ORIGINAL BNET Appress By C. Everett Koop, M.D. SURGEON GENERAL U.S. Pupic HEALTH SERVICE AND Deputy ASSISTANT SECRETARY FOR HEALTH U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PRESENTED TO THE First ANNUAL PENNSYLVANIA MEDICAL STUDENT SYMPOSIUM PHILADELPHIA. PENNSYLVANIA Marcu 23, 1985 (GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.) I'VE BEEN ASSOCIATED WITH A NUMBER OF “FIRSTS” IN MY CAREER, MOST OF THEM HAD TO DO WITH SOME INNOVATION IN DIRECT PATIENT CARE, BUT TODAY’S “FIRST” IS OF SPECIAL INTEREST TO ME. SINCE IT HAS 10 DO WITH AN INNOVATION IN DIRECT STUDENT CARE. GETTING YOU ALL TOGETHER LIKE THIS IS AN EXCELLENT IDEA -- EVEN AT THIS HOUR ON A SATURDAY MORNING, YOU SHOULD BY ALL MEANS NOURISH YOUR ATTACHMENT TO YOUR ALMA MATER. 1 HOPE YOU WILL ALL BE GOOD ALUMNI IN THE YEARS AHEAD, SUPPORTING YOUR MEDICAL SCHOOLS WITH YOUR IDEAS AND YOUR CHECKBOOK, BUT NOW IS AS GOOD A TIME AS ANY TO BEGIN UNDERSTANDING THE FACT THAT YOU WILL SOON BECOME FULL-FLEDGED MEMBERS OF A MUCH LARGER COMMUNITY OF PHYSICIANS... MEN AND WOMEN FROM OTHER SCHOOLS... WITH DIFFERENT CULTURAL BACKGROUNDS AND DIFFERENT POINTS OF REFERENCE FOR THEIR CAREER DEVELOPMENT... PHYSICIANS WHO, IN YOUR OPINION, MAY NOT MEASURE UP 10 THE PHILADELPHIA STANDARD OF PHYSICIAN EDUCATION AND TRAINING. AND 1 CAN TELL YOU THAT THROUGH THE YEARS THE MEDICAL AND NURSING SCHOOLS OF PHILADELPHIA HAVE MAINTAINED A COMMENDABLY HIGH STANDARD OF PERFORMANCE FOR BOTH FACULTY AND STUDENTS, A SYMPOSIUM SUCH AS THIS IS, TO MY THINKING, ANOTHER GOOD OPPORTUNITY FOR YOU TO BEGIN TO UNDERSTAND THE PRESENCE OF DIFFERENCES WITHIN MEDICINE...DIFFERENCES WHICH ARE EVERY BIT AS SIGNIFICANT AMONG PRACTICING PHYSICIANS AS THEIR SIMILARITIES, OF COURSE, THE PUBLIC HAS THE HABIT OF TALKING CASUALLY ABOUT “THE MEDICAL PROFESSION.” BUT I HAVE YET TO COME UPON ANY HOMOGENEOUS OR MONOLITHIC GROUP OF DOCTORS. I THINK THAT EVEN THE AMERICAN MEDICAL ASSOCIATION, WHICH PURPORTS TO BE THE VOICE OF MEDICINE IN AMERICA, WOULD HAVE TO ADMIT THAT THERE HAS ALWAYS BEEN -- AND STILL IS -- DISSENSION AND PLURALISM IN ITS RANKS AS WELL, REPRESENTING, AS IT DOES, LESS THAN HALF OF ALL PHYSICIANS IN THE COUNTRY. AND I DON’T THINK I’M TELLING TALES OUT OF SCHOOL WHEN I SAY THAT THE SAME ALSO HOLDS TRUE FOR THE PENNSYLVANIA MEDICAL SOCIETY AND THE COUNTY SOCIETIES THAT FUNCTION ALL ACROSS THE COMMONWEALTH, THAT'S MY OPINION, BUT I THINK IT WILL STAND UP TO HISTORY BECAUSE, IF I MAY SAY SO, I’M NO “JOHNNY-COME-LATELY” TO THE PROFESSION, THIS SUMMER WILL MARK MY 50TH YEAR IN MEDICINE, INCLUDING THOSE PRE-DEGREE YEARS OF MY YOUTH WHEN I WORKED AT DIFFERENT JOBS IN MEDICINE IN SUMMERS AND