ADDRESS

ORIGINAL

         PREPARED FOR

      C, EVERETT KOOP, M,D,
        SURGEON GENERAL
     UA PUBLIC HEALTH SERVICE

                 AND

     DEPUTY ASSISTANT SECRETARY

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

PRESENTED BY

ASSISTANT SURGEON GENERAL JOHN DUFFY, M,D,

TO THE

FIRST INTERNATIONAL CONFERENCE ON CONTINUING MEDICAL EDUCATION

           PALM SPRINGS, CALIFORNIA
             NOVEMBER 30, 1986


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(GREETINGS TO HOSTS, GUESTS, ETCJ

   I BRING YOU GREETINGS FROM OUR SURGEON GENERAL, DR, C, EVERETT

KOOP, AND I ALSO WISH TO RELAY HIS EXPRESSIONS OF DEEP REGRET THAT HE

COULD NOT BE WITH YOU TODAY, AS YOU KNOW, DR, KOOP RECENTLY UNDERWENT

A DELICATE BUT SUCCESSFUL LAMINECTOMY AND IS NOW RECUPERATING AT HOME,

   I ALSO WANT TO CONVEY DR. KOOP'S CONGRATULATIONS TO THE

DISTINGUISHED COMMITTEE OF INTERNATIONAL SCHOLARS WHO PLANNED THIS

CONFERENCE, THE SESSIONS ARE SPECIFIC AND IMPORTANT AND WILL NO DOUBT

YIELD VALUABLE INFORMATION AND INSIGHTS FOR EVERYONE ATTENDING,

   DR, KOOP AND I TALKED ABOUT THIS MEETING BEFORE HE WENT INTO

SURGERY, SO I WILL BE PRESENTING TO YOU THIS MORNING NOT ONLY GREET-

INGS FROM SURGEON GENERAL KOOP, BUT HIS THOUGHTS ON CONTINUING MEDICAL

EDUCATION AS WELL,


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  OUR PRINCIPAL PURPOSE THIS MORNING WILL BE TO EXPLORE WHAT MIGHT
BE THE CONTEXT OF THIS IMPORTANT FIRST INTERNATIONAL CONFERENCE ON
CONTINUING MEDICAL EDUCATION, WHAT IS IT THAT'S GOING ON IN MEDICINE
AND IN PUBLIC HEALTH THAT SHOULD REQUIRE AN INVIGORATED PROGRAM OF
C,M,E,?

  IT'S TRUE, OF COURSE, THAT EDUCATION IS A GOOD THING ALL BY
ITSELF, AND THE GOAL OF AN EDUCATION MAY BE NOTHING MORE THANvTHAT
IT BE ACHIEVED,

  BUT THAT'S NOT ON OUR AGENDA, ENRICHMENT,,,IDLE CURIOSITY,,,A
WELL-ROUNDED PERSONALITY,,,THESE OBJECTIVES ARE ALL WELL AND GOOD,
BUT THEY DON'T APPEAR TO BE OURS,

  AND, TO BE QUITE CANDID, SUCH EPICUREAN GOALS MAY NOT BE
SUFFICIENT MOTIVATION FOR MOST PHYSICIANS TO SWAP THEIR WHITE COATS
AND TONGUE DEPRESSORS FOR BLUE BLAZERS AND BOOK-BAGS,


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  ACTUALLY, WE SEE THE GOAL OF C,M,E, AS TIED VERY MUCH TO THE REAL
'rlORLD OF PRACTICE, IT IS RATHER SUCCINCTLY SPELLED OUT IN THE WORKING
TITLE OF THIS CONFERENCE: TO "IMPROVE MEDICAL AND HEALTH CARE,"
NOTHING FANCY THERE,

  BUT WITHIN THAT INNOCENT LITTLE TITLE ARE TWO BASIC -- AND
BASICALLY CORRECT -- ASSUMPTIONS:

THE FIRST IS THAT THE MEDICAL AND HEALTH CARE WE NOW DELIVER CAN
BE IMPROVED, JT CAN BE MADE BETTER THROUGH THE ABSORPTION OF NEW
AND CURRENT KNOWLEDGE,,,

