AMA Annual Meeting
Saturday, June 9, 2015
Steven J. Stack, MD
American Medical Association
Thank you. I am both honored and humbled to stand before you tonight as AMA president. Of course, I would not be here were it not for the love and encouragement of my family; the support of my colleagues, both in medical practice and in organized medicine; the inspiring examples of previous AMA presidents; or the ongoing labors of our leadership on behalf of the profession. To each of you – to all of you – I am eternally grateful.
It is a special privilege to become the first emergency physician to serve as AMA president. Like many in this room, my specialty has profoundly shaped who I am as a physician, and as a person.
One thing I love about emergency medicine is its capacity to teach. Every day I'm in the emergency department I learn something about life. For one thing, I learn what not to do in life. For example, never put a firecracker in an upside down beer can, light the fuse, and put your foot on top to see what happens.
And if you're going to hammer a nail into a board, don't swing the hammer toward your face. Believe it or not, you may miss the board entirely and etch a hammer-shaped arc in your two front teeth. It's been said truth is stranger than fiction. Let me assure you, truth in the ED is a lot stranger than fiction.
Of course, it's the deeper, more profound lessons that truly leave their mark. The emergency department is the great equalizer in the health care system – a place where rich and poor, insured and uninsured, those at death's door, and those with minor aches and pains, lay side by side. You quickly realize that illness does not discriminate – that the C-suite executive is no more immune to accidents or emergencies than the homeless man living under a bridge.
You also become increasingly aware of society's failings and the people who fall through the cracks in the system…The elderly woman who visits the ED week after week because she is lonely. The man so addicted to opioids he makes the rounds of all the area emergency departments, scoping out the new physicians and duping them into writing a prescription.The young mother who works two jobs but can't afford health care, so now she seeks care in the ED with a large mass in her pelvis.
Being an emergency physician also teaches you how important it is to be able to adapt. Sometimes there aren't enough beds available. Sometimes there aren't enough nurses or specialists on hand to attend to a patient. So you quickly move from plan A to B. And from B to C. When lives are at stake, there's no time to lament the challenges before you. You make the most of what you've got and move forward. And, more often than not, it works out.
These lessons have furnished me with a sense of perspective regarding the challenges we face in organized medicine. If one lesson stands above the rest, however, it's how tenuous and precious life is – and what a gift it is to be a physician.
I recall a particular patient who drove this point home for me. It was about 4 a.m. Christmas morning, 2010. I was working the night shift. A young man arrived in the emergency department with symptoms about as vague as it gets. For the sake of anonymity, I'll call him Joe.
Joe had been sitting at his computer doing some work, when he got a funny feeling in his back – a strange pain that just wouldn't go away. So he went to the hospital to get it checked out. Obviously, many conditions – mostly minor – can trigger a funny feeling in the back. But something about the way he described his symptoms led me to suspect a 1 in 100,000 diagnosis: a thoracic aortic dissection.
Joe was in his 30s, by all indications healthy, and his pain could best be described as mild. Nevertheless, something didn't sit right with me. So I ordered a CT scan, and sure enough, my fear was confirmed.
I went to Joe and explained that we needed to immediately transfer him to a bigger hospital for emergency surgery. Some of his family had shown up by this point, and I had to make sure they understood the gravity of the situation. If Joe's aorta ruptured, he would die in transit. They needed to take this opportunity to exchange last words.
At the same time, I didn't want to deprive them of hope. This was one of those situations where both the patient and his family needed to have the utmost confidence in his physicians. So I did my best to walk that fine line between being compassionate and being strong.
As we were getting him ready to leave, Joe asked his nurse to write down a phone number. He said to the nurse, "Please, don't let me die. But if I do, promise me you'll call my girlfriend and tell her I'm sorry we argued."
As I said, it was Christmas morning. After my shift ended, my wife drove us to Cincinnati to spend the holiday with her family. All day, I kept logging on to check the University health records. As long as laboratory data kept showing up, I knew he was still alive.
Now, fast forward to Christmas 2011. I didn't work the holiday that year, but suddenly the phone rings and it's my colleague. He says, "Some guy just stopped by and said you took care of him last year. He wanted to thank you for saving his life."
For many, that life changing moment – that defining moment when what's important suddenly draws into focus and the mundane falls back into relief – occurs in a physician's care. The birth of a child. The loss of a loved one. An unexpected diagnosis. The physician's life is defined not by one, but by hundreds of these moments. Our profession is literally built around them. And to play a part in these moments is a priceless gift. These are the moments we went to medical school for. These are the moments for which we forego nights with our families. These are the moments that sustain us.
Unfortunately, too often these life-changing moments are overshadowed by other, more mundane matters – the day-to-day trials and tribulations we face as we navigate the health care system. During my travels across the country I've been struck by the sense that so many physicians feel under siege. It's easy to understand why.
