ADDRESS BY

DR. C.  .EVERETT KOOP

BEFORE

THIRD INTERNATIONAL CONFERENCE ON

CONi'INUING MEDICAL EDUCATION

ANNENB.ERG CENTER FOR HEALTH SCIENCBS

PALM SPRINGS, CALIFORNIA

DECEMBER 14,   1989


THANK YOU FOR THAT KIND INTRODUCTION AND YOUR
WARM WELCOME. IT IS A GENUINE PLEASURE TO JOIN YOU

TODAY, AND TO DISCUSS A TOPIC SO IMPORTANT TO OUR
PROFESSION AND TO THE TIMES IN WHICH WE LIVE.

IT IS IMPOSSIBLE FOR ME TO ADDRESS THIS QUESTION, "WHY

CME?" AS-EFFECTIVELY AS I MIGHT WITHOUT BRIEFLY
GLANCING BACK OVER MY SHOULDER AT MY RECENTLY-
COMPLEflED SERVICE AS THE U.S. SURGEON GENERAL, TO SEE
MH'AT IT TAUGHT ME.

WHEN PRESIDENT REAGAN ASKED ME TO SERVE AS SURGEON

GENERAL, IT WAS, TO SAY THE LEAST, AN INVITATION TO AN
AD?ENTURE, A LEAP INTO THE GREAT UNKNOWN. I HAD NO

IDEA WHAT THE JOB DESCRIPTION W&, -- AND YOU DON'T
DARE ASK.


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ER ALL, QUITE FULFILLED'PROFESSIONALLY, AS SURGEON-
F THE CHILDREN'S HOSPITAL OF PHILADELPHIA AND

P'ROFESSOR'OF PEDIATRIC SURGERY AT THE UNIVERSITY OF

PENNSYLVANIA.  AND I WASN'T, AT FIRST, ENTIRELY CERTAIN OF THE
FULL JOB DESCRIPTION THE PRESIDENT WAS ASKING ME TO ASSUME --
BESIDES, dF COURSE, PLACING WARNING LABELS ON CIGARETTE PACKAGES.

IN FACT, A LITTLE VOICE IN THE BACK OF MY MIND TOLD ME I COULD BE
WALKING INTO THE FOOTSTEPi OF THE NOTED PHYSICIST, DR. ROBERT

MILLIKAN, WHOSE YOUNG DAUGHTER ONCE ANSWERED THE TELEPHONE BY

SAYING, "YES, THIS IS WHERE DR. MILLIKAN LIVES, BUT HE'S NOT THE
KIND OF DOCTOR WHO DOES ANYBODY'ANY GOOD,"


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OR, AS MY THIRD SON DAV1.D ONCE SAID TO A FRIEND, "YES, I WANT TO

BE A DOCTOR, BUT I WANT TO BE A REGULAR DOCTOR, NOT A DOCTOR LIKE
MY FATHER."

I ASKED MYSELF, AM I GOING TO BECOME KNOWN TO CHILDREN
EVERYWHERE AS THE KIND OF GENERAL WHO DOESN'T FIGHT ANY WARS?

I FOUND OUT SOON ENOUGH, THOUGH, THAT THERE ARE INDEED WARS TO
FIGHT IN THIS NATION OF OURS,  THERE ARE BATTLES TO BE WAGED
AGAINST THE CAUSES OF PREMATURE DEATH AND DISABILITY, AGAINST THE

ILLNESSES THAT MAKE THE AGING PROCESS AN AGONIZING, RATHER iHAN

ENRICHING, EXPERIENCE.


WE A.RlZ AT WAR WITH THE SICKNESS THAT DEVASTATE THE
POOR AND DISADVANTAGED, AND THE-PHYSICAL AND
PSYCHOLOGICAL INJURIES THAT DESTROY FAMILIES AND STEAL
?ZHI? JOY FROM CHILDHOOD.

AS SURGEON GENERAL, I HAVE HLQD THE GOOD FORTUNE OF
MEETING -AND VISITING WITH THOUSANDS OF PEOPLE
THROUGHOUT THE COUNTRY, AND I GAINED A VALU-LE
LESSON FROM THOSE ENCOUNTERS. I HAVE SEEN FIRSTWAND
THAT THE AMERICAN PEOPLE AND THEIR PHYSICIANS ARE
READY AND WILLING TO FIGHT IN THESE WARS AND, IN FACT,

ARE ALREADY DOING SO.


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I BELIEVE HISTORY WILL REMEMBER THE 1980'S AS THE DECADE IN
WHICH PEOPLE, ijY AND LARGE, BEGAN TO RECOGNIZE THE OPPORTUNITY
THEY HAD.TO TAKE CHARGE OF THEIR HEALTH AND DID, IN A SENSE,

CHANGE THEIR OPTIONS AND AFFECT THEIR OWN DESTINIES.
m E OF THIS IS ALL AROUND US, FROM EXERCISE VIDEO

CASSETTES TO THE EVER-PRESENT OAT BRAN ON OUR GROCERY STORE
SHELVES.  IT IS ALSO MATERIALIZING IN MORE CONCRETE WAYS.
SMOKING CONTINUES TO DECLINE.  CASUAL DRUG USE HAS, ACCORDING TO
                                          .- . .
STUDIES, LEVELED OFF AND IS, IN SOME CASES, DROPPING. ALCOHOL
CONSUMPTION IS ALSO DOWN, BUT ESPECIALLY HARD LIQUOR; PEOPLE ARE
TURNING FROM THAT TO BEER, WINE OR EVEN WATER.


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LIFESTYLES ARE BEING RESTRUCTURED BECAUSE OF A GREATER AWARENESS
OF THE.C.$jU$ES OF HEART DISEASE, CANCER AND STROKE. THE ELDERLY
WHO PLAN AHEAD -- SAY, AT 45 OR SO, -- CAN LIVE QUALITY YEARS

AFTER 65 BECAUSE THEY HAVE CHANGED LIFESTYLES AND TAKEN CHARGE OF

THEIR HEALTH.

HEALTH CARE IS NO LONGER AN ABSTRACT CONCEPT TO MILLIONS OF

AMERICANS -- IT IS A VERY PERSONAL COMPONENT IN THE MAKEUP OF

OUR EVERYDAY LIVES.  AND I THINK THE AMERICAN PEOPLE ARE
BEGINNING TO UNDERSTAND PUBLIC HEALTH, -- THANKS TO AIDS.

