Crimson: It seems that under this system doctors would actually have an incentive to do less than they normally would. Would health care suffer because of this?

Relman: Well, that's the risk. Under the present mode, the prevailing mode, the risk is that the doctor is going to do too much. Under the prepayment mode, the risk is that the doctor will not do enough. You have to start from the assumption that most doctors, the vast majority of doctors, are conscientious and are not going to do what is inappropriate and will not fail to do what is necessary. You have to start from that assumption. If you don't then health care is chaotic anyway.

Crimson: What makes you hesitant about the program?

Relman: I started out saying in principle I'm in favour of prepaid health care, but it certainly should be explored...One of the great things about this country is that we're big enough and rich enough so that we can be very pluralistic and we don't have to commit ourselves to one solution for anything. I think we ought to try a number of different approches...And if you personally don't like one way of health care, you have a number of options and the same for doctors...We may fall flat on our face in this state because of bad implementation. The trick will be to get providers, high quality providers who'll be willing to go into this market.

Crimson: A recent editorial in the Wall Street Journal claimed that the American Medical Association (AMA) is losing the political clout it once had due to a drop in membership. Is this true and can you explain it?

Relman: The facts are the facts. They are not a matter of opinion. I think it is true that now that AMA has a smaller regular full-dues-paying membership and a smaller fraction of the total practicing population of American doctors than a few decades ago...It's posing a real problem because if the AMA wants to speak for American medicine, it has to be able to demonstrate that it represents at least a majority and right new it does not...Now what is this due to?...The first and most obvious reason why the AMA is having membership trouble I would suggest is that doctors belong to speciality societies and they feel more of an allegiance to their own specialty and Subspecialty...but some don't want to have leadership in the hands of the AMA leadership.

Another reason why the AMA may be having membership trouble is that the AMA has been very active politically and although I suspect that American physicians in general tend to be more conservative as a group than other segments of middle class America, they are still pretty heterogenous politically. I think there are many physicians, particularly young physicians, who hesitate to join the AMA because the AMA doesn't speak for their political views...I think that's too bad. I recognize the practical necessity of organized medicine to become involved in political affairs. You can't separate health care from politics these days. But I think that the AMA pays a price for this. The AMA, by taking political stands, alienates a very significant number of physicians who might otherwise be attracted to the noncontroversial professional activities of the AMA. The AMA, you must remember, does many...good things. It supports education, it supports research, it fights quackers, it's constantly working to improve the quality of American Medical care and when it was founded it was one of the major social forces in this country to professionalize the practice of medicine and move it out of occuitism.

STRIKES? "Simply to walk off the job is nothing for a doctor to do. A doctor doesn't have any right to walk off the job."

"The public interest is not served by rapid dissemination of premature, incomplete, inaccurate, sensataional information.:

"The profession has to pull up its socks and take more responsibility for monitoring what it does."