Am Fam Physician. 2000;61(10):2941-2947
This feature is part of a year-long series of excerpts and special commentaries celebrating AFP's 50th year of publication. Excerpts from the two 1950 volumes of GP, AFP's predecessor, appear along with highlights of 50 years of family medicine.
This feature contains excerpts from the “Report of the Executive Secretary,” by Mac F. Cahal, published in the July 1950 issue of GP , and commentary by Robert Graham, M.D., executive vice president of the AAFP. See also “Inside AFP,” page 2939.
LAST YEAR, in my annual report, I said that the state of the Academy was good. Today, I am happy to tell you that the state of the Academy continues to be good.
If this statement sounds familiar to you, permit me to offer the assurance that any similarity between this annual report and President Truman's recent message on the state of the union ends at this point.
The attempts of Messrs. Truman and Ewing to destroy one of the vestigial rights of freedom in our country—the right to choose and pay for one's own doctor—the attempt to supplant this with a system spawned in the fetid soil of socialism received a serious set-back during the year.
The President's proposal to elevate Ewing to cabinet status and thus give him a more powerful instrument for the dissemination of propaganda for sickness insurance was soundly defeated in the Senate.
Do not underestimate the importance or the significance of this development. This was perhaps the first turning point in the insidious move for socialized medicine in this country during the past 18 years. Remark, for instance, that for the first time in nearly two decades, the President submitted a tax message to Congress last month that contained no attempt to use the taxing power of the Federal government for some social or ideological reform.
The atmosphere has changed. I do not mean to imply that this battle is won—it is to be hotter than ever during the next two years. It is not too much to say that in this critical period final decision will be made on the system of political economy under which the citizens of this country are to live in the future.
But the path has veered slightly. Witness the vague and unenthusiastic remarks the President had to offer about “health insurance” in his last official message to Congress.
The turning point came in the defeat of the President's reorganization plan No. 1. And, the American Academy of General Practice played an important role in defeating this proposal.
This, ladies and gentlemen, is significant. It serves to underline the enormous potential power of the Academy and it points the way in which that power can best be used on the national scene. The Academy, following policies laid down by this Congress of Delegates last year, has not gone to Washington with a separate voice for medicine. It has occupied its place in the solid ranks of organized medicine, using its considerable weight for the good of the whole. . . .
But, when word came down the line that action was required on the attempts to boost Mr. Ewing into a strategic spot for the opposition, the Academy swung into action. The Committee on Legislation and Public Policy acted promptly. Telegraphic appeals went out to our state chapters. The result was spectacular. Seasoned Washington lobbyists were astounded at the pressure that began to be felt in Congress from “back home.” A legislative proposal that nearly everyone thought would pass unanimously was decisively defeated.
The entire credit does not belong to the Academy, of course. But, its influence was felt, promptly and effectively.
This gives a hint of the strategic position the Academy of General Practice will fill years ahead while the issue of socialized medicine is debated in the forum of public opinion. . . .
This is one of the direct and tangible results of the very existence of the Academy. The formation of this vital new organization less than three years ago, the creation of 44 active state chapters, and the enrollment of more than 10,000 members in every state in the union has created currents of influence that are already bringing about a renascence in the basic element of our of medical practice. At least once every week, during the past year, some officer of the Academy has participated in a meeting, somewhere in this broad country, where he was invited to represent the American Academy of General Practice. Whether it is so intended or not, the fact is that in filling such an engagement, our representative speaks with the concerted and unified voice of the 100,000 general practitioners in America. Even some of our own members may not have been fully aware of this profoundly important fact.
Last year at this time I reported to you a total of 7,373 members whose election had been certified by state chapters and whose enrollment had been completed at headquarters. As of the first of January this year, that number had increased to 10,395; new members have been added to the roster at a fairly steady rate of about 250 per month. . . . The truth is that we have taken in new members about as rapidly as we could process their enrollment. More rapid increase would have required that practically the entire attention of our staff be devoted to this business alone. . . . The important thing is that the American Academy of General Practice has been accepted by the rest of the profession as the representative of and the spokesman for the general practitioners of America. . . .
The publication of our journal GP next month will undoubtedly stimulate membership applications. You will hear more about GP from the Publication committee. Permit me to assure you that it will attain the standard you expect of it; it will be the best in the field. A pre-publication issue distributed to the advertising trade has caused widespread comment. Competitive national journals are laying down a heavy barrage to secure their positions. Our journal will create something of a sensation in the field of medical publishing. In developing it we have followed exactly the same principles we adopted for our first annual Assembly. It has to be good; it will be good. . . .
Of the numerous resolutions adopted by the Congress of Delegates last year, four called for affirmative action:
One directed that copies of a statement opposing socialized medicine should be forwarded to the President of the United States, the Federal Security Administrator, and all members of Congress. This was promptly done.
Another directed that an endorsement of the AMA educational campaign against socialized medicine be communicated to the secretary of the AMA. This was done and an appreciative acknowledgment was received.
