[Congressional Record Volume 145, Number 59 (Wednesday, April 28, 1999)]
[Senate]
[Pages S4396-S4399]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                     REMARKS BY DR. HENRY BUCHWALD

 Mr. HOLLINGS. Mr. President, I offer for the Record the text 
of a lecture delivered at the Central Surgical Association by Dr. Henry 
Buchwald, Professor of Surgery at the University of Minnesota. Dr. 
Buchwald, a past president of the association, is a highly regarded 
surgeon, and as we address Medicare reform and related matters in the 
months ahead, I believe we would do well to consider his words. At this 
time, I ask that excerpts of Dr. Henry Buchwald's presidential address 
be printed in the Record.
  The material follows.

  Presidential Address: A Clash of Cultures--Personal Autonomy Versus 
                           Corporate Bondage

                        (By Henry Buchwald, MD)


                           personal autonomy

       A constellation of principles embody the personality of the 
     surgeon. At its core are the tradition and the ethos of 
     personal autonomy. One of the distinguished past presidents 
     of the Central Surgical Association, Donald Silver, who has 
     been a role model for me, entitled his 1992 presidential 
     address, ``Responsibilities and Rights.'' He allowed very few 
     intrinsic rights to surgeons, but first among the limited 
     prerogatives he granted was autonomy.
       As surgeons, we tend to be individualists and to espouse 
     individual responsibility. To us, maturity means being 
     responsible for our actions. We keep our commitments. We view 
     fiscal independence as essential. We take pride in earning a 
     living and, should we have a family, in providing for its 
     needs. To give the gift of an education to our children has 
     been integral to our aspirations.
       The years of medical school, residency, and the post-
     postgraduate education of clinical practice finally give 
     birth to a surgeon. This individual has acquired a base of 
     knowledge and the insight to apply facts and rational 
     suppositions to the care of patients. This individual has 
     obtained operating room skills secured by observation, trial 
     and error, repetition, and respect for tissues and tissue 
     planes and has learned the art of being gentle with a firm 
     and steady hand. The surgeon has been sobered by death, by 
     bad results, by the frustration of the inadequacies of even 
     the most modern medical advances, and by the vagaries of 
     human nature that obstruct the best of intentions and 
     efforts. The surgeon has acknowledged fallibility and his or 
     her power to do harm. The surgeon has become comfortable in a 
     profession in which decisions are singular and responsibility 
     is particular. The mature surgeon has achieved personal 
     autonomy.
       Within our company of surgeons we take just pride in our 
     accomplishments. We are a distinct discipline with a unique 
     body of knowledge. We are, for the most part, successful. We 
     save lives, we increase life expectancy, we enhance the 
     quality of existence. In addition, we have provided society 
     with numerous competent surgical practitioners and built 
     dynasties of surgical educators and researchers--individuals 
     who bridge the present with the future of our profession.
       Unfortunately, this golden age for surgery and the personal 
     autonomy of the individual surgeon are threatened with 
     imminent destruction by a force that will, if not countered 
     and checked, lead us into corporate bondage. I will term this 
     force administocracy.


