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Legacies in the circle of life

June 14, 2008

Opening Session of the AMA House of Delegates
Hyatt Regency Chicago
Chicago, Illinois

Ronald M. Davis, MD
President
American Medical Association

Thank you so much. Good afternoon.

I wanted to start out with that song, because "The Lion King" was by far the best stage play I've ever seen. And that opening music reminds us that we all eventually will take a journey around that circle of life. What's important is what we accomplish on that path. Leaving a good legacy is something each of us will eventually consider, some sooner than others.

This year has been the most eventful year of my life, in large part because I've had the privilege of being the president of this extraordinary organization. And as those lyrics said, "There's more to see than can ever be seen; more to do than can ever be done." I can't think of a better job description. It's overwhelming.

It's also been an eventful time because I was diagnosed earlier this year with pancreatic cancer. And I want to thank all of you for your thoughts and prayers over these past few months. They mean the world to me, and to my family.

Things were especially eventful a couple of weeks ago when my hair began falling out because of a toxic chemotherapy reaction. I used to have a pretty decent head of hair. Now, as you've seen, I have this new hairstyle. It's actually been kind of fun, to be honest with you. I very briefly had a Mohawk, and an earring. There's evidence out there, somewhere. And being bald is a medical reminder of our natural state of being. It happens to those who age, and those who get sick. We very often lose our hair, there's simply no denying it. But getting back to the circle of life, that's how we came into the world as well. Telly Savalas used to say, "We're all born bald, baby." There's another quote I actually prefer, from the Roman philosopher Seneca the Younger. He said, "I don't consider myself bald, I'm just taller than my hair." My wife Nadine's favorite is that there are three ways a man wears his hair: parted, unparted, or departed.

As a physician trained in epidemiology, I look for data to understand the effects of illness. So I was happy to find a survey on HairBoutique.com in which more than 2,600 people answered the question, "What do you think of bald men?" Of course, this survey does not meet the CDC's standards for valid epidemiologic research. But I was interested to read that the top response was, "Bald men are hot."

Well, we can look at a bald pate as a kind of circle, too. And that's what I'm going to talk about today: circles.

I'd argue that there's no profession as closely identified with the circle of life as is the physician. Even before conception, we have those who specialize in Reproductive Medicine. Then we have the OB/GYNs who administer prenatal care, and bring newborns into the world. We have Pediatricians and Family Physicians who nurture our children. The majority of physicians care for adults. And then we have Geriatricians and physicians who specialize in Hospice and Palliative Medicine who take care of people in their twilight years. So we physicians help people move through the circle of life.

Organized Medicine has its own circle as well. I was privileged to start at the AMA in the Medical Student Section, about 30 years ago. For those in the MSS today, go ahead and raise your hands high. Please. The same for those in the Resident and Fellow Section. And for those in the Young Physicians Section. And now, how about the rest of us old fogies giving them our kudos, for them getting involved so early in their careers?

Ladies and gentlemen, they are the future of medicine. Like the rest of us, they'll transition into a multitude of positions, in state and specialty medical societies, in medical schools, on hospital medical staffs, and elsewhere. Many of them have already done so. Once they're established, they'll move on into the twilight of their own careers, and eventually become part of our AMA Senior Physicians Group. And that's a place where even we old goats can thankfully still contribute.

They are the ones to whom each of us will leave our own legacy. They'll be the ones who pick it up and move it after we're gone. And establish legacies of their own.

So where are we on our current AMA legacy? The issues that tie us together, that bring us here today as this august body?

Well, our Medicare physician payment and SGR status remind me of another circle; actually, a wheel. It's one we sometimes get a little traction on. But mostly, it just spins. And I'm not talking about us spinning our wheels in a hot rod at the starting line, ready to go forward at 200 miles an hour as soon as Natalie Wood drops the handkerchief, as she did in the movie "Rebel Without a Cause." What I am talking about is a hamster wheel. We just keep going around and around in circles.

Senate leaders are working right now to give us positive updates for Medicare payment for the next 18 months. But these proposals rely on a financing mechanism that's expected to create the potential for a 21 percent physician payment cut in 2010. So the meltdown scenarios we've been talking about for years are becoming more and more ominous. But perhaps the specter of a 21 percent cut in Medicare physician payment, and what that will mean for seniors' access to physician services, is what will finally get us off the SGR hamster wheel. Two days ago, the Senate fell several votes short of passing one of the SGR relief bills, Senate Bill 3101. So we continue to chase our tails, or the tail of Congress, as the case may be.

