The Journal of

ALLERGY and

CLINICAL IMMUNOLOGY VOLUME 53 NUMBER 5

Presidential address The quest for excellence-who is responsible?

Charles E. Reed, M.D. LMadi.son, Wis.

All men strive to excel. Indeed, the quest for excellence is almost as strong an instinct as the hunt for food. And man, the tool builder, builds social structures to help him achieve excellence.

In this spirit a generation ago allergists joined to found the Academy. Then, as now, the main direction of the Academy’s quest was research into mechanisms and treatment of disease, and continuing education of its members. Our meeting this week, with the most scientific papers we have ever had, testifies that we have gone a long way toward achieving these goals, though there is, of course, still a very long way to go. I am proud of our successes and know that if all those founders could be here with us, each of them would be proud of the Academy, too. Not only am I proud but I am also confident for the future of research in allergy. True, the amount of money for research is no longer in- creasing. True, support for training the next generation of investigators is diminishing. But our momentum is strong. The instinct for excellence will carry us along.

Unfortunately, however, all is not well with the practice of allergy. Today, you and I face issues that the founders of the Academy could not foresee. In our practice, in our job of helping patients cope with allergic diseases, we come up against social and organizational problems that have nothing to do with science, or research into mechanisms of disease. Our generation needs to reshape our Academy to help us direct as much energy and talent now into the socio- economic aspects of allergy as we have been directing into science. After all, the

Presented at the Thirtieth Annual Meeting of the American Academy of Allergy, January 22, 1974.

Received for publicatiqn Feb. 5, 1974.

Vol. 55, No. 5, pp. .%‘57-860

258 Reed J. ALLERGY CLIN. IMMUNOL. MAY 1974

science is useless unless it is applied by skillful physicians for the benefit, of individual patients. The conditions of pract,ice arc vital.

As doctors, we feel threatened by the changes occurring in the conditions of pract,ice, changes such as PSRO, FDA regulations, Phases III and IV, Medicare rules about hospital admissions, human research committees, pressures for recertification-the list seems endless. WC tencl to react to these changes with anger and resistance. But, to bc able to deal with t,hese changes constructively, and see to it that they ult,imately work for the benefit of our patients, we must understand both the reasons for t,hrm a.ntl the reasons for our anger and re- sistance. Both, it seems to me, arise out of the instinct for cxcellencr. The tensions arise out of conflict between two distinctly different traditions about the responsi- bility for the achievement of excellence.

Our heritage of medical ethics passed down to us from the ancient Hebrew theologians and Greek philosophers places the responsibility for excellence un- equivocally on the physician. Tho physician alone carries the responsibility for the wisdom of his advice and is obligated always to a.ct in the best inter&s of the patients. This responsibility cannot bc avoided. It r&s on us all regardless of personal interest, type of practice, or political allegiance. It rests on physician administrators just as much as on those in private practice. Physicians in- stinctively and properly oppose anyt,hing t,hat interferes with the exercise of this responsibility.

Though this heritage of medical ethics provides an invaluable guide -for personal conduct, it proves inadequate to guide public policy. Individuals are fallible. Even Moses never reached the promised land. We have another heritage, a principle basic to the very foundations of our democracy, that government is responsible for doing things the people cannot do for themselves individually, In this tradition long ago we established means of assuring sanitary water supplies and pure foods. 1)octors have never hesitated to support legislation promoting public health, that is, health of the public a,s a whole.

Now, recently the people of our count,ry have become increasingly concerned about their personal medical care. Despite the spectacular advances in medicine, they find it too specialized. It is too hard to get to see a doctor, especially in the blighted parts of the cities or in the country. Medical care has become very es- pensive and people are not sure they arc getting their money’s worth. Since as individuals, or even as communities, they cannot convince doctors to move back to small towns, or cannot control hospital costs, or cope with other problems of medical care, they call on government for help. And the goverment responds. The country has decided that just, as war is too important to bc left t,o generals, health is too important to be left to doctors.

This trend of governmental control over individual private and personal acts is not limited to medical affairs. Our century has seen government taking on more and more responsibilities that used to be left to the people themselves. Laws have been passed on Social Security, unemployment insurance, civil rights, and racial and sexual equality. Banks and security exchanges are closely regulated. Labor-management relations have become a legal specialty. Laws even regulate our petty habits. We not only require automobile manufacturers to install seat belts but also require people to wear them.

