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William W. Parmley, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology, 415 Judah St., San Francisco, California 94122, USA.
We are a bottom-line society. My perception is that a “bottom-line mentality” has become even more pervasive in the last decade. The bottom line is obtained by subtracting expenses from revenue to determine net profit. The bottom line focuses exclusively on money and nothing else. It can be a pervasive part of our thinking. In academia, it seems like department chairs and division chiefs spend a large amount of their time worrying about the bottom line. Faculty members have balance sheets that determine their bottom lines and how much they can be paid. If the bottom line becomes negative, then a “salary reduction plan” kicks in. Like other association societies, the American College of Cardiology is also struggling with its own bottom line. The recent decision to close the Heart House Learning Center, in part, reflects the fact that expenses far outweighed income in courses given at Heart House. Next, the College is looking at extramural courses in the same light. Businesses rise and fall, based on their bottom lines. Individuals thrive or go bankrupt depending on their bottom lines. Senior citizens on fixed incomes lose their ability to survive in hard times. Their choice may be between medicine and food in some cases.
The pharmaceutical industry seems to fare quite well during hard times (1). The drug bill for the nation rises at 14% to 18% per year. In 2001, it will be between $160 and $170 billion. We are definitely on a collision course between the rising costs of medicines and technology, and the ability of the government, health care plans, and individuals to pay for their medical care. Think of the implications of the MADIT 2 Study. Do we need to put a defibrillator in every patient after a myocardial infarction who has an ejection fraction below 30%? Since the majority of these patients are over 65, how will Medicare deal with this enormous increment in cost. With the nation in a recession, things are only going to be worse in the future.
Is there any way to avoid this preoccupation with the bottom line? Let me suggest something I will call the “Top Line.” The Top Line has nothing to do with profit. It may frequently be in the red because it may cost something. The Top Line includes all those things we do and experience that have nothing to do with making a profit. Let me give some simple examples. A Top Line activity is when you take a child or grandchild to the zoo, visit a sick friend, or drop some money in a Salvation Army kettle. It includes watching your child’s soccer game or going to a school play or choir concert to hear your family members participate. It is going to church together, walking hand in hand with your spouse on a quiet beach, offering a thanksgiving prayer before cutting the turkey. It involves flying the flag, writing a thank-you note to a friend, calling someone you haven’t talked to in a long time. It involves volunteering at a local community organization, being a scoutmaster, teaching a Sunday school class, and supporting local theatre and arts programs. Top Line activities have a lot of joy and happiness associated with them—the kind that one can never get by focusing on the bottom line. People who spend a lot of time on the Top Line seem to be happier and more content than those who are completely immersed in the bottom line. If you remember Dickens “A Christmas Carol,” Scrooge and his nephew seem to epitomize bottom-line and Top-Line people. By now you have already figured out that one of them is capitalized and the other isn’t.
In real life, of course, if there is a Top Line and a bottom line, then there will be all gradations in between. In truth, people probably move back and forth between these two lines in their daily, weekly, monthly, and yearly activities. It is of interest, therefore, to engage in a little introspection:
How often do I participate in Top-Line activities? Are they a part of my daily life, or do I engage in them rarely? How preoccupied am I with the bottom line? Is it an obsession with me? Does my life revolve around the bottom line, with little time to even consider Top-Line activities? How we manage our time says a lot about our bottom-line or Top-Line mentality. If we do not allow time for Top-Line activities, then the bottom-line mentality may never let go of us.
I would love to explore this theme some more, but my grandchildren are coming over and I promised to take them to the local park to feed the ducks. I love Top-Line activities. I hope you do too!
↵1 Editor-in-Chief, Journal of the American College of Cardiology
- American College of Cardiology Foundation
- ↵Business Week, December 10, 2001, P. 60