EDITORIALS
ANNALS of Internal Medicine Volume 85 • Number 5 November 1976 PUBLISHED monthly by the American College of Physicians under the direction of the Publications Committee of the Board of Regents; see advertising page 1-5 for listing of the Committee, the Editorial Staff, the Editorial Board, and the Business Staff. Editorial Policy ANNALS OF INTERNAL MEDICINE pub-
lishes original papers, topical reviews, editorials, book reviews, and medical news in the broad field of internal medicine and allied sciences. Detailed information on the kinds of papers that will be considered for publication, the proper form and style for manuscripts, and submission of manuscripts to the Editor are given in "INFORMATION FOR AUTHORS" on advertising page 1-6. Selected books will be reviewed monthly. Review copies should be sent to the Editor. The content of this journal is protected by copyright. Manuscripts are accepted for publication with the understanding that their contents, all or in part, have not been published elsewhere and will not be published elsewhere, except in abstract form or by the express consent of the Editor. The ANNALS OF INTERNAL
MEDICINE accepts no responsibility for statements made by contributors. Subscriptions The ANNALS OF INTERNAL MEDICINE
is issued monthly; new volumes begin with the January and July issues each year. Subscription price per year, net postpaid: $21.00 in North and Central American countries, Puerto Rico, and Canal Zone; $24.00 in other countries; half price to medical students and to young physicians within four years after graduation from medical school. Single copies of recent issues: $2.75 in North and Central American countries, Puerto Rico, and Canal Zone; $3.00 in other countries; price of supplements provided on request. Checks should be made payable to the American College of Physicians and remitted to the Circulation Manager. Communications to the Editor or the Circulation Manager should be sent to
Annals of Internal Medicine 4200 Pine St. Philadelphia, PA. 19104 USA Phone: 215/243-1200
National Health Policy 1976 I F ONE ACCEPTS the statement that not making a decision is in fact making a decision to allow events to proceed without any overt action by the "nondecision" maker, then the United States does indeed have a national health policy in its bicentennial year of 1976. That policy is an ever changing amalgam of laws, regulations, judgments, opinions, prejudices, and actions of governmental agencies such as the Social Security Agency, Social and Rehabilitation Service, Food and Drug Administration, National Institutes of Health, Environmental Protection Agency, Office of Management and Budget, National Institute of Occupational Safety and Health, the U.S. Senate, the U.S. House of Representatives, and the committee staffs dealing with health issues for those two legislative groups, as well as the American Medical Association, the Association of American Medical Colleges, state public health officers, the insurance industry, the American Hospital Association, the specialty boards of internal medicine, surgery, radiology, family practice, and on and on and on. From these often conflicting many, many groups come a shifting series of decisions, goals, policies, priorities, and programs. This nation does not have a rational, coherent, and consistent health policy, but it does have policies. Responsibility
In attempts to develop policy, responsibility must be fixed for each element in the system. In this nation today, no institution or group is responsible for educating our citizens for healthy living, nor for most of the other elements in the promotion of health or the care of the ill. Prudent diet, appropriate exercise, avoidance of tobacco, and avoidance of abuse of alcohol and other drugs would do more to improve the health of the American people than any other known factors. The educating of our citizenry in promoting their health is carried out in a desultory fashion through unrelated and scattered actions by the federal and local governments, and by organized and unorganized groups of physicians, educators, television broadcasters, and writers for newspapers and magazines. As a society we are exposed to erratic, untested, and unorganized programs of health information and misinformation. Responsibility for health education can and should be fixed. Cooperation between government and private groups is possible and desirable, but the programs must be professionally designed, adequately tested, and adequately supported and evaluated if they are to have the right content and any impact. We do not need a Soviet-style 5-year plan for medicine. We do need recognition and acknowledgment by each government body and voluntary organization that its decisions affect the decisions of other groups and are themselves affected by others' decisions. The Federal Role: Structure and Personnel
A first and necessary step is for the federal government to get its house in order. Currently medical schools, hospitals, the insurance industry, public health officials, and practicing physicians must deal individually with multiple bureaucracies, which are implementing multiple laws and regulations, often in conflict with one another. A Department of Health is needed. Its structure and personnel system
Annals of Internal Medicine 85:669-676, 1976
