"So you don't think the AMA would do such a thing?" asked Straus.
"I can't imagine it."
"Ho-ho, my friend. Are you aware of the glorious history of the AMA?"
"What do you have in mind? I know some things about the organization." Actually, I was far from being an authority on the subject, both because it had been ignored in medical school and because — well, I just hadn't been very interested in it.
"What do you mean, some things about the AMA? Are you a member?"
"Well, sort of. You know interns and residents can join at a reduced rate. So I did. But I haven't done anything. I mean I haven't gone to any meetings, or voted, or participated in any way."
"There, that's one of the problems. You are a member. You're one of their statistics. They like to think that everybody is a member, only some are more active than others. The AMA claims it represents some two hundred thousand M.D.'s in the country, but do you know what?"
"What?" Straus definitely gave the impression of knowing what he was talking about.
'Their figures are out of whack. In lots of states, it's rigged that in order to get hospital privileges a doctor must join the local medical society, and with it comes automatic and compulsory membership in the AMA. And do you think most of those doctors care or even think about what's going on in the AMA? Well, dream on, because they don't. They say to themselves, I'm too busy; I don't have time. Or perhaps they have a feeling, although they don't examine it very carefully, that the AMA is dirty politics. In that they are correct. But through their apathy the sweet old AMA stands up in Washington and says that it speaks for some two hundred thousand M.D.'s, who never contradict the allegation. To make matters worse, it not only speaks for them, but throws their money around as well. Do you realize the AMA budget is over twenty-five million dollars a year, paid in dues by the doctors who say they haven't the time to find out what’s going on?"
"Okay, okay." I had to interrupt him; he was getting too excited. Two of the residents on the other side of the table stood up and left, dropping their napkins onto their trays. It was after six, and I had to get to my packing. Yet I couldn't ignore Straus. By now he was leaning toward me, literally in front of Jan, who had to sit bolt upright to accommodate him. I could see his eyes. He was a skinny, intense guy, anyway, and his eyes were burning.
"Straus, I'm not going to defend the AMA, but it is common knowledge that they've lifted the art of medicine out of the chaos it was in the nineteenth century. Before the Flexner report, around 1910, medical training was a joke, and it was the AMA that took on the burden of altering that."
"Yeah, sure they did. But let me ask you, for what end?"
"What do you mean, what end? To rectify a sorry situation."
"Perhaps, but also for their own ends."
"What do you mean by that?"
"Just that they cut the number of medical schools and made them better — that I'll agree to. But at the same time they locked up their control over the accreditation of medical schools. Translated, that means they have control over the supply of MD.'s and control over the curriculum. In other words, they have determined the social path through which potential doctors must pass, and they make damn sure that the students are nicely molded into the system."
"Straus, you are a romantic. Are you sure you want to start an internship?"
"I want to be a doctor, and if there were any other way of getting there, I'd do it. But to change the subject, tell me, Peters, are you aware of the burden of history you're assuming in entering the medical profession in America?"
"What are you driving at?" The last two doctors who had been sitting silently opposite us scraped back their chairs and departed. Only Straus, Jan, and I remained, leaning on a table littered with dirty dishes and soiled trays.
Undaunted, Straus continued. "The AMA has an almost unblemished record of failure in supporting, much less initiating, progressive social changes. For instance, the AMA was against the Public Health Service giving diphtheria shots and setting up V.D. clinics. And against Social Security, voluntary health insurance, and group practice. In fact, in the thirties the AMA labeled medical groups as Soviets!"
I sputtered, trying to say something, but I couldn't get it out.
"A couple more points. Did you know the AMA fought against full-time salaried hospital chiefs, and, closer to home, even against federal low-interest loans to medical students?"
"What was that?" I had started tuning Straus out when he lapsed into his list of grievances, until the words "loans" and "students" connected in my head. I still owed quite a bit of money from my medical-school days. "They were against loans to medical students?"
"You better believe it."
"Why?" That really did surprise me.
"Lord only knows! I guess it opened medicine up to the nonrich. But one of the most pathetic aspects of this scene is that after such reforms have been accepted by society and forced on the AMA, the AMA later tries to take credit for them. Makes you think of Orwell's newspeak in 1984. I mean the whole crummy scene has got to change. I think the government has to do it."
"Okay, Straus. Are you trying to tell me that after going all through those years of study, and all the years you still face, you're going to be willing to work for the federal government? That’s what you seem to be suggesting."
"Not necessarily. All I'm saying is that doctors have had the control, and they've screwed it up. Their responsibility is a lot broader than their solitary practices, treating a succession of individual patients. They've got to consider the totality of health care, including the treatment of the man in Harlem and the family in Appalachia — they're as important as treating a chairman of the board in Harkness Pavilion. If doctors fail again, the government will have to take control and order the medical profession to accomplish what is needed. After all, adequate health care is the right of every citizen."
"That’s easy enough to say, but I'm not so sure. After all, when someone is bothered by a headache at 4:30 a.m., and he gets a doctor out of bed because health care is his right, what about the rights of that doctor? I mean how much can you impose on one person for the rights of another? Surely the doctor has rights, too.
"And besides, if somebody's kidneys give out, but all the artificial-kidney machines are in use, whom does the patient sue? Society can't have an artificial-kidney machine sitting in the corner for every citizen. The fact of the matter is, health care is a service industry provided by highly trained people and sophisticated equipment, both of which are always in short supply. You can't promise health care to all when you have limited resources."
"I'm not going to argue that point, Peters. The federal government has clearly defined health care as a right of its citizens by passage of the Medicare and Medicaid laws."
"Well, Straus, I'd like to talk to you again after you finish your internship. Up until now you've been a student, and let’s face it, if things got too bad you could just walk out and leave somebody else with the responsibility. I wonder if you'll feel the same after this year is over."
Jan had been listening quietly, more, or less on my side, I thought. Now she chimed in. "There might be some problems with health-care distribution, but we do have the best medicine in the world, Straus. Everybody knows that."
"Nonsense," retorted Straus. 'Take infant mortality. The United States ranks fourteenth in prevention of infant mortality, eighteenth in projected male life span, and twelfth—"
"Hold on a minute, Straus," I said, refusing to listen to another statistic.
"Only fourteenth in infant mortality?" asked Jan. Straus had really gotten to her.
"Jan, dear, don't be misled by statistics. You can prove almost anything with statistics if you deal with different sample populations. It can be a kind of mathematical gerrymandering. Straus, being fourteenth or whatever we are in infant mortality probably has more to do with the fact that we keep such accurate records in this country. Lots of countries record only the births in hospitals. All others go unrecorded."