ON HOLIDAYS. THAT’S A LONG TIME. AND IT’S BEEN AN EXCITING AND PERSONALLY REWARDING TIME. AND LET ME ASSURE MY HOSTS THIS MORNING -- CHAIRMAN CARTER AND OTHERS -- THAT I WOULDN’T TRADE ONE MINUTE OF ALL THOSE YEARS TO HAVE BEEN DOING SOMETHING ELSE. AND I CAME PREPARED 10 SAY JUST THAT TO YOU TODAY. BUT I ALSO CAME HERE TO TALK A LITTLE BIT ABOUT THAT IDEA OF "DIFFERENCES” IN THE MEDICAL PROFESSION.. DIFFERENCES THAT HAVE OCCURRED, AND ARE STILL OCCURRING. WITHIN MEDICINE. SO, ALTHOUGH I COME BEFORE YOU TODAY AS YOUR SURGEON GENERAL -- WHICH, BELIEVE ME. IS A 24-HOURS-A-DAY, 7-DAYS-A-WEEK OCCUPATION -- I‘M NOT GOING TO TALK ABOUT WHAT I DO IN THAT CAPACITY. INSTEAD, | WANT TO TALK WITH YOU ABOUT SOMETHING YOU AND I BOTH SHARE: WE’RE DOCTORS. WHILE PREPARING FOR THIS OCCASION. I TRIED TO RECALL THOSE DAYS WHEN I WAS IN MEDICAL SCHOOL. IT WAS BEFORE THE AGE OF ANTIBIOTICS ARRIVED, IN FACT. I WAS ALREADY PRACTICING MEDICINE WHEN PENICILLIN FIRST BECAME AVAILABLE. HOWARD FLOREY DEVELOPED A PRACTICAL FORM OF THE DRUG ONLY IN 1940, THE YEAR BEFORE I GRADUATED FROM CORNELL UNIVERSITY MEDICAL COLLEGE. MOST OF THE PENICILLIN AVAILABLE DURING WORLD WAR II WAS NATURALLY SENT TO OUR TROOPS EITHER IN THE PACIFIC OR EUROPEAN BATTLEGROUNDS. BUT THE HOME FRONT DID GET A SMALL ALLOTMENT, BUT NOT VERY MUCH, IN FACT, AT ONE POINT THE ENTIRE SUPPLY OF PENICILLIN FOR THE CITY OF PHILADELPHIA WAS IN THE SMALL REFRIGERATOR IN MY LAB AT THE UNIVERSITY OF PENNSYLVANIA HOSPITAL. AND NO PATIENT RECEIVED MORE THAN 100,000 UNITS IN ANY 24-HOUR PERIOD. SOQ THAT’S DIFFERENT, FOR SURE. BUT THERE'S SO MUCH MORE THAT HAS CHANGED, ALSO. I VENTURE TO SAY THAT 90 PERCENT OR MORE OF WHAT YOU ARE NOW LEARNING IN YOUR COURSE OF STUDY FOR THE MEDICAL DEGREE IS NEW AND DIFFERENT FROM WHAT I LEARNED DURING MY YEARS OF EDUCATION AND TRAINING AT DARTMOUTH, CORNELL, AND PENNSYLVANIA, AT LEAST 90 PERCENT. THAT’S A RATHER AWESOME FIGURE. HOWEVER. I AM ALSO PLEASED 10 REPORT THAT I’VE BEEN PERSONALLY INVOLVED IN THE DEVELOPMENT OF SOME OF THAT 90 PERCENT THAT’S NEW: * FOR SEVERAL YEARS I WAS ONE OF -- AT THE MOST -- A HALF DOZEN SURGEONS IN THE COUNTRY WHO HAD BEGUN TO SPECIALIZE IN A NEW AND UNCHARTED AREA OF MEDICINE: PEDIATRIC SURGERY. * I ALSO BUILT THE FIRST UNIT FOR NEONATAL INTENSIVE CARE, * AND I WAS THE FIRST PHYSICIAN, AS FAR AS I KNOW, WHO EVER USED A POLYETHYLENE LINE INTRAVENOUSLY IN A PATIENT, IKNEW IT HAD BEEN USED IN CATS -- IN FACT. THAT’S WHERE I GOT THE IDEA, IS ALL THE CHANGE THAT’S OCCURRED A GOOD THING OR A BAD THING FOR MEDICINE AND FOR THE PUBLIC? THAT‘S A GOOD QUESTION. [ TEND TO THINK THERE’S BEEN SOME POSITIVE CHANGE IN THE WAY MEDICAL