SPEECH

AMA NATIONAL LEADERSHIP CONFERENCE

PHOENIX, AZ

FEBRUARY 25,199O

C; EVERETT KOOP, MD


GREETINGS, ETC.

I AM DELIGHTED TO HAVE BEEN ASKED TO ADDRESS THIS

DISTINGUISHED GROUP OF LEADERS IN AMERICAN MEDICINE.

YOU ARE THE MOVERS AND SHAKERS.

THAT'S GOOD.

WE NEED SOME THINGS --AND PEOPLE-- MOVED AND SHAKEN.


IT STILL SURPRISES ME, BUT I HAVE BECOME A RECOGNIZABLE

FELLOW. WALKING ALONG THE STREET IN WASHINGTON, IN THE

NEW YORK SUBWAY. ON THIS TRIP - AFI`ER HEARING AD

NAUSEAM ABOUT SAFE CIGARETTES AND SAFE SEX - A MAN

OFFERED TO CUT ME IN ON HIS INVENTION FOR SAFE

HAMBURGERS.

PEOPLE COME UP TO ME:

"HI, DOC!", OR "KEEP UP THE GOOD WORK!" OR,

"I KNOW YOU! YOU'RE THE ATTORNEY GENERAL. KEEP AFI'ER

THOSE TOBACCO COMPANIES."

IF MY PLANE IS DELAYED, I OFTEN END UP HOLDING OFFICE

HOURS IN THE AIRPORT WAITING AREA.

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YOU ARE THE ONE WHO FINALLY MADE ME STOP SMOKING!"

OR EVEN, "SAY, I HATE TO BOTHER YOU, BUT I'VE GOT THIS PAIN


IN MY ELBOW..."

ON A NUMBER OF OCCASIONS I'VE BEEN RECOGNIZED BY A

STRANGER, AND THEN BOTH PLEASED AND SADDENED BY

SOMEONE SAYING TO ME,

"I WANT TO THANK YOU FOR MAKING ME PROUD, ONCE AGAIN,

TO BE A DOCTOR."


I'M PLEASED, OF COURSE, BECAUSE,I'VE GIVEN MY LIFE TO THIS

PROFESSION, AND IT HAS BEEN GOOD TO ME.

BUT I'M SADDENED TO HEAR FROM SO MANY OF MY

COLLEAGUES WHO HAVE LOST THE PRIDE, THE JOY OF BEING A

PHYSICIAN.

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IF YOU WANT TO KEEP A FINGER ON THE PULSE OF THE

NATION, -- READ

THE PRESIDENT'S MAIL. SECOND BEST IS THE SURGEON

GENERAL'S MAIL, ESPECIALLY IF THE PUBLIC THINKS HE IS

THEIR FAMILY DOCTOR, AND THE MEDICAL PROFESSION TAKES

PRIDE IN WHAT HE IS DOING.

MY MAIL HAS CONVINCED ME THAT TI3E PUBLIC IS VERY

CRITICAL OF DOCTORS AND THE HEALTHCARE SYSTEM THAT

SURROUNDS THEM. AND DOCTORS NO LONGER LIKE THEIR

PATIENTS.


I HAPPEN TO THINK IT ALL BEGAN WHEN DOCTORS LET

THEMSELVES BE CALLED PROVIDERS, AND PATIENTS BECAME

CONSUMERS.

WE NEED TO GET AWAY FROM THE CONSUMER-PROVIDER

MENTALITY.

WE NEED TO RESTORE THE DOCTOR-PATIENT RELATIONSHIP.

EACH OF US.


"CONSUMER" BRINGS TO MIND SOMEONE SHOPPING FOR

GROCERIES OR CHECKING OUT THE FEATURES OF A NEW CAR.

"PROVIDER", ON THE OTHER HAND, SOUNDS LIKE A GARAGE

ATIXNDANT PUMPING GAS.


IF THE PATIENT. THINKS OF HIMSELF PRIMARILY AS A


CONSUMER,

GETL'ING THE MOST FOR HIS MONEY, HE AUTOMATICALLY PUTS

THE DOCTOR IN THE ROLE OF THE SELLER, GETTING THE MOST

FOR HIS TIME.

IF THE DOCTOR IS PRIMARILY CONCERNED WITH COLLECTING

HIS FEE,

HE AUTOMATICALLY AROUSES THE CONSUMER MENTALITY IN

HIS PATIENT.

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THE NEXT TIME PEOPLE REFER TO YOU AS A "HEALTHCARE

PROVIDER", CORRECT THEM.

REMIND THEM YOU ARE A DOCTOR, AND THAT YOU WORK, NOT

WITH CONSUMERS, BUT WITH PEOPLE WHO ARE YOUR PATIENTS.

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RECENTLY, ONE OF MY FRIENDS, QUITE ACCUSTOMED TO

SPENDING HIS TIME WITH OTHER DOCTORS, FOUND HIMSELF

WITH A GROUP OF LAWYERS INSTEAD ---YES, THE TWO CAN GET


TOGETHER!

THE ATL'ORNEYS WERE CONGRATULATING THEMSELVES ON

WHAT THEY WERE ABLE TO DO FOR THEIR FELLOW CITIZENS.


IT HAD BEEN A LONG TIMX SINCE MY FRIEND HAD HEARD

DOCTORS SPEAK IN THAT VEIN.

10


IF LAWYERS CAN FEEL GOOD ABOUT WRITING A WILL,

CAN'T WE FEEL PROUD ABOUT POSTPONING ITS USE?

AMERICAN MEDICINE IS AT A CROSSROADS.

I HOPE YOU KNOW WHAT THE STAKES ARE.

11


TEN YEARS FROM NOW YOU WILL BE DOING ONE OF TWO

THINGS:

(AND WHEN I SAY YOU, I AM ADDRESSING THE PHYSICIANS OF

AMERICA. YOU ARE THE LEADERSHIP.)

EITHER YOU WILL BE WORKING WITH THE PUBLIC TO FREE US

ALL FROM A HASTILY IMPOSED NATIONAL HEALTH SERVICE,

OR,

YOU WILL BE PRACTICING MEDICINE IN A WAY VERY DIFFERENT

THAN YOU ARE DOING NOW, AS PART OF THE BEs;r SYSTEM OF

MEDICAL CARE IN THE WORLD, BUT ONLY AFIXR A DECADE OF

PAINFUL AND DIFFICULT CHANGE.

12


THIS HAS NOTHING TO DO WITH YOUR INCOME.

PLEASE DISABUSE YOURSELF OF THIS IDEA. THE SOONER

DOCTORS REALIZE THIS, THE BETTER

THEY MUST PUT THE BOlTOM LINE ON THE BOTTOM OF THEIR

LIST OF PRIORITIES.

IF DOCTORS PAY AlTENTION TO HIGH QUALITY AND HIGH

EFFICIENCY IN THEIR MEDICAL PRACTICE, IN MOST INSTANCES

THE BOTTOM LINE WILL TAKE CARE OF ITSELF.

13


I KNOW ORGANIZED MEDICINE DOES NOT CONSIDER ITSELF A

UNION.

BUT WE DO COMBINE FOR COMMON PURPOSES.

AND WE CAN LEARN FROM WHAT HAS HAPPENED TO UNIONS.

FOR FAR TOO LONG THEIR ONLY CONCERNS WERE INCOME,

WORKING CONDITIONS, AND BENEFITS.

MEANWHILE QUALITY AND EFFICIENCY WERE IGNORED.

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NOW, BELATEDLY, THEY ARE SCRAMBLING TO ADDRESS QUALITY


AND EFFICIENCY.

T-HE AMERICAN AUTO INDUSTRY AFFORDS A GOOD EXAMPLE.

I IMAGINE THAT MANY DOCTORS WHO USED TO DIUVE BUICKS

AND CADILLACS NOW SIT BEHIND THE WHEEL OF CAMRYS AND

MAXIMAS.

15


I KNOW WE DON'T LIKE TO HEAR --OR VOICE-- CRITICISM OF

OUR PROFESSION.

