GREETINGS, ETC.
I ALWAYS HAVE FELT AT HOME AMONG SURGEONS.

I AM A SURGEON, AND I HOPE I HAVE BEEN AN EFFECTIVE
ADVOCATE FOR SURGEONS.

WHEN I WAS IN THE GOVERNMENT YOU AND I WENT ABOUT OUR
WORK IN OUR OWN WAYS, AND NOW IT IS GOOD TO BE BACK.
THERE'S A BASIC HONESTY ABOUT SURGERY.
SURGEONS UNDERSTAND THAT SOMETIMES SOME THINGS NEED
TO BE SAID, EVEN IF THEY AREN'T ALWAYS PLEASANT TO HEAR.

YOU ARE THE MOVERS AND SHAKERS.

THAT'S GOOD.
WE NEED SOME THINGS --AND PEOPLE-- MOVED AND SHAKEN.
THROUGHOUT MY LIFE AS A SURGEON I HAD NEVER
CONTEMPLATED GOVERNMENT SERVICE. FOR ME, PROBABLY
LIKE MOST OF YOU, THE VERY THOUGHT WAS ANATHEMA.
NEVERTHELESS I PROVED RECEPTIVE TO THE FIRST SMALL
BEGINNING BECAUSE IN AUGUST 1980 SOMEONE TELEPHONED ME
AND ASKED CRYPTICALLY,

"DON'T YOU THINK THE SURGEON GENERAL SHOULD BE A

SURGEON." IT GOT ME THINKING POSITIVELY.
EVEN THOUGH IT HAS NOW BEEN SEVERAL MONTHS SINCE I
HUNG UP THE UNIFORM OF THE SURGEON GENERAL, I STILL
SEEM TO BE A RECOGNIZABLE FELLOW.

WALKING ALONG THE STREET HERE IN SAN F RANCISCO, IN THE
NEW YORK SUBWAY, IN AIRPORT WAITING ROOMS, PEOPLE
COME UP TO ME:

"HI, DOC!", OR "KEEP UP THE GOOD WORK" OR,

"I KNOW YOU! YOU'RE THE ATTORNEY GENERAL. KEEP AFTER
THOSE TOBACCO COMPANIES."

If MY PLANE IS DELAYED, I OFTEN END UP HOLDING OF FICE
HOURS IN THE AIRPORT WAITING AREA.
"YOU ARE THE ONE WHO FINALLY MADE ME STOP SMOKING!"
OR EVEN, "SAY, I HATE TO BOTHER YOU, BUT I'VE GOT THIS PAIN

IN MY ELBOW..."

ON A NUMBER OF OCCASIONS I'VE BEEN RECOGNIZED BY A
STRANGER, AND THEN BOTH PLEASED AND SADDENED BY
SOMEONE SAYING TO ME,

"I WANT TO THANK YOU FOR MAKING ME PROUD, ONCE AGAIN,

TO BE A DOCTOR."
I'M PLEASED, OF COURSE, BECAUSE I'VE GIVEN MY LIFE TO THIS
PROFESSION, AND IT HAS BEEN GOOD TO ME.

BUT I'M SADDENED TO HEAR FROM SO MANY OF MY
COLLEAGUES WHO HAVE LOST THE PRIDE, THE JOY OF BEING A
PHYSICIAN.
MORE THAN SADDENED, I'M ANGRY.

I'VE JUST FINISHED FILMING 5 PRIMETIME SPECIALS ON HEALTH
TO BE AIRED LATER THIS YEAR ON N.B.C. I'VE SPENT 5 MONTHS
GOING BACK AND FORTH ACROSS THIS COUNTRY, FILMING IN 20
CITIES, A FEW TOWNS AND HAMLETS, AND IN REMOTE CORNERS
OF RURAL AMERICA.
THIS EXPERIENCE WITH SO MANY FACETS OF AMERICAN
MEDICINE HAS MADE ME ANGRY.

I AM ANGRY ABOVE ALL BECAUSE OF THE DETERIORATION OF
THE IMAGE OF THE AMERICAN DOCTOR, FOR I BELIEVE THAT
THE DOCTOR-PATIENT RELATIONSHIP LIES AT THE HEART OF ALL
MEDICINE. —
MUCH OF IT IS OUR FAULT. | .
iV oF

WHY HAVE WE PERSISTED NOT '®® ROOT OUT TH@ REEESE=FN

_jite DECKAP a
&

OUR PROFESSION?

WE TOLERATE PEOPLE WHO ARE INCOMPETENT, WHO ARE

GREEDY, WHO ARE ABUSIVE OF PATIENTS, WHO ARE ALCOHOL

AND DRUG ABUSERS.

THESE PEOPLE SHOULD BE REMOVED, AND WHERE POSSIBLE,
REHABILITATED, OW4/ 74éw srtevLo 7hEY RE CESTOEEY
BUS DRIVERS AND AIRLINE PILOTS DO BETTER IN POLICING

THEIR OWN. A MEDICAL SCHOOL DEGREE SHOULD NOT PROVIDE
MORAL IMMUNITY.

10
MEDICINE HAS SUFFERED FROM AN INABILITY TO
SELF-REGULATE ITS MEMBERS, AND THIS FAILING HAS PLAYED
HAVOC WITH THE SYSTEMS AND PROCESSES OF PROFESSIONAL
INSURANCE AND LICENSING AND ACCREDITATION...IN OTHER
WORDS, THE SYSTEMS AND PROCESSES OF PUBLIC TRUST.

11
AS A RESULT, THE CONGRESS HAD TO STEP IN AND ENACT
P GACT TOW ER
LEGISLATION SETTING UP A NATIONAL, DATA BANK ON

PHYSICIANS SO THAT WE COULD FIND THE BAD APPLES --IN THE
SAME WAY WE FIND DRUNK DRIVERS AND BANK ROBBERS AND
ASSORTED OTHER FUGITIVES FROM JUSTICE.

IT'S AN IGNOMINIOUS DEVELOPMENT, TO SAY THE LEAST.

BUT THEREITIS, 7#¢¢& #2€ same UME ACR.

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12
AND IT'S A TRAGEDY BECAUSE IT SHOULD HAVE BEEN AVOIDED.
IT'S A TRAGEDY BECAUSE DAY IN AND DAY OUT MOST

AMERICANS RECEIVE GOOD MEDICAL CARE - AS GOOD AS ANY

PLACE IN THE WORLD - FROM HONEST, COMPETENT PHYSICIANS.

13
UNFORTUNATELY GOOD NEWS IS NOT HEADLINE NEWS - -THE
OCCASIONAL BAD APPLE IS, ....AND DOES GRAB THE HEADLINES,
SAD TO CONTEMPLATE, BUT THE MEDICAL PROFESSION HAS
FOOLISHLY SQUANDERED ITS PUBLIC TRUST AND POSITION OF
LEADERSHIP. |

14
NOW, PHARMACISTS HAVE REPLACED DOCTORS AS THE MOST
TRUSTED PROFESSION IN AMERICA.

THE PUBLIC IS VERY CRITICAL OF DOCTORS.

AND DOCTORS NO LONGER LIKE THEIR PATIENTS.

15
DOCTORS LET THEMSELVES BE CALLED PROVIDERS, AND
PATIENTS BECAME CONSUMERS.
WE NEED TO GET AWAY FROM THE CONSUMER-PROVIDER

MENTALITY.
WE NEED TO RESTORE THE DOCTOR-PATIENT RELATIONSHIP.

EACH OF US.

16
RECENTLY, ONE OF MY FRIENDS, QUITE ACCUSTOMED TO
SPENDING HIS TIME WITH OTHER DOCTORS, FOUND HIMSELF
WITH A GROUP OF LAWYERS INSTEAD ---YES, THE TWO CAN GET
TOGETHER!

THE ATTORNEYS WERE CONGRATULATING THEMSELVES ON
WHAT THEY WERE ABLE TO DO FOR THEIR FELLOW CITIZENS.
IT HAD BEEN A LONG TIME SINCE MY FRIEND HAD HEARD

DOCTORS SPEAK IN THAT VEIN.

17
IF LAWYERS CAN FEEL GOOD ABOUT WRITING A WILL,
CAN'T WE FEEL PROUD ABOUT POSTPONING ITS USE?

WE SHOULD BE PROUD ABOUT WHAT WE HAVE ACCOMPLISHED
FOR THE AMERICAN PEOPLE.
LIFE EXPECTANCY IN THIS COUNTRY HAS GONE FROM 47 YEARS

IN 1900 TO 75 BY 1990.