AND THE SECOND ASSUMPTION IS THAT WE CAN PROVIDE MUCH BETTER
HEALTH CARE IN THE FUTURE, WITH THE HELP OF PERTINENT, NEW
KNOWLEDGE TRANSMITTED IN AN ORGANIZED WAY THROUGH C,M,E,


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  WE'LL LOOK MORE CLOSELY AT BOTH ASSUMPTIONS IN ORDER TO COME UP

WITH THE POSSIBLE CONTEXT FOR THE CaMmE, DISCUSSIONS THIS WEEK,

  NO\;J, WHAT OF THAT FIRST ASSUMPTION-THE ONE THAT SAYS WE CAN
IMPROVE THE MEDICAL CARE BEING DELIVERED TODAY?

   TODAY WE ARE HEIRS TO A REMARKABLE PARADE OF NEW PRODUCTS, NEW

KNOWLEDGE, AND NEW TECHNOLOGIES THAT HAVE EMERGED AFTER SOME TWO

DECADES IN RESEARCH AND DEVELOPMENT,

   NEW DRUGS, NEW DEVICES, NEW ARRANGEMENTS OF PERSONNEL, NEW

PROCEDURES,,,ALL HAVE BEEN INTRODUCED, ONE AFTER THE OTHER,

   WE'VE BARELY HAD TIME TO CATCH OUR BREATH OVER ONE DEVELOPMENT

a, nTHE CAT SCAN, FOR EXAMPLE, ,&BEFORE WE ARE INTRODUCED TO ANOTHER,, ,

AN IMPLANTABLE INSULIN PUMP OR A MEASLES VACCINE,


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  TODAY'S PRACTITIONER MUST AT LEAST UNDERSTAND -- IF NOT

NECESSARILY PRACTICE -- THE TECHNOLOGIES OF ORGAN TRANSPLANTATION,
TOTAL PARENTERAL NUTRITION, MONOCLONAL ANTIBODIES, AND MAGNETIC

RESONANCE IMAGING,

  THESE RESULTS OF OUR EXTRAORDINARY BIOMEDICAL R & D ENTERPRISE
COLLECTIVELY DEFINE \iHAT WE COMMONLY CALL "CONTEMPORARY MEDICAL

PRACTICE,"  IT MAY NOT BE AN ACCURATE DEFINITION OF THIS OR THAT
INDIVIDUAL'S MEDICAL PRACTICE IN PARTICULAR, NOR MAY IT EVEN REFLECT
THE ROUTINE EXPERIENCE OF CLINICIANS GENERALLY,

  BUT THAT'S QUIBBLING, THE FACT IS THAT THE APPEAL ~MEDICINEmu
SOCIETY'S FAITH j&MEDICINE,,,AND THE WILLINGNESS OF THE PUBLIC TO PAY
HANDSOMELY FOR- MEDICINE,,,ALL ARE BASED NOT ON THE WELL-PUBLICIZED,
HIGH-TECH SKILLS OF WHAT IS PURPORTEDLY THE CONTEMPORARY PRACTICE OF
MEDICINE AND PUBLIC HEALTH,


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  HOWEVER, THAT CONTEMPORARY, PROGRESSIVE LOOK OF MEDICINE IS NOT
ONLY A GLORIOUS LIGHT TO BASK fi,JT'S ALSO A GLARING LIGHT TO BE
EXAMINED UNDER,

  THE ISSUE FOR EACH PRACTITIONER, THEN, IS TO FIND THE MOST
EFFECTIVE WAY TO MOVE BACK AND FORTH FROM ONE CIRCLE OF LIGHT TO THE
OTHER, WITHOUT LOSING ONE'S WAY AND WITHOUT CRASHING INTO THE

FURNITURE,

  THE PRACTICING PHYSICIAN'S BEST RESOURCE TO HELP HIM OR HER
NEGOTIATE THAT SHADOWY PASSAGE BETWEEN THE SPOTLIGHT OF PUBLICITY AND
THE SEARCHLIGHT OF PROFESSIONAL ACCOUNTABILITY ISJONTINUING MEDICAL