WE USED TO FEEL GOOD ABOUT OURSELVES AND OUR HEALTH

CARE SYSTEM.

NO LONGER.

IN A WORD --WE HAVE BIG PROBLEMS.

SOMETIMES I USED TO WONDER IF THERE SHOULD NOT HAVE

BEEN ANOTHER SURGEON GENERAL'S WARNING:

"WARNING! THE AMERICAN HEALTH CARE SYStiM CAN BE

HAZARDOUS TO YOUR HEALTH!

16


TO BEGIN WITH, THIS IS A TIME IN WHICH WE HAVE VERY HIGH

EXPECTATIONS FOR MEDICINE AND HEALTH.

WE'VE PUT A GREAT DEAL OF FAITH INTO NEW TECHNOLOGIES,

NEW PHARMACEUTICALS, NEW SURGICAL PROCEDURES, AND SO

ON, AND WE CONTINUE TO HAYE FAITH IN WHAT I LIKE TO CALL

THE MAGIC OF MEDICINE.

THE PUBLIC ROUTINELY EXPECTS MIRACLES TO HAPPEN -- EVEN

THOUGH THE REAL WORLD OF MEDICINE ISN'T ALWAYS ABLE TO

DELIVER.


WE HAVE THAT SITUATION RIGHT NOW WITH AIDS.

FOR THE PAST 8 YEARS, SCIENTISTS AND CLINICIANS. HAVE BEEN

WORKING AROUND-THE-CLOCK TO UNDERSTAND AND CONQUER

THE DISEASE OF AIDS. BUT IT STILL REMAINS SOMEW&%T OF A

MYSTERY AND I DOUBT THAT WE'LL GET FULL CONTROL OVER

THE AIDS VIRUS BEFORE THE TURN OF THE CENTURY.

BUT, AS FAR AS THE GENERAL PUBLIC IS CONCERNED, THE AIDS

SITUATION IS THE EXCEPTION AND NOT THE RULE.

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THE AMERICAN PEOPLE STILL MAINTAIN HIGH HOPES FOR WHAT

MEDICINE AND HEALTH CARE CAN DO FOR THEM,

BUT I THINK IT'S ALSO BECOMING CLEAR THAT THOSE HIGH

EXPECTATIONS ARE FAST OUT-RUNNING OUR ABILITY TO PAY

FOR THEM.

IN OTHER WORDS, WE HAVE A CLEAR GAP IN OUR SOCIETY

TODAY BETWEEN WHAT WE WOULD LIKE `t0 SEE HAPPEN IN

HEALTH CARE ..- AND WHAT CAN REALIST#iCALLY HAPPEN IN

HEALTH CARE.

19


MANY OF OUR GREAT EXPECTATIONS COME FROM OUR ABIDING

FAITH IN EVER-IMPROVING MEDICAL TECHNOLOGY.

BUT NOW, I BELIEVE THE PUBLIC WONDERS IF MEDICAL

TECHNOLOGY MIGHT BE A MIXED BLESSING.

THANKS TO AN EXPLOSION OF NEW KNOWLEDGE IN SCIENCE

AND TECHNOLOGY OVER THE PAST SEVERAL DECADES, WE KNOW

HOW TO DO MANY NEW AND FASCINATiNG THINGS.

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BUT KNOWING HOW TO DO SOMETHING HAS NEVER BEEN

ENOUGH.

PEOPLE ALSO WANT TO KNOW WHY . . . OR WHY NOT?

AND TODAY, AS THE COST OF OUR MAGIC TECHNOLOGY SOARS,

THEY ARE ASKING "WHY?" MORE OFTEN AND MORE INSISTENTLY.

IN REGARDS TO PROLONGING LIFE, FOR EXAMPLE,    BOTH


THE LAY PUBLIC AND THE MEDICAL PROFESSION ARE EVEN NOW

DEBATING THE WISDOM OF USING SO-CALLED "EXTRAORDINARY"

lkmmnws To sfwtz 0~ PROLONG THE ~rv~s OF PERSONS

PROFOUNDLY TRAUMATIZED OR TERMINALLY ILL.

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FOR MANY PEOPLE WHO MUST DECIDE THE FATE OF LOVED

ONES, HIGH-TECH MEDICINE SOMETIMES ACTS LIKE A FRIEND . . .

AND SOMETIMES IT ACTS LIKE AN ENEMY.

HENCE, SOME PEOPLE ARE TURNING TO LEGAL INSTRUMENTS


LIKE THE SO-CALLED "LMNG WILL" AND THE "DURABLE POWER

OF ATTORNEY" TO PROTECT THEMSELVES FROM RUNAWAY

MEDICAL TECHNOLOGY, IN THE EVENT THEY ONE DAY HAVE A

TERMINAL ILLNESS OR INJURY.

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HENCE, IN MANY REAL-LIFE SITUATIONS, TECHNOLOGY IS A

MIXED BLESSING . . . AT BEST . . . AND CAN BE A CURSE, AT THE

WORST.

IS OUR SOCIETY STILL READY AND WILLING TO DELIVER HIGH-

QUALITY, TECHNOLOGY-INTENSIVE MEDICAL CARE TO

EVERYONE, REGARDLESS OF COST?

I'D HAVE TO SAY THE ANSWER I GET AS I TRAVEL AROUND THE

COUNTRY IS, "PROBABLY NOT."

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WHAT WE HAVE, THEN, IS A RISE IN THE NEW TECHNOLOGIES

AVAlUBLE TO PHYSICIANS . . .

BUT, AT THE SAME TIME, A DECLINE IN THEIR SIGNIFICANCE FOR

A SUBSTANTIAL NUMBER OF PATIENTS.

IN ONE OF HIS PLAYS, GEORGE BERNARD SHAW ASKED WHY WE

PAY DOCTORS TO TAKE A LEG OFF BUT WE DON'T PAY THEM TO

KEEP A LEG ON. NOW, ALMOST 80 YEARS HAVE PASSED AND WE

j$I&L HAVEN'T COME UP WITH A GOOD ANSWER.

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OUR TECHNOLOGY-DRIVEN REIMBURSEMENT SYSTEM --

WHETHER BY GOVERNMENT OR OUT-OF-POCKET -- IS STILL

PREDICATED ON TAKING THE LEG OFF.

25


THE STRUGGLE BETWEEN OUR ASPIRATIONS AND OUR

RESOURCES HAS COME AT THE WORST POSSIBLE TIME,

A TIME WHEN DEMOGRAPHIC TRENDS ARE RUNNING AGAINST US.

IN A CLIMATE OF SCARCITY AMERICANS WILL HAVE TO WORK

OUT AN EQUITABLE SHARING OF NEEDED MEDICAL RESOURCES

BETWEEN ONE POPULATION GROUP THAT IS GROWING -- THAT IS,

THE ELDERLY, PEOPLE OVER THE AGE OF 65 -0 AND THE

qoPULA!IlON GROUP THAT IS COMPARATIVELY SHRINKING --

THAT IS, CHILDREN UNDER THE AGE OF 18.

26


OVER THE PAST 8 YEARS I'VE DEALT WITH ADVOCATES FOR

CHILDREN AND I'VE DEALT WITH ADVOCATES FOR THE ELDERLY.

THEY ARE BOTH VERY DEDICATED AND VERY PERSUASIVE

GROUPS.  AND BOTH WILL BE QUITE RIGHTLY COMPETING FOR

A LARGER PIECE OF A SMALLER PIE.

THIS HAS CHILLING ETHICAL IMPLICATIONS, AND WE MUST

GUARD AGAINST LETTING OUR ETHICS BE DETERMINED BY OUR

ECONOMICS,

AND NOT THE OTHER WAY AROUND.

27


WHEN I OR OTHER PEOPLE TALK LIKE THIS, OUR CRITICS COME

BACK AT US AND SAY THAT THINGS REALLY AREN'T THAT BAD . . .

