Presidential Address

The Eternal Spiral* ALEJANDRO F. CASTRO, M.D. Rockz4lle, Ma~la~zd

A TORNADO, a devastating spiral, will u p r o o t most a n y t h i n g in its pathway and b r i n g it crashing d o w n s o m e w h e r e . Medicine finds itself in the midst o f the t o r n a d o o f bureaucracy, now spiraling as a political football to fall in the midst o f chaos and d i m i n i s h e d health benefits. In 1972, the year I was elected Secretary o f this illustrious organization, Dr. Walter B i r n b a u m s p o k e o f the sigmoid curve. I would like today' to project this curve into a spiral, a spiral being a "curve traced by a point moving r o u n d a fixed point in the s a m e plane, while steadily increasing or diminishing its distance f r o m it." P e r h a p s the principal reason for my thinking of a spiral is the general r e f e r e n c e to this type o f curve in relation to o u r inflationary behavior, not only f r o m the economic standpoint, but also f r o m the point o f view o f practically every facet o f life itself, b e g i n n i n g with the spiral o f the D N A molecule, to the trajectory o f the world a r o u n d the sun. As we progress in o u r endeavors, we say we progress upwards, not downwards, n o r in a straight line, but m o r e c o m m o n l y in a spiral; sometimes retreating, sometimes a p p r o a c h i n g , but always with at least some progress towards perfection. So it has been with medical progress t h r o u g h the years; we have had o u r d a r k m o m e n t s , but most have been bright a n d shiny, j u s t as o u r halos should be. Yet it is principally due to this p r o g r e s s that we m u s t blame ourselves for our present situation. The A m e r i c a n way o f life has t a u g h t us to " h e l p the u n d e r d o g " and to refrain f r o m "beating a m a n w h e n he is down"; but in the heights we as physicians have achieved, we are an ideal t a r g e t for a n y o n e w h o would like to t h r o w a missile o u r way. It is n e i t h e r profitable n o r edifying to d e g r a d e or d e r i d e an u n d e fined or u n f o r t u n a t e p e r s o n or group. Let that p e r son or g r o u p be one that has b e c o m e recognized because o f its achievements a n d enviable position in the * Presidential address read at the meeting of the American Society of Colon and Rectal Surgeons, San Diego, California, June 11 to 15, 1978. Address reprint requests to Dr. Castro: 11125 Rockville Pike, #308, Rockville, Maryland 20852.

c o m m u n i t y , a n d all the envy, r a n c o r a n d hate held in by' an o p p o n e n t will be u n l e a s h e d in an a t t e m p t to discredit and level such " h i g h a n d mighty'." Medicine has been a target since b e f o r e 1938, w h e n the p r o f e s s i o n was d e c l a r e d a " t r a d e " in a suit b r o u g h t by the Federal T r a d e Commission. Since that time man,,' o t h e r b r a n c h e s o f g o v e r n m e n t , federal and state, have j o i n e d the b a n d w a g o n , not because the;,' particularly wanted to, but because they' have been led into it by the increasingly vociferous cons u m e r o f health care. It is this d e m a n d f r o m the A m e r i c a n people that has b r o u g h t so m a n y proposals for a c u r e to the H e a l t h Care System in the f o r m o f bills or legislation by Congress. As physicians, we know that the cure o f an ailing H e a l t h Care System is not simple; evidence to this effect is given by the n u m e r o u s proposals published in the Cozzgressional Record. As physicians, we are well a w a r e that the m o r e proposals t h e r e are for a cure, the less we know of the disease. It seems ludicrous that o u r leaders c a n n o t come u p with a unified solution by getting their heads t o g e t h e r a n d thinking as a united g r o u p r a t h e r than trying the usual " o n e - u p m a n s h i p a p p r o a c h " so prevalent a m o n g legislators. Recently, t h e r e seems to be an e f f o r t to throw e v e r y t h i n g back into the lap o f the c o n s u m e r by increasing his e d u c a t i o n in the H e a l t h System and t h e r e b y telling him to f e n d for h i m s e l f in this system, as well as in his choice o f the latest medical "gimmicks." This is the reason, I ' b e l i e v e , that the Federal T r a d e C o m m i s s i o n wants doctors to advertise their wares, their training, a n d their prices. O n c e these items are on record, they' claim, the c o n s u m e r can better choose w h o m he wants to care for his p r o b lem. T h e Federal T r a d e C o m m i s s i o n has f o r g o t t e n t h a t the r e a s o n a d v e r t i s e m e n t was f o r b i d d e n f o r physicians early in this c e n t u r y was that it p r o v i d e d n u m e r o u s avenues for the charlatanism, false claims, and testimonials which spiraled in the 19th a n d early 20th century. Personally, I a m not o p p o s e d to educating the public, b u t I a m o p p o s e d to d u m p i n g th( responsibility for the H e a l t h C a r e System in their

