GREETINGS, ETC.

1


I ALWAYS HAVE FELT AT HOME AMONG SURGEONS.

I AM A SURGEON, AND I HOPE I HAVE BEEN AN EFFECTIVE

ADVOCATE FOR SURGEONS.

WHEN I WAS IN THE GOVERNMENT YOU AND I WENT ABOUT OUR

WORK IN OUR OWN WAYS, AND NOW IT IS GOOD TO BE BACK.


THERE'S A BASIC HONESTY ABOUT SURGERY.

SURGEONS UNDERSTAND THAT SOMETIMES SOME THINGS NEED

TO BE SAID, EVEN IF THEY AREN'T ALWAYS PLEASANT TO HEAR.

YOU ARE THE MOVERS AND SHAKERS.

THATS GOOD.

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


THROUGHOUT MY LIFE AS A SURGEON I HAD NEVER

CONTEMPLATED GOVERNMENT SERVICE. FOR ME, PROBABLY

LIKE MOST OF YOU, THE VERY THOUGHT WAS ANATHEMA.

NEVERTHELESS I PROVED RECEPTJVE TO THE FIRST SMALL

BEGINNING BECAUSE IN AUGUST 1980 SOMEONE TELEPHONED ME

AND ASKED CRYPTICALLY,

"DON'T YOU THINK THE SURGEON GENERAL SHOULD BE A

SURGEON."  IT GOT ME THINKING POSITIVELY.


EVEN THOUGH IT HAS NOW BEEN SEVERAL MONTHS SINCE I

HUNG UP THE UNIFORM OF THE SURGEON GENERAL, I STILL

SEEM TO BE A RECOGNIZABLE FELLOW.

WALKING ALONG THE STREET HERE IN SAN FRANCISCO, IN THE

NEW YORK SUBWAY, IN AIRPORT WAITING ROOMS, PEOPLE

COME UP TO ME:

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

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

THOSE TOBACCO COMPANIES."

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

HOURS IN THE AIRPORT WAITING AREA.


"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."

6

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

PHYSICIAN.


MORE THAN SADDENED, I'M ANGRY.

I'VE JUST FINISHED FILMING 5 PRIMETIME SPECIALS ON HEALTH

TO BE AIRED LATER THIS YEAR ON N.B.C. I'VE SPENT 5 MONTHS

GOING BACK AND FORTH ACROSS THIS COUNTRY, FILMING IN 20

CITIES, A FEW TOWNS AND HAMLETS, AND IN REMOTE CORNERS

OF RURAL AMERICA.


THIS EXPERIENCE WITH SO MANY FACETS OF AMERICAN

MEDICINE HAS MADE ME ANGRY.

I AM ANGRY ABOVE ALL BECAUSE OF THE DETERIORATION OF

THE IMAGE OF THE AMERICAN DOCTOR, FOR I BELIEVE THAT

THE DOCTOR-PATIENT RELATIONSHIP LIES AT THE HEART OF ALL

MEDICINE.


MUCH OF IT IS OUR FAULT.
            /iv      jrlk   SE it/i* &dPdP f?
WHY HAVE WE PERSISTED NOT m ROOT OUT TH@

OUR PROFESSION?

WE TOLERATE PEOPLE WHO ARE INCOMPETENT, WHO ARE

GREEDY, WHO ARE ABUSIVE OF PATIENTS, WHO ARE ALCOHOL

AND DRUG ABUSERS.

THESE PEOPLE SHOULD BE REMOVED, AND WHERE POSSIBLE,

REHABILITATED.  (-J/q 7&E/v s*pLD mtE3( zQ= =-=-ye-y

BUS DRIVERS AND AIRLINE PILOTS DO BElTER IN POLICING

THEIR OWN. A MEDICAL SCHOOL DEGREE SHOULD NOT PROVIDE

MORAL IMMUMTY.

IO


MEDICINE HAS SUFFERED FROM AN INABILITY TO

SELF-REGULATE ITS MEMBERS, AND THIS FAILING HAS PLAYED

HAVOC WITH THE SYSTEMS AND PROCESSES OF PROFESSIONAL

INSURANCE AND LICENSING AND ACCREDITATION...IN OTHER

WORDS, THE SYSTEMS AND PROCESSES OF PUBLIC TRUST.

11


AS A RESULT, THE CONGRESS HAD TO STEP IN AND ENACT
                       p ~7/fiLMc5c

LEGISLATION SETTING UP A NATIONALqATA BANK ON

PHYSICIANS SO THAT WE COULD FIND THE BAD APPLES --IN THE

SAME WAY WE FIND DRUNK DRIVERS AND BANK ROBBERS AND
ASSORTED OTHER FUGITIVES FROM JUSTICE.

12


AND ITS A TRAGEDY BECAUSE IT SHOULD HAVE BEEN AVOIDED.

ITS A TRAGEDY BECAUSE DAY IN AND DAY OUT MOST

AMERICANS RECEIVE GOOD MEDICAL CARE - AS GOOD AS ANY

PLACE IN THE WORLD - FROM HONEST, COMPETENT PHYSICIANS.

13


UNFORTUNATELY GOOD NEWS IS NOT HEADLINE NEWS - -THE

OCCASIONAL BAD APPLE IS, . . ..AND DOES GRAB THE HEADLINES.

SAD TO CONTEMPLATE, BUT THE MEDICAL PROFESSION HAS

FOOLISHLY SQUANDERED ITS PUBLIC TRUST AND POSITION OF

LEADERSHIP.

14


NOW, PHARMACISTS HAVE REPLACED DOCTORS AS THE MOST

TRUSTED PROFESSION IN AMERICA.

THE PUBLIC IS VERY CRITICAL OF DOCTORS.

AND DOCTORS NO LONGER LIKE THEIR PATIENTS.

15


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.

16


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 ATTORNEYS WERE CONGRATULVI'ING THEMSELVES ON

WHAT THEY WERE ABLE TO DO FOR THEIR FELLOW CITIZENS.

IT HAD BEEN A LONG TIME SINCE MY FRIEND HAD HEARD

DOCTORS SPEAK IN THAT VEIN.

17


IFLAWYERSCANFEELGOODABOUTWRITINGAWILL,

CAN'TWEFEELPROUDABOUTPOSTPOMNG'ITSUSE?

WESHOULDBEPROUDABOUTWHATWEHAVEACCOMPLISHED

FORTHEAMERKANPEOPLE.

LIFEEXPECTANCYINTHISCOUNTRYHASGONEFROM47YEARS

IN1900 TO 75 BYl990.

18


NOW DOCTORS DO MORE AND GET THANKED LESS.

INSTEAD OF CELEBRATING, DOCTORS AND PATIENTS ARE

SQUARING OFF AGAINST EACH OTHER.

DOCTOR-BASHING HAS BECOME A POPULAR SPORT.

