Farewell address

Monday, July 01, 2013 12:28 PM

Every day is a winding road

Jeremy A. Lazarus, MD, President, American Medical Association

Editor’s note: Dr. Jeremy Lazarus was just the second Colorado physician and the first in 91 years to serve as president of the American Medical Association. The following is a complete transcript of his June 15, 2013 farewell address delivered to a packed AMA House of Delegates at the start of the AMA annual meeting.

Mr. Speaker, members of the Board, delegates, colleagues and guests – and our international friends. I’m honored to speak with you for the last time as president. This is a bittersweet moment. I’ve long been involved in organized medicine – most of it associated with the AMA – and I want you all to know, I have truly loved serving this past year as your president.

Of the many posts I’ve held: President of the Colorado Medical Society and the Colorado Psychiatric Society, Speaker of this House of Delegates, I can now report to you that nothing can completely prepare someone for all of the challenges encountered as the public face of the AMA.

Naturally, I had my expectations – and suspicions – of what it would entail. But after 12 months seeing up close the breadth and depth of this amazing organization, I better understand – and appreciate – our role in the minds of the public, physicians, and the political landscape that can so often undermine the best of intentions.

At times, I was surprised and occasionally blindsided by the whims of Washington politics and the world’s random savagery. Each time, I proudly witnessed the AMA rally and rise to the occasion.

In these 12 non-stop months, I’ve learned that one of the few constants is change – and that you never know what life – or the government – or science – or Mother Nature – will throw at you. Expecting the unexpected has helped me become a better dancer – because the course of advocating for medicine and promoting the AMA’s agenda has more twists and turns than a tango danced during an earthquake.

Were it a song, it might be Sheryl Crow’s “Every Day is a Winding Road.” In it, she sings about “swimming in a sea of anarchy,” but it’s important to remember, every day, we are getting a little bit closer to the goal. For me, those first steps were a doozy.

Affordable Care Act

Just after my inaugural, the Supreme Court ruled that personal responsibility to obtain health insurance coverage – the so-called individual mandate – is constitutional. It cleared the path to extend health insurance coverage to millions of people – many of whom will become our new patients. At the same time, the Court struck down the Affordable Care Act’s mandatory Medicaid expansion.

At the AMA, we believe Medicaid expansion is necessary for needy citizens to get the care they deserve. But for the program to be viable, I believe we all agree, physicians must be adequately reimbursed.

Fortunately, the provision in the ACA that calls for raising Medicaid pay to Medicare levels for primary specialties from 2013 – 2014 will help. That’s why, when proposals surfaced to eliminate this increase at the end of last year, the AMA organized 261 state, national and specialty medical societies in a letter of opposition. And guess what – Congress actually listened!

Yet another example of why it’s important to proactively confront these problems with a unified voice. As states began wrestling with Medicaid and Health Insurance Exchanges, the AMA mobilized – working with medical and specialty societies to assure access to care for as many as possible, despite the patchwork of state approaches. But whether state or federally run, exchanges will start operating early next year. And countless physicians – including many in this room – will participate in and benefit from these exchanges.

The AMA is working to minimize whatever burdens they might create. For instance, we made inroads in the federal rules to help physicians. And we continue to work with groups such as the National Association of Insurance Commissioners and the National
Conference of Insurance Legislators to cement these hard-fought gains.

Gun regulation, mental illness and public education

Other policy debates raged outside the halls of power. A month after my inaugural, in my home state of Colorado, a gunman opened fire in a movie theater, killing 12 and wounding 58 more. In December, a different young man, in a matter of minutes, killed 26 people – 20 of them children – at a Connecticut elementary school.

First there was shock. And then, dozens of physicians, physician organizations and other health care professionals mobilized within days – even hours – to again denounce the plague of gun violence. It also brought to the forefront problems with our mental health system – and our capacity to prevent at least some of these tragic events.

And as a psychiatrist myself, I was at the same time all too aware of the potential backlash against mental health patients. Some may paint them all with the same broad brush of potential violence – but we know that the vast amount of violence – whether guns are involved or not – has no relation to mental illness.

So we went to work on initiatives to remove the stigma still present against those with mental illness and to offer better treatment options for those affected. Shortly after Sandy Hook, we met with administration officials in Washington to discuss a strategy to address gun regulation, mental illness and public education. And though legislation has not passed this year, we remain committed to seeing it happen.

We also believe strongly that physicians must be able to have frank discussions with their patients and families about firearm safety issues and risks. Maybe fewer 4-year-olds will accidentally shoot a parent or sibling.

And we are pleased also that the CDC will again be able to begin epidemiological research on gun violence to better inform the ongoing debate.

Sunshine Act

The tragedy in Newtown isn’t the only high-profile event that has sparked AMA action. We recently reiterated our ethical position opposing physician involvement in force-feeding hunger strikers.

That takes me from the search for more information – to the subject of TMI – too much information. In February, my travels took me to a Senate hearing on the Sunshine Act, the new transparency regulations regarding interaction between physicians and representatives from the pharmaceutical, medical device and other industries.