EDUCATION,


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  THIS CHALLENGE IS NOT EXCLUSIVE TO THE PHYSICIANS OF ONE OR
ANOTHER COUNTRY, IT EXISTS THE WORLD OVER, PHYSICIANS IN THE
DEVELOPED COUNTRIES, SUCH AS THE UNITED STATES OR GREAT BRITAIN, NEED
C,M,E, TO ENSURE THAT THEIR PRACTICE REFLECTS ;/HAT THE PUBLIC
GENERALLY UNDERSTANDS TO BE STANDARD, CONTEMPORARY MEDICINE,

  AND THE SAME IS TRUE FOR PHYSICIANS IN THE DEVELOPING NATIONS
ACROSS THREE CONTINENTS, THEY ALSO NEED TO BE UPDATED ON NEW DRUG
THERAPIES, NEW DIAGNOSTICS, AND NEW TECHNOLOGIES,,,EVERYTHING FROM
RESPIRATOR DEPENDENCE TO LUMPECTOMIES,,,FOR ALL OF THESE THINGS ARE
ENTERING THEIR CLINICAL PRACTICES AS WELL,

  THE ONLY DIFFERENCE -- ALBEIT A SIGNIFICANT ONE -- SEEMS TO BE
THE RATE OF SPEED AT WHICH THEY ENTER,


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   THIS IS NOT A CHALLENGE WE CAN SIMPLY PASS ALONG TO OUR MEDICAL

SCHOOLS, THE TASK OF CHANGING INDIVIDUAL BEHAVIOR IS A MUCH EASIER
AND CERTAINLY MUCH QUICKER TASK TO ACCOMPLISH THAN THE TASK OF
CHANGING INSTITUTIONAL BEHAVIOR,

  MEDICAL SCHOOLS ARE NOT ORGANIZED FOR MAXIMUM FLEXIBILITY,,,AND I

SUSPECT THAT'S EXACTLY WHAT WE PREFER,

  BUT C,M,E, Is AN INSTRUMENT THAT IS BOTH FLEXIBLE AND ADJUSTABLE,
IT CAN BECOME THE MOST COST-EFFECTIVE AND TIME-EFFECTIVE MECHANISM FOR
KEEPING THE COMMUNITY OF PHYSICIANS UP TO DATE ON DEVELOPMENTS IN

THEIR OWN PROFESSION,

   IN THE CONTEXT, THEN, OF AN EVOLVING PROFESSION -- ONE THAT IS
CHALLENGED BY THE VERY DYNAMICS OF ITS OWN EVOLUTION -- WE CAN SEE
THAT C,M,E, MAY BE OUR BEST WAY FOR MAKING SURE THAT TODAY'S MEDICAL

AND HEALTH CARE WILL, IN FACT, BE IMPROVED,


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  SO MUCH FOR THAT FIRST ASSUMPTION, BUT WHAT OF THE SECOND

ASSUMPTION, ,,THE ONE THAT SAYS CaMmEn IS ALSO OUR BEST METHOD FOR
ADJUSTING TO THE FUTURE OF MEDICAL PRACTICE AS WELL? HERE AGAIN, IT
IS WELL TO EXAMINE THE REAL-WORLD CONTEXT OF OUR DISCUSSION,

  AND THE CONTEXT NOW BECOMES QUITE DIFFERENT FROM WHAT WE'VE BEEN

DESCRIBING SO FAR,

   IT MIGHT BE FAIR TO SAY THAT MOST OF THE NEW DEVELOPMENTS BEING

INCORPORATED INTO PROGRESSIVE, CONTEMPORARY MEDICAL PRACTICE SIGNIFI-
CANTLY IMPROVE THE QUALITY OF CURATIVE, REPARATIVE, AND REHABILITATIVE

MEDICINE IN OUR SOCIETY,

   BUT THERE IS MUCH EVIDENCE TO INDICATE THAT THE FUTURE OF MEDICAL

PRACTICE IN OUR COUNTRY AND IN COUNTRIES AROUND THE WORLD WILL NOT
REST WITH CURATIVE, REPARATIVE, AND REHABILITATIVE MEDICINE BUT RATHER

IT WILL REST WITH PREVENTIVE MEDICINE,


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WHAT'S OUR EVIDENCE FOR THIS?