THERE IS EXASPERATION ON BOTH SIDES OF THE STETHOSCOPE.
<- -                      -_              -I--

19


AMERICAN MEDICINE IS AT A CROSSROADS.

I HOPE YOU KNOW WHAT THE STAKES ARE.

TEN YEARS FROM NOW YOU COULD BE DOING ONE OF SEVERAL

THINGS:

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

AMERICA. YOU ARE THE LEADERSHIP AMONG SURGEONS)

20


YOU COULD BE WORKING WITH THE PUBLIC TO FREE US ALL

FROM A HASTILY IMPOSED NATIONAL HEALTH SERVICE,

OR,

YOU COULD HAVE SHiILiTED FROM PATIENT-ADVOCATE TO AGENT

FOR ALL INSURANCE COMPANIES.

OR,

YOU COULD HAVE LOST YOUR PROFESSIONAL STATUS AND COME

TO BE REGARDED AS A MEMBER OF ANY ONE OF A NUMBER OF

JOURNEYMEN GUILDS.

OR,

21


YOU COULD BE PART OF THE BEST SYSTEM OF MEDICAL CARE IN

THE WORLD, DELIVERING HEALTHCARE TO THE GREAT

SATISFACTION OF YOUR PATIENTS AND YOURSELF.

AND YOU COULD BE PART OF A SYSTEM THAT DELIVERS

REASONABLE HEALTHCARE TO EVERY AMERICAN AT

REASONABLE COST, --URGING w THEM TO PREVENT

DISEASE AS WELL AS TO TREAT IT..

22


PLEASE FIND SOME WAY TO DISABUSE THE PUBLIC AND THE

PRESS OF THE NOTION THAT YOUR INCOME IS YOUR NUMBER

ONE PRIORITY, AND THAT YOU HAVE CEASED TO BE THE

PROFESSIONALS THAT YOUR FATHERS AND GRANDFATHERS IN

MEDICINE WERE.

IF DOCTORS PAY ATI'ENTION TO HIGH QUALITY AND HIGH

EFFICIENCY IN THEIR MEDICAL PRACTICE, IN MOST INSTANCES

THE BOTTOM LINE WILL TAKE CARE OF ITSELF.

23


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.

24


NOW, BELATEDLY, THEY ARE SCRAMBLING TO ADDRESS QUALITY

AND EFFICIENCY.

THE AMERICAN AUTO INDUSTRY AFFORDS A GOOD EXAMPLE.

I IMAGINE THAT MANY DOCTORS WHO USED TO DRIVE BUICKS

AND CADILLACS NOW SIT BEHIND THE WHEEGOF CAMRYS AND

MIAXIMAS.

25



WHEN N.B.C. FIRST ASKED ME TO DO A TELEVISION SERIES, THEY

WANTED ME TO FOCUS UPON THE STATE OF THE ART OF

AMERICAN MEDICINE.

AS A FORMER PIONEER IN THE FIELD OF PEDIATRIC SURGERY, I

THOUGHT IT WOULD BE FASCINATING TO BRING BEFORE THE

AMERICAN PEOPLE THE FULL RANGE OF THINGS THAT MODERN

MEDICINE COULD DO FOR THEM.

26


BUT IN MY YEARS AS SURGEON GENERAL, I SAW ALL TOO

CLEARLY THAT 37 MILLION AMERICANS COULD NOT AVAIL

THEMSELVES OF MODERN MEDICINE.

SO I SHIFTED THE FOCUS OF MY EFFORTS TO THE PROBLEMS

WITH OUR HEALTHCARE SYSTEM, OUR HEALTH POLICY.

27


THERE COULD HAVE BEEN ANOTHER SURGEON GENERAL'S

WARNING:

"WARNING! THE AMERICAN HEALTH CARE SYSTEM CAN BE

HAZARDOUS TO YOUR HEALTH!

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

OUR PROFESSION. BUT WE HAVE BIG PROBLEMS.

28


m EXASPERATION ON BOTH SIDES OF THE STETHOSCOPE.

YOU HAVE YOUR REASONS WHY YOU ARE EXASPERATED.

R ~7 WHY ARE PATIENTS EXASPERATED?
      I

29


1.  THE PUBLIC HAS HIGH EXPECTATIONS FOR MEDICINE AND

HEALTH. THEY HAVE A GREAT DEAL OF FAITH IN NEW

TECHNOLOGY, AND THEY CONTINUE TO HAVE FAITH IN THE

MAGIC OF MEDICINE. BUT IN THE REAL WORLD WE CAN'T

ALWAYS DELIVER.

30


7wGk// fcsb
2.  HIGH EXPECTATIONS ARE FAST OUTRUNNING OUR ABILITY TO

PAY FOR THEM. AND THE AMERICAN PEOPLE ARE ENGAGED IN

DEBATE ABOUT ASPIRATIONS VERSUS RESOURCES.

3.  ALTHOUGH THERE HAS BEEN A RISE IN NEW TECHNOLOGY,
e

THERE HAS BEEN A DECLINE IN ITS USEFULNESS TO A LARGE

NUMBER OF PATIENTS.

31


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 QJ. NOW, OVER 80 YEARS HAVE PASSED AND WE

STILL HAVEN'T COME UP WITH A GOOD ANSWER.

OUR TECHNOLOGY-DRIVEN REIMBURSEMENT SYSTEM --

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

PREDICATED ON TAKING THE LEG OFF.

32


OUR HEALTHCARE SYSTEM MAY FUNCTION WITH COMPASSION

AND COMPETENCE --EVEN EXCELLENCE-- FOR SOME

INDMDUALS.

BUT FOR TOO MANY AMERICANS OUR HEALTH CARE SYSTEM IS A

TYRANNY, MORE A CURSE THAN A BLESSING.

33


4. PATIENTS, OFTEN AFTER AN UNCONSCIONABLE WAIT OF
HOURS OR EVEN DAYS IN THE EMERGENCY ROOM, ASK
THEMSELVES NOT ONLY "WILL I RECOVER?", BUT ALSO "HOW

WILL I PAY FOR THIS?"

"WILL MY INSURANCE PAY FOR THIS? WILL MY ILLNESS COST ME
MY SAVINGS, MY HOUSE?"

HEALTH INSURANCE HAS BEEN LIKENED TO A SHELL GAME.

34


5. OUR PRICES MAKE PEOPLE ANGRY.

THEY MAY SIGH ABOUT CONSTRUCTION AND EDUCATION COSTS,

BUT THEY DON'T GET ANGRY WITH CONTRACTORS OR

PROFESSORS, AS THEY DO WITH DOCTORS.

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.

35


TRUE, THE PRESS IS OBSESSED WITH THE INCOME OF DOCTORS.

FOR EXAMPLE, 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.