These days just about everyone has an opinion about how we should do our jobs. The government compels us, under threat of penalty, to purchase electronic health records. So we go out and buy them. But instead of increasing efficiency they slow us down, eating up valuable time that would be far better spent at the bedside.
The health system executive institutes policies that don't make clinical sense – abandoning patient interests in favor of spreadsheets and financial models. And physicians are left scrambling to fill in the gaps.
The insurance company steps in with its medical opinion, questioning whether a particular procedure was necessary – denying payment for tests that in cases like my patient Joe's – can mean the difference between life and death.
And the lawyer circles like a hawk above us, witnessing the failures of the system, looking for any opportunity to assign blame to the person most easily accountable under law – the physician.
All these demands leave us exhausted – accountable to everyone, yet without the autonomy needed to deliver on everyone's expectations. And the highest expectations, of course, come from ourselves. We know the level of care our patients need and deserve. And we are unwilling to compromise on that care, regardless of the obstacles and burdens the system throws in our path.
I experience these trials and tribulations regularly in the ED. I've labored through the 70-page transition of care documents. I've been forced, in this day of nanotechnology and genetic sequencing, to head over to the fax machine because our hospital computer can't talk to the one across town.
I've marveled at the sparkling legibility of the reams of paper produced. Perfectly legible…yet utterly incomprehensible. I've marveled at the fact that an industry responsible for one fifth of this nation's economy can be less technologically adept than a fantasy football website or an online video game.
These kinds of daily frustrations are disheartening. And there are days when I feel overwhelmed. Powerless to shape my own future, let alone those of my patients. But that is only part of the story.
A couple of months ago, I attended the 200th meeting of the World Medical Association in Norway. During my stay, I had the opportunity to tour some of Oslo's highlights, including a dramatic bridge by the artist Gustav Vigeland. What makes the bridge so striking are the 58 life-size sculptures perched along its two rails.
As you approach one of the rails, the first thing you encounter is a woman fighting a dragon. Further down, there's a man and woman arguing. A bit further along a child clenches his fists in anger. The images continue in this way, captivating in their own right.
But then when you look across the bridge to the other rail you're surprised to see the polar opposites portrayed. The other side of the story. There's a sculpture of a child, but this time he's skipping in reverie. The couple that was so fiercely arguing is now kissing. And the woman who bravely fought the dragon…is now clutching it in warm embrace.
All along the bridge this duality is movingly displayed. The joys of love. The anguish of love. The pleasures of childhood. The frustrations of childhood. It's all part of the human condition. Part of the rich pageantry of life.
When I reflect on being a physician today, I see many challenges. But for each story of frustration, there is a story of vision, perseverance, and success. There is a story of hope. Think of some of the AMA's recent victories…
For well over a decade, America's physicians toiled to fix the broken Medicare payment system. Year after year we marched to Capitol Hill with solutions. And year after year we were turned away. But we refused to give up.
In the face of adversity, we gathered our strength. As the obstacles mounted, we redoubled our efforts. With every passing year, our voice grew stronger. With every year, our voice grew louder. Until finally, we could not be ignored.
Two months ago, because of a quest that started right here in the House of Medicine, Congress passed the Medicare Access and CHIP Reauthorization Act. And because of this law, today 49 million seniors and 10 million members of the military and their families are assured access to care in their time of need. And the one million physicians who serve them, have the stability we need to provide the best possible care.
This is just one example – just the most recent example – of the kind of impact America's physicians can have when we stand together. And there are more.
Today, because of a quest that started in the House of Medicine, the number of uninsured Americans has dropped to the lowest level in seven years. Today, because of a quest that started in the House of Medicine, 10 million more Americans are taking control of their health – engaging with the system in times of wellness, as well as in illness. Today, because of a quest that started in the House of Medicine, physician-led accountable care organizations have become the top performers in Medicare. They're not only improving patient care…they're saving tens of millions of dollars for the system.
Since the AMA was founded in 1847, physicians have faced one obstacle after another. Medical quackery. Substandard medical education. Ethical dilemmas. The perils of smoking. HIV/AIDS. Whatever the obstacles, the AMA has faced them head on. And together, we have overcome them.
As some of you know, I studied the Classics during my undergraduate years. This background has furnished me with a wealth of useful knowledge. For example, when most people hear the name Cicero they think of history's most famous orator. I think of hummus. That's because the Latin word for Cicero essentially translates to chickpea.
In addition to giving me a clear advantage in Trivial Pursuit, studying the Classics affords valuable insight into human behavior and politics – lessons as valid today as they were two millennia ago.