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should be designed by a blue-ribbon board jointly picked by the executive and legislative branches of government and by the private sectors of medicine. Authorities of the department should be defined and limited; authority for medical education, medical research, licensure to practice (a state authority), and accreditation of professional personnel should remain in the voluntary sector of medicine. A Department of Health must have legislative review or oversight for program content and budgetary allocations. This would be in addition to the usual internal reviews by the executive branch. But if there were a single health committee in the Senate and the House of Representatives responsible for a Department of Health, programs and policies could be developed with some semblance of rationality, coordination, cohesiveness, and continuity. Currently the Commissioner of the Food and Drug Administration, or the Director of the National Institutes of Health, or the Assistant Secretary for Health of the Department of Health, Education, and Welfare, spends hours and days testifying before multiple committees about similar programs, problems, and issues. Of equal importance is the development of a cadre of health professionals within the federal government. A new personnel system is needed to provide means for attracting the best young as well as mature and experienced minds into government service, even if only for limited periods. Salaries should be competitive with the academic and professional medical and scientific worlds. Retirement benefits should be transferrable into and out of government. Government careers in health should be as desirable at all levels as they are in the academic world. It has not been difficult to recruit top federal officials, but the day-today decisions are made by lower level government employees. If these employees do not have high morale or are not in highly desirable and competitive positions, they may work by the letter, rather than the spirit, of a law or regulation, with less than desirable consequences. Government officials must recognize that health changes do not occur overnight. Careful plans—agreed to by both government and voluntary groups—should be supported, while monitored and continually evaluated, until the desired impact is both possible and probable. Rapid shifts in government priorities and policies in medical research and medical education and health care delivery programs— while they may be politically opportune—may injure or destroy those educational and research programs of medical schools that are needed for any successful health program to mature. The Voluntary Role: Professional and Citizen Groups Cooperating with Government
While the federal government is getting its house in order, voluntary groups should form coalitions and develop plans for regular and continuing action and interaction with each other and with government. Continuity is critically important. The yearly election of a new president and board of our voluntary health and professional organizations is compatible more with social functions of organizations than with responsibility for input by the 570
private sector into national health policy. The voluntary groups must provide the same continuity in policy, programs, priorities, and leadership as that of the elected representatives, their staff, and governmental officials with whom they should effectively interact. Our system can work better than it has if the interrelations are clear and specific. Agreement on necessary changes in the system can be reached if long-range plans and policies are understood by all parties. Otherwise we may legislate a national program for personal health and medical services without the personnel or other resources to implement it. Or we may have, as we do now, a surplus of one specialty with a large deficit or maldistribution of another. The country must solve its problems realistically. The "problem" of attracting physicians to the urban ghetto is a misstatement of the problem. Eliminate the urban ghetto, and physicians then will be available to care for that population in another and more wholesome social and physical environment. Current concern about numbers and distribution of physicians illustrates the problem of multiple authorities and responsibilities facing our current nonsystem. Residency programs are proposed by physicians expert in a particular specialty who have sufficient patients and other resources to meet the criteria of the accrediting board of that specialty. In the past such boards have approved training programs solely on the basis of their individual merit, rather than of local, national, or international needs. Decisions on numbers, types, and distribution of primarycare physicians as well as specialists should result from informed discussions between both the voluntary and governmental sectors. Failure of specialty societies to act appropriately will result in the federal government's establishing criteria on arbitrary bases and with the effect of law. Changing laws to deal with changing patterns of practice may not be accomplished with enough speed to avoid even more problems than are the result of the current, admittedly deficient supply-demand equation, which follows rather than anticipates society's