BULLETIN OF TlIE NEWV YORK ACADEMY
OF MEDICINE
VOL. 54,NO.1
JANUARY 1978
THE THEME OF THE CONFERENCE* DUNCAN W. CLARK, M. D. Professor and Chairman Department of Environmental Medicine and Community Health State University of New York Downstate Medical Center Brooklyn, New York
T HOSE of you who know the writings of Malcolm Muggeridge may remember a book entitled Affairs of the Heart, which contains a passage which is relevant for us. It has been suggested that you substitute the word medicine whenever you hear the word love. Muggeridge wrote: I have always been deeply interested in the administrative side of love, which I find more absorbing than its purely erotic aspects. What Lady Chatterley and her gamekeeper did in the woods is, to me, of only passing interest compared with how they got there, what arrangements were made for a shelter in the case of inclement weather, and for refreshments, how they accounted for their absence, whether either party could recover incidental expenses, and if so how?2
This audience is deeply interested in the administrative side of medicine: a side we find more absorbing than its purely clinical aspects; a side that includes health policy; steps that anticipate where we are going; arrange*Presented at the 1977 Annual Health Conference of the New York Academy of Medicine, Health Policy: Realistic Expectations and Reasonable Priorities, held April 28 and 29, 1977. Address for reprint requests: P.O. Box 43, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, N.Y. 11203.
6
6
D. W. CLARK
ments to get there; contingencies to allow for; even the matter of incidental expenses-can we recover them, control them, and, if so, how? We meet to discuss the subject Health Policy: Realistic Expectations and Reasonable Priorities. I shall return to some meanings of this theme in a moment. The division of our subject is evident in the session subtitles. But the coherence of the several parts-how they all hold together-may be less than instantly evident and some explanation seems in order. Today we have sessions on the ideology and etiology of health policy. This morning, specific policy that might be advocated; this afternoon, how policy is evolved. We could have opened the program with either topic, but we chose to begin with policy to be advocated, in this case, matters relating to the determinants of health, namely, health care, health education, and environmental protection. With this approach we touch lightly on the four strategies of medicine: prevention and health, cure and care. The panel has been asked to include ideas likely to be of interest to healthplanning agencies. This afternoon, devoted to the origins of health policy, we shall learn how policy is formulated, its link with planning, the future of national health planning, and technical assistance in planning. At lunch two concurrent panels will include spokesmen responsible for the day-to-day application of National Health Planning and Resources Development Act requirements in this geographic area. Here the panelists will address the problems they face, their early experience under this law, and their relation at intergovernmental levels. The three sessions today aim at an understanding of policy and planning for their own sake and, from this background, to sharpen the questions that can be addressed to the specific issues to be discussed tomorrow. Tomorrow morning we shall focus on one of the most timely issues of our day, the rising cost of health care. We begin with a sort of debate by two economists on the use of health regulation as a device to control costs. Then we take a quick trip to Canada for a report of their experience in trying to contain costs and the lessons we may learn from this. The morning session will end with an effort to respond to the question whether any form of national health insurance could serve to control costs and, if so, under what circumstances. The program closes tomorrow afternoon with attention to two of the dilemmas that confront us in cost containment-one concerning our need for costly medical technologies and problems in rationing their use, anBull. N.Y. Acad. Med.
