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President’s Convocation Address

Whitney W. Addington, MD, MACP

April 13, 2000

It Is All I Ever Hoped For

I congratulate and welcome the 771 Internists who tonight are inducted as new Fellows of the ACP-ASIM.

You represent the best of the medical profession: gifted, superbly and expensively educated, and trained in sophisticated disciplines and technologies. You have demonstrated exemplary ethical and moral principles in your care of patients and in your relationships with colleagues.

And you can write. I received the following from one of you:

“When I close the door and sit alone with my patient, it’s all I ever hoped for. But all that goes on outside that door is so different from what I expected, so overwhelming. It is as if the world surrounding my examining room is on fire.”

A powerful statement about the joy of being a physician and the threats and challenges confronting us.

It is my most fervent hope that each of you comes to know “the all I ever hoped for” that I have received as an internist from caring for patients, from teaching and from writing.

Let me give you an example. It has been my privilege for thirty years to care for patients with cystic fibrosis. I have seen them face numerous problems, complications, deterioration, successful and unsuccessful lung transplantation, and death. With every patient I have experienced the breadth of reasons for which you and I have pursued the practice of medicine: the intellectual challenge of sorting out symptoms and findings, the emotion of dealing with each patient’s and their families’ feelings toward each other and the illness; the utilization of modern science; and the grace and dignity of these patients in their final days. Caring for my patients made me a better doctor and a better human being. I’ve also had the pleasure of teaching others about this disease and of attempting to contribute to new knowledge. I know that all of you will have similar experiences during your careers.

That new Fellow of the College is also correct about the environment outside the examining room. There is a fire that threatens patients and physicians. To patients, it comes in the form of delays, of not being able to identify who is in charge, and confusing and expensive health insurance. To physicians it includes restrictions on our ability to properly care for patients, overwork and financial insecurity. Outside our examining rooms is on fire.

I am from Chicago and Chicagoans know about fires. On October 8, 1871, a fire began in Chicago that raged for days. Most of Chicago’s buildings were wood and to make conditions worse, Chicago’s infamous wind was howling. The City was destroyed.

Soon after the fire, a commission was formed by Chicago’s civic leaders. Daniel Burnham, an architect, was asked to create a plan which enabled Chicago to develop its inspiring architecture, its much copied transportation system, and its beautiful lakefront parks. Burnham wrote at the beginning of his report:

“Make no little plans. Little plans have no magic to stir women’s and men’s blood and themselves will not be realized. Make big plans. Aim high in hope and work, remembering that a noble, logical diagram once recorded will never die, but long after we are gone will be a living thing, asserting itself with ever-growing insistency.” The Burnham plan revolutionized urban design and energized the Chicago community.

The fires consuming our health care environment -- the fires of the for-profit insurance companies will die off and a new, post-managed care era will begin. Who should write the “big, noble plan that with ever-growing insistency” that will lead to a high quality, compassionate and affordable health system for all Americans? Physicians. And what better group to lead this effort than Internists? And what better organization to lead than this learned society, this College.

I am convinced that the joy from practicing “all I ever hoped for” shall always be ours providing that our professionalism, and the sanctity of the patient-physician relationship is preserved. But to preserve it, we as individuals, and this College itself must change. Be the change you want to see in the world.

Tonight I will identify three issues which require change to ensure our leadership role in the reform of the healthcare system: postgraduate medical education, patient advocacy and physician renewal.

Postgraduate medical education must become a continuous career long process in which every educational effort is planned and evaluated on the basis of its ability to change physician performance. As a pulmonary physician, I despair over the large numbers of asthmatic patients who are not receiving optimal therapy because of inappropriate physician management. These deficiencies will only be corrected by fundamental changes in our educational strategies. Physician behavior must be assessed. Interactive strategies using Web-based technology and others one-on-one, need to be developed. New knowledge needs to be transferred in a manner that cause changes in the way physicians care for their patients. Guidelines are important, but only a part of this process. There have been some recent successes, the most notable in the care of patients at the end of their lives.