  FIRST OF ALL, WE ALREADY SEE THAT A SUBSTANTIAL PART OF EVERYDAY
CLINICAL PRACTICE IS DEVOTED NOT TO "MAKING THE PATIENT BETTER" BUT
RATHER TO "KEEPING THE PATIENT WELL," MORE AND MORE PATIENT

ENCOUNTERS ARE NOW TAKEN UP WITH RECOMMENDATIONS FOR ROUTINE EXERCISE,
IMPROVED DIET, STRESS MANAGEMENT, REDUCTION OF ALCOHOL INTAKE, AND SO

ON,

   IN FACT, THE MAJOR ISSUES FACING THE PUBLIC HEALTH SERVICE OVER
THE PAST FEW YEARS HAVE NOT FIT VERY WELL WITH THE TRADITIONAL VIEW OF
MEDICINE,,,THE CURATIVE VIEW, AND THESE THREE ISSUES MAY VERY LIKELY

BE OUR BELWETHERS FOR THE FUTURE,


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  THE FIRST ISSUE IS SMOKING, CIGARETTE SMOKING IS THE LEADING
CAUSE OF LUNG CANCER AND A MAJOR CONTRIBUTING CAUSE OF HEART DISEASE,
STROKE, AND A VARIETY OF OTHER DISEASES OF THE CARDIOVASCULAR AND
GASTROINESTINAL SYSTEMS,

  SMOKING IS EITHER THE PRIMARY CAUSE OR THE MAJOR CONTRIBUTING
CAUSE OF 340,000 PREMATURE DEATHS EACH YEAR IN THE UNITED STATES
ALONE, WE HAVE NO COMPARABLY RELIABLE FIGURES FROM OTHER COUNTRIES
WHERE PER CAPITA CIGARETTE CONSUMPTION IS HIGH, BUT WE COULD SAFELY
ESTIMATE THAT THE NUMBER OF PREMATURE, SMOKING-RELATED DEATHS EACH
YEAR WORLDWIDE COULD EASILY BE IN EXCESS OF 5 MILLION,

  THE DAMNING EVIDENCE BEHIND SUCH AN ESTIMATE -- SOME 50,000
STUDIES INVOLVING THE SMOKING EXPERIENCE IN MORE THAN 30 COUNTRIES
AROUND THE WORLD -- IS NOW SIMPLY IRREFUTABLE,


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   IF YOU HAVE A SINGLE DOUBT ABOUT THE ANTI-SMOKING DATA, IT MUST
BE BECAUSE YOU YOURSELF ARE ADDICTED TO SMOKING OR BECAUSE YOU ARE

CONCERNED ABOUT THE COLLAPSE OF A TOBACCO-BASED ECONOMY, OR BOTH,

AND ONE CAN UNDERSTAND SUCH DOUBTS OR MISGIVINGS,

   BUT AS FOR THE SCIENTIFIC BASIS BEHIND THE ANTI-SMOKING CAMPAIGN
,,,YOU CAN'T HAVE DOUBTS ABOUT THAT AND STILL CALL YOURSELF A MAN OR

WOMAN OF SCIENCE:

THE SCIENTIFIC CASE AGAINST SMOKING HAS BEEN MADE, IT IS

VOLUMINOUS, ,,AND IT IS CLEAR,

  THE DISEASES CAUSED BY SMOKING ARE, OF COURSE, IRREVERSIBLE,
THERE IS NO CURE FOR HEART DISEASE, ,,NO CURE FOR STROKEmNO CURE

EMPHYSEMAnuN CURE FOR LUNG CANCER, ORAL CANCER, OR ESOPHAGEAL
CANCER, INSTEAD, WE CAN ONLY PREVENT THESE DISEASES FROM OCCURRING BY

ELIMINATING SMOKING,


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  THAT'S A MEDICAL PROBLEM,, ,A BIOBEHAVIORAL PROBLEM, ,,A PROBLEM

FOR EVERY CLINICIAN,

  TWO YEARS AGO SURGEON GENERAL KOOP ISSUED A CALL FOR THE UNITED
STATES TO BECOME A "SMOKE-FREE SOCIETY BY THE YEAR 2000," THE
RESPONSE HAS BEEN EXTRAORDINARY, NOT ONLY IN THIS COUNTRY BUT AROUND
THE WORLD AND HE HAS TAKEN PART IN -- OR HAS ADVISED ON -- THE
LAUNCHING OF SIMILAR NATIONAL CAMPAIGNS IN GREAT BRITAIN, ISRAEL,
ITALY, AND THAILAND,

