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President’s Convocation Address

William A. Reynolds, MD, MACP

April 1998

Ladies and gentlemen, honored guests, Members, Fellows, Masters and friends and families of our new Fellows: As one of my last official duties as President, I am extremely pleased to be part of this important event in the life of the College.

I would like to address these next remarks to the new Fellows for you are what the Convocation is all about. You are the life blood and the future of the College. You are the cream of internists in the Americas and increasingly from overseas. By the conferring of Fellowship you have been recognized by your peers for your outstanding accomplishments, for your achievements and expertise in medicine and most importantly for your contributions to your patients, to your communities, to the College and to those students and physicians who have benefited from your teaching. I’ve become increasingly convinced that it is our contributions that make us feel good about ourselves, that propels us each morning to start a hard day and sometimes a night serving our patients, that gives meaning and sense of purpose to life. To large measure our service to others determines whether we are going to be happy or unhappy with our lives. It doesn’t take much reflection of life experience to realize that it isn’t the amount of money that we make that quantifies our happiness. Achieving awards, accolades and even celebrity status can be a source of great satisfaction and pleasure but again not lasting happiness. Clearly it’s what we have given and not what we have taken that gives us our identity and worth. In the fourth century Aristotle proclaimed that true happiness is found in the virtuous life. For we physicians of the College, virtue to a large degree is defined by our service to others

So it is this service to our patients, colleagues and communities that bestowal of Fellowship honors. Fellowship of course does not delineate the end of that service but is the beginning of a new period of your professional life that offers the opportunity for you to become involved in the leadership of the College both on the chapter and the national level. A number of you will go on to become Governors, to serve on regional and national ACP committees and to attain leadership positions.

All of you should be very proud of your newly awarded FACP which carries with it the expectation of your patients ,colleagues, friends and family that you will continue to live up to the high standards defined by being a Fellow. The high point of the College’s activities each year is embodied in this ceremony and for me it has always been an inspiration. The first one I attended was in Denver in 1971 when I received my Fellowship. I’ve attended 13 Convocations since that time. The pomp and ceremony of the occasion still sends a tingle of excitement up my spine and I hope you share that feeling.

Fellowship is an honor that approximately only a quarter of our membership and only 14% of the internists in the US have reached. There have been significant changes in the criteria for qualification for Fellowship since the founding of the College in 1915. Initially all members were Fellows with Mastership bestowed on a select few. By 1932 a period of three years of Associateship (probationary status) was required of all new members with expectation that all would go on to Fellowship within five years. Criteria for Fellowship included presentation of written material including case histories and publications. With the establishment of certification by the American Board of Internal Medicine in 1936, such certification became a requirement for Fellowship. The publication and written scholarly material requirement remained making it easier for academic members to qualify but difficult for many full time practitioners to advance to Fellowship. After nearly a decade of urging by then EVP Robert Moser, the Regents in 1989 adopted three new pathways to Fellowship which opened advancement to many outstanding members. This change was objectionable to some feeling it cheapened the value of Fellowship. Time has proven this decision to be very prudent and one of the most important in the history of the College. The standard for Fellowship remains high and demanding but now nearly all motivated members can by hard work and dedication qualify and have the opportunity to be enfranchised as Fellows. Had we not made this change, approximately half of you new Fellows having qualified by a non publication pathway would not be here today. Extending membership to internal medicine residents as Associates in 1969 was also a watershed initiative. These two changes have been responsible in large part for our continued and amazing growth in membership and the ever increasing success and influence of the College.

Another major impact on our future was the decision this past year for the College and American Society of Internal Medicine to merge effective July 1, 1998. The strengths and talents of both will be combined to result in a stronger more influential organization which will speak with one voice for all of internal medicine. The mission and goals and values of the College will remain intact in this new entity which will be known as ACP-ASIM.

During the 27 years that I’ve been a member there have been major changes in the College as a result of a democratization process. As many more Members advance to Fellowship and on to leadership positions, the representation of the grass roots membership in the governance structure has increased. The role and influence of the Governors has changed considerably. The Board of Governors responsibilities, power and influence in the governance of the College is now vastly greater. With this has come a greatly increased workload for the governors. We are fortunate to have so many outstanding , hardworking and dedicated governors. With these changes the College has prospered and grown to over 100,000 members including 58% of the ABIM certified internists in the United States. and has become a more vibrant and influential organization without sacrificing any of it’s lofty ideals, standards or goals.

Major changes in the College during my lifetime pale in comparison to the advances in science, medicine and technology during this period. When I started medical school in 1952, penicillin, the first antibiotic, had been available for only a decade. There were no effective antihypertensive drugs nor oral diuretics and only 7 effective cardiac drugs. Psychoactive drugs were limited to bromides, barbiturates, choral hydrate and paraldehyde. The era of open heart surgery was about to begin. Computers were people who determined results by calculation. Knowledge of science and medicine was exploding at virtually a logarithmic rate and without doing a rigorous quantitative review, I suspect that the accumulated medical knowledge and progress during the past 6 decades exceeds that of what we knew up until then from the dawn of history. The number of medical and scientific journals listed in Index Medicus in 1946 was 1127 compared to the current number in Medline of 3500 containing 1600 biomedical papers published daily.