36


YOU SEE, THE REPORTER LOST SIGHT OF THE FACT THAT HE WAS
i%iiiiiG ABOUT THE SALARIES OF COLLEGE PRESIDENTS AND

TOOK OFF ON DOCTORS' INCOMES INSTEAD. HE OBVIOUSLY

WANTED THE PUBLIC TO HAVE A HARD TIME SWALLOWING THAT,

,$ e/ THE PUBLIC HAS A HARD TIME SWALLOWING THAT.

37


IF WE COULD SEPARATE 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,

ATHLETES, AND LAWYERS WHO RAKE IN LARGE CONTINGENCY

FEES FOR LAWSUITS AGAINST DOCTORS, LAWSUITS ABOUT A

MALOCCURANCE THAT EVERYONE USED TO CALL AN ACT OF

GOD..

38


BUT THE PUBLIC IS MORE CRITICAL OF DOCTORS, &sJjD m  P /+Ldric /R @

COULD DO A LOT MORE TO LEAD PATIENTS TO UNDERSTAND

THEY ARE GETTING HIGH-QUALITY, HIGH-EFFICIENCY,

CONSIDERATE, SENSITIVE CARE FOR THEIR MONEY, INSTEAD OF
  \4r-.

THE PRESENT BELIEF THAT THEY ARE PAYING MORE AND MORE

FOR LESS AND LESS.

39


$, PATIENTS TELL US THEY CAN'T FIND A SHRED OF EVIDENCE
TO PROVE THAT THE QUALITY OF CARE IS IMPROVING AT THE

SAME RATE THE COST OF THE CARE ESCALATES.

EVEN YOU WOULD AGREE THAT HOSPITAL CARE AND PHYSICIAN

CARE AREN'T TWICE AS GOOD AS THEY WERE EIGHT OR NINE

YEARS AGO, EVEN THOUGH NOW THEY COST ABOUT TWICE AS

MUCH.

40


WE SEEM TO LIVE WITH THE PERCEPTION OF A SYSTEM OF

HEALTH CARE THATS 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.

41


7.  AS FOLKS VOICE THESE CRITICISMS AND REALIZE THAT 37

MILLION OF THEIR FELLOW CITIZENS HAVE m ACCESS TO

HEALTH CARE THEY SAY THERE'S SOMETHING TERRIBLY WRONG

WITH A SYSTEM OF HEALTH CARE THAT SPENDS MORE AND

MORE MONEY TO SERVE FEWER AND FEWER PEOPLE.

IN THE PAST MOST AMERICANS TURNED CONFIDENTLY TO THEIR

INSURANCE TO PAY THE HEALTHCARE BILL. BUT THOSE DAYS

ARE OVER. THEY ARE EXASPERATED ABOUT THAT, AND FEEL

POWERLESS TO DO ANYTHING ABOUT THAT UNREGULATED

INDUSTRY.

42


/F-s F/&c p.) f~J(/12~ut/CE fJ codcE(tk/er3/

WE HAVE THREE GROUPS IN THIS COUNTRY:

THE INSURED, THE UNINSURED, AND THE UNINSURABLE.

THE LARGEST GROUP, FORTUNATELY, IS THE 160 MILLION

AMERICANS WHOSE HEALTH INSURANCE IS PROVIDED THROUGH

EMPLOYERS -THEIR OWN OR FAMILY MEMBERS--, AND THE

SMALL FRACTION WHO PURCHASE THEIR OWN INSURANCE.

43


THESE PEOPLE USUALLY ENJOY ACCESS TO THE BEST MEDICINE

IN THE WORLD, AS LONG AS THEIR INSURANCE HOLDS OUT, OR

THEIR PREMIUMS ARE NOT RAISED BEYOND REACH.

BUT EMPLOYERS NOW ASK EMPLOYEES TO ASSUME MORE OF

THE COST OF HEALTHCARE, THROUGH HIGHER DEDUCTIBLES

AND CO-PAYMENT--APPROPRIATELY--, OR GIVE UP CERTAIN

SERVICES.

THEN EMPLOYEES DIG IN THEIR HEELS AND SAY. "NO!"

44


HEALTH BENEFITS WERE THE MAJOR REASON FOR 78 PERCENT

OF THE WORKING MEN AND WOMEN WHO WENT OUT ON STRIKE

LAST YEAR...PRODUCTION WORKERS AND MINERS AND PUBLIC

EMPLOYEES AND TELEPHONE WORKERS AND SERVICE WORKERS

AND SO ON.

THEY ASKED FOR MORE MONEY IN HEALTH BENEFITS...AND

MANAGEMENT SAID IT COULDN'T AFFORD TO PAY IT.

AND THEY CAN'T.

45


WHEN THOSE STRIKES ARE SETTLED AND OVER MORE MONEY

DOES GO INTO EMPLOYEE HEALTH BENEFITS, AND THOSE

INCREASED COSTS ARE EXPRESSED IN THE MARKETPLACE AS

HIGHER PRICES FOR THE GOODS YOU PURCHASE AND UTILITIES

YOU USE.

46


YEARS OF FULL INSURANCE COVERAGE HAVE LED TO HIGHER

FEES WITHOUT CONSUMER RESISTANCE. WE CAN NEVER

CONTAIN COSTS IF DOCTORS CAN BILL UNENDINGLY BECAUSE

EMPLOYEES CAN SPEND EMPLOYER INSURANCE FOR

TREATMENT.

47


THEN TOO, I AM EMBARRASSED BY PHYSICIANS WHO MILK THE

SYSTEM FOR MONEY.

WE SHOULD NEVER JOIN PHYSICIANS AND HOSPITAL

ADMINISTRATORS WHO ATTEND SEMINARS ON HOW TO

MANIPULATE THE CODING SYSTEM OF CPT (CURRENT

PROCEDURAL TERMINOLOGY) TO MULTIPLY THEIR

COMPENSATION.

THE FINANCIAL SIDE OF OUR PRACTICES MUST EXEMPLIFY HIGH

ETHICS, HONESTY, AND PROFESSIONALISM.

48


THE TWO THIRDS OF OUR POPULATION COVERED BY EMPLOYER-

PURCHASED HEALTH INSURANCE ARE THE PEOPLE WHO HAVE

THE MOST CLOUT TO CHANGE THINGS FOR THE BETTER.

BUT FIRST THESE PEOPLE --AND YOU AND BUSINESS AND

INDUSTRY-- MUST IDENTIFY THE LEADERSHIP TO BRING

HEALTHCARE COST UNDER CONTROL.

IT IS NOT THE PRESENT LEADERSHIP.

THEY ARE THE ONES WHO GOT US INTO OUR CURRENT

PROBLEMS OF PROFLIGACY AND POOR CARE.

49


NOR IS IT BIG BUSINESS AND LABOR.

I THINK THAT THIS IS THE WRONG COALITION.