  WE WOULD LIKE TO SAY CATEGORICALLY THAT, WITHIN THE NEXT 14
YEARS, THE UNITED STATES WILL INDEED BECOME "SMOKE-FREE," BUT WE ARE
FIGHTING A VERY FORMIDABLE ADVERSARY: THE CIGARETTE INDUSTRY, THE
INDUSTRY IS NOT GIVING UP WITHOUT A FIGHT,

  THE INDUSTRY IS FIRING ITS HEAVIEST MARKETING GUNS AT TWO
SIGNIFICANT MARKETS: YOUNG PEOPLE AND MINORITIES


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  WE CONDEMN ITS BEHAVIOR, WE DO NOT BELIEVE THAT MILLIONS OF OUR

CITIZENS SHOULD BE PUT AT MORTAL RISK, IN ORDER TO MAINTAIN A

FAVORABLE PROFIT-AND-LOSS SHEET FOR THE TOBACCO INDUSTRY,

  WILL WE "SMOKE-FREE" BY THE YEAR 20001 MAYBE NOT COMPLETELY,

MAYBE ONLY SUBSTANTIALLY SMOKE-FREE SOCIETY,

   ALL OF WHICH MEANS THAT THE JOB OF PREVENTING PEOPLE FROM SMOKING
WILL REMAIN AN INTEGRAL PART OF CLINICAL PRACTICE WELL INTO THE 21ST

CENTURY,

THE ROLE OF CaMmE, IN THIS ISSUE IS CLEAR ENOUGH:

PHYSICIANS IN THE FUTURE WILL NEED TO BE EDUCATED ON THE

PREVALENCE AND THE SERIOUSNESS OF SMOKING AND BE COUNSELED ON THE

MOST EFFECTIVE WAYS TO CONFRONT SMOKING IN CLINICAL MEDICINE, WITH

SPECIAL ATTENTION TO THE NEEDS OF WOMEN, YOUNG PEOPLE, AND

MINORITIES,


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  BUT WHAT WE'RE SAYING ABOUT SMOKING IS WHAT WE WOULD ALSO SAY
ABOUT DRUG ABUSE, ALCOHOLISM, OBESITY, HIGHWAY TRAUMA, AND MOST
OCCUPATIONAL DISEASES AND DISABLING CONDITIONS, THERE IS NO HANDY
CURE AVAILABLE FOR ANY OF THESE, BUT ALL ARE CANDIDATES FOR
PREVENTION,

  PREVENTION, OF COURSE, IS A LEARNED BEHAVIOR~~~TO BE TAUGHT BY
THE MEDICAL AND PUBLIC HEALTH PRACTITIONERS TODAY AND WELL INTO THE
FUTURE, BUT THE PREVENTION CONCEPT IS ONLY GRADUALLY BEING ABSORBED
INTO THE CURRICULA OF MEDICAL SCHOOLS AROUND THE WORLD, AND IT IS NOT
CLEAR TO WHAT EXTENT FORMAL MEDICAL EDUCATION CAN DEAL WITH PREVEN-

TION,

  THERE ARE MANY REASONS FOR THIS, BUT ONE OF THEM MAY SIMPLY BE
THE FACT THAT THE MOST EFFECTIVE STRATEGIES IN PREVENTION TEND TO BE
MULTI-DISCIPLINARY,,,COMBINING BEHAVIORAL AND PHYSICAL MEDICINE,,,OR
PHYSICAL MEDICINE 'dITH NUTRITION, ,mOR FAMILY MEDICINE WITH MENTAL
HEALTHmOR PEDIATRIC MEDICINE WITH PUBLIC EDUCATION,