THAT ALL WE NEED TO DO IS PUT A REIMBURSEMENT CAP ON

THIS . . . OR CHANGE THE ELIGIBILITY REGULATIONS FOR THAT . . .

OR CUT BACK A LITTLE HERE . . . OR PRUNE BACK A LI'ITLE THERE.

28


DURING 8 YEARS AS YOUR SURGEON GENERAL, I'VE LISTENED TO

THESE DEBATES AND I'VE THOUGHT ABOUT THE TRUE HUMAN

COSTS ASSOCIATED WITH THAT KIND OF A PATCHWORK

APPROACH.

AND TODAY I'M MORE CONVINCED THAN EVER THAT OUR WHOLE

HEALTH CARE SYSTEM NEEDS TO BE STUDIED WITH AN EYE TO

MAKING A NUMBER OF VERY MATOR CORRECTIONS.

29


NOW, I CAN ALREADY HEAR THE CRITICS SAYING,

"WAIT A MINUTE, DR. KOOP. THE SYSTEM AIN'T BROKE, SO DON'T


FIX IT."

TO WHICH I WOULD REPLY, "YOU'RE WRONG. THE SYSTEM&j

BROKEN . . . AND IT MUST BE F'IXED."

BAND-AIDS WON'T DO.

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HOSPITAL COSTS ARE STILL CLIMBING . . . AND NO ONE CAN

PROVE TO THE AMERICAN PEOPLE THAT THE OUALITY OF

HOSPITAL-BASED CARE IS UNIFORMLY GOING Up AS WELL.

ON THE CONTRARY, OUR PEOPLE COMPLAIN THAT THEY ARE

PAYING MORE AND MORE Ii'OR MEDICAL CARE, AND ARE GETTING

LESS AND LESS.

WORSE STILL, AS THE COST OF HOSPITAL-BASED CARE

INCREASES, SOME HOSPITALS THEMSELVES ARE TRYING TO

NARROW THEIR PATIENT POOL . . . FOR EXAMPLE, ELIMINATING

THE NEED TO PROVIDE IN-PATIENT MEDICAL CARE FOR POOR

AND DISADVANTAGED AMERICANS.

31


I SAY THERE'S SOMETHING TERRIBLY WRONG WITH A SYSTEM OF

HEALTH CARE THAT SPENDS MORE AND MORE MONEY TO SERVE

FEWER AND FEWER PEOPLE.

AND WE HAVE MUCH THE SAME PROBLEM IN RESPECT TO

PHYSICIAN SERVICES AND FEES.

32


I KNOW THAT MANY OF YOU, MY FRIENDS AND COLLEAGUES IN

MEDICAL PRACTICE, ARE TRYING TO DO WHAT YOU CAN TO

INCREASE THE QUALITY OF CARE YOU DELIVER WITHOUT

INCREASING THE COSTS.

I KNOW YOU ARGUE THAT YOU HAVE LITI'LE OR NO CONTROL

OVER SOME OF HE INFLATIONARY THINGS YOU DO.

AND THAT'S TRUE.

33


I'VE BEEN THERE - I PRACTICED SURGERY FOR 40 YEARS - SO IT'S

NOT J-UST GIVING YOU THE BENEFIT OF THE DOUBT.

BUT THE FACT STILL REMAINS THAT PHYSICIAN FEES ARE GOING

UP, AND THEY DO ADD TO A BURDEN ON THE PUBLIC THAT IS

BECOMING INSUPPORTABLE.

AND, AGAIN -- AS WITH HOSPITAL-BASED CAItE -- THE AMERICAN

PEOPLE HAVE NOT BEEN ASSURED, IiV ANY RATIONAL AND

MEASURABLE WAY,

THAT THE HIGHER COSTS OF A PHYSICIAN'S CARE WILL IN FACT

BUY THEM A PROPORTIONATELY HIGHER OUALti OF SUCH

CARE.

34


BEFORE I GO ANY FURTHER, LET ME SAY THAT IN GENERAL I

SUPPORT THE CONCEPT OF A hi.lSSEZ-FAIRE MARKETPLACE AND

I BELIEVE IN A FREELY COMPETITIVE ECONOMY.

NOW, HAVING SAID THAT, LET ME GO ON TO SAY THAT THE

HEALTH CARE MARKETPLACE 1s LAISSEZ-FAIRE . . .

BUT IT'S NOT FREELY COMPETITIVE AND, HENCE, IT HAS

VIRTUALLY NO MODERATING CONTROLS WORKING ON BEHALF

OF THE CONSUMER,

THAT I STILL PREFER TO CALL, THE PATIENT.

35


IN MOST OTHER AREAS OF OUR ECONOMY, THE MARKETPLACE

DOES EXERCISE SOME CONTROL OVER ARBITRARY RISES IN

CHARGES TO THE CONSUMER. THERE REALLY Is COMPETITION.

HERE AND THERE IT MIGHT BE RATHER THIN . . . BUT IT DOES

EXIST AND IT DOES PROVIDE SOME ASSURANCE THAT

INEFFECTLVE, UNCOMPETITIVE, HIGH-COST, LOW-QUALITY

ENTERPRISES WILL FAIL.

36


BUT IN HEALTH CARE, RIGHT ACROSS THE BOARD+ PRICES HAVE

GONE UP IRRESPECTIVE OF THE QUALITY OF CARE BEING

DELIVERED OR OF ANY OTHER MARKETPIACE CONTROL.

TRY AS THEY MIGHT, I DON'T SEE THE MEDICAL PROFESSION

ACHIEVING MUCH SUCCESS IN SELF-REGULATION.

37


GRANTED, IT'S NO SIMPLE TASK  BUT, UNTIL THE PURCHASING

PUBLIC "BUYS RIGHT=- AS WALTER MCCLURE PUTS IT-- THE

MARKET CANNOT CHANGE.

PHYSICIANS CAN HELP PUT THE BRAKES ON SOME GENERAL

EXPENDITURES, BUT THERE ARE VERY FEW PHYSICIANS WHO CAN

HONESTLY AND EFFECTIVELY CONTROL EVEN THE DELIVERY OF

SERVICE -- MUCH LESS CONTROL THE COSTS OF THAT SERVICE --

WHILE CARING FOR A SPECIFIC, INDIVIDUAL PATIENT AT THX

BEDSIDE.

38


WE SEEM TO HAVE, THEREFORE, A SYSTEM OF HEALTH CARE

THAT'S DISTINGUISHED BY A VIRTUAL ABSENCE OF SELF-

REGULATION ON THE PART OF THE PROVIDERS OF THAT HEALTH

CARE -- THAT IS, HOSPITALS AND PHYSICIANS -- AND

DISTINGUISHED AS WELL BY THE ABSENCE OF SUCH NATURAL

MARKETPLACE CONTROLS AS COMPETITION IN REGARD TO

PRICE, QUALITY, OR SERVICE.

39


WHAT IS THE EFFECT OF SUCH A SYSTEM ANYWAY?

OUR PROBLEMS HAVE RESULTED IN A THREE-TIER FRAMEWORK

OF HEALTH CARE.

40


WE'VE ALWAYS SAID WE NEVER WANTED EVEN A TWO-TIER


SYSTEM.

BUT WE HAVE IT . . . AND A THIRD TIER, ALSO.

IN THE FIRST TIER . . . THE BOTTOM TIER . . . ARE UPWARDS OF

PERHAPS 30 MILLION AMERICANS -- ABOUT. 12 PERCENT OF THE

POPULATION -- WHO FALL BETWEEN THE CRACKS AND HAVE m

HEALTH INSURANCE COVERAGE . . . NO HIGH OPTIONS . . . NO LOW

OPTIONS . . . NO OPTIONS AT ALL.

41


THEY'RE NOT OLD ENOUGH FOR MEDICARE AND NOT POOR

ENOUGH FOR MEDICAID.

WHAT, THEN, DOES THIS "HEXLTH CARE SYSTEM" OF OURS DO

FOR THE UNINSURED?

IN THE VAST MAJORITY OF CASES THE ANSWER IS . . . VERY LITTLE

. . . OR NOTHING.

