Living wisdom from a living treasure
Chicago Phi Beta Kappa does not often do what it did on May 21. President Judi Strauss-Lipkin made that clear. PBKACA presents its Living Treasure Award only when there is someone truly deserving of it, she said. On this particular evening at the Dana Hotel, that person was Richard Wilbur, M.D., J.D.
He has contributed to the Chicago Association and has had a career based in the ideals of what PBK stands for. It was such a lengthy and varied career that an hour of questioning barely covered the surface, as interviewer Randi Belisomo of WGN television pointed out.
Belisomo started the conversation with a question about Obamacare. It was a natural topic because Wilbur’s involvement in the implementation of Medicare gives him a perspective on the latest effort to retool the U.S. health system.
When the Medicare bill passed in 1965, Wilbur was practicing medicine in the San Francisco Bay area and was also chairman of the board of California Blue Shield, which was responsible for making Medicaid and Medicare work. The bill was highly contentious, Wilbur said. No one suggested we should not care for the aged and the needy. . The debate was about how best to do that, and there was a lot more general anti-government feeling in those days than there is now, he said. That remark drew chuckles.
Like so many compromises, there was a good deal wrong with the Medicare bill when it cleared Congress, Wilbur said. Compromise is not a word that fits with the image of President Lyndon Baines Johnson, Belisomo said. “By the time he was finished twisting your arm, you were with him,” Wilbur said. LBJ was a consummate politician. He pressured people and handed out favors, but he also conducted the formulation of Medicare in the open. The bill may have been messy at the end, but it was better than when it entered Congress, he said. As LBJ promised, the bill was modified as it went through the legislative process, in contrast with Obamacare.
The new system was riddled with problems, yet there was no call to give up. “Nobody suggested we repeal Medicare. Everybody said, ‘How do we make this work?’”
There is speculation about what may happen under Obamacare. Wilbur said it will certainly accelerate trends already part of health care.
About the time of World War I we passed a point at which going to a doctor was more likely to help rather than hurt. People sought more care from physicians, but that care was still limited because no solo doctor could solve every problem. Increased specialization provided better care because a group of doctors could bring more knowledge and tools to bear, yet this also reduced the solidity of the doctor-patient relationship.
Obamacare seems more interested in collecting population data than in individual patients, Wilbur said. Doctors will have to enter data in a computer instead of attending fully to patients, and this will increase the depersonalization of medicine that began decades ago. Patients will be patients not of a particular doctor but of a large system and may see a different physician on each visit. Some people pay a supplemental fee to buy more of a doctor’s time (concierge service), but the economic realities of medical practice, including huge student debts exacerbated by Obama administration cuts in money for post-graduate medical education, make it almost impossible for a single doctor to set up his own practice, he said.
Then there was law
Wilbur went to law school because he was tired of paying lawyers. At the time he headed the Accreditation Council for Continuing Medical Education. Because of a decision it made, the Council was sued for $450 million by several people in New Jersey whose tax avoidance continuing medical education scheme had been spoiled by the Council. Wilbur wanted to learn enough law so he didn’t have to pay lawyers so much from his small budget. But the law pulled him in. “When I graduated I was 66,” Wilbur said.
He is still involved in groups concerned with the intersection of law and medicine, such as the American College of Legal Medicine and the World Association of Medical Law. He also has a good handle on medical malpractice. “Very few people who are injured can afford to go to court.” As a result, he said, less than 1 percent of people injured receive money from a legal judgment.About two/thirds of the cash flows to the people who run the system, including the attorneys on both sides. And although insurance companies complain about large jury awards, what that really says is the companies want to collect premiums, but not pay the cost for providing insurance, he said.
In the Pentagon
It was not political donations that put Wilbur in a Pentagon job during the Vietnam War. Melvin Laird, Secretary of Defense under Richard Nixon, wanted answers to three questions: how to handle a projected shortfall of military doctors because 85 percent of them were drafted into service; what to do about Agent Orange, an effective defoliant that also contained the carcinogen dioxin; and how to handle the heroin abuse problem among troops, a problem that military brass insisted did not exist. Laird d made some calls, and someone recommended Wilbur who was named Assistant Secretary of Defense to tackle the issues.
What did you do about the heroin?, Belisomo asked. We developed a urine test to find out who was using, Wilbur said. The rule said no addict could leave the country, but had to stay in Vietnam until heroin-free for a week. This disincentive to use was clear even to a dull GI, and a follow-up survey five years after found 95 percent of those who tested positive remained off the narcotic.
Some other topics
What is the most revolutionary medical advance you have seen?, Belisomo asked. Antibiotics, Wilbur said. In 1940 mortality from infectious diseases was 40 percent. Scourges now forgotten—polio, tuberculosis, diphtheria, and others—killed people regularly, and many of them were young people. Twenty years after introduction of effective vaccines and the first antibiotics, mortality from infectious diseases had fallen to 4 percent. There is still death from disease of course, but now it has been shifted from the young to older people, he said.
What field has progressed least? Psychiatry, Wilbur said. It’s better, and the medications are better, but basic knowledge and treatments have not expanded as one may have expected as much as other parts of medicine have.
What about Richard Nixon? “I think he’s one of the smartest people I ever met.” He had an extraordinary ability to analyze situations, and he was willing to oppose people in his own party if he thought an action was right. He supported the Equal Rights Amendment, created the Environmental Protection Agency, and although a lifelong anti-Communist opened diplomatic relations with China, which made the Vietnam struggle unimportant in geopolitics and opened a path to ending U.S. involvement in the war.
There was something missing in Wilbur’s comments. For anyone paying attention to political and policy debates of the moment there was a noticeable absence of the partisan righteousness that allows no nuance and extinguishes opposition. Richard Wilbur’s perspective is the product of a career so long and insights so deep that no room remains for dogma.