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Presidential Address

Toward the Undiscovered Country

June 18, 2011

AMA Annual Meeting
Hyatt Regency Hotel
Chicago, Illinois

Cecil B. Wilson, MD
President
American Medical Association

Mr. Speaker, Members of the Board, delegates and friends—colleagues and guests—including our international friends. I am honored be with you today, to speak as your President.

Today I have three goals:

To say thank you.

To say where we—the AMA, the physicians of this country—go from here.

And to describe how we get there.

First, I want to thank you, the leaders of this association, for what you do for our profession.

I want especially to thank the staff of the American Medical Association, for all they do to help improve medicine and to help physicians help patients.

To see their dedication, their expertise, their diligence and their loyalty to the AMA up close is to be inspired and to feel privileged to be working with them. Let’s give them a round of applause.

As your president this past year I have tried to follow the words  of my father—when he reminded me and my brothers that we represent the whole family—and to act accordingly.

I am often asked if I am enjoying my year as AMA President. My reply, almost always, is that I am having a wonderful time, and thoroughly enjoying what I do.

Not uncommonly, I get a quizzical look in return and the word—“really?”

The implication is, of course, that they may have heard only the noise of the conflicts in the health care debate and seen only the slings and arrows sometimes fired our way.

They wonder how speaking on behalf of the AMA—and to act accordingly—could be so rewarding, and yes, so much fun.

It’s ironic, but the challenges and even the conflicts, tell me the work of an AMA president is an important pursuit of a noble cause.  The satisfaction I get from it tells me it’s worthwhile—not just for me, but for the family of medicine.

There’s a quote from a Philadelphia journalist during the American Revolution that captures that sentiment. He wrote:

“These are the times that try men’s souls.
The summer soldier and the sunshine patriot will in this crisis shrink from the service of their country but he that stands by it now, deserves the love and thanks of men and women. …
What we obtain too cheap we esteem too lightly. It is dearness only that gives every thing its value.”

That, of course, was Thomas Paine, the voice of the Revolution.

George Washington was so impressed he required that Paine’s writings be read to his troops. They still resonate today.

Now, as then, you too often hear complaints that can be summarized like this:

If something is difficult, it is not worth doing.

But I find the opposite to be true. A couple of examples:

In conversations with AMA members about the AMA’s goals, particularly in the advocacy arena in Washington, I usually include a clear-eyed assessment of the chance for success.

And if I mention that achieving our goals will not be easy, I’m sometimes asked if that means the AMA will not work to make it happen?

My response: If it were easy, there would be no need for the AMA.

This work is difficult.  And so are the challenges to our health care system that the AMA is called upon to meet. And to overcome.

All in support of the profession and the patients we are privileged to serve.

Almost 50 years ago—it doesn’t seem that long—President John F. Kennedy gave a speech at Rice University in Houston.

In the can-do spirit of the space age, Kennedy spoke of the conquest not only of physical and technological barriers, but psychological ones:

He said:

“We choose to go to the moon. We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard. Because that goal will serve to organize and measure the best of our energies and skills.  Because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one that we intend to win.”

Kennedy called on this country to expand its horizons—to find the undiscovered country that is our universe.

Not because we could.  But because we should.

So—is the job difficult? Yes. Is the path long and winding? Absolutely. Is success not assured?

Certainly. All the more reason to embrace it.

Not because it is easy.  But because it is hard.

The AMA is not unmindful of the differences of opinion about its position on the Affordable Care Act.

We respect that people of equal good will, of equal intelligence, in equal possession of the facts and of equal loyalty to a group or position—may form far different opinions about the course we take.

But to the vast majority of the public—our patients—and the press—and in government—the AMA speaks for doctors in this debate.

That’s not just me saying that, or you, but the American people. In poll after poll when asked who speaks for doctors they by a wide margin—90 percent—say the AMA. By similar margins, they express a positive opinion of the AMA.

Our policy springs from physicians from every state medical association and the District of Columbia, and every national specialty society.

 In this sense, the deliberations of this body, in this room, represent all doctors. No other forum can even pretend to speak for them.

The people have spoken. But in the halls of power in Washington, D.C.? Who do they think speaks for physicians?

I am reminded of the refrain from that 1984 movie “Ghostbusters.”

It’s theme song asks: “Who ya gonna call?”

I can tell you that when Washington wants to know what doctors think, they’re  “gonna” call the AMA.

Now, this cuts both ways. When a member of Congress attacks the AMA for being on a different side of an issue—and casts aspersions on the AMA.

You should know that the motive is generally not a genuine grievance—but to divide us—to rend the House of Medicine— for their own purposes.

And 10 will get you 20 that at the same time they still work behind the scenes with the AMA, asking us what doctors and patients are thinking—and what they want.

For all the public bluster, they are well aware that it’s the AMA that speaks for this nation’s physicians—and the needs of their patients.