THE COALITION THAT NEEDS TO BE FORMED COMBINES
BUSINESS AND ORGANIZED HEALTH CARE. wl7U 3' f~~~~' t  CJ `= lh' F_
                                        /&iOUUWOP

THE ACS NEEDS TO BE PART OF THIS EFFORT IN A MORE           /' I


FORCEFUL WAY.

50



TOGETHER, THESE 160 MILLION INSURED AMERICANS AND THEIR
NEW CO-BELLIGERENTS CAN FORGE THE ALLIANCE THAT
REWARDS HIGH QUALITY AND HIGH EFFICIENCY WITH MORE
PATIENTS, RATHER THAN REWARDING POOR QUALITY CARE WITH
DOLLARS AS WE DO NOW.


8.  EXASPERATION RUNS HIGH AMONG THE INSURED AMERICANS

WHO RELY UPON GOVERNMENT INSURANCE --MEDICARE FOR

THE ELDERLY, MEDICAID FOR THE POOR-- TO MEET THEIR

HEALTHCARE BILLS.

THESE INSURANCE PLANS NO LONGER FILL THE BILL.

52


MEDICARE IS NOT WHAT MOST PEOPLE THINK.

IT IS NOT A SYSTEM THAT PROVIDES FOR THE HEALTHCARE

COSTS OF THE ELDERLY.

OLDER AMERICAN CITIZENS MUST FIRST MUST SPEND THEIR

OWN MONEY BEFORE MEDICARE KICKS IN.

MEDICARE USUALLY DOESN'T PROVIDE THE DRUGS MANY

ELDERLY NEED TO STAY ALIVE.

53


NOR IS THERE PROVISION FOR LONG-TERM CARE IN HOSPITALS

OR NURSING HOMES.

ELDERLY PEOPLE AND THEIR GROWN CHILDREN ARE OFTEN

SHOCKED WHEN THEY DISCOVER THAT WHEN THE AGING

PARENT NEEDS NURSING HOME CARE, IT IS NOT COVERED BY

MEDICARE.

54


FURTHERMORE, THERE IS NO PROVISION IN MEDICARE FOR THE

HOUSEHOLD HELPS THAT WOULD KEEP ELDERLY PEOPLE

INDEPENDENT, AND OUT OF INSTITUTIONS, AT A TINY FRACTION

OF THE COST OF NURSING HOME CARE.  I AM TALKING ABOUT

SOMEONE STOPPING BY ONCE A DAY TO SPEND AN HOUR ON THE

HEALTH AND HOUSEHOLD CHORES THAT NEED TO BE

ACCOMPLISHED.

55


MEDICARE IS ONE OF THE MOST DECENT THINGS THAT THIS

COUNTRY HAS DONE, TO REMOVE MUCH OF THE FEAR AND

UNCERTAINTY FROM THE FRAIL YEARS OF ELDERLY LIFE, AND IT

SHOULD STAND AS A LANDMARK TO THE BASIC DECENCY OF THE

AMERICAN ETHICAL CORE.

BUT IT NEEDS TO WORK AS ORIGINALLY INTENDED, AND

PROMISED.

56


THEN THERE IS MEDICAID, THE FEDERAL INSURANCE PROGRAM

DESIGNED FOR THE POOR.

IF MEDICARE IS A DISAPPOINTMENT, MEDICAID IS A FRAUD.

MEDICAID IS A FRAUD BECAUSE MEDICAID EXCLUDES MOST OF

THE POOR.... BY CALLING THEM TOO RICH.

57


INDIVIDUAL STATES ADMINISTER MEDICAID, AND CAN SET THE

MAXIMUM INCOME LEVEL NEEDED TO QUALIFY FOR MEDICAID.

THIS HAS LED TO SHAMEFUL STANDARDS.

IN MANY STATES A FAMILY OF THREE WITH AN INCOME OF $3000

A YEAR IS TOO RICH TO QUALIFY FOR MEDICAID. THERE ARE

FEW STATES BETTER, AND FORTUNATELY FEW WORSE.

MEDICAID NEEDS TO BE STANDARDIZED, EXPANDED AND

REFORMED.

MEDICAID NEEDS TO EMBRACE FAMILIES RATHER THAN

EXCLUDE THEM.

58


9. THE COUNTRY IS EXASPERATED OVER THE PLIGHT OF THE

UNINSURED, THE 12 TO 15 PERCENT OF OUR POPULATION --

THAT'S 33 TO 37 MILLION AMERICANS-- WHO ARE UNINSURED,

UNDER-INSURED, OR ONLY SEASONALLY INSURED.

THEY'RE NOT OLD ENOUGH FOR MEDICARE AND NOT POOR

ENOUGH FOR MEDICAID.

59


THESE PEOPLE, THE WORKING POOR, WHOSE INCOMES ARE TOO

LOW TO LIVE ON, BU'i TOO HIGH TO QUALIFY FOR MEDICAID,

OFI'EN EXHIBIT A STEELY PRIDE THAT MANY OF US CAN ENVY.

THESE ARE NOT PEOPLE ON WELFARE. THEY COULD GO ON

WELFARE, GET FOR FREE THE DENTURES, EYEGLASSES, AND

SHOES, AND FOODSTAMPS THEY NEED, BUT THEIR DIGNITY

KEEPS THEM OFF WELFARE, AND THEY STRUGGLE ALONG,

FEARFUL OF THAT ILLNESS THAT MIGHT CLAIM ALL THE LITTLE

THEY HAVE.

60


CONTRARY TO THE WHINING OF SOME CONSERVATIVE

COLUMNISTS, THESE PEOPLE ARE NOT LOOKING FOR A

HANDOUT.

90 PERCENT OF THE UNINSURED ARE WORKING PEOPLE, MANY

WORKING AT SEVERAL JOBS, NONE OF WHICH PROVIDES A

HEALTH PLAN.

61


THEY ARE SUFFERING THE CONSEQUENCES.

STUDY AFTER STUDY INDICATES THE CORRELATION BETWEEN NO

MEDICAL INSURANCE AND SERIOUS HEALTH PROBLEMS.

AND ALL OF US WILL SUFFER THE CONSEQUENCES TOO, BECAUSE

THE HEALTH PROBLEMS OF THE UNINSURED, IF IGNORED BY

SOCIETY NOW, WILL BE BORNE BY SOCIETY LATER.

62


10. TRAGICALLY, IF EXASPERATION CHARACTERIZJ$fIXIESE

COMPLAINTS, THEN DESPAIR IS THE HALLMARK OF THE

UNINSURABLE: THE TWO AND A HALF MILLION AMERICANS WITH

SERIOUS MEDICAL PROBLEMS WHO CAN'T EVEN BUY INSURANCE

BECAUSE THEY ARE CONSIDERED TO BE BAD RISKS.

AND NOW, WITH INCREASING FREQUENCY, SOME PATIENTS HAVE

THEIR INSURANCE PREMIUMS RAISED OUT OF SIGHT RIGHT IN

THE MIDDLE OF A SERIOUS ILLNESS.

