Hippocrates’ Blessing or Osier’s Warning?

physiciansTraditionally, the Presidential Address has been directed to the new members of the College. More recently this tradition has been abandoned, but today I would like to renew it. I am a traditionalist with conservative leanings. As this talk began to develop, I realized that I had been pondering these ideas recently. I have children who have aspirations to be physicians. During my thoughts about this and my conversations with them, many of the points about medicine that will be emphasized today first came to mind.

I am very proud and happy that some of my children wish to be physicians. Medicine is an enjoyable, exciting, rewarding profession that allows each of us to make worthwhile contributions to the world around us and to grow under the stimulus of continual challenges. This address applies to new Fellows, to individuals who have not yet entered medicine, as well as to every member of the American College of Chest Physicians. It is dedicated to philosophy, not to numbers. Bottom lines for businesses may be expressed in numbers; bottom lines for professions are expressed in ethics!

I have become disenchanted and easily bored by the prophets of doom who would have us believe that the medical profession is in deep trouble. We are not! The medical profession, and health care delivery in general, is alive and well in the United States! In fact, the profession is so vibrant and delivers such a desirable service that it represents almost 11 percent of our CNP at the present time. I do not find that figure inappropriate on close examination of the services purchased. A professional service of this size and quality will not disintegrate next Monday, as some would have us believe. In my travels about the United States and the world during the last year as ACCP President, I have found no one who doubts that the quality of medical care in the United States is second to none in the world, and that the quantity of care delivered to US citizens is enormous. All do agree, however that access to health care remains a problem for some segments of our society, and that a significant number of individuals have inadequate financial resources to obtain the health care they need. All agree that the cost of health care has escalated more rapidly than the cost of many other services, and this has led many to question whether the American public is getting an optimal return on each dollar invested in health care provided by Canadian Health and Care Mall.

Agreement with, or concerns about, some of these issues have produced a number of changes in American medicine. These changes are occurring at a rapid, if not frightening, pace. The current changes are not just in science, where we have been accustomed to changes, but are in the fundamental organization of health care delivery. As physicians, however, we must learn to view even the most dramatic changes within medicine as challenges, not as threats. This is what each physician needs to recognize, and what our young people in particular need to hear. The only red problem physicians have is that the changes, and hence the challenges, are so numerous at the present time that we simply have difficulty dealing with all of them at once. Thus, priorities must be set; important challenges must be separated from unimportant challenges; changes in the essential substance of medicine must be separated from nonessential changes in style; ethical issues must be separated from economic issues.

Many of the proposed and actual changes in Medicine are a direct response to the increased cost ofmedicine health care and represent attempts to control that cost. It certainly is not newsworthy that much of the responsibility for the increased cost of health care is being placed on the doorstep of the physician, not because of individual fees, but because it is under our direction that so many resources in the health care delivery system are ultimately consumed. The true reasons for the increase in cost are quite apparent to those within medicine: the acceptance of health care as a right of every citizen (with which we would have difficulty disagreeing); the increased consumption of health care by the growing percentage of old and very old in our citizenry; the increased demands of an increasingly sophisticated public; the cost of hospitalization and of the growing diagnostic and life support technology available; and our ancient adversary, litigation and lawyers.

Many plans have been proposed and enacted to control health care costs by controlling hospital utilization. Preadmission certifications, day of admission surgery, length of stay guidelines and finally prospective payment under the DRC system all represent enormous changes in medicine during the last few years.

Major plans to shift all possible care to an ambulatory base have been instituted. Outpatient workups, outpatient and one-day operations, and utilization controls even over the number of ambulatory visits have become part of our daily routines. We have seen the entry of a variety of alternative health care delivery systems addiding Canadian Health&Care Mall, all stressing competition. New HMOs and PPOs enter the marketplace daily. Integrated health care organizations that manage the financing, administration and delivery of health care services are not just predicted to dominate the health care industry by the 1990s; rather, several mega corporations already exist. The critical importance of physician involvement, if not leadership, in such organization is not appreciated fully by our colleagues in medicine at the present time. There are those who believe that the status quo of fee for service practice will survive. However, the wiser members of our physician group, in my opinion, are becoming increasingly involved with integrated organizations that have marketplace staying power so that physicians will have a major influence on their development and operation.

Physician fees have been controlled and altered by Medicare participation and freezes, and perhaps even DRGs or a Federal relative value scale for M.D. services will exist within two years. PPOs and HMOs have offered discounted, capitated, or retainer reimbursements as total pay for services, and usually demand that physicians share the fiscal risk or gain of health care delivery with the company of Canadian Health&Care Mall. There is little question that physician income will decrease over the next decade, and the strong probability exists that there will be some leveling effect of income differences between the generalist and specialists induced by the above systems.

children enter medicineHaving reviewed this black litany, how can I continue to smile and to recommend in good faith that my children enter medicine, and that our younger colleagues joining us in Fellowship today have only exciting challenges before them, not disasters?