18
NOW DOCTORS DO MORE AND GET THANKED LESS.

_ INSTEAD OF CELEBRATING, DOCTORS AND PATIENTS ARE
SQUARING OFF AGAINST EACH OTHER.
DOCTOR-BASHING HAS BECOME A POPULAR SPORT.

THERE IS EXASPERATION ON BOTH SIDES OF THE STETHOSCOPE.

——e

 

 

—
——,

 

19
AMERICAN MEDICINE IS AT A CROSSROADS.
I HOPE YOU KNOW WHAT THE STAKES ARE.

TEN YEARS FROM NOW YOU COULD BE DOING ONE OF SEVERAL

THINGS:
(AND WHEN I SAY YOU, I AM ADDRESSING THE PHYSICIANS OF
AMERICA. YOU ARE THE LEADERSHIP AMONG SURGEONS)

20
YOU COULD BE WORKING WITH THE PUBLIC TO FREE US ALL
FROM A HASTILY IMPOSED NATIONAL HEALTH SERVICE,

OR,

YOU COULD HAVE SHIFTED FROM PATIENT-ADVOCATE TO AGENT
FOR ALL INSURANCE COMPANIES.

OR,

YOU COULD HAVE LOST YOUR PROFESSIONAL STATUS AND COME
TO BE REGARDED AS A MEMBER OF ANY ONE OF A NUMBER OF
JOURNEYMEN GUILDS.

OR,

21
YOU COULD BE PART OF THE BEST SYSTEM OF MEDICAL CARE IN
THE WORLD, DELIVERING HEALTHCARE TO THE GREAT
SATISFACTION OF YOUR PATIENTS AND YOURSELF.

AND YOU COULD BE PART OF A SYSTEM THAT DELIVERS
REASONABLE HEALTHCARE TO EVERY AMERICAN AT

REASONABLE COST, --URGING PESFEE THEM TO PREVENT
DISEASE AS WELL AS TO TREAT IT.

22
PLEASE FIND SOME WAY TO DISABUSE THE PUBLIC AND THE
PRESS OF THE NOTION THAT YOUR INCOME IS YOUR NUMBER
ONE PRIORITY, AND THAT YOU HAVE CEASED TO BE THE
PROFESSIONALS THAT YOUR FATHERS AND GRANDFATHERS IN

MEDICINE WERE.

IF DOCTORS PAY ATTENTION TO HIGH QUALITY AND HIGH

EFFICIENCY IN THEIR MEDICAL PRACTICE, IN MOST IN STANCES
THE BOTTOM LINE WILL TAKE CARE OF ITSELF.

23
I KNOW ORGANIZED MEDICINE DOES NOT CONSIDER ITSELF A
UNION.

BUT WE DO COMBINE FOR COMMON PURPOSES.

AND WE CAN LEARN FROM WHAT HAS HAPPENED TO UNIONS.

FOR FAR TOO LONG THEIR ONLY CONCERNS WERE INCOME,
WORKING CONDITIONS, AND BENEFITS.

MEANWHILE QUALITY AND EFFICIENCY WERE IGNORED.

24
NOW, BELATEDLY, THEY ARE SCRAMBLING TO ADDRESS QUALITY
AND EFFICIENCY.

THE AMERICAN AUTO INDUSTRY AF FORDS A GOOD EXAMPLE.

I IMAGINE THAT MANY DOCTORS WHO USED TO DRIVE BUICKS
AND CADILLACS NOW SIT BEHIND THE WHEELSOF CAMRYS AND
MAXIMAS.

25
WHEN N.B.C. FIRST ASKED ME TO DO A TELEVISION SERIES, THEY
WANTED ME TO FOCUS UPON THE STATE OF THE ART OF
AMERICAN MEDICINE.

AS A FORMER PIONEER IN THE FIELD OF PEDIATRIC SURGERY, I
THOUGHT IT WOULD BE FASCINATING TO BRING BEFORE THE
AMERICAN PEOPLE THE FULL RANGE OF THINGS THAT MODERN

MEDICINE COULD DO FOR THEM.

26
BUT IN MY YEARS AS SURGEON GENERAL, I SAW ALL TOO
CLEARLY THAT 37 MILLION AMERICANS COULD NOT AVAIL
THEMSELVES OF MODERN MEDICINE.

SO I SHIFTED THE FOCUS OF MY EFFORTS TO THE PROBLEMS

WITH OUR HEALTHCARE SYSTEM, OUR HEALTH POLICY.

27
THERE COULD HAVE BEEN ANOTHER SURGEON GENERAL'S
WARNING:
"WARNING! THE AMERICAN HEALTH CARE SYSTEM CAN BE

HAZARDOUS TO YOUR HEALTH!

I KNOW WE DON'T LIKE TO HEAR --OR VOICE-- CRITICISM OF
OUR PROFESSION. BUT WE HAVE BIG PROBLEMS.

28
(NM THIS
SERDREYTS EXASPERATION ON BOTH SIDES OF THE STETHOSCOPE.

YOU HAVE YOUR REASONS WHY YOU ARE EXASPERATED.
R U7 WHY ARE PATIENTS EXASPERATED?

29
1, THE PUBLIC HAS HIGH EXPECTATIONS FOR MEDICINE AND
HEALTH. THEY HAVE A GREAT DEAL OF FAITH IN NEW
TECHNOLOGY, AND THEY CONTINUE TO HAVE FAITH IN THE
MAGIC OF MEDICINE. BUT IN THE REAL WORLD WE CAN'T

ALWAYS DELIVER.

30
THEW, 780
2. HIGH EXPECTATIONS ARE FAST OUTRUNNING OUR ABILITY TO

PAY FOR THEM. AND THE AMERICAN PEOPLE ARE ENGAGED IN
DEBATE ABOUT ASPIRATIONS VERSUS RESOURCES,

3. ALTHOUGH THERE HAS BEEN A RISE IN NEW TECHNOLOGY,

—

THERE HAS BEEN A DECLINE IN ITS USEFULNESS TO A LARGE
NUMBER OF PATIENTS.

31
IN ONE OF HIS PLAYS, GEORGE BERNARD SHAW ASKED WHY WE
PAY DOCTORS TO TAKE A LEG OFF BUT WE DON'T PAY THEM TO
KEEP A LEG ON. NOW, OVER 80 YEARS HAVE PASSED AND WE
STILL HAVEN'T COME UP WITH A GOOD ANSWER.

OUR TECHNOLOGY-DRIVEN REIMBURSEMENT SYSTEM --

WHETHER BY GOVERNMENT OR OUT-OF-POCKET -- IS STILL
PREDICATED ON TAKING THE LEG OFF.

32
OUR HEALTHCARE SYSTEM MAY FUNCTION WITH COMPASSION
AND COMPETENCE --EVEN EXCELLENCE-- FOR SOME

INDIVIDUALS.
BUT FOR TOO MANY AMERICANS OUR HEALTH CARE SYSTEM IS A

TYRANNY, MORE A CURSE THAN A BLESSING.

33
4, PATIENTS, OFTEN AFTER AN UNCONSCIONABLE WAIT OF
HOURS OR EVEN DAYS IN THE EMERGENCY ROOM, ASK
THEMSELVES NOT ONLY "WILL I RECOVER?", BUT ALSO "HOW
WILL I PAY FOR THIS?" |

"WILL MY INSURANCE PAY FOR THIS? WILL MY ILLNESS COST ME
MY SAVINGS, MY HOUSE?"

HEALTH INSURANCE HAS BEEN LIKENED TO A SHELL GAME.

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34
= OUR PRICES MAKE PEOPLE ANGRY.

THEY MAY SIGH ABOUT CONSTRUCTION AND EDUCATION COSTS,
BUT THEY DON'T GET ANGRY WITH CONTRACTORS OR
PROFESSORS, AS THEY DO WITH DOCTORS.

PART OF THE ANGER, THE DISSATISFACTION MAY BE
UNAVOIDABLE.

NO ONE WANTS TO BE SICK,

AND TO HAVE TO PAY FOR IT MAKES IT WORSE.