Then there's the issue of 47 million uninsured people in this country. The AMA has done a Herculean effort to bring this to the attention of the public. Yesterday, 400 AMA medical students and residents attended the Chicago White Sox game to talk to Chicago families about the crisis of the uninsured, and to encourage adults to vote in the November election with this issue in mind. Before the start of the game, the AMA's "Voice for the Uninsured" television advertisement played on the stadium jumbotron. I'd like to applaud those students and residents, and everyone else who has been involved in our national campaign.

And when it comes to campaigns, we're now down to the final two presumptive nominees from their parties running for President. Here are a couple of pins, one for each of them. They're circles, too.

One of the true pleasures of observing this historic presidential race is that health care, including the problem of the uninsured, is finally at the top of everyone's domestic agenda. For the candidates, for the media, and for the voters, our patients. Both of the candidates have plans to deal with the issue. And when you study them closely, you'll find that many elements in each of their proposals come right out of what we've been talking about at the AMA for quite a while.

We've asked both candidates to respond to 10 questions about health system reform. One question, for example, is, "How many Americans would have health care coverage under your proposal, and what are the total costs and sources of financing for your proposal?" Another question is, "What's the role of health information technology (Health IT) under your proposal, and how would the purchase and maintenance of Health IT tools be financed?" Go to the AMA home page, and you'll find a link to a document showing answers to these questions from Senators McCain and Obama.

The third issue I have to mention, since I'll always be a Preventive Medicine physician, is our advocacy of Healthy Lifestyles.

We all have our own favorite circles when it comes to this category. Unfortunately, for most of us, they're pizzas, hamburgers, and doughnuts. In the Detroit area, which has a large Polish population, we have a tradition of eating paczki, the Polish deep-fried pastries that resemble jelly-filled doughnuts. They're especially popular around Mardi Gras time.

Mardi Gras means "Fat Tuesday" in French. As many of you know, it's the day before the beginning of Lent, the 46-day period before Easter, which involves fasting and abstinence. So Fat Tuesday is the opportunity to pig-out before Lent begins. But what seems to happen is that people use Fat Tuesday to pig-out, and then forget about the fasting and abstinence that are supposed to follow.

Each year in Detroit, we have a paczki-eating contest on Fat Tuesday. A few years ago, the winner of the contest ate 15 paczki in 15 minutes. Ladies and gentlemen, that's 6,000 calories and 375 grams of fat, in 15 minutes. Another vivid example of our toxic food environment.

But did you know that at the AMA Board meetings now, we're all eating "healthy choices"? And that at our headquarters in Chicago, we have nutritional value charts posted in our cafeteria? You can't miss them, and they tell you what those bacon bits will cost you in the long run.

The New York City Board of Health recently adopted rules to make restaurant chains do something similar to that, displaying calorie information on their menus or menu boards. Information on calories would be provided as prominently as the price of each menu item, so that consumers would get this information before they decide what to purchase.

The restaurant industry has challenged the rules in court. But we've joined with the Medical Society of the State of New York and several public health organizations in signing onto an amicus brief that defends the new regulation. And I'd urge all of you to push for similar laws or rules in your own states and communities.

Getting back to circles, there are some that we ought to be embracing. Circles like bicycle wheels. Tennis balls. And hockey pucks. And I confess, I include hockey pucks to give a shout-out to my hometown heroes who now, once again, possess the Stanley Cup, the Detroit Red Wings. I think our son Evan has already spent his entire summer entertainment allowance on Red Wings' championship paraphernalia.

Most of you have heard about our collaboration with the American College of Sports Medicine. I'm referring to the "Exercise is Medicine" initiative. Just remember, the old saying, "Do as I say, not as I do," does not apply to exercise. As physicians, we need to be physically active for the same reasons that apply to our patients. Plus, physicians who exercise are more likely to counsel patients about exercise. Let's heed the advice of the renowned second-century physician Galen, who said, "That physician will hardly be thought very careful of the health of his patients if he neglects his own."

For those who attended the Presidents' Forum in February, you had a chance to see the Steelcase WalkStations inspired by research conducted by the Mayo Clinic's Dr. James Levine. He's shown that people who walk on a treadmill, at the slow pace of one mile per hour, can do computer work at the same time, in their normal work attire, without working up a sweat, while burning 100 calories an hour more than sitting in a chair. So three or four hours of walking at that pace would burn at least as many calories as a vigorous workout. Now we have a new strategy to combat the obesity epidemic, creating opportunities for what Dr. Levine calls Nonexercise Activity Thermogenesis, or NEAT. Nothing would please me more than to see WalkStations in use at future House of Delegates meetings, so we can "walk the talk" while we do the business of the AMA.