                           corporate bondage

       Ideally, the role of health care administration is to 
     facilitate the work of physicians and health care personnel. 
     But the chief administrators in our health care institutions 
     and universities are no longer facilitators. They now seek 
     to control. They have been redefining medical practice, 
     clinics, academic departments, and universities on a 
     corporate model, a model that subverts the essential 
     nature of an intellectual society, a model totally alien 
     to the definition of a university as a community.
       Administrocracy, the term I have coined to epitomize this 
     force, is the rule of centralized administration, based on 
     the top-down control of money, resources, and opportunities. 
     Its primary beneficiaries are the administrative hierarchy. 
     Administocracy has established itself as a new ruling class, 
     an order clearly separated from the toilers in the vineyard 
     of medicine. Administocracy is governance not by facilitation 
     but by intimidation. Administocracy has gained or is gaining 
     control of our medical schools, our teaching and community 
     hospitals, and our current means of providing health care. I 
     will outline administocracy's practices, codified into its 
     own perverted Ten Commandments.
       I: Thou shalt have no other system. The glory of our 
     nation's democracy, the longest surviving democracy in the 
     history of the world, is its ability to tolerate 
     differences--to take new initiatives and then to retrench, to 
     be liberal and to be conservative--and, concurrently, to be 
     responsible to the will of the governed and to the precepts 
     of fundamental code of principles and individual rights. An 
     autocracy, on the other hand, denies flexibility and 
     governance alternatives. An autocracy's overriding objective 
     and only goal, regardless of any protestations of working for 
     the common good, is its own perpetuation. By definition, such 
     a system denies the will of the governed and refuses 
     recognition of individual rights.
       Administocracy is, of course, an autocracy. Once in power, 
     administocracy's first order of business is to replicate 
     itself. For example, in 1993 the academic administocracy at 
     the University of Minnesota cut 435 civil service positions, 
     while simultaneously adding 45 more executives and 
     administrators.\1\ The Office of the Senior Vice President 
     for Health Sciences at Minnesota, a unit that did not even 
     exist some years ago, now has 25 members.
       The growth of medical administocracy is the result of 
     genuine problems in the distribution of health care, 
     including cost problems not adequately addressed by the 
     medical profession itself. Our failure, or inability, to take 
     action on these issues has allowed outsiders and opportunists 
     within our own profession to hijack the delivery of health 
     care. Among practicing physicians, a general ennui and a lack 
     of resistance have been the reactions to the administocracies 
     that are becoming our overlords. Perhaps one reason for this 
     seeming complacency is that, individually, physicians feel 
     powerless when faced with the well-organized, implacable 
     machine of administocracy--an entity that knows its purpose 
     and will use any means to attain its goals. Another reason is 
     well expressed by Thurber's paraphrase of

[[Page S4397]]