This provision will require those companies to report any payments or other “transfers of value” they make to physicians on an annual basis – and to publish that information via a public database.

The AMA has long supported greater transparency between physicians and industry, but as I declared to the Senate directly – we want the law implemented appropriately and physician rights to challenge false or misleading reports protected. Now for the hard work – to get the word out. CMS starts tracking this information on Aug. 1 – and not everyone’s aware of it. So we’ve launched a Sunshine Act resource page on our website to educate physicians on the requirements, and we’re offering online modules and webinars to explain it in detail.

As dermatologists tell us, sunshine might feel good but it’s also important to apply some good sunscreen.

Physician satisfaction/patient sustainability

In another practice issue, the AMA has launched the Integrated Physician Practice Section to help physicians shape policy that enhances physician satisfaction and improves practice sustainability.

It’s now crystal-clear to me that the future of medical care depends much on how well physician-led integrated practices work to keep patients healthy, and how well they function for their physician members.

In my practice, I’ve seen thousands of patients one at a time. Now we can leverage what we can do for so many more patients by working more effectively together. That’s what the IPPS is all about. It will address the issues and needs facing physicians in group and integrated practices, and provide a forum for those who have moved into the many new non-traditional types of practice. To you, I say “Welcome to our House of Delegates.”

Legislative successes

Our work isn’t just among individual physicians, of course. Will Rogers said, “If you want to be successful, it’s just this simple. Know what you are doing. Love what you are doing. And believe in what you are doing.”

Following that credo is why – in the past year – the AMA earned more than 125 legislative victories at the state level – from insurer transparency to preserving medical liability reforms – by working with state medical societies across the nation. For instance, AMA support and resources, combined with the tireless advocacy efforts of the Kentucky Medical Association, led to legislation to expand access to quality medical care while ensuring physician leadership of health care teams.

Georgia enacted a state physician shield act based on AMA model legislation. The AMA was proud to help the Maryland State Medical Society, Nevada State Medical Association and Texas Medical Association successfully push for legislation based in part on the AMA’s model bill on Truth in Advertising.

And in a major decision earlier this week, the U.S. Supreme Court ruled that individual physicians can come together as a group to fight the unfair business practices of large health insurance companies. Sutter v. Oxford Health Plans concludes a dispute that alleged the company systematically bundled, down-coded and delayed payments for 20,000 physicians in its network.

The AMA-led brief with the Medical Society of New Jersey noted that health insurers know that arbitrating disputes with individual physicians works to their advantage. They allow contract violations and underpayments to persist and leave physicians helpless to fight them. But thanks to this ruling, thousands of physicians will be allowed to use class arbitration against a health insurer that has underpaid them for more than a decade. This finally gives physicians a weapon to challenge unfair payment practices.

Thursday, June 13, the Supreme Court ruled again and affirmed the AMA position opposing patents on the human genome. To ensure the Supreme Court heard our voices loud and clear, the AMA joined with other health care organizations to file a brief to defend a federal court ruling that invalidated gene patents. This ensures that scientific discovery and medical care based on insights into human DNA will remain freely accessible and widely disseminated, not hidden behind a thicket of exclusivity.

And in the interests of a free flow of information, we established the JAMA Network, which provides easier access for physicians to vital, breaking medical news. For the next few months, access will be free with the new JAMA app – a tremendous service for all physicians in the U.S. and around the world.

Continued progress

Then there were issues that can be neither sparked nor solved with a single gesture or action – but that require ongoing attention. We made progress improving the health insurance billing and payment system. At the AMA, we didn’t wait for Congress to act on this issue on behalf of consumers and physicians. Our efforts to tame the chaotic health insurance billing and payment system has cut in half the number of incorrectly paid medical claims, according to our fifth annual National Health Insurer Report Card.

I’m also happy to report significant progress in our long campaign to convince Congress to eliminate the Sustainable Growth Rate (SGR) physician payment formula in Medicare. Thanks in part to the relentless education efforts of the AMA and those of more than 100 physician groups and others, we see a light at the end of this tunnel. The House Energy and Commerce Committee recently released a draft of legislation to repeal the SGR and replace it with a fair and stable physician payment system, building on a framework jointly developed with the Ways and Means Committee. The Senate Finance Committee is also making progress toward developing legislation to reach this goal.

In our discussions with each of these panels, we are hearing the messages delivered by medicine echoed back to us: That one size does not fit all; that in addition to a viable fee-for-service payment option, physicians in their diverse practice settings, specialties and communities must be free to choose new payment and delivery models that work best for them and their patients. Finally, we might have the right prescription to put this issue to rest.

Strategic plan

Fixing the SGR is of course a big issue. I’ll turn my attention now to the big picture. I would like to note the positive reaction I’ve seen to the AMA’s new strategic plan. Like the enthusiastic response to our $11 million grant-funded initiative to accelerate change in medical education for the 21st century. Last night, it was my honor to announce the 11 grant recipients. I look forward to their important work to bring needed change to how we educate and train future physicians.