STUDENTS AND MEDICAL FACULTY INTERACT. I SENSE A GREATER CAMARADERIE AMONG YOU, A SENSE OF SHARED MISSION AND MUTUAL RESPECT. IN MY DAY. I MUST CONFESS, THERE WAS A HIGH, COLD WALL BETWEEN QUR LIVES AS STUDENTS AND “THEIR” LIVES AS FACULTY, TODAY, WHEN A STUDENT HAS AN APPOINTMENT WITH A FACULTY MEMBER, IT CAN BE FOR ANY NUMBER OF POSITIVE OR NEGATIVE OR BENIGN REASONS. BUT MY FELLOW STUDENTS AND I STOOD IN FEAR AND TREPIDATION WHEN WE ARRIVED AT AN APPONTMENT WITH A FACULTY MEMBER. IT ALWAYS SEEMED THAT THE REASON FOR SUCH AN APPOINTMENT COULD ONLY BE NEGATIVE... THERE WEREN‘T ANY POSITIVE OR EVEN BENIGN REASONS FOR BEING CALLED IN FOR A TALK, BUT THAT KIND OF ATMOSPHERE HAS APPARENTLY CHANGED AND FOR THAT I SAY, “THANK GOODNESS!” ON THE OTHER HAND, I BELTEVE 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 OUT, THE SCIENTIFIC UNDERPINNING FOR OUR PRACTICE WAS, TO BE HONEST, RATHER MARGINAL. LET’S FACE IT: WE PRACTICED MEDICINE WITHOUT ANTIBIOTICS, NOW, WAS THAT REALLY MEDICINE...OR MAGIC? A LITTLE OF BOTH, I SUPPOSE. BUT, FOR ME, MEDICINE WAS VERY MUCH AN ART MORE THAN IT WAS A HARD SCIENCE. AND I THINK MOST OF MY COLLEAGUES FELT THE SAME WAY. AS A RESULT, MOST PATIENTS FELT THAT WAY, TOO, BECAUSE IN A HUNDRED SUBTLE WAYS WE TRANSMITTED OUR FEELINGS TO THEM. BUT WHAT‘S THE REAL SIGNIFICANCE OF THE STATEMENT THAT “PREVIOUS GENERATIONS OF DOCTORS PRACTICED THE ART, RATHER THAN THE SCIENCE, OF MEDICINE”? PRIMARILY, I BELIEVE IT MEANS WE SAW MEDICINE AS A RELATIONAL ENTERPRISE. AND WE ASKED THE KINDS OF QUESTIONS THAT TENDED TO MAKE US MORE SENSITIVE TO THE NATURE OF OUR RELATIONSHIPS, FOR EXAMPLE... 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? DID OUR PATIENTS AND THEIR FAMILIES WORK WITH US AND BECOME OUR ALLIES AGAINST THE PARTICULAR MALADY AFFECTING THE PATIENT? 10 THOSE WERE ALL VERY IMPORTANT QUESTIONS FOR US BECAUSE I THINK WE WERE PEOPLE-ORITENTED. OF COURSE, WE HAD TO BE. IT WAS AN ATTITUDE BORN AS MUCH OF PROFESSIONAL NECESSSITY AS OF PERSONAL INCLINATION. THIS WAS AGE, REMEMBER, WITHOUT THE BENEFIT OF P.E.T.-SCANS OR C.A.T.-SCANS OR N.M.R.s OR AUTOMATED ANALYZERS OF ONE KIND OR ANOTHER. JUST ABOUT EVERYTHING WE LEARNED ABOUT OUR PATIENT CAME FROM THE TAKING OF GOOD HISTORIES... THROUGH SENSITIVE DEALINGS WITH FAMILY MEMBERS...AND THROUGH LOTS OF NON-STOP TALK WITH SYMPATHETIC AND EQUALLY INQUISITIVE COLLEAGUES, BUT THAT WAS ALSO, FOR ME, THE FUN OF MEDICAL PRACTICE. EVERY PATIENT WAS A CHALLENGE. AND IN PEDIATRICS, AS MANY OF YOU ALSO KNOW, THE CHALLENGE WAS ESPECIALLY DIFFICULT. I] 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 YOUR DIAGNOSES ARE GOOD. AND YOU PROBABLY ARRIVE AT