Still, the most neglected part of medical education is the measurement of the patient’s outcome. Is this not what matters? Patients want to feel better, enjoy their families, work, fulfill their potential and live their lives as they choose. They want to get well. They do not want to be subjected to diagnostic tests or therapeutic interventions which we cannot demonstrate to them will be beneficial.

What we need are studies on medical education that in one continuous exercise links new science with physician performance and patient outcomes.

Two recent developments are on the right track: the College’s exciting Clinical Theme initiative and the American Board of Internal Medicine’s revitalized recertification, the new Program of Continuous Professional Development.

Linking postgraduate education to patient outcomes and health status will be enthusiastically accepted by patients. It will be enjoyable for physicians. It will serve well our commitment to professionalism and its mandate for continuous scholarship. And it will send packing the bean-counting "productivity" people.

The second area in which changes are required to assure our leadership position is patient advocacy. The College presently enjoys unrivaled credibility because of its enlightened health policy. Patients’ rights and universal health insurance are only two examples from an impressive list.

I wish that all of you were with me at the National Press Club this last year when I presented a call for affordable, high quality health insurance for all Americans. With me were the Presidents of the seven major U.S. professional medical societies. Together we represented more than 600,000 physicians. It was an unprecedented moment. The house of medicine spoke with a single voice.

The College has initiated a series of publications entitled “No Health Insurance: It’s Enough to Make You Sick!” They document the health consequences facing the 45 million Americans without health insurance. This national disgrace hurts and kills patients. It is unjust and it is un-American. Addressing the health effects of the medically uninsured represents our individual and collective sense of professionalism at its very best.

I need not remind you that the work is only beginning. But the issue of the medically uninsured is back on the national agenda.

Involving patients more in the College's campaign will be crucial. Patients already know about it because at some time most families have had a member medically uninsured. Patients know that the majority of Americans without health insurance are working people. They also know that the adverse health effects of being medically uninsured are visited most severely on America's most vulnerable populations, minorities and the poor.

The only, and most crucial, ingredient lacking for health system reform and universal health insurance is the political will to get it done. An educated public will make the right decisions. You, our new members, and this College need to educate and inform the public in many different ways about the consequences of lack of health insurance.

Elected lawmakers will not be able to resist the demands of a combination of physicians, other health professionals, church groups, civic organizations and, most importantly, the people.

de Tocqueville warned over 100 years ago that “America is great because America is good. When America is no longer good, it will no longer be great.”

A third and my final area in which change and leadership is required, is in the care of ourselves, the professionals. Physicians take terrible care of themselves. And it starts early. A recipe for disaster is the following:

Take one bright, motivated, compulsive, curious, compassionate human being
Add four years of medical school
Bake at high heat during residency training
Season liberally with managed care
And then serve burn out.

We need to “Get a life!”

The successful management of our professional and personal health requires that we have our own Internist, board certified, and a Fellow in this College – just like one of you – a doctor for adults, a doctor for adult physicians.

“Physician Heal thyself” is a terrible piece of advice, from no less than the Biblical physician Luke. Physicians are no better than regular patients on taking care of themselves.

Each of you out there look to your right and left and to the rows of brightly robed physicians on this stage, many of the most distinguished in the world. At least one out of every four of us in the course of our lifetime will experience a clinical depression. Will you recognize it in yourself? Guess again.

Remember Osler: “The Physician needs a clear head and a kind heart.” Your generation is fitter and healthier than mine. Listen to your family, continue to exercise, pursue the arts; music in particular has helped me.

When symptoms of burnout, depression, substance or alcohol overuse appear, be in the care of your Internist. Superwoman or superman we are not.

I have had several wonderful internists care for me and I have had the pleasure to care for physicians. It is an honor, it is challenging and it is fun. Be at your best, physicians are masters of self-denial. Everyone needs an Internist just like one of you.

I am confident that if we individually and this College collectively make the required changes in medical education, patient advocacy and in our approaches to our own health, the joy of medicine will be ours in abundance.

The world will little note, nor long remember what I say here, but it will never forget what we begin to do here. It is for us to become dedicated to the unfinished work which those who have gone before us have so nobly advanced.

It is for us to be here dedicated to assure that your future in medicine is all you ever hoped for.

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