Book Review

Health Care Politics

The Serpent on the Staff: The Unhealthy Politics of the American Medical Association

N Engl J Med 1994; 331:1463-1464November 24, 1994

Article

The Serpent on the Staff: The Unhealthy Politics of the American Medical Association
By Howard Wolinsky and Tom Brune. 267 pp. New York, G.P. Putnam, 1994. $24.95. ISBN: 0-87477-754-2

Since the 1920s a tradition has grown up of cataloguing the misdeeds of the American Medical Association (AMA) for nonprofessional audiences. In one of the earliest works in this category, written in 1929 and entitled The Medical Trust Unmasked (New York: L.S. Siegfried), John L. Spivak depicted the AMA as a vast political machine designed to control all health-related legislation in the United States. Some 65 years later, the same complaint is heard in The Serpent on the Staff: The Unhealthy Politics of the American Medical Association, by Howard Wolinsky and Tom Brune. The authors, both reporters for the Chicago Sun-Times, make no attempt to hide their contempt for the ways in which the AMA and its political-campaign arm, the American Medical Political Action Committee, have attempted to shape national health care policy. Their stated intent in the book is to help readers “see through the imagery and mythology” perpetrated by the AMA to understand how the organization has, above all else, promoted physicians' self-interest at the expense of the public health.

The serpent of the title is the Asklepian viper featured on the AMA logo. Originally, the viper was depicted with fangs and a forked tongue, but it was redrawn in 1990 without them to appear friendlier and less menacing. In the authors' minds, this change, which followed a financial scandal involving the AMA's top leadership, is only window dressing. To Wolinsky and Brune, the AMA remains as committed as ever to five key goals: preserving the primacy of the AMA as a professional organization, guaranteeing physicians' autonomy in medical decision making, maintaining physicians' influence over the structure of the health care system, ensuring a role for fee-for-service medicine, and maximizing physicians' income.

The chapter subtitles reveal the authors' one-sided perspective: “Looking after Medicine's Special Interests,” “Stopping National Health Insurance at All Costs,” “Turning Medicare into a Cash Cow,” “Buying Time and Clout in Washington,” “Keeping Medicine's Business Ethic Alive,” “Waging War on Alternative Medicine,” “Playing Politics with Tobacco and the Public's Health,” “Putting Physician Choice First in the Abortion Crisis,” and “Bungling Health Policy on the AIDS Epidemic.” Unlike some earlier anti-AMA tracts, The Serpent on the Staff presents historical events with careful documentation. However, the events are carefully selected to illustrate the authors' conviction that the AMA leaders are masters of political pragmatism, willing to sacrifice ethical principles to achieve their own political ends. For example, in the chapter devoted to the historical links between the AMA and the tobacco industry, the authors discuss how the AMA allied itself with tobacco-state congressmen in the 1960s to help impede the passage of Medicare legislation and in return permitted a delay in passing a national ban on cigarette advertising.

The book recognizes the AMA's current problems with its public image and acknowledges that the AMA and the American Medical Political Action Committee are no longer the sole voices of the medical community on Capitol Hill. Thus, Wolinsky and Brune do not talk about the monopolistic powers of the AMA as Spivak did in 1929. Like him, however, they are deeply suspicious of the motives of the AMA, admonishing their readers to “Beware the Serpent on the Staff” as health reform comes into play. The book is valuable reading for physicians who would like to see how the AMA has dealt with the legislative process over the years, but it is less rewarding for readers seeking guidelines on how organized medicine -- the AMA or specialty societies -- can play an acceptable part in the debate about health care reform.

Joan B. Trauner, Ph.D.
Coopers and Lybrand, San Francisco, CA 94105