THIS CHANGE FOR THE BETTER IN THE NATIONAL MINDSEi BRINGS WITH IT
SIGNIFICAbiT RESPONSfBILITIES FOR THOSE OF US IN THE MEDICAL
PROFESSION.


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m, WE HAVE TO BE MORE THAN A PASSIVE RESOURCE IN THIS
MOVEMENT TOWARD A HEALTHIER AMERICA. IT IS NOT SUFFICIENT FOR US
TO SIT BACK AS INTERESTED SPECTATORS, PROVIDING AN ANSWER OR TWO
WHEN ASKED.  WE HAVE AN OBLIGATION TO BE ACTIVE PARTNERS IN.THESE
MATTERS OF DISEASE PREVENTION, OF HEALTH MAINTENANCE AND HEALTH

PROMOTION, PLAYING A HAND-IN-HAND ROLE WITH THOSE SEEKING TO WARD
OFF DISEAS-E AND DISABILITY.

OUR RESPONSIBILITY EXTENDS TO, AND IN FACT, IS MADE MORE ACUTE BY
THOSE WHO DO NOT NECESSARILY FIT INTO THIS CATEGORY OF SELF-

HELPING AMERICANS.  WE HAVE A SACRED OBLIGATION TOWARD THE POOR,
THE AG'ED, THE PHYSICALLY HANDICAPPED, THOSE WHO LIVE IN DISAD-
VANTAGED RURAL AND INNER-CITY COMMUNITIES, AND, OF CO.URSE,
MOTHERS AND CHILDREN, THE ESSENTIAL CORE OF Plf3LIC HEALTH.


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ADDRESSING THEIR NEEDS REQUIRES A PRACTICE OF MEDICINE THAT IS
PROACTIVE.  A PRACTItEeOF.MEDICINE THAT IS AGGRESSIVE. A
PRACTICE OF MEDICINE THAT'.iS IN STEP WITH THE CURVE OF HISTORY,
NOT TRAILING IT.  IT NECESSITATES THAT EACH OF US BE AS PROFI-
CIENT AND-WELL-VERSED AS HUMANLY POSSIBLE IN THE PRINCIPLES AND

TECHNIQUES OF HEALTH CARE IN THE 19903.

IT REQUIRES, IN SHORT, A DEVOTION TO CONTINUING MEDICAL EDUCA-

TION.

CME SHOULD, IN ANY EVENT, BE AN I-NHERENT PART OF OUR BELIEF

SYSTEM AS PHYSICIANS.  THE ERA IN WHICH WE LIVE MAKES IT
                                         .
CRI,TICAL THAT WE EMBRACE THE'C(jN&pT & CONTINUOUS LEARNING.
EMBRACE IS THE KEY WORD.  YOU HAVE TO HAVE THE'MINDSET TO DO

CME.  ONCE YOU SLIP OUT OF THAT MINDSET, IT IS VERY, VERY HARD TO
GET BACK IN.


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AS HISTORY IS MADE, SO ARE THE PRACTICES AND STANDARDS OF HEALTH
CARE.  HEALTH AND MEDICINE ARE CONSTANTLY AFFECTED BY THE
ENVIRONMENT AND BY SOCIETAL NEEDS.

IT WAS A-CENTURY AGO THAT CITIES AND STATES BECAME MORE

CONCERNED ABOUT WHERE TO BURY THEIR DEAD AND ABOUT THE

POTENTIALLY ADVERSE IMPACT OF UNSAFE DRINKING WATER AND
CONTAMINATED MILK SUPPLIES.  THEY ESTABLISHED PUBLIC HEALTH AND

HYGIENE DEPARTMENTS TO OVERSEE THE PROPER HANDLING OF THOSE

COMMODITIES.

IN THE 1930'S, THE.HUNGER THAT PERMEATED THE COUNTRY DURING THE

DEPRESSION LED TO THE EM.ERGENCE OF VITAMINS AND OF NUTRITION AS A
SCIENCE.


DURING WORLD WAR II, MEDICAL SCIENCE DEVELOPED ANTIBIOTICS WHICH

DID A LOT TO SAVE THE LIVES OF OUR WOUNDED.

AND, THROUGHOUT THE LATTER PART OF THE CENTURY, STAGGERING LEAPS

IN BIOTECHNOLOGY HAVE SPAWNED A SERIES OF GOLDEN AGES...A GOLDEN

AGE OF SURGERY.. .A GOLDEN AGE OF DRUG THERAPY...A GOLDEN AGE OF

ORGAN TRANSPLANTATION, AND SO ON.

THIS HASN'T ALL BEEN HYPE AND HYPERBOLE BY ANY MEANS. HEALTH

CARE TECHNOLOGY HAS TAKEN REMARKABLE STRIDES IN THE LAST THREE
DECADES AND, BECAUSE IT HAS, COUNTLESS LIVES HAVE BEEN SAVED AND

EXTENDED.


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I BELIEVE, THOUGH, THAT WE ARE IN THE EARLY STAGES OF A NEW

PERI.OD IN MEDICAL HISTORY.   A PERIOD IN WHICH WE LOOK AT

TECHNOLOGY WITH A MORE CRITICAL EYE AND A SHARPER PERSPECTIVE. A

PERIOD IN WHICH WE REAFFIRM THE ROLE OF THE HUMAN,TOUCH IN

PROVIDING-HEALTH CARE.

TECHNOLOGY IS, AS I NOTED, A BLESSING, BUT IT IS A MIXED ONE.
THE PUBLIC HAS, ALL TOO FREQUENTLY, COME TO BELIEVE IN THE MAGIC
OF MEDICINE, TO EQUATE THE TECHNOLOGICAL WITH THE MIRACULOUS.

AND, TOO OFTEN, SOME OF OUR COLLEAGUES HAVE PROMOTED THAT KIND OF
REVERENCE FOR TECHNOLOGY, THE BELIEF THAT MACHINES ARE SELF-
PERPETUATING AGENTS OF SALVATION RATHER THAN SIMPLY LIMITED

TOOLS.


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THAT'S,YESTERDAY AND TODAY.  I DON'T BELIEVE IT WILL BE THE CASE

TOMORROW.  IN FACT, I BELIEVE IT IS CHANGING RIGHT NOW.

THERE IS AN INCREASING SENTIMENT IN THE PUBLIC THAT TECHNOLOGY
DOES NOT, --- CANNOT -- ANSWER ALL OF ITS NEEDS-OR, FOR THAT
MATTER, WHAT .IT NEEDS AND WANTS THE MOST.