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   FOR THIS KIND OF NON-TRADITIONAL INFORMATION, OUR BEST MEANS OF

TRANSMISSION HAS BEEN -- AND WILL SURELY BE IN THE FUUTRE -- CONTINU-
ING MEDICAL EDUCATION, WITH THE ASSISTANCE OF STRONG BUT FLEXIBLE
PROGRAMS OF C,M,E, IT WILL BE POSSIBLE FOR OUR SOCIETY TO BE SERVED BY
CLINICIANS WHO PRACTICE PREVENTIVE AS WELL AS CURATIVE AND REPARATIVE

MEDICINE,

  BUT OTHER CHANGES IN MEDICAL PRACTICE ARE GOING ON AS WELL, THE
NEXT EXAMPLE IS THE MYSTERIOUS DISEASE CALLED AIDS

   I WON'T GO INTO THE DETAILS OF THIS PARTICULAR CHALLENGE TO
SCIENCE, MEDICINE, AND PUBLIC HEALTH, I'M SURE THE DETAILS ARE QUITE
WELL-KNOWN TO EVERYONE HERE,


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  RATHER, LET'S LOOK AT AIDS FROM THE POINT OF VIEW OF WHAT IT HAS
REVEALED IN GENERAL ABOUT OUR CAPACITY TO RESPOND TO NEW AND UNKNOWN
THREATS TO THE PUBLIC HEALTH,

  FIRST, THE AIDS ISSUE HAS RAISED A LOT OF QUESTIONS ABOUT ACCES-
SIBILITY IN OUR COUNTRYwACCESSIBILITY BOTH WAYS,

  FOR EXAMPLE, WHEN THE AIDS CASES WERE FIRST REPORTED BACK IN
1981, THE U,S, PUBLIC HEALTH SERVICE WANTED TO PUT TOGETHER INFORMA-
TION ABOUT THE DISEASE AND GET IT INTO THE HANDS OF HOMOSEXUAL AND
BISEXUAL MEN, THE PRIMARY HIGH-RISK GROUP,

  BUT THE TRADITIONAL AND ROUTINE CHANNELS FOR PUBLIC HEALTH
INFORMATION WERE NOT ADEQUATE TO THE TASK, AS A RESULT, WE SPENT MUCH
VALUABLE TIME AND RESOURCES DISCOVERING NEW AND EFFECTIVE WAYS TO GAIN
ACCESS TO THAT AND OTHER AFFECTED, HIGH-RISK POPULATIONS,


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  AT THE SAME TIME, WE DISCOVERED THAT THEIR ACCESS TO INFORMATION
AND MEDICAL CARE WAS, ITSELF, ALSO LIMITED, BUT CORRECTING THAT
SIUTATION HAS NOT BEEN SO AMENABLE TO EFFORTS BY GOVERNMENT AND

OTHERS,

IT COULD HAVE BEEN -- BUT IT WAS NOT -- OUR FINEST HOUR,

   THERE ARE MANY THINGS WE STILL HAVE TO LEARN ABOUT DOCTOR-PATIENT

RELATIONS AND PATIENT CARE, ,,THINGS WE THOUGHT WE KNEW BUT WHICH

PROVED NOT TO BE TRUE OR NOT TO BE PERTINENT,

   WE ALSO NEED TO LEARN HOW SMALL A WORLD THIS IS, THE FIRST
REPORTS OF AIDS, AFTER ALL, WERE GATHERED IN AFRICA AND IN HAITI. BUT
THEY RAISED NO QUESTIONS AND NO ALARMSmNOT EVEN IN THOSE COUNTRIES
WHICH, IRONICALLY, HAVE THE MOST HIGH-RISK INDIVIDUALS, THEY SHOULD
HAVEwBUT THEY DIDN'T,


  UNFORTUNATELY MANY NATIONS -- MAYBE MOST NATIONS -- SHARE THIS
INCLINATION TOWARDS ISOLATION, IT MAY BE CULTURALwIT MAY BE

HISTORIC,,,IT MAY BE DEFENSIVE, BUT IT IS NOT HELPFUL,

   HOW CAN AN ENLIGHTENED MEDICAL AND SCIENTIFIC COMMUNITY COMBAT

THIS KIND OF ISOLATIONISM? THE ANSWER: WITH INFORMATION AND EDUCATION



I I I ESPECIALLY WITH EDUCATIONwAND ESPECIALLY WITH CONTINUING MEDICAL

EDUCATION,

  MY FINAL EXAMPLE OF WHAT THE FUTURE CONTEXT OF CLINICAL PRACTICE
MIGHT BE IS A FAIRLY NEW ISSUE IN AMERICAN PUBLIC HEALTH, IT IS