THEM MORE QUICKLY THAN WE DID, BUT TO ME, THE CHALLENGE AND THE FUN OF MAKING A DIFFICULT DIAGNOSIS QUICKLY AND CORRECTLY IS GONE. THE ART OF THE THING HAS BEEN ALMOST WHOLLY SUBLIMATED TO THE SCIENCE OF THE THING, AND SOMETHING MAY HAVE BEEN LOST IN THE PROCESS...SOMETHING VERY IMPORTANT TO THE CONTINUED STRENGTH OF THE MEDICAL PROFESSION, 1 BELTEVE THAT “SOMETHING” IS THE RELATIONAL, HUMAN BOND BETWEEN THE PHYSICIAN AND THE PATIENT, 12 I UNDERSTAND THAT SOME OF TODAY’S BUZZ-WORDS AMONG MEDICAL STUDENTS ARE “CARING.” “COMPASSION,” “DIGNITY,” “HUMANE”,..AND THOSE ARE MOST CERTAINLY AMONG THE MOST BEAUTIFUL WORDS IN THE ENGLISH LANGUAGE. BUT I’M AFRAID THEY ARE FORCED TO EXIST ALONGSIDE SOME OTHER CONTEMPORARY BUZZ-WORDS... TERMS LIKE “DAMAGE CONTROL” AND “DEFENSIVE MEDICINE” AND “MALPRACTICE”... TERMS WHICH, TO MY MIND, ARE AMONG THE UGLIEST IN THE LANGUAGE, WHY ARE THEY UGLY? BECAUSE THEY CONVEY THE VERY ANTITHESIS OF “CARING” AND “COMPASSION” AND SOQ ON, THEY CONVEY THE IDEA THAT THE PATIENT AND THE DOCTOR ARE ADVERSARIES...THAT EACH ONE MUST GUARD AGAINST THE SURREPTITIOUS TACTICS OF THE OTHER. 13 HOW DID THIS HAPPEN? I THINK IT HAPPENED WHEN DOCTORS BEGAN TO PRESS TO THEIR COLLECTIVE BOSOM EVERY NEW TECHNOLOGICAL DEVELOPMENT OF THE PAST 20 OR 30 YEARS. T THINK ITT HAPPENED WHEN PHYSICIANS BEGAN TO SEE SCIENCE AND TECHNOLOGY AS THE HEART AND SOUL OF MEDICAL PRACTICE, INSTEAD OF SEEING MEDICAL PRACTICE AS HAVING A HEART AND SOUL OF ITS OWN, ONE OF THE IMPORTANT INFLUENCES IN MY CHOICE OF MEDICINE AS A CAREER WAS OUR OWN FAMILY DOCTOR, A MAN WHO WOULD HAVE BEEN GENUINELY BAFFLED NOT ONLY BY THE TERM BUT ALSO BY THE VERY CONCEPT OF "DEFENSIVE MEDICAL PRACTICE.” HE WAS QUITE A GENTLEMAN... IN AN ERA WHEN GENTLEMEN WERE STILL CONSIDERED NECESSARY FOR A CIVILIZED SOCIETY, 14 OUR DOCTOR CAME TO OUR HOUSE WHEN ONE OF US WAS ILL. WHEN HE CAME, WE ALL WALKED AROUND ON TIP-TOE AND SPOKE IN WHISPERS. IT HAD NOTHING TO DO WITH HIS STETHOSCOPE. THE REASON WAS SIMPLE: WE TRULY HONORED AND RESPECTED HIM, HE WAS NO MAGICIAN OR HIGH PRIEST...HE WAS JUST A VERY SPECIAL HUMAN BEING, BUT WHAT MADE HIM SO SPECIAL? THE FACT THAT HE DISPENSED COLORFUL MEDICINES RIGHT IN YOUR HOME, RIGHT FROM HIS LITTLE BLACK BAG? NO, THAT WASN'T IT BECAUSE MOST OF THE TIME THE MEDICINES WERE INEFFECTIVE AND BARELY SAFE, WAS IT ThE FACT THAT HE HAD A DEGREE? POSSIBLY. BUT IN OUR NEIGHBORHOOD THE PEOPLE WHO WERE TRULY RESPECTED WERE THOSE WHO EARNED DEGREES TO BE TEACHERS, ESPECIALLY COLLEGE TEACHERS, THE MEDICAL DEGREE SEEMED TO BE MORE A KIND OF PERMIT TO WORK NIGHTS AND WEEKENDS AND HAVE THE KIND OF PEOPLE COME TO YOUR OFFICE WHOM YOU'D NEVER INVITE TO