     Lincoln: ``You can fool too many of the people too much of 
     the time.''\2\
       II: Thou shalt make new images. In his classic novel 1984, 
     Orwell beautifully illustrated the power of language and its 
     willful distortion by governments. His use of ostensibly 
     neutral words for disguising uncomforting realities set the 
     standards for the current proliferation of Orwell's 
     ``Newspeak.'' \3\ The medical and academic administocracies 
     of today have devised their own Orwellian glossary of 
     deception, often borrowing and redefining phrases from 
     corporate industry and the military.
       CEO, for chief executive officer, obviously comes from the 
     corporate world. In academia and in hospital administration, 
     it means a titular despot who controls the destiny and income 
     of faculty and staff.
       Reporting to and chain of command come from the military. 
     These designations of caste and of obedience have not only 
     been fully accepted by members of our profession but actually 
     embraced and fostered by certain of our colleagues.
       Executive management group means a cluster of deans.
       Managed care is a euphemism for reducing patient services 
     and physicians' fees to redistribute income to the ever-
     increasing number of administrators.
       Utilization review stands for a bureaucratic sleight of 
     hand to justify a predetermined reduction in patient services 
     and health care personnel.
       Market and consumer mean patient.
       Market share means the number of patients you can hold 
     hostage in a provider network.
       Health care team means that the physician is only as 
     essential to patient care as the multitude of people who 
     stare into computers on nursing stations.
       Vendor means you, the doctor.
       II: Thou shalt take what is in vain: reengineer. 
     Reengineering is the golden calf of administrocracy and takes 
     in vain much of what we hold sacred. Reengineering would 
     substitute dicta for scientific inquiry, the ``clean sheet'' 
     for methodology, and assumptions for acquired knowledge. 
     Reengineering has never been critically tested, certainly not 
     in academia and hospital administration. No randomized 
     clinical trials of reengineering have ever been conducted.
       The definitions of reengineering are all quite similar. 
     Michael Hammer and James Champy, two of the principal writers 
     and consultants in the field, define it as follows: ``the 
     fundamental rethinking and radical redesign of business 
     processes, management systems, and structures of the business 
     to achieve dramatic improvements in critical, contemporary 
     measures of performance such as cost, quality service, and 
     speed.'' \4\
       The stages of reengineering are usually listed by its 
     author advocates as preparing for change, planning for 
     change, designing for change, implementing change, and 
     evaluating change. Obviously, ``change'' is the key message, 
     often spoken of as ``swift and radical change.'' Initiates to 
     reengineering are instructed that it is essential to start 
     this swift and radical change with the proverbial ``blank 
     sheet of paper.'' Besides the logical fallacy of changing 
     that which is blank, the sheet of paper is not blank; it 
     contains our heritage. To start with a blank sheet means to 
     erase the past. This concept of eliminating what we have 
     painstakingly learned denies the most fundamental precept 
     that we, as teachers, have passed on to generations of our 
     students; namely, know the past and build on it. That way 
     offers progress. Paul's First Epistle to the Thessalonians 
     (5:21) states ``Prove all things; hold fast that which is 
     good.''
       If we do not learn from experience, from accumulated data 
     and analyses, we will continually repeat history, and often 
     bad history. Reengineering is a denial of the methodology of 
     learned skills to deal with the business at hand, a denial of 
     accumulated knowledge, a denial of the wisdom based on that 
     knowledge. It is an abrogation of the scientific method.
       In too much of the corporate-industrial world, 
     reengineering has been the death blow to the company as 
     family, a place to work with pride until retirement. In its 
     place, reengineering has imposed the lean and mean corporate 
     model of harsh downsizing--an organization devoid of workers' 
     loyalty; characterized by a disregard for the customer in 
     favor of the stockholder, plagued with a heavy load of debt, 
     and ripe for a merger, conglomerate integration, and, 
     eventually, extinction.
       But enlightened industry has been abandoning reengineering, 
     and the gurus of this nonsense have found it profitable to 
     shift their expensive consultative services to academia and 
     health care. Many of our associates have bitten hard into 
     this apple of poisoned knowledge: Harvard, Tufts, Columbia, 
     Cornell, Stanford, the University of California-San 
     Francisco, Michigan, Henry Ford, and Minnesota are just some 
     of the great institutions that have, to one degree or 
     another, adopted reengineering. Physician-administrators, 
     with little or no experience in the business world, are 
     pushing hard to sell reengineering as a panacea for success 
     and good fortune in the health sciences and in health care. 
     They are huckstering a placebo.
       The former provost of the University of Minnesota Academic 
     Health Center and current president of Johns Hopkins, Dr. 
     William R. Brody, brought the aforementioned James Champy to 
     a University of Minnesota ``leadership retreat'' in July of 
     1995. At that meeting Mr. Champy, was quoted as saying: ``We 
     live in debate . . . but you may have to exercise powers and 
