November 14, 1990
Q: Today's date is November 14. This is the second part of the interview with Dr. Ralph Wallerstein. My name is Keith Wailoo. Yesterday you spoke about your relationship with Dr. [Paul] Aggeler briefly, and I was wondering if you could talk a little bit more about the nature of your collaboration, both personal and private and professional?
Wallerstein: Privately, when I went East he came to me and said it was a great opportunity for me to learn something about clinical investigation, and he hoped that when I returned I would bring some of the acquired expertise to the San Francisco area, where so little of it existed. The collaboration was not so much at the bench, because he was interested in an area I knew little about, coagulation. While I certainly had a chance to review everything he did, and his manuscripts as they came along, I sometimes had a chance to look at them early and discuss some things with him, he was so much of an expert in that area and I was not that that was an unequal contest.
He was quite interested in what I was doing, iron deficiency, but again he felt that this was not his area. But he looked at drafts of my papers and drafts of my discussions and criticized and helped and had some pertinent questions. It was this kind of relationship. We ran by the other person either a working draft or some results and interpretations and got input and questions. It was very, very pleasant.
Then in the training grant that we obtained, we did a fair amount of formal teaching to our fellows and made ourselves available to them for questions and answers. And it was just customary for each of us to describe our medical clinical problems and have the other person have some input. Inevitably, we talked about some administrative concerns. It was pretty much at that level.
The relationship, which was primarily professional, did extend to some extent in our personal lives. We did visit with each other and our families from time to time. But it was mostly professional. Discussed some of the university politics. National medical politics. The future of hematology. So it was a very all-encompassing thing.
Q: And another relationship that I was interested in was the relationship with your father in private practice. I was wondering how much time was devoted to private practice as opposed to hospital work?
Wallerstein: About half. The afternoons we were usually at the office. Mornings were usually at San Francisco General Hospital, at least for many years. Eventually the practice became more demanding.
From my father I learned just the opposite. From my father I learned how to handle and take care of people rather than the diseases, and my life style, dealing with patients, their families, their problems, the kind of demands patients made, the kind of demands patients wanted to have satisfied--over and beyond the technical medical things. Father and I didn't really talk too much about technical medical things. He always assumed that my knowledge was more up-to-date. I felt that his knowledge was more practical, seasoned.
It was a very personal relationship. My father was very much of an extrovert person, unlike me, and things that had worked well for him didn't necessarily work for me. Also I was much more interested in hematology than I was in internal medicine. I think in a general way, the sicker the patient was, the better I liked it, and the less sick the patient was, the better my father liked it. He spent most of his time at the office and I felt much more comfortable in the hospital, where patients were good and sick and needed my technical skills. But I did learn in the office the enormous demands private patients make on physicians.
Seems like a generation ago, more than a generation ago, for now the demands are set and the styles are set so much more by payors than by anybody else. It seems almost nostalgic to talk about patient demands and granting them.
Q: You mean patients' demands in terms of your time and attention?
Wallerstein: Time. Attention.
Q: That's an interesting distinction between dealing with patients as opposed to payors. That is a theme that one sees frequently in modern critiques of medicine, the idea of attention.
Wallerstein: Well, it's almost a paradox. As I got older, I've become very much better at dealing with patients actually. I did quite well with that. But while I was learning all those new personal skills, medicine was marching in a different direction. When I first started studying hematology, but true for general internal medicine, there wasn't much you could do. You could analyze a lot and talk about prognosis. But since I started, there's an enormous amount of things you can do. Chemo is perhaps the epitome of this. Certainly the management of leukemias and lymphomas is an outstanding example. You can cure Hodgkins disease, which was almost a hundred percent fatal when I started.