YOUR HOME, 15 WAS IT THE FACT THAT HE CURED YOU OF THE THINGS THAT AILED YOU? CERTAINLY NOT THAT, LIKE HIS LITTLE COLLECTION OF PILLS AND POTIONS, I’M AFRAID OUR FAMILY DOCTOR -- ALONG WITH SO MANY OF HIS COLLEAGUES -- WAS ALSO GENERALLY INEFFECTIVE AND ONLY MARGINALLY SAFE. EVERYONE ALIVE AND MY AGE TODAY CAN THANK A BENEFICENT MOTHER NATURE FOR PULLING US THROUGH SOME TOUGH TIMES AS CHILDREN. IN MOST CASES IT WOULD BE STRETCHING A POINT TO THANK THE PROFESSION OF MEDICINE, THEN WHY DID WE HAVE SUCH GREAT RESPECT FOR THE FAMILY DOCTOR? 1 THINK THERE WERE SEVERAL VERY GOOD REASONS. FOR ONE THING, HE APPARENTLY CARED ABOUT US. WHEN WE WERE SICK, HE CAME OVER TO OUR PLACE TO SEE WHAT HE COULD DO. NOT TO SEE “WHAT COULD BE DONE”...BUT TO SEE WHAT HE -- PERSONALLY -- COULD DO. 16 THE FIRST THING HE DID WHEN HE GOT TO OUR HOUSE WOULD BE 10 SIT DOWN AND TALK WITH THE PATIENT AND WITH MEMBERS OF THE FAMILY. HE WANTED ALL THE DETAILS HE COULD GET, THEN, AFTER A QUICK AND USUALLY ACCURATE DIAGNOSIS, HE TRIED TO EXPLAIN IN LAYMAN’S LANGUAGE JUST WHAT THE TROUBLE SEEMED TO BE AND WHAT HE THOUGHT WE -- THAT IS, HE. THE PATIENT, AND THE FAMILY -- COULD DO ABOUT IT. HE MADE US HIS ALLIES IN THE FIGHT AGAINST DISEASE. WE WEREN'T JUST PART OF THE PROBLEM...WE WERE PART OF THE SOLUTION, REMEMBER, IN THOSE DAYS -- THESE ARE THE 1920s AND THE 1930s 1’M TALKING ABOUT -- WE DIDN'T EXPECT MIRACLES, WE HARDLY EXPECTED CURES, NEVERTHELESS, WE GENUINELY LOVED AND RESPECTED OUR DOCTORS, TODAY. WE DO EXPECT MIRACLES AND WE DO EXPECT TO BE CURED, BUT THE PUBLIC IS COMING TO HATE ITS DOCTORS, 17 I‘VE KEPT THE VISION OF THAT FAMILY DOCTOR IN MY MIND OVER THE YEARS BECAUSE I’VE TRIED TO PRACTICE HIS KIND OF MEDICINE: I‘VE SAT DOWN AND TALKED WITH 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. IVE VISITED THEM AT HOME AND SERVED WITH THEM ON COMMITTEES OF NEIGHBORHOOD IMPROVEMENT, MY PATIENTS AND THEIR FAMILIES KNEW ME ON THE SAME TERMS THAT I KNEW OUR OWN FAMILY DOCTOR. HAS IT BEEN WORTH IT? YES, IT HAS...ON MANY LEVELS. FOR ONE THING, I’VE GOTTEN TO KNOW DOZENS AND DOZENS OF SMART, COURAGEOUS, GENEROUS, COMPASSTONATE FAMILIES. 18 I MAY HAVE HELPED THEIR CHILDREN OVERCOME SOME DISABLIITY OR OTHER...BUT THEY ALL HELPED ME OVERCOME PESSIMISM AND DEFEATISM AND FRUSTRATION AND DISCOURAGEMENT,..FEELINGS THAT ARE COMMON ENOUGH AMONG HARD-WORKING PHYSICIANS, WHAT ELSE DID I LEARN? I’LL TELL YOU WHAT I DIDN'T LEARN. I DIDN’T LEARN HOW TO FIGHT MALPRACTICE CASES ONE AFTER THE OTHER WHILE TRYING TO EARN A LIVING IN MEDICINE AT THE SAME TIME, IVE NEVER BEEN SUED, I’VE NEVER HAD TO SETTLE A POTENTIAL SUIT BEFORE IT CAME TO COURT. MY PATIENTS AND