I'VE SEEN THIS GROWING ANTIPATHY TOWARD HIGH TECH IN NEONATAL

INTENSIVE CARE.  I'VE WATCHED IT CLOSELY, -- AFTER ALL, I DID

BUILD THE FIRST NEONATAL INTENSIVE CARE UNIT IN THE COUNTRY, --
BACK IN WHAT MY CHILDREN WOULD REFER TO AS OLDEN TIMES. THIS IS
A FIELD THAT HAS SEEN EXTENSIVE TECHNOLOGICAL GROWTH, FROM INFANT
RESPIRATORS AND SMALL-BORE ENDOTRACHEAL TUBES TO MICRO BLOOD GAS

ANALYZERS.


THIS MINIATURIZATION OF SPECIALIZED EQUIPMENT HAS
BROUGHT NEW HOPE TO SLCK INFANTS AT THE SAME TIME,
HOWEVER, IT HAS NOT ALWAYS BROUGHT COMFORT AND
ASSURANCE TO THEIR PARENTS, ESPECIALLY IN THE
EXORBITANT COSTS. WITH THE INCLUSION OF MORE COMPLEX
EQUIPMENT, MORE PERSONNEL WITH PARTICULAR AREAS OF

EXPERTISE ARE INVOLVED. WHERE PARENTS USED TO
INTERACT WITH ONE PHYSICLAN WHO KNEW EVERYTHING
ABOUT THEIR NEWBORN SON OR DAUGHTER, TODAY THEY
DON'T ALWAYS KNOW WHERE TO TURN WITH THEIR

QUESTIONS AND CONCERNS,

SEVERAL DOCTOR S AND NURSES, IN THESE CASES, KNOW WILL
THEIR OWN PARTICULAR PERSPECTIVE OF THE BABY'S CASE.
DOES ANYONE HAVE A GRASP OF THE WHO.LE? HOW MANY
FEEL THE NEED TO SEEK THAT MORE COMPREHENSIVE VIEW?


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TECHNOLOGY, IN CIRCUMSTANCES LIKE THESE, HAS BROUGHT US THE
EPITOME OF IMPERSONALIZED CARE; COMPUTERS, WIRES, TUBES AND
MONITORS t -- WATCHING THE BABY, CHECKING EVERY VITAL FUNCTION
AND A FEW THAT AREN'T,  -- ALL IN PLACE OF HUMAN EYES AND HANDS.

NEONATAS`AREN'T ALONE.  WE DEAL WITH THEIR GREAT-GRANDPARENTS IN

THE SAME WAY.IN THEIR FINAL ILLNESSES.

HAVE WE REACHED THE ULTIMATE IN CARE, OR IS THERE A BETTER WAY?
I HAVE TO BELIEVE IN THE LATTER.


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I THINK THE PUBLIC BELIEVES THE BALANCE BETWEEN TECHNOLOGY AND
HUMANITY IN MEDICAL CARE HAS TIPPED TOO FAR TO ONE SIDE. THIS IS

EVIDENT IN THE GROWING NUMBER OF PEOPLE WHO OPPOSE THE USE OF
EXTRAORDINARY MEASURES TO PROLONG THE AGONY OF DYING. THEY SEE,
IN THOSE CIRCUMSTANCES, TECHNOLOGY AS A CURSE RATHER THAN A
BLESSING. _

WE ARE BEGINNING TO HEAR THE PUBLIC SAY THAT IT NEEDS AND WANTS
THE KIND OF SYSTEMS THAT PROMOTE HEALTHFUL LIVING OR THAT HELP
OLDER PEOPLE AND.PEOPLE WITH DISABILITIES OR CHRONIC ILLNESSES
LIVE AS HEALTHFULLY AS POSSIBLE AND INDEPENDENTLY IN THEIR OWN

HOMES.


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AND, WITH THAT KIND OF POSITIVE, LIFE-AFFIRMING HARDWARE, THEY
WANT RESPONSIBLE, KNOWLEDGABLE, UP-TO-DATE PHYSICIANS -- NOT
COMPUTERS, BUT PEOPLE -- TO PROVIDE PERSONAL, COMPETENT, COM-
PASSIONATE CARE.

IT IS THEN OUR DUTY AS PROFESSIONALS TO PROVIDE TH.AT KNOW-
LEDGABLE, UP-TO-DATE CARE,  IT SHOULD ALSO BE OUR DESIRE, OUR
PRIVILEGE AND OUR ULTIMATE FULFILLMENT.

ANOTHER KEY FACTOR IN THIS NEW PERIOD IN MEDICAL HISTORY IS THE

GROWTH OF THE SELF-HELP MOVEMENT. WHEN, TWO YEARS AGO, I

CONVENED A SURGEON GENERAL'S WORKSHOP ON SELF-HELP, I DISCOVERED
AN ESTIMATED 15 MILLION PEOPLE DEEPLY, DEVOTEDLY,INVOLVED IN THIS
INITIATIVE.  I NOW BELIEVE I SEVERELY UNDERESTiMATED THAT'NUMBER.


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THESE PEOPLE, CUTTING ACROSS ALL SOCIAL, RACIAL, ETHNIC AND
ECONOMIC LINES, ARE PROVIDING LEADERSHIP IN AREAS IN WHICH THEY
PERCEIVE TRADITIONAL MEDICINE IS NOT: HEALTH PROMOTION, DISEASE

PREVENTION, COUNSELING AND MUTUAL AID, -- WHAT SOME CALL
COGNITIVE..MEDICINE.

THE SELF-HELP MOVEMENT EMBRACES A WIDE ARRAY OF ACTIVITIES,
EVERYTHING FROM ALCOHOLICS ANONYMOUS AND ITS SISTER ORGAN-
IZATIONS, SMOKING CESSATION GROUPS AND PROGRAMS, DRUG COUNSELING

AND TREATMENT, TO AN ASSORTMENT OF SUPPORT GROUPS FOR PERSONS
WITH FAMILY, PERSONALITY, SEXUALITY AND INFECTIOUS DlSEASE

PROBLEMS, AS WELL AS THOSE RECOVERING FROM A MAJOR HEALTH ORDEAL.


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THESE GROUPS AND INDIVIDUALS ARE REMARKABLY SUCCESSFUL AT WHAT

THEY DO.  THEY ARE HELPING PEOPLE, IN' LARGE NUMBERS.