35
TRUE, THE PRESS IS OBSESSED WITH THE INCOME OF DOCTORS.
FOR EXAMPLE, NOT LONG AGO I READ AN ARTICLE IN THE
NEWSPAPER OF MY OLD HOMETOWN, PHILADELPHIA, WHICH
POINTED OUT THAT WHILE THE PRESIDENT OF THE UNIVERSITY
OF PENNSYLVANIA MIGHT BE A TRIFLE OVERPAID AT $220,000 A
YEAR, FIVE PROFESSORS OF SURGERY MADE BETWEEN $440,000

AND $620,00.

36
YOU SEE, THE REPORTER LOST SIGHT OF THE FACT THAT HE WAS
WRITING ABOUT THE SALARIES OF COLLEGE PRESIDENTS AND
TOOK OFF ON DOCTORS' INCOMES INSTEAD. HE OBVIOUSLY
WANTED THE PUBLIC TO HAVE A HARD TIME SWALLOWING THAT.

fh up THE PUBLIC HAS A HARD TIME SWALLOWING THAT.

37
IF WE COULD SEPARATE INCOME FROM THE PUBLIC'S
PERCEPTION OF DOCTORS, A LOT OF THE PUBLIC HOSTILITY
WOULD DISAPPEAR, EVEN THOUGH DOCTORS DON'T MAKE AS
MUCH AS TOP CORPORATE EXECUTIVES, ENTERTAINERS,
ATHLETES, AND LAWYERS WHO RAKE IN LARGE CONTINGENCY
FEES FOR LAWSUITS AGAINST DOCTORS, LAWSUITS ABOUT A
MALOCCURANCE THAT EVERYONE USED TO CALL AN ACT OF

GOD..

38
BUT THE PUBLIC IS MORE CRITICAL OF DOCTORS, ASD WE P/F Dec (rhe
COULD DO A LOT MORE TO LEAD PATIENTS TO UNDERSTAND

THEY ARE GETTING HIGH-QUALITY, HIGH-EFFICIENCY,

CONSIDERATE, SENSITIVE CARE FOR THEIR MONEY, INSTEAD OF

THE PRESENT BELIEF THAT THEY ARE PAYING MORE AND MORE

FOR LESS AND LESS.

39
S

TO PROVE THAT THE QUALITY OF CARE IS IMPROVING AT THE

PATIENTS TELL US THEY CAN'T FIND A SHRED OF EVIDENCE

SAME RATE THE COST OF THE CARE ESCALATES.
EVEN YOU WOULD AGREE THAT HOSPITAL CARE AND PHYSICIAN

CARE AREN'T TWICE AS GOOD AS THEY WERE EIGHT OR NINE

 

YEARS AGO, EVEN THOUGH NOW THEY COST ABOUT TWICE AS
MUCH.

40
WE SEEM TO LIVE WITH THE PERCEPTION OF A SYSTEM OF
HEALTH CARE THAT'S DISTINGUISHED BY A VIRTUAL ABSENCE OF
SELF-REGULATION ON THE PART OF THE PROVIDERS OF THAT
HEALTH CARE -- THAT IS, HOSPITALS AND PHYSICIANS -- AND
DISTINGUISHED AS WELL BY THE ABSENCE OF SUCH NATURAL
MARKETPLACE CONTROLS AS COMPETITION IN REGARD TO
PRICE, QUALITY, OR SERVICE.

41
7. AS FOLKS VOICE THESE CRITICISMS AND REALIZE THAT 37
MILLION OF THEIR FELLOW CITIZENS HAVE NO ACCESS TO
HEALTH CARE THEY SAY THERE'S SOMETHING TERRIBLY WRONG
WITH A SYSTEM OF HEALTH CARE THAT SPENDS MORE AND

MORE MONEY TO SERVE FEWER AND FEWER PEOPLE.

IN THE PAST MOST AMERICANS TURNED CONFIDENTLY TO THEIR
INSURANCE TO PAY THE HEALTHCARE BILL. BUT THOSE DAYS
ARE OVER. THEY ARE EXASPERATED ABOUT THAT, AND FEEL
POWERLESS TO DO ANYTHING ABOUT THAT UNREGULATED

INDUSTRY.

42
Ad Fat AS rSvRawee (3 COWCERM dD,
WE HAVE THREE GROUPS IN THIS COUNTRY:
THE INSURED, THE UNINSURED, AND THE UNINSURABLE.

THE LARGEST GROUP, FORTUNATELY, IS THE 160 MILLION
AMERICANS WHOSE HEALTH INSURANCE IS PROVIDED THROUGH
EMPLOYERS -THEIR OWN OR FAMILY MEMBERS--, AND THE

SMALL FRACTION WHO PURCHASE THEIR OWN INSURANCE.

43
THESE PEOPLE USUALLY ENJOY ACCESS TO THE BEST MEDICINE
IN THE WORLD, AS LONG AS THEIR INSURANCE HOLDS OUT, OR

THEIR PREMIUMS ARE NOT RAISED BEYOND REACH.
BUT EMPLOYERS NOW ASK EMPLOYEES TO ASSUME MORE OF
THE COST OF HEALTHCARE, THROUGH HIGHER DEDUCTIBLES

AND CO-PAYMENT--APPROPRIATELY--, OR GIVE UP CERTAIN

SERVICES.

THEN EMPLOYEES DIG IN THEIR HEELS AND SAY. "NO!"

44
HEALTH BENEFITS WERE THE MAJOR REASON FOR 78 PERCENT
OF THE WORKING MEN AND WOMEN WHO WENT OUT ON STRIKE
LAST YEAR...PRODUCTION WORKERS AND MINERS AND PUBLIC
EMPLOYEES AND TELEPHONE WORKERS AND SERVICE WORKERS
AND SO ON.

THEY ASKED FOR MORE MONEY IN HEALTH BENEFITS...AND
MANAGEMENT SAID IT COULDN'T AFFORD TO PAY IT.

AND THEY CAN'T.

45
WHEN THOSE STRIKES ARE SETTLED AND OVER MORE MONEY
DOES GO INTO EMPLOYEE HEALTH BENEFITS, AND THOSE
INCREASED COSTS ARE EXPRESSED IN THE MARKETPLACE AS
HIGHER PRICES FOR THE GOODS YOU PURCHASE AND UTILITIES

YOU USE.

46
YEARS OF FULL INSURANCE COVERAGE HAVE LED TO HIGHER
FEES WITHOUT CONSUMER RESISTANCE. WE CAN NEVER
CONTAIN COSTS IF DOCTORS CAN BILL UNENDINGLY BECAUSE
EMPLOYEES CAN SPEND EMPLOYER INSURANCE FOR

TREATMENT.

47
THEN TOO, I AM EMBARRASSED BY PHYSICIANS WHO MILK THE
SYSTEM FOR MONEY.

WE SHOULD NEVER JOIN PHYSICIANS AND HOSPITAL
ADMINISTRATORS WHO ATTEND SEMINARS ON HOW TO
MANIPULATE THE CODING SYSTEM OF CPT (CURRENT
PROCEDURAL TERMINOLOGY) TO MULTIPLY THEIR

COMPENSATION.

THE FINANCIAL SIDE OF OUR PRACTICES MUST EXEMPLIFY HIGH

ETHICS, HONESTY, AND PROFESSIONALISM.

48
THE TWO THIRDS OF OUR POPULATION COVERED BY EMPLOYER-
PURCHASED HEALTH INSURANCE ARE THE PEOPLE WHO HAVE
THE MOST CLOUT TO CHANGE THINGS FOR THE BETTER.

BUT FIRST THESE PEOPLE --AND YOU AND BUSINESS AND
INDUSTRY-- MUST IDENTIFY THE LEADERSHIP TO BRING

HEALTHCARE COST UNDER CONTROL.

IT IS NOT THE PRESENT LEADERSHIP.

THEY ARE THE ONES WHO GOT US INTO OUR CURRENT

PROBLEMS OF PROFLIGACY AND POOR CARE.

49
NOR IS IT BIG BUSINESS AND LABOR.
I THINK THAT THIS IS THE WRONG COALITION.

THE COALITION THAT NEEDS TO BE FORMED COMBINES

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THE ACS NEEDS TO BE PART OF THIS EFFORT IN A MORE co

FORCEFUL WAY.

50
TOGETHER, THESE 160 MILLION INSURED AMERICANS AND THEIR
NEW CO-BELLIGERENTS CAN FORGE THE ALLIANCE THAT
REWARDS HIGH QUALITY AND HIGH EFFICIENCY WITH MORE
PATIENTS, RATHER THAN REWARDING POOR QUALITY CARE WITH
DOLLARS AS WE DO NOW.