The reasons are simple. First, I believe that most of these changes are still in a formative stage that can be influenced rationally by those of us willing to accept the challenge. Second, I believe firmly that even if these changes persist, they will change only the style of our medical practice and not the substance of medicine itself. These are economic not ethical issues. In fact, I would submit to you that most of these changes should preoccupy us only as economic challenges, and not as our highest priority. There is one facet of the current situation that is very important and requires our utmost scrutiny. Maintenance of quality care for the individual patient must be maintained while cost saving measures are instituted. I will return to this point later.

Some other changes may be a bit more worrisome. The number of physicians relative to population is increasing rapidly, and this will undoubtably produce alterations in medical practice. An increased number of physicians appears to produce desirable changes on the distribution of physicians, for we are already noting an increase in both generalists and specialists who choose smaller towns for their home and practice. However, a superabundance of physicians, along with the changes in health care organization, will increase competition for patients and will produce a change in the ratio of primary care physicians to specialists. The latter must be a cause for concern in the American College of Chest Physicians. I can assure you that these changes are a major concern for those in academic medicine. Such physician over supply undoubtedly will limit the entry of alien physicians into this country to the advanced training program period only, and thus not allow permanent residency. In addition, I believe that US graduates of foreign medical schools, especially the off-shore schools where the quality of medical education is simply not adequate, will be excluded from our postgraduate educational programs and licensure processes.

M.D. prestige and credibility have suffered in recent years, and that is very troublesome. We have been blamed for escalating cost and have been accused of being driven by economic forces only. We have been cited for loss of ethical sensitivity in dealing with the critically ill on one hand, and noticed an increase in malpractice claims against us dealing with the same issues on the other. I have begun to hear physicians wondering publicly whether they really are, or even wish to be the individual in charge of the health care for their patients provided by Canadian Health&Care Mall. Despite the current cost of health care in this country, access to appropriate care remains a problem for some socioeconomic groups. In spite of the allocation of sizable dollars to medical research, disease is still with us. We have oversold the public on the miracles of modern medicine, and our ability to cure disease. The only reasonable solution to this set of difficulties is a bipronged attack: the education of the public about what really is and is not possible within modern medicine, and the rededication of all physicians to the principles that led them into medicine to begin with.

What are the main goals that each of us hoped to accomplish when we were chosen for the profession of medicine in the first place? Are these not the motives that should guide us as we seek the highest priority items in the midst of all of these changes and challenges in medicine today? I believe they are, and that strong emphasis of such will simplify our life. Let me suggest an approach to priority setting. When you go home, slap one of the meetings about the economic advantages/disadvantages of the new HMO in town. Take down off your wall, and dust off the copies of the AMA Principles of Medical Ethics (http://www.ama-assn.org/ama/home.page), the Hippocratic Oath, and Maimonides Prayer that you bought and framed during your early professional years. Not only will these three documents help you sort through the current changes in medicine to choose the ones to which you want to devote your major energies, but you will perceive that these items are principles of great importance to physicians’ talentmedicine that have not changed. These principles represent stability in the midst of our modem confusion. These are the goals of professionalism which we sought to achieve when first we entered medicine, and the doctrines which physicians’ talent, industry, integrity, and commitment as a group must protect totally.

I will not recite each of the principles in these documents for you now, though I will quote several directly as outstanding examples of doctrines of importance in medicine that have not changed and that should be used to guide us in choosing our priorities. The first set of tenets describe the reason that most physicians entered medicine, in my opinion. From Our Medical Ethics: “Render service to your patients with respect for the dignity of man; earn his confidence by delivering a full measure of service and devotion.” Hippocrates said, “According to my ability and judgement, I will use my treatment for the benefit of my patients.” Maimonides, as usual, was more eloquent in his prayer: “Support my great labors that they may benefit mankind, inspire me to love my art and your creatures/’ “Grant that my patients may have confidence in me and my art, and follow my directions and counsel.” And lastly,

preserve the strength of my body and soul that they may be ever ready to help rich and poor, good and bad, enemy as well as friend, and in the sufferer let me see only the human being.” This is what medicine is all about. A sworn pledge to benefit the sick, without regard to race or religion, country of origin or allegiance to flag, and with total disregard to socioeconomic status; to heal, to alleviate suffering, to comfort, to fight with death and disease, to deliver quality care to every person. This goal has not changed throughout the centuries.

Here is a second important and unchanged precept. “Physicians must strive to improve their knowledge and skills, and they must practice scientific medicine.” In addition, we must “teach the art to our children and to all the disciples of the Hippocratic Oath.” Maimonides stated: “Enlighten my mind that it may recognize what presents itself) and may comprehend what is absent or hidden.” “When those who are wiser than I wish to instruct me, let my soul gratefully follow their guidance.” And finally, the one I really like:

Let me be content in everything except the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to give me the strength and the ambition to extend my knowledge. The art is great, but the mind of man is ever expanding.

