Review of Who?
Sen. Graftin Cloakroom entered the house with his cape flowing. He handed me his cane and a high hat with a velvetized surface that shone even in the dim light of the foyer. Lapius had warned me that he was coming to discuss some of the legislative aspects of peer review, so I wasn’t exactly taken by surprise, but I wasn’t quite prepared for his sartorial get up, black string tie and all. When I placed his hat and cape in the closet he tipped me a dime.
S.Q. Lapius was polite but reserved. “Yes, Senator,” he said, after they had shaken hands, “To what do I owe the honor of this visit?”
After Cloakroom had been seated and was coddling a glass of port wine, I lighted the fire. He muttered some pleasantries, hemmed and hawed and then got to the point. “Simon I want you to help us with the peer review thing. You are aware, of course, that your state society is contemplating bringing suit in Federal court to upset the Bennett Amendment that establishes the Professional Standards Review Organizations. This bill will give the government a chance to monitor its Medicare and Medicaid payments, to be sure that the medical profession is giving good value for the dollar spent. I can’t imagine why doctors wouldn’t flock to the standard and help out. It’s their patriotic duty.”
“I didn’t catch that, Senator, did you say idiotic duty?”
“Patriotic, Lapius, patriotic,” Cloakroom reiterated sounding a bit miffed.
“You are an important member of the society, Simon. You could talk to the leadership and try to forestall the wild hairs who are bucking this amendment.”
“Yes, I could--.”
“Then it’s agreed,” the Senator said smugly. “I knew you would come around. Any sensible man would be in favor of peer review. Not that we don’t trust the doctors, mind you, but anyone that spends money should have available the means to be sure he has gotten his money’s worth, and that includes government.”
“Just a moment, Senator, I said I could – but I won’t.”
“You mean you are not in favor of peer review?”
“On the contrary, I do favor it.”
“But you just said --.”
“I’m in favor of peer review of the Congress and the executive branch of government, not of doctors.”
“Aren’t you being ridiculous, Simon. We are reviewed by the voters every four years, and by the press daily.”
“Not good enough for me. You should have someone looking over your shoulder day and night, checking your expense accounts, questioning your appropriations, watching your voting record. If your peer reviewer doesn’t like what he sees he should have the power to kick you out of the Congress.”
Cloakroom scrutinized Lapius carefully seeking signs of jest and good humor but found none. Indeed, Lapius was frowning, no mean feat since it meant that he had to do physical work to mobilize his heavy jowls.
“Senator,” Lapius said slowly, “I’ve given this matter considerable thought. Wouldn’t you agree that the medical profession has attained a record of remarkable proficiency? That the practice of medicine is extremely effective. We can prevent disease, cure what once were incurable diseases, transplant organs, replace arthritic joints.”
“Yes, of course I would agree with that. But you must remember that it was the government that subsidized much of the research that enables you to do these things.”
“Of course it did. But the medical profession was alert and disciplined enough to take advantage of new findings and to incorporate them into practice. The cooperation of industry has been important. We have remarkable drugs, electronics, plastic implements to assist us. But the important thing is that all these advances have been brought to the patient.”
“That’s the problem, Simon. They haven’t been brought to enough of the people.”
“Hell Senator, that’s not our fault. The point is that when the government brings the people to us through Medicare and Medicaid, these patients can get the best medical care available anywhere up to and including coronary bypass surgery, renal dialysis – you name it.”
“Of course that’s true.”
“Well, damn it, Senator, if you believe that’s true why do you want to monitor us? Do you believe there is some sort of collusion between doctors and patients to fleece the government? Do you believe that just because it’s free someone is going to be willing to spend one day more in a hospital than is necessary, or undergo a kidney transplant, or walk on crutches?”
“Of course not.”
“Then why look over our shoulders. How can there be too much care? Don’t the poor have as much right to nurse their neuroses as the rich? Haven’t they the privilege of being hypochondriacs if they want? Who are you or any government to say just how much medicine is enough? If a patient feels better for no other reason than that his fears are allayed, or gets moral support and reassurance from a visit to his doctor, are you prepared to say that that is over utilization? Of course some people take advantage. Sure some people are doctor addicts – but then a visit to the doctor is what they need. If they had money they would support the habit. Why deny the privilege to the poor. And keep in mind also Senator, that some people only go to doctors when they are sick. Are you going to legislate what is sickness? Are you going to make laws deciding just how lousy you have to feel before you are entitled to go to a doctor? That is what peer review will lead to.”
“So I take it you won’t help me,” the senator said lamely.
“Not in peer review for medicine. But, Senator, perhaps you could help me with a project.”
“What would that be,” asked the disconsolate solon.
“You could help me on the Senate floor to pass a bill that would enable the medical profession to peer review the government.”
“You are out of your mind, Lapius,” Cloakroom said sternly.
“Perhaps, but hear me out. I’ve always been impressed with your logical mind, senator. You have just agreed with me that the American medicine is efficient, well disciplined and effective. We both agree that the fact that it doesn’t reach everyone is an economic problem not a medical problem. Right?”
I had to fill the Senator’s glass with more of the rich port wine before he would nod assent.
“Well, then,” continued Lapius. “In contrast, let us consider the record of the government since the end of World War II. Our country has fought 10 years of unremitting warfare in South East Asia. We have allowed our cities to deteriorate. We have lost most of our public transportation and our railroads are shambles. We have subsidized turnpikes and thereby the trucking and automobile industries, and fixed things so that each American uses more energy in a year than the entire nation did during the civil war. Finally we have allowed ourselves to run out of energy reserves, polluted the air, stripped the country side, and lost command of our coal fields. That’s a lousy record, and I haven’t even started to list my complaints. It was certainly a smaller list that caused the revolution against George III.
“Yet our government with its record of continuing failure at properly managing our affairs, now has the gall to ask the public to believe that if it were allowed to manage the medical profession, the standards of practice would improve. No my dear Senator. It is the other way around. The medical profession has proved itself at its chosen task.
“Logic demands, it seems to me, that the government should place itself in the hands of the medical profession. After all, we have a better record of accomplishment than you do.”
“Lapius,” Cloakroom said, “If I wasn’t sure you were joking I’d say you lost your mind. Incidentally, can’t you turn up the heat? This place is freezing. The fire in the fireplace can’t warm this room.”
“Sorry Senator. We have to conserve heat. Harry, get the senator a hot-water bottle.”