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Ann Thorac Surg 2001;71:1410-1414
© 2001 The Society of Thoracic Surgeons
a United States Senate, Washington, DC, USA
Presented at the Thirty-seventh Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 29–31, 2001.
The importance of a larger view
It’s a great honor to present the inaugural lecture in this series named for Dr Thomas B. Ferguson, a man who has always understood the profound and far-reaching implications of public policy on the practice of medicine, an understanding that was, in many ways, far ahead of its time.
Throughout his distinguished career, Dr Ferguson not only recognized the necessity of staying current in our changing world, but dedicated himself to making that necessity apparent to the cardiothoracic surgeon, challenging him to move beyond his traditional frame of reference—the basic and clinical sciences—to the larger world of technology, economics, ethics, and, of course, public policy, perhaps the most powerful external force impacting medicine today.
Happily, his efforts to educate his colleagues and urge them to action has borne fruit, as the many cutting edge initiatives of the STS so amply demonstrate. Not the least of these are the STS Foundation for Research and Education; the Professional Affairs Committee, that has been so active on issues in Washington; and the STS National Database, which has been at the forefront of data acquisition and analysis and is the only national data base pertinent to an entire specialty and developed voluntarily by the profession.
These purposeful connections to public policy are critically important because, more than any other single factor, public policy will define our future—what happens not only with the delivery of health care in general, but with the individual practices of each and every one of you, which is why understanding public policy is so important.
It is in that tradition, and with that purpose, that I speak to you today. Because, as I have learned quite directly, the need for your participation is greater today than ever before.
Public policy in the founding era
But, as I have also learned, participation takes many forms.
In the early days of our Nation, physicians led the American people in war and in peace, on battlefields and in field hospitals, as aide-de-camps and officers, as statesmen and legislators, governors and historians. In fact, when I consider Dr David Cobb, who achieved the rank of Brigadier General under George Washington; Dr Eliphalet Downer, the "fighting surgeon" of the American Revolution; Dr John Hazlett, who was killed at the Battle of Princeton; Dr Samuel Prescott, who finished sounding the alarm after Paul Revere was captured by the British, serving in the Senate seems like pretty tame duty by comparison.
Since the Founding era, 51 practicing physicians have served in the U.S. Senate (Fig 1). Some were active in local or state politics before they ran. Some, well-known for military or other service, were appointed or drafted to serve. Others simply realized that through politics they could address the medical problems that affected all patients, not just their own.
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However, physician participation in public life has diminished steadily over time. The greatest number served between 1800 and 1849, when there were 23 physicians in the Senate. From 1850 to 1900, there were 14. From 1900 to 1949, only eight, and from 1950 through 2000, just two.
Today, physician-senators are rare, for the reasons obvious to us all: the exponential growth in the body of medical knowledge, the increased investment in time and training; and the lack of appeal of political life.
But different times demand different models.
Public policy in the current age
When I came to the US Senate in 1994, the first practicing physician to be elected in almost 70 years, I had a purpose different from that of America’s Founding physicians. My goals were to halt the proliferation of unnecessary federal regulations; modify the steadily progressing trend of increasing government intrusion into the practice of medicine; reverse the swelling tide of increasing micro-management of medical practice; and stop the slide towards socialized medicine that was moving the center of gravity away from patients and toward a federal bureaucracy.
I focused on three primary objectives: refocusing federal efforts on quality not just cost; protecting the sanctity and authority of the doctor-patient relationship; and defending the profession against excessive intrusion from HMOs and managed care.
I helped pass laws to eliminate so-called "drive-by deliveries;" allow physicians to determine length of maternal stay after delivery; extend the portability of health insurance; double funding for the National Institutes of Health; increase funding for graduate medical education; create a new NIH center for minority health; modernize the FDA; reinvigorate our public health infrastructure; and refocus the Agency of Health Care Research and Quality (AHRQ) on improving the research behind quality health care delivery.