THE THEME OF THE CONFERENCE
THE
THEME
OF
7
other concerning the use of regulation to control utilization and the problem of maintaining clinical freedom. Now, to return to some meanings for the theme of this conference. Realistic expectations and reasonable priorities seem to urge caution, a vote for prudence and common sense to all who act upon or react to health policy. Who would quarrel with these? That they are urged upon us at all is witness to the view that they are paid too little heed by many if not all concerned. Will each speaker directly address this theme? Most probably not. Rather, the ideas contained stand as signposts around which the speakers weave their way on the Academy's course. At the very least these thoughts should temper what is likely to be advocated as policy in the course of this meeting. In our choice of theme we risk inventing a new slogan, one that could become tomorrow's cliche. So we need to\ enlarge upon it, defend it, define each term, and then reassemble the terms. This procedure may seem an exercise in reaching for criteria to explain criteria. But the wealth of meanings that can be associated with each specific term requires this approach. The tantalizing terms to define are realistic expectations and reasonable priorities. What will seem reasonable to me might seem not only unreasonable but even unrealistic to you. But we have to try. As we define a term, we must advert to its opposite as well. In this way we may also grasp the ways in which we fail to realize such expectations and priorities. Expectations are things we look forward to as certain or probable; at times they even imply the prospect of a future benefit. Realistic means life-like, genuine, hard-headed, based on fact. Our preference among these might well be "based on fact"-facts that are historically and socially verifiable and, ideally, measurable. Even so, the observer's value judgments may intrude in inferences drawn from objectively derived data. Realistic is opposed to unreal, which can be illusory and can run the gamut from mythical to romantic to ideal to utopian and the like-more succinctly, "where the rhetoric ends and reality begins." When the terms are taken in tandem and in the context of health policy, realistic expectations belong to consumers and providers equally and alike, to government and society as well, in mutually placed claims of one upon the other. At first glance it might seem that realistic expectations are commended to guide the behavior of consumers and that reasonable Vol. 54, No. 1, January 1978
8
8
CLARK D. W. CLARK
D.
W.
priorities are something peculiarly appropriate to the province of providers. But it is just as easy to reverse the equation. One could ask whether reasonable priorities are evident in the life style of most people, and physicians could be queried whether their expectations of society are always realistic. The public may come to hold realistic expectations to the extent that medicine contributes to a high level of informed public opinion. Medicine itself creates the very expectations that medicine then attempts to satisfy. A major problem in medicine is the general diffusion of innovations before their justification is demonstrated, and in this area physicians at all times have the obligation to act responsibly and with restraint. If you have a flair for keeping score you will find in the titles of the papers in the program much more reference to priorities than to expectations. But this is only program shorthand, to keep titles of papers short. We do wish to give equal time to expectations. Now for reasonable priorities. Priorities are measures that take precedence, or which merit a preferential rating when goods and services in limited supply are allocated. But priorities are needed for more than the reason that goods are in short supply. We must not only avoid waste but we must have value for money; we must regularly ask if better ways exist to deploy what we already have. We need priorities just to maintain a balance within a system. Priorities in medicine depend on the purposes of medicine and we have already cited these purposes as health and prevention, care and cure. Are the resources we devote to each in balance? Moreover, are medical priorities attuned to social priorities or are social priorities attuned to medical priorities? What dimensions must be considered when programs based on new health policy are proposed? Should it be capable of producing measurable improvement in health status? Be substantially acceptable to the profession and the public alike? Administratively manageable? Politically feasible? Fiscally possible, without accelerating the inflation of medical costs?3 The term reasonable refers to that which is rationally fitting or proper. It assumes that if one acts in conformity with the dictates of reason, this will help to distinguish between the true and the false. The term rational is a synonym for reasonable. Is there any distinction? The dictionary describes a rational man as one capable of using his reasoning powers and a reasonable man as one who exercises such powers habitually. What then is unreasonable? Misguided and visionary statements at one Bull. N.Y. Acad. Med.
THE THEME OF THE CONFERENCE
9
extreme, doomsaying on the other-as in the case of would-be reformers who use the rhetoric of crisis to portray American medicine as failing on all fronts. Such overstatement, intended to spur public action, in the last analysis only impedes a fair and realistic appraisal of competing policy proposals.3 A not unreasonable question is whether medicine has all of its priorities right and whether they are reasonable? One basis for the question is that physicians have so much initiative for determining the volume of services, the locale of care, the design of facilities-among the many considerations that affect total cost. Finally, it would be simplistic to suggest that realistic expectations and reasonable priorities provide an easy formula to use when trying to anticipate the value or the probable outcome of a health policy on which a new health program is to be based. To cite a single reason, the solution of one problem often conflicts with the solution of another. A basic American problem is to balance the claims of access, cost, and quality. The solution of one, and certainly two, may combine to undercut the third. REFERENCES
Muller, S.: The Johns Hopkins Institutions: A Case Study in Administration. In: Medicine, Law and Public Policy, Kettrie, W. H., Hirsh, H. L., and Wagner, G., editors. New York, AMS Press, 1975, vol. 1.
Vol. 54, No. 1, January 1978
2. 3.
Muggeridge, M.: Affairs of the Heart. New York, Walker, 1961, p. 61. Marmor, T. R.: Rethinking national health insurance. Public Interest 46: 73-95, 1977.