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laps. I believe such responsibility must lie in o u r hands a n d that o u r own A M A should c o n t i n u e to lead in this field. I am, therefore, o p p o s e d to advertising. A n o t h e r spiral that we face every day as practitioners is the spiral in the world o f technology (gimmicks, if you will). It is this spiral that has so greatly increased not only the daily cost o f a hospital bed, but also, the charges physicians find themselves forced to m a k e for the a d d e d responsibility o f k e e p i n g u p a n d using newer instruments. I am sure you are all aware that hospitals are being asked by the present administration to decrease the p r e s e n t 16 per cent annual rate of cost increase to a less inflationary one which would be closer to the annual rise in the cost o f living. T h e President wants a 9 per cent figure, but a m o r e equitable one would seem to be in the n e i g h b o r h o o d o f 12 per cent. It might not be long before physicians themselves will be the target, being requested to comply with annual rises closer to the rise in the cost o f living. All this is not so bad really, if we in the Health Care System--physicians comprising only 8 per c e n t - - a r e not singled out for curtailment of o u r fees. I f g o v e r n m e n t (including all legislators, a d m i n i s trators, and justices), business, a n d the trades would agree to the same p e r c e n t a g e o f annual rise in incomes we could have no complaint, but this does not seem to be the case. T h e r e seems now to be such scrambling to maintain this spiral o f inflation that it has now b e c o m e "the n a m e o f the game." Be that as it may, we physicians can start the ball rolling towards a reduction o f the cost of medical care by showing m o r e responsibility in eliminating the unessential frills that we have b e c o m e used to in o u r delivery of health care. P e r h a p s where we fail most is in o u r complacency and acceptance of the so-called routine testing o f a patient. As an example, let us take a h e m o r r h o i d e c t o m y on a 40-year-old man who gives a history o f n o r m a l health p r i o r to his present p r o b l e m and who has n o r m a l physical a n d sigmoidoscopic findings. We hospitalize him, a n d then comes the barrage o f routine tests: EKG, chest x-ray, SMA-12 or Hycell-17, urinalysis, and, in most instances, a b a r i u m e n e m a o r p e r h a p s even a colonoscopy. I ' d like to postulate that 99 times out o f 100 we can do the same p r o c e d u r e (as we used to) with only the i n f o r m a t i o n given by a CBC and urinalysis. You may answer that the shorter way m a y lead to missing colonic polyps in one o f 200 40-year-olds or even an early cancer in one of 500. But does this justify subjecting all the rest o f these patients to b a r i u m e n e m a s a n d / o r colonoscopies? You m a y say that o n e can miss an early' a s y m p t o m a t i c heart or p u l m o n a r y lesion, a b n o r m a l blood changes, etc., but the point is that we have c o m e to rely on a m o r e expensive c o m p u t e r i z e d medicine