DOMESTIC VIOLENCE,

  THIS IS A PROFOUNDLY UGLY ISSUE, LEAVING IN ITS AN ESTIMATED 4
MILLION VICTIMS, THEY ARE MAINLY WOMEN AND SMALL CHILDREN AND OLD
PEOPLE, THE MOST VULNERABLE MEMBERS OF OUR SOCIETY,


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  THEY ARE ASSAULTED AND BEATENmTHEY ARE TERRORIZED,,,THEY ARE
RAPED AND KILLEDwFREQUENTLY BY THE PEOPLE THEY LOVE, OR THINK THEY

LOVE,

AND IT HAPPENS MOST OFTEN WITHIN THE PRIVACY OF THEIR OWN HOMES

  VIOLENCE, ESPECIALLY DOMESTIC VIOLENCE, HAS AN ENORMOUS IMPACT
UPON THE PHYSICAL, PSYCHOLOGICAL, AND EMOTIONAL HEALTH OF OUR CITI-

ZENS,

   IN LIGHT OF THIS, SURGEON GENERAL KOOP LAST YEAR CONCLUDED THAT
VIOLENCE WAS IN FACT A PUBLIC HEALTH PROBLEM, ,.A PROBLEM THAT COULD
NOT BE SOLVED BY THE CRIMINAL JUSTICE SYSTEM ALONEannA PROBLEM,
RATHER, THAT REQUIRED THE PROFESSIONAL ATTENTION OF PHYSICIANS,

NURSES, PSYCHOLOGISTS, AND SOCIAL WORKERS, IN ADDITION TO THE POLICE

AND THE COURTS OF LAW,


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  THE PUBLIC HEALTH SERVICE IS NOW IN THE PROCESS OF HELPING THE
MEDICAL AND HEALTH PROFESSIONS TO UNDERSTAND THE ISSUEwTO SEE HOW
THEY ARE AFFECTED BY -- AND IN TURN CAN AFFECT -- THE ISSUE,, ,AND TO
EDUCATE THEIR MEMBERS TO PLAY SUCH A ROLE,

  VIOLENCE IS NOT A PHENOMENON EXCLUSIVE TO ANY ONE SOCIAL OR
ECONOMIC OR RACIAL OR ETHNIC GROUP, VIOLENCE IS A DEPRESSINGLY HUMAN
PHENOMENON,, BAND ALL HUMAN BEINGS -- NORTH AMERICANS, EUROPEANS,
ASIANS, AFRICANS, AND LATIN AMERICANS -- ARE EQUALLY SUSCEPTIBLE,

  VIOLENCE, HOWEVER, IS ONE OF SEVERAL NEW ISSUES THAT WILL SURELY
BECOME MORE PROMINENT IN MEDICAL AND HEALTH CARE IN THE FUTURE, THEY
ARE HEALTH ISSUES THAT SPRING FROM DYSFUNCTIONING PERSON-TO-PERSON
RELATIONSHIPS, anPERSON-TO-ENVIRONMENT RELATIONSHIPS, ,,AND PERSON-TO-
COMMUNITY RELATIONSHIPS,


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  TO VIOLENCE WE MIGHT ADD THE SIMILAR ISSUES, SUCH AS ECONOMIC OR
SEXUAL EXPLOITATION,,,TOXIC WASTESmAND FAMILY REORGANIZATION AND
DYSFUNCTION,

  THESE ARE ALL MULTI-LAYERED ISSUES CONFRONTING MODERN SOCIETY THE
WORLD OVER,

  THEY ARE ALSO ISSUES WITH A SERIOUS MEDICAL OR HEALTH COMPONENT
REQUIRING OUR PROFESSIONAL ATTENTION AND INVOLVEMENT,

  AND THEY ARE ISSUES WHICH WON'T GO AWAY, THEY WILL STAY WITH US
FOR A WHILE, ,,AND OTHER ISSUES WILL SURELY JOIN THIS LIST,

