President’s Convocation Address
C. Anderson Hedberg, MD, MACP
April 6, 2006
A Patient, A System, A Future
Good evening. Congratulations to the 500 physicians who will soon be inducted as Fellows of the American College of Physicians. This is a moment of great distinction in your careers. Our College summarizes this as follows: “Fellowship is an honor achieved by those recognized by their peers for personal integrity, superior competence in internal medicine, professional accomplishment, and demonstrated scholarship.”
All of you are active in the vast humanistic endeavor that is Internal Medicine. Whether you practice in offices, clinics, or hospitals; in a rural or urban area; on a battlefield or at a disaster site; or pursue scientific research, clinical investigation or teaching; you apply the science and humane compassion that are the foundation of our great field. This is an evening to celebrate your accomplishments with your family, friends, and your colleagues assembled here.
I want to thank our distinguished International guests, who have traveled from many parts of the globe to be with us. Today’s medicine requires a world view. We are partners in the struggle against disease, as well as against natural and man-made disasters. We greatly need each other, and we welcome you here tonight.
Internal Medicine began at the end of the 19th Century, rooted in the scientific study of the pathophysiology of disease, which led to a remarkable history of research, clinical care, and education. The distinguished individuals receiving Awards and Masterships tonight have stood tall on the shoulders of their illustrious predecessors. We honor them for their contributions, and the inspiration they give us to advance knowledge and medical care.
When I entered medical school 49 years ago, medicine was greatly different. At that time, therapeutic options were very limited for many diseases. CT and MRI scans, mammography and colonoscopy were years in the future. Since then, it has been exciting to see my patients benefit from dramatic advances in biomedical knowledge and technology. Yet at the same time the application of medicine for our patients has become fragmented, commercialized, and extremely expensive. We are presently immersed in an era of competitive market place medicine, which is not solving the problems of our health care system. Accompanying this has been a weakening of the doctor-patient relationship. Dana Reeve, wife of the late actor Christopher Reeve and herself an accomplished actress, who passed away from cancer last month at the age of 44 said, “It has become clear to me that high-tech medicine, with all it wonders, often leaves out that all important human touch….We need to worry about the here and now.”
Unfortunately, important components of the American health care system are on the brink of a crisis. Today, we are in the early stages of revolutionary changes on how medical care is conducted and financed in the United States. My focus over my years of practice and teaching has been on the individual patient, so I want to tell you about someone who illustrates many of our dilemmas.
Our patient, who we will call Mrs. Evans, is a 60 year old woman, who is a domestic worker. She has the diagnoses of obesity, Type II diabetes mellitus, hyperlipidemia, hypertension, and coronary artery disease. Two years ago she developed angina pectoris, and underwent angioplasty with stent placement, eliminating this symptom. She is on twelve medications, but she rarely observes her diet, and only occasionally tests her blood glucose and blood pressure. She seldom visits her primary care doctor, because she has to miss a day of work to attend an office where the wait is long and the doctor is rushed. Her husband was recently laid off work, and their medical insurance was cancelled.
What is striking about this common scenario? On the bright side, she has had the benefit of a remarkable cardiology breakthrough in the treatment of obstructed coronary arteries. But her chronic disorders place her at serious risk, and we know that proper treatment can reduce complications and even prolong her life. Yet national surveys have revealed that the application of our scientific knowledge to the individual patient is often inadequate. Studies have shown that a large proportion of diabetics do not have adequate control of their disease, and in ambulatory settings only about 55% of recommended therapeutic and preventive measures for a large spectrum of diseases are routinely provided to patients.
What does Mrs. Evans need? First, she needs to partner in a trusting relationship with a personal physician and health care team that will provide continuous, coordinated, comprehensive care. This should include appropriate office visits, prompt telephone contact, and if possible long-range electronic monitoring and email communication. She needs to be educated about her diseases and their medical management, and what she can do to help herself, such as following her diet, exercising, and carefully monitoring blood glucose and blood pressure. She must understand the timing, benefits, and side effects of her medications. Much of this instruction can be done by a nurse or physician’s assistant who works with her physician, and uses language that is clear and informative. She must interact regularly with her care givers, transmitting reports from her home to the office team, and in return receiving necessary changes in her regimen. When subspecialty or specialty care is indicated, she needs help navigating our complex medical system. If the services of a nutritionist, occupational or physical therapist, or community resource such as a social worker are necessary, they should be reasonably accessible.
The medical care I just described for Mrs. Evans is the goal of a new ambulatory care model proposed by the ACP. It is called “The Advanced Medical Home: a Patient-Centered, Physician-Guided Model of Health Care.” It is inspired by the chronic care model of Dr. Edward Wagner, FACP, of the state of Washington. It includes concepts also proposed by our colleagues in primary care, the American Academy of Pediatrics and the American Academy of Family Practice. A fundamental component is Health Information Technology, which includes the Electronic Health Record. This houses all the clinical information on Mrs. Evans on demand, and can produce timely reminders for her caregivers to update her care. It can generate performance measurements for her physician to identify practice areas that need quality improvement, and it can provide the technology for tracking and reporting quality measures. An information resource embedded in the Electronic Health Record, such as the ACP PIER system, can aid evidence-based clinical decision making, and practice-based learning. Also, her physician can easily access the on-line programs for Maintenance of Competence that are provided by the American Board of Internal Medicine and the ACP.