HAVING SAID THAT, THOUGH, I HAVE A CONCERN, A MAJOR CONCERN. IT
DISTURBS ME THAT SOME PEOPLE WHO NEED THE HELP OF PROFESSIONALS,
WITH MEDICAL TRAINING MAY NOT BE GETTING IT. ARE THEY PUTTING

THEIR HEALTH AND THEIR LIVES IN PERIL AS A CONSEQUENCE?

I BELIEVE THERE IS ALWAYS A ROLE FOR TRADITIONAL MEDICINE TO

PLAY. SELF HELP IS-SIIPPORTIVE, AN ADJUNCT. PHYSICIANS AND
NURSES SHOULD LOOK TOWARD TAKING A PARTNERSHIP ROLE WITH THE

SELF-HELP MOVEMENT, PROVIDING THAT NEEDED EXPERTISE FOR THOSE IN

NEED OF HELP AND SUPPORT WITHOUT TAKING AWAY ANY OF THEIR

PREROGATIVES.


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THIS, AGAIN, REQUIRES AN AGGRESSIVE, .FORWARD-THINKING APPROACH.
THESE PEOPLE AND ORGANIZATIONS WORK WITH SOME OF THE MOST SERIOUS

PUBLIC HEALTH PROBLEMS WE FACE TODAY -- SUBSTANCE ABUSE,
INCLUDING CIGARETTES,-AIDS, HEART DISEASE, CANCER. YOU CAN'T
PLAY IN THIS LEAGUE WITHOUT KNOWING TODAY'S RULES.

IF TRADITIONAL MEDICAL PROVIDERS ARE TO BECOME JNVOLVED IN THIS
SELF-HELP AREA, AND MY INCLINATION IS THAT THEY SHOULD, THEN
CONTINUING MEDICAt EDUCATION IS NOT A LUXURY, IT IS A NECESSITY
IN DEALING WITH CONTEMPORARY HEALTH PROBLEMS.


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CUE, OF COURSE, IS NOT A NEW IDEA, IT PREDATES HIPPOCRATES.
BUT, IT IS IN THIS CENTURY, THAT CONTINUING MEDICAL EDUCATION
HAS MADE THE TRANSITION FROM A VAGUE NOTION OF WHAT PHYSICIANS
SHOULD DO IN THEIR SPARE TIME TO A MORE-PROGRAMMATIC, BETTER-
DEFINED ENTERPRISE.

SIR WILLIAM OSLER, A NOTED CLINICIAN AND ONE OF THE KEY THINKERS
ON THIS SUBJECT IN THE EARLY PART OF THE CENTURY, GAVE A SPEECH
AT JOHNS HOPKINS UNIVERSITY IN 1905 IN WHICH HE SAID THREE THINGS

THAT ARE STILL QUOTED TODAY.

HE TOLD HIS AUDIENCE, FIRST, THAT PHYSICIANS MUST BE LIFELONG
STUDENTS TO RETAIN COMPETENCE,


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THEN, HE SAID, THAT CONTINUAL STUDY IS AN ANTIDOTE AGAINST
PREMATURE SENILITY AMONG PHYSICIANS, THAT IT PROVIDES

REFRESHMENT AND RENOVATION.  THAT'S.WHY I DID NOT RETIRE ON THE

TWO OCCASIONS I HAD THE OPPORTUNITY TO DO SO.

AND, FINALLY, HE SAID THAT HE HAD A.FIXED IDEA THAT, AND I QUOTE
"ABOUT THE USELESSNESS OF MEN ABOVE 60 YEARS OF AGE, AND THE

INCALCULABLE BENEFIT IT WOULD BE IN COMMERCIAL AND PROFESSIONAL

LIFE IF, AS A MATTER OF COURSE, MEN STOPPED WORK AT THIS AGE."

I APPLAUD OSLER'S FIRST TWO POINTS, AND MY 73 YEARS ON THIS

EARTH HAVE GIVEN ME THE CHARITY TO FORGIVE HIM THE FOOLISHNESS OF

HIS THIRD.


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OSLER SAID, ON ANOTHER OCCASION, SOMETHING I FOUND QUITE
INTERESTING.  HE DIVIDED PHYSICIANS INTO TWO DISTINCT GROUPS --
THE ROUTINIST, WHO FALLS INTO A RUT, IN OSLER'S WORDS,
"VICTIMIZED BY THE VICE OF INTELLECTUAL IDLENESS," AND THE
RATIONALIST, THE DOCTOR WHO SEES THE CARE OF THE PATIENT AS A
PROBLEM TO BE SOLVED, AND WHO WILL GO TO ANY LENGTHS TO FIND THE

ANSWER TO THAT PROBLEM.

APPLYING THE OSLER DEFINITIONS TO TODAY'S WORLD, A WORLD WITH

UNPRECEDENTED HEALTH CARE CHALLENGES AND CHANGING PERCEPTIONS

ABOUT MEDICINE, WE FIND WE SIMPLY DON'T HAVE THE LUXURY OF
AFFORDING ROUTINISTS IN THE RANKS, WHILE OUR RATIONALISTS ARE
VALUABLE COMMODITIES INDEED.


THE AVAILABILITY OF CONTINUING MEDICAL EDUCATION TODAY IS FAR

GREATER THAN IT WAS EARLY IN THE CENTURY, AND AFFORDS MORE

DOCTORS TODAY THE OPPORTUNITY TO BE WELL-INFORMED AND BETTER

ABLE TO PROVIDE SUPERLATIVE CARE.

WHEN FORMAL CM_E BEGAN IN THE EARLY 19005, IT WAS LITTLE MORE
THAN REMEDIAL EDUCATION TO MAKE UP FOR GAPS IN MEDICAL SCHOOL

TRAINING.  TO A LARGE DEGREE, IT STAYED THAT WAY UNTIL THE

1930's.


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THAT'S WHEN A SCHISM STARTED TO APPEAR, CLEAVING THE PHYSICIANS
OF THAT TIME INTO TWO GROUPS.  THE EXTRAORDINARY SCIENTIFIC

ADVANCES OF THAT EARLY PART OF THE CENTURY CREATED A GAP BETWEEN
THOSE PHYSICIANS WHO STAYED UP-TO-DATE ON NEW DEVELOPMENTS AND

THOSE LESS INSPIRED PRACTIONERS WHOSE LEARNING ENDED WITH THEIR

DEGREE.