While I recognize that few of you will ever run for the U.S. Senate, you should know that the skills that have served me best in that arena are the very same skills that you possess. Indelibly ingrained from the first day of medical school, they are skills collectively unique to medicine and especially to surgery, and they make you uniquely qualified to participate effectively in public policy.
What are they? A solid work ethic, honed by years of disciplined training; an ability to rapidly assess benefits and risks; the organized thought processes by which our decisions are made—the ability to listen, assimilate, diagnose and decide; the endurance, responsibility, and accountability we are willing to invest, as well as the compassion, dedication, and courage we bring to our work; our commitment to improve the lives of others and put their interest before our own; our role as sacred repositories of our patients’ trust; our oath to do no harm; and our recognition that the relationship between doctor and patient is special and must be preserved.
Taken together, these skills result in an approach to problem-solving that instills confidence, produces credibility, ensures objectivity, and facilitates cooperation—a combination that is both special and powerful.
But Congress is not the only place where these skills can be put to work. In fact, we are entering an age when physicians will have the opportunity to use them much closer to home.
Before we can use them, however, we must understand how they can be applied to the public policy process, which is why the Thoracic Surgery Foundation’s "Executive Course in Health Care" at the Kennedy School of Government is so important. It not only teaches you the principles of health care reform but actually helps you understand how you can initiate the changes in medical health care delivery that are so needed today.
More than 200 cardiothoracic surgeons have been through the course thus far. All are well-informed and highly-motivated to take their new-found knowledge and apply it in their own medical practices, in their own local communities, and across the nation. Some may even get the chance to apply it in ways they never imagined.
To give you an idea of just how far-reaching an effect one’s medical experience can have, not just on our Nation, but also on the world, I’d like to relate how I was able to apply the medical experience I gained on a recent trip to Africa to the public policy arena in the United States Senate.
In July, 2000, I spent six days in Sudan with the relief organization Samaritan’s Purse. Sudan is a classic example of what has come to be known as "humanitarian warfare," a type of aggression, characteristic of the post-Cold War era, that deliberately seeks to inflict pain and suffering on civilian noncombatants by denying them vital human needs.
Unlike other wars in which so-called "collateral" damage is unintentional, humanitarian warfare uses starvation, forced migration, and the manipulation of medical resources and food supplies as an integral part of its military strategy.
During the 17 years in which civil war has raged in Sudan, four million Sudanese have been displaced, making them the largest internally displaced population in the world. In just one area, Paboung, 31,000 people have fled into a swamp where they not only suffer from extreme malnutrition (Fig 2) but are prone to infections of all kinds. Cut off from the rest of the world, a once strong, well-nourished people are now thin, gaunt, and fragile. In fact, when I met with the leader of the resistance he told me that their number one problem is not war but health care.
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When I returned from Africa, I used my medical knowledge and experience to develop and pass several bills that addressed the problems I encountered there. The first condemned the gross violations of human rights in Sudan, supported sanctions until substantial progress could be verified, and linked the foreign aid to the cessation of the civilian targeting and the delivery of humanitarian assistance. A second, established a trust fund to educate AIDS orphans. A third provided practical incentives to research a vaccine for AIDS, malaria and TB, and a fourth improved our own public health infrastructure, addressed the growing threat of antimicrobial resistance, and strengthened our capacity to prevent and respond to the very real threat of bioterrorism. Just as important as these immediate results, however, are the longer-term effects that medical experience can have in modernizing federal agencies, like AHRQ, and improving huge federal systems, like Medicare.
Public policy in a new era: hope is on the way
Yet just as participation demanded of physicians in the 19th century has been dramatically different from my own in the 20th, so will the participation required of you be different still. That’s because the 21st century is a vastly different environment from that of ten, or even five, years ago.
Ten years ago, the clinical surgeon’s greatest fear was government micro-management, loss of autonomy, and the slide toward socialized medicine. We worried that bureaucrats in Washington would strip away choice, burden us with paperwork, and destroy the doctor-patient relationship.