63


FAMILIES WHO THINK THEY HAVE A MILLION DOLLAR COVERAGE

FOR EACH MEMBER OF THE FAMILY FIND THAT WITH THE FIRST

EXPENSIVE ILLNESS THE FAMILY HEALTH INSURANCE

PREMIUMS CAN UNDERGO A SIXFOLD INCREASE.. LIKE ONE I

KNOW THAT WENT FROM $198 A MONTH TO $1375 A MONTH.
&v,. ANtl7fl~P  F* /3o+zd 4   /lOU'o.

HOW MANY OF US COULD AFFORD THAT KIND OF A JUMP?

64


@_l9gJP THOUGHT IT MUST BE A COMPUTER ERROR, BUT WERE

TOLD COLDLY BY THE INSURANCE COMPANY THAT IF THEY

DIDN'T LIKE IT, THEY COULD CANCEL THEIR INSURANCE.

HOWEVER, NO OTHER COMPANY WOULD INSURE THEM BECAUSE

THEIR YOUNGSTER HAD A "PRE-EXISTING CONDITION."

65


OTHER AFFLICTED AMERICANS WHO THOUGHT THEY WERE

COVERED BY INSURANCE SUDDENLY DISCOVERED THAT THEIR

INSURANCE COMPANIES WERE SIMPLY NOT PAYING THE BILLS.

IN CALIFORNIA ALONE, 100,000 PEOPLE LOST THEIR INSURANCE

IN 1989 BECAUSE THEIR INSURANCE COMPANIES HAVE GONE

UNDER.

SOME OF THESE PEOPLE HAD ALREADY PAID AS MUCH AS $200,000

IN PREMIUMS OVER THE YEARS.

66


11.  SOCIETY IS EXASPERATED BY THE DISRUPTION CAUSED BY

THE ESCALATING COST OF HEALTH CARE.

THOUSANDS AND THOUSANDS OF AMERICAN FAMILIES EACH

YEAR ARE LITERALLY IMPOVERISHED BY THE AMERICAN HEALTH

CARE SYSTEM.

WE CANNOT LET THAT CONTINUE.

67


THEY ARE ALSO EXASPERATED BECAUSE OUR HEALTH DOLLARS

DON'T SEEM TO BE GOING FOR OUR HEALTH.

PEOPLE FUME WHEN THEY READ THAT HEALTHCARE

ADMINISTRATION NOW CONSUMES ABOUT 22% OF HEALTHCARE

SPENDING.

DOCTOR'S OFFICES OFI'EN SPEND MORE TIME ON THE

INSURANCE FORMS THAN THE DOCTOR SPENT WITH THE

PATIENT.

EVEN THE INSURANCE INDUSTRY ITSELF HAS BEGUN TO CALL

FOR REGULATION AND REFORM.

68


EMPLOYERS SHOULD BE REOUIRED TO PROVIDE HEALTH

INSURANCE, BUT WITH APPROPRIATE COST-SHARING, HEALTH

EDUCATION, AND FITNESS PROGRAMS, SO THAT THE ECONOMIC

IMPACT ON SMALL BUSINESS CAN BE LESSENED BY TAX BREAKS

AND RISK-POOLING.

OTHERWISE SMALL EMPLOYERS JUST DROP SOME EMPLOYEES

FROM THE PAYROLL.

69


THOSE NOT INCLUDED IN EMPLOYER-PROVIDED INSURANCE

SHOULD BE ABLE TO HAVE ACCESS TO SIMILAR COVERAGE

ACCORDING TO SLIDING SCALE COST-SHARING AND RISK-

POOLING.

WE NEED TO EXPECT SOME FORMS OF TAX INCREASE IF WE ARE

TO ACT ACCORDING TO OUR ETHICS, AND PROVIDE HEALTH

INSURANCE FOR THOSE WHO ARE NOW UNINSURED.

70


WE CAN LOWER BOTH HEALTHCARE COST AND INSURANCE COST

BY LINKING INSURANCE COVERAGE TO BEHAVIOR.

IT MAKES SENSE TO VOID OR REDUCE INSURANCE COVERAGE

FOR PEOPLE WHO PRACTICE HIGH RISK BEHAVIOR: NOT

WEARING MOTORCYCLE HELMETS, NOT BUCKLING SEATBELTS,

DRIVING AFTER DRINKING, AND YES, CONTINUING TO SMOKE.

71


WHY SHOULD THE REST OF US SUBSIDIZE THE INSURANCE

COVERAGE OF PEOPLE WHO KNOWINGLY AND CONTINUALLY

PLACE THEMSELVES AT GREATER RISK FOR ILLNESS?

EVEN HIGHER TOBACCO AND ALCOHOL TAXES SHOULD BE

DEMANDED TO PAY FOR HEALTHCARE COSTS ATTRIBUTED TO

THOSE DEADLY SUBSTANCES.

72


ON THE POSITIVE SIDE, WE NEED INSURANCE PROGRAMS THAT

ENCOURAGE PREVENTIVE HEALTHCARE.

IT IS ABSURD FOR AN INSURANCE COMPANY TO COUGH UP

$150,000 TO REMOVE A CANCEROUS LUNG, BUT NOT PAY $64 OR

$200 FOR A SMOKING CESSATION PROGRAM.

73


INSURANCE PEOPLE TELL ME THAT I DON'T UNDERSTAND

INSURANCE.

IT WAS MEANT FOR CATASTROPHES. BUT I'M SMART ENOUGH TO
                        c*7)957*fll#/ t

KNOW THAT $200 SPENT TO AVOID AnBILL OF $150,000 IS GOOD

BUSINESS. BUT THEN I LIKE LONG TERM GAINS, NOT THIS

YEAR'S SOFT PROFITS.

74


NO ONE CAN DOUBT MY CO MMITMENT TO CUITING

HEALTHCARE COSTS, TO GETTING RID OF MISMANAGEMENT,

WASTE, AND FRAUD.

BUT I AM DEEPLY DISTURBED AND EVEN FRIGHTENED WHEN

THIS IS ATTEMPTED BY MISGUIDED INTERFERENCE IN THE

DOCTOR-PATIENT RELATIONSHIP.

75



12.  PATIENTS WOULD BE FURTHER EXASPERATED IF THEY KNEW

THAT WHEN THEY COME TO SEE YOU THERE ARE OTHER PEOPLE

THERE: THE THIRD PARTY REGULATORS, THE OUTSIDERS WHO

EARN THEIR KEEP BY HARASSING DOCTORS. EACH OF YOU

COULD COME UP WITH MANY EXAMPLES OF THIS: HAVING YOUR

JUDGMENTS SECOND-GUESSED LONG-DISTANCE TO SHAVE A FEW

BUCKS OFF THE COST OF A HOSPITALIZATION:

76


h NEUROSURGEONQ TRYING TO EXPLAIN TO THE CLERK ON THE

OTHER END OF THE TELEPHONE WIRE WHY THE 10 HOUR BRAIN

SURGERY SHOULD NOT BE SCHEDULED IN THE AFTERNOON,

JUST SO THE PATIENT DOESN'T STAY IN THE HOSPITAL THE

NIGHT BEFORE THE PROCEDURE.