And after this year of talking with physicians and patients all over the country, I am more convinced than ever that the way the AMA has chosen—is the path to good health for our patients, our profession and our entire system of health care.

So thank you—thank you—thank you for making me part of all that. Thank you for this most rewarding experience. I will be forever grateful.

Now, second, where do we go from here?

I had a conversation recently with a leader in one of the country’s premier group practices.

I told her about the AMA’s role in responding to issues of national importance, such as health system reform.

She said: “I hope your members are urging you to keep moving forward, and telling you we cannot stay where we are and cannot go back to where we have been.”

She was right. The reality is that we cannot go back.

Now, I’ve been told where we can go several times in the course of the year, and it wasn’t always “forward.”

But we cannot go back.

We’re emerging from a place capable of the best health care in the world. But at a cost higher than anywhere else— and ballooning at unsustainable rates.

Emerging from a place where tens of millions have little or no access to care because they lack health insurance. Tens of millions more at risk of losing coverage because of a job change, a health change, or a pre-existing condition.

We’re emerging from a place where about one in four Americans last year didn't visit the doctor when sick because they couldn't afford it.

One in four skipped a test, treatment, or follow-up recommended by a doctor. One in four didn't fill a prescription. Because they couldn’t afford it.

Behind us is everything that conspires to sow misery in a physician’s life.  We cannot go back there.

Virtual monopoly power in the insurance market that makes fair negotiation on behalf of patients impossible.  That creates mountains of administrative waste, and adds $200 billion a year to health costs.

A lack of standardization unspools ribbons of red tape and at its worst is a Kafka-esque nightmare of conflicting procedures and policies for physician offices.

We cannot go backwards, and we cannot stay where we are.

We navigate a treacherous liability landscape that promotes defensive medicine and adds billions to the cost of health care. That subjects physicians to empty lawsuits. And that fails to fairly, promptly compensate those actually injured. 

Where we are—unfunded mandates, a ban on billing consultations and misaligned incentives — all requirements that damage physician practices.

Where we are: The annual threat of Medicare payment cuts—next year, almost 30 percent—even as the Medicare population  soon tops 50 million and more.

All of this—That is where we are.

Some prefer the devil they know.  They think that no matter how bad things are now, change might bring something worse.

But even if you somehow endure it now, the present course leads to something much, much worse.

We cannot go back. And we cannot stay where we are.

Moving forward is the right course.

I think of it this way. Our destination now is the undiscovered country—to which we’ve never set sail to before. But for the bold, it holds great promise.

I’ve been a physician for more than 40 years, and during that time I’ve seen the multiplying marvels of medicine brought forth by some of the world’s most creative minds.

But it’s also created a complex system, with more than 60,000 diagnoses; 11,000 surgical procedures; and at least 4,000 different drugs.  Not to mention thousands of pages of regulations, private and public.

The response has been more specialization, more advanced technology, and more need than ever for a team approach to treating our patients.

This physician-led team approach to care—with each member of the team playing the role they are educated and trained to play—helps ensure patients get high quality care and value for their money.

It’s not simply the logical approach—or the most effective. It soon may be the only approach. There’s no turning back.

Good medicine demands we move forward.

And moving forward means:

To assure that the promise of a better health care system for the American people is achieved.

For Congress to repeal the SGR and replace it with a mechanism that pays for the cost of care and enhances care coordination, quality and appropriateness. All while reducing costs.

For Congress to pass an additional option that allows Medicare patients and their physicians to privately contract without penalty. We call it My Medicare My Choice.

For meaningful medical liability reform at the federal level while protecting effective state laws.

Moving forward means leadership in the face of fewer physicians and more demand—an aging population, the flood of baby boomers swamping Medicare, the rising incidence of chronic disease and the millions new to insurance coverage.

Moving forward means corrections where Congress just plain got it wrong—such as the Independent Payment Advisory Board that puts physicians in double jeopardy by adding yet another target to the discredited SGR.

Moving forward means bull-dogging the regulatory process to assure reform benefits both physicians and their patients.

Provisions such as accountable care organizations and health information technology.

Goals such as administrative simplification and transparency of insurance regulations and claims filing. And regulation of medical loss ratios to assure that more money is spent by the insurance companies on medical care.

Moving forward means starting on a path toward a redesigned and improved education system to meet the demands of 21st century medicine —

A journey we started last year with the Association of American Medical Colleges in our centennial celebration of the groundbreaking Flexner Report.

Moving forward, that’s the course.

Now, it isn’t always easy to find the right direction—or to follow it once you do.

And that leads me to my third point. How do we get there?

Let me suggest—bottom line—it’s a matter of attitude.

It’s a matter of working together.

It’s staying true to the high ethical principles of our profession—the moral high ground stated in our mission:

To promote the art and science of medicine and the betterment of public health.

