 So our next speaker is Dr. Daniel Bronner, who is a longstanding faculty member in the section of geriatrics in the McLean Center here at the University of Chicago. Dan's research focuses on interdisciplinary approaches to clinical and ethics research with a particular interest in the care of older people. Dan, for example, has used innovative methods from the field of linguistics to develop novel approaches to improving communication of persons with dementia. Currently, Dan is developing a method for evaluating decision-making capacity in persons with dementia based on linguistics theory and discourse analysis. Dan is also writing a book on the history and evolution of cardiac resuscitation and DNR orders. Currently, Dan is co-director of the Ethics Consult Service here at the University of the McLean Center, and today, Dan will speak on the topic the AMA in the cardiac arrest paradigm. Thank you, Mark, for encouraging me to present my work today in this forum. Today, I'm going to talk about a small part of a larger project, as Marshall mentioned, which was occasioned by a series of visits I made to the AMA archives, which are right downtown. Around the time, Mark was asking for titles for talks. So, cardiac arrest CPR, I use that as a, this slide got, somehow got, just being around the PC will make an app work funny. I'm not paranoid. So, cardiac arrest CPR stands, I use it as a metaphor for understanding how a indication procedure gets established. And cardiac arrest in CPR stands as a metaphor for a procedure that is given, that is applied based on very narrow indications, usually involving a single organ, and often does not take other patient factors into consideration. And the cardiac arrest paradigm speaks to as a metaphor for the applications of procedures more generally. So, we see the pervasive application of procedures in medicine today, often based on narrowly defined indications, frequently pertaining to a single organ system. And the problems with this become most obvious at the end of life, but one needn't be dying to get indication procedures that are not helpful and that fit in this model. So, the constellation of indications for procedures constitutes the standard of care as we practice it today. And I use the changing indications for CPR and its various historical incarnations to illustrate the contingent nature of our understanding of medical conditions. Cardiac arrest exists as a diagnosis because of the therapy or potential therapy to treat it. But this model can also be used as a lens to study the constellation of forces that shape the indications for its application. And by extension, the indication procedures that compromise the rest of the standard of care. So, looking at these forces that created sort of the indications for CPR, we have over 200 year history of resuscitation medicine and it's evolving indication that I'm not going to go into today, but that forms a very compelling history. The very nature of the treatment of death has an impact is one of the forces that affected the indication. There's a strong belief system in the CPR project and we've heard a lot today about beliefs. Also the response to the default, which again I'm not going to get into, but the whole way the discourse at the end of life is a very important factor and I think was instrumental in creating CPR as a default. I'll talk a little bit about that later. And also political and economic forces that are not usually talked about that much are also important forces. And that's what I'm going to talk about today a little bit. I'm going to posit that an important force that made CPR for cardiac arrest the default for every patient who died, whether or not it was going to help them, was its presence on this list. This is the revised and greatly expanded, this comes from the revised and greatly expanded second edition of current procedural terminology that was published in 1970 by the AMA, American Medical Association, Burgess Gordon, MD editor. It was a thin volume when it was first published in 1966, providing codes for mostly surgical billable procedures, but by the second edition in 1970 it had grown by 70% and included CPR for cardiac arrest for the first time. It also included a handy form for billing the government in this form of this mock billing form. Anyway, so my visit to the AMA archives, and this is a painting that hangs in the AMA archives that I took a picture of, it was sort of hidden away because apparently our former Dean Madeira did not like it. But it was painted by Stephen DeHanos who was a member of the Social Realism School along with Norman Rockwell, and he did a bunch of Saturday evening post covers. And this was actually a cover for the Medical Times, and it depicts around the time and around the which I'm speaking of, and this is at the convention in 1960. And this is a paper from the 50s that describes how the AMA each year held two large scientific meetings, and I'm assuming that this was one of those meetings. So anyway, we all have a vague notion of the AMA's role in shaping contemporary medicine, but today I'd like to sharpen it just a little bit. And by answering the question, how did CPT come to be? And these two people here, anybody recognize them? Baxter and Whitaker were the first political consulting firm. They were initially hired by the California Medical Association in 1945 to fight then Governor Earl Warren's proposed plan for comprehensive compulsory health insurance for the state of California. They actually the ones who termed the term Socialized Medicine to describe this plan. They were then retained by the AMA in 1948 after Truman was elected with the promise of federal health insurance program. And this history is covered very nicely by Jill LaPour actually in a New Yorker article. So anyway, this is