42


AND THEY ARE SUFFERING THE CONSEQUENCES. AS YOU KNOW,

STUDY AFTER STUDY INDICATES THE CORRELATION BETWEEN NO

MEDICAL INSURANCE AND INCREASING HEALTH PROBLEMS.

THE HEALTH PROBLEMS OF THE LOWEST TIER,

IF IGNORED BY SOCIETY NOW, WILL BE BORNE BY SOCIETY


LATER.

43


THEN WE-HAVE A SECOND TIER.

THIS TIER RECEIVES A NARROW RANGE OF BASIC MEDICAL AND

HEALTH SERVICES WITH MORE OR LESS FIXED LEVELS OF

RELMBURSEMENT.

THIS IS LOW-OPTION COVERAGE . . . MEDICARE AND MEDICAID

COVERAGE . . . WITH THE PATIENT PAYING MANY COSTS OUT-OF- '

POCKET OR WITH THE HELP OF SOME FORM OF SUPPLEMENTAL

INSURANCE, WHICH IS -- IN MY BOOK -- JUST ANOTHER KIND OF

OUT-OF-POCKET EXPENSE.

44


FINALLY, WE HAVE THE THIRD TIER, THE TOP TIER.


THE PEOPLE IN THIS TIER RECEIVE A FULL RANGE OF MEDICAL

AND HEALTH SERVICES. THEY ARF, COVERED BY HIGH-OPTION

HEALTH INSURANCE AND ALSO HAVE A FEW DOLLARS LEFT OVER

TO PAY THE 15 OR 20 PERCENT DIFFERENCE BETWEEN THE

ACTUAL BILL FROM THE DOCTOR AND THE CHECK FROM THE

INSURANCE COMPANY.

45


BUT BUSINESS IS FINALLY COMING AROUND TO UNDERSTAND

THAT IT CANNOT CONTINUE TO BURY INFLATED COSTS OF

HEALTH CARE IN THE PRICE-TAGS OF THEIR GOODS AND

SERVICES.

SINCE 1984 THE AVERAGE PREMIUMS FOR EMPLOYER-PROVIDED

HEALTH INSURANCE HAVE APPROXIMATELY DOUBLED... TO $3,117

PER YEAR,

AND HAVE RISEN FROM 8 PERCENT OF BUSINESS PAYROLL COSTS

TO X3.6 PERCENT LAST YEAR.

46


BUSINESSES CAN'T ABSORB THESE COSTS AND ALSO EXPECT TO

BE COMPETITIVE.

AMERICAN BUSINESSMEN AND LABOR LEADERS ARE FINALLY

COMING TO UNDERSTAND WHAT THIS MEANS.

THERE IS A "HEALTH BENEFITS SURCHARGE", IF YOU WILL,ON

EVERY MANUFACTURED PRODUCT.

47


FOR EXAMPLE, ON EVERY CAR THAT GENERAL MOTORS

MANUFACTURES IN THIS COUNTRY, IT AMOUNTS TO WELL OVER

$600 PER CAR.

IN CONTRAST, CARS MADE AT THE NEW NISSAN PLANT IN

TENNESSEE, THE "HEALTH BENEFITS SURCHARGE" IS ONLY SIXTY

DOLLARS PER CAR.

THE GENERAL MOTORS HEALTH PLAN IS A GENEROUS ONE, AND

IT COVERS RETIRED EMPLOYEES AS WELL AS ACTIVE WORKERS.

NISSAN, ON THE OTHER HAND, OFFERS A LIMITED PLAN THAT

DOES NOT EVEN PROVIDE MATERNITY BENEFITS OR PEDIA'I;RIC

CARE FOR ITS ACTIVE EMPLOYEES.

48


THIS SITUATION, THIS DISPARITY BETWEEN RESOURCES AND

ASPIRATIONS, THIS SENSE OF COSTS OUT OF CONTROL, HAS


PLACED AMERICAN MEDICINE UNDER THE GUN.

MOMENTUM IS BUILDING FOR RESTRUCTURING THE FINANCING

AND DELIVERY OF HEALTHCARE IN THE UNITED STATES.

EVEN BUSINESS LEADERS WHO CRINGE AT THE THOUGHT OF

GOVERNMENT INTERVENTION ARE ASKING FOR A SYSTEM OF

NATIONAL HEALTH CARE AS A SOLUTION TO RISING INSURANCE

COSTS.

49


A SURPRISING AND VERY SIGNIFICANT EVENT TOOK PLACE AT

THE BEGINNING OF LAST SUMMER.

TWO GROUPS, UNLIKELY PARTNERS IN THIS SORT OF ISSUE,

EACH CALLED FOR A NATIONAL HEALTH SERVICE.

THE FIRST WAS ONE OF THE MAJOR AUTOMOBILE

MANUFACTURERS,

AND THE OTHER WAS THE HERITAGE FOUNDATION, A MOST

CONSERVATIVE BODY.

50


NEVER BEFORE HAVE THERE BEEN SO MANY VOICES CLAMORING

FOR RADICAL REFORM OF THE AMERICAN HEALTHCARE SYSTEM.

IN CONGRESS, IN LABOR, IN BUSINESS, IN PHYSICIANS' OFFICES

PEOPLE AGREE: SOMETHING MUST BE DONE.

51


RECENTLY I'VE NOTICED A STRANGE INTEREST IN THE CANADIAN

SYSTEM.

EVERYWHERE I GO PEOPLE SAY TO ME, "WE NEED THE CANADIAN

SYSTEM." SO I SAY, "TELL ME, WHAT IS IT YOU LIKE ABOUT THE


CANADIAN

SYSTEM.?"

THEY ALWAYS ANSWER, "I DON'T REALLY KNOW, BUT IT'S A GOOD

SYSTEM."

52


THE GROWING INFATUATION WITH FOREIGN NATIONAL HEALTH

SERVICES IS BASED MORE UPON DISSATISFACTION WITH OUR

SYSTEM THAN UPON UNDERSTANDING OF ANOTHER ONE.

BUT IF WE DON'T HEED THE CALL, THE AMA LOGO MAY BE

REPLACED BY THE MAPLE LEAF.

53


IF WE DON'T OFFER SOMETHING BETIER, WE WILL GET A

GOVERNMENT CONTROLLED MEDICAL SYSTEM, AND LOSE

FOREVER THE PRESENT POTENTIAL FOR THE BEST SYSTEM

POSSIBLE.

MOST AMERTCANS DO NOT REALIZE THAT ANY NATIONAL

HEALTH SERVICE, IS BASED UPON PLANNED SCARCITY.

54


EXPERIENCE THE WORLD OVER HAS SHOWN THAT WHEN

GOVERNMENT ECONOMIC CONTROLS ARE APPLIED TO HEALTH,

THEY PROVE --IN TIME- TO BE DETRIMENTAL.

EVENTUALLY-THERE IS AN EROSION OF QUALITY, PRODUCTIVITY,

INNOVATION, AND CREATIVITY.

THIS IS ESPECIALLY TRUE OF RESEARCH.

THEN, LACK OF RESPONSIVENESS TO PATIENTS.

55


FINALLY, RATIONING AND WAITING IN LINES.

AMERICANS DO NOT PATIENTLY QUE UP FOR ANYTHING,

ESPECIALLY FOR MEDICAL CARE.

TE3E MAJORITY HAS BECOME ACCUSTOMED TO AVAILABLE CARE,

IF NOT ACCESSIBLE CARE.

56


WE ARE IN A PERIOD OF TIGHT FINANCIAL CONSTRAINTS, AND IF

YOU READ THE LIPS OF THE PRESIDENT -- NO NEW TAXES.

IF THAT WFXE NOT SO, I THINK CONGRESS WOULD TAKE THE

FIRST STEPS TOWARD A GOVERNMENT-CONTROLLED NATIONAL

HEALTH SERVICE ALMOST IMMEDIATELY.