Is anybody here a fan of the travel writer, Bill Bryson? He wrote a wonderful book called "A Walk in the Woods," which was about hiking the 2,100-mile Appalachian Trail, from Georgia to Maine. During a stop in Waynesboro, Virginia, he needed to find a store to buy insect repellent. A man outside the post office suggested that he try Kmart, and asked him where his car was.

Bryson said he didn't have a car.
The man said, "It's over a mile, I'm afraid."
Bryson said no problem.
So the man gave him directions, but then he said, "You know, when I think about it, it's well over a mile – maybe a mile and half, mile and three-quarters. You walking back as well?"
Bryson said yes.

The man shook his head and said, "Long way."
Bryson thought a second, and he replied, "I'll take emergency provisions."

The man missed the joke entirely. Then he told Bryson, as an afterthought, that there was a taxicab company around the corner. Of course, when you're in the middle of walking more than 2,000 miles, a few extra ones out of the way to the local Kmart are no big deal. But the point is that many of us have forgotten how to walk.

Let's turn to tobacco and cigarette smoking in particular, which kills more than 400,000 Americans annually.

Last year, the AMA strongly backed increases in federal excise taxes on tobacco products to help fund the State Children's Health Insurance Program (SCHIP) and legislation to avoid Medicare physician payment cuts. Unfortunately those tax increases, though passed separately by the House and Senate, did not become law. So we'll need to bring them back, and get them passed.

In addition, we've strongly supported pending legislation to give the Food and Drug Administration (FDA) authority to regulate tobacco. We've commented many times about how outrageous it is that the most important preventable cause of death in our society is one of the most unregulated consumer products. Bills to give the FDA authority over tobacco have passed the Senate Committee on Health, Education, Labor, and Pensions and the House Committee on Energy and Commerce. It's time for the full Senate and House to approve those bills.

Last month, the AMA hosted the release of the updated national guideline on treating tobacco use and dependence. It's a blueprint for clinicians that identifies pharmacologic and behavioral interventions that can help people quit smoking. We urge all physicians to screen all of their patients for tobacco use, and to advise and assist them in quitting.

Many physicians are not yet leading the way in healthy eating and exercise. But fortunately, very few among us are smokers. We've come a long way since a 1940s advertising campaign proclaimed that "More doctors smoke Camels than any other cigarette." Our challenge now is to get our patients to follow suit.

As one last item on the tobacco front, I'd like to congratulate the AMA Alliance for their Screen Out! Program, a campaign to get smoking out of the movies. On Thursday the Alliance issued a press release to warn parents about yet another Hollywood film that exposes children to gratuitous smoking scenes: "The Incredible Hulk." This Universal Studios movie, which opened yesterday, is a follow-up to the 2003 film "Hulk," which did not contain tobacco imagery. In the new version, however, the Army general trying to capture the Hulk is shown puffing on a cigar in nearly every scene. So let's thank the Alliance again for drawing attention to this problem and trying to fix it.

Last month, we launched our Healthier Life Steps program. It's a comprehensive online tool kit. It's all about starting discussions between patients and physicians about healthy lifestyle choices. It has patient screening checklists, intervention plans, and motivational tools. And physicians can download them all for free at www.ama-assn.org/go/healthylifestyles. As a nice fringe benefit, if you complete the Physicians' Guide and evaluation form, you get CME credit. You've heard one of our new mantras about the new AMA, "Helping doctors help their patients." Well, that's what this program is all about: helping doctors help their patients live a healthier lifestyle. I invite you and all of your colleagues back home to participate.

There's one huge circle I'll just touch on. It's one that's been around since the beginning of time, but we're all just now starting to take care of it. I'm talking about our home, the planet Earth.

Why shouldn't physicians be the loudest advocates for a safe and healthy world for our children to grow up on? Ironically, in the health care arena, we've been behind the eight-ball when it comes to issues like being advocates for new ways of making materials, new ways of growing and distributing food, and new ways of building buildings. We in this room should try to use our clout to get products to be less toxic, to achieve more sustainable agriculture, and to show some real leadership in developing energy efficiency.

So we're working hard to catch up to where we need to be. With our recent involvement in the CleanMed conference (where Dr. Jerry Lazarus gave a forceful speech), with partners on this issue like the Canadian Medical Association, with the introduction of several resolutions on this subject at this meeting, and with follow-up by our Council on Science and Public Health, we're poised to achieve a greener health care system, with physicians leading the way.

At the June 2007 meeting, you approved Resolution 530, directing the AMA to support an initiative that promotes collaboration between human and veterinary medicine. Since then, we've participated in a task force established by the American Veterinary Medical Association (AVMA) to jumpstart that initiative.