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Presidential address 259

I mention these things to illustrate that present and proposed legislation regulating medical practice is not isolated, but is part of a powerful, profound, and pervasive social development. Physicians have no particular grounds for paranoia.

It is futile for us to try to prevent these changes. It is not only futile, I believe, but wrong, for the purpose behind much of this legislation is what we as physicians want for our patients, anyway. For example, Congress has directed the FDA to assure that the drugs and biologicals available for us to prescribe are effective and not unreasonably dangerous. What more could we ask? The PSRO legislation is intended to see that people admitted to hospitals really need to be there and that they receive appropriate treatment while they are there-our goals exactly. No, the tension between doctors and government arises not from differences in the ends but in the means, not in the conception of the laws but in the details of their administration. The tension comes from conflict between the inescapable individual responsibility of the physician and the collective re- sponsibility of society fundamental to our democracy.

Is this conflict inevitable ! When the ends are the same cannot means be found that reconcile differences? In a free society are not the individual responsibility of the physician to his patients, and the collective responsibility of society ex- pressed through its government not only compatible but also complementary? I believe that they are, and that it is up to us to work out the structure and se- quence of this kind of complement with the same skill and diligence as was exerted on hemolytic complement.

Some of you may quite rightly object at this point that I have presented a simplistic approach to a very complicated matter and that in speaking in ethical terms I have overlooked the real issues, namely, money and who will control the day-to-day decisions of medical practice.

I will plead guilty to the charge of oversimplification. Surely, this is one of the most complicated social issues of our time. But I hold fast to the belief that ethics is at the heart of the socioeconomic difficulties facing the medical pro- fession today. Further, I believe that describing the situation in ethical terms sheds light on the path the Academy and similar professional societies should follow toward a resolution of these difficulties.

How, then, can we proceed? In dealing with governmental bureaucracy each of us individually is powerless, for local and regional officials have no authority to make policy or interpret regulations. The proper time and place to influence Federal decisions is in Congress as the legislation is being written, and in the various Executive Offices as the details of the regulations and language in- terpreting and implementing the legislation are prepared. This past year the Academy has sent representatives, Francis C. Lowell and William Pierson, to testify before congressional committees. Both reported they were well received and felt their effort was rewarding. Incidentally, so far as I know, they were the only representatives of specialty societies who took the trouble. We need more of this activity on many other subjects. Congress needs and welcomes our views. Who better than allergists, for example, can explain the need for full labeling of processed foods or of goods that contain sensitizing chemicals.

Sidney Friedlaender, representing our Committee on Specific Therapy,

260 Reed J. ALLERGY CLIN. IMMUNOL. MAY 1974

presented testimony to an expert panel of the FDA on bacterial vaccines. We have reason to believe that this testimony, too, will be helpful to the pane1 when it makes its final recommendations. Again we need more activity of this kind.

I recommend that the Academy establish a Socioeconomic Council with a sufficient number of committees of hardworking members who keep themselves informed and who establish effective working relationships with Congress and the various appropriate Federal offices. Our aim should be to see that legislation and administrative regulations really do work for the benefit of our patients. Attention to details is essential, for the details make the difference between beneficial and harmful regulation.

In addition, the Council can play a valuable role in a full examination cost, of the regulatory processes. The costs include not only the budget of t,he agencies, but also costs of physicians’ time spent both in carrying out peer review, and perhaps even more in preparing to bc reviewed. We should examine the ratio of atlvantages to disadvantages. Regulat,ions not only can keep things from happening that should not happen, but also can prevent good things that should happen. Our committees should cxaminc t,he cost-effectiveness ratio. We shoulcl also have committees offering assistance to state and regional allergy societies in their dealings with insurance carriers, HMO’s, and similar agencies. These committees should develop a liaison with similar c*ommittees in other specialty societies, and if such committees do not exist we should encourage their de- velopment. It is not yet too late, but it would he dangerous for us to delaS much longer.

The Socioeconomic Council would require a substantial budget for adequate staff including legal council. The ,Judicial Branch of government is assuming increasing importance. WC must be prepared to seek relief from the courts as a last recourse if the regulations become overzealous and oppressive. To do the job right might eventually take twice as much money as we spend now. Obviously we will have to raise our dues as other large specialty societies with active programs in education and public affairs have done.

I urge, too, that the Academy continue to cooperate with the College and the Association in these matters, and that we pursue the merger negotiations to the end that allergy speaks in public with one strong voice, though we disagree sometimes among ourselves, as good friends should.