  WE WILL BE ASKED BY OUR FELLOW CITIZENS TO MAKE OUR SPECIAL CON-
TRIBUTION TO THE AMELIORATION OR ELIMINATION OF THESE CONDITIONS
PECULIAR TO INDUSTRIALIZED OR TECHNOLOGICALLY ADVANCED SOCIETIES, AND
WE WILL HAVE TO MAKE OUR CONTRIBUTION, AS RESPONSIBLE CITIZENS AS WELL
AS RESPONSIBLE HEALTH WORKERS,


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   HERE AGAIN C,M,E, WILL BE OUR OUR MOST EFFECTIVE TOOL FOR PASSING

ON TO OUR COLLEAGUES IMPORTANT NEW INFORMATION ABOUT THESE ISSUES AS

THEY RISE, YEAST-LIKE, WITHIN OUR RESPECTIVE SOCIETIES

CONTINUING MEDICAL EDUCATION, THEN, CAN BE MANY THINGS:

+

   IT CAN BE A MODEST BUl- NEVERTHELESS HIGHLY EFFECTIVE METHOD

FOR BRINGING ALL COLLEAGUES TOGETHER WITHIN THE PERIMETERS OF A
SINGLE NATIONAL STANDARD OF PROFICIENCY FOR THE CONTEMPORARY

PRACTICE OF MEDICINE,

IT IS CLEARLY IMPOSSIBLE FOR ALL MEDICAL SCHOOLS -- NATIONWIDE OR

WORLDWIDE -- TO PREPARE THEIR STUDENTS TO MEET A SINGLE STANDARD
OF PROFICIENCY, BUT IT Is POSSIBLE, THROUGH C,M,E,, TO REQUIRE
INDIVIDUAL GRADUATES AND PRACTITIONERS TO MEET A NATIONAL

STANDARD,


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  C,M,E, CAN ALSO BE AN EFFICIENT METHOD FOR TRANSMITTING
INFORMATION ABOUT NEW MEDICAL TECHNOLOGIES TO ALL HEALTH PROFES-
SIONALS WHO, BY VIRTUE OF THEIR SPECIALTIES, HAVE A "NEED TO
KNOW,"  THIS IMPROVES BOTH CONTEMPORARY AND FUTURE MEDICAL AND
PUBLIC HEALTH PRACTICE,

9

  BUT C,M,E, IS ALSO THE BEST AVAILABLE METHOD TO INFORM THE
PROFESSION OF NEW AND COMPLEX DEVELOPMENTS AFFECTING HEALTH AND
MEDICAL CARE TOMORROW AND WELL INTO THE FUTURE, THESE MAY WELL BE
REGARDED AS ESSENTIALLY NON-MEDICAL ISSUES, BUT THEY NEVERTHELESS
REQUIRE OUR ATTENTION AND OUR PROFESSIONAL INVOLVEMENT,

  THESE REMARKS WERE NOT MEANT TO BE SCHOLARLY AND EXHAUSTIVE,
IT'S TOO EARLY IN THE MORNING FOR THAT, AND BESIDES, YOUR PROGRAM
INCLUDES MANY HIGHLY QUALIFIED PEOPLE WHO WILL ATTEND TO MANY OF THESE
THESE MATTERS IN MORE ILLUMINATING DETAIL,


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  OUR INTENT, INSTEAD, HAS BEEN TO PROVIDE A POSSIBLE CONTEXT FOR
THE DISCUSSIONS THIS WEEK, ,,A CONTEXT THAT REFLECTS SOME OF THE REAL
CHALLENGES TO MEDICAL PRACTICE BOTH TODAY AND TOMORROW,

ONCE AGAIN, ON BEHALF OF SURGEON GENERAL KOOP, ,a

I WANT TO CONGRATULATE THE ORGANIZERS OF THIS CONFERENCE FOR THE
WONDERFUL JOB THEY'VE DONE,, a

I WANT TO WELCOME TO THESE DISCUSSIONS OUR FRIENDS AND COLLEAGUES
FROM FOREIGN LANDS,,,

AND I WANT TO WISH YOU ALL A MOST SUCCESSFUL MEETING,
THANK YOU,

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