one of the papers or actually it's a talk I found in the archive. This is part of the campaign against socialized medicine that had many manifestations. This is a talk by Lewis Bauer, Chairman of the Board of Trustees of the AMA. And he gave it to the National Association of Retail Drugists. It's now called the National Community Pharmacist Association in September of 1949. And it's useful, very useful because it defines what they really meant by socialized medicine. First of all, what is socialized medicine? This is from the beginning of the paper. You can get a variety of definitions depending upon whom you are talking. But I think it's a general rule. We may say that socialized medicine is any plan which the government supports financially by direct or indirect taxation, prescribes the rules and regulations under which medical care will be administered as far as doctors, patients and hospitals are concerned, and when it determines directly or indirectly the fees to be paid for services rendered. This is uncanny in its accuracy of the description of medicine today. But I think it sort of becomes ironic because the AMA I think did a lot to sort of push for medicine to move in a certain direction that I'll be talking about. This is a paper from an interesting journal, The Yale Scientific Magazine, which I don't think is in existence anymore, published in April of 1954, and it's very similar to other papers that the AMA was putting out. Socialized medicine, a case for free Entebuk Prize by George F. Lowell, Secretary General Manager of the AMA. And he talks about, instead of repeating the familiar arguments against socialized medicine, the American Medical Association presents its positive program. It's pointing out the past accomplishments, the present progress, and the future potential of the American medical system. The AMA serves notice that the world's best medical system stands a fair chance of deteriorating under government control. And that really was the big worry at the time. This is a paper, again I found this in the archives, and I found the reference to this in the archives. And this comes from a paper that was published in a journal called Problems of Communism, but was then truncated and published in JAMA the very same year. And that was really, the fear was that US medicine would become more like that in the USSR. So the several factors in this fear were, one was just the loss of sort of economic financial one, the financial worry here. They talk about medical doctors making much less than the workers in the plant in which they took care of them. So the workers were getting 2,000 rubles, and the physicians were only getting 750 to 800 rubles a month. The other fear expressed in this paper, again that was published in JAMA afterwards, is the amount of control by the government. And here we see doctors working for the government in doing health evaluations. And here we see this guy is before entering technical school, he's in the picture of health. But then in the second image we see when he summoned for duty in the provinces, all of a sudden he has medical certificates indicating that he's not healthy anymore. So doctors then becoming sort of workers for the state was one of the worries. And the other worry was the impending bureaucracy and taking patients away, doctors away from their patients. This is actually a time study of two Soviet doctors work in 1953. And you can see listening to and examining patients was only 1.9 minutes per patient. Reading and writing case histories was 2.6 minutes per patient. And then the paperwork in scare quotes was 3.7 minutes per patient, the longest amount of time. And I think this is similar for the second patient. So it's a very interesting look at their fear that medicine was going to become more bureaucratized as it was in the Soviet Union. So this is another treasure from the archive that illustrates another important movement in the AMA that was developing in the 1950s. And this was in the form of the Committee of Medical Practice that was instrumental in sort of creating CPT eventually. But the primary goal for it when it was developed in the 1950s was the inequity between medical and surgical fees. And so the Committee was put together to address this. And you can see here that medical specialists were only making $10,944 whereas surgeons were making $15,000. And a pediatrician again was not making very much. A neurosurgeon was making the most at $24,000. And so the Committee was put together to sort of address this differential. So looking at the introduction to the first CPT, we find an interesting notion here, the relative value studies, which was something that I really didn't know about prior to visiting the archives and which actually turns out to be one of the main goals of this committee, the Committee on Medical Practice. And they have many proceedings. I found a bunch of series of these conference proceedings going through the archives. And this was one of the more telling ones. This was the fourth regional conference on relative value studies. And this gives you sort of an idea what they were about. So this is the opening remarks by Lester Bibler to this fourth conference. And he's like to emphasize that in holding this meeting we are trying to carry out the mandate of AMA delegates first expressed in the 58 clinical session. The purpose of this conference is not to indoctrinate anybody. It is to inform medical professions of an important development in which a number of constituent associations are participating to inform you of the purposes, scope and objectives of relative value studies. So these were meetings in which they were trying to get this idea of relative value studies and the need for them. And he said at the end of his talk here, these last lines, I would suggest as