Five years ago, fears of government micro-management were exacerbated by an even greater fear of private sector micro-management—HMOs and insurance companies whose heavy-handed attempts at cost control left physicians powerless in negotiations. In fact, it’s gotten so bad that we almost prefer more government to more HMOs!
Today we are moving into an era filled with new hope but also new challenges.
Where’s the hope? Rather than an overly-prescriptive government solution, or a micro-managing private sector solution, this new era offers a third way, an approach centered on physician involvement, local decision-making, and unprecedented patient empowerment.
Why am I so optimistic that this will be so? Two reasons. First, Federal Reserve Chairman Alan Greenspan’s announcement that, after 30 years of annual deficits, the United States is not only running a surplus but that by 2011 that surplus will reach an astounding $800 billion a year. That means that the entire federal debt will be erased by the end of the decade—a development that will allow investments in other areas of value to society, such as health care.
Second, we now have a President committed to reducing federal micro-management of Medicare, Medicaid, and physician practices, and to implementing real Medicare reform.
What does that mean? It means that the 130,000 pages of regulations and regulations that govern your every move in Medicare will be replaced by less centralized decision-making. It means that HCFA will no longer be in the business of ruling on reimbursements for each and every new technique. It means that the five-year ordeal of HMOs dictating medical decisions will be at least partially addressed by a real, enforceable Patient Bill of Rights (PBOR) that moves medical decision-making away from the HMO and back toward the doctor and patient where it belongs. Rather than the AMA/trial lawyers version that would have resulted in a litigation lottery, we will see a strong appeals and review process with doctors at the table; final medical decisions made by physicians, not bureaucrats; and an appropriate right to sue coupled with real tort reform.
And this is good, because as Dr Bob Replogle recently asked, "How do we explain to the medical profession that insistence on litigation as a method to ensure quality in Managed Care Organizations is inconsistent with the view of the profession that malpractice litigation does not ensure quality in medical practice?" He is exactly right, as was Dr Ferguson when he recognized 20 years ago that "The roots of the problem are the tort system itself." Finally, those roots will be addressed. Patients will be empowered, and physicians not bureaucracies will have leverage.
This plays to our strength which, as Dr Ferguson also observed, "is our humanism." "No matter how complex the distribution of health care becomes," he said, "no matter how devious the reimbursement structure, the most satisfactory and successful care is vis-a-vis—a one-to-one relationship between a patient and a physician."
"We want it that way," he said, "but more importantly, our patients want it that way."
So, your influence as an individual, as a community, and as a professional society will be more powerful. You will influence not just outcome but direction. You will shape the policy governing coverage of new technologies, reimbursement, and the definition of medical necessity. You will be consulted. Moreover, as your influence increases, government’s will decrease.
That’s the Hope. What’s the Challenge?
Over the next five years, the new environment will be characterized by five developments:
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A little-known poet named Ted Loder once implored God: "Empower me to be a bold participant, rather than a timid saint in waiting."
What the medical profession needs now are bold participants—not surgeon-soldiers, like Eliphalet Downer or John Hazlett; not surgeon-crusaders like Lewis Linn or Jacob Gallinger; not even surgeon-senators, like Bill Frist, but men and women with a vision of the future who are willing to work to develop strategies to make that vision come true.
There has never been a worthier challenge nor a better time. With a President committed to ending federal micro-management, restoring local control, and reforming systems broken for too long, now is the time to develop a solution grounded in physicain-patient centeredness. Now is the time to join forces with our patients in the economic battle for health. Now is the time to develop a systems approach to medicine. Now is the time to harness innovation and employ information for the greater good.
Now is the time, and you are the way. Be bold participants in your own future. Then Dr Ferguson will surely be as proud of us as we are of him.
This article has been cited by other articles:
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  J. M. Matloff The practice of medicine in the year 2010: revisited in 2001 Ann. Thorac. Surg., October 1, 2001; 72(4): 1105 - 1112. [Full Text] [PDF]
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