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The Future of American Health Care Is in Our Hands

Inaugural Address
AMA Annual Meeting
Chicago, Illinois
June 18, 2013

Ardis D. Hoven, MD
President
American Medical Association

Good evening and thank you.

A few weeks ago I had the honor of addressing the graduates at the University of Kentucky School of medicine. As I said to them, had you told me 30 years ago I would become AMA president one day, I would not have believed you.

Back then I spent more time contemplating survival. Specifically, whether it was possible to survive biochemistry with one’s sanity still intact. Today we know the survival part is possible. The sanity… Well that’s another matter.

The fact that I am standing here today is thanks in no small part to everyone behind me on this dais. The leaders of our state societies. The presidents who have gone before me. And the members of our Board.

Without your guidance – without your willingness to mobilize and take action on behalf of the physicians and patients of this country – the AMA would not be what it is today.

So I would like to ask everyone in this room to join me in expressing our gratitude. And of course I also owe my gratitude to the family members, friends and colleagues who have supported me. Thank you all very much.

Tonight I stand before you as so many things. A woman. A Kentuckian. A lover of the finer things in life…basketball, Churchill Downs, and a good mint julep.

Most importantly, I stand before you as a physician. Specifically, an infectious disease specialist. When you tell people you’re an infectious disease doctor you get a lot of reactions.

Some greet you with a look of curiosity . . . Mingled with thinly veiled anxiety. When you go to shake their hand they smile and offer an elbow.  And before you’ve turned your back, they’re dashing off to wash their hands.

Others politely raise their eyebrows and say “Interesting,” in approximately the same tone they would use to address a mortician. You can almost see the thoughts running through their minds.

“So…blood and guts were not good enough for her. She needed something more… Germs. Microbes. Deadly bacteria…”

The truth is, not a day passes where I don’t give thanks for my choice of specialty. Like so many in this room, my experiences as a physician have molded me and made me who I am today.

I began my career back in the late 70s at the Lexington Clinic – a large, multispecialty practice. At the time I was the only infectious disease doctor in the community.  I threw myself into my work, eagerly treating patients with an array of diseases, from TB to infective endocarditis to legionella.

And then I started seeing a new kind of patient. Mostly young men, many of them very talented, afflicted with a horrific disease that killed them within months – sometimes even weeks. AIDS.

One of my patients at the time was a young gay man who taught in the local school system – Paul.

Paul came into the emergency department suffering from pneumocystis pneumonia, one of the AIDS-defining infections. I told Paul what he had, and over the next few months we did everything we could to fight it.

But the disease was stronger.  Eventually I told Paul he needed to inform his family. But he wouldn’t hear of it. His family didn’t know he was gay, and he was terrified they would disown him.

So instead, he told them he was sick. He didn’t say how sick – or with what.  Well one day Paul’s family came to visit. They were from out of town, so they hadn’t seen him in a while. They took one look at his emaciated frame and just fell apart.

His sister grabbed me by the arm and said, “Doctor, you’re a nice person. But you don’t know what’s wrong with my brother. We need to move him to the Mayo Clinic.” You can imagine my exasperation.

This went on for a few days, but eventually I convinced Paul to tell his family the truth. I’ll never forget the poignancy of that moment. Paul’s mother looked at him and said, “Son, why didn’t you tell us sooner? We don’t care that you’re gay. We love you, and we will always be at your side.”

One of the great gifts of being a physician is how your patients change you. Just as you have an impact on them – comforting them, hopefully curing them – they leave an indelible mark on you. And it’s not just the patients, but also their families.

My AIDS patients and their family members taught me about strength. About courage. And about never, ever passing judgment about something you do not understand. Unfortunately, the hardships for Paul – and for countless patients like him – were just beginning.

Shortly after that encounter with his family Paul became progressively more ill and unable to go to work. He lost his teaching position . . . And with it…his health insurance. It was a scene I witnessed over and over again.

First my AIDS patients faced the physical trauma of the disease itself. Next, they were terrified of discovery by employers, families and friends. Of being “outed,” and suffering from a disease people considered akin to the plague.  Third, just when they needed health insurance the most, they lost it. Then came the final straw.

As AIDS began to spread, fear gripped the nation. People thought you could catch it on the street, riding the bus, or shaking hands. Some absurd laws were proposed, such as incarcerating AIDS patients so they could not infect the community.