WE'D HAVE IT AS A RESULT OF CONGRESSIONAL FRENZY, AND IT

WOULD SEEM MARVELOUS AT THE BEGINNING. BUT

DISSATISFACTION WOULD COME UNTIL YOU COULDN'T WAIT TO

CHANGE IT AGAIN.

57


THERE IS A BETTER WAY.

AS I EXPLAINED TO THE PRESIDENT BEFORE HIS ELECTION,

AS I HAVE WRITTEN IN EDITORIALS IN NEWSWEEK AND OTHER

JOURNALS, AS I HAVE SAID FROM MANY PODIUMS ACROSS THIS


LAND,....

IF WE DO THINGS IN A FOCUSED AND DELIBERATE WAY, WE CAN

HAVE EXCELLENT AND AFFORDABLE MEDICINE WITHOUT THE

FURTHER INTRUSION OF THE GOVERNMENT INTO THE DELIVERY

OF HEALTH CARE.

AND THE MONEY SAVED BY INCREASED EFFICIENCY,

ECONOMISTS TELL ME, WOULD TAKE CARE OF THOSE

CURRENTLY WITHOUT ACCESS

58


A MARKET-BASED STRATEGY MUST ADDRESS THE FORCES

DRIVING COSTS UPWARD WHILE AT THE SAME TIME ATTACKING

BARRIERS TO ACCESS.

WE HAVE THE PARADOX OF TOO MUCH CARE AND TOO LIITLE


CARE FOR DIFFERENT SEGMENTS OF SOCIETY AT THE SAME

TIME.

AS HIGH-TECH MEDICINE GROWS OUT OF CONTROL, UNBRIDLED

BY INFORMED PURCHASERS, MANY PEOPLE ARE DENIED BASIC


PREVENTIVE AND PRIMARY CARE.

59


TWO THIRDS OF OUR POPULAmON - ABOUT 160 MILLION

AMERICANS ARE COVERED BY EMPLOYER-PURCHASED HEALTH

INSURANCE.

EMPLOYERS AND WORKERS TOGETHER MUST IDENTIFY THE

LEADERSHIP TO BRING HEALTHCARE COST UNDER CONTROL.

SUCH A NATIONAL ALLIANCE HAS BEEN FORMED AND IS

GROWING.

60


AS THIS REFORM IN THE PRIVATE SECTOR IS TAKING PLACE

THERE MUST BE FURTHER JOINING OF FORCES WITH

GOVERNMENT - AT FEDERAL AND STATE LEVELS - WHERE

MEDICARE AND MEDICAID ARE ADMINISTERED,IF WE ARE TO


RESTRUCTURE THE ENTIRE SYSTEM OF PURCHASING AND

PROVIDING HEALTHCARE.

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THEN, INSTEAD OF REWARDING POOR QUALITY AND

INEFFICIENCY -- WITH DOLLARS, AS WE NOW DO,-- HIGH

QUALITY, AND EFFICIENCY WILL BE REWARDED WITH PATIENTS.

THE PATIENTS WILL COME FROM THE POOR QUALITY,

INEFFICIENT SYSTEMS WHICH WILL HAVE TO IMPROVE OR

PERISH.

WE WILL NEED - AND THEY ARE BEING DEVELOPED - TOOLS TO

MEASURE MEDICAL NECESSITY, APPROPRIATENESS,
EFFECTIVENESS AND OF COURSE OUTCOMES, QUiLITY, AND

EFFICIENCY ARE DIFFICULT IF NOT IMPOSSIBLE TO MEASURE.

62


\ FOR THOSE WITHOUT ACCESS, THE GOAL IS UNIVERSAL


COVERAGE TO BE ACHIEVED THROUGH COMPREHENSIVE

REFORMS OF GOVERNMENT PROGRAMS FOR THE POOR AND

UNINSURED COMBINED WITH RISK POOLING.

MEANWHILE INTERIM STEPS INCLUDE MEDICAID EXPANSION,

UNDER EXISTING LAW, AND TAX INCENTIVES TO ENCOURAGE

SMALL BUSINESS INSURANCE COVERAGE.

THESE LATTER ELEMENTS ARE THE ONLY ONES THAT REQUIRE

PUBLIC POLICY REFORMS.

63


THE OPPORTUNITY IS NOW.

THE TIME IS SHORT.

THE STAKJXS ARE HIGH.

THE ALTERNATIVES UNDESIRABLE.

IT REMAINS TO BE SEEN WHETHER OR NOT THE AMEXICAN

MEDICINE, THE AMA, SEIZES THIS ONE AND ONL+ OPPORTUNITY.

64


WE ALL NEED TO BE A PART OF THE EFFORT.

BUT THERE IS NO QUICK FIX.

FROM HERE TO THERE COULD TAKE A DECADE, BUT WE'D

IMPROVE YEAR BY YEAR ALONG THE WAY.

65


OF COURSE, MEDICINE IS NOT ALONE IN ITS RAPIDLY RISING

COSTS. BUT OUR PRICES MAKE PEOPLE ANGRY.

66


RECENTLY, I ASKED THE CONTRACTOR BUILDING MY NEW HOUSE

TO MOVE THE OUTLET FOR AN OVERHEAD LIGHT 18 INCHES --

THE CONTRACTOR
BEFORE THE CEILING WAS FINISHED.


WANTED TO CHARGE ME $450!

WHEN PEOPLE HEAR THAT, THEY MAY LAUGH KNOWINGLY,

OR GROAN IN SYMPATHY,

BUT THEY DON'T GET ANGRY.

67


THE SAME IS TRUE FOR THE ESCALATING COSTS IN PRIVATE

EDUCATION. ALTHOUGH NO ONE IS HAPPY ABOUT THE RISING

COST OF A COLLEGE EDUCATION, IT DOES NOT CREATE THE

SAME ANGER OR RESENTMENT AS THE RISING MEDICAL COSTS.

STUDENTS PAY THE PRICE FOR PRIVATE HIGHER EDUCATION

BECAUSE THEY FEEL THEY ARE GETTING QUALITY-IN RETURN,

EVEN THOUGH THE EXPECTATIONS IN EDUCATION ARE LOWER

THAN IN HEALTH, AND THE FAILURES MORE FREQUENT.

68


THE STUDENT-TEACHER RELATIONSHIP HAS NOT BECOME ONE

OF

CONSUMER-PROVIDER.

THAT IS BECAUSE STUDENTS DO NOT SEE TEACHERS AS THE

DIRECT BENEFICIARIES OF THE RISING COSTS, THE WAY

PATIENTS SEE DOCTORS.

A HIGH QUALITY EDUCATION, STUDENTS AND PROFESSOR ALIKE

WILL SAY, IS SOMETHING YOU CAN'T EVALUATE IN DOLLARS AND

CEN?S ALONE.

69


PATIENTS USED TO FEEL THE SAME ABOUT RESTORED HEALTH.

BUT NOW THEY ARE ANGRY.

PART OF THE ANGER, THE DISSATISFACTION MAY BE

UNAVOIDABLE.

NO ONE WANTS TO BE SICK,

AND TO HAVE TO PAY FOR IT MAKES IT WORSE.

70


BUT PART OF THE ANGER IS OF OUR OWN MAKING.

NOT LONG AGO I READ AN ARTICLE IN THE NEWSPAPER OF MY

OLD HOMETOWN, PHILADELPHIA, WHICH POINTED OUT THAT

WHILE THE PRESIDENT OF THE UNIVERSITY OF PENNSYLVANIA

MIGHT BE A TRIFLE OVERPAID AT $220,000 A YEAR,  FIVE

PROFESSORS OF SURGERY MADE BETWEEN $440,000 AND $620,00.

THE REPORTER LOST SIGHT OF THE FACT THAT HE WAS WRITING

ABOUT THE SALARIES OF COLLEGE PRESIDENTS AND TOOK OFF

ON DOCTORS' INCOMES INSTEAD. HE OBVIOUSLY WANTED THE

PUBLIC TO HAVE A HARD TIME SWALLOWING tiT.