But with this opportunity to do something for disease and with the relative ease of diagnosis--which I mentioned yesterday, we have so much imaging--diagnosis becomes much less of a task. But with the possibility of doing so much more for patients, more time is spent on these technical aspects and these technical skills are rewarded better by the payor. And for these two reasons, that there's so many things you have to do in a technical fashion and the fact that you don't really get paid for talking to patients, you do less of that. If you're really good at it, you explain very carefully what the implication of the diagnosis is and what you're about to do--I find myself less patient with patients who are not all that sick, who come with minor complaints. I feel like telling them, I have all those leukemia patients to take care of, don't take my valuable time with your minor problems. Patients nostalgically demand that you spend more time with them, but that's unrealistic. You have to do the work.
The work can be measured and your results are available. Your whole practice style, the outcomes are highly visible to payors and if you do something that isn't efficient and effective, you may be in trouble, and I think this will become much more so. Thirty, forty years ago it was much more difficult to measure what a doctor would do, because there wasn't that much he could do. But now what a doctor does is very measurable, the outcome is very measurable, and if you do not perform properly and efficiently, you may become embarrassed by not having patient contracts. It's just accelerating right now. I think, the ability to measure a doctor's profile, pick up an outline, examine further, is becoming much more available. I think in the next two or three or four years those physicians who do not practice intelligent and efficient medicine may find themselves very much embarrassed by what's going to be available to them.
Q: Where is that measurement being made?
Wallerstein: Payors. Payors can run a profile on your practice patterns. They can very easily obtain a measurement of how you approach disease. They can pick up the physician who does an enormous amount of testing at every visit and compare this physician with somebody who's much more efficient. While on a given case this may be difficult to criticize, if a whole pattern emerges, which is very easy for insurance companies to do, then this physician may not be part of this particular payor program.
In this area, in the San Francisco area, where so much of what we do is under some sort of contract, some sort of HMO, what we do is an open book, and I think it's going to be universal. It's going to be more each year. They'll reach other areas. The number of private, private patients, who pay the whole thing out of their own pockets, is vanishing small. They're still there.
There's some physicians can survive by having a highly private practice. But even the private, private practice, once they reach Medicare age, there will be some limitations on what they can do.
So the insurance companies, Medicare, have very easy access to our diagnostic and therapeutic patterns. If you don't measure up, you're in trouble.
Interesting--I was just thinking the other day--I spent so much time being involved in the American Board of Internal Medicine, eventually became chairman of it, but we spent so much time trying to develop a recertification program. We finally have it in place. Now in internal medicine, also pediatrics, certificates are time limited, and after ten years you have to take another examination. I have no quarrel with this. This was a nice little exercise. But the real recertifying agency has got to be the payors, who will not pay you or will not have you part of their panel if you do not measure up to standards. It's a much more effective recertification program than the voluntary ABIM. I'm sorry to say this, having spent so much time and effort on it, but when all is said and done, that's the way it's going to go.
Q: Would you say that in a case of leukemia, for instance, today that we're approaching much more sort of standardized form of therapy?
Wallerstein: I think when you get to the sub-specialties you do. It's very much getting to standardized therapy. If you do it right, most of your patients should be on protocols, some rationally devised protocols. You don't have the freedom to treat patients individually. There's a down side to this. You cannot individualize the patient's needs, desires, fears and anxieties. But on the other hand, and more importantly, by standardizing your treatment, you're more apt to do what works and not take short cuts at the patient's pleasure, that are really not in the patient's best interests. Patients may plead with you to reduce dosages, and while your heart goes out to them, your head should say, don't do that, you follow the protocol and maximize your chance of getting good results. I think the time when hematologists and oncologists made these personal adjustments is vanishing and that's a good thing.
Q: Do you think that the changes that you've pointed to have also changed the nature of clinical research? Remember you mentioned yesterday the sorts of work you would do at the Thorndike Memorial Laboratory?
Wallerstein: Well, research is quite different. Of course the informed consent issue that we mentioned yesterday has changed a great deal. But research is also much more a collaborative effort. You have so many people entering into a research protocol. The thing that I was doing at Thorndike, what we were all doing, of one man doing one job, that's pretty rare, a sort of simple clinical research. It's also an expensive way to do research, not only in terms of instrumentation, but also in the time that you can allot to it. So it's much more difficult today. I'm not sure I answered your question.