THEIR FAMILIES WERE NEVER MY ADVERSARIES IN A COURT OF LAW. WILL I SHARE MY SECRET WITH YOU? WELL, I ALREADY HAVE. MY SECRET -- IF YOU WANT TO CALL IT THAT -- IS TO FORM A BOND WITH YOUR PATIENTS...TO CONFIDE IN THEM IN THE WAY YOU WANT THEM TO CONFIDE IN YOU...TO RESPECT THEM FOR BEING WHAT THEY ARE: SENSITIVE, DECENT, INTELLIGENT HUMAN BEINGS. LET THAT OPINION BE THE ONE THAT GUIDES YOU IN YOUR DOCTOR-PATIENT RELATIONSHIPS, 19 OF COURSE, YOU’RE GOING TO BE DISAPPOINTED NOW AND THEN. THERE ARE AMONG PATIENTS THE SAME PERCENTAGE OF CHUMPS, CHEATS, FOOLS. AND BLOW-HARDS AS THERE ARE AMONG DOCTORS OR IN THE POPULATION GENERALLY, AND, DEPENDING ON YOUR PARTICULAR PRACTICE. YOU JUST MIGHT DRAW MORE THAN YOUR FAIR SHARE OF DEADBEATS AND MALCONTENTS. I’M SORRY ABOUT THAT. BUT IT’S 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, 20 AS MEDICAL STUDENTS IN THIS GLITZY FINAL QUARTER OF THE 20TH CENTURY, YOU HAVE A BETTER CHANCE OF HEALING AND CURING THAN ANY OF YOUR PREDECESSORS, GOING BACK TO AESCULAPIUS HIMSELF. BUT MEDICINE IS NOT SILICON VALLEY AND YOUR CLINIC IS NOT THE REDSTONE ARSENAL. I HOPE YOU WILL COME TO BELIEVE THAT. 1 DO. AND 1 GUESS THAT'S THE REASON I’M LOSING PATIENCE WITH SOME MODERN PHYSICIANS, PARTICU- LARLY THE GO-GO ENTREPRENEURS CURRENTLY RIDING THE ARTICIFICAL HEART IMPLANT BUSINESS, DOWN AT HUMANA HOSPITAL IN LOUISVILLE, KENTUCKY, THE MEDICAL LEADERSHIP AND THE CORPORATE LEADERSHIP -- WHO SEEM TO BE QUITE INTERCHANGEABLE -- INDICATED EARLY ON THAT AMONG THE BENEFICIARIES OF THE ARTIFICIAL HEART PROCEDURE WAS NOT ONLY MR. WILLIAM SCHROEDER BUT ALSO HUMANA’S MANY, MANY STOCKHOLDERS. OH? IS THAT S0? 21 AND ECHOING THIS OPINION WAS A STOCK ANALYST AT DILLON, READ. THE WELL-KNOWN WALL STREET BROKERAGE HOUSE. WHO SAID THAT THE SCHROEDER OPERATION ATTRACTED EXTRAORDINARY PRESS COVERAGE AND, THEREFORE, IT WAS PRICELESS ADVERTISING FOR NEW PATIENTS. REALLY? TS THE HUMANA HOSPITAL AND ITS APPROACH TO PUBLICL RELATIONS GOING TO BE THE WAVE OF THE FUTURE? I. FOR ONE. SINCERELY HOPE IT IS NOT, AND, CONFRONTING THE SPIRALLING COSTS OF HEALTH CARE, MANY OF US HAVE THOUGHTFULLY MAINTAINED THAT COMPETITIVE. CORPORATE MEDICINE MIGHT BE MORE EFFICIENT, MORE COST-EFFECTIVE. AND SAFER FOR PATIENTS, HAVE WE BEEN CORRECT...OR WERE WE TAKEN IN? AS I READ THOSE PRESS ACCOUNTS EMANATING FROM KENTUCKY, MY MEMORY WENT BACK TO A TIME WHEN I ALSO WAS ENGAGED IN TRYING SOME EXPERI- MENTAL PROCEDURES, I RECALL, FOR INSTANCE. THE SITUATION OF ONE PARTICULAR NEWBORN ON MY OPERATING TABLE MANY YEARS AGO. THIS BABY HAD BEEN BORN WITH ESOPHAGEAL ATRESIA. BUT WHEN I WENT AHEAD TO CORRECT THAT, I DISCOVERED THAT THE CHILD HAD NO LOWER