And the mood in Kentucky was no different. The state legislature was intent on passing a bill that would have made life significantly harder for my AIDS patients. And for me, that was one indignation too many.  I may not have been able to save my AIDS patients at the time, but I knew I could do something about the legislature.

Right away I recognized it would take the clout of an organization like the Kentucky Medical Association. So I stepped up my involvement at my local society, and was soon elected to the KMA House of Delegates. We fought the legislation, and I’m happy to say…we won.

In that moment, I recognized the power of organized medicine. For the first time, I saw how an issue I faced in my exam room could be taken to a higher level. And if resolved at that higher level, the benefits would reach not only my own patients, but every patient in the state of Kentucky.

To put it simply, in that moment I realized that the collective voice – the voice of America’s physicians – had the power to make a difference.

Ironically, during my travels over the past year as president-elect I’ve been struck by just how many physicians feel dis-empowered. It’s not hard to imagine why. After all, we are living through some of the most dramatic changes to America’s health care system in a century. Accountable care organizations… EMRs… physician quality reporting…health insurance exchanges…

When it comes down to it, physicians fear losing their autonomy. They fear that crucial health care decisions will be dictated by the government, or administrators, or health insurance companies. They fear someone else will tell them how to practice medicine …someone who has never sat next to a patient and delivered a life-saving treatment. Or a life-changing diagnosis.

I will not stand here today and tell you that change is not upon us. I will not deny that the ground is shifting beneath our feet. But I will tell you this: our foundation is solid.  Because this platform of ours – organized medicine – is as solid as they come. It has survived some 166 years.

A Civil War…two World Wars…the Cold War…and 34 presidencies. This platform yielded the first code of medical ethics, the first standards for medical education and the most widely circulated medical journal in the world.

This platform has helped physicians address challenges throughout the decades… Whether it was fighting quackery at the turn of the century… or promoting the adoption of modern surgical technique… or battling the disease that has defined my career: HIV/AIDS.

This platform is powerful. It was powerful 100 years ago. It was powerful 50 years ago. And it is powerful today.  So yes, right now we are living through historic change. And some may lament that fact.  But I say, we are lucky. Because the great thing about living through history, is we don’t have to just witness it. We can shape it.

Not far from my home in Lexington is a city called Georgetown, where they make Toyota cars. I’ve had the opportunity to tour the Toyota plant, and it’s fascinating to witness the transformation of steel coils into newly minted automobiles.

Even more fascinating is learning about the Toyota Way, with its focus on two key areas: respect for people, and “kaizen” – or striving for continuous improvement.

Each Toyota team member takes ownership of their part of the production process. If a problem emerges, the team member has the ability to stop the production line and fix it before sending it on.  Moreover, team members actively contribute to process improvement. In fact, the company adopts more than 90,000 employee suggestions every year.

The Toyota Way is about innovation. It’s about each individual bringing their own unique perspective, and working with the group to continually advance the end product.

Just imagine if we took a similar approach to health care today. Imagine what we could accomplish if we face the challenges before us head on. Together we can ensure that a solo practice in rural South Dakota, an academic center in New York, and a large, integrated system in Chicago have equal chance at prosperity.

Together we can combat the epidemic of chronic conditions plaguing the nation. Together we can foster innovation in medical education, so future physicians are better prepared for the realities of 21st century health care.

Together we can improve health care technology, so we don’t have to spend two hours at the end of the day typing data into an EMR. Together we can achieve meaningful medical liability reform. Together we can eliminate the Independent Payment Advisory Board.  And together we can put the so-called “sustainable” growth rate formula to bed once and for all!

By standing together, united in vision and commitment, physicians can shape the health care system this country needs.  And I’m not just singing the party line. I’m speaking from first-hand experience.

To continue my story…as most of you know I was elected KMA president in1993. That very same year, the governor of Kentucky attempted to pass legislation that would have made it virtually impossible for physicians to continue caring for the uninsured.

So all of us at KMA banded together. We fought the legislation, and we prevented it from passing.

Meanwhile, here at the AMA we were fighting for reform at the national level. In the late 90s, as Chair of the AMA Council on Medical Service I had the opportunity to help develop policy for covering the nation’s tens of millions of uninsured.

In 2007, as you will recall, we launched the "Voice for the Uninsured” campaign. We gave America’s underserved a voice in the halls of Congress, on TV and in the newspapers.  And the nation listened. Health system reform became a central topic of the 2008 presidential election.  As a result, just eight months from now some 30 million Americans will gain access to insurance.

