The three founders of National Medical Care were drawn to the Peter Bent Brigham Hospital to study kidney disease and the revolutionary therapies of dialysis and transplantation that transformed nephrologists from the ushers of death into the extenders of life. In Boston these young, energetic doctors studied with the pioneers in kidney dialysis and transplantation, contributed fresh research to the neglected field of nephrology, and perfected the application of dialysis to an ever expanding population of patients with an ever widening array of medical complications. They didn't come to the Harvard Medical School and the Peter Bent Brigham Hospital to study health care economics or to develop new ways to deliver complicated therapies more efficiently than the charitable hospitals where they had received their training. But the atmosphere of adventure, innovation and risk-taking that sparked the Brigham environment led them to break the mold, shift the paradigm, and shake the system of health care delivery. The genesis of NMC lay in the intellect and character of its founders as these were shaped and sharpened by their encounters at the Peter Bent Brigham Hospital, where they had developed an appreciation of risk-taking for life.

The lack of controversy and dearth of effort to enact major reforms in the End-Stage Renal Disease Program since the mid-1980's has had both benign and harmful effects. On the one hand, the industry has matured and settled. The inefficient providers have been absorbed or replaced and there remains sufficient capacity to attend to the increasing dialysis demands from not just more patients, but older and increasingly sicker patients as well. No one would have predicted in 1972 that there would be 350,000 ESRD patients by the end of the twentieth century. Reimbursement has become predictable and assured and the providers and the government have been less antagonistic and more cooperative and civil. However, at the same time the system has tended toward an unhealthy, uncreative and numbing stasis. The patients, nephrologists, providers and government officials have avoided critical analysis. Where the ESRD Program was seen in its infancy as a fresh, exciting forerunner of health care reform, it has now become accepted as an embarrassment, almost like the crazy uncle in the attic of Medicare. Nephrology, once considered a challenging and worthy medical specialty, has been attracting too few qualified physicians, creating a shortage of kidney specialists. The serious problems - increasing morbidity, insufficient transplantation, higher costs, to name three - have simply been ignored. Complacency has replaced controversy.

The founders of National Medical Care confronted, challenged, and changed a health care system that was unresponsive to an inhumane system of rationing dialysis resources among kidney patients who had reached "end-stage". Without any business, financial, organizational or public relations experience among them, these kidney specialists, tutored in a school and tradition of risk-taking to save lives, stepped out of the cocoon of the academy and began a corporation to deliver dialysis in a new way, with little expectation of government assistance or financial reward. The radical approach of empowering physicians by making them responsible for their individual clinics financed with private capital met fierce resistance.

Physicians need to recognize that the practice of medicine has become and will continue to be corporately organized, that the days of private practice are in most of America, over, and that governments and charities are no longer willing or able to subsidize the costs of medical services. The choice for physicians is whether they move to control the corporate system of delivering care or stay controlled by the system. The essential first step is acceptance of the environment in which doctors practice today and embracing a desire and a commitment to change those circumstances.