New York State Academy of Family Physicians
PAST PRESIDENT'S ADDRESS
Neil Calman, MD
June 6, 1998

Family Medicine: A Vision for the Future

 

Good evening everyone.

Last year, in his outgoing address to you, my predecessor, Dr. Bertoni, paid tribute to the Past Presidents of this Academy, a distinguished group I have joined just a few moments ago. If he had not done that already, I would have done that this evening. Because what these individuals have contributed to our Academy over the years and the inspiration they have given to so many of us personally in terms of leadership, encouragement and role-modeling could not be left unrecognized. I would like to ask the Past Presidents to please stand so we can recognize them for their years of dedication and commitment to the Academy.

As you know, I have chosen this year to break a long tradition of the Academy: the black-tie dinner that has been held every year for the Board and Past Presidents. I did this in order to emphasize to our entire membership my belief that we must focus on our past achievements and applaud those who have been responsible, but at the same time must open our arms to welcome new and rising leadership in the Academy.

Therefore, tonight, I would like to pay special tribute to those of you in this room who are future leaders of family practice in New York State. Of course, I can only guess who you are at this point by the energy and commitment some of you have already put into the Academy and other family practice activities. But many of our future leaders are in this room this evening and I would like to share a personal perspective on where we need to go in the future as a specialty.

In the very few minutes I have, I would like to focus not on the accomplishments we have achieved as a discipline — and they are myriad — but the challenges we face moving forward into the second half century of our life as a specialty. To understand these challenges, one needs both a scientific and a political perspective. I will start with science.

The science of medicine is progressing at breakneck speed; every day new diagnostic modalities are developed using computers that analyze billions of tiny x-ray images into a comprehensible photograph of a cross section of the human body; and now new methods allow us to look at the metabolic characteristics of those body parts as well as their structure.

We have endoscopes to probe every portal in the body — the ear, nose, throat, mouth and everywhere else, too. When there is no opening we make a tiny one where we want it and through that, perform miraculous diagnostic investigations and surgery. Medications are developing, not just with minor differences from those available previously, but in entire new categories of action:  medications for diabetes that increase insulin sensitivity, drive insulin uptake in tissues; those for depression that change the chemistry of the brain to improve one's outlook on life. We have new abilities to transplant organs — from parts of the eye, to kidneys, hearts, lungs, livers and maybe soon, pancreas cells to cure diabetes. But transplantation is nothing when you think about the fact that now, thanks to Pfizer, we even have a drug that can bring a part of the body that has died back to life.

So what does all of this have to do with the future? Everything. It means that our craft is constantly changing. Diseases, like ulcer disease, have moved largely out of the gastroenterologists office, soon maybe even for diagnosis, and the surgeons office, and back into our offices as family physicians. Yet other diseases, once treated readily by family physicians, like HIV infection, have become incredibly complex to treat and now move, perhaps only temporarily, into the offices of specialists who have mastered the ever changing scene of the protease inhibitors and who can provide optimal treatment for our patients.

The specialty of family medicine is ever changing and we must be vigilant to be able to define and redefine our role in medicine as often and as aggressively as the work of medicine requires.

There is a great opportunity for our specialty in the field of evidenced-based medicine. You know, I really laughed when I first heard that term, "evidenced-based medicine". What does that say about the rest of what we do? Well, it has been shown in the literature that doctors don't really pay attention to evidence. They have deeply rooted traditions that are hard to break. And our patients have come to depend on those traditions to identify a doctor who is thorough from one who is not. My own doctor still performs a "complete physical" on me every year, even though it has been shown without a doubt that only two or three parts of that lengthy exam actually have any significant chance of finding any new pathology that would benefit me and prolong my life or well-being. Yet I still go every year and he still performs his non-evidence based magic.

Family practice led the way in the past by introducing the concepts that a single physician could care about the individual patient's body and mind at the same time, could treat an entire family in the context of their life as a family, and could be interested in the epidemiology of diseases in the community at the same time. Wow!

We also led the way in board recertification, faculty development, continuing education requirements, and in detailing the educational goals and objectives of our residency training programs. All these are now commonplace after we boldly put them on the agenda of medicine. Now we must embrace the concepts of evidenced-based medicine and lead the way in discarding those parts of our practice that have proved useless and in assuring that the things that are important are done for every one of our patients. It is frightening how much we know, yet how much of that knowledge is not applied to our everyday practice.

We must also look at the way we educate ourselves. I am tired of going to lectures, sponsored by pharmaceutical companies, where the references on the slides are from last weeks issue of the Idaho Journal of Pediatric Neuroendocrinology, a journal with a circulation of 23 copies and paid for in its entirety by ads from that same company. Yes, even here, yesterday, some of us were exposed to such nonsense. The information we learn must be researched without bias and taught without bias, for it is all we have on which to base our practice and how we care for people. While this situation has improved somewhat, it still terrifies me that we allow ourselves to be subjected to this type of information transfer.

I could speak much more about the science part, but let me segue to the political for a moment.

I am about to go to my third WONCA meeting. Every four years, family and general practitioners from around the world meet to share insights into general practice with a global perspective. Both times I have been previously, it has been one of the most incredible experiences of my professional life and I am so looking forward to next week in Ireland.

There are three things which make this meeting incredible for me.

