In his final film performance, Paul Muni starred in the “Last Angry Man,” the story of Sam Abelman, a grumpy aging physician beset with patients who suffice and suffer in the crumbling urban landscape of 1950s Brooklyn. A capable diagnostician, Abelman is nonetheless losing to competition with young specialists. Unable to maintain his practice, Abelman complains that “the bastards just won’t let you live” foreshadowing his sudden death at the movie’s end.
Although only 12 when I saw the film, it made a lasting impression and contributed my views about the intersection of society and medicine, when I became a physician. In recalling this movie, I decided to name my blog “The Last Angry Doc” when I discovered that the “The Last Angry Man” had already been claimed as a website.
In 1991, a real physician hero of mine, Dr. Arnold Relman, was about to retire as Editor-in-Chief of the New England Journal of Medicine. In “The Last Angry Doctor” a profile of Relman in the Journal of the American Medical Association, he expounded on his concerns regarding the direction of American health care. Riffing on President Eisenhower’s term, “the military-industrial complex,” Relman, coined the term, “The New Medical-Industrial Complex,” and described a health care ecosystem consisting of proprietary hospitals, nursing homes, laboratories, and dialysis facilities, driven by profit, answerable only to investors, and without quality controls. Physician payment, he declared, was also a profit-driven system run by “the entrepreneurs, the buccaneers.” To the contrary, he argued, physicians should be in “a profession engaged in a social service.” “Payment for medical piecework has to go, if medicine is to remain a profession.” Relman also worried that the number of specialists were increasing more rapidly than primary care .
Although soft-spoken, in his essays, Relman could bristle with rage, directed at medical profiteers, charlatans, and marketeers who understood little about the medical profession and cared less. Critics particularly resented his pointed indictments of the profit-driven health care industry. One CEO called him a “zealot…[who] lives in a cloistered utopian enclave…He has no idea how wrong he is.”
In rebuttal to his critics, Relman described them as “nonphysicians who have to represent the self-interests of medical entrepreneurialism.” “The system is failing,” he went on, “and we have to face some unpleasant facts. The current system is wrong, and it’s getting worse. It’s impossibly expensive, it’s wasteful, and millions of patients are not getting the medial care they need.” And in statements which reverberates today, he added, “the physicians I talk to are angry, bleak, sullen.”
Thirty year later, Arnold Relman’s critique of American health care is astonishingly prophetic. The current health care environment has grown worse. Americans suffer in a chaotic, non-system of health care. Both for- and non-profit hospitals have consolidated into corporate giants, which dominate the healthcare landscape and fuel increased health care costs. In just a decade, number of primary care physicians has decreased from 46.6 to 41.4 per 100,000 population, an indication of the broken condition of this country’s primary care infrastructure. And burnout and depression, already rampant among young physicians, have accelerated during the COVID-19 pandemic.
So, like Sam Abelman and Arnold Relman, I am angry. And we should all be enraged that, despite an abundance of resources, wealth, and wisdom, our nation has failed, so far, to develop a functional health care system. We desperately need a national system of care, which conserves valuable assets (such as antibiotics,) eschews waste and overuse of technology, supports health care workers, addresses health inequities, and elevates public health and prevention.