THE PROFESSION BECAME VERY CONCERNED ABOUT THE WIDE EXTREMES IN
HEALTH CARE QUALITY BEING PROVIDED TO PATIENTS AND SENTIMENT GREW
THAT, IF MEMBERS WERE NOT MONITORED MORE CLOSELY INTERNALLY, THEN
GOVERNMENT AGENCIES MIGHT STEP IN TO DO SO. WHERE HAVE 1 HEARD

THAT BEFORE?


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GIVEN THE NUMBER OF STATES THAT CURRENTLY HAVE MANDATORY CME
LAWS ON THE BOOKS, I WOULD SAY THEIR CONCERNS HAD A TINGE OF

PROPHECY IN THEM.

SOON, E-TOOK ON A MORE DEFINITE FORM AS ACADEMIA, COMMUNITY

HOSPITALS AND CLINICS AND, LATER, PRIVATE ENTREPRENEURS BEGAN

PROVIDING EDUCATIONAL SERVICES,  A FURTHER ~CATALYST TO PROGRESS
WAS THE EXPLOSION OF BIOLOGICAL SCIENCE RESEARCH AND DEVELOPMENT
DURING WORLD WAR II AND, SUBSEQUENTLY, THE ACCELERATION IN
GOVERNMENT-SPONSORED RESEARCH AT THE NATIONAL INSTITUTES OF

HEALTH.

.SO THAT'S WHERE CONTINUING MEDICAL EDUCATION STANDS TODAY, A

DECENTRALIZED, DIVERSE ARRAY OF PROGRAMS OFFERED BY A VARIETY OF

SPONSORS.


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NOW, THE QUESTION ASKED IN THE TITLE OF MY ADDRESS, "WHY CMJ"
SEEMS ABSURD ON ITS FACE.  AFTER ALL, THIS IS A CONCEPT

CENTURIES OLD.  IT IS INHERENT WITHIN THE SCIENCE OF MEDICINE.
THERE SEEMS TO BE LITTLE REASON FOR ME TO HAVE COME 3,000 MILES
TO ANSWER -THE Q.UESTION, "WHY CME?"

AND YET, WE ALL KNOW THAT ALL IS NOT NIRVANA, THAT THERE ARE
PHYSICIANS WHO DO QUESTION THE QUALITY AND ORGANIZATION OF
CONTINUING EDUCATION AS IT STANDS TODAY, THERE ARE THOSE WHO
RESENT ATTENDING LECTURES THAT THEY FEEL TELL THEM WHAT THEY

ALREADY KNOW.  THERE ARE THOSE WHO FEEL THEY ARE SPENDING TOO
MUCH MONEY, WASTING TOO MUCH TIME FOR PROGRAMS THAT HAVE LIMITED

VALUE.


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THERE ARE THOSE WHO QUESTION CMJS BASIC VALUE, SAYING THAT
THERE IS NO EMPIRICAL PROOF THAT CME IS TRULY EFFECTIVE IN

CHANGING PHYSICIAN PRACTICES IN ANY MEANINGFUL OR LASTING WAY.

THEY ASK THE RHETORICAL QUESTION,  "CAN YOU MAKE GOOD DOCTORS OUT

OF BAD ONES BY MAKING THEM ATTEND CME EXERCISES?"

I WANT TO MAKE A FEW POINTS OF MY OWN REGARDING CONTINUING

MEDICAL EDUCATION, SOME OBSERVATIONS, SUGGESTIONS AND

CRITICISMS.  BUT, FIRST, LET ME DISMISS THE IRRELEVANCIES.

DOES CME MAKE BAD DOCTORS INTO GOOD ONES? PROBABLY NOT. BUT
THAT'S NOT THE PROVINCE OF ADULT EDUCATION. THE QUESTION OF BAD

DOCTORS FALLS WITHIN THE PARAMETERS OF PEER REVIEW, NOT CME.


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FURTHERMORE, I DON'T BELIEVE THAT THE VALIDITY OF CONTINUING

MEDICAL EDUCATION IS DEPENDENT UPON WHETHER OR NOT WE CAN

SUPPORT IT WITH EMPIRICAL DATA. IT WAS PLATO THAT SAID,

"EDUCATION IS A LIFELONG PROCESS." NOW, THAT IS TRUE FOR ALL
PEOPLE, BUT NONE MORE SO THAN FOR THOSE OF US IN THE MEDICAL

PROFESSION.  OURS IS A CONTINUAL LEARNING EXPERIENCE. THAT IS

UNDERSTOOD IN THE OATH WE TAKE. OUR PATIENTS DEMAND IT. OUR

PROFESSION DEMANDS IT.

AND YOU DON'T NEED A DOUBLE BLIND STUDY TO VALIDATE THE NEED FOR

CONTINUING EDUCATION.

NOW, HAVING SAID THAT, I ALSO BELIEVE WE MUST SHAPE CME TO MEET
THE GROWING NEEDS OF PHYSICIANS IN THE 19903.'


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WHILE I BELIEVE THERE IS SOMETHING TO GAIN FROM CLASSROOM

LECTURES AND JOURNAL READINGS IN CONVEYING IMPORTANT, BROAD-
BASED INFORMATION, EFFECTIVE CME IN TODAY'S WORLD MUST GO A STEP

BEYOND.

IF CME'S GOAL IS TO HELP PRACTIONERS PROVIDE BETTER CARE TO

THEIR PATIENTS, THEN TRULY EFFECTIVE CME MUST BE MORE TARGETED TO

SPECIFIC PATIENT NEEDS.


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THIS IS A CASE IN WHICH MODERN TECHNOLOGY CAN BE UTILIZED TO
BRING ABOUT GREATER PERSONAL CARE. THROUGH THE USE OF PERSONAL
COMPUTERS AND MODEMS, PHYSICIANS CAN LINK THEIR OFFICES TO
UNIVERSITIES, TO HOSPITALS, CLINICS, AND DATA BASES. IN FACT, I
HAVE BEEN'CAMPAIGNING, AND WILL CONTINUE TO LOBBY FOR, STRONGER
DATA COLLECTION AT THE NATIONAL LIBRARY OF MEDICINE TO MAKE IT
POSSIBLE FOR DOCTORS TO DRAW UPON THOSE RESOURCES FROM THE
CONVENIENCE OF THEIR OFFICES.

DATA LINKS CAN EVEN BE USED TO SHARE INFORMATION FROM COLLEAGUE
TO COLLEAGUE RATHER THAN WAITING FOR A CHANCE MEETING IN A

CORRIDOR OR CAFETERIA.