OF MEDICINE
VOL. 54,NO.1
JANUARY 1978
THE THEME OF THE CONFERENCE* DUNCAN W. CLARK, M. D. Professor and Chairman Department of Environmental Medicine and Community Health State University of New York Downstate Medical Center Brooklyn, New York
T HOSE of you who know the writings of Malcolm Muggeridge may remember a book entitled Affairs of the Heart, which contains a passage which is relevant for us. It has been suggested that you substitute the word medicine whenever you hear the word love. Muggeridge wrote: I have always been deeply interested in the administrative side of love, which I find more absorbing than its purely erotic aspects. What Lady Chatterley and her gamekeeper did in the woods is, to me, of only passing interest compared with how they got there, what arrangements were made for a shelter in the case of inclement weather, and for refreshments, how they accounted for their absence, whether either party could recover incidental expenses, and if so how?2
This audience is deeply interested in the administrative side of medicine: a side we find more absorbing than its purely clinical aspects; a side that includes health policy; steps that anticipate where we are going; arrange*Presented at the 1977 Annual Health Conference of the New York Academy of Medicine, Health Policy: Realistic Expectations and Reasonable Priorities, held April 28 and 29, 1977. Address for reprint requests: P.O. Box 43, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, N.Y. 11203.
6
6
D. W. CLARK
ments to get there; contingencies to allow for; even the matter of incidental expenses-can we recover them, control them, and, if so, how? We meet to discuss the subject Health Policy: Realistic Expectations and Reasonable Priorities. I shall return to some meanings of this theme in a moment. The division of our subject is evident in the session subtitles. But the coherence of the several parts-how they all hold together-may be less than instantly evident and some explanation seems in order. Today we have sessions on the ideology and etiology of health policy. This morning, specific policy that might be advocated; this afternoon, how policy is evolved. We could have opened the program with either topic, but we chose to begin with policy to be advocated, in this case, matters relating to the determinants of health, namely, health care, health education, and environmental protection. With this approach we touch lightly on the four strategies of medicine: prevention and health, cure and care. The panel has been asked to include ideas likely to be of interest to healthplanning agencies. This afternoon, devoted to the origins of health policy, we shall learn how policy is formulated, its link with planning, the future of national health planning, and technical assistance in planning. At lunch two concurrent panels will include spokesmen responsible for the day-to-day application of National Health Planning and Resources Development Act requirements in this geographic area. Here the panelists will address the problems they face, their early experience under this law, and their relation at intergovernmental levels. The three sessions today aim at an understanding of policy and planning for their own sake and, from this background, to sharpen the questions that can be addressed to the specific issues to be discussed tomorrow. Tomorrow morning we shall focus on one of the most timely issues of our day, the rising cost of health care. We begin with a sort of debate by two economists on the use of health regulation as a device to control costs. Then we take a quick trip to Canada for a report of their experience in trying to contain costs and the lessons we may learn from this. The morning session will end with an effort to respond to the question whether any form of national health insurance could serve to control costs and, if so, under what circumstances. The program closes tomorrow afternoon with attention to two of the dilemmas that confront us in cost containment-one concerning our need for costly medical technologies and problems in rationing their use, anBull. N.Y. Acad. Med.
THE THEME OF THE CONFERENCE
THE
THEME
OF
7
other concerning the use of regulation to control utilization and the problem of maintaining clinical freedom. Now, to return to some meanings for the theme of this conference. Realistic expectations and reasonable priorities seem to urge caution, a vote for prudence and common sense to all who act upon or react to health policy. Who would quarrel with these? That they are urged upon us at all is witness to the view that they are paid too little heed by many if not all concerned. Will each speaker directly address this theme? Most probably not. Rather, the ideas contained stand as signposts around which the speakers weave their way on the Academy's course. At the very least these thoughts should temper what is likely to be advocated as policy in the course of this meeting. In our choice of theme we risk inventing a new slogan, one that could become tomorrow's cliche. So we need to\ enlarge upon it, defend it, define each term, and then reassemble the terms. This procedure may seem an exercise in reaching for criteria to explain criteria. But the wealth of meanings that can be associated with each specific term requires this approach. The tantalizing terms to define are realistic expectations and reasonable priorities. What will seem reasonable to me might seem not only unreasonable but even unrealistic to you. But we have to try. As we define a term, we must advert to its opposite as well. In this way we may also grasp the ways in which we fail to realize such expectations and priorities. Expectations are things we look forward to as certain or probable; at times they even imply the prospect of a future benefit. Realistic means life-like, genuine, hard-headed, based on fact. Our preference among these might well be "based on fact"-facts that are historically and socially verifiable and, ideally, measurable. Even so, the observer's value judgments may intrude in inferences drawn from objectively derived data. Realistic is opposed to unreal, which can be illusory and can run the gamut from mythical to romantic to ideal to utopian and the like-more succinctly, "where the rhetoric ends and reality begins." When the terms are taken in tandem and in the context of health policy, realistic expectations belong to consumers and providers equally and alike, to government and society as well, in mutually placed claims of one upon the other. At first glance it might seem that realistic expectations are commended to guide the behavior of consumers and that reasonable Vol. 54, No. 1, January 1978
8
8
CLARK D. W. CLARK
D.