a method of procedure that questions be deferred until after we have heard from Dr. Cox who will conclude the presentation this morning. You will be able to direct your questions and problems to all the speakers in there, boy, avoid any necessary repetition. So this was really a very sort of hot button topic at the time. And these were these relative value studies that were done across the country. And I found one of these surveys in the archives. And you can see here that they were created by the California Medical Association. They were following their model and I'll talk more about that. But basically what they did was they predicted there would be like 1900 items ultimately. But what they did was they took a small representative sample of the procedures that doctors did in their offices and they asked the doctors how much did they charge for these procedures. And they did surveys, every state medical association did a survey of their constituents to find out what the relative values of the procedures that doctors were doing. You can see this for surgery, medicine, fractures. And this was just at the beginning of computer using computers to deal with data and so they were using these punch cards at the time. So this is Francis Cox and he was actually the mastermind of the relative value surveys starting in the early 1950s in California. And he said he starts off with the fundamental premise that no doctor in the nation likes a schedule of fees but if we did not have one and if we didn't have one we'd be better off, this accepted fact. These physicians who object to a concept of the relative values index post the following arguments and you can read the arguments here. You know it's basically controlling what doctors do. But the way he explains it is he goes to the history. And in this history he talks about government really sponsoring medicine since the late 1700s with the creation of the United States Marine Hospitals. And then he goes to the specific state situation that happened in California with a brief historical resume of what happened there in 1910 to 1912 when they initiated workman's compensation. Basically physicians wanted no part of that. He calls it putting their head in the sand. And so they were not involved in creating that at all. And now the physicians have to, every time they want to negotiate a new fee schedule they're obligated to bargain piecemeal for each fee that is approved. So he saw this as problematic especially when he talked about in 1959 the government is already putting in a fair amount of money into the medical enterprise and this was their way of getting physicians to be able to have a say in what was going on. So basically what he says that if we want to continue he concludes with a quote by Lincoln. He says, fellow citizens we cannot escape the history and we of this congress and this administration will be remembered in spite of ourselves. No personal significance nor insignificance can spare one or the other. The fiery trial through which we pass will write us down in honor or dishonor in the pages of our generation. So he's comparing what they're doing to sort of Lincoln talking to the congress in 1862. So he says, yes this I think presents in a succinct fashion as I can the philosophies and reasons I personally believe a relative value study or index if you will should and must be developed by physicians themselves if the private practice of medicine as we know it is to continue. Yes, I just in big words. So this is an example of the relative value studies that came out of California in the 1950s. This is the third edition and basically it laid out what it was that physicians do and compared the relative values. See, it was illegal to set fees. So you couldn't set a fee schedule for physicians. So what the way they got around this was by creating these relative values so that you could compare one service for the other and then you would have a multiplier. Here we see hospital visits. I blew it up here so you can see it better. And also we see consultations. And so this was put into effect basically nationwide with the CPT coming out in 1966 which was just around when Medicare was beginning to pay out. So here you can see how this works. You have a multiplier which then allows you to figure out what your fee service should be here. And interestingly they made the point that you can't compare medical services with surgical services so those were different relative. The relative value didn't translate one to the other which ended up not really helping the medicine get parity. So anyway, so they create the CPT. They don't include the relative value scale with the CPT because each state had their own relative value scale. But basically what it was was a list of conditions that now could be billable to the government. And I don't think that it's really a coincidence that if you look at the evolution of CPR for cardiac arrest that it's not until the early 1970s really that you see the beginning of the default application of CPR for everybody who develops cardiac arrest. I'm not saying here that people were doing CPR to make money that doctors were billing them because they said, oh, you know, this is the way I'm going to become a rich doctor. That's not my intent. I think what happened was it's just being on a list as changed the nature of the procedure and the indication became reified on this list. Also, I think the CPR project required a lot of money to fund. And so the initiation of Medicare in 66 really brought in a fair amount of money. We then see in early 1970s sort of in response to this default, the first order, codified order not to resuscitate which then really seals the default status because everybody who doesn't opt out is opted in. And as I say, the rest is history. Thank you. Thank you, Dan.