Equally dramatic has been the change in organization, delivery and payment of health care. From a cottage industry with no insurance, low cost care and generally happy but financially poorly rewarded practitioners such as my grandparents who came to Montana to do general practice in 1901, we evolved to an insurance based system after World War 2. Then came Medicare and Medicaid and now corporatization of health care with managed care, HMO’s, risk sharing, capitation, provider panels and much more. Cost of care and incomes for physicians have escalated. In 1963 I was paid $12,500 as a staff internist for my first year by my multi specialty fee for service group practice. In 1994 the mean income for primary care internists was $133,000. Hospital charges increased at an even greater pace. In 1955 the semi-private room rate in my state of Montana was $9 per day and full health insurance for one individual was $3.90 per month. Compare that with a daily room rate of $358.20 currently and comparable indemnity insurance for an individual ranging from $109 to $160 per month.

The Chinese blessing “may you live in interesting times” would be considered a curse by many physicians today. Some of our colleagues are very angry and discouraged as they experience erosion of their autonomy and professionalism. The major driver producing change has been the economics of financing medical care both in the private and public sectors. The high rate of inflation in medical costs far exceeding the inflation rate of the general economy brought business and industry together to find a way to control cost of their insurance plans for employees in the 1980’s. That plus the growing numbers of uninsured was the impetus for health care reform during Clinton’s first campaign and term as president. After the failure of his national health care plan came an explosion of managed care and of large for profit hospital chains. This resulted in stabilization of health care spending at 13.7% of gross domestic product in 1994 to 1997. In 1996 for the first time managed care attracted a majority of Americans and managed care now provides coverage for 160 million Americans including 77% of those insured through their employers. There are now about 1500 managed care plans of which 83% are for profit. With that has come egregious profiteering by some corporations and incentives for limiting services as well as a loss of professionalism by some physicians who are viewed by some captains of industry as tradesmen and technicians. Nearly half of all physicians are now employees.

These and other societal changes have resulted in huge challenges and problems for our profession generally and internal medicine specifically. It is critical that we have a clear vision of what we want in our health care system in the future and we need to be willing to play an active role in shaping it. Lets take a quick look at a few of the major problems facing us and some of the strategies needed to deal with them.

We are all aware of horror stories resulting from limitation of appropriate care under managed care programs and most physicians have experienced exasperating hurdles and red tape imposed on their practices while trying to provide the best care for their patients. At the same time discounting of fees and tardy payments by MCO’s have threatened the survival of some practices. Rather than being forced to accept whatever contracts that are offered by managed care organizations, many physicians have become aggressive in setting up physician controlled organizations and even health care plans so they can deal from a position of strength with purchasers and intermediaries. A variety of business arrangements have evolved between physicians and hospitals, physician management companies, insurance companies and others providing variable degrees of physician control and autonomy in their practices.

To level the playing field for all parties in today’s health care delivery system it seems unavoidable that some regulation of the health care industry is needed. There are a number of specific legislative initiatives that I believe we should support: 1) A federal initiative to establish more uniform regulation of managed care in all states with enforceable standards of behavior for all providers and minimum benefits across plans to replace the hodge podge of laws by 50 states, 2) further incentives to encourage provider sponsored care networks, 3) published standards for utilization and quality assurance 4) A Patient Bill of Rights similar to the one recently formulated by President Clinton’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry 5) Accountability by managed care organizations for adverse clinical outcomes influenced or resulting from protocols imposed on physicians and patients including removal of ERISA exemption for health plans 6) Disclosure to prospective purchasers and subscribers of health plans the track record of withdrawals from plans by patients and by physicians and other providers. Plans should be free to compete on basis of quality, benefits and price. The amount of regulation required ultimately will be inversely proportional to the degree of competiton in the market place. It is easier to enact legislation that to repeal it so a sunset provision on regulations should be considered. Nearly all regulation of managed care bears a price which ultimately is born by the payers of health care so careful cost-benefit evaluation is essential.

The second is the increasing numbers of uninsured Americans and limited access for the poor in inner cities and some rural areas. This I believe is the most serious problem that we are facing. After failure to enact any health care reform during President Clinton’s first term, there has been little political imperative to address the problem. Universal insurance has been a cherished goal of the College for nearly a decade and we have been frustrated by the lack of progress. At a recent meeting of the Royal College of Physicians and Surgeons of Canada I had the rare opportunity to get some insight into the future of reform from the highest authority. My host had arranged for the Presidents of the Royal College of Physicians of London , the Royal College of Physicians and Surgeons of Canada and myself to have an audience with God on this subject. President George Alberti of London asked God how long it would be before the reforms in the English system would resolve their current problems. God’s answer was 3 years. Professor Alberti began weeping and implored that “my people can’t wait”. Dr. Luc Deschenes of Canada then asked how long it would take to resolve the increasing financial problems wreaking havoc on the Canadian health care system. God’s answer was 5 years and there was great gnashing of teeth and weeping as Dr Deschenes proclaimed that Canadians could not possibly wait that long. When I asked how long it would be before we had Universal health insurance in the U. S., God burst out with uncontrollable weeping .