MOST OF YOU ARE TRAINED TO ADVOCATE YOUR PATIENTS'
INTERESTS, AND YOU ARE BEITER AT CLINICAL DECISIONS %HAN

ECONOMIC DECISIONS.


ALL TOO OFTEN THESE INTERFERING REGULATORS FORCE

DOCTORS TO FIGHT FOR WHAT IS BEST FOR THEIR PATIENTS, TO

SPEND TIME ON THE PHONE OR WRITING LEXTERS, TIME THAT

WOULD BE BETTER SPENT WITH THEIR PATIENTS.

78


I THINK THIS IS ONE PLACE WHERE THE TIDE OF OPINION MAY

BE TURNING IN THE PHYSICIAN'S FAVOR, AS A NUMBER OF

RECENT NEWS PROGRAMS HAVE HIGHLIGHTED THE ABUSES OF

THE REGULATORS.

COST CONTROL SHOULD NOT MEAN REMOTE CONTROL

MEDICINE.

WE DON'T WANT TO SEE MEDICINE TURNED INTO A PUBLIC

UTILITY, OVER-REGULATED AND UNDER-RESPONSIVE TO THE

NEEDS OF INDMDUAL PATIENTS.

79


BUT, TO MAKE SURE WE ALL GET MORE FOR OUR HEALTHCARE

DOLLAR, FOR OUR INSURANCE COVERAGE, WE NEED m NEED

MORE OPEN COMMUNICATION ABOUT THE QUALITY AND

EFFICIENCY OF HEALTHCARE.

13.  WHAT SOME PEOPLE SAY IS ANOTHER SOURCE OF

EXASPERATION IS THAT THEY CALL THE CONSPIRACY OF

SILENCE.

THEY NEED TO KNOW WERE PEOPLE CAN GET HIGH-QUALITY

AND EFFICIENT CARE.

80


THEN THE PATIENTS WILL DESERT THE POOR QUALITY,

INEFFICIENT SYSTEMS THAT WILL HAVE TO IMPROVE OR PERISH.

THE PUBLIC --AS WELL AS OUR PROFESSION-- IS ALSO

EXASPERATED ABOUT GLARING REGIONAL DIFFERENCES.

WHY SHOULD HOSPITAL USE IN THE MIDWEST BE 60% HIGHER

THAN IN THE WEST? WKY, IN A GIVEN YEAR, SHOULD 10% OF

DELIVERIES IN DETROIT BE BY CAESAREAN, BUT IN WASHINGTON

DC CAESAREANS FORM 24%?

81


WHY SHOULD SOME REGIONS ORDER CAT SCANS 7 TIMES MORE

FREQUENTLY THAN THE NATIONAL RATE?

WHY DO KNEE REPLACEMENTS VARY 6-FOLD FROM REGION TO

REGION?

THE EXPLANATION OR CORRECTION OF THOSE DISCREPANCIES

SHOULD COME FROM YOU, AND NOT FROM A SOCIAL PLANNER.

82


QUALITY, AND EFFICIENCY ARE DIFFICULT TO MEASURE.

BUT THEY ARE MORE IMPORTANT THAN MERE QUANTITY.

WE ARE DEVELOPING TOOLS TO MEASURE MEDICAL NECESSITY,

APPROPRIATENESS, EFFECTIVENESS AND OF COURSE OUTCOMES.

83


OUTCOMES WILL BE MORE AND MORE PART OF OUR

RELATIONSHIP WITH PATIENTS.

BATTING AVERAGES OF PHYSICIANS AND HOSPITALS FOR

VARIOUS DIAGNOSES WILL BE COMMON KNOWLEDGE.

BE SURE THEY ARE PROPERLY CALCULATED AND CONVEYED.

DON'T ALLOW THIS TO BE ANOTHER REASON FOR PATIENT

EXkPERATION.

MANAGE THE SYSTEM; DON'T FIGHT IT.

84


MALPRACTICE SUITS CORRFIYBASIC EMOTIONAL CLIMATE OF
MEDICINE, MAKING THE DOCTOR AFRAID OF THE PERSON SHE

OR HE WANTS TO HELP.

MALPRACTICE DOES EXIST, AND WHERE THERE IS MALPRACTICE

--BAD, OR NEGLIGENT PRACTICE-- RESTITUTION AND

COMPENSATION ARE IN ORDER.

MEDICINE MUST RID ITSELF OF THE BAD APPLES THAT BRING

JUSTIFIED CRITICISM TO THE PROFESSION.

85


YET MANY MALPRACTICE SUITS ARE BROUGHT BECAUSE A

TRAGEDY HAS OCCURRED, IN SPITE OF THE DOCTOR'S BEST

EFFORTS.

OUR CURRENT SYSTEM DOES NOT SERVE THE PATIENT WELL.

EVERY INAPPROPRIATE MALPRACTICE SUIT DRIVES UP THE COST

OF MEDICINE FOR ALL PATIENTS AND DOCTORS ALIKE, WHILE

NEGLIGENT DOCTORS CONTINUE TO PRACTICE AND SOME VERY

GOOD DOCTORS LEAVE.

86


MALPRACTICE REFORM IS DIFFICULT TO GET BECAUSE

CONGRESS AND STATE LEGISLATURES INCLUDE SO MANY

LAWYERS, AND THEY AREN'T LIKELY TO ACT AGAINST THEIR

OWN.

BUT WE --NOT JUST SURGEONS, BUT ALSO CITIZENS CONCERNED

ABOUT HEALTHCARE COSTS-- WE MUST DEMAND REFORM.

87


WE MUST ELIMINATE AWARDS FOR ALLEGED PAIN AND

SUFFERING, AND WE MUST DO AWAY WITH CONTINGENCY FEES

WHICH CLOG THE COURTS, BLACKMAIL PHYSICIANS, AND

PROMPT INSURANCE COMPANIES TO SPEND OUR MONEY OUT OF

COURT J-UST TO GET IT OVER.

ALTHOUGH WE MUST HOLD OUR PHYSICIANS TO THE HIGHEST

STANDARDS,

WE MUST REALIZE THAT HEALING AND RECOVERY ARE NOT

PERFECT.

88


THE HEALTH CARE SYSTEM IN AMERICA TODAY IS A TERRIBLE

MORAL BURDEN FOR SOCIETY TO BEAR, IN THAT THE SYSTEM

DOES NOT RESPOND AT ALL TO SOME 12 TO AS HIGH AS 15

PERCENT OF OUR POPULATION.