Q: I'm not quite sure it was a perfectly formed question. Let me take another track approach to that question. The safeguards, such as informed consent, how do you think they've changed the whole structure of clinical research? Has it influenced the kind of questions that--is it entirely a beneficial sort of development?
Wallerstein: Oh, probably. I think most of us did things that were at least potentially dangerous to patients without really thinking about it all that much. Patients had to be brave without knowing they were brave. It makes it more difficult in many ways, but it's probably the right thing to do. It goes along with the role of physician in society. The physician's not the only decision-maker. You bring others into the process. I think it's quite appropriate for--I'm searching for a word right now--
Q: Individualistic?
Wallerstein: No, it is not individualistic. There's another term I'm searching for right now. It'll come to me in just a second. It's a matter of ethics. Autonomy. The patient's autonomy is an important thing. It makes it more difficult, but you have to think a little bit harder about what you do.
The two things that fight with each other are the paternalism, the traditional paternalism of the doctor, and with the autonomy of the patient. Traditionally paternalism, the doctor made all the decisions about what in his or her mind was the best that went on. And the last couple of decades we've dealt much more with the patient's autonomy. They have to be brought into the decision-making process. They can do what they choose or not choose, with what is being offered to them. Those things are to some extent in conflict, they balance each other. It's probably a good thing in the long run.
Q: Would you say the doctors are much more managers?
Wallerstein: Managers? I'm not sure I understand the question.
Q: I guess what I'm referring to is the emphasis on sort of the rules of patient management, understanding that there are certain standard approaches to dealing with particular types of patients. It seems to me that that has been emphasized.
Wallerstein: I'm still not entirely clear what you're after. Well, doctors will have to present options to patients about therapy. If you want to call this management, so be it. The other management position doctors have--I don't think that's what you asked me, but it's nevertheless an important thing. Most medical encounters are so complicated that when a patient is sick--most medical encounters with a sick patient are so complex that it involves not just one, but multiple physicians, and there the original doctor, the internist perhaps, is a manager. I don't know if you meant it in that sense. There is some management function involved by a primary care physician, when he manages all the other consultants. Up to a point, that's a management function.
The other management function is to present multiple choices, multiple options to patients.
Q: How would you characterize your collaboration with your son in private practice? You mentioned that you seemed to be happier than your dad when the patients were sicker.
Wallerstein: By the time my son came to join me, I was just as happy when people were not terribly sick, and if they were, let him take care of them. This is a generation problem, particularly in his field. The oncology part was thrust upon me.
I started hematology because I kind of liked red cells and anemias. As the years went by, I found myself treating breast cancers, ovarian cancers. I generally wasn't terribly comfortable with it. I don't do it any more. I had no formal training in it. The only excuse one had to do this, that it involved using very similar agents, such as you would use in leukemia, where I had become with ease with using them. But I never really felt completely at ease without formal training. Formal training was not available when I went through my training, because the field didn't exist. But my son, who had very good formal training, a very high personal standard, was very much more at ease, and when I had a difficult--in the last few years, when I had a difficult oncology problem, I introduced my son to the patient and let him take care of it. This worked exceedingly well. The elderly patients, who needed somebody to talk to, or the patients who were referred to me by other physicians, with oncology problems, were--I sensed that neither the doctor nor the patient wanted to be treated, but wanted somebody of authority to say, well, it's okay to give only palliative treatment. Those came to me. And I think it was a fair division.
Now I enjoyed my son's extremely high standards. He would absolutely not compromise. Much less than I ever did. He told it like it is to patients and doctors. Sometimes perhaps to his detriment, but nevertheless he was always right. He's always right. And he is an extraordinarily good student. Any new problem, what he doesn't know, he finds out the information. Not by asking some authority, but by thoroughly studying the problem and the possible solutions from the available literatures. Very learned, very much more scholarly than I ever was. Has written a great deal. And I enjoyed seeing that in him. I couldn't tell if I ever had it to that extent. I sure as hell don't have it any more.