People with pre-existing conditions. People struggling to make ends meet. People like my patient all those years ago . . . Paul. The fact is, each and every day – each and every one of us – has the opportunity to make a difference.

If you hear in the doctor’s lounge that your hospital is planning to ship their entire electronic medical program to a foreign country, speak up.  If an administrator decides you need to see a new patient every 15 minutes, push back. If your practice is seeing a rise in addictions to prescription drugs, go to the local Rotary meeting. Or the school board meeting.

Never forget the tremendous influence physicians carry in our communities.  We are considered the indisputable authorities on health care. Whether it’s in the church, the local civic organization, or the government, we bring something to the table no one else can – the physician perspective.

Of course those two words – “physician perspective” – can mean a lot of things. During this contentious time there are plenty of opinions to go around.  So what exactly is the physician perspective? And how do we agree on the best path forward?

One of my favorite activities as a child was walking along the beach with my Aunt Rowina. She lived in Oregon and whenever we visited, Rowina would take me “treasure hunting” along the Pacific Coast. Treasures were things you could see, feel, and hear.

We would see the driftwood blown up by a storm, the spindly sea urchins, the clouds on the horizon. We would feel the cold water dart between our toes, or run our fingers along the whorls of a shell. And we would hear the crush of waves over rocks, or bird calls on the wind.  By the time we finished our walk we’d discovered an array of treasures – of details really – that hadn’t been immediately apparent when we arrived.

During this controversial time, physicians need to take a step back and carefully examine their environment. We need to recognize all the options, weigh them, and dig into the details before rushing in with an opinion. Above all, we need to listen.

We need to take the politics out of medicine and listen to our colleagues not as Republicans, Democrats or Independents, but as physicians.  Too often the members of America’s health care system operate in silos. The pharmacy silo. The physician silo. The hospital silo. The insurance company…the government…the medical school.

If we are to fix the system, we need to step outside our silos and learn to connect to each other in a meaningful way. And there is another way.

A perfect example is the Ryan White Program – a national initiative that works with communities to provide care for HIV patients. I work at a Ryan White Clinic and have experienced the benefits of its physician-led, team based approach.

As a physician I am like a quarterback, coordinating care for my patients. I work hand-in-hand with a team of physician assistants, nurses, pharmacists, counselors, dieticians, and case managers.  Each of us has a role to play, whether it’s ensuring a patient takes their medicine or addressing their psychological needs. Together we increase efficiency and improve outcomes. Together, we accomplish what none of us could have alone.

Colleagues, these days “change” has become something of a dirty word. Something to be resisted at all costs. But the reality is –change breeds opportunity…and more often than not, progress.

The changes I’ve witnessed in my own lifetime have been incredible. About 22 years ago, a young woman was brought into the emergency department suffering from grand mal seizures. We admitted her and discovered she had CNS lymphoma, one of the AIDS defining illnesses.  Two weeks later, she died.

About a month after that, I looked at the office schedule and saw a six-year-old boy on the list – Tommy. It turned out he was the son of the woman who had recently died. He’d gone to live with his aunt and uncle, and now they were concerned he might have AIDS.

So here was this poor little guy in my office. He was cute as a button. And smart. He didn’t know what was going on, but he could tell by the tension in the room it wasn’t good. My heart went out to him. I tested Tommy, and sure enough our fears were realized – he was HIV positive.

But fortunately – a couple things were working in Tommy’s favor. Number one: It was 1991, not 1981. And number two: he had HIV, not AIDS. In just a decade, the advances the medical field had made in its understanding of HIV were incredible.

Thankfully, Tommy responded well to treatment. And he continues to respond well to this day. Today Tom is 28 years old. He works on the family farm and leads a full, active life. In almost three decades, he has never once been hospitalized for HIV.

My fellow physicians, change can be scary. But we must never forget: change can also be good.  Today we stand at a crossroads in the history of health care in this great nation. Behind us lies a century of failed attempts to improve the system. Ahead of us lie two distinct paths.

One is the path of inaction. Of glorifying the past, succumbing to partisan politics, and thwarting any attempt to move forward. The other is the path of action. Of collaborating, innovating, and leading the drive toward productive change.

Colleagues, I think you know which path we belong on. And I look forward to walking it with you in the year ahead. Let’s do right by our patients.  Let’s leverage the power of organized medicine.  And let’s never forget… The future of American health care . . . is in our hands. Thank you.

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AMA President Ardis Dee Hoven, MD