needs. Again, neither medical schools, state medical societies, national voluntary organizations, nor government at any level has the responsibility or the authority to determine the needs for numbers and distribution of physicians. A voluntary effort with the flexibility that derives from cooperation among many groups is preferable to a federal mandate. If the role of government in a free society is to do for citizens what they cannot or will not do for themselves, then those in the voluntary sectors concerned with the health of the American people must recognize and act on the urgent need for cooperation in setting priorities, principles, and goals of a rational health policy. Current trends strongly suggest such decisions otherwise will be made shortly by elected or appointed politicians. Current Political Answers are Inadequate
Our society, saturated with television adventures of great complexity being solved in the last minute of frantic action before the final commercial message, demands
November 1976 • Annals of Internal Medicine • Volume 85 • Number 5
Downloaded from https://annals.org by Karolinska Institute user on 01/18/2019
similarly simple solutions to complex problems. Our electoral process often leads political candidates to promise a simple solution to our complex medical dilemma of providing prompt, efficient, effective, economic, and sympathetic care for the ill. But there is no simple answer to these complex questions. Advancing technology, competition among hospitals for the latest expensive equipment, the emphasis on cure rather than prevention, the prior emphasis upon hospitalization by insurance companies, the entrepreneurial solo practice of medicine, and our fascination with the latest research findings have all led the United States to the current crisis. We have at the same time the best and the most expensive health nonsystem in
the world. Our society can no longer afford the existing nonsystem. Competition must now be replaced by cooperation so that we can preserve the best of what we have rather than those elements that are the most expensive, for their benefits, in the world. Our society will not tolerate health policy through nondecision for much longer. Voluntary groups and government will not find agreement on programs and policies easy to reach, but surely agreement is an urgent and necessary prerequisite for a rational, coherent, and consistent national health policy. (JESSE L. STEINFELD, M.D., F.A.C.P.; Dean, School of Medicine, Medical College of Virginia, Virginia Commonwealth University; Richmond, Virginia)
Editorials
Downloaded from https://annals.org by Karolinska Institute user on 01/18/2019
671
ANNALS of Internal Medicine Volume 85 • Number 5 November 1976 PUBLISHED monthly by the American College of Physicians under the direction of the Publications Committee of the Board of Regents; see advertising page 1-5 for listing of the Committee, the Editorial Staff, the Editorial Board, and the Business Staff. Editorial Policy ANNALS OF INTERNAL MEDICINE pub-
lishes original papers, topical reviews, editorials, book reviews, and medical news in the broad field of internal medicine and allied sciences. Detailed information on the kinds of papers that will be considered for publication, the proper form and style for manuscripts, and submission of manuscripts to the Editor are given in "INFORMATION FOR AUTHORS" on advertising page 1-6. Selected books will be reviewed monthly. Review copies should be sent to the Editor. The content of this journal is protected by copyright. Manuscripts are accepted for publication with the understanding that their contents, all or in part, have not been published elsewhere and will not be published elsewhere, except in abstract form or by the express consent of the Editor. The ANNALS OF INTERNAL
MEDICINE accepts no responsibility for statements made by contributors. Subscriptions The ANNALS OF INTERNAL MEDICINE
is issued monthly; new volumes begin with the January and July issues each year. Subscription price per year, net postpaid: $21.00 in North and Central American countries, Puerto Rico, and Canal Zone; $24.00 in other countries; half price to medical students and to young physicians within four years after graduation from medical school. Single copies of recent issues: $2.75 in North and Central American countries, Puerto Rico, and Canal Zone; $3.00 in other countries; price of supplements provided on request. Checks should be made payable to the American College of Physicians and remitted to the Circulation Manager. Communications to the Editor or the Circulation Manager should be sent to
Annals of Internal Medicine 4200 Pine St. Philadelphia, PA. 19104 USA Phone: 215/243-1200
