Book Review

Severed Trust: Why American Medicine Hasn't Been Fixed

N Engl J Med 2001; 344:2032June 28, 2001

Article

Severed Trust: Why American Medicine Hasn't Been Fixed
By George D. Lundberg, with James Stacey. 371 pp. New York, Basic Books, 2001. $26. ISBN: 0-465-04291-0

All editors of medical journals are expendable. But the fall, when it comes, is frequently painful and unexpected. Not so for George Lundberg, editor-in-chief of the Journal of the American Medical Association (JAMA) for 17 years: he knew that his sacking in 1999 was inevitable. He had upset too many people for too long a time, and he had courted controversy once too often. His editorial strategy, he has said, was “to deliberately give [readers] something to complain about.” Lundberg's wish to tell the truth — in his words, “no matter how embarrassing, insulting, or offensive” — had eroded the patience of his corporate superiors at the AMA. His editorship had become so vulnerable that, in the end, it collapsed not on a point of principle or integrity but over his decision to publish a study of students' attitudes about oral sex during the public travails of President Bill Clinton. A sublime career tripped in a ridiculous pothole. Lundberg is rueful about the outcome: “The Monica Lewinsky affair resulted in the loss of my job,” he writes, “but not Bill Clinton's.” Severed Trust provides his first opportunity for serious payback.

Lundberg begins with a series of stinging indictments of the AMA. The present organization has “lost its credibility” and lacks leadership; “has too much money and too little purpose”; and is filled with “bloated senior staff,” of which Lundberg was once, of course, a leading member, together with “a group of pampered voluntary officers.” Life as an AMA executive involves “inflated per diems and multiple junkets.” According to Lundberg, the fact that over two thirds of physicians in the United States refuse to join its ranks proves that the AMA is reviled by its constituency. Lundberg's first dispute with his former employer began after an editorial he wrote about boxing. Declaring that “boxing is an obscenity,” he clashed with AMA trustees. From then on he was marked as an irritant.

He watched — horrified, one is led to believe — as the AMA adopted staunchly pro-Republican policies, campaigned for the interests of doctors rather than patients, failed to protect the fragile mantle of professionalism surrounding physicians, and preferred to fight within its own committees rather than openly on behalf of the public. His departure, when it came, must have been a blessed relief, rather than a personal tragedy.

Yet this distinguished pathologist, who began his career in medicine as a hospital orderly mopping floors in Mobile, Alabama, is equally scathing about his clinical colleagues in America. For Lundberg, medicine is a moral vocation, but there has been a “disastrous severance of trust” during his half-century in practice. The origins of this crisis lie in the ways in which doctors, their egos inflated by the prospect of unbridled affluence, have sought new ways to make money from the sick. As a result, professional standards have plummeted. Too many doctors are incompetent, and they now work in a “culture of blame and cover up.”

Medicine, in Lundberg's eyes, has been seduced by business. Its corridors of power have been infiltrated by “money-grubbers.” Powerful specialists have trumpeted their own interests with the covert intention of filling their pockets with profit, irrespective of the risk to patients. These trends have taken place in a health care system “guilty of institutional racism.” Lundberg has written a devastating — and, to an English doctor all too aware of the deficiencies in the National Health Service of the United Kingdom, shocking — critique of American values and the medical system it has spawned.

Lundberg wants doctors to take back their profession, and he believes that they can do so only if they provide a package of basic health care to all citizens. When the uninsured are properly protected, he would make all proven preventive services freely available. To achieve such an ambitious goal, rationing must be embraced, not resisted. As unpleasant an idea as this might seem, the benefits — charitable care, quality assurance, listening to patients' preferences, tackling health inequalities — would be overwhelming, and a strengthened, independent Institute of Medicine would nurture the profession in a new era of public trust.

Lundberg's polemical memoir has engaging faults. He sometimes attributes too close a connection between pungent editorials or articles published in JAMA and the great turning points in American medical history. He also has an inclination to put himself at the center of national events when, in truth, his role seems to have been rather peripheral (the death of Elvis Presley is one startling example).

But this account of a life and its times has the ring of honesty. For instance, Lundberg confesses to fear about publishing research on medical error. He released one such paper in a December holiday issue of JAMA, which he hoped would be missed by vacationing journalists. It was not. He also recognizes that his expulsion from JAMA was to the journal's eventual advantage. Stronger systems to safeguard editorial independence are now in place. His successor owes him a huge debt.

The personal lesson I take from Severed Trust is that every so often an editor of a medical journal must be sacrificed just to remind doctors why they need editors at all. My feeling is that history will record that George Lundberg was among the best.

Richard Horton, M.B., Ch.B., F.R.C.P.
, London WC1X 8RR, United Kingdom