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A.E.I.O.U. => Summer 2005

Guy I. Benrubi, M.D.

The Hapsburg emperor of the Austrian Empire, Frederick III (1415 – 93), would stamp all his personal effects and documents with the acronym AEIOU. This was short for Austria erit in orbe ultima (Austria will be in the world to the end). It is not hard to understand why Frederick III would have this opinion. His empire covered all of central Europe, from a truncated France to the borders of the nascent Ottoman Empire. His lands included the fertile valleys of what are now Germany, Hungary, Romania and parts of the Ukraine. He controlled what geographers call the bread basket of Europe. Yet Frederick exhibited another trait that was perpetuated by his Hapsburg heirs. As the historian and literary critic Claudio Magris describes, Frederick exhibited a "reluctance to act, a defensive posture of those who do not aim to win but to survive." After Frederick's reign, Austria entered an inexorable decline and finally disappeared from the map of Europe when Hitler absorbed it into the Third Reich. After World War II and the partition between the allies and the Soviets, it reemerged as a truncated version of itself.

So what's the point?

In 1990, American medicine was about to enter the last decade of the 20th century having completed its own most remarkable century of achievement. If we date the beginning of modern American medicine to the creation of the first modern medical school at Johns Hopkins in 1890, then we can appreciate the amazing achievement of those 100 years. Prior to the Johns Hopkins initiative, American medicine was little more than quackery. The merchant Johns Hopkins, in his bequest, mandated that those teaching medicine would be only of the highest caliber. Among the five original faculty members was J. Whitridge Williams, who was hired to teach obstetrics. During the next 100 years American medicine became a beacon to the world. It was an edifice constructed by science, innovation, and societal support. By 1990, after 25 years of governmental support through Medicare reimbursement, medical school faculties had increased by tenfold. Hospitals had embarked on an expansion program the likes of which had not been seen in any land. Medical advances were announced with such frequency that diseases, long the scourge of humankind, were now facing eradication. We thought the ride would never end. American medicine erit in orbe ultima.

Fifteen years later we know that we were naďve. Medicine in the US is facing the perfect storm, being buffeted by forces it seemingly cannot control. Industry, government, and individuals refuse to pay the costs of health care. Yet industry, government, and individuals demand the same level of excellence and innovation that can only be provided by adequate resource allocation. Decreased compensation per RVU, increased mandated documentation for regulatory and reimbursement requirements, increased expense for medical litigation, and increased scrutiny from all sources have put what was thought to be the indestructible edifice of American medicine in full confrontation with the wrecking ball. Additionally, no one seems to want to bear the cost of training the next generation of American physicians.

We have responded fitfully to this. At times we have been energized and have tried to reverse the course of events. More frequently we have been complacent and have tried to "survive rather than win." This fight will continue for the rest of our professional lives. We drop the fight at our peril. As incomprehensible as it may seem, it is possible that we will lose control of our profession and thus lose our profession. We need to stay together, and we need to fight in order to win.