First, is the absolute clarity with which we see how the practice of medicine around the world is based in the political and economic framework of each society. In the United States, Mecca of the free market economy, we allow medicine to be part of the marketplace. It is perfectly fine for us to accept that some people — about 70 million of them, can't afford insurance and that we do not question the hundreds of studies in good journals that show that the uninsured get less preventive care, get sicker with diseases which are treatable, and have a poorer prognosis in almost every disease studied.

In other "less-developed" countries, health care is a right of every citizen, free and accessible and planned.

In the US it is fine to accept that some wealthy neighborhoods have a doctor on every street corner yet there are a growing number of rural and urban communities without a single primary care physician. Family physicians are best at going into these areas, but we have no National policy that mandates where people have to go into practice. Instead, we continue to flood our training programs with Federal dollars as if we were addressing the public's well-being.

The second thing that amazes me is that what we have come to accept as standard practice in the US seems incomprehensible to people from other countries. I made some house calls with a family doctor from the Netherlands a few years ago and in the Netherlands, the delivery of babies is done at home, unless there is a problem which would require transport and admission to the hospital. There are prepackaged cartons which contain all the materials needed for the delivery and newborn care delivered to the expectant mother's home during her pregnancy and this box is kept at hand until delivery time. Then, when the family doctor arrives, she opens the box, and all the drapes and equipment and even emergency equipment is contained in this box.

Wow! If you or I perform a home birth in our society people think we are crazy. We worry more about malpractice suits than about what is in the best interests of the mother and child.

The third thing that always shocks me is seeing that other Nations have so much better health statistics than we do in the U.S., yet spend one-third as much per person on health care. I love to watch what they do, the decisions they have made about their health care system and to listen to them give us advice about where we are going wrong.

On a political front, then, I am afraid we have a huge job ahead of us. We absolutely must create a National health insurance program and get the waste out of our current commercial, competitive, insurance-based system. Think of the marketing and administrative costs of the insurance industry, the time and money spent in switching people from one health plan to another, the disruption in care that has come from all this so called "managed care" — and it is clear that the only solution is through a single-payer system.

We have to bite the bullet and get medicine and health insurance out of a competitive industrial model and make health care a public utility — not necessarily free — but available to all. Our job as physicians must be to help create a health care system in which every person has access to all the health care they need, especially preventive care.

And finally — let me broaden my charge to you as future leaders of the Academy. Another part of your job as physician leaders must be a renewed emphasis on issues of social justice in our society; for they are inseparable from the health concerns we all share.

Health is not the absence of diabetes or hypertension or heart disease. It is also not the absence of schizophrenia or depression or anxiety. Health is a multi-factorial state of being that cannot be achieved when people live in inadequate housing; have inadequate access to food and clothing; live in fear of violence in their community; where their children are exposed to drugs and violence every day in their schools; and where our wealthy society cannot even figure out how to get health care to all who need it.

We are in the midst of a deep-rooted political insanity that must be put to an end.

In the midst of the incredible downward trend of hospital bed usage in New York City, New York Hospital was given a Federally guaranteed loan for three quarters of a billion dollars to build a hospital that hangs over the East River at a cost of $1.4 million per bed. I figured out that for the cost of that single hospital, a 5-physician health care facility could be built to serve every man, woman and child in the entire New York City Metropolitan Area. And dozens of other hospitals that have recently been  built or rebuilt have entire floors that are vacant.

Last month, because the religious leaders from St.Vincent's Hospital and St . Clare's Hospital, a mere 30 blocks away in Manhattan, could not come to an agreement about the political control of a merged entity, the State approved a $45 million dollar loan of our tax dollars to guarantee the rebuilding of St Clare's into a shining new 118 bed institution — just what we don't need.

Yet I know of three community health centers in New York City that serve the poor and uninsured and that are awash in red ink and will likely be forced to sell-out or close because of a lack of funding.

So this fight — to bring health services to everyone in New York and in our country — is a political one, and one to which every family physician must be committed. If we believe in health we have to believe that every person has a right to health care. And if we believe in health, we must see that the underclass in our society has all the opportunities I have had — to decent education, housing, clothing, job opportunities and life in a safe community. Unfortunately, I see a major reactionary trend in our State and National government; but it will not last.

It was born in a decade of selfishness, when the concerns that the "have's" in our society had for the themselves triumphed. But ultimately, we are a compassionate people, a people who care deeply for one another. I believe that, and believe that we will move again into an era where we will address, as we did in the 60's and 70's, some of the injustices in our society through permanent changes in the way we treat those less fortunate than ourselves.

This is where you all, as future leaders of this Academy will need to bring us. But fear thee not, I will still be here. I leave my position as President full of energy and commitment and a joy that you have shared with me and allowed me to share with you over nearly 25 years of involvement in the Academy.

I am so energized by the new structure of the Academy, the many new leaders who are emerging from our ranks, the energy that our commissions have put into refining an Agenda for our work for the years to come, the sincerity and intelligence with which our Congress debated critical issues yesterday and the leadership of our headquarters provided by Vito Grasso, Bobbi Markowitz and Pat Poklemba.

And I turn over the reigns to a longstanding friend and colleague, John DeSimone, and then to my personal friend and co-conspirator in Manhattan, Steve Tamarin. In their hands the Academy will continue to thrive and meet the challenges ahead.

Thanks for letting me be your President this year. It has been an honor and a privilege.