ESOPHAGUS AT ALL. 22 THIS WAS NOT A TOTAL SURPRISE TO ME. 1 HAD COME UPON IT BEFORE AND, FROM TIME TO TIME, I HAD DISCUSSED THE PROBLEM WITH MY COLLEAGUES. SOME OF US HAD EVEN TALKED ABOUT THE POSSIBILITY OF INTERPOSING A LENGTH OF COLON IN JUST SUCH SITUATIONS. AND THEN ONE DAY A BABY WITH JUST SUCH A DISABILITY WAS DELIVERED TO OUR HOSPITAL. FOR THAT PARTICULAR BABY -- BORN PREMATURELY. WEAK, AND WITH POOR PROSPECTS GENERALLY -- I WENT AHEAD AND TRIED. TO THE BEST OF MY ABILITY, TO PERFORM THE FIRST COLON INTERPOSITION. BUT IT WAS NOT A SUCCESS AND THE CHILD DIED, BUT I AND MY STAFF LEARNED FROM THAT EXPERIENCE. OVER THE NEXT COUPLE OF YEARS, WE HAD OCCASION TO CARRY OUT 12 MORE SUCH OPERATIONS TO SAVE CHILDREN WITH THAT SAME RARE DISABILITY. A MISSING ESOPHAGUS, AND WE WERE SUCCESSFUL THOSE 12 TIMES. 23 AT THAT POINT WE SUBMITTED OUR FINDINGS TO A PROFESSIONAL JOURNAL AND WAITED FOR THE JUDGMENTS OF OUR COLLEAGUES, WE MADE MEDICAL HISTORY. BUT WE MADE IT OUR WAY.,..WHICH ALSO HAPPENED TO BE MEDICINE’S TRADITIONAL WAY... WHICH IS THE BEST WAY. WE DIDN’T CALL UP THE WIRE SERVICES AND THE LOCAL RADIO STATIONS FOR INTERVIEWS BEFORE WE SCRUBBED UP AND STEPPED INTO THE OPERATING ROOM. AND WE DIDN’T WANT THE PRESS WAITING FOR US AND FOR THE PATIENT’S FAMILY WHEN IT WAS ALL OVER EITHER. WE WEREN'T SELLING STOCK...WE WERE SAVING LIVES, I THINK THIS IS ONE OF THOSE PROFOUND “DIFFERENCES” THAT HAS COME TO DWELL IN THE HOUSE OF MEDICINE. AND IT IS NOT PLEASANT TO BEHOLD. IF I WERE JUST BEGINNING A CAREER IN MEDICINE TODAY, I WOULD BE SERIOUSLY CONCERNED ABOUT THIS FOR A NUMBER OF REASONS: 24 FIRST, THE COMMERCIALISM THAT HAS BEGUN TO TAINT AND TARNISH OUR PROFESSION CAN TAINT AND TARNISH THE PEOPLE IN IT AS WELL. YOU OUGHT TO WORRY ABOUT THAT. SECOND, THE MOST PERVASIVE GOVERNMENT CONTROLS AND REGULATIONS THAT HAVE APPEARED IN MEDICINE IN RECENT YEARS WERE PUT THERE NOT FOR MEDICAL REASONS BUT FOR ECONOMIC REASONS. HOWEVER, THE RESULTS CAN AFFECT THE QUALITY OF MEDICAL CARE RENDERED BY PHYSICIANS AND HOSPITAL STAFFS, FOR EXAMPLE, THE COMPLEX ART OF MEDICAL DIAGNOSIS IS NOW NEATLY CODIFIED INTO 467 DIAGNOSIS-RELATED GROUPS -- OR “D.R.G.s” -- IN ORDER TO CONTROL THE COST OF IN-PATIENT CARE. YOU OUGHT TO BE CONCERNED ABOUT THIS AS WELL, AS YOU SEEK TO MAINTAIN A HIGH QUALITY OF CARE, THIRD, WE ARE ENTERING AN ERA WHEN THERE IS SUPPOSED TO BE A "GLUT" OF PRACTICING PHYSICIANS. ALREADY WE’RE SEEING DOCTORS AND CLINICS ADVERTISING LOWER FEES FOR CERTAIN ROUTINE MEDICAL SERVICES... THE KIND THAT ARE THE BREAD AND BUTTER, IF NOT THE HEART AND SOUL, OF ANY COMMUNITY PRACTICE. 