence, still suits occur.
I had a suit against me that was without merit. This happened five years ago and actually was only resolved about six months ago. For four and a half years I lived with this suit over me. This paper arrived with a deputy sheriff saying all these awful things that you have done and you begin to think, I'm not a very good doctor. It really shakes your confidence even if you think that you have done everything in a proper way, which I clearly did. Well, nevertheless, even if you think you are okay, your mind starts running away from you and you start thinking the worst. You read in the newspapers about suits for millions of dollars, awards for millions of dollars. My coverage at that time was for one million dollars. About the time when the subpoena arrived, there was a big article in the newspapers about some award for three or four million dollars that was not justifiable, and that really bothers you. It made me feel depressed and upset for a couple of years, but finally I was able to pull out of it and say it is going to come out all right and quit worrying about it and get on with things. Eventually my own suit did come out all right, and actually the judge finally dismissed it in my favor as not having merit, but that was after four and a half years of a lot of worry on my part.
I will never practice medicine with the same spirit that I did prior to that because I now sort of regard everybody as a possible litigant. Medicine has become increasingly confrontational, and that it is very destructive. That episode to me really changed a lot of my behavior. It made me act in a much more defensive way. It made me order more tests, spend more of the patient's money in order to be sure that nobody could say that I didn't do exactly as I should have done. Increasingly, if you make a medical judgment and you don't back it up with tests, you are getting into risky territory; and that is not good. We need some sort of method of dealing with bad outcomes short of a malpractice suit. I hope that the legislature will come around to that. There are some states in the union that have done this, and it does require legislative relief.
While I used to be a very active leader in medicine, politically, I have begun to retreat. I think I have retreated in recent years partly because things have become so hectic and so pressurized that I have just gotten tired after 28 years. I recently decided that I am going to change things personally. I am going to stop practice because it has become too stressful. I just can't take the stress of all of this, not just the malpractice thing. Instead of working less hard as one gets older, it seems to me all I do is work harder every single year, and finally a few months ago I decided it just is not worth it. I have been trying to pull back a bit over the last few years unsuccessfully and have not been able to improve my work day enough that I can live with it for another five or ten years, so I am going to stop practice and will work for the Health Service at Harvard University, which will be a much more structured and orderly existence. It is a 9-5 type job at the Law School. I shall be caring primarily for students but also some faculty, some staff, some retirees. So, I shall still be practicing medicine but in a different format. Well, it certainly is a passage. Now I will get on the train with my newspaper and go into Cambridge.
I have been very involved with an international group called International Physicians for the Prevention of Nuclear War. I have spent a lot of time working for them over the last several years. It seems to me if one looks at the hazards that surround us, certainly at the top of the list, right along with the destruction of our environment, is nuclear war. What greater public health hazard is there than to explode these bombs? Physicians have felt that, although there are a lot of political overtones to this, it still is a medical issue. It is the ultimate public health threat, and we have been increasingly involved in this. The aim of IPPNW and its U.S. affiliate, Physicians for Social Responsibility, is to try to educate other physicians and in turn the public and our government leaders that the consequences of nuclear war are so awful that it is just not a viable political option. I think no matter what happened, there could be no excuse for ever dropping one of these things again.
I have been to the Soviet Union several times, three times actually, in connection with these efforts. I think what impressed me most of all is that without exception every single Soviet that I have ever talked to has said in essence the same thing. They do not want confrontation with the United States. They do not want to be spending their money for nuclear and military buildup, and they do want a peaceful co-existence. I think there are incredible misperceptions and stereotyping that we each have about the other. IPPNW has worked a lot to try to counteract these stereotypes -- the enemy image that the Soviets are bad and evil. They think similar things perhaps of us. This has been a major focus of the organization -- to try to break down some of these misconceptions that we have of one another. I was fortunate at one meeting I went to in Moscow to listen to Mr. Gorbachev speak for an hour. He spoke to a peace forum that had assembled there. This was in the Kremlin where the Supreme Soviet normally meets, and it was a very exciting occasion. It was the culmination of a four-day meeting on peace. That was in February 1987. Various people had been invited by the Soviet Union as the host government. They paid for everything and invited 800 people from all over the world from different disciplines. There were 100 physicians, and I was very fortunate to be one of those. Gorbachev's speech was translated simultaneously. I wasn't too far away from him, close enough to see all of his facial features and expressions, and I found him very, very compelling. I felt that what he said gave the feeling of being sincere, and he said the bottom line was that they did not want to continue to spend money for arms and that what they needed to do was to devote their energies to their domestic problems. They did not want confrontation. They wanted to be able to spend their energy on solving the problems within their own country. I believed it. I don't think I was taken in, and I think if by some magic way the people of this country could all have heard that speech, it would go a long way toward helping to reduce tensions between our two countries.
It was thrilling to be with my medical counterparts in the Soviet Union. We met prior to this plenary session at the Kremlin for two and a half days, these hundred physicians, to discuss ways that we felt the medical profession could help in reducing world tensions. That was a wonderful exchange. There were all sorts of people there from all over the world, but we were able to agree on everything that came up, and I like to think that, if the world leaders could let some of the lay people (the non-governmental people) take over, in a few days we could hammer out all sorts of agreements.
Another interest of mine has been the right to die, living- will issue. This came up beginning perhaps 10 years ago. I went to the State House in Boston to testify on behalf of a bill that would legalize the living will and make it a legal document in this state. While there I met an older person, a person I had known for a long time who was then a vice-president of the Society for the Right to Die. This is a New York based organization that has through the years been involved in getting state laws enacted that help people have control over the way they die. These are the living will laws. Anyway, this person at the State House invited me to think about joining the organization, which I did. I was on the Board of Directors for quite a few years, and I became quite active in these affairs. I was the chairman of the Committee for the Living Will in Massachusetts for the first few years of its existence. We tried to get and still have been trying to get a law through the legislature. We have come several times very close, and each time it has been stymied by a few individuals -- most recently by the Senate President William Bulger. We know that if the Senate and the House were allowed to vote, if it would come to a vote, this law would pass. We have got the counts of people that would do it, but they won't allow it to get out of committee or to get on the floor.
