They Also Serve Who Simply Pay Their Dues

Michael L. Nahrwold, MD
Article Type: 
Spring 1996
Volume Number: 
Issue Number: 

“Stop whining, Mike.” The voice belonged to J.B., a fellow Ski Patroller at Ski World Ski Area in Nashville, Indiana. It was our first duty shift of the season, and the snow was absolutely perfect, with a substantial man-made base covered by several inches of natural snowfall, a rare occurrence for southern Indiana. I had looked forward to this day for months, but now that it had arrived, I found myself in the throes of a modest depression.

“I have lots of reasons to whine,” I replied, “my life is falling apart.”

“Well, you will just have to deal with it. We have a great group of patrollers on our shift, and if you’re going to be like this, you’ll just have to work another day.”

I started thinking to myself. J.B. was right, of course, but I did have plenty of reasons to whine. After all, in a period of a few short weeks my whole world seemed to have come crashing down around me. First, my eighty-nine year-old mother died. It was not unexpected, as she had contracted a terminal illness some months previously. But I had to watch her endure substantial change in her usually ordered life as our family was forced to move her from an apartment to a nursing home to a specialized care facility. Near the end, she was in a great deal of pain and it seemed as if we had to beg her physicians and nurses to provide her with adequate analgesic medication. She died over the Thanksgiving holiday, and what should have been a wonderful few days with my wife and children turned out to be a sad occasion indeed.

This was just the beginning. I always find solace in the church during trying times. Although I am in no danger of imminent canonization, I have participated in a folk music group each week for many years. I enjoy being around people with spirituality and it truly helps me during difficult times. As I looked forward to our next week’s practice session, the leader of the group called. It seems that the minister, the music director and the other members of the group had all been bickering, and everyone but me had quit. So much for organized religion.

At times like these, I have also used jogging as a way to get through life’s rough spots. I particularly look forward to my regular Monday night run with an old friend. He is always a font of commiseration and good advice. But that option was not available, either. You see, a chronic knee injury has forced me to stop running for several months. I have gained fifteen pounds and l look awful. To make matters worse, my loss of stamina has affected my skiing ability.

I am afraid the situation at work has not been much better. My partners have just voted to reduce our pay and to give up control over a portion of our income.

So there you have it. Except for my family, most of my social support network had crumbled and I was left to reorganize and reprioritize my life. At least not much else could go wrong, could it?

Well, there is the little matter of the merger. You see, I practice and teach at a university hospital. For a couple of years, there had been vague rumors that the largest private hospital in Indianapolis wanted to merge with my hospital, but no one gave it much thought. Then one day, out of the blue, our Dean and Hospital Director announced that they had agreed to a merger. They said we needed to do this to ensure that we would not lose the patients necessary for teaching medical students to the many managed care groups that were gobbling up physicians and patients in Indiana. Never mind that we could reduce the size of our medical school class (one of the largest in the country) and achieve the same end. Never mind that the legislature could simply mandate that all managed care organizations doing business in Indiana must not exclude University Hospital. Never mind that the private hospital was in deep financial trouble and our hospital was in the black. Never mind that the CEO of the “non-profit” private hospital, who was announced as becoming the CEO of the merged hospitals, was laying off patient care personal right and left to try and stay afloat while collecting annual compensation of $580,000. Never mind that our hospital staff consists of full-time teachers while the staff of the private hospital are physicians in private practice for whom teaching is a sidelight. And on and on and on.

Perhaps you are wondering why anyone in a leadership position would embrace such a merger.  Well, I left out the part about the managed care organization. You see, the merged hospitals are going to form a managed care network that is supposed to be one of the largest in the country. It is projected to do over one billion dollars’ worth of business annually. So now we are talking big bucks and big egos. Perhaps this is beginning to sound vaguely familiar.

I am afraid the rest of the story will sound familiar, too. The governor appointed a commission to study the merger and then make a recommendation. At the hearing, I and a colleague were the only rank-and-file faculty members who spoke out in opposition. The rest were either to naive or too fearful of their jobs. I wrote a long letter to the editor of our newspaper. Few others did the same. Some of my colleagues started talking about how it might not be too bad after all. No one wanted to make waves or become involved. To make a long story short, the commission advised the governor to approve the merger, and he did so. So ended the final chapter in the continuing saga of my life gone awry.

“So snap out of it, Mike,” said J.B, interrupting my train of thought. “Put it all behind you and get on with your life.” He was right, of course. I would simply have to accept many of the things that troubled me. The rest I would have to try to deal with as best I could. The merger, though, presented a particularly nasty dilemma.

You see, as a member of the Association of American Physicians and Surgeons, I have always supported the practice of private medicine. Now, it would appear, I am going to be a part of a huge managed care organization. Many such entities put profits before patients, and physicians who participate in them violate their Hippocratic Oath. So what am I supposed to do, leave academic medicine and try to find a private practice to my liking? I have one daughter in law school, one in college, and a son in a private high school. Do I take a chance on substantially lowering my income and cheat them out of a decent education? Do I really want to change my whole life around because of some stupid merger?

I am sure many other AAPS members find themselves in a similar situation. Although we have many members who do adhere strictly to the principles of the practice of private medicine, it is my belief that most cannot. Should they be ostracized and drummed off the membership roll? Of course not.

Last fall, several members and I manned an AAPS exhibit at the annual meeting of the American Society of Anesthesiologists. Talking to prospective AAPS members was a real eye opener for most of us. A vast number of them were opposed to managed care, even though they were involved in it in their daily lives. They wanted to do something about it, but feared for their jobs if they spoke out in any way. They felt that they could not join the AAPS because they were not strictly practicing private medicine.

Most of them were surprised when I admitted that I was involved in managed care to some degree. I explained to them that the AAPS is not an exclusive society. Simply agreeing with its principles and sending a check demonstrates sufficient zeal to become a member. I pointed out the glee with which I greeted the news that the Clinton task force was being forced by the AAPS to turn over its documents. I told them how I relished seeing Ira Magaziner trying desperately to explain things on television, knowing that my money paid in the form of AAPS dues contributed to his being there. I explained that we have a diverse membership in terms of their ability to speak out publicly. Those who, for practical reasons, must remain silent are no less valuable than those who are interviewed by the national media.

I picture the AAPS as an inclusive society of physicians who are united by a common philosophical bond which centers around the practice of private medicine. Accordingly, membership is open to anyone who wishes to return the delivery of health care to a sacred contract between doctors and patients. As such, there are a lot of prospective members out there. We need to give them our message and encourage them to join our ranks.

Dr. Nahrwold is a Professor of Anesthesiology at Indiana University School of Medicine. His address is 1120 South Drive, Fesler Hall 204, Indianapolis, IN 46202-5115.

Originally published in the Medical Sentinel 1996;1(1):23-24. Copyright ©1996 by Michael L. Nahrwold. All rights reserved.




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