For me, one figure that always stood out is Alexander the Great. Crowned king of Macedonia at age 20, by 30 he had amassed one of the largest empires of antiquity. It stretched 3,000 miles across parts of modern day Europe, Asia and Africa. With unparalleled ambition and endurance, Alexander conquered nations, founded cities in his name, and built a personal legacy that endures to this day. But just a few years after Alexander died, his massive empire had fragmented and fallen apart. Rome, by contrast, thrived for centuries. The lesson from the pages of history could not be more clear: an empire built by one man will not stand. An empire built by many endures.
I have always felt that the power of the AMA lies in the sheer diversity of our membership. Instead of representing one particular specialty, or one particular state, we represent all physicians, in all states. We represent medical students, residents, young physicians, international medical graduates. We represent minority physicians, senior physicians, LGBT physicians. Our membership is as diverse as the patients we serve. Each one of us brings something different to the equation. And together, our collective voice is as rich and nuanced as it is strong.
Today our quest is broader, bolder, and more visionary than ever before. Rather than reacting to the changes and challenges transforming health care, the AMA is stepping out to lead the way forward. Rather than waiting for tomorrow, we're creating the future of health care today. Our vision is ambitious:
- To profoundly improve health outcomes for the 86 million people in this country with pre-diabetes and the 70 million with hypertension.
- To forge a generation of physicians prepared to meet the needs of our 21st century health care system.
- To restore the joy in medicine and enable physicians to spend their time where it matters most – helping patients.
These are lofty goals, and achieving them will not be easy. Nothing worthwhile ever is. But as physicians, we have never shied away from challenges. Rather, by working together, we have always found a way to overcome them – one patient at a time, one family at a time, one community at a time.
I recall a truck driver I treated early in my career in Memphis. Let's call him Matt. Matt arrived to the ED in a taxi. I point that out because some folks don't hesitate to call an ambulance for a runny nose. But Matt was the opposite. He made his living crossing the continent in an 18-wheeler, and he'd been having chest pain for hours before he finally decided to pull over.
He walked into a truck stop and asked the cashier, "Can you call me a cab? And by the way, can you recommend a hospital?"
Matt found us, and we immediately did an EKG. It showed he was clearly having a heart attack – he'd probably been having it for hours. My team and I administered numerous medications and were able to stabilize him to such a degree that he could be admitted to the hospital.
The next night when I arrived for my shift in the ED, a "Code Blue" was called in the operating room. One of the nurses turned to me and said, "I think the fellow we took care of last night just went up there." So I went up to the OR and sure enough, there was Matt on the table – a cardiac surgeon leaning over him. I asked the surgeon what had happened, and he filled me in on the extraordinary chain of events.
After leaving the ED, Matt had spent an uneventful night in the hospital. In the morning he saw a cardiologist for a catheterization. The cardiologist discovered blockage so severe that stents would not be enough, so he scheduled Matt for an urgent open heart bypass. At the appointed time, Matt arrived in the operating room. But the moment the anesthesiologist put him under, he went into cardiac arrest. A code blue was called, and for all intents and purposes, Matt was dead.
That's when the cardiac surgeon made a series of split-second decisions. With lightning speed he attempted to put Matt on the bypass pump so the surgery could proceed. But when he tried to insert the catheters into Matt's femoral artery and vein, they were so calcified that the catheters would not pass. Without blinking, the surgeon moved to plan B. He cracked open Matt's chest, inserted the bypass catheters directly into Matt's aorta and vena cava, and commenced open heart surgery. All of this, within the four or so minutes necessary to prevent brain damage.
A few days later, I stopped by Matt's room to see how he was doing. And in a surreal moment, this man who had nearly died before my eyes in the ED – and literally died before my eyes in the OR – stood up, walked across the room, and gave me a bear hug.
When it comes to something as important as saving a life, numerous factors come into play. Speed. Mental dexterity. Decades of training. Hope. Above all, it takes a team. At the end of the day, which one of us was responsible for saving Matt's life? Was it the quick-thinking cardiac surgeon? Was it the cardiologist who detected the blockage? Was it those of us in ED who stabilized his heart attack? What about the nurses who cared for him, or the assistants in the OR?
Like everyone in this room, I was drawn to organized medicine because I realized that the only way to take on big problems is through collaboration with others. Each one of us has a role to play. Each one of us contributes something the other cannot.
The same can be said of health care in this country. When it comes to something as important as shaping a better, healthier future, it will take every single one of us. Physicians. Payers. Policymakers. Patients. Every one of us has a part to play. We cannot do it alone.
As that famous orator Cicero once said, "We were born to unite with our fellow men, and to join in community with the human race."
Colleagues, it is my honor to join with you in the year ahead. It is my honor to fight alongside you, on behalf of this country's physicians and patients. Today the AMA tenaciously pursues a healthier future. And we will get there because of our past.
We will get there because of the rich foundation that supports us. We will get there because of the vision and fortitude that are the hallmarks of this profession. We will get there because America's physicians have always stood – and still stand today – united as one.
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