Q: Which I guess brings us to your early involvement with ASH. How did you first-- (?)
Wallerstein: Well, I was just an ordinary member and liked the annual meetings. The first started going primarily to listen to the plenary session of the case presentation. Not case--paper presentations. Simultaneous sessions. And felt that the educational sessions were something I need not attend, because I knew all that stuff.
As years went by, I sort of went the other way. I needed the educational sessions, the simultaneous sessions. I frequently didn't understand what was going on anyway. But I'm talking about a very long time spent. In between there, before I reached the stage I just described, I was really intimately involved in everything. I think my involvement with leadership may have started when I was asked to be the local arrangements chairman in 1971, the year before the San Francisco meeting. I think they asked me because I was more highly visible than other members of the community. By that time I'd reached a certain amount of seniority stage and it was natural they ask me. Paul Aggeler had already died. So I was the senior person here and I had some of those skills. Anyway, people really did a first-rate job on this annual meeting. It was a much smaller society and we could offer things you can't offer right now. But we also did something that we felt should never be done again. We did all the registrations, collected all the money and all this kind of stuff, but perhaps the major contribution I made to the Society was, when, this meeting was finished, I said, no one should ever do that again. And we went out to recruit and hire Charley Slack, who became our office. It was an absolutely wonderful relationship with the superlative job Charley did. His heirs apparently have been less successful, but that's neither here nor there.
One of the first jobs for the Society I had to interview Slack. I went to New Jersey to see his organization and asked a million questions. I finally decided he was our man and I presented these views to the executive committee of the Society. And they bought that. Everybody agreed that we should have outside help. It was sort of the way to go. And in retrospect it was absolutely essential perhaps a year or so later. Nevertheless, I guess they liked what I did, and a year or so later Sam [Samuel I.] Rapaport asked me whether I would be interested in becoming a member of the executive committee, which was about the first time I'd ever been involved in anything of national significance. And I liked that a whole lot. I felt that I could perhaps bring a practitioner's perspective to the discussions. I could involve myself in discussions, and I guess I listened well enough and didn't talk too much. What I had to say was reasonable, that I could sort of feel myself moving up in the Society, the nominating committee, once chairman of the nominating committee. So I gradually sort of moved through the chairs, as it were, and I was perhaps not totally surprised when they asked me to stand for election. Now when this came up--and it's still true for the Society--the key election is that of vice-president, the vice-president in this organization becomes the president-elect. So that's the key election. That's very unlike most societies I know, where to become a vice-president, it's not hello, it's goodbye. But in the American Society of Hematology the vice-president has been the first step of a three-year term, as it were. Not officially, but in practice.
So when they asked me to stand for election, I was delighted, even though the nominating committee, which was Wendell Rosse, told me that this was a real election and the other candidate was Paul Marks, who was and still is a formidable figure in American medicine in general, hematology in particular. And I was very flattered to be put in the same box with Paul. I didn't think that it was deserved and I didn't really count on being elected. But it turned out there were quite a--I had more friends than I thought and perhaps Paul had some people that didn't want to see him elected. Be that as it may, there was a public election at the first, maybe the second business meeting. You sit there when the votes have been counted, there at the ripe old age of--let's see, what was I, fifty-five, six, something like that? You sit there and have to be told in front of everybody else who won the election. It was an interesting, stimulating day, and while I could have survived perfectly well without having been elected, once you get that close, you want to win. And it was an interesting day, having to stand for election, and I was very pleased I was elected. Paul congratulated me. He had much more experience relative to me, but this was not only the first time that I'd been elected, I was the first practitioner the Society had ever elected.
So I was very pleased and I had a very good year as president. I dealt with all sorts of issues and was surrounded by a superb group of other physicians.
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