THE PUBLIC HAS A HARD TIME SWALLOWING THAT.

71


IF WE COULD SEPERATE INCOME FROM THE PUBLIC'S

PERCEPTION OF DOCTORS, A LOT OF THE PUBLIC HOSTILITY

WOULD DISAPPEAR, EVEN THOUGH DOCTORS DON'T MAKE AS

MUCH AS TOP CORPORATE EXECUTIVES, ENTERTAINERS, AND

ATHLETES. BUT THE PUBLIC IS MORE CRITICAL OF DOCTORS.

THAT SEPERATION ISN'T POSSIBLE, BUT I KNOW A LOT COULD BE

DONE TO LEAD THE PATIENT TO BELIEVE HE IS GETTING HIGH-

QUALITY, HIGH-EFFICIENCY, CONSIDERATE, SENSITIVE CARE FOR

HIS MONEY, INSTEAD OF THE PATIENT'S PRESENT BELIEF THAT

HE IS PAYING MORE AND MORE FOR LESS AND LESS.

72


LET ME SAY IT AGAIN, THAT THE RESTORATION OF THE DOCTOR-

PATIENT RELATIONSHIP IS MOST ESSENTIAL.

MANY THINGS WOULD HAVE TO CHANGE IN ORDER THAT IT BE

RESTORED, BUT ONCE RESTORED, MANY OTHER THINGS WOULD

FALL INTO PLACE.

DOCTORS AND PATIENTS MUST STOP VIEWING EACH OTHER AS

AN ECONOMIC THREAT.

73


WE CAN'T HAVE PATIENTS WONDERING IF DOCTORS MAKE

BEDSIDE OR EMERGENCY ROOM DECISIONS ON CARE BASED

UPON INSURANCE COVERAGE.

WE CAN'T HAVE DOCTORS WONDERING IF THE PATIENT ON THE

EXAMINING TABLE WILL NEXT MEET HIM IN COURT,

SURROUNDED BY MALPRACTICE LAWYERS.

74


I AM DEEPLY SADDENED WHEN DOCTORS TELL ME THAT THIS

NEW ADVERSARY RELATIONSHIP HAS MADE THEM DISLIKE THEIR

PATIENTS.

AND THAT THEIR PATIENTS DISLIKE THEM.

I AM MORE THAN SADDENED WHEN A PHYSICIAN BRAGS THAT HE

TALKED HIS SON OR DAUGHTER OUT OF GOING TO MEDICAL

SCHOOL.

75


I NEED NOT EXPLAIN IN GREAT DETAIL TO THIS GROUP THE

SORRY REIXI'IONSHIP BETWEEN RISING COSTS AND THE

MALPRACTICE MESS.

REFORM IS IMPERATIVE, BUT IT MAY BE IMPOSSIBLE IN THE

FACE OF ENTRENCHED INTERESTS,

DOCTORS PROTECTING DOCTORS, LAWYERS DEFENDING


LAWYERS.

76


PERHAPS A BLUE-RIBBON PANEL OF RETIRED ATTORNEYS AND

PHYSICIANS, MEN AND WOMEN WITHOUT A PERSONAL

FINANCIAL STAKE IN THE SYSTEM, COULD SERVE THE PUBLIC

INTEREST BY ADJUDICATING CLAIMS,

DECIDING WHETHER OR NOT THE CASE SHOULD GO TO COURT.

EVEN THOUGH THE TORT SYSTEM IN CANADA AND THE UNITED

KINGDOM IS DIFFERENT FROM OURS, IT IS NOT POSSIBLE IN


EITHER OF THOSE COUNTIUES FOR A CONTINGENCY FEE TO

TEMPT THE LEGAL PROFESSION.

77


SOMETIMES, FOR EXAMPLE, AFl?ER A MAJOR ILLNESS IN A

PREMATURE NEWBORN, THE CHILD IS RESTORED TO THE

FAMILY, NOTHING WENT WRONG, BUT THE FAMILY IS NOW

IMPOVERISHED. WE HAVE TO FIND A WAY TO FOR THOSE

FAMILIES TO COVER THEIR CATASTROPHE IS SOME WAY OTHER

THAN SUING A DOCTOR FOR IMAGINED GRIEVANCES IN ORDER

TO PROVIDE FOR THE CHILD'S FUTURE AND TO CLEAR THE

FAMILY DEBT.

7%


I'M SURE THAT BOTH THE DOCTOR AND THE PATIENT WOULD

PREFER TO HAVE THAT OLD RELATIONSHIP OF TRUST THEY USED

TO HAVE.

UNLESS WE RESTORE THE DOCTOR-PATIENT RELATIONSHIP, WE

HAVE LOST OUR WAY COMPLETELY.

IT CAN BE RESTORED.

BUT IT WILL TAKE COMMITM ENT BY PEOPLE ON jBO'Il3 SIDES OF

THE STETHOSCOPE.

79


THERE ARE OTHER THINGS WE CAN DO, AS DOCTORS,

EACH DAY WE PRACTICE.

I AM AWARE, OF COURSE, ABOUT THE DIFFERENCES WITHIN OUR


PROFESSION. "THE MEDICAL PROFESSION" IS NOT MONOLITHIC.

AMONG THE DIFFERENCES I NOTE IS ONE ALONG THE LINES OF

GENERATIONS.

80


I BELIEVE THE PHYSICIANS OF MY GENERATION HAVE A

STRONGER SENSE OF THE "ART" OF MEDICINE, AND TEND TO

GIVE LESS VENERATION TO THE "SCIENCE" OF MEDICINE.

MAYBE WE CONDUCT OURSELVES THAT WAY BECAUSE WHEN WE


WERE FIRST STARTING IN PRACTICE, THE SCIENTIFIC

UNDERPINNING FOR OUR PRACTICE WAS, TO BE HONEST, RATHER


MARGINAL.

81


BUT WHAT'S THE REAL SIGNIFICANCE OF THE STATEMENT THAT

"PREVIOUS GENERATIONS OF DOCTORS PRACTICED THE ART,

RATHER THAN THE SCIENCE, OF MEDICINE?

PRIMARILY, I BELIEVE IT MEANS THAT WE SAW MEDICINE AS A

RELATIONAL ENTERPRISE. WE ASKED THE KINDS OF QUESTIONS

THAT REFLECTED CONCERNS ABOUT RELATIONSHIPS:

HOW DID WE REACT TO PATIENTS?

HOW DID WE TREAT i-HEM?

HOW DID THEY RESPOND TO us?

DID WE CARE ABOUT THEM?

DID WE CARE ABOUT THEIR FAMILIES?

82


WE HAD TO BE PEOPLE-ORIENTED BECAUSE, WITHOUT THE

BENEFIT OF C.A.T. SCANS OR N.M.Rs, JUST ABOUT EVERYTHING


WE LEARNED ABOUT OUR PATIENT CAME FROM THE TAKING OF

GOOD HISTORIES.. . THROUGH SENSITIVE DEALINGS WITH


FAMILY MEMBERS.


FOR ME THAT WAS THE FUN OF MEDICINE.
              EVERY PATIENT WAS


A CHALLENGE.

83


TODAY, YOU HAVE ALL THAT TECHNOLOGY TO HELP YOU OUT.. IF

A PATIENT IS UNCOMMUNICATIVE FOR ANY REASON --INCLUDING

THE PATIENT'S AGE --YOU'RE NOT TERRIBLY UPSET BECAUSE

YOU'LL GET MOST OF THE INFORMATION YOU WANT FROM A

VARIETY OF MACHINES, LABORATORIES, AND TECHNICIANS.


NO DOUBT THESE DIAGNOSES ARE SPEEDY AND ACCURATE.

THE SCIENTIFIC ADVANCES IN MEDICINE IN THE LAST

GENERATION ARE MAGNIFICENT..

84


THEY HAVE PROLONGED MANY LIVES. WE HAVE ALL MADE FULL

USE OF THE ADVANCES IN MEDICAL SCIENCE FOR OUR PATIENTS

. . .