     say sometimes., `The debate is over. This is the way we are 
     going to be.' . . . visions are not built by groups . . . 
     people in organizations want to be told what to do . . . 
     There is a thirst for leadership, for top-down direction.'' 
     \1\
       Champy gave this advice pro bono. Eventually, however, his 
     consulting firm, CSC Index, was paid $2.2 million by the 
     University of Minnesota to put his philosophy into 
     practice.\1\
       Ever since the Brody mindset took hold of the university's 
     administocracy, I have listened to speech after speech 
     emphasizing that ``everything is on the table'' (freely 
     translated to mean--tell us what you have so that we can 
     take it away from you), and that the ultimate goal of 
     reengineering was the ``reinvention of the academic health 
     center.'' I was also present when straightforward 
     questions about a prospective hospital merger were met 
     with evasion and statements such as ``The negotiations are 
     as yet too delicate to be openly discussed'' and ``I am 
     not at liberty to provide these details.'' Only when the 
     secret discussions had been concluded and the final 
     decisions had already been made were faculty members 
     informed of the swift and radical changes that would 
     forever affect their lives and that these changes were 
     ``non-negotiable.''
       IV: Thou shalt keep horizontal integration holy. In the 
     application of reengineering to academia and health care, the 
     basic work unit is achieved by horizontal integration across 
     disciplines. The medical community until recently has been 
     discipline oriented. The change to horizontal integration 
     represents a major paradigm shift. This change means that a 
     patient would proceed not from one physician to other 
     disciplinary specialists, as needed, but would be referred to 
     a disease- or system-complex of physicians. This unit has 
     been designated as a disease-based cluster, also called in 
     various institutions a center, an institute, a service-line 
     unit, and an interdisciplinary service program. The disease-
     based cluster is an imposition on patient care of management 
     by a standing committee.
       Contrary to the promises of the administocrats, life within 
     the horizontally integrated unit is far from utopian. Because 
     the income allocated to the unit by the administocrats is 
     distributed by formula to the members of the disease-based 
     cluster, the fewer members in the cluster, the more money for 
     those who are retained. That formula encourages the urge to 
     lighten ship. In this cluster, the members of the group have 
     yielded the control of their practice and of their personal 
     income to the group mentality. The surgeon is an employee of 
     this group of primarily nonsurgeons, a fully salaried 
     employee with few, if any, financial incentives.
       Further, each cluster decides on the optimal time 
     management for its employees. Economic unit pressure will 
     limit the amount of time allocated for teaching and for 
     research. If you want to teach, you will be told that 
     extensive teaching is a luxury that the unit cannot afford 
     for its surgeons. You will be told to limit your time with 
     medical students and to limit the operating room time you 
     offer residents, because this use of time does not serve the 
     market-driven goals of your new workplace. Time spent in 
     laboratory research by members of a clinical unit, especially 
     the unit's surgeons, will be restricted or disallowed, 
     because it would most assuredly decrease the unit's ability 
     to compete in the clinical marketplace. Although the surgeon 
     is the main stoker of the unit's economic furnace, decisions 
     for the individual surgeon's distribution of time will no 
     longer be at his or her discretion, but rather at the 
     discretion of the economic will of the group. And, because 
     the surgeon must spend an extensive amount of time in the 
     operating room, the director of this disease-based cluster 
     will, more than likely, not be a surgeon.
       Where are the positive incentives for surgeons in the 
     horizontally integrated unit? We have seen that the incentive 
     is not in money, in teaching, or in research. Is it in the 
     practice of our craft? Even that pleasure may not be allowed. 
     Disease management in the cluster will be by what has been 
     termed clinical pathways. This means surgery by the numbers; 
     every surgeon will do the same procedure for a specific 
     problem, in exactly the same manner, with a prescribed set of 
     instructions for the use of nasogastric tubes, drains, 
     antibiotics, alimentation, and so on. This assembly-line 
     concept of surgery represents the ultimate destruction of the 
     autonomy of the surgeon.
       What will be left? The negative incentives of job security 
     and the threat of punishment for expressions of 
     individuality. Criteria for employment will be obedience to 
     the group and a proper sense of beholdenness.
       The emergence of horizontal integration in reengineered 
     institutions is being vigorously proselytized by its 
     advocates. Indeed, several plenary sessions at the 1997 
     meeting of the American College of Surgeons gave podium time 
     to the leading proponents of horizontal integration, but none 
     to its opponents. A more balanced analysis of this ``brave 
     new world'' is needed. In the words of Aldous Huxley: 
     ``Thought must be divided against itself before it can come 
     to any knowledge of itself.'' \5\
       V: Dishonor thy father and thy mother. The professional 
     fathers and mothers of practicing doctors of medicine are the 
     departments of the medical school. For use as surgeons, our 
     professional parent is the department of surgery. Most of us 
     have a