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641

when we should, as we were taught, rely on history and physical e x a m i n a t i o n , a n d w h e n f o u n d necessary, t h e n go a h e a d with the a p p r o p i a t e tests. This, o f course, is not f a v o r e d by the hospital laboratories, x-ray d e p a r t m e n t s , or E K G stations, because these tests help to pay for the rising cost of hospitalization and for the e n o r m o u s increase in hospital p e r s o n n e l d e e m e d necessary n o w a d a y s to run these institutions. T h i s m i g h t h e l p u n e m p l o y m e n t , b u t it c e r t a i n l y creates havoc in any a t t e m p t to decrease the cost of health care. O n e o t h e r e x a m p l e I would like to p r e s e n t to you is that o f a 20-year-old girl who has b e e n having lower a b d o m i n a l pains for several years, is constipated, is an A s t u d e n t in school, is involved in m a n y social school functions, as well as athletics, eats on the run, a n d has no time for breakfast. H o w m a n y o f this type o f person have you seen in y o u r practice, not too m a n y probably, but a few no doubt. So you p e r f o r m your usual exam, including an a b d o m i n a l palpation that reveals a " r o p e y " t e n d e r sigmoid. A sigmoidoscopy is negative except that it r e p r o d u c e s the a b d o m i n a l pains c o m p l a i n e d o f by the patient. You then put the girl on bran, give her s o m e fatherly advice as to the benefits of a good sensible diet, a n d follow her for a time. T h e total cost o f this care should be a r o u n d $50.00 m a x i m u m . Now c o m p a r e this with an aggressive diagnostic routine: physical e x a m i n a t i o n , sigmoidoscopy, G1 a n d small-bowel series, colonoscopy and, perhaps, rectal biopsy to the tune of s o m e w h e r e about 300 ol- 400 dollars. I will agree that the simpler d i a g n o s t i c a t t e m p t m a y fail to d i s c o v e r an e a r l y C r o h n ' s disease, but the chance that this disease is causing the patient's p r o b l e m is remote. In the early stages, C r o h n ' s disease in not life-threatening, and the e x p e n d i t u r e o f the a d d e d health care dollars is uncalled for because of the rarity of this particular trouble. T h e s e are just two e x a m p l e s o f what we can do to lower individual costs o f caring for patients; there are m a n y others I could give that would focus on the use of tests used because o f f e a r o f malpractice litigation, d e p e n d e n c y on daily "routine" blood or x-ray studies in the follow-up o f p o s t o p e r a t i v e patients, etc.. T h e new sophisticated machines will also be used, not because o f absolute need, but because o f o u r medical c u r i o s i t y f o r new g a d g e t s a n d b e c a u s e we h a v e learned to rely on machines r a t h e r than on having to think. Much o f this has really b e e n forced u p o n us by the c l a m o r for excellence in health care and by the peer-review systems we now have. It is difficult to try to be reasonable a b o u t lowering the cost of illness a n d at the same time to avail oneself o f all possible helpful m e a n s to e x p e d i t e diagnosis and recovery; simply, we