We’re also making progress in our work in our strategic focus area aimed at enhancing professional satisfaction and practice sustainability. Our work will enable physicians to make more informed choices about their practice environment. Finally, I’m gratified for the rave reviews for our initiative to improve health outcomes. Our initial targets are cardiovascular disease and Type 2 diabetes and to improve health outcomes for people with these conditions. As physicians, we know the devastation these and other chronic diseases impose on our patients and the system. This will allow all of us to join this effort.

Toward this end, the AMA is also supporting the Medicare Diabetes Prevention Act, which provides coverage for the National Diabetes Prevention Program as a Medicare benefit. It’s estimated an expansion of community-based diabetes prevention programs like this one would save $191 billion over 10 years. So call your member of Congress and ask them to cosponsor S. 452 or H.R. 962.

I’ve just scratched the surface, and Dr. Madara will provide a more detailed update on our plan. But these are big issues – and big stakes. On the table is a better health care system, better outcomes for our patients, better training and education for tomorrow’s physicians, and a brighter practice picture for physicians today.

And throughout, our compass for our Strategic Plan is the AMA Code of Medical Ethics. It tells us that we must recognize responsibility to patients first and foremost, as well as to society, to other health professionals and to ourselves.

Compassion and bravery

To witness ethics in action, think back on the response to a deadly turn in the winding road just two months ago, with two horrific incidents involving explosions. Two bomb blasts detonated at the Boston Marathon finish line and still another in a fertilizer plant in the town of West, Texas.

Personally, the Boston tragedy struck especially close to my heart. I’ve run that race many times. I know exactly what it feels like to cross the finish line, exhausted and yet exhilarated. I can tell you that as a psychiatrist and runner, this is one of those events that challenges a doctor’s best training.

In the Washington Post, columnist Mike Wise, who also runs marathons – described why this tragedy captured hearts and headlines around the world. “Of all places to ruin and end lives,” he wrote, “where the runners work so hard to embrace a pure and noble goal. Of all places to attack the majesty of the human spirit: At the finish line.” So many enter this race to overcome a personal loss or reach a personal goal as an act of therapy. To attack it, Wise wrote, “is so wrong and personally destructive, it’s almost unspeakable.”

For runners throughout the country – as well as those who support their loved one’s ambitious goals – this was an attack on our spirit as much as upon the fragility of human flesh. Those who came to the finish line exhilarated to complete this grueling race fell from the highest high to the lowest low. Our hearts sank with them. Yet at the same time, many brave people exemplified who we are as Americans. I watched this violent violation on the news – and then, on a rainy, gloomy night, flew to Boston to do a television interview to offer perspective on this nightmare. It was also the same night the second suspect was chased down and cornered.

Soon after the tragedy, I spoke to the Massachusetts Medical Society. I was reminded how the Boston Marathon is not just a competition among runners, it’s an institution embroidered into the fabric of the city. And it reminded me, too, of an event almost 40 years ago when I flew to Boston to take my oral exams in psychiatry. It rained that night, too. And when I arrived at my hotel, a helicopter circled the block, shining a spotlight on the crowd in front of my destination, I never found out who or what it sought. I was already anxious about my tests, and this sure didn’t help.

It tells me that stresses and traumas that happen to us are often relived and stay with us a long time, and we may never know in advance what might trigger it. We know what the immediate reaction is to an explosion, however – and that’s paralyzing shock.

But in Boston, instead of being frozen in horror, bystanders fashioned tourniquets from their own clothing and carried casualties to safe havens for medical attention. One pediatric resident who ran the race, without hesitation jumped over the barricades and evaded the police cordon to attend to the injured. A surgeon who had finished the race an hour before the bombings was at home and was called in to the hospital. He didn’t hesitate for an instant.

Volunteers turned a medical tent near the finish line into a triage station, and a network of nearby hospitals was ready in minutes, expertly executing disaster plans to quickly treat the 180 people injured in the blasts. Many said they were “just doing their jobs.” I don’t see it that simply. These were images that are only seen during the worst of war, not on the streets of a major city.

This level of bravery and presence of mind saved many lives. It reminded me that as Americans – this is who we are as a people. And I have rarely been more proud to be a physician.

In the New Yorker, George Packer noted that when we look around at this country, we see many institutions that don’t work. In Boston, the institutions of civilization met our highest standards of courage, competence and humanity. We saw it in the fertilizer factory explosion in West, Texas. And we saw that same human compassion again in the quick, effective response for the injured in Moore, Okla. after a tornado last month.

For the victims – and for physicians – the marathon – West, Texas – Oklahoma, if the unexpected happens we want to be ready. And as you saw in our video tribute earlier – they were.

An incredible journey

This year’s Boston marathon reminded me of another thing – that as AMA president, I may have spent the year negotiating these twists and turns – amid unexpected events and the milestones of our advocacy achievements – but I wasn’t alone either.

While any marathon is an individual