[[Page S4398]]

     strong allegiance to the departments that trained us and to 
     those we now represent. We cite the teachings of our 
     department as a justification for what we do and what we 
     believe. We extol the achievements of the heroes of our 
     department, and we have been known to contest between 
     departments with fierce team loyalties. We tell departmental 
     anecdotes into our dotage.
       Historically, the strongest medical schools have had the 
     most powerful departments. Feudalism may not have been an 
     intellectual success in the Middle Ages, but it has been 
     the appropriate medical school governance system for our 
     golden age of surgery. The independent department of 
     surgery has, as a rule, been financially sound. It is 
     able, therefore, to provide its faculty, in addition to a 
     clinical practice, research opportunities, as well as the 
     time to teach and to travel. The clinical atmosphere is 
     exciting, allowing faculty to interact with questioning 
     residents, and, through grand rounds and mortality and 
     morbidity conferences, offering the best second opinions 
     available anywhere. Independent departments gave birth to 
     independent individuals, who had the imagination, 
     innovative spirit, incentive, and drive to make surgery in 
     the United States the best and the most envied in the 
     world.
       Reengineering would have us deny our departments, abandon 
     them as mere relics. We are being told to dishonor our 
     parental heritage and to deprive future generations of its 
     nurturing. Horizontal integration is the death knell of the 
     strong department of surgery as we know it. Independent 
     departments that give rise to individualists are anathema to 
     an administocracy, which would replace departmental parenting 
     with the cloning of conformists.
       The proponents of radical change are proposing that 
     departments, for now, be maintained only for teaching 
     students and lower levels of residents, and that their income 
     will somehow be supplied by the dean of the medical school, 
     to whom they will be indebted. The department chairs who will 
     head these units will no longer be selected for scholarship, 
     clinical acumen, and research accomplishments, but for 
     administrative experience and political aspirations. As the 
     lowest tier of the administocracy, they will not uphold or 
     defend the department. In the future this system will 
     eliminate clinical departments altogether, including their 
     independent research, and delegate the teaching of the 
     basic's of surgery to other than practicing surgeons.
       VI: Thou shalt kill tenure. Tenure had its origins in the 
     high Middle Ages and into the Reformation when royal edicts 
     protected the person of the scholar and guaranteed safe 
     passage.\6\ As the university tradition developed on the 
     continent and at Cambridge and Oxford, tenure became more of 
     a fortification against the internal threat of dismissal at 
     the pleasure of the clerical and political appointees who 
     constituted the administration of these universities.\6\
       In the 1990s, once again, tenure has become a highly 
     charged controversy emerging from the academic cloister into 
     the everyday world. Tenure is under attack in institutions of 
     higher learning throughout the United States. This foundation 
     of academic freedom, which includes the tenets of due process 
     and freedom of expression, is being challenged as unwieldy 
     and as an impediment to progress in today's fast-moving world 
     and economy. It is seen as a barrier to effective top-down 
     university administration. A lifelong commitment of 
     appointment for faculty is being considered an unreasonable 
     limit to a university's competitiveness. Tenure-track 
     appointments per se are becoming more and more difficult to 
     obtain, and the possibility of abolishing tenure is a current 
     reality.
       In the field of medicine we have traditionally not been 
     strong advocates of the tenure system. Most surgeons, in and 
     out of academia, have usually thought of tenure as the 
     subterfuge of the weak and unaccomplished, the refuge of 
     idlers and ne'er-do-wells. For my part, however, I am a 
     strong proponent of tenure on principle and from experience. 
     I have seen the University of Minnesota administocracy 
     attempt to kill tenure. I have seen an outside consultant 
     lawyer, hired by the Board of Regents, write a new tenure 
     policy, subsequently put forth by the Board of Regents, that 
     would have seriously restricted many aspects of academic 
     freedom, denied due process, and allowed the disciplining of 
     faculty for not having ``a proper attitude of industry and 
     cooperation.'' I have seen the provost of the Academic Health 
     Center become the leading opponent of tenure at the 
     University of Minnesota and promise the state legislature to 
     destroy tenure in exchange for increased funding for his 
     personal vision of reengineering.
       That threat to tenure has gone hand in hand with, and has 
     served as the primary impetus for, unionization efforts by 
     faculty, a turning to collective bargaining, the terminal 
     polarization of a university into ``them'' and ``us.'' The 
     union movement has been successful in some institutions and 
     almost successful in others. We must recognize that the 
     alternative before us is not between tenure or no tenure, but 
     between tenure or membership in a trade union.
       Centuries of reflection, turmoil, and hard-earned victories 
     for freedom of expression within institutions of higher 
     learning are embodied in tenure. That 1000-year-old legacy 
     should not be swept aside by the know-nothing approach of 
     ``reinventing the university.'' In the final analysis, tenure 
     is the only protection that allows university faculty open 
     criticism of the administocracy. Make no mistake about it, 