A mission made effective through its core values of leadership, excellence, integrity and ethical behavior.

Let me illustrate.

When I spoke last year, I shared a couple of my experiences while pursuing my love of sailing—and the lessons I learned—that relate to our purpose and predicament.

Since then, in taking the soundings of physicians and patients across the country, I believe more than ever that organized medicine has set the right course—and is making time toward our destination.

If you sense a sailing story coming on—you’re right.

It was one of those idyllic weekends we’re fortunate to get in Florida. We sailed out of St. Petersburg on a warm sunny morning, prodded along by a brisk breeze out of the northeast.

A crew of seven on the yacht Misty Blue, headed across Florida Bay for the Dry Tortugas.

At this point, it may go without saying that the crew was all doctors. That’s called “foreshadowing.”

The Dry Tortugas is a cluster of seven small islands 70 miles west of Key West in the Gulf of Mexico.

It was named by the Spanish fortune seeker Ponce de Leon, after the turtles he found when he landed in 1513. It’s called “Dry,” because there’s no source of fresh water. For Ponce de Leon, it meant no fountain of youth.

A point of interest there is Fort Jefferson.  Built in the mid-nineteenth century, it is the largest masonry structure in the western hemisphere—more than 16 million bricks. Not surprisingly, perhaps, it was never finished.

Because the islands are low—the highest elevation is just ten feet—at first view Fort Jefferson appears to rise from the sea.

So the following morning, I stood in the cockpit drinking a first cup of coffee and saw the massive walls of the fort emerge from the water like a mirage made of brick.

We anchored and for the next two days swam in pristine waters, ate fresh fish purchased from passing fishermen, explored the fort and pondered its dark history as a prison during and after the Civil War.

We then sailed back to Florida, and for a change it was without incident. I know that’s disappointing for some of you. Did I say the crew was all doctors?

But if this foreshadowed the future, things were looking up—are looking up—for doctors.

We will get back to Ft. Jefferson, but for now, I’ll ask you to suspend reality for a moment and imagine you are not here, in the ballroom of a Chicago hotel, but instead are a physician practicing in the mid- nineteenth century.

You supplement a meager income by growing tobacco on your family farm.

You’re in a hamlet in Maryland called Bryantown, and the 30 miles to Washington, DC might as well be 300.

At four in the morning there is a knock on your door.  Standing on your porch is a well-known actor, whom you have met a few times before, who broke his leg the previous night in a fall from a balcony.

You’re a physician. You set the leg and he leaves.

You subsequently learn that the actor, John Wilkes Booth, broke that leg in a leap to the stage of Ford’s Theater in Washington. This after he fatally shot President Abraham Lincoln in the back of the head with a derringer.

And your name is Mudd, Dr. Samuel Mudd—and your life has just turned upside down.

Imagine.

You are convicted of conspiracy in Lincoln’s assassination, and escape the death penalty by a single dissenting vote on the jury.

You are sentenced to life in prison and transported to Fort Jefferson in the Dry Tortugas—the end of the earth for America’s borders—to serve your time.

Imagine what you would do. How you would respond.

Two years later, in 1867, a yellow fever epidemic swept through the prison. Of 400 inmates, 270 were infected and 38 died. The prison doctor was among the first to go.

Samuel Alexander Mudd, Dr. Mudd, locked down because he’d tried to escape, volunteered to help.

His heroic efforts were credited with containing the epidemic, and earned the praise of prison officials, inmates and the public.

Citing a selfless dedication to a higher duty, President Andrew Johnson pardoned Dr. Mudd in 1869. He returned to Maryland and  resumed the practice of medicine.

Dr. Mudd didn’t have to respond to the epidemic. A scapegoat in a national tragedy, he could have stayed in his cell. But he turned his misfortune into a mission to help others. He was a physician.

We may feel buffeted by the storms, the winds of change and feel driven toward the rocks, or shoals or shallows. But we have a rudder, and we have our sails.

We can sit in a cell, however unjustly imprisoned—and curse the darkness—curse an incompetent government, or like Dr. Mudd we can see an opportunity, light a candle, fulfill our responsibility—set a course and move forward.

And at the AMA, we face a choice— we can move forward toward unity—or we can move apart.

We can work together to be a force for positive change—or we can move apart.

We can serve our profession, our patients and our country by using our experience to shape health system reform. Or we can move apart.

We can work together to attack the issues that afflict our profession. Or we can move apart.

To me, moving forward is not only the option of choice—it’s the only option.

I opened by saying I’d make 3 points.

To summarize—in six words:

Thank you …

Let’s move forward …

Together.

It’s been said, “Man cannot discover new lands without the courage to lose sight of the shore.”

So let us set out—together—to find this undiscovered country—and claim it for our patients, our profession, and the art and science of medicine.

Thank you.

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