AND OURSELVES.

BUT THE SCIENCE OF MEDICINE SHOULD NOT ECLIPSE THE ART

OF MEDICINE.

IN OUR SCIENTIFIC PROGRESS SOMETHING MAY HAVE BEEN

LOST... SOMETHING VERY IMPORTANT TO THE CONTINUED


STRENGTH OF THE MEDICAL PROFESSION: THE RELATIONAL

BOND BETWEEN PHYSICIAN AND PATIENT.

85


A FRIEND OF MINE WENT TO HER PHYSICIAN'S OFFICE

RECENTLY, AND ABTER A BRIEF HISTORY WAS TAKEN, WAS TOLD,


   "I'LL SEE YOU NEXT WEEK."

THE PATIENT ASKED,

"AREN'T YOU GOING TO EXAMINE ME NOW."

THE DOCTOR RESPONDED,

"NOT UNTIL THE TESTS COME BACK MY NURSE WILL TELL

YOU ABOUT THEM."

86


I UNDERSTAND THAT SOME OF TODAY'S BUZZ-WORDS AMONG

MEDICAL STUDENTS ARE "CARING", "COMPASSION", "DIGNITY",

"HUMANE" . . . .


AND THOSE ARE CERTAINLY SOME OF THE MOST BEAUTIFUL

WORDS IN OUR VOCABULARY.

BUT I'M AFRAID THEY CO-EXIST WITH SOME OTHER MODERN

BUZZ-WORDS LIKE "DAMAGE CONTROL", "DEFENSIVE MEDICINE",

"MALPRACTICE" . . . TERMS THAT ARE AMONG THE UGLIEST IN THE

LANGUAGE.

THEY CONVEY THE IDEA THAT THE PATIENT AND DOCTOR ARE

ADVERSARIES.

87


INSTEAD, WE MUST VIEW OUR PATIENTS AS HUMAN BEINGS, AS

ALLIES,

WORKING WITH US IN THE STRUGGLE AGAINST DISEASE.

THIS INCLUDES PREVENTION AS WELL AS TREATMENT AND

REHABILITATION.

THE DENTISTS HAVE DONE A MUCH BETTER JOB IN THIS THAN

WE HAVE, JOINING WITH THEIR PATIENTS IN PREVENTIVE

DENTAL HABITS,

EVEN THOUGH THIS HAS THE EFFECT IN SOME WAYS OF

WORKING THEMSELVES OUT OF A JOB.

88


MOST AMERICANS REALLY FEEL THEIR DENTIST WANTS THEM TO

HAVE FEWER CAVITIES.

THEY DON'T VIEW THEIR RELATIONSHIP WITH THEIR DOCTOR IN

THE SAME WAY.

89


FOR EXAMPLE, IF OVER THE LAST DECADE, DOCTORS HAD

QUIZZED THEIR PATIENTS ABOUT SMOKING, AND THEN HAD

GIVEN SOUND ADVICE, WE MIGHT ENJOY THAT SAME ALLIANCE


IN PREVENTION.

AFTER ALL, IT HAS BEEN KNOWN FOR MANY YEARS THAT THE

MOST LIKELY CAUSE OF SMOKING CESSATION IS FOR A DOCTOR

TO LOOK HIS OR HER PATIENT IN THE EYE AND TELL HIM,

"SMOKING IS GOING TO KILL YOU." AND I HAVE NOT EVEN

MENTIONED THE LIVES SAVED.

90


TREATING OUR PATIENTS LIKE ALLIES IN THE FIGHT AGAINST

THEIR DISEASE MEANS BEING CLEARER AND MORE COMPLETE

ABOUT INFORMED CONSENT..

THAT MAY MEAN TELLING MORE ABOUT WHAT WE KNOW IN

SOME CASES, SHARING OUR UNCERTAINTIES IN OTHERS.

91


EARLY IN MY OWN PEDIATRIC SURGICAL PRACTICE, I

DETERMINED THAT I WOULD MAKE MY PATIENTS' PARENTS

ALLIES WITH ME AGAINST THEIR CHILD'S SURGICAL PROBLEM.

I'VE SAT DOWN AND TALKED WITH THE PARENTS OF MY TINY

PATIENTS.

WE'VE SWEATED OUT THE HOURS TOGETHER IN RECOVERY.

WE'VE BEEN ON THE PHONE TOGETHER WITH COMMUNITY

SERVICES AND VOLUNTARY AGENCIES TO SEE WHAT KIND OF

HELP WILL BE OUT THERE WHEN THE FAMILY TAKES ITS BABY

HOME.

92


HAS IT BEEN WORTH IT?  YES, IT HAS.. . ON MANY LEVELS.

FOR ONE THING, I'VE GOITEN TO KNOW DOZENS OF

COURAGEOUS, GENEROUS, COMPASSIONATE FAMILIES.

I MAY HAVE HELPED THEIR CHILDREN OVERCOME SOME

DISABILITY. . . BUT THEY ALL HELPED m OVERCOME

PESSIMISM, DEFEATISM, FRUSTRATION, AND DISCOURAGEMENT.

. . FEELINGS THAT ARE COMMON ENOUGH AMONG HARD-


WORKING PHYSICIANS.

I DID THIS SIMPLY BECAUSE I THOUGHT IT WAS &OOD MEDICAL

PRACTICE, BUT IT ALSO HAD THE UNFORSEEN DIVIDEND OF

HAVING NO ONE SUE ME FOR 39 YEARS WHEN I WAS IN PRACTICE.

93


OF COURSE WE'LL BE DISAPPOINTED NOW AND THEN. THERE

ARE AMONG PATIENTS THE SAME PERCENTAGE OF CHUMPS,

CHEATS, FOOLS, AND BLOW-HARDS AS THERE ARE AMONG

DOCTORS, OR IN THE POPULATION IN GENERAL.

AND, DEPENDING ON YOUR PARTICULAR PRACTICE, YOU JUST

MIGHT DRAW MORE THAN YOUR SHARE OF DEADBEATS AND


MALCONTENTS.

94


BUT IT'S STILL NO EXCUSE FOR DISCARDING FROM YOUR

ARMAMENTARIUM THE KEY ELEMENTS OF THE ART OF

MEDICINE:

THE ELEMENT OF PERSONAL ATI'ENTION AND INTEREST

THE ELEMENT OF TRUE CARING

THE ELEMENT OF SINCERE HUMAN FEELING

AND THE ELEMENT OF GENEROSITY OF SPIRIT.

95


WE ALSO MUST DO BElTER IN POLICING OUR OWN PROFESSION.

AS I SAID EAkLIER, FOR A VARIETY OF COMPLEX REASONS, THE

NORMAL COMPETITION OF THE MARKETPLACE DOES NOT

ALWAYS OPERATE IN MEDICINE TO GET RID OF THE BAD APPLES.

96


I KNOW A SURGEON IN A CITY WHERE ABOUT 40 SURGEONS DO A

SPECIFIC OPERATIVE PROCEDURE. 16 OF THESE DO MOST OF

THEM. THE SURGEON IN QUESTION HAS MORE SUITS AGAINST

HIM AT PRESENT THAN THE OTHER 15. THEY SHOULD DO

SOMETHING ABOUT IT. HE COULD TEACH ANATOMY, RUN A

DIAGNOSTIC CLINIC, DO ADMINISTRATION, BUT NOT OPERATE -

AT LEAST THAT'OPERATION.

THE POWER LIES IN THIS: "IF YOtJ DON'T, WE'LL BE THE EXPERT

WITNESSES AGAINST YOU, NEXT TIME AROUND."

97


AS PHYSICIANS, AS WELL AS CITIZENS, WE NEED TO DO

SOMETHING FOR THOSE AMERICANS WHO, UNDER OUR PRESENT

SYSTEM, ARE DENIED ACCESS TO REASONABLE CARE.

WHILE WE WAIT FOR NATIONAL OR EVEN STATE LEGISLATIVE

SOLUTIONS, WE CAN DO OUR PART BY REVITALIZING THE

PRACTICE OF OFFERING FREE CARE TO APPROPRIATE PATIENTS.