W.
priorities are something peculiarly appropriate to the province of providers. But it is just as easy to reverse the equation. One could ask whether reasonable priorities are evident in the life style of most people, and physicians could be queried whether their expectations of society are always realistic. The public may come to hold realistic expectations to the extent that medicine contributes to a high level of informed public opinion. Medicine itself creates the very expectations that medicine then attempts to satisfy. A major problem in medicine is the general diffusion of innovations before their justification is demonstrated, and in this area physicians at all times have the obligation to act responsibly and with restraint. If you have a flair for keeping score you will find in the titles of the papers in the program much more reference to priorities than to expectations. But this is only program shorthand, to keep titles of papers short. We do wish to give equal time to expectations. Now for reasonable priorities. Priorities are measures that take precedence, or which merit a preferential rating when goods and services in limited supply are allocated. But priorities are needed for more than the reason that goods are in short supply. We must not only avoid waste but we must have value for money; we must regularly ask if better ways exist to deploy what we already have. We need priorities just to maintain a balance within a system. Priorities in medicine depend on the purposes of medicine and we have already cited these purposes as health and prevention, care and cure. Are the resources we devote to each in balance? Moreover, are medical priorities attuned to social priorities or are social priorities attuned to medical priorities? What dimensions must be considered when programs based on new health policy are proposed? Should it be capable of producing measurable improvement in health status? Be substantially acceptable to the profession and the public alike? Administratively manageable? Politically feasible? Fiscally possible, without accelerating the inflation of medical costs?3 The term reasonable refers to that which is rationally fitting or proper. It assumes that if one acts in conformity with the dictates of reason, this will help to distinguish between the true and the false. The term rational is a synonym for reasonable. Is there any distinction? The dictionary describes a rational man as one capable of using his reasoning powers and a reasonable man as one who exercises such powers habitually. What then is unreasonable? Misguided and visionary statements at one Bull. N.Y. Acad. Med.
THE THEME OF THE CONFERENCE
9
extreme, doomsaying on the other-as in the case of would-be reformers who use the rhetoric of crisis to portray American medicine as failing on all fronts. Such overstatement, intended to spur public action, in the last analysis only impedes a fair and realistic appraisal of competing policy proposals.3 A not unreasonable question is whether medicine has all of its priorities right and whether they are reasonable? One basis for the question is that physicians have so much initiative for determining the volume of services, the locale of care, the design of facilities-among the many considerations that affect total cost. Finally, it would be simplistic to suggest that realistic expectations and reasonable priorities provide an easy formula to use when trying to anticipate the value or the probable outcome of a health policy on which a new health program is to be based. To cite a single reason, the solution of one problem often conflicts with the solution of another. A basic American problem is to balance the claims of access, cost, and quality. The solution of one, and certainly two, may combine to undercut the third. REFERENCES
Muller, S.: The Johns Hopkins Institutions: A Case Study in Administration. In: Medicine, Law and Public Policy, Kettrie, W. H., Hirsh, H. L., and Wagner, G., editors. New York, AMS Press, 1975, vol. 1.
Vol. 54, No. 1, January 1978
2. 3.
Muggeridge, M.: Affairs of the Heart. New York, Walker, 1961, p. 61. Marmor, T. R.: Rethinking national health insurance. Public Interest 46: 73-95, 1977.