Two facts underscore the importance of this effort. Of the roughly 1,500 diseases now recognized in humans, about 60% are due to multi-host pathogens that move across species. And, during the past three decades, three-quarters of newly emerging human infectious diseases have been zoonotic—animal diseases transmitted to humans.

This threat occurs when we have infected animals, susceptible human hosts, and an environment that enables the transmission of disease. So we have one more reason to pay attention to the environment.

The immediate past president of the AVMA, Dr. Roger Mahr, put it best when he said: "The convergence of human and ecosystem health dictates that the one world, one health, one medicine concept must be embraced." Humans, animals, and the environment we inhabit, are linked together in the circle of life.

Speaking of the world, several of your current and former AMA leaders attended a World Medical Association meeting last month near Geneva. Our AMA involvement in critical global health activities continues. And thus we're very pleased to see so many international guests here today for our own meeting, including the current President of the WMA, Dr. Jon Snaedal, from Iceland, and the Secretary General of the WMA, Dr. Otmar Kloiber. Please give all of our international guests another very warm welcome.

Let me circle back to the point I made at the beginning, the need for each of us to think about the legacy we're leaving. As you might expect, my illness has pushed me to think much more about my own legacy. But I began to think about that even before my diagnosis, when I read another book by Bill Bryson, "A Short History of Nearly Everything." He asked us to imagine the 4.5 billion years of Earth's history compressed into one normal day.

Life begins at about 4 a.m., with the rise of the first simple, single-celled organisms. It doesn't really get any further for the next 16 hours.

Then the first sea plants appear, followed 20 minutes later by the first jellyfish.

At 10:24 p.m., carboniferous forests cover the Earth, and the first winged insects take flight.

Dinosaurs arrive just before 11 p.m. And they vanish at 11:39 p.m., when the age of mammals begins.

We humans emerge one minute and 17 seconds before midnight. Our recorded history, on this scale, would be no more than a few seconds, and a single human lifetime would span barely an instant.

Thus, our existence, when compared to the history of the earth, is quite fleeting. So whether we are ill or well, we should not waste any of that time before figuring out how to leave our mark on this planet.

I'd like to end with some personal comments about being a patient.

Of course, having a serious illness is not what I'd call fun. But I've always been a cup-half-full kind of guy, so let me tell you about some of the good things that have come out of my experience.

First, getting back to this business about being bald. My son Connor no longer tells me in the morning that I have "wacky hair." I didn't have to pack a large tube of hair gel in my toiletry bag. And when I was walking here in the Windy City a few days ago, I reached for the comb in my pocket, and then realized that I didn't have one. And I didn't need it.

Also, people are giving me caps to wear. Just a few days ago, a few AMA staffers gave me a collection of AMA caps, plus a cap to recognize my affection for Star Trek. It shows a quote from Dr. Leonard McCoy, the ship's physician in the original Star Trek series. It says, "Damn it, Jim! I'm a doctor, not an engineer."

The caps come in handy because I've now realized, for the first time in my life, that it can get cold up there, especially when the air conditioning is blasting away. And as we move into the hot summer months, the caps will help me avoid getting sun burns on my newly exposed scalp.

On a more serious note, I've learned about another noble cause, raising awareness about pancreatic cancer, and raising funds for research to improve treatment for this nasty disease. Pancreatic cancer is the fourth leading cause of cancer death in the United States. This year, more than 38,000 Americans will be diagnosed with pancreatic cancer, and more than 34,000 will die from it. But pancreatic cancer research accounts for less than 2 percent of the National Cancer Institute's research funding.

The Pancreatic Cancer Action Network (or PanCAN) is leading an effort to enact and fully fund a National Plan to Advance Pancreatic Cancer Research. I'm very proud that our son Jared and many other members of my family put together a team of walkers who raised $25,000 for PanCAN at the PurpleStride Walk, right here in Chicago six weeks ago. AMA staff and Michigan State Medical Society delegates and colleagues at Pfizer were among the major contributors to our team effort.

Another good thing to come out of my illness is that I've learned about a few essential ingredients in improving the quality and safety of health care, from the patient's perspective. In my president's column in our "eVoice" newsletter two weeks ago, I wrote about the value of team care, and how it has benefited me. I've had wonderful care from physicians representing many specialties, and from oncology nurses, registered dieticians, genetics counselors, and many others.

Of course some teams work well, and others do not. So we must ensure that health care teams operate within a framework based on good communication, coordination, and cooperation. I've seen breakdowns in communication, now from the view of an educated patient, that have led to several near-misses. And so now I'm more convinced than ever before, that we must continue to intensify our efforts to improve communication, among our colleagues and with our patients, in order to prevent medical errors.