AND UNTIL THE PURCHASING PUBLIC "BUYS RIGHT" THE

SITUATION WILL NOT CHANGE.

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51
8. EXASPERATION RUNS HIGH AMONG THE INSURED AMERICANS
WHO RELY UPON GOVERNMENT INSURANCE --MEDICARE FOR
THE ELDERLY, MEDICAID FOR THE POOR-- TO MEET THEIR

HEALTHCARE BILLS.

THESE INSURANCE PLANS NO LONGER FILL THE BILL.

52
MEDICARE IS NOT WHAT MOST PEOPLE THINK.
IT IS NOT A SYSTEM THAT PROVIDES FOR THE HEALTHCARE

COSTS OF THE ELDERLY.

OLDER AMERICAN CITIZENS MUST FIRST MUST SPEND THEIR
OWN MONEY BEFORE MEDICARE KICKS IN.
MEDICARE USUALLY DOESN'T PROVIDE THE DRUGS MANY

ELDERLY NEED TO STAY ALIVE.

 

53
NOR IS THERE PROVISION FOR LONG-TERM CARE IN HOSPITALS
OR NURSING HOMES.

ELDERLY PEOPLE AND THEIR GROWN CHILDREN ARE OFTEN
SHOCKED WHEN THEY DISCOVER THAT WHEN THE AGING
PARENT NEEDS NURSING HOME CARE, IT IS NOT COVERED BY

‘MEDICARE.

54
FURTHERMORE, THERE IS NO PROVISION IN MEDICARE FOR THE
HOUSEHOLD HELPS THAT WOULD KEEP ELDERLY PEOPLE
INDEPENDENT, AND OUT OF INSTITUTIONS, AT A TINY FRACTION
OF THE COST OF NURSING HOME CARE. I AM TALKING ABOUT
SOMEONE STOPPING BY ONCE A DAY TO SPEND AN HOUR ON THE
HEALTH AND HOUSEHOLD CHORES THAT NEED TO BE

ACCOMPLISHED.

35
MEDICARE IS ONE OF THE MOST DECENT THINGS THAT THIS
COUNTRY HAS DONE, TO REMOVE MUCH OF THE FEAR AND
UNCERTAINTY FROM THE FRAIL YEARS OF ELDERLY LIFE, AND IT
SHOULD STAND AS A LANDMARK TO THE BASIC DECENCY OF THE

AMERICAN ETHICAL CORE.

BUT IT NEEDS TO WORK AS ORIGINALLY INTENDED, AND

PROMISED.

56
THEN THERE IS MEDICAID, THE FEDERAL INSURANCE PROGRAM

DESIGNED FOR THE POOR.

IF MEDICARE IS A DISAPPOINTMENT, MEDICAID IS A FRAUD.

MEDICAID IS A FRAUD BECAUSE MEDICAID EXCLUDES MOST OF
THE POOR.... BY CALLING THEM TOO RICH.

o7
INDIVIDUAL STATES ADMINISTER MEDICAID, AND CAN SET THE
MAXIMUM INCOME LEVEL NEEDED TO QUALIFY FOR MEDICAID.
THIS HAS LED TO SHAMEFUL STANDARDS.

IN MANY STATES A FAMILY OF THREE WITH AN INCOME OF $3000
A YEAR IS TOO RICH TO QUALIFY FOR MEDICAID. THERE ARE
FEW STATES BETTER, AND FORTUNATELY FEW WORSE.

MEDICAID NEEDS TO BE STANDARDIZED, EXPANDED AND

REFORMED.
MEDICAID NEEDS TO EMBRACE FAMILIES RATHER THAN

EXCLUDE THEM.

58
9, THE COUNTRY IS EXASPERATED OVER THE PLIGHT OF THE
UNINSURED, THE 12 TO 15 PERCENT OF OUR POPULATION --
THAT'S 33 TO 37 MILLION AMERICANS-- WHO ARE UNINSURED,

UNDER-INSURED, OR ONLY SEASONALLY INSURED.

THEY'RE NOT OLD ENOUGH FOR MEDICARE AND NOT POOR
ENOUGH FOR MEDICAID.

59
THESE PEOPLE, THE WORKING POOR, WHOSE INCOMES ARE TOO
LOW TO LIVE ON, BUT TOO HIGH TO QUALIFY FOR MEDICAID ,
OFTEN EXHIBIT A STEELY PRIDE THAT MANY OF US CAN ENVY.

THESE ARE NOT PEOPLE ON WELFARE. THEY COULD GO ON
WELFARE, GET FOR FREE THE DENTURES, EYEGLASSES, AND
SHOES, AND FOODSTAMPS THEY NEED, BUT THEIR DIGNITY
KEEPS THEM OFF WELFARE, AND THEY STRUGGLE ALONG,
FEARFUL OF THAT ILLNESS THAT MIGHT CLAIM ALL THE LITTLE
THEY HAVE.

60
CONTRARY TO THE WHINING OF SOME CONSERVATIVE
COLUMNISTS, THESE PEOPLE ARE NOT LOOKING FOR A

HANDOUT.
90 PERCENT OF THE UNINSURED ARE WORKING PEOPLE, MANY
WORKING AT SEVERAL JOBS, NONE OF WHICH PROVIDES A

HEALTH PLAN.

61
THEY ARE SUFFERING THE CONSEQUENCES.
STUDY AFTER STUDY INDICATES THE CORRELATION BETWEEN NO
MEDICAL INSURANCE AND SERIOUS HEALTH PROBLEMS.

AND ALL OF US WILL SUFFER THE CONSEQUENCES TOO, BECAUSE
THE HEALTH PROBLEMS OF THE UNINSURED, IF IGNORED BY

SOCIETY NOW, WILL BE BORNE BY SOCIETY LATER.

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62
10. TRAGICALLY, IF EXASPERATION CHARACTERIZESTHESE
COMPLAINTS, THEN DESPAIR IS THE HALLMARK OF THE
UNINSURABLE: THE TWO AND A HALF MILLION AMERICANS WITH
SERIOUS MEDICAL PROBLEMS WHO CAN'T EVEN BUY INSURANCE
BECAUSE THEY ARE CONSIDERED TO BE BAD RISKS.

AND NOW, WITH INCREASING FREQUENCY, SOME PATIENTS HAVE
THEIR INSURANCE PREMIUMS RAISED OUT OF SIGHT RIGHT IN

THE MIDDLE OF A SERIOUS ILLNESS.

63
FAMILIES WHO THINK THEY HAVE A MILLION DOLLAR COVERAGE
FOR EACH MEMBER OF THE FAMILY FIND THAT WITH THE FIRST
EXPENSIVE ILLNESS THE FAMILY HEALTH INSURANCE
PREMIUMS CAN UNDERGO A SIXFOLD INCREASE... LIKE ONE I
KNOW THAT WENT FROM $198 A MONTH TO $1375 A MONTH.

AWD ANGTHER Fit /300/My & No0G0.

HOW MANY OF US COULD AFFORD THAT KIND OF A JUMP?

64
4it€ FIRST Epmicd
CEQ THOUGHT IT MUST BE A COMPUTER ERROR, BUT WERE

TOLD COLDLY BY THE INSURANCE COMPANY THAT IF THEY
DIDN'T LIKE IT, THEY COULD CANCEL THEIR INSURANCE.
HOWEVER, NO OTHER COMPANY WOULD INSURE THEM BECAUSE

THEIR YOUNGSTER HAD A "PRE-EXISTING CONDITION."

65
OTHER AFFLICTED AMERICANS WHO THOUGHT THEY WERE
COVERED BY INSURANCE SUDDENLY DISCOVERED THAT THEIR
INSURANCE COMPANIES WERE SIMPLY NOT PAYING THE BILLS.
IN CALIFORNIA ALONE, 100,000 PEOPLE LOST THEIR INSURANCE
IN 1989 BECAUSE THEIR INSURANCE COMPANIES HAVE GONE

UNDER.
SOME OF THESE PEOPLE HAD ALREADY PAID AS MUCH AS $200,000

IN PREMIUMS OVER THE YEARS.

66
11. SOCIETY IS EXASPERATED BY THE DISRUPTION CAUSED BY
THE ESCALATING COST OF HEALTH CARE.