     without tenure the outspoken individualists in the academic 
     departments of surgery will be among the first to be fired 
     for insubordination, for not having a proper attitude. 
     They will be fired without due process and without the 
     least concern for their productivity, hard work, loyalty, 
     and demonstrable accomplishments. If not for tenure, many 
     of our predecessors would not have survived to found and 
     to sustain the Central Surgical Association. If not for 
     tenure, many of us in this room would not be signing our 
     names as professor of surgery.
       VII: Thou shalt not commit to more than one career option. 
     Once it was considered laudable in academia to pursue more 
     than one career option--to be a researcher, a teacher, a 
     consultant, as well as a practicing clinician. In the system 
     of administocracy, such pursuits are adulterous, and they are 
     prohibited. William Kelley, the apostle of linear career 
     tracks, has made the laboratory doctors the highest order in 
     the academic departmental hierarchy.\7\ They follow a 
     standard tenure track, spend little time with patients, and 
     obtain their income from grants and from the efforts of their 
     clinical-tract colleagues. Clinicians are confined, in turn, 
     to patient activities, can have no laboratories, and may do 
     only clinical research. Their primary job is to make the 
     money needed by a two-track department. If these clinical 
     doctors cannot keep up with the overall monetary demands, a 
     third and fluid group of physicians, fresh out of residency, 
     may be hired to see patients on a strict salary basis and to 
     generate a sufficient overage of income to maintain the 
     lifestyles of the nonclinicians.
       Where does the double-threat, triple-threat, or even 
     quadruple-threat academic surgeon of yesterday and today fit 
     into such a system? He or she does not fit. Where is there 
     allowance for the person who has honed his or her clinical 
     judgment and operating room technique to achieve superb 
     clinical outcomes and is also known as an eminent researcher, 
     an outstanding teacher, and, possibly, an administrator-
     educator in the field of surgery? We may not find such 
     renaissance individuals in the university of the first 
     century of the third millennium. Those who exist today--many 
     of them in this room--are the equivalents of the dinosaur. 
     Honored today for their stature, their breed is destined for 
     extinction.
       VIII: Thou shalt steal. If the goal of administocracy is 
     power, the means to achieve that goal is the control of 
     money. For most of us, our incomes have been primarily 
     derived from patient care on a fee-for-service basis. In the 
     academic centers we ourselves allocated a percentage of our 
     income to research, to resident education, to travel, and to 
     departmental needs, as well as to paying a tithe to the dean. 
     Currently, we are being forced to acquiesce to a seizure of 
     our income at its source for redistribution outside of our 
     control, consent, and often, knowledge. The imposition of 
     layer upon layer of administrators and managers siphons off 
     money to pay for their income, for the maintenance of their 
     staff, and for the fulfillment of their, not our, 
     aspirations. What finally trickles down to surgeons is a 
     small fraction of the income we generate. In my opinion, this 
     is theft.
       The proliferation of health care provider organizations has 
     given rise to a boom in building construction and occupancy 
     to provide for the newly created health care managers. CEOs 
     of managed care empires now take home millions of dollars 
     annually. This is not capitalism but the embodiment of the 
     Communist Manifesto: ``From each according to his abilities; 
     to each according to his needs.'' \8\ Apparently, 
     administocrats have the greatest needs. We have seen the 
     advent of a plethora of executives, echelons of supervisors, 
     authorizers of services, accountants, marketing and sales 
     personnel, secretaries, telephone operators, and so on--all 
     to do what we were able to do with a relatively minimal 
     support staff. What feeds these engines of power? Fewer 
     available patient services, less compensation for services, 
     and an unparalleled redistribution of what we, the surgeons, 
     earn. Whereas surgeons have a long and honorable history of 
     providing care free of charge to the needy, the new system, 
     through gatekeepers, restricts care for the needy and, 
     through capitation, provides income to the greedy.
       IX. Thou shalt bear false witness. The administocracy 
     rewards or punishes faculty members in promotion and tenure 
     proceedings, bestows awards and recognition, and grants 
     institutional honors. The threat and implementation of both 
     false-positive and false-negative witnessing are standard 
     procedures in academic advancement and in the closure of 
     academic careers. In certain institutions this method of 
     control has extended to the misuse of the legal arm of 
     central administration and the subversion of the internal 
     judicial system of the university. Administocrats and their 
     attorneys have made up rules as they go, with no basis for 
     them in institutional regulations, the ``Calvin-ball'' \9\ 
     approach to adjudication. For those who insist on believing 
     that not all individuals in power can be corrupt and that 
     decency at some level must still exist, I cite the words of 
     17th century aphorist, Jean de La Bruyere: ``Even the best-
     intentioned of great men need a few scoundrels around them; 
     there are some things that you cannot ask an honest man to 
     do.'' \10\
       X: Thou shalt covet. Finally, we come to coveting (Exodus 
     20:17): ``Thou shalt not covet thy neighbor's house, . . . 
     nor anything that is thy neighbor's.''