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I ALSO BELIEVE THE PROVIDERS OF CONTINUING EDUCATION HAVE TO DO A

THOROUGH SELF-EXAMINATION TO DETERMINE WHETHER THEY ARE DOING

JUSTICE TO THEIR PROGRAMS,  ARE THEY GIVING THEM SUFFICIENT

PRIORITY?

I HAVE SEEN TOO MANY CME MANAGERS AT ORGANIZATIONS AND INSTITU-
TIONS WHO DON'T MAKE&R PROGRAMS AS STRONG AS THEY COULD

POSSIBLY BE, BECAUSE THEY AREN'T GIVEN THE STAFFING OR THE

FINANCIAL RESOURCES TO DO SO.

AND IT IS NO SECRET THAT THE CME PROGRAMS AT MEDICAL SCHOOLS ARE

THE WEAK SISTERS ON CAMPUS.  MANY SCHOOL ADMINISTRATORS DON'T

LIKE THE PROGRAMS, DON'T REALLY UNDERSTAND THEM AND, IN GENERAL,
GIVE THEM SHORT SHRIFT.


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AS A RESULT, WHAT WE HAVE TOO OFTEN IS CONTINUING EDUCATION THAT

RESEMBLES JUNIOR HIGH -- LECTURES AND SLIDE SHOWS. THAT IS NOT

WITHOUT VALUE, BUT WE CAN DO SO MUCH BETTER. THE TECHNOLOGY IS

THERE.  THE RESOURCES CAN BE THERE. ALL THAT IS LACKING IS THE

INCLINATION TO DO SO.

PROVIDERS AND CONSUMERS OF CME NEED TO REALIZE THAT WE ARE IN AN

AWFUL MESS IN REFERENCE TO HEALTH CARE IN THIS COUNTRY. WE HAVE

ALL SORTS OF PEOPLE IN BUSINESS, IN CONGRESS, IN THE PROFESSION
CALLING FOR A NATIONAL HEALTH SERVICE. WE HAVE DOCTORS DISLIKING

THEIR PATIENTS AND WE HAVE A PUBLIC LESS THAN SATISFIED WITH

THEIR PHYSICIANS.


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I DO NOT BELIEVE IT HAD TO DEVELOP THAT WAY AND MIGHT NOT HAVE IF
THOSE RESPONSIBLE FOR C$ HAD FACED THE CHANGING TIMES, ISSUE BY
ISSUE, AND HAD DEVELOPED LESS EXPECTATION ON THE PART OF THE
PUBLIC AND TRAINED DOCTORS TO BE MORE RESPONSIVE TO THE NEEDS OF

PATIENTS. .

IN Q& THE SHOE IS ON THE OTHER FOOT. PHYSICIANS ARE THE
CONSUMERS IN THIS ARRANGEMENT. THEY NEED TO BE DEMANDING
CONSUMERS, MAKING THEIR NEEDS KNOWN AND INSISTING UPON CME
BEFITTING MEDICAL CARE IN THE 1990's. CME IS NOT JUST NEW
PHARMACEUTICALS AND NEW PROCEDURES. IT; KEEPING UP WITH
ATTITUDES IN AND ABOUT MEDICINE.

THOSE WHO ARE LEARNING HAVE THE OBLIGATION TO $EMAND WHAT THEY

b/ANT AND NEED.  AND THE EDUCATORS HAVE A RESPONSIBILITY TO GIVE
THE KIND OF EDUCATION PHYSICIANS NEED, BUT DON'T NECESSARILY

WANT.


34

MEDICAL PROFESSIONALS MUST BE DEMANDING BECAUSE THEY HAVE

DEMANDING CONSTITUENCIES.  THE PUBLIC IS INSISTING, RIGHTFULLY
SO, ON DOCTORS WHO ARE NOT ONLY CARING AND CONCERNED, BUT WHO
HAVE ALSO ALREADY ABSORBED YESTERDAY'S NEW MEDICAL DEVELOPMENTS.

WE HAVE SEVERAL IMPERATIVES BEFORE US.

WE HAVE AN ELDERLY CARE IMPERATIVE. A GREATER PROPORTION OF
MEDICAL TREATMENT IN THE YEARS AHEAD WILL BE DEVOTED TO THE
NATION'S FASTEST GROWING POPULATION GROUP, THOSE 65 AND OLDER.
WE ARE IN THE MIDST OF A SENIOR CITIZEN BOOM, AND IT WILL AFFECT
THE WAY WE APPROACH HEALTH CARE IN THE UNITED STATES.


35

ALL TOO OFTEN, ELDERLY CARE IS PERCEIVED AS LITTLE MORE THAN
PATIENT MAINTENANCE, MANAGING THE PATIENT'S` INEVITABLE DECLINE IN

HIS OR HER TWILIGHT YEARS,

BUT, ELDERLY CARE SHOULD BE SO MUCH MORE THAN THAT, AND CAN BE

WHEN THE PRACTIONER IS MOTIVATED AND WELL-VERSED IN CONTEMPORARY

GERIATRIC PRACTICES.

THE AGING PROCESS CAN BE A LIVING PROCESS, NOT A DYING ONE.
HUMAN AGING CAN BE SICKNESS-FREE, DISEASE-FREE, JUST LIKE ANY

OTHER PERIOD IN ONE'S LIFE.  AMONG OTHER THINGS, IT TAKES A
CARING PHYSICIAN hlITH BOTH THE INCLINATION AND THE KNOWLEDGE.


WE ALSO HAVE A CHILDRENS' IMPERATIVE, SO MANY CHILDREN IN THIS
COUNTRY HAVE A DIRE NEED FOR QUALITY HEALTH CARE. ON ONE FRONT,

WE HAVE THE 12 MILLION CHILDREN WHO GROW UP IN POVERTY, THE

LARGEST SINGLE GROUP OF POOR PEOPLE IN THE UNITED STATES.

THESE ARE CHILDREN FROM FAMILIES WITHOUT ACCESS TO HEALTH CARE.

THEY ARE UNLIKE THE AGED POOR WHO, AT LEAST, HAVE MEDICARE AND

SOMETIMES MEDICAID.  POOR CHILDREN, VERY FREQUENTLY, HAVE NO
ACCESS WHATSOEVER TO MEDICAL TREATMENT.