The third called for the appointment of a committee to study the problems of medical care insurance. A special committee was appointed by the Board of Directors, with Dr. Jack DeTar to maintain a liaison with the Blue Shield plans.
The fourth recommended that the activities in public relations be expanded to the fullest extent. This has been done to the extent permitted by Academy finances.
The purposes of the Academy are set out in its Constitution. These are not, however, identical with the principles that give vitality to its program. What are these principles, in which we all believe? Running through the reports of all these committees, I think you will find certain assumptions, truths so self-evident as to need no recitation. Put together they form a kind of creed, a creed that has bound the members of this Academy together in a common endeavor. It is worthwhile, perhaps, at this point in your deliberations, to state them. These tenets fall, it seems to me, under five general headings. We believe that:
First: A system of medical practice in which both doctors and patients are free agents unfettered by governmental control will, notwithstanding admitted deficiencies, guarantee to the American people the finest possible quality of medical care. Any effort to improve the distribution or availability of medical care through compulsion creates evils and disadvantages that far outweigh any theoretical benefits. The social problems of sickness can be solved through voluntary means and agencies: the government's role in medical care should be supplemental to the voluntary efforts of free citizens.
Second: The strength and value of any system of medical practice must ultimately rest upon the foundation of general practice—it can be no better than this basic foundation. The consuming public will benefit most if each family has a family doctor as health consultant and adviser. Furthermore, the cost of medical care will be minimized if the family doctor is consulted first in all cases of illness. In his key position as family physician, the general practitioner is, and should be regarded as, a specialized practitioner performing a service that cannot properly or safely be performed by any other type of practitioner.
Third: The practice of medicine is a public trust. Every physician owes a duty to himself, to his patients, to his profession, and to his country. He is obligated to participate in the political activities of his nation, in the civic life of his community, in the organizational work of medicine, and in the scientific aspects of his profession.
Fourth: Every competent physician should have access to the facilities of a hospital in his community where, within the limits of his training and experience, he should be privileged to care for his patients as a member of the active staff. Such privilege should carry the corollary obligation to participate in the educational activities of the hospital and to subject himself to the supervisory and disciplinary control of the staff organization.
Fifth: The practice of medicine is a continuing discipline; no physician can keep abreast of scientific progress without engaging in sustained postgraduate studies. Facilities for such continuation study should be made available to every practicing physician.—MAC F. CAHAL
‘Health Care Reform’—The Issues from 1950
Our review of the 50-year history and contribution of AFP has provided a wonderful opportunity to become reacquainted with some of the burning issues from the early days of the Academy. Some of those issues seem clearly related to the unique elements of mid-century U.S. medicine—physicians returning from war, the unavailability of hospitals in rural areas, etc.—while others have a definite ring of contemporary relevance. The Academy's first executive secretary (the position now titled as executive vice president) was a young lawyer named Mac Cahal. Mr. Cahal's address to the Academy's Congress of Delegates in February 1950 was captured in the July issue of GP and was a detailed description to the Congress of the Academy's role in the Washington debate around President Truman's proposal to offer “health insurance” to all Americans.
Whereas the Academy today is one of the most forceful advocates within the profession for assuring that all Americans have financial access to basic health services, the concerns of the Academy leadership in 1950, as captured by Mr. Cahal's comments, were markedly more cautious. In the debate that year, the positions had clearly hardened into “socialized medicine” versus the desire of the medical community for a system of medical practice with minimal participation from the federal sector. Mr. Cahal noted in detail the political strategies that the Academy had entered into with the AMA and others in medicine to work with the Congress in Washington to assure that President Truman's plan was not adopted.
So, it might appear that things have changed substantially in this area of Academy policy advocacy in the past 50 years. But, perhaps the change is less obvious than would be apparent from the juxtaposition of the Academy's fighting “socialized medicine” in 1950, and our efforts today to assure access to needed health services for all Americans. Whereas the 1950 debate appeared to create a dichotomy between a totally new federal program or the status quo, few in America today seem to advocate the takeover of the health care system by the federal government— a step that the Academy would oppose.
Instead, today's debates are more complicated and multifaceted, with it being generally acknowledged by all participants that substantial numbers of Americans face significant barriers to needed health services because of the type of medical coverage they have, or don't have. Now the discussions seem to center on mechanisms by which that gap can be closed, whether by expansion of existing federal programs, creating tax incentives for purchase of private coverage, or providing incentives or mandates for employers to provide coverage. Like 1950, the Academy is very much involved in the debate, and has its own legislative priorities. And, as in 1950, the Academy is pursuing this based on a set of principles that seek to put the interests of the patient in the forefront and demand that the role of the family physician be a central one in organizing and delivering services.
Membership-based organizations of the complexity of the Academy frequently see evolutions in the policies that they articulate. In the case of universal coverage (or “national health insurance”), we have a fine example of where the Academy's policy has both evolved in 50 years and at the same time remained true to the core principles of physician advocacy for patients and the central values of family physicians to the health care system.—ROBERT GRAHAM, M.D.