National Health Policy 1976 I F ONE ACCEPTS the statement that not making a decision is in fact making a decision to allow events to proceed without any overt action by the "nondecision" maker, then the United States does indeed have a national health policy in its bicentennial year of 1976. That policy is an ever changing amalgam of laws, regulations, judgments, opinions, prejudices, and actions of governmental agencies such as the Social Security Agency, Social and Rehabilitation Service, Food and Drug Administration, National Institutes of Health, Environmental Protection Agency, Office of Management and Budget, National Institute of Occupational Safety and Health, the U.S. Senate, the U.S. House of Representatives, and the committee staffs dealing with health issues for those two legislative groups, as well as the American Medical Association, the Association of American Medical Colleges, state public health officers, the insurance industry, the American Hospital Association, the specialty boards of internal medicine, surgery, radiology, family practice, and on and on and on. From these often conflicting many, many groups come a shifting series of decisions, goals, policies, priorities, and programs. This nation does not have a rational, coherent, and consistent health policy, but it does have policies. Responsibility
In attempts to develop policy, responsibility must be fixed for each element in the system. In this nation today, no institution or group is responsible for educating our citizens for healthy living, nor for most of the other elements in the promotion of health or the care of the ill. Prudent diet, appropriate exercise, avoidance of tobacco, and avoidance of abuse of alcohol and other drugs would do more to improve the health of the American people than any other known factors. The educating of our citizenry in promoting their health is carried out in a desultory fashion through unrelated and scattered actions by the federal and local governments, and by organized and unorganized groups of physicians, educators, television broadcasters, and writers for newspapers and magazines. As a society we are exposed to erratic, untested, and unorganized programs of health information and misinformation. Responsibility for health education can and should be fixed. Cooperation between government and private groups is possible and desirable, but the programs must be professionally designed, adequately tested, and adequately supported and evaluated if they are to have the right content and any impact. We do not need a Soviet-style 5-year plan for medicine. We do need recognition and acknowledgment by each government body and voluntary organization that its decisions affect the decisions of other groups and are themselves affected by others' decisions. The Federal Role: Structure and Personnel
A first and necessary step is for the federal government to get its house in order. Currently medical schools, hospitals, the insurance industry, public health officials, and practicing physicians must deal individually with multiple bureaucracies, which are implementing multiple laws and regulations, often in conflict with one another. A Department of Health is needed. Its structure and personnel system
Annals of Internal Medicine 85:669-676, 1976
Downloaded from https://annals.org by Karolinska Institute user on 01/18/2019
669
should be designed by a blue-ribbon board jointly picked by the executive and legislative branches of government and by the private sectors of medicine. Authorities of the department should be defined and limited; authority for medical education, medical research, licensure to practice (a state authority), and accreditation of professional personnel should remain in the voluntary sector of medicine. A Department of Health must have legislative review or oversight for program content and budgetary allocations. This would be in addition to the usual internal reviews by the executive branch. But if there were a single health committee in the Senate and the House of Representatives responsible for a Department of Health, programs and policies could be developed with some semblance of rationality, coordination, cohesiveness, and continuity. Currently the Commissioner of the Food and Drug Administration, or the Director of the National Institutes of Health, or the Assistant Secretary for Health of the Department of Health, Education, and Welfare, spends hours and days testifying before multiple committees about similar programs, problems, and issues. Of equal importance is the development of a cadre of health professionals within the federal government. A new personnel system is needed to provide means for attracting the best young as well as mature and experienced minds into government service, even if only for limited periods. Salaries should be competitive with the academic and professional medical and scientific worlds. Retirement benefits should be transferrable into and out of government. Government careers in health should be as desirable at all levels as they are in the academic world. It has not been difficult to recruit top federal officials, but the day-today decisions are made by lower level government employees. If these employees do not have high morale or are not in highly desirable and competitive positions, they may work by the letter, rather than the spirit, of a law or regulation, with less than desirable consequences. Government officials must recognize that health changes do not occur overnight. Careful plans—agreed to by both government and voluntary groups—should be supported, while monitored and continually evaluated, until the desired impact is both possible and probable. Rapid shifts in government priorities and policies in medical research and medical education and health care delivery programs— while they may be politically opportune—may injure or destroy those educational and research programs of medical schools that are needed for any successful health program to mature. The Voluntary Role: Professional and Citizen Groups Cooperating with Government