THOUSANDS AND THOUSANDS OF AMERICAN FAMILIES EACH
YEAR ARE LITERALLY IMPOVERISHED BY THE AMERICAN HEALTH

CARE SYSTEM.
WE CANNOT LET THAT CONTINUE.

67
THEY ARE ALSO EXASPERATED BECAUSE OUR HEALTH DOLLARS
DON'T SEEM TO BE GOING FOR OUR HEALTH.

PEOPLE FUME WHEN THEY READ THAT HEALTHCARE
ADMINISTRATION NOW CONSUMES ABOUT 22% OF HEALTHCARE
SPENDING. .

DOCTOR'S OFFICES OFTEN SPEND MORE TIME ON THE
INSURANCE FORMS THAN THE DOCTOR SPENT WITH THE

PATIENT.

EVEN THE INSURANCE INDUSTRY ITSELF HAS BEGUN TO CALL

FOR REGULATION AND REFORM.

68
EMPLOYERS SHOULD BE REQUIRED TO PROVIDE HEALTH
INSURANCE, BUT WITH APPROPRIATE COST-SHARING, HEALTH
EDUCATION, AND FITNESS PROGRAMS, SO THAT THE ECONOMIC
IMPACT ON SMALL BUSINESS CAN BE LESSENED BY TAX BREAKS
AND RISK-POOLING.

OTHERWISE SMALL EMPLOYERS JUST DROP SOME EMPLOYEES
FROM THE PAYROLL. |

69
THOSE NOT INCLUDED IN EMPLOYER-PROVIDED INSURANCE
SHOULD BE ABLE TO HAVE ACCESS TO SIMILAR COVERAGE
ACCORDING TO SLIDING SCALE COST-SHARING AND RISK- —
POOLING.

WE NEED TO EXPECT SOME FORMS OF TAX INCREASE IF WE ARE
TO ACT ACCORDING TO OUR ETHICS, AND PROVIDE HEALTH

INSURANCE FOR THOSE WHO ARE NOW UNINSURED.

70
WE CAN LOWER BOTH HEALTHCARE COST AND INSURANCE COST
BY LINKING INSURANCE COVERAGE TO BEHAVIOR.

IT MAKES SENSE TO VOID OR REDUCE INSURANCE COVERAGE
FOR PEOPLE WHO PRACTICE HIGH RISK BEHAVIOR: NOT
WEARING MOTORCYCLE HELMETS, NOT BUCKLING SEATBELTS,

DRIVING AFTER DRINKING, AND YES, CONTINUING TO SMOKE.

71
WHY SHOULD THE REST OF US SUBSIDIZE THE INSURANCE
COVERAGE OF PEOPLE WHO KN OWINGLY AND CONTINUALLY
PLACE THEMSELVES AT GREATER RISK FOR ILLNESS?

EVEN HIGHER TOBACCO AND ALCOHOL TAXES SHOULD BE

DEMANDED TO PAY FOR HEALTHCARE COSTS ATTRIBUTED TO
THOSE DEADLY SUBSTANCES.

72
ON THE POSITIVE SIDE, WE NEED INSURANCE PROGRAMS THAT
ENCOURAGE PREVENTIVE HEALTHCARE.

IT IS ABSURD FOR AN INSURANCE COMPANY TO COUGH UP
$150,000 TO REMOVE A CANCEROUS LUNG, BUT NOT PAY $64 OR
$200 FOR A SMOKING CESSATION PROGRAM.

73
INSURANCE PEOPLE TELL ME THAT I DON'T UNDERSTAND

INSURANCE.

IT WAS MEANT FOR CATASTROPHES. BUT I'M SMART ENOUGH TO
CA TAS Tg PHI

KNOW THAT $200 SPENT TO AVOID A BILL OF $150,000 IS GOOD

BUSINESS. BUT THEN I LIKE LONG TERM GAINS, NOT THIS

YEAR'S SOFT PROFITS.

74
NO ONE CAN DOUBT MY COMMITMENT TO CUTTING
HEALTHCARE COSTS, TO GETTING RID OF MISMANAGEMENT,
WASTE, AND FRAUD.

BUT I AM DEEPLY DISTURBED AND EVEN FRIGHTENED WHEN
THIS IS ATTEMPTED BY MISGUIDED INTERFERENCE IN THE

DOCTOR-PATIENT RELATIONSHIP.

75
12. PATIENTS WOULD BE FURTHER EXASPERATED IF THEY KNEW
THAT WHEN THEY COME TO SEE YOU THERE ARE OTHER PEOPLE
THERE: THE THIRD PARTY REGULATORS, THE OUTSIDERS WHO
EARN THEIR KEEP BY HARASSING DOCTORS. EACH OF YOU
COULD COME UP WITH MANY EXAMPLES OF THIS: HAVING YOUR
JUDGMENTS SECOND-GUESSED LONG-DISTANCE TO SHAVE A FEW
BUCKS OFF THE COST OF A HOSPITALIZATION:

76
A. NEUROSURGEONB TRYING TO EXPLAIN TO THE CLERK ON THE
OTHER END OF THE TELEPHONE WIRE WHY THE 10 HOUR BRAIN
SURGERY SHOULD NOT BE SCHEDULED IN THE AFTERN OON,
JUST SO THE PATIENT DOESN'T STAY IN THE HOSPITAL THE
NIGHT BEFORE THE PROCEDURE.

MOST OF YOU ARE TRAINED TO ADVOCATE YOUR PATIENTS'

INTERESTS, AND YOU ARE BETTER AT CLINICAL DECISIONS THAN

ECONOMIC DECISIONS.

77
ALL TOO OFTEN THESE INTERFERING REGULATORS FORCE
DOCTORS TO FIGHT FOR WHAT IS BEST FOR THEIR PATIENTS, TO

SPEND TIME ON THE PHONE OR WRITING LETTERS, TIME THAT
WOULD BE BETTER SPENT WITH THEIR PATIENTS.

78
I THINK THIS IS ONE PLACE WHERE THE TIDE OF OPINION MAY
BE TURNING IN THE PHYSICIAN'S FAVOR, AS A NUMBER OF
RECENT NEWS PROGRAMS HAVE HIGHLIGHTED THE ABUSES OF

THE REGULATORS,

COST CONTROL SHOULD NOT MEAN REMOTE CONTROL
MEDICINE.

WE DON'T WANT TO SEE MEDICINE TURNED INTO A PUBLIC
UTILITY, OVER-REGULATED AND UNDER-RESPONSIVE TO THE
NEEDS OF INDIVIDUAL PATIENTS.

79
BUT, TO MAKE SURE WE ALL GET MORE FOR OUR HEALTHCARE
DOLLAR, FOR OUR INSURANCE COVERAGE, WE NEED DO NEED
MORE OPEN COMMUNICATION ABOUT THE QUALITY AND
EFFICIENCY OF HEALTHCARE.

13. WHAT SOME PEOPLE SAY IS ANOTHER SOURCE OF
EXASPERATION IS THAT THEY CALL THE CONSPIRACY OF
SILENCE.

THEY NEED TO KNOW WERE PEOPLE CAN GET HIGH-QUALITY
AND EFFICIENT CARE.

80
THEN THE PATIENTS WILL DESERT THE POOR QUALITY,
INEFFICIENT SYSTEMS THAT WILL HAVE TO IMPROVE OR PERISH.

THE PUBLIC --AS WELL AS OUR PROFESSION-- IS ALSO
EXASPERATED ABOUT GLARING REGIONAL DIFFERENCES.

WHY SHOULD HOSPITAL USE IN THE MIDWEST BE 60% HIGHER
THAN IN THE WEST? WHY, IN A GIVEN YEAR, SHOULD 10% OF
DELIVERIES IN DETROIT BE BY CAESAREAN, BUT IN WASHINGTON

DC CAESAREANS FORM 24%?

81
WHY SHOULD SOME REGIONS ORDER CAT SCANS 7 TIMES MORE
FREQUENTLY THAN THE NATIONAL RATE?

WHY DO KNEE REPLACEMENTS VARY 6-FOLD FROM REGION TO
REGION?

THE EXPLANATION OR CORRECTION OF THOSE DISCREPANCIES

SHOULD COME FROM YOU, AND NOT FROM A SOCIAL PLANNER.

82
QUALITY, AND EFFICIENCY ARE DIFFICULT TO MEASURE.
BUT THEY ARE MORE IMPORTANT THAN MERE QUANTITY.

WE ARE DEVELOPING TOOLS TO MEASURE MEDICAL NECESSITY,
APPROPRIATENESS, EFFECTIVENESS AND OF COURSE OUTCOMES.