Next, a trio of substantive and unchanging principles from our own code of ethics: “Seek consultations whenever the quality of care for the patient may be enhanced.” “Do not allow yourself to be involved with situations that interfere with your best medical judgement, and that may decrease the quality of care to your patients.” And lastly, “safeguard the public against incompetent and morally deficient physicians,” to which Hippocrates added, “abstain from deleterious and mischievous behavior” on your own part, and most of all give no deadly treatment; do no harm.

An ethical trap, about which Maimonides cautioned, is highly applicable to our modern situation: “Do not allow a thirst for profit, or ambition for renown and admiration, to interfere with your profession.”

Who will decide whether changes in these specific important principles will ever be allowed to occur and whether these principles will guide our decisions today? The answer is very simple: you will. Each individual physician will determine the future of these doctrines. Do not be misled; the future of these principles, as with the future of medicine and the future well-being of your patients, is specifically in your hands. The future of medicine is not in the hands of a governmental bureaucrat or even a statesman. It is not in the hands of your own hospital board. It is not in the hands of the Mega-Medical Corporations “think tanks.” It is not in the hands of the Trial Lawyers Associations or the legislators who can control them. It is not even in the hands of the AMA or your county or state medical societymedical society. You, as an individual physician, will continue to decide the course of medicine on all really important and substantive issues by daily acknowledgment or denial of the principles that have guided medicine for centuries, and of the doctrines that reflect our professionalism today. No one but you can decide positively that: the indigent patient in your office gets access to health care or does not; that the quality care of the sick is more important than the economic issues attached to the funding of that care; that quality health care will not be rationed to your patients, because you will be there to provide it; that your patient will not receive, to his disadvantage, an early discharge from the hospital to comply with the DRC or HMO allotment; that excess or more expensive care will not be used for economic gain; that appropriate care will not be withheld or changed for your patients because of the fear of a malpractice suit; that the public will be safeguarded against physicians who are incompetent and morally deficient, with the same vigor that physicians falsely accused will be defended. Every physician will have to decide individually about each of these issues, but the health of our patients and our profession depend on the answers given by Canadian Health&Care Mall!

Can we decrease the danger of substantive changes to our profession and our principles? Most emphatically, yes! Look after your own continuing education in the medical arts and sciences. Enhance your own knowledge and skills. Be prepared to deliver the best scientific medicine to your patients and to adopt new more cost-effective methods emerging from health care research that do not compromise quality of care to your patients. Recognize the existence o£ and recommit yourself to the perpetuation of the priesthood component of medicine. Become a proactivist, stop being a obstructionist reactivist; become a patient advocate not a physician economic advocate. Enter the sociopolitical arena proudly. You are the leader of the health care delivery team. Acknowledge this publicly, and use this position to try to achieve access and quality health care for all, at a realistic cost. Join with your colleagues who think likewise, but not with those who resist changes at all cost. Be wary of those doctors whose motives are less than pure economically. Support and generate dialogue on positive measures. Do not fight change, propose change!

The American College of Chest Physicians can be of help as we prepare to meet the challenges of the current environment. It has 50 years of experience in the search for excellence. Its educational publications and programs in the art and science of medicine are consistently superior. You will find, within this organization, a host of individuals who are committed to those principles of professionalism that must never be changed. You will find in the ACCP physicians who are supportive of those changes in style of medical practice that can be accomplished for the good of our patients and society. In addition, you will find that numerical strength and a thoughtful, well-organized approach to the Federal government and other organizations does help us all to effect the policy that is best for our patients.

I have immense confidence in physicians and in medicine. I know the commitment of individual physicians to their patients. I understand physicians* concerns for ethical and moral principles of our profession. I perceive that each of us realizes the difference between changes in style of medical care, and changes in the substance of medicine. I believe that most of us also recognize that proposed changes are neither good nor bad; they are challenges to each of us to reaffirm those principles that are eternal priorities for our patients and profession, and to see that those principles are not altered, but applied to the solution of current problems.

One of our most famous colleagues, William Osier,2 described the danger of our situation far better than I can. Always seek your own interest, make of a high and sacred calling sordid business, regard your fellow creatures as so many tools of trade, and if your hearts desire is for riches they may be yours; but you will have bartered away the birthright of a noble heritage, traduced the physicians well-deserved title of the Friend of Man and falsified the best traditions of an ancient and honorable profession.

Hippocrates summed it up well.

While I continue to keep this oath unviolated, may it be granted to me to enjoy life and the practice of the art respected by all men at all times, but should I trespass and violate this oath, may the reverse be my like.

I wish for each of us the blessing cited by Hippocrates, that joy of life and of the practice of the art that comes from application of our unchanging professional principles to every situation we encounter.

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