While the federal government is getting its house in order, voluntary groups should form coalitions and develop plans for regular and continuing action and interaction with each other and with government. Continuity is critically important. The yearly election of a new president and board of our voluntary health and professional organizations is compatible more with social functions of organizations than with responsibility for input by the 570
private sector into national health policy. The voluntary groups must provide the same continuity in policy, programs, priorities, and leadership as that of the elected representatives, their staff, and governmental officials with whom they should effectively interact. Our system can work better than it has if the interrelations are clear and specific. Agreement on necessary changes in the system can be reached if long-range plans and policies are understood by all parties. Otherwise we may legislate a national program for personal health and medical services without the personnel or other resources to implement it. Or we may have, as we do now, a surplus of one specialty with a large deficit or maldistribution of another. The country must solve its problems realistically. The "problem" of attracting physicians to the urban ghetto is a misstatement of the problem. Eliminate the urban ghetto, and physicians then will be available to care for that population in another and more wholesome social and physical environment. Current concern about numbers and distribution of physicians illustrates the problem of multiple authorities and responsibilities facing our current nonsystem. Residency programs are proposed by physicians expert in a particular specialty who have sufficient patients and other resources to meet the criteria of the accrediting board of that specialty. In the past such boards have approved training programs solely on the basis of their individual merit, rather than of local, national, or international needs. Decisions on numbers, types, and distribution of primarycare physicians as well as specialists should result from informed discussions between both the voluntary and governmental sectors. Failure of specialty societies to act appropriately will result in the federal government's establishing criteria on arbitrary bases and with the effect of law. Changing laws to deal with changing patterns of practice may not be accomplished with enough speed to avoid even more problems than are the result of the current, admittedly deficient supply-demand equation, which follows rather than anticipates society's needs. Again, neither medical schools, state medical societies, national voluntary organizations, nor government at any level has the responsibility or the authority to determine the needs for numbers and distribution of physicians. A voluntary effort with the flexibility that derives from cooperation among many groups is preferable to a federal mandate. If the role of government in a free society is to do for citizens what they cannot or will not do for themselves, then those in the voluntary sectors concerned with the health of the American people must recognize and act on the urgent need for cooperation in setting priorities, principles, and goals of a rational health policy. Current trends strongly suggest such decisions otherwise will be made shortly by elected or appointed politicians. Current Political Answers are Inadequate
Our society, saturated with television adventures of great complexity being solved in the last minute of frantic action before the final commercial message, demands
November 1976 • Annals of Internal Medicine • Volume 85 • Number 5
Downloaded from https://annals.org by Karolinska Institute user on 01/18/2019
similarly simple solutions to complex problems. Our electoral process often leads political candidates to promise a simple solution to our complex medical dilemma of providing prompt, efficient, effective, economic, and sympathetic care for the ill. But there is no simple answer to these complex questions. Advancing technology, competition among hospitals for the latest expensive equipment, the emphasis on cure rather than prevention, the prior emphasis upon hospitalization by insurance companies, the entrepreneurial solo practice of medicine, and our fascination with the latest research findings have all led the United States to the current crisis. We have at the same time the best and the most expensive health nonsystem in
the world. Our society can no longer afford the existing nonsystem. Competition must now be replaced by cooperation so that we can preserve the best of what we have rather than those elements that are the most expensive, for their benefits, in the world. Our society will not tolerate health policy through nondecision for much longer. Voluntary groups and government will not find agreement on programs and policies easy to reach, but surely agreement is an urgent and necessary prerequisite for a rational, coherent, and consistent national health policy. (JESSE L. STEINFELD, M.D., F.A.C.P.; Dean, School of Medicine, Medical College of Virginia, Virginia Commonwealth University; Richmond, Virginia)
Editorials
Downloaded from https://annals.org by Karolinska Institute user on 01/18/2019
671