AND THEN THERE ARE THE ABUSED CHILDREN, THE VICTIMS OF FAMILY

VIOLENCE.  THIS IS AN ISSUE THAT COMES TO LIGHT PERIODICALLY

WHEN AN EXTREME CASE, LIKE THE STEINBERG EPISODE, IS DISCOVERED.
BUT, ALL TOO OFTEN, CHILD ABUSE GOES UNDISCOVEiED AND THOUSANDS

OF LITTLE BOYS AND GIRLS SUFFER IN SILENCE.


37

WHEN WE TALK ABOUT CONTINUING MEDICAL EDUCATION, WE WOULD BE

REMISS IS WE DIDN'T CONCENTRATE UPON THE TRAINING NECESSARY TO

RECOGNIZE THE HEALTH CARE NEEDS OF CHILDREN IN POVERTY, AS WELL

AS TO RECOGNIZE THE SYMPTOMS OF CHILD ABUSE, WE MUST UTILIZE CME

TO SAVE YOUNG LIVES.

MEDICINE TODAY IS MORE THAN JUST STRAIGHT TEXTBOOK MEDICINE.

PEOPLE ARE ASKING DOCTORS TO HANDLE SOCIOECONOMIC PROBLEMS.

AND, ALTHOUGH THEY CAN'T BE ALL THINGS TO ALL PEOPLE, THEY DO
HAVE TO KNOW SOMETHING ABOUT THE BRIDGES AND THE GAPS BETWEEN

THE WORLD OF SOCIOECONOMICS AND THE HEALTH PROBLEMS ASSOCIATED

WITH THEM.


30

WE HAVE A DISEASE IMPERATIVE, AS WELL, SPECIFICALLY THE DISEASE

CALLED AIDS.  AFTER EIGHT YEARS OF A DISEASE WITH NO CURE AND NO
VACCINi, THE PROFESSION IS BECOMING COMPLACENT AND THE PUBLIC,, --
NOT IDENTIFYING WITH MOST PEOPLE WITH AIDS, -- HAS ASSUMED A WE-

THEY POSTURE.  NO MEDICAL PROFESSIONAL IN THE UNITED STATES CAN

AFFORD TO TURN HIS OR HER BACK ON THIS DISEASE THAT WILL GO ON

KILLING WELL INTO THE NEXT CENTURY.

WE HAVE A TREMENDOUS RESPONSIBILITY IN DEALING WITH AIDS. WE

NEED TO MAINTAIN STRONG SUPPORT FOR PROGRAMS THAT PROVIDE
INFORMATION TO PEOPLE AT RISK OF GETTING AIDS, AND WE NEED TO
ASSURE MEDICAL SERVICES TO THOSE WHO NEVER DID GET THE MESSAGE --
AND ARE DYING.


39

AND, AS DIFFICULT AS IT IS, WE MUST CONVINCE PEOPLE WITH AIDS TO

CHANGE THE BEHAVIOR THAT GAVE THEM THE DISEASE. THEY HAVE NO

INCENTIVE TO DO SO.  THERE'S NO CARROT AT THE END OF THE STICK.

BUT WE HAVE TO TRY ANYWAY, FOR THE SAKE OF SOCIETY, TO STOP THE

SPREAD OF-THE VIRUS.

THAT'S WHY IT IS INCUMBENT ON EVERY INDIVIDUAL IN THE HEALTH
CARE ARENA TO LEARN AS MUCH AS POSSIBLE ABOUT AIDS, TO SPREAD
THE WORD AS EFFECTIVELY AS POSSIBLE, TO BE EFFECTIVE COMBATANTS
AGAINST THIS INSIDIOUS DISEASE.


40

AND, FINALLY, WE HAVE A PREVENTIVE HEALTH IMPERATIVE. EACH OF
US, ARMED WITH THE MOST UP-TO-DATE KNOWLEDGE AVAILABLE, SHOULD BE
CARRYING THE FLAG AGAINST ONE OF THE LEADING KILLERS OF OUR TIME,

CIGARETTES.

YES, WE HAVE WON SOME VICTORIES IN THIS AREA. PER CAPITA

CIGARETTE SALES HAVE DECLINED EACH YEAR SINCE 1973. SMOKING IS
NO LONGER SOCIALLY ACCEPTABLE, AND IT IS BANNED IN MORE PUBLIC
PLACES THAN EVER BEFORE.

BUT THE BATTLE IS FAR, FAR FROM OVER. THERE ARE STILL 50
MILLION AMERICANS WHO CONTINUE TO SMOKE, REDUCING THEIR
LIFESPANS WITH EACH INHALATION.  MORE THAN 380,000 MEN AND WOMEN

DIE EACH YEAR FROM SMOKING-ATTRIBUTABLE DISEASi. THOSE NUMBERS
ARE CONSTANT REMINDERS OF WHY WE MUST NEVER BECOME COMPLACENT.


A CORE FUNCTION OF CONTINUING MEDICAL EDUCATION
SHOULD BE THE CONSTANT DISSEMINATION OF THE MOST
RECENT INFORMATION THE HARMS OF SMOKING BUT
ESPECIALLY HOW TO USE THAT KNOWLEDGE TO COUNSEL
THEIR PATIENTS, OBTAIN AND DISPLAY EDUCATIONAL
MATERIALS FOR THEIR OFFICES, HELP PROMOTE SMOKING
CESSATION PROGRAMS IN THEIR COMMUNITIES, AND USE
THEIR INFLUENCE WITH ELECTED OFFICLALS TO PROMOTE
STIFFER TOBACCO-CONTROL POLICIES. THE CIGARETTE
INDUSTRY HAS VAST AMOUNTS OF MONEY AND A HISTORY OF
ABUSING POWER ON ITS SIDE. WE HAVE COLLECTIVE
INFLUENCE AND MORAL STRENGTH ON OURS. I BELIEVE THAT
THOSE QUALITIES, COMBINED WITH ACCURATE INFORMATION
AND A DEEPLY-HELD COMMITMENT TO LIFE, WILL MARE US THE
EVENTUAL VICTORS IN THIS WAR.


THE SAME COULD BE SAID IN ESSENTIALLY EVERY REGARD

ABOUT ALCOHOL, -- WITH THE CAVEAT THAT ALCOHOL DOES

NOT DAMAGE ALL WHO USE IT, WHERE TOBACCO DOES

NONE OF US WOULD HAVE ENTERED THE MEDICAL

PROFESSIONAL WERE IT NOT FOR OUR BELIEF IN TH VALUE OF

LIFE AND OUR CALLING TO TRY TO PRESERVE AND ENHANCE
LIFE. CONTINUING MEDICAL EDUCATION IS A VITAL,

INDISPENSABLE TOOL IN PRACTICING OUR BELIEFS AND IN

PURSUING OUR BELIEFS AND IN PURSUING OUR CALLING.