This care model is a systems-based team approach with modern health information technology that will improve the quality and safety of Mrs. Evans’ medical care. It is designed for primary care internal medicine offices, as well as for subspecialists who provide principle care for their patients. It recognizes that excellent medical care occurs when patients are activated to help themselves, and have physicians and their team proactively providing the medical care. The Knowledge and Education Committee of the College proposes redesigning the third year of internal medicine residency training to include the skills and leadership necessary for those who plan to practice this model of ambulatory care. Practicing physicians report that after a break-in period to adapt their work flow to the new information technology, and implementing the systems and team approach, their offices become more efficient.
Hopefully, this increased efficiency provides Mrs. Evans’ physician with more time for the trusting human relationship that is at the heart of all medical care. Today, patients frequently report that their doctor does not talk with them enough. Understanding a patient’s problems, feelings and needs, establishing the correct diagnosis and treatment, and counseling the patient cannot be rushed. This is the way patients want to receive care, and doctors want to practice medicine. It is possible that with a shift to this paradigm, our traditional instincts for caring and public service will merge with a modern practice design that will rejuvenate our profession.
A major problem clouds the emergence of this care model, and the ability of Mrs. Evans to get the medical care she needs. In recent years a marked decrease has occurred in the number of medical students and residents entering the specialty of primary care general internal medicine. In January the ACP reported on “The Impending Collapse of Primary Care” in its annual report on The State of the Nation’s Health. From 1998 to 2005, the number of third year internal medicine residents choosing primary care dropped 63%, and in 2005 only 13% of first year residents reported that they intend to pursue general internal medicine careers. Another disturbing study showed that 21% of general internists who became board certified in the early 1990’s have left the field.
We know the major reasons are low reimbursement of generalists in the face of unsustainable practice costs and high education debts, as well as excessive patient case loads and burdensome administrative work. There are areas of subspecialty internal medicine that face exactly the same problems, as do our colleagues in Family Practice. In the next few years, 75 million Baby Boomers will begin to flood the Medicare System. Internists are the principal medical caregivers for the majority of Medicare patients, who frequently have or develop multiple chronic illnesses. It would be tragic if these physicians who are exquisitely trained to care for complicated chronically ill patients are washed out of the system, just when society’s need for them is greatest. Importantly, a large majority of American adults of all ages count on having a primary care doctor providing first-contact and continuing medical care and health maintenance.
To have primary care practices that do not just survive, but can thrive and provide access to patients, it is in the best interests of society that major changes be made in the physician reimbursement system. Resources must be provided for long-term chronic care coordination and management, practicing preventive medicine, financing the acquisition and use of health information technology, improved funding for office visits that include education and counseling, and rewarding a high quality of care. I am convinced that a primary care general internist, working with a well-functioning team, and using the care model just described, can provide great social good, have a gratifying career, and lead a balanced life.
Mrs. Evans has entered the category of approximately 45 million American citizens who are uninsured. This number is growing, because health insurance in our country is increasingly unaffordable. We know that the uninsured are at risk for poor outcomes for many illnesses. They usually do not have a primary care doctor, and rely on crowded emergency rooms and clinics. If they become seriously ill, medical debt often leads to tragic bankruptcies. Since 1990 the College has advocated guaranteed universal health care for all our citizens. In 2002 the ACP presented an incremental plan, hoping to arouse political action.
Impeding an easy solution is the relentless yearly increase in health care costs. The US has by far the highest per-capita health expenditure in the world, even though many quality indicators rank us below those of other developed nations. There are documented disparities in the delivery and quality of health care based on geographic, ethnic, racial, and class differences.
A former governor of my state, Adlai Stevenson, said “Man is a strange animal. He generally cannot read the handwriting on the wall until his back is up against it.” It is time for medicine, government, business and the public to forge a national commitment for action to control the costs of health care, eliminate disparities, and provide health coverage to all Americans, because we are very close to hitting that wall.
Throughout history, the art of medicine has blended science and humanism. The humanistic doctor without adequate science can be incompetent, and a doctor who is a scientist without humanity can be monstrous. Our commitment to caring, compassion, and putting our patients’ welfare first is a constant, whatever our mode of practice. In our present commercialized medical world, achieving the appropriate professional and ethical balance cannot be taken for granted. We must maintain constant attention to the venerable concepts of professionalism and ethics, as was so eloquently addressed by Dr. Jock Murray at opening ceremonies this morning. Emphasis must be on our commitment to the altruistic and trusting doctor-patient relationship, patient welfare and autonomy, physician knowledge and competence, the improved access and quality of care, and avoidance of conflicts of interest. We must always remember that medicine is not just a job or business, but an idealistic calling deeply connected to humanity.
I am optimistic about the future. Using innovative ideas and methods we can improve the health and welfare of patients like Mrs. Evans and all our citizens. This will take time, but it is an exciting agenda with many possibilities and challenges. I am pleased to report that the efforts of the ACP to redesign practice and improve the quality and value of medical care and education are being increasingly recognized by the government and the public.
But I maintain ….that the opportunities are still great, that the harvest is truly plenteous and the labors scarcely sufficient to meet the demand.”
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