83
OUTCOMES WILL BE MORE AND MORE PART OF OUR
RELATIONSHIP WITH PATIENTS.

BATTING AVERAGES OF PHYSICIANS AND HOSPITALS FOR
VARIOUS DIAGNOSES WILL BE COMMON KNOWLEDGE.

BE SURE THEY ARE PROPERLY CALCULATED AND CONVEYED.
DON'T ALLOW THIS TO BE ANOTHER REASON FOR PATIENT
EXASPERATION.

MANAGE THE SYSTEM; DON'T FIGHT IT.

84
Tire
MALPRACTICE SUITS CORRUPT, BASIC EMOTIONAL CLIMATE OF

MEDICINE, MAKING THE DOCTOR AFRAID OF THE PERSON SHE

OR HE WANTS TO HELP.

MALPRACTICE DOES EXIST, AND WHERE THERE IS MALPRACTICE
--BAD, OR NEGLIGENT PRACTICE-- RESTITUTION AND
COMPENSATION ARE IN ORDER.

MEDICINE MUST RID ITSELF OF THE BAD APPLES THAT BRING
JUSTIFIED CRITICISM TO THE PROFESSION.

85
YET MANY MALPRACTICE SUITS ARE BROUGHT BECAUSE A
TRAGEDY HAS OCCURRED, IN SPITE OF THE DOCTOR'S BEST

EFFORTS.

OUR CURRENT SYSTEM DOES NOT SERVE THE PATIENT WELL.
EVERY INAPPROPRIATE MALPRACTICE SUIT DRIVES UP THE COST
OF MEDICINE FOR ALL PATIENTS AND DOCTORS ALIKE, WHILE
NEGLIGENT DOCTORS CONTINUE TO PRACTICE AND SOME VERY

GOOD DOCTORS LEAVE.

86
MALPRACTICE REFORM IS DIFFICULT TO GET BECAUSE
CONGRESS AND STATE LEGISLATURES INCLUDE SO MANY
LAWYERS, AND THEY AREN'T LIKELY TO ACT AGAINST THEIR

OWN.

BUT WE --NOT JUST SURGEONS, BUT ALSO CITIZENS CONCERNED
ABOUT HEALTHCARE COSTS-- WE MUST DEMAND REFORM.

87
WE MUST ELIMINATE AWARDS FOR ALLEGED PAIN AND
SUFFERING, AND WE MUST DO AWAY WITH CONTINGENCY FEES
WHICH CLOG THE COURTS, BLACKMAIL PHYSICIAN S, AND
PROMPT INSURANCE COMPANIES TO SPEND OUR MONEY OUT OF

COURT JUST TO GET IT OVER.

 

ALTHOUGH WE MUST HOLD OUR PHYSICIANS TO THE HIGHEST

STANDARDS,
WE MUST REALIZE THAT HEALING AND RECOVERY ARE NOT

PERFECT.

88
THE HEALTH CARE SYSTEM IN AMERICA TODAY IS A TERRIBLE
MORAL BURDEN FOR SOCIETY TO BEAR, IN THAT THE SYSTEM

DOES NOT RESPOND AT ALL TO SOME 12 TO AS HIGH AS 15

 

PERCENT OF OUR POPULATION.

AND IT IS A TERRIBLE ECONOMIC BURDEN FOR SOCIETY TO
BEAR, IN THAT THE SYSTEM SATISFIES ITS OWN UNCONTROLLED
NEEDS AT THE EXPENSE OF EVERY OTHER SECTOR OF AMERICAN

SOCIETY.

89
WE NEED TO CHANGE THAT SYSTEM.
NOT JUST A LITTLE CHANGE HERE AND A LITTLE CHANGE THERE.

WE NEED TO BRING ABOUT A PROFOUND CHANGE, ACROSS-THE-
BOARD, IN THE WAY WE MAKE MEDICAL AND HEALTH CARE

AVAILABLE TO ALL OUR CITIZENS.

BUT CAN WE DO IT?

90
WE NEED TO TAKE SOME IMAGINATIVE STEPS.

FOR EXAMPLE, WE NEED TO SOLVE THE PROBLEM CAUSED BY
THE ENORMOUS EDUCATION DEBT THAT MOST YOUNG DOCTORS
HAVE TO SHOULDER AS SOON AS THEY BEGIN PRACTICING
MEDICINE. |

MOST MEDICAL STUDENTS GRADUATE FROM MEDICAL SCHOOL
WITH A DEBT THAT SHAPES THEIR PRACTICE OF MEDICINE FOR

THE NEXT 20 YEARS.

91
BUT I DO HAVE A SIMPLE SUGGESTION ABOUT THE PROBLEM OF

MEDICAL SCHOOL DEBT.

WHEN A MEDICAL STUDENT GRADUATES, AN ACCOUNT COULD BE
ESTABLISHED BY THE FEDERAL GOVERNMENT, AND EVERY TIME
THE DOCTOR SEES AN UNINSURED PATIENT WITHOUT CHARGE,
THAT DEBT IS LOWERED BY THE AMOUNT EQUIVALENT TO A FAIR

COMPENSATION FOR THAT SERVICE.

92
THIS SOLUTION HAS SEVERAL ADVANTAGES:
IT'S GRADUAL;

IT DOESN'T REQUIRE A BIG OUTLAY BEFOREHAND;
IT OFFERS CARE TO THE UNINSURED WHO NEED IT;
IT ENCOURAGES PHYSICIANS TO OFFER CARE WITHOUT FEE; —
AND IT LOWERS THE DOCTOR'S DEBT.

IT SEEMS TO ME THAT EVERYBODY GAINS.

93
WE ALSO NEED TO DO SOMETHING ABOUT THE INFLATIONARY
ASPECT OF RECRUITMENT MONEY, WHEN HOSPITAL "X" WANTS
THE SAME KIND OF SURGEON AS THE HOSPITAL ACROSS TOWN,
AND THEN LURES SOMEONE FROM ACROSS THE COUNTRY WITH

AN ASTRONOMICAL PACKAGE, FORCING COSTS UP ALL AROUND.

94
_ J REALIZE THAT THIS IS A COMPLICATED PROBLEM, INVOLVING
REGULATIONS, JOINT COMMITTEES OF ACCREDITATION OF
HOSPITALS, ETC., BUT COMPLEXITY SHOULD NOT KEEP US FROM

GETTING A HANDLE ON A SOLUTION.

95
WE NEED TO DO SOMETHING, TO DO MANY THINGS,

BECAUSE WE ARE AT A CROSSROADS.

WE CANNOT AFFORD TO DO NOTHING, TO CONTINUE BUSINESS
AS USUAL.

THE PRESSURE FOR RADICAL CHANGE IS COMING FROM ALL
DIRECTIONS:

FROM MEMBERS OF CONGRESS, FROM BUSINESS, FROM LABOR,
AND FROM THE GENERAL PUBLIC.

INCREASINGLY WE HEAR THE DEMAND FOR RESTRUCTURING THE
FINANCING AND DELIVERY OF HEALTHCARE IN THE UNITED

STATES.

96
EVEN SOME BUSINESS LEADERS WHO NORMALLY CRINGE AT THE
THOUGHT OF GOVERNMENT INTERVENTION OR REGULATION |
FIND THEMSELVES CALLING FOR A SYSTEM OF NATIONAL

HEALTH CARE AS A SOLUTION TO RISING INSURANCE COSTS.

97
EXASPERATION WITH OUR SYSTEM LEADS SOME PEOPLE TO SEE

GREENER GRASS ON THE OTHER SIDE OF THE FENCE.

THE GROWING INFATUATION WITH FOREIGN NATIONAL HEALTH

SERVICES IS BASED MORE UPON DISSATISFACTION WITH OUR

SYSTEM THAN UPON UNDERSTANDING OF ANOTHER ONE.

 

98
MOST AMERICANS DO NOT REALIZE THAT ANY NATIONAL

HEALTH SERVICE, IS BASED UPON PLANNED SCARCITY.

EXPERIENCE THE WORLD OVER HAS SHOWN THAT WHEN
GOVERNMENT ECONOMIC CONTROLS ARE APPLIED TO HEALTH,
THEY PROVE --IN TIME-- TO BE DETRIMENTAL.

EVENTUALLY THERE IS AN EROSION OF QUALITY, PRODUCTIVITY,

INNOVATION, AND CREATIVITY.