Another positive to come out of my illness is that family and friendship have been redefined for me. It's cliché to say this, but yes, a serious illness does force one to reexamine one's priorities in life. And I've been so very happy to be able to spend more time with Nadine and our three sons during these past four months. A person cannot be president of the AMA without having incredible love and support back home. And when you add the big "C" to the mix, that love and support become your lifeline. So Nadine and Jared and Evan and Connor, I can't thank you enough.

I've been so happy, as well, to reconnect in a more meaningful way with many members of our large extended families. I've been happy to hear recently from friends and former classmates with whom I've had no contact for years, or even decades. And I've been blessed to receive good wishes and prayers from many of you.

I've been asked several times, "What's it like being a physician with your illness? Does being a doctor help or hamper your situation?"

Well, here's my answer: A benefit of being a physician is that I understand what's happening to me. But a disadvantage of being a physician is that I understand what's happening to me.

As a physician, I know the survival statistics for someone with stage 4 pancreatic cancer. But if the five-year survival is 5 percent, that's not zero. And as someone with relative youth, good functional status, outstanding health care, love and support from family and friends, and a thirst for life that feeds into a strong mind-body connection, then who knows what the future holds for someone in my situation. So never take away someone's hope.

And there's one more ingredient to add to that equation, and that's faith and spirituality. Through the years I have not had a strong religious faith. But since my diagnosis, it has been rekindled.

Dr. Ed Langston, chair of our AMA Board of Trustees, pointed me toward Proverbs 3:5: "Trust in the Lord with all your heart and lean not on your own understanding." Applied to my situation, it seems to say that I should ignore the statistics on the prognosis for pancreatic cancer, but instead put my faith in God. And so, Nadine and I have prayed together several times, asking for God to help my chemotherapy to work, and for Him to heal me, and to give strength to my family in dealing with this situation. And so I count that rekindling of faith as another positive that has come out of my illness.

The last benefit of my illness that I'll mention is that it has helped me to appreciate, and to teach others about, the value of patient Web sites, such as those on CarePages.com and CaringBridge.com. Many of you have been reading the updates I've posted on my own CarePage. These websites make it easy for patients and their families to share information, to receive good wishes and prayers, and to build a community of support. I'm pleased that the Associated Press ran a story last Monday about patient websites, and I encourage physicians to educate their patients about this therapeutic tool.

When I've experienced pain from my cancer, or nausea from my chemotherapy, my physicians and nurses have often asked me to rank that pain or nausea on a one-to-ten scale. Part of the reason for that, as you know, is to assess my response to treatment, and the effectiveness of anti-nausea and analgesic medication. Hearing this, my wife began to ask me the same question: "How's that Compazine working? How bad is the nausea now? What's the number?"

Well, I got tired of saying two, or three, or four. So at one point, I said, "I'd put my nausea at Pi." She said, "What?"

I said, "You know, the Greek letter Pi. 3.14159. That's where my nausea is right now, on a one-to-ten scale."

Pi, as you know, is connected to the circle in a fundamental way. It's the ratio of the circumference of a circle to its diameter.

What got me thinking about Pi was a book I'd read recently by Daniel Tammet, entitled "Born on a Blue Day." Tammet, a 27-year-old Briton, described his life as an autistic savant with Asperger syndrome. His functional level was not only good enough to allow him to write a compelling autobiography, but also enabled him to establish the European record for reciting Pi to 22,514 digits. He did so on March 14, 2004, as a charity event to raise funds for epilepsy, a condition he experienced as a child.

So what's Daniel Tammet's legacy? I think, in part, it's to remind us how extraordinarily powerful the human mind is. To remind us that anything is possible, as we contemplate what legacy we want to leave.

If a person with autism can recite Pi to more than 22,000 digits, we ought to be able to figure out why some cancers are so amenable to effective treatment, while others are not. We ought to be able to figure out how to get more of ourselves and our patients to live a healthy lifestyle. We ought to be able to figure out how to get off the SGR hamster wheel. And we ought to be able to figure out how to provide health insurance to all Americans.

There's one thing that we may never be able to figure out, and that's how I had the good fortune to become the President of the American Medical Association. I've been humbled with the privilege of representing the healers of this nation. I've been one of your designated advocates with the leaders of our government. You put me in a unique position to try to make lives better for both physicians and patients, all across this country.

So thank you. Thank you all, for your part in this great association. Thank you for your help in our achievements during this last amazing year. And thank you for your friendship, as we continue our journeys through the circle of life. God bless you all.