[[Page S4399]]

       The administocracy does indeed covet your ``house,'' 
     because space is power. The personal space that you occupy 
     outisde of the hospital and clinic, your office and your 
     laboratory, is controlled by the administocracy. Allocation 
     decisions are made not to facilitate your work and not as an 
     incentive for productivity, but as a threat to achieve 
     conformity and to guarantee compliance with their policies. 
     When income is limited and proscribed, when the surgeon has 
     become a 100% employee, then space and the use of that space 
     become powerful inducements for faculty recruitment and 
     retention. Space become a means to form a faculty to fit the 
     new corporate mold. More than ever, space becomes a weapon to 
     enforce compliance and to deny personal autonomy.
       If money and space have been removed from the surgeon's 
     control, how about the control of an individual's research? 
     Here, too, administocracy has moved in. The formerly 
     automatic forwarding of a properly prepared grant application 
     has recently been subjected to additional internal 
     institutional review and the threat of an institutional 
     refusal to forward certain grant applications. This newly 
     assumed institutional power has been termed a violation of 
     academic freedom by a regional president of the American 
     Association of University Professors.\1\ Ongoing grants have 
     been challenged by administocrats, with attempts at mandating 
     personnel changes on a faculty research team. Faculty peer 
     committees to supervise proper contract relations with 
     industry have been disbanded and replaced by an administrator 
     or a group subservient to the administocracy. Autonomy of 
     research has been replaced by research at the pleasure of the 
     administocracy.
       There is, unfortunately, no limit to coveting. According to 
     Horace: ``The covetous man is ever in want.'' \11\


                               resolution

       Although I coined the term administocracy, all else in this 
     version of the Ten Commandments, as perverted by this new 
     corporate bondage, is based on what has happened, is 
     happening, and will happen. For many of us, certain, if not 
     all, of the forces and events outlined are already part of 
     our personal histories. Those fortunate enough to have been 
     spared thus far will not be so favored in the future. I hope 
     no one in this audience suffers from ``mural dyslexia,'' \12\ 
     the inability to read the handwriting on the wall.
       My intent in this narrative has been to express, in words 
     and by examples, the manifestations of a calamitous reality 
     that is altering the basic fabric of our professional lives, 
     as well as the quality of medical care. We cannot elect 
     simply to observe this transformation. The structures we 
     stand on are disintegrating. If we continue to be complacent, 
     if we do not oppose the powerful economic elements arrayed 
     against us, if we take little interest in understanding the 
     nature of our enemies, then surgery, as a discipline, and we, 
     as surgeons and as independent practitioners, free to act 
     within the boundaries of our conscience, will lose our 
     culture, as well as our personal autonomy.
       I have tried in these remarks to outline a brief 
     differential diagnosis of this malady of encroaching 
     administoracy, in order that we may formulate practical 
     deterrents. I ask you to consider, each for your own 
     situations, a workable, achievable alternative to 
     administocracy, the forging of an ethical governance for 
     academia, income distribution, and administration by 
     facilitation. All of us need to take an active role in this 
     process of evolution and innovation, to take it now, and to 
     commit to it in the years to come.
       Further, to maintain the individuality we prize, we have to 
     realize that, individually, we are easy pickings. We must 
     work together, as a community of surgeons, in our academic, 
     cultural, and political organizations to defend our values. 
     Ironic as it may be, we will need to give up some of our 
     precious autonomy to safeguard that very autonomy. In his 
     Republic, Plato expressed the concept of banding together as 
     fundamental to preserving individualty: `` . . . a state 
     comes into existence because no individual is self-
     sufficient. . . .'' \13\
       A satisfactory resolution of this clash of cultures will 
     not be achieved quickly or easily. This contest will not be 
     decided by the sprinters. Victory will belong to the 
     marathoners. Fortunately, surgeons are trained for the long 
     haul.


                                closure

       I would like to close with one final quotation, four 
     questions of self-examination from the Talmud, which express 
     my personal aspirations: ``Have I lived honorably on a daily 
     basis? Have I raised the next generation? Have I set aside 
     time for study? Have I lived hopefully? \14\


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