98


I'M DISTURBED WHEN I READ THOSE ADVERTISEMENTS IN A

COUNTY MEDICAL SOCIETY BULLETIN, PLEADING WITH DOCTORS

IN MY DAY --I GUESS I SOUND, AND LOOK, LIKE AN OLD-TIMER --

I FOUND MYSELF EXTRAORDINARILY FORTUNATE IF I GOT PAID

FOR 40% OF WHAT I DID.

99


BUT I WAS HAPPY IN MY PRACTICE,  MY PATIENTS APPRECIATED


WHAT I DID, AND I CERTAINLY ENJOYED WHAT I DID FOR THEM.

BUT ONCE ENTITLEMENTS CAME ALONG, DOCTORS WHO HAD

BEEN VERY HAPPY TO PERFORM A CERTAIN AMOUNT OF FREE

SERVICE BEGAN TO FEEL THAT THEY HAD TO BE PAID FOR

EVERYTHING.

I SEE NO REASON WHY CERTAIN FREE CLINICS COULD NOT

OPERATE UNDER LAWS THAT FORBID LITIGATION.

GMNG, CHARITY, HAS ALWAYS BEEN PART OF OriR CALLING. WE

OUGHT TO FIND WAYS TO DO IT WITHOUT PENALTY.

100


FINALLY, IN ADDITION TO ALL WE MUST DO, WE NEED TO MAKE

CLEAR WHAT WE CANNOT DO.

IN A MODERN SOCIETY, THE PRACTICE OF MEDICINE HAS

BECOME COMPLICATED.

IT INVOLVES NOT ONLY DIAGNOSIS AND TREATMENT, BUT ALSO

THE RELATIONSHIP BETWEEN HEALTH AND SOCIO-ECONOMIC

FACTORS.

101


INCREASINGLY PEOPLE LOOK TO MEDICINE TO SOLVE THESE

DEEPER PROBLEMS, PROBLEMS THAT ARE BEYOND THE ABILITY

OF MEDICINE OR DOCTORS TO SOLVE.

DOCTORS CANNOT ELIMINATE THE POVERTY FROM WHICH

PATIENTS COME; THEY CANNOT KEEP PATIENTS' CHILDREN OFF

DRUGS;

THEY CANNOT BRING BACK THE HUSBAND WHO HAS DESERTED

THEIR PATIENT. . .

102


A YEAR OR TWO AGO I WAS ASKED TO TAKE GRAND ROUNDS IN

PEDIATRICS AT A MAJOR TEACIJING HOSPITAL.

WHEN I WAS FINISHED LISTENING TO THREE CASES, HAVING

DONE THE BEST I COULD WITH THE PROBLEMS, I HAD TO

REMIND THE RESIDENT STAFF WHEN THE AUDIENCE LEFT THAT I

WOULD NOT HAVE GOTTEN AWAY WITH PRESENTING THOSE

THREE PATIENTS WHEN I WAS IN THEIR POSITION BECAUSE THEY

WERE NOT STRICTLY MEDICAL PROBLEMS:-- WHAT THEY HAD

PRESENTED TO ME WERE SOCIO-ECONOMIC PROBLEMS THAT

HAD COME TO THE HOSPITAL BECAUSE THE PATtENT HAD AN

ILLNESS.

103


FINALLY, LET ME REMIND EACH OF YOU, THAT IN THIS CRITICAL

HOUR FOR AMERICAN MEDICINE, EACH OF YOU, EACH OF US,


CARRIES THE ENTIRE PROFESSION ON HIS OR HER SHOULDERS.

NOT LONG AGO, AFJXR I HAD FINISHED AN APPEARANCE ON CBS

AND WAS ABOUT TO DO A PIECE FOR NATIONAL PUBLIC RADIO IN

CONNECTION WITH CRITICAL CARE WEEK, I WAS SPEAKING

WITH TWO YOUNG WOMEN, BOTH BRIGHT, KNOWLEDGEABLE,


ARTICULATE HEALTH REPORTERS.

104


I ASKED THEM EACH THE SAME QUESTION:

"ARE YOU SATISFIED WITH YOUR HEALTH CARE?"

ONE SAID SHE WAS;

ONE SAID SHE WASN'T.

I ASKED WHY.

105


THE ONE WHO SAID SHE WAS SATISFIED SAID,

"MY DOCTOR LISTENS TO ME, AND HE TELLS ME WHAT THE

PROBLEMS ARE, WHAT HE'LL DO, AND I HAVE A LOT OF

CONFIDENCE IN HIM."

THE ONE WHO WAS DISSATISFIED SAID,  "I'M FURIOUS AT MY


DOCTOR.

IN ORDER TO HAVE SOME SURGERY DONE, I SAW HIM 7 TIMES IN

2 WEEKS, HAD VARIOUS TESTS AND CONSULTATIONS, AND WHEN

I CALLED HIM TO ASK A QUESTION, HE SAID, `NOti REMIND ME


WHO YOU ARE AND WHY I KNOW YOU.`"

106


I SAID TO THEM BOTH,

"IN OTHER WORDS, WHEN I ASKED YOU `ARE YOU SATISFIED

WITH YOUR HEALTH CARE?`,

ONE OF YOU SAID "YES",  ONE SAID "NO",

BUT WHAT YOU REALLY WERE SAYING IS THAT ONE OF YOU

LIKED YOUR DOCTOR AND ONE OF YOU DIDN'T. ONE HAD

CONFIDENCE IN YOUR DOCTOR, ONE DID NOT."

107


THEREFORE, MY MESSAGE TO THE DOCTORS IN AMERICA IS:

WHEN YOU ARE DEALING WITH A PATIENT,

YOU ARE REPRESENTING ALL OF AMERICAN MEDICINE, YOU ARE

REPRESENTING AMERICAN HEALTH CARE.

THIS IS SUNDAY MORNING - AND I FEEL UP TO DELIVERING A

SERMON - AND IT WOULD BE BETTER THAN THE TWO I HEARD

PARTS OF BEFORE COMING HEAR THIS MORNING.

I WON'T - BUT I WILL GIVE YOU THE TITLE - YOU KNOW ENOUGH

TO FILL IN THE REST. "THE LEADER AS SERVANT."

108


WE HAVE MUCH TO DO, BUT LET'S NOT LOSE OUR POSITIVE

ENERGY.

THE MESSAGE WE HAVE TO SHARE WITH OURSELVES AND WITH

THE AMERICAN PEOPLE IS A POSITIVE ONE.

WE DON'T NEED THE PAST TENSE,... NOSTALGIA ABOUT "THE

GOOD OLD DAYS";

NOR DO WE NEED SOME FUTURISTIC MANIFESTO PROMISING

WHAT WE INTEND TO DO.

109


WE NEED CLEAR AND PERSISTENT AFFIRMATION OF THE MANY

GOOD THINGS WE DO,

DAY IN AND DAY OUT,

TO MAKE OUR SYSTEM OF MEDICINE --ONCE WE TAKE THINGS IN

HAND -- POTENTIALLY THE BEST IN THE WORLD.

110


I HAVE NEVER REGRETTED GOING INTO MEDICINE.

I'D DO IT AGAIN TOMORROW.

AND I TELL THAT TO ANY YOUNGSTERS WHO ARE CONSIDERING

IT.

OURS IS A CALLING.

IT IS NOT A BUSINESS.

111


WE COULD HAVE MADE MONEY DOING OTHER THINGS.

WE CHOSE MEDICINE BECAUSE IT COMBINED A QUEST FOR

KNOWLEDGE WITH A WAY TO SERVE, TO SAVE LIVES, AND TO


ALLEVIATE SUFFERING.

WE HAVE TO CONVINCE THE PUBLIC WE STILL MEAN IT..

YOU'LL HAVE TO TAKE STEPS INDIVIDUALLY AND COLLECTIVELY.

THANK YOU

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