AND IT IS A TERRIBLE ECONOMIC BURDEN FOR SOCIETY TO

BEAR, IN THAT THE SYSTEM SATISFIES ITS OWN UNCONTROLLED

NEEDS AT THE EXPENSE OF EVERY OTHER SECTOR OF AMERICAN

SOCIETY.

89


WE NEED TO CHANGE THAT SYSTEM.

NOT JUST A LITTLE CHANGE HERE AND A LI'ITLE CHANGE THERE.

WE NEED TO BRING ABOUT A PROFOUND CHANGE, ACROSS-THE-

BOARD, IN THE WAY WE MAKE MEDICAL AND HEALTH CARE

AVAILABLE TO ALL OUR CITIZENS.

BUTCANWEDOIT?

90


WE NEED TO TAKE SOME IMAGINATIVE STEPS.

FOR EXAMPLE, WE NEED TO SOLVE THE PROBLEM CAUSED BY

THE ENORMOUS EDUCATION DEBT THAT MOST YOUNG DOCTORS

HAVE TO SHOULDER AS SOON AS THEY BEGIN PRACTICING

MEDICINE.

MOST MEDICAL STUDENTS GRADUATE FROM MEDICAL SCHOOL

WITH A DEBT THAT SHAPES THEIR PRACTICE OF MEDICINE FOR

THE NEXT 20 YEARS.

91


BUT I DO HAVE A SIMPLE SUGGESTION ABOUT THE PROBLEM OF

MEDICAL SCHOOL DEBT.

WHEN A MEDICAL STUDENT GRADUATES, AN ACCOUNT COULD BE

ESTABLISHED BY THE FEDERAL GOVERNMENT, AND EVERY TIME

THE DOCTOR SEES AN UNINSURED PATIENT WITHOUT CHARGE,

THAT DEBT IS LOWERED BY THE AMOUNT EQUIVALENT TO A FAIR

COMPENSATION FOR THAT SERVICE.

92


THIS SOLUTION HAS SEVERAL ADVANTAGES:

IT'S GRADUAL;

IT DOESN'T REQUIRE A BIG OUTLAY BEFOREHAND;

IT OFFERS CARE TO THE UNINSURED WHO NEED IT;

IT ENCOURAGES PHYSICIANS TO OFFER CARE WITHOUT FEE;

AND IT LOWERS THE DOCTOR'S DEBT.

IT SEEMS TO ME THAT EVERYBODY GAINS.

93


WE ALSO NEED TO DO SOMETHING ABOUT THE INFLATIONARY

ASPECT OF RECRUITMENT MONEY, WHEN HOSPITAL "X" WANTS

THE SAME KIND OF SURGEON AS THE HOSPITAL ACROSS TOWN,

AND THEN LURES SOMEONE FROM ACROSS THE COUNTRY WITH

AN ASTRON@klICAL PACKAGE, FORCING COSTS UP ALL AROUND.


I REALIZE THAT THIS IS A COMPLICATED PROBLEM, INVOLVING

REGULATIONS, JOINT COMMITTEES OF ACCREDITATION OF

HOSPITALS, ETC., BUT COMPLEXITY SHOULD NOT KEEP US FROM

GETI'ING A HANDLE ON A SOLUTION.


WE NEED TO DO SOMETHING, TO DO MANY THINGS,

BECAUSE WE ARE AT A CROSSROADS.

WE CANNOT AFFORD TO DO NOTHING, TO CONTINUE BUSINESS

AS USUAL.

THE PRESSURE FOR RADICAL CHANGE IS COMING FROM ALL

DIRECTIONS:

FROM MEMBERS OF CONGRESS, FROM BUSINESS, FROM LABOR,

AND FROM THE GENERAL PUBLIC.

INCREASINGLY WE HEAR THE DEMAND FOR RESTRUCTURING THE

FINANCING AND DELIVERY OF HEALTHCARE IN THE UNITED

STATES.

96


EVEN SOME BUSINESS LEADERS WHO NORMALLY CRINGE AT THE

THOUGHT OF GOVERNMENT INTERVENTION OR REGULATION

FIND THEMSELVES CALLING FOR A SYSTEM OF NATIONAL

HEALTH CARE AS A SOLUTION TO RISING INSURANCE COSTS.

97


EXASPERATION WITH OUR SYSTEM LEADS SOME PEOPLE TO SEE

GREENER GRASS ON THE OTHER SIDE OF THE FENCE.

THE GROWING INFATUATION WITH FOREIGN NATIONAL HEALTH

SERVICES IS BASED MORE UPON DISSATISFACTION WITH OUR

SYSTEM THAN UPON UNDERSTANDING OF ANOTHER ONE.

98


MOST AMERICANS DO NOT REALIZE THAT ANY NATIONAL

HEALTH SERVICE, IS BASED UPON PLANNED SCARCITY.

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.

99


THIS IS ESPECIALLY TRUE OF RESEARCH.

AMERICANS DESIRE, NOT ONLY AFFORDABLE HEALTH CARE, BUT

ALSO MEDICAL ADVANCES.

BUT MEDICAL RESEARCH IS NOT CHEAP, AND SOMEONE MUST

PAY FOR IT. AMERICANS ARE NOT LIKELY TO TOLERATE

HEALTHCARE SAVINGS IF IT MEANS SKIMPING ON AIDS OR

ALZHEIMER'S RESEARCH.

100



NATIONAL SYSTEMS OF HEALTHCARE EVENTUALLY BECOME

BUREAUCRATIC, UNRESPONSIVE TO PATIENTS, AND FINALLY THEY

BRING RATIONING AND WAITING IN LINES.

AMERICANS DO NOT PATIENTLY QUE UP FOR ANYTHING,

ESPECIALLY FOR MEDICAL CARE.

101


I DO NOT FAVOR TOTALLY SCRAPPING THE SYSTEM WE HAVE

NOW;

BECAUSE OF ITS DIVERSITY, IT IS POTENTIALLY THE BEST IN THE

WORLD. AND BECAUSE OF THIS DIVERSITY THERE IS NO

PANACEA, NO SINGLE MAGIC BULLET.

IT WOULD TAKE AT LEAST SIX BULLETS, FIRED SEPARATELY, TO

CONQUER THE DISEASES AFFECTING THE UNITED STATES'

HEALTH CARE NONSYSTEM.

102


IT REMAINS TO BE SEEN WHETHER OR NOT THE PRIVATE SECTOR

SEIZES THIS ONE AND ONLY OPPORTUNITY ---WHILE THE

GOVERNMENT IS TOO POOR-- TO EFFECT SOME CHANGE.

BUT WE ALL NEED TO BE A PART OF THE EFFORT.

THERE IS NO QUICK FIX.