99
THIS IS ESPECIALLY TRUE OF RESEARCH.

AMERICANS DESIRE, NOT ONLY AFFORDABLE HEALTH CARE, BUT
ALSO MEDICAL ADVANCES.

BUT MEDICAL RESEARCH IS NOT CHEAP, AND SOMEONE MUST
PAY FOR IT. AMERICANS ARE NOT LIKELY TO TOLERATE
HEALTHCARE SAVINGS IF IT MEANS SKIMPING ON AIDS OR

ALZHEIMER'S RESEARCH.

100
NATIONAL SYSTEMS OF HEALTHCARE EVENTUALLY BECOME
BUREAUCRATIC, UNRESPONSIVE TO PATIENTS, AND FINALLY THEY
BRING RATIONING AND WAITING IN LINES.

AMERICANS DO NOT PATIENTLY QUE UP FOR ANYTHING,
ESPECIALLY FOR MEDICAL CARE.

101
I DO NOT FAVOR TOTALLY SCRAPPING THE SYSTEM WE HAVE
NOW;

BECAUSE OF ITS DIVERSITY, IT IS POTENTIALLY THE BEST IN THE
WORLD. AND BECAUSE OF THIS DIVERSITY THERE IS NO
PANACEA, NO SINGLE MAGIC BULLET.

IT WOULD TAKE AT LEAST SIX BULLETS, FIRED SEPARATELY, TO
CONQUER THE DISEASES AFFECTING THE UNITED STATES'

HEALTH CARE NONSYSTEM.

102
IT REMAINS TO BE SEEN WHETHER OR NOT THE PRIVATE SECTOR
SEIZES THIS ONE AND ONLY OPPORTUNITY ---WHILE THE

GOVERNMENT IS TOO POOR-- TO EFFECT SOME CHANGE.

BUT WE ALL NEED TO BE A PART OF THE EFFORT.
THERE IS NO QUICK FIX.
FROM HERE TO WHERE WE WANT TO GO COULD TAKE A DECADE,

BUT WE'D IMPROVE YEAR BY YEAR ALONG THE WAY.

103
LET ME SAY IT AGAIN, THAT THE RESTORATION OF THE DOCTOR-
PATIENT RELATIONSHIP IS MOST ESSENTIAL.

BUT IT WILL TAKE COMMITMENT BY PEOPLE ON BOTH SIDES OF
THE STETHOSCOPE.

THERE ARE THINGS WE CAN DO, AS DOCTORS,

EACH DAY WE PRACTICE.

104
I AM AWARE, OF COURSE, ABOUT THE DIFFERENCES WITHIN OUR
PROFESSION. "THE MEDICAL PROFESSION" IS NOT MONOLITHIC.
AMONG THE DIFFERENCES I NOTE IS ONE ALONG THE LINES OF

GENERATIONS.

105
I BELIEVE 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 IN PRACTICE, THE SCIENTIFIC
UNDERPINNING FOR OUR PRACTICE WAS, TO BE HONEST, RATHER

MARGINAL.

106
NOW, OF COURSE, PEOPLE WANT THE BEST OF BOTH WORLDS, A
DOCTOR WHO IS UP TO THE MINUTE ON THE LATEST HIGH-TECH,
BUT HAS THE COMPASSION, CARE ...AND TIME.. OF THE OLD-

FASHIONED COUNTRY DOC. AND IT'S TOUGH TO BE BOTH.
BUT WHAT'S THE REAL SIGNIFICANCE OF THE STATEMENT THAT

"PREVIOUS GENERATIONS OF DOCTORS PRACTICED THE ART,

RATHER THAN THE SCIENCE, OF MEDICINE?

107
PRIMARILY, I BELIEVE IT MEANS THAT WE SAW MEDICINE AS A
RELATIONAL ENTERPRISE. WE ASKED THE KINDS OF QUESTIONS
THAT REFLECTED CONCERNS ABOUT RELATIONSHIPS:

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?

108
WE HAD TO BE PEOPLE-ORIENTED BECAUSE, WITHOUT THE
BENEFIT OF C.A.T. SCANS OR N.M.R.S, JUST ABOUT EVERYTHING
WE LEARNED ABOUT OUR PATIENT CAME FROM THE TAKING OF
GOOD HISTORIES .-- THROUGH SENSITIVE DEALINGS WITH
FAMILY MEMBERS.

FOR ME THAT WAS THE FUN OF MEDICINE. EVERY PATIENT WAS

A CHALLENGE.

109
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 THESE DIAGNOSES ARE SPEEDY AND ACCURATE.

THE SCIENTIFIC ADVANCES IN MEDICINE IN THE LAST

GENERATION ARE MAGNIFICENT.

110
THEY HAVE PROLONGED MANY LIVES. WE HAVE ALL MADE FULL

USE OF THE ADVANCES IN MEDICAL SCIENCE FOR OUR PATIENTS

AND OURSELVES.

BUT THE SCIENCE OF MEDICINE SHOULD NOT ECLIPSE THE ART
OF MEDICINE.

IN OUR SCIENTIFIC PROGRESS SOMETHING MAY HAVE BEEN
LOST ... SOMETHING VERY IMPORTANT TO THE CONTINUED
STRENGTH OF THE MEDICAL PROFESSION: THE RELATIONAL

BOND BETWEEN PHYSICIAN AND PATIENT.

111
A FRIEND OF MINE WENT TO HER PHYSICIAN'S OFFICE
RECENTLY, AND AFTER A BRIEF HISTORY WAS TAKEN, WAS TOLD,
"I'LL SEE YOU NEXT WEEK."
THE PATIENT ASKED,
"AREN'T YOU GOING TO EXAMINE ME NOW."
THE DOCTOR RESPONDED,
"NOT UNTIL THE TESTS COME BACK. MY NURSE WILL TELL

YOU ABOUT THEM."

112
I UNDERSTAND THAT SOME OF TODAY'S BUZZ-WORDS AMONG
MEDICAL STUDENTS ARE "CARING", "COMPASSION’, "DIGNITY",
"HUMANE" ....

AND THOSE ARE CERTAINLY SOME OF THE MOST BEAUTIFUL

WORDS IN OUR VOCABULARY.

BUT I'M AFRAID THEY CO-EXIST WITH SOME OTHER MODERN
BUZZ-WORDS LIKE "DAMAGE CONTROL", "DEFENSIVE MEDICINE",
"MALPRACTICE' ... TERMS THAT ARE AMONG THE UGLIEST IN THE
LANGUAGE.

THEY CONVEY THE IDEA THAT THE PATIENT AND DOCTOR ARE

ADVERSARIES.

113
INSTEAD, WE MUST VIEW OUR PATIENTS AS HUMAN BEINGS, AS
ALLIES,

WORKING WITH US IN THE STRUGGLE AGAINST DISEASE.

THIS INCLUDES PREVENTION AS WELL AS TREATMENT AND

REHABILITATION.

114
THE DENTISTS HAVE DONE A MUCH BETTER JOB IN THIS THAN
WE HAVE, JOINING WITH THEIR PATIENTS IN PREVENTIVE
DENTAL HABITS,

EVEN THOUGH THIS HAS THE EFFECT IN SOME WAYS OF
WORKING THEMSELVES OUT OF A JOB.

MOST AMERICANS REALLY FEEL THEIR DENTIST WANTS THEM TO
HAVE FEWER CAVITIES.

THEY DON'T VIEW THEIR RELATIONSHIP WITH THEIR DOCTOR IN

THE SAME WAY.

115
FOR EXAMPLE, IF OVER THE LAST DECADE, DOCTORS HAD
QUIZZED THEIR PATIENTS ABOUT SMOKING, AND THEN HAD
GIVEN SOUND ADVICE, WE MIGHT ENJOY THAT SAME ALLIANCE

IN PREVENTION.

AFTER ALL, IT HAS BEEN KNOWN FOR MANY YEARS THAT THE
MOST LIKELY CAUSE OF SMOKING CESSATION IS FOR A DOCTOR
TO LOOK HIS OR HER PATIENT IN THE EYE AND TELL HIM,
"SMOKING IS GOING TO KILL YOU." AND I HAVE NOT EVEN

MENTIONED THE LIVES SAVED.

116
TREATING OUR PATIENTS LIKE ALLIES IN THE FIGHT AGAINST
THEIR DISEASE MEANS BEING CLEARER AND MORE COMPLETE

ABOUT INFORMED CONSENT.

