Q&AA look back at a career spent fighting for internists
By Deborah Gesensway
For the first time in nearly 30 years, organized internal medicine will have to make do without the services of Alan R. Nelson, FACP. ACPASIM's Associate Executive Vice President—and ASIM's Executive Vice President (EVP) before the 1998 merger—is stepping down at the end of the year.
Dr. Nelson's career in organized medicine began when he was 36 and working in private internal medicine and endocrinology practice at Memorial Medical Center in Salt Lake City. He was tapped by the Utah Society of Internal Medicine to urge the state medical society to take ownership of the then-hot issue of peer review.
One thing led to another, and Dr. Nelson ended up a delegate from Utah to the AMA. He then became one of the youngest members ever elected to the AMA's Board of Trustees, eventually serving as AMA president from 1989-90. He was appointed ASIM's EVP in 1992.
Dr. Nelson has seen how organized medicine can be an effective voice for all sorts of issues important to medicine. These include public health concerns such as vaccine safety, as well as public policy issues such as health insurance access and promoting the importance of internal medicine in the health care system.
Most recently, he takes credit for helping bring about the merger between ACP and ASIM, saying it was important both "because almost all internists wanted it" and because it "enhances our capability to represent the internist and get adequate recognition of our value."
Now 66, Dr. Nelson looked back on his career during an interview with ACPASIM Observer this fall.
Q: What was the most pressing issue you had to deal with when you started with ASIM?
A: One of my main goals was to gain better recognition of the value of the internist in the health care system. At the time, that meant gaining recognition for the value of internal medicine services in terms of reimbursement. Now, of course, it means establishing the value of internal medicine within managed care entities. It's still an issue, but I think we've made progress. "The Internist Today" project [the College's public education campaign] is the latest effort to differentiate the value of an internist.
Another of the big challenges early on was to better understand the environmental factors that make internists unhappy. It's not just pay; it has to do with the hassles. I keep saying that unhappy physicians don't provide as good care as those that are satisfied. A calm, confident, secure physician provides better care to patients than one who is under siege.
Q: Have we made any progress on another issue that was at the top of your agenda when you came to ASIM: the excess capacity in the health care system?
A: No, and there are a million reasons. One of them is that the public is cynical about professional birth control. The media say that we don't want to share the buck with other practitioners. But there are ample reasons why this is society's problem. Excess capacity isn't good for people. It isn't good that there are doctors who are not busy enough providing necessary services and who lapse into less honorable activities like selling products out of their offices, which the profession would be better off not doing.
Maybe there has been a little progress. At least now we can have the discussion. Fifteen years ago, whenever the AMA tried to raise the issue, it had to worry about being charged with antitrust.
Q: What's your view of the AMA's decision to form a labor union for some of its doctors?
A: I was not in favor of the AMA creating a collective bargaining unit. It was not that I didn't understand the need for physicians to have some additional way of representing their interest in this environment, but more that I didn't think it was the right way with respect to the public image of physicians. But the AMA had a valid survey that found that the public felt the AMA had to have some sort of bargaining capability to hold its own against managed care. The managed care industry is ranking right down there with the tobacco industry in the minds of the public.
Q: So why is Congress having such a tough time passing patient protection legislation?
A: There are eight or nine very important provisions on which both sides agree, such as prudent layperson standards for emergency rooms, conflict-of-interest reporting and reviews and appeals within a system.
The trouble lies in those areas where Republicans traditionally have problems: One involves states' rights and ERISA plans, and the other has to do with litigation. I think that even if they have to compromise on things like this, they will have accomplished an enormous amount. If the conferees can't get the whole nine yards, I really want them to get enough that the president can sign it.
Q: For a pragmatist like yourself, it must be frustrating to try to work in the current Washington climate where the two parties are so polarized.
A: It's true that every conscious act is taken with a view toward next year's election, but I look back on the last eight years with a good sense that it wasn't time wasted. Either we came out better than we otherwise would have—like on Medicare cuts, where internists came out better than most physicians—or we actually were able to accomplish something to increase the care for our patients. The Kennedy-Kassebaum bill is a good example because it had an important provision expanding health insurance to kids.
Q: What do you see as the biggest challenge to the profession down the line?
A: Making sure that we don't lose our humanism. I believe that if the technologic advances that are occurring in medicine aren't accompanied by humanistic behavior, then doctors risk losing the bond that they have with patients. By humanism, I mean compassion and understanding and respect for patients' rights and for their need for information and their family's need for information and for assuring continuity of care and returning your phone calls
Q: What are your future plans?
A: First of all, I am going to continue working as a consultant to the executive leadership of ACPASIM. I'm also on the board of Intermountain Health Care in Utah and am serving on an Institute of Medicine roundtable on environmental health sciences and research. I'm continuing to receive speaking requests, and I may very well get back into clinical medicine as a volunteer.
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