I think Bulger blocked it because of two groups that are opposed -- the Catholic Church and the Right to Lifers. To consider about the Right to Lifers first, I think that their position is not defensible. Their opposition is irrational because it is not a matter of killing people; it simply is a matter of allowing a person to say at the end of their life, "I do not want my life prolonged by extraordinary means and I want to be allowed to die in a natural way without aggressive support." There is nothing in that which should be opposed by a Right to Lifer. Yet they do oppose it, and I think the reason they oppose it is probably because of the foot-in-the-door sort of an argument that if you let this go through, then the next thing we will be having is euthanasia. This is irrational.
The Catholic Church, I haven't quite figured out. The Pope has said in official documents that he has no argument with the basic issues we are concerned with. It is not something that the Pope opposes in a direct way, but there are a lot of conservative bishops, and you know the Catholic Church is a very big bureaucracy and hierarchy. The Pope is not the only one there, and the bishops and others have traditionally not been enthusiastic about living will laws. I think that both the Church and Right to Lifers get all of this a little bit linked also in an irrational way to abortion, but there should be no connection between these two. So these are two powerful lobbies that have spoken against the living will law. I do remember that at the initial committee hearing that I went to some years ago at the State House, one of the monsignors stated when speaking in opposition to the living will law, and this is an absolute quote: "It is good for the soul to suffer." Now, I think that is a pretty primitive, backward view. There is no positive benefit to be attained from suffering. But progress has been made all over the country. There are now in the neighborhood of 44 states that have living will laws, and these are good laws. The Society for the Right to Die has been very active in this. They have become a real resource center for information for legislators, lawyers, and also individual patients who want to know what is the situation and what rights individuals do have.
I feel the votes are in the Massachusetts Legislature, and sometime in the next two, three, or four years I think we are going to have a law in Massachusetts. As it is now, even without a law, the living will is still an important document. It is a statement of intent, although it does not have some of the legal backup that the law would give it. Also, the law will give protection to the physician who acts in accordance with the patient's wishes; that is, if a physician stops such things as intravenous and tube feedings, etc., the physician is protected by the law for withdrawing treatment at the patient's request, such that he could not then be sued by some member of the family that says you should have pushed on.
The living will has importance in that it is a written statement of an individual's wish as to the manner of his or her dying, and that is really what the courts all want to know in these cases that have been adjudicated. They all come back to wanting to know what the patient would have done. A living will in this state, even without a law, is a very good statement of that intent and can be very important at a later time. But the other states that have laws, give the patients more rights and the physician more protection.
Middlesex Central District Medical Society was an outgrowth of the fact that we at Emerson felt that the district society that did represent us at that time. It centered around the Cambridge area and was really too much of a bureaucratic, old-guard, old-boys type organization that didn't do much of anything. In particular they did not do much about trying to improve the public health. If one looks at the by-laws and charters both of the AMA and also the Massachusetts Medical Society, both of them state very clearly that the purpose of the organization is to improve the public health. This is not something that these organizations have historically been too good about because (here I am referring more to the state organization) it has been largely a union involved in protecting and promoting physicians' interests. We felt that we ought to have a little more enlightened attitude and that the doctors in their organizations (district, state and national) ought to adopt a more progressive stance, taking positions on public health issues and really talking about cigarette smoking and all the problems involved there -- all the myriad issues of public health in which doctors could have more of an influence in an organized way. So, that was the feeling that we had, and we petitioned the state to make a new district society in this area. We won barely that permission to do so. It ended up we were the smallest and still are the smallest district in the state, but it was good.
We got involved in social issues. I can remember shortly after that, one of the things we really pushed for hard was doing something about television violence. For several years I was chairman of a committee for the Massachusetts Medical Society to address the problems of television violence and what this is doing to our society.
Another thing we did do with our new district society was to try to improve the health in the state prison that is located in Concord. That was a disappointment, because I had wanted a group of physicians in this town to take on the care of the prisoners as a civic duty, and we were not successful in doing this. We got the state to agree to a contract. We really went quite far down the line in terms of pulling this off. Let me back up first to say that the reason this came up as an issue is that one of the doctors, Leroy Houck, who for a long time was general practitioner here and who had almost single handedly delivered medical care at the prison for years and years, finally got to the point where he just couldn't do it anymore. He said he was going to have to resign -- it just was too much for one person. So at that point we said, well, why don't we have the medical society sponsor a group effort to provide this.
This was probably 15 to 20 years ago. As I said, we went into negotiations with the state. They agreed to pay us a reasonable amount of money to do the job, but our committee could not get enough doctors to agree to participate, and the thing failed. We figured we had to have five physicians who would say yes, and we could only get two or three (I was one of those). So that was a disappointment. I really felt keenly that we should have done that, but we weren't able to pull it off. Subsequently, the state brought in some doctors in a contract arrangement from outside. I don't know exactly what is going on there now. The only time we interact in treating those patients is if something comes up that requires their being in the hospital, and they are sometimes brought to Emerson. They are kept separately and there is always a guard right there the entire time -- 24 hours a day. Most of the time they try to hospitalize their patients at the Norfolk Prison which has got a hospital unit, but sometimes we will get acute problems because we are only down the street.
These have been a few thoughts about my years of practice in Concord. They have been wonderful and tremendously rewarding years. I wouldn't have done otherwise. It has been a privilege.