THAT MAY MEAN TELLING MORE ABOUT WHAT WE KNOW IN

SOME CASES, SHARING OUR UNCERTAINTIES IN OTHERS.

117
EARLY IN MY OWN PEDIATRIC SURGICAL PRACTICE, I

DETERMINED THAT I WOULD MAKE MY PATIENTS' PARENTS

ALLIES WITH ME AGAINST THEIR CHILD'S SURGICAL PROBLEM.
| AT LEneri4

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.

118
HAS IT BEEN WORTH IT? YES, IT HAS. .. ON MANY LEVELS.
FOR ONE THING, I'VE GOTTEN TO KNOW DOZENS OF

COURAGEOUS, GENEROUS, COMPASSIONATE FAMILIES.

I MAY HAVE HELPED THEIR CHILDREN OVERCOME SOME
DISABILITY ... BUT THEY ALL HELPED ME OVERCOME

PESSIMISM, DEFEATISM, FRUSTRATION, AND DISCOURAGEMENT .
. . FEELINGS THAT ARE COMMON ENOUGH AMONG HARD-

WORKING PHYSICIANS.

119
I DID THIS SIMPLY BECAUSE I THOUGHT IT WAS GOOD MEDICAL
PRACTICE, BUT IT ALSO HAD THE UNFORSEEN DIVIDEND OF

HAVING NO ONE SUE ME FOR 39 YEARS WHEN I WAS IN PRACTICE.

OF COURSE WE'LL BE DISAPPOINTED NOW AND THEN.
AND, DEPENDING ON YOUR PARTICULAR PRACTICE, YOU JUST
MIGHT DRAW MORE THAN YOUR SHARE OF DEADBEATS AND»

MALCONTENTS.

120
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.

121
AS PHYSICIANS, AS WELL AS CITIZENS, WE NEED TO DO
SOMETHING FOR THOSE AMERICANS WHO, UNDER OUR PRESENT

SYSTEM, ARE DENIED ACCESS TO REASONABLE CARE.

WHILE WE WAIT -AND TAKE PART IN FINDING REGIONAL AND
NATIONAL SOLUTIONS, WE CAN DO OUR PART BY REVITALIZING
THE PRACTICE OF OFFERING FREE CARE TO APPROPRIATE

PATIENTS.

122
IN MY EARLY DAYS I FOUND MYSELF EXTRAORDINARILY
FORTUNATE IF I GOT PAID FOR 40% OF WHAT I DID.
BUT I WAS HAPPY IN MY PRACTICE, MY PATIENTS APPRECIATED

WHAT I DID, AND I CERTAINLY ENJOYED WHAT I DID FOR THEM.

BUT ONCE ENTITLEMENTS CAME ALONG, DOCTORS WHO HAD
BEEN VERY HAPPY TO PERFORM A CERTAIN AMOUNT OF FREE
SERVICE BEGAN TO FEEL THAT THEY HAD TO BE PAID FOR

EVERYTHING.

123
I SEE NO REASON WHY CERTAIN FREE CLINICS COULD NOT
OPERATE UNDER LAWS THAT FORBID LITIGATION.
GIVING, CHARITY, HAS ALWAYS BEEN PART OF OUR CALLING.

WE OUGHT TO FIND WAYS TO DO IT WITHOUT PENALTY.

124
NOT LONG AGO, I WAS SPEAKING WITH TWO YOUNG WOMEN,
BOTH BRIGHT, KNOWLEDGEABLE, ARTICULATE HEALTH

REPORTERS.

I ASKED THEM EACH THE SAME QUESTION:

"ARE YOU SATISFIED WITH YOUR HEALTH CARE?"

ONE SAID SHE WAS;

ONE SAID SHE WASN'T.

125
I ASKED WHY.

THE ONE WHO SAID SHE WAS SATISFIED SAID,

"MY DOCTOR LISTENS TO ME, AND HE TELLS ME WHAT THE
PROBLEMS ARE, WHAT HE'LL DO, AND I HAVE A LOT OF

CONFIDENCE IN HIM."

THE ONE WHO WAS DISSATISFIED SAID, "I'M FURIOUS AT MY
DOCTOR.

IN ORDER TO HAVE SOME SURGERY DONE, I SAW HIM 7 TIMES IN
2 WEEKS, HAD VARIOUS TESTS AND CONSULTATIONS, AND WHEN
I CALLED HIM TO ASK A QUESTION, HE SAID, *NOWREMIND ME

WHO YOU ARE AND WHY I KNOW YOU."

126
I SAID TO THEM BOTH,

"IN OTHER WORDS, WHEN I ASKED YOU *AREYOU SATISFIED
WITH YOUR HEALTH CARE?',

ONE OF YOU SAID "YES", ONE SAID "NO",

BUT WHAT YOU REALLY WERE SAYING IS THAT ONE OF YOU
oKED YOUR DOCTOR AND ONE OF YOU DIDN'T. ONE HAD

CONFIDENCE IN YOUR DOCTOR, ONE DID NOT."

127
THEREFORE, MY MESSAGE TO THE DOCTORS IN AMERICA IS:
WHEN YOU ARE DEALING WITH A PATIENT YOU ARE
REPRESENTING ALL OF AMERICAN MEDICINE, YOU ARE

REPRESENTING AMERICAN HEALTH CARE.

128
WE HAVE MUCH TO DO, BUT LET'S NOT LOSE OUR POSITIVE

ENERGY.

THE MESSAGE WE HAVE TO SHARE WITH OURSELVES AND WITH
THE AMERICAN PEOPLE IS A POSITIVE ONE.

WE DON'T NEED THE PAST TENSE,... NOSTALGIA ABOUT "THE

GOOD OLD DAYS";

129
NOR DO WE NEED SOME FUTURISTIC MANIFESTO PROMISING

WHAT WE INTEND TO DO.

WE NEED CLEAR AND PERSISTENT AFFIRMATION OF THE MANY
GOOD THINGS WE DO,
DAY IN AND DAY OUT,
TO MAKE OUR SYSTEM OF MEDICINE --ONCE WE TAKE THINGS IN

HAND -- POTENTIALLY THE BEST IN THE WORLD.

130
I HAVE NEVER REGRETTED GOING INTO MEDICINE.

I'D DO IT AGAIN TOMORROW.

AND I TELL THAT TO ANY YOUNGSTERS WHO ARE CONSIDERING

IT.

OURS IS A CALLING.

IT IS NOT A BUSINESS.

WE COULD HAVE MADE MONEY DOING OTHER THINGS.

131
WE CHOSE MEDICINE --SURGERY-- BECAUSE IT COMBINED A
QUEST FOR KNOWLEDGE WITH A WAY TO SERVE, TO SAVE LIVES,

AND TO ALLEVIATE SUFFERING.

WE HAVE TO CONVINCE THE PUBLIC WE STILL MEAN IT.

IF WE DO, WE'LL GET WHAT WE NEED TO DO THE JOB RIGHT.

132
I THINK I POSSESS A CERTAIN AMOUNT OF CREDIBILITY, BOTH
WITH YOU AND THE GENERAL PUBLIC.

I HOPE MY REMARKS TO YOU TODAY DID NOT COST ME SOME OF
MY CREDIBILITY WITH SOME OF YOU BECAUSE YOU DON'T LIKE
WHAT I SAID.

I THINK YOU ALL KNOW THAT MEDICINE IN AMERICA IS IN DEEP

TROUBLE, MAYBE AT A TRUE CROSSROADS.

133
IF YOU DON'T WANT TO SEE US TAKE THE ROAD TO CANADA, OR
QRH GREAT BRITAIN, DO SOMETHING NOW.

WE MUST DO SOMETHING, SOMETHING TO REKINDLE THE LOVE
OF OUR PROFESSION, THE PRIDE IN LOFTY ETHICS, THE
ENJOYMENT OF MEDICINE.

DON'T JUST WRING YOUR HANDS AND GRUMBLE BECAUSE "THEY"
HAVEN'T DONE SOMETHING.

YOU ARE THEY.

THANK YOU.

HHEEHHF

134
SPEECH
"EXASPERATION ON BOTH SIDES OF THE STETHOSCOPE"
AMERICAN COLLEGE OF SURGEONS
SAN FRANCISCO, CA

OCTOBER 8, 1990

C. EVERETT KOOP, MD

135

a