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want Shangri-La, but we don't want to pay for it. T h e advent of the President's boost for preventive care, in my estimation, is not going to r e d u c e the overall exp e n d i t u r e for health care, it is only going to shift the responsibility for it to a n o t h e r b u r e a u in the Departm e n t of Health, Education, and Welfare. T h e m o r e the g o v e r n m e n t becomes involved in health care, the more it is going to cost the American people. Why? Because and assuming that health care will be o f the same quality as that we now have f r o m a private sector, the need for the a d d e d m o n i t o r i n g and administering o f this care will be e n o r m o u s . Look at how Medicare and Medicaid have failed to lower the cost o f health care in their own segments of population. Outside o f medicine, look at how the Social Security and postal systems have failed to realize economic feasibility. O u r g o v e r n m e n t fails to take notice and learn f r o m o t h e r nations that have been b u r d e n e d by a national health system. This nation seems to strive for b a n k r u p t c y and self-destruction, and there may be very little we can do about it, in spite o f what one hears to the contrary. Medical care is today the most controversial subject in this country, and it most likely will be for some time to come. Fortunately, health care is only part of the spiral o f progress and therefore inflation. O t h e r professions, trades, and businesses will have their respective days as targets once medicine has been swallowed u p by National Health Insurance. Perhaps one of the reasons we physicians were first on the line is because illness is something no one in his right mind asks for, as o p p o s e d to his asking for legal care o f worldly goods, the comforts o f life, entertainment, and the satiation o f his various appetites, these being things for which we wilt work, beg, borrow, or steal. One o t h e r thing that physicians are accused o f is the p o o r distribution o f o u r members. We seem to congregate in u r b a n centers and have little desire to go to small communities, which would not a f f o r d the type o f life most doctors are exposed to d u r i n g their training years. T h e era o f the itinerant p i o n e e r doctor is over, for the simple reason that we know too m u c h to be satisfied with the way it was. We are used to m o d e r n hospitals, and the t h o u g h t o f going to places where the nearest hospital is 100 miles away does not seem to attract very many o f us. In our specialty, o f course, there is the a d d e d fact that it takes a c o m m u nity o f 100,000 or m o r e to necessitate a specialist in colonic and rectal surgery. So it would seem that the profession o f medicine has no friends outside o f its ranks. We must be aware o f the fact that even t h o u g h o u r many patients may love us individually, they do not hesitate to raise their

Dis. CoL & Rect

Nov.-Dec, 1978

voices individually or in conjunction with civil, cons u m e r or c o m m u n i t y groups. Why? Because they want all bills that pertain to health care to be paid by someone else, be that the insurance c o m p a n y , Medicare, or Medicaid. Years ago, in o r d e r to help pay the bills, the Blue Shield p r o g r a m s were started by dedicated physicians who pledged a delay in the p a y m e n t o f their charges to p r e v e n t an early b a n k r u p t c y o f the p r o g r a m and who took time out f r o m their practices to r u n what, in reality, were separate insurance companies. T h e doctors involved associated themselves with people who knew the insurance business and who, along with o t h e r specialists, served as advisors and members o f the boards o f directors. Physicians now compose less than 50 per cent of most o f these boards, and there is a clamor by state legislators to r e d u c e their n u m b e r s still more. It should be no surprise that in the past year, there have been n u m e r o u s examples of the role the Blues are playing in joining the mud-slinging games against the medical profession and in trying to disallow p r o c e d u r e s that "they" say are unnecessary, without consuhation with representatives o f the specialties most involved in these procedures. T h e aim o f the Blues is to r e d u c e the e x p e n d i t u r e o f m o n i e s c o l l e c t e d f o r h e a l t h care coupled with an increase in p r e m i u m s , so that there will be more m o n e y for capital investments and construction o f plush buildings for their h o m e bases. T h e y don't m e n t i o n that the cost o f administering these companies is constantly rising. As the T o w e r o f Babel that came crashing down because o f lack o f communication, and because o f fragmentation, so too seems the spiral o f medicine. Due to "spiraling" d e m a n d s for p r o l o n g a t i o n o f life and improved general health, we have c o m e u p o n a f r a g m e n t a t i o n t h r o u g h specialization: the a m o u n t o f sophisticated knowledge n e e d e d and the involved dev e l o p m e n t o f techniques d e m a n d e d today are too much for one person to handle alone. This f r a g m e n tation once seemed satisfactory, as o u r specialty can attest, but f r a g m e n t a t i o n continues not in medical specialization alone, but in bits o f medical practice that are being c h i p p e d away f r o m the main body by the i n d e p e n d e n c e of nurses, who now are allowed their own practices, by the physician's assistant who may take away parts o f practice so as to free the physician for other chores, by the podiatrist who is taking the feet away, the rescue squads who have assumed the initial e m e r g e n c y care, the g o v e r n m e n t who is trying to tell us how and w h e n to practice, the optometrists who want all eye t r e a t m e n t and m o r e recently, the midwives who are trying to take over normal deliveries, etc.. In the f u t u r e I see e n d o s c o p y going the same way; sigmoidoscopy is now in some