FROM HERE TO WHERE WE WANT TO GO COULD TAKE A DECADE,

BUT WE'D IMPROVE YEAR BY YEAR ALONG THE WAY.

103

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

PATIENT RELATIONSHIP IS MOST ESSENTIAL.

BUT IT WILL TAKE COMMITMENT BY PEOPLE ON BOTH SIDES OF

THE STETHOSCOPE.

THERE ARE THINGS WE CAN DO, AS DOCTORS,

EACH DAY WE PRACTICE.

104


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.

105


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.

106


NOW, OF COURSE, PEOPLE WAN't THE BEST OF BOTH WORLDS, A

DOCTOR WHO IS UP TO THE MINUTE ON THE LATEST HIGH-TECH,

BUT HAS THE COMPASSION, CARE . ..AND TIME.. OF THE OLD-


FASHIONED COUNTRY DOC. AND ITS TOUGH TO BE BOTH.

BUT WHATS THE REAL SIGNIFICANCE OF THE STATEMENT THAT

"PREVIOUS GENERATIONS OF DOCTORS PRACTICED THE ART,

RATHER THAN THE SCIENCE, OF MEDICINE?

107


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 THEM?

HOW DID THEY RESPOND TO us?

DID WE CARE ABOUT THEM?

DID WE CARE ABOUT THEIR FAMILIES?

108


WE HAD TO BE PEOPLE-ORIENTED BECAUSE, WITHOUT THE

BENEFIT OF C.A.T. SCANS OR N.M.R.S, 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.

109


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.

110


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.

111


A FRIEND OF MINE WENT TO HER PHYSICIAN'S OFFICE

RECENTLY, AND AFTER 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."

112


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.

113


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.

114


THE DENTISTS HAVE DONE A MUCH BEITER 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.

MOST AMERICANS REALLY FEEL THEIR DENTIST WANTS THEM TO

HAVE FEWER CAVITIES.

THEY DONT VIEW THEIR RELATIONSHIP WITH THEIR DOCTOR IN

THE SAME WAY.

115


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.

Al?CER 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.

116


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.

117


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.
               167 LElrlG71~

I'VE SAT DOWN AND TALKEDnm 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.

118

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

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

COURAGEOUS, GENEROUS, COMPASSIONATE FAMILIES.

I MAY HAVE HELPED THEIR CHILDREN OVERCOME SOME

DISABILITY. . . BUT THEY ALL HELPED ME OVERCOME

PESSIMISM, DEFEATISM, FRUSTRATION, AND DISCOURAGEMENT.

. . FEELINGS THAT ARE COMMON ENOUGH AMONG HARD-


WORKING PHYSICIANS.

119


I DID THIS SIMPLY BECAUSE I THOUGHT IT WAS GOOD MEDICAL

PRACTICE, BUT IT ALSO HAD THE UNFORSEEN DMDEND OF

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

OF COURSE WE'LL BE DISAPPOINTED NOW AND THEN.

AND, DEPENDING ON YOUR PARTICULAR PRACTICE, YOU JUST

MIGHT DRAW MORE THAN YOUR SHARE OF DEADBEATS AND

MALCONTENTS.

120


BUT ITS STILL NO EXCUSE FOR DISCARDING FROM YOUR

ARMAMENTARIUM THE KEY ELEMENTS OF THE ART OF

MEDICINE:

THE ELEMENT OF PERSONAL ATTENTION AND INTEREST

THE ELEMENT OF TRUE CARING

THE ELEMENT OF SINCERE HUMAN FEELING

AND THE ELEMENT OF GENEROSITY OF SPIRIT.

121


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 -AND TAKE PART IN FINDING REGIONAL AND

NATIONAL SOLUTIONS, WE CAN DO OUR PART BY REVITALIZING

THE PRACTICE OF OFFERING FREE CARE TO APPROPRIATE

PATIENTS.

122


IN MY EARLY DAYS I FOUND MYSELF EXTRAORDINARILY

FORTUNATE IF I GOT PAID FOR 40% OF WHAT I DID.

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.

123


I SEE NO REASON WHY CERTAIN FREE CLINICS COULD NOT

OPERATE UNDER LAWS THAT FORBID LITIGATION.

GIVING, CHARITY, HAS ALWAYS BEEN PART OF OUR CALLING.

WE OUGHT TO FIND WAYS TO DO IT WITHOUT PENALTY.

124


NOT LONG AGO, I WAS SPEAKING WITH TWO YOUNG WOMEN,

BOTH BRIGHT, KNOWLEDGEABLE, ARTICULATE HEALTH

REPORTERS.

I ASKED THEM EACH THE SAME QUESTION:

"ARE YOU SATISFIED WITH YOUR HEALTH CARE?"

ONE SAID SHE WAS;

ONE SAID SHE WASN'T.

125



I ASKED WHY.

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, `NOWREMIND ME

WHO YOU ARE AND WHY I KNOW YOU.`"

126


I SAID TO THEM BOTH,

"IN OTHER WORDS, WHEN I ASKED YOU -AREYOU 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."

127


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.

128


WE HAVE MUCH TO DO, BUT LETS 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";

129


NOR DO WE NEED SOME FUTURISTIC MANIFESTO PROMISING

WHAT WE INTEND TO DO.

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.

130


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.

WE COULD HAVE MADE MONEY DOING OTHER THINGS.

131


WE CHOSE MEDICINE --SURGERY-- 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.

IF WE DO, WE'LL GET WHAT WE NEED TO DO THE JOB RIGHT.

132


I THINK I POSSESS A CERTAIN AMOUNT OF CREDIBILITY, BOTH

WITH YOU AND THE GENERAL PUBLIC.

I HOPE MY REMARKS TO YOU TODAY DID NOT COST ME SOME OF

MY CREDIBILITY WITH SOME OF YOU BECAUSE YOU DON'T LIKE

WHAT I SAID.

I THINK YOU ALL KNOW THAT MEDICINE IN AMERICA IS IN DEEP

TROUBLE, MAYBE AT A TRUE CROSSROADS.

133


IF YOU DON'T WANT TO SEE US TAKE THE ROAD TO CANADA, OR

il@$# GREAT BRITAIN, DO SOMETHING NOW.

WE MUST DO SOMETHING, SOMETHING TO REKINDLE THE LOVE

OF OUR PROFESSION, THE PRIDE IN LOliTY ETHICS, THE


ENJOYMENT OF MEDICINE.

DON'T JUST WRING YOUR HANDS AND GRUMBLE BECAUSE "THEY"

HAVEN'T DONE SOMETHING.

YOU ARE THEY.

THANK YOU.

######

134


SPEECH

"EXASPERATION ON BOTH SIDES OF THE STETHOSCOPE"

AMERICAN COLLEGE OF SURGEONS

SAN FRANCISCO, CA

OCTOBER 8,199O

C. EVEREYT. KOOP, MD

135