25 THE BIG MONEY THAT MANY PHYSICIANS HAVE MADE -- THE AVERAGE FOR THE PROFESSION IS $100,000 A YEAR. AS I’M SURE YOU KNOW -- THAT BIG MONEY MAY NOT BE AVAILABLE TO YOU. OF COURSE. I HOPE YOU WON’T CARE IF YOU ONLY EARN $70,000 A YEAR INSTEAD OF $100,000. BUT IF YOU WILL CARE...THEN PLEASE...DO SOMETHING ELSE. I DON'T WANT TO DWELL ON THAT TOPIC. I THINK I’VE MADE MY POINT. LET ME INSTEAD CONCLUDE THIS ADDRESS WITH THE OBSERVATION THAT MANY OF THE CHANGES AND THE DIFFERENCES OCCURRING IN MEDICINE ARE ALSO RIGHT, ..THEY’RE EXCITING, ..AND THEY ARE GOOD FOR MEDICINE AND GOOD FOR OUR COUNTRY. FOR EXAMPLE, WE ARE FAR MORE SENSITIVE THESE DAYS TO WOMEN’S HEALTH THAN WE EVER WERE BEFORE. TO OUR GREAT SHAME. BUT TODAY, WE’RE CONCERNED NOT ONLY ABOUT WOMEN AS CHILD-BEARERS -- THE TRADITIONAL BUT RATHER NARROW VIEW -- WE’RE CONCERNED ABOUT WOMEN BEING ABLE TO LIVE FULL LIVES DOING WHATEVER THEY WANT TO DO,..FOLLOW CAREERS, PURSUE EDUCATION, RUN BUSINESSES, OR -- YES -- MARRY AND HAVE CHILDREN, 26 ALL OF US -- WOMEN AND MEN ALIKE -- NEED OUR HEALTH IF WE WISH TO PURSUE OUR OWN PERSONAL DESTINIES. AND WE ARE DOING A BETTER JOB THESE DAYS HELPING WOMEN ACHIEVE THE BEST POSSIBLE HEALTH STATUS. AND WE’RE MORE CONSCIOUS THAN EVER BEFORE OF THE ROLE THAT MUST BE PLAYED BY THE INFORMED PUBLIC IN PROMOTING THEIR OWN GOOD HEALTH AND IN PREVENTING BAD THINGS FROM HAPPENING. AND THE PUBLIC IS RESPONDING WELL. AS YOU KNOW, I’VE CALLED FOR AMERICA TO BECOME A “SMOKE-FREE SOCIETY BY THE YEAR 2000.” AND THE RESPONSE TO THAT CALL HAS BEEN EXTRAORDINARY, FROM WHERE I STAND, WE COULD BE A SMOKE-FREE SOCIETY A GOOD BIT EARLIER WITH NO TROUBLE, 2] IN ADDITION, WE’VE BECOME ONE OF THE MOST HEALTH-CONSCIOUS SOCIETIES IN THE WORLD, PEOPLE ALWAYS TALK GLOWINGLY ABOUT THE SCANDINAVIANS AND THE BRITISH AND HOW THEY’RE SO CONCERNED ABOUT THE HEALTH OF THEIR CITIZENS. AND THEY ARE, BUT TODAY I THINK THAT THE CITIZENS OF THOSE COUNTRIES ARE PROBABLY LESS WELL INFORMED ABOUT EXERCISE AND DIET AND MEDICATION AND STRESS AND SO ON THAN AMERICANS ARE. AND I TEND TO THINK THAT THEIR CITIZENS TAKE FEWER INDIVIDUAL, PERSONAL INITIATIVES IN HEALTH PROMOTION AND PREVENTION THAN OUR CITIZENS DO. FOR THOSE AND MANY OTHER REASONS, I DO ENVY YOU AS YOU START OUT ON A NEW CAREER IN MEDICINE. 1 REGRET SOME THINGS THAT ARE GOING ON -- THE LACK OF GOOD DOCTOR-PATIENT RELATIONSHIPS, THE PREOCCUPATION WITH MONEY AND POWER, THE GROWTH OF REGULATION. AND SO ON, 28 BUT I ALSO KNOW THAT MEDICINE STILL OFFERS THE INDIVIDUAL ONE OF THE MOST SATISFYING WAYS TO MAKE A LIFE THAT I HAVE EVER ENCOUNTERED, I DON’T EVER REGRET MY DECISION TO BE A PHYSICIAN,..AND I’M WILLING TO BET THAT NONE OF YOU WILL REGRET IT EITHER, THANK YOU, HHH # #