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areas in the hands o f technicians. Fragmentation and the lack of a unified front in medicine (which some physicians in the Southwest have tried to correct by forming a medical union) may ultimately result in the fall of a progressive medical spiral and the creation of a computerized, mechanical medical world controlled by buttons and a lay bureaucracy (a static world, sure, but without that quality we call progress). I see the erosion o f the image of the doctor and the decreasing control o f the health care system by the physician as two continuous problems to be f o u g h t and, at least, delayed in the medicine of the future. Such a legacy is hard to swallow, since medicine has been a profession particularly admired and respected for generations, ever since the first witch doctor raised a rattle against the evil spirits in us. In conclusion, we have been singled out once again by the administration, this time to start the ball rolling for the control o f the eternal inflationary spiral. We

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have been asked to stop the waste that is innate to a society that depends so much on disposable materials; we are asked to stop unwarranted procedures, tests, and hospitalization. If we do not make progress along these lines the administration will see to it that legislation is passed to regulate our ways of practice in order to reduce the cost o f health care. We have made some progress in reducing hospital costs in the past year, but more progress is n e e d e d to show that, we as physicians, can cope with this situation and do not need the extremely expensive "helping" hand of big brother to do our .job for us. One thought I would like to leave with you is that now is the time to start and continue a grass roots revolt by yourselves and your patients by writing or talking to your elected officials and expressing disapproval of the way g o v e r n m e n t is trying to interfere with and take over the practice o f medicine. We still have time. What are you going to do about it?

S T A T E M E N T OF O W N E R S H I P . M A N A G E M E N T A N D C I R C U L A T I O N (.Act of August 12, 1970: Section 3685. Title 39, United States Code) Date of Filing--September 12. 1978 Title of Publication--Diseases of the Colon & Rectum Frequency of I s s u e - - E i g h t I s s u e s Per Year Location of Known Office of Publication--East W a s h i n g t o n Square, Philadelphia, PA 19105 Location of the Headquarters of General Business Offices of the Publishers--East Washington Square. Philadelphia, PA 19105 Publisher--3. B. Lippincott Compan>. East Washingt0n Square, Philadelphia. PA 19105 Editor--John R. Hill, M.D.. First National Bank Building. Room 403, Rochester, MN 55901 Managing Editor--Peter Dechnik. East Washington Square, Philadelphia, PA 19105 Owner--American Society of Colon and Rectal Surgeons, 615 Griswold. Suite 516, Detroit, Michigan 48226 Kno',,.n Bondholders. Mortgagees. and other security holders owning or holding I per cent or more of total amounts of bonds, mortgages or other securities--None Nonprofit Organizations Authorized To Mail at Special Rates--The purpose, function, and nonprofit status of this organization and the exempt status for Federal income tax purposes have not changed during preceding 12 months

A. T o t a l no. c o p i e s printed (nel press run) B. Paid circulation 1. Sales through dealers and carriers, street ' . e n d o r s and c o u n t e r sales 2. Mail subscriptions C. Total paid circulation D. Free distribution b> mail, carrier or ether means. Samples, comp l i m e n t a r y , and other free copies E Total distribution

(S~]

[)l/

C

and

D)

F. C o p i e s not d i s t r i buted I. O f f i c e use. leftover, unaccounted, spoiled after printing 2. Returns from news agents G. Total (sum o/ E & F - - s h o u h l equal ne~ presa run s h o w n in A)

Average No Copies Each Issue during Preceding 12 Months

Actual No. of Copies of Single Issue Published Nearest to Filing Date

3.733

3.900

1,576 1,752

1.756 1.791

3.32•

3.547

178

18 I

3.506

3,728

227

172

--

--

3,733

3,900

I certify that the statements made b~ me above are correct and complete. John M. Wehner. Jr.. Publisher