HIPPOCRATES ONCE SAID, "HEALING IS A MATTER OF TIME, BUT
IT IS SOMETIMES ALSO A MATTER OF OPPORTUNITY."
OPPORTUNITY, IN THIS CASE, IS NOT A QUESTION OF CHANCE.
WE PRESENT GREATER OPPORTUNITIES FOR OURSELVES BY

ACQUIRING GREATER KNOWLEDGE. IT IS THE `ESSENCE OF
OUR PROFESSION. THANK YOU VERY MUCH.


THANK YOU FOR THAT KIND INTRODUCTION AND YOUR WARM WELCOME. IT

IS A GENUINE PLEASURE TO JOIN YOU TODAY, AND TO DISCUSS A TOPIC

SO IMPORTANT TO OUR PROFESSION AND TO THE TIMES IN WHICH WE LIVE.

IT IS IMPOSSIBLE$$!,,ME TO ADDRESS THIS QUESTION, "WHY CME?" AS
EFFECTIVELY AS I @@4 WITHOUT BRIEFLY GLANCING BACK OVER MY

SHOULDER AT MY RECENTLY-COMPLETED SERVICE AS THE U.S. SURGEON
GENERAL. &Sff W+ld? /I 7433cffq kz

WHEN PRESIDENT REAGAN ASKED ME TO SERVE AS SURGEON GENERAL, IT
WAS, TO SAY THE LEAST, AN INVITATION TO AN ADVENTURE, A LEAP INTO
THE GREAT UNKNOWN.  I HAD NO IDEA WHAT THE JOB DESCRIPTION WAS,

-- AND YOU DON'T DARE ASK.


4

WE ARE AT WAR WITH THE SICKNESSES THAT DEVASTATE THE POOR AND

DISADVANTAGED, AND THE PHYSICAL AND PSYCHOLOGICAL INJURIES THAT

DESTROY FAMILIES AND STEAL THE JOY FROM CHILDHOOD.

AS SURGEON GENERAL, I HAVE HAD THE GOOD FORTUNE OF MEETING AND

VISITING WITH THOUSANDS OF PEOPLE THROUGHOUT THE COUNTRY, AND I

GAINED A VALUABLE LESSON FROM THOSE EN
           It-NO -iil#~~EP~P~~~&E SEEN
FIRSTHAND THAT THE AMERICAN PEOPLE&RE READY AND WILLING TO FIGHT
IN THESE WARS AND, IN FACT, ARE ALREADY DOING SO.


13

THIS MINIATURIZATION OF SPECIALIZED EQUIPMENT HAS BROUGHT NEW
HOPE TO SICK INFANTS.  AT THE SAME TIME, HOWEVER, IT HAS NOT
ALWAYS BROUGHT COMFORT AND ASSURANCE TO THEIR PARENTS,

ESPECIALLY IN THE EXORBITANT COSTS. 3

WITH THE INCLUSION OF MORE COMPLEX EQUIPMENT, MORE PERSONNEL
WITH PARTICULAR AREAS OF EXPERTISE ARE INVOLVED. WHERE PARENTS
USED TO INTERACT WITH ONE PHYSICIAN WHO KNEW EVERYTHING ABOUT

THEIR NEWBORN SON OR DAUGHTER, TODAY THEY DON'T ALWAYS KNOW WHERE

TO TURN WITH THEIR QUESTIONS AND CONCERNS.

SEVERAL DOCTORS AND NURSES, IN THESE CASES, KNOW WELL THEIR OWN
PARTICULAR PERSPECTIVE
       rp ,FwT;i"$BY'S CASE. DOES ANYONE HAVE A
GRASP OF THE WHOLE?  t2z2im FEEL THE NEED TO SEEK THAT MORE
COMPREHENSIVE VIEW?


41

A CORE FUNCTION OF CONTINUING MEDICAL EDUCATION SHOULD BE THE

CONSTANT DISSEMINATION OF THE MOST RECENT INFORMATION ON THE

HARMS OF SMOKING@@ HOW TO USE THAT KNOWLEDGE TO COUNSEL THEIR
PATIENTS, OBTAIN AND DISPLAY EDUCATIONAL MATERIALS FOR THEIR

OFFICES, HELP PROMOTE SMOKING CESSATION PROGRAMS IN THEIR

COMMUNITIES, AND USE THEIR INFLUENCE WITH ELECTED OFFICIALS TO

PROMOTE STIFFER TOBACCO-CONTROL POLICIES. +3

r THE CIGARETTE INDUSTRY HAS VAST AMOUNTS OF MONEY AND A HISTORY OF

ABUSING POWER ON ITS SIDE.  WE HAVE COLLECTIVE INFLUENCE 4ND
MORAL STRENGTH ON OURS.  I BELIEVE THAT THOSE QUALITIES, COMBINED
WITH ACCURATE INFORMATION AND A DEEPLY-HELD COMMITMENT TO LIFE,
WILL MAKE US THE EVENTUAL VICTORS IN THIS WAR.


0
42

THE SAME COULD BE SAID IN ESSENTIALLY EVERY REGARD ABOUT

ALCOHOL, -- WITH THE CAVEAT THAT ALCOHOL DOES NOT DAMAGE ALL WHO
USE IT, WHERE TOBACCO DOESJ

NONE OF US WOULD HAVE ENTERED THE MEDICAL PROFESSIONALflF NOT
FOR OUR BELIEF IN THE VALUE OF LIFE AND OUR CALLING TO TRY TO

PRESERVE AND ENHANCE LIFE,  CONTINUING MEDICAL EDUCATION IS A
VITAL, INDISPENSIBLE TOOL IN PRACTICING OUR BELIEFS AND IN

PURSUING OUR CALLING.

HIPPOCRATES ONCE SAID, "HEALING IS A MATTER OF TIME, BUT IT IS
SOMETIMES ALSO A MATTER OF OPPORTUNITY." OPPORTUNITY, IN THIS

CASE, IS NOT A QUESTION OF CHANCE. WE PRESENT GREATER
OPPORTUNITIES FOR OURSELVES BY ACQUIRING GREATiR KNOWLEDGE. IT
IS THE ESSENCE OF OUR PROFESSION, THANK YOU VERY MUCH.