Despite that pessimistic prediction I am hopeful that persistence and advocacy in reaching that goal will result in incremental steps both by the government and by private initiatives and that we will succeed. The measure passed by Congress last year to cover an estimated 2.5 to 5 million additional uninsured children and the Kassebaum-Kennedy bill in 1996 to guarantee availability of insurance during periods of unemployment or after job change are steps in the right direction. Many states have initiated programs to increase coverage. Despite these initiatives, the number of uninsured is projected continue to rise. It is now 42 million. Resolving this problem is an essential piece of the puzzle in solving the financial crises we are facing in the near future. These include the impending bankruptcy of Medicare, the return of inflation of medical costs, and the unsustainable financial pressures that many of our health care institutions are facing as they no longer are able to cost shift to cover deficits from uncompensated care.

Another area of major concern is the threat of diminishing support of post graduate education and clinical medical research. Because graduate medical education funding depends primarily on Medicare hospital payments, decreased funding has resulted from a declining number of hospitalizations, and managed care contracting for Medicare patients. The latter is a trend that is expected to rapidly accelerate. Ambulatory services previously did not include dollars for education but thanks to the BBA of ‘97 now does. Other provisions of the Act will decrease funding of GME. Another specific problem is that the career physician clinical investigator has become an endangered species. As Dr. Lynn Loriaux (Chair, Dept. of Medicine, Oregon Health Sciences University, endocrinologist and former long time NIH senior investigator ) has so eloquently argued, we need a mechanism of support for clinical investigation of a basic nature that will put clinical investigation back into as many academic medical centers as possible.

He states “ Without that America now known every where as producing the best airplanes and the best physicians will be reduced to only one best thing”. New sources of funding for these essential programs is needed as is more support for medical school teaching and graduate medical education. A mechanism to require a fair share contribution to graduate medical education by all health care payers needs to be devised and legislated. Eternal vigilance and pressure on Congress to provide adequate funding for graduate medical education is crucial.

A third area of major concern is the threat of diminishing support of post graduate education and medical and basic clinical medicine research. Already because of lack of funding, the career physician clinical investigator has become an endangered species. As Dr. Lynn Loriaux ( 1997 American College of Physicians Award recipient ) has so eloquently argued, we need a mechanism of support for clinical investigation of a basic nature that will put clinical investigation back into as many academic medical centers as possible. Quoting Dr. Loriaux “Without that , America now known every where as producing the best airplanes and the best physicians will be reduced to one best thing.” New sources of funding are needed. A mechanism to require a fair share contribution to graduate medical education by all health care payers needs to be legislated.

Another threat to internal medicine is blurring of the difference between an internal medicine and family practice particularly as providers of primary care in the minds of insurers and HMO’s as well as by the public. The College’s current public educational initiative called The Internist Today using the media and ACP members to deliver the message is designed to make a difference expending $5 million in a three year period. Our most recent tracking efforts indicate that there has been a measurable impact and if the trend continues we will invest an additional $10 million over two subsequent years. Internists must be identified by the public as highly trained and skilled doctors for adults.

Despite the gloom and doom about the future of medicine and health care heard in some quarters, I am very optimistic for several reasons. The young people I see going into medicine are extremely bright and competent and very enthusiastic about entering such a wonderful profession. There will be no lack of skilled and motivated physicians. The other forces that will drive our evolving system include the public’s demand for the best in health care, the appropriate regulatory function of government, the ultimately self regulating effects of competition in both quality and cost and the profession’s continuing commitment to our patients.

Now on a more personal level, I’ve noted that as one gets more gray hair, younger colleagues sometimes ask for and more often we volunteer “sage advice”. I can vividly remember receiving such words of wisdom as a senior medical student , the central theme being “concentrate on practicing good medicine and the finances will take care of themselves”. In today’s world we obviously have to amend the second part as all physicians in practice need to pay strict attention to the business of medicine in order just to remain in practice. There are 3 more rules of practice that have been helpful to me: 1) always tell the truth to patients and their families,not just because your mother told to you it was the right thing to do but by so doing you’ll never have to remember later what you said, 2) when a patient wants you to certify something falsely, refuse saying “ that if I’d lie for you now how will you ever be sure that I am not lying to you”. 3) Never do or say anything behind closed doors with a patient or employee that you couldn’t justify to your peers or in a court of law because you just might have to. And on a happier note, if you are looking an exciting change of pace to rejuvinate your enthusiasm for practice and medicine and life for that matter may I recommend taking a sabbatical for even a few months. I took three of them during my practice career and each was a unique, wonderful and valuable experience. If you’re interested look at my editorial in the Observer for January this year.

In closing let me emphasize that it will be up to you new Fellows to show the way by always taking the high road, by always putting your patients first and to insure that internal medicine not only survives as a specialty but thrives. You can depend on the College to help you make that happen. I hope that you share my conviction that the practice of medicine will continue to be the highest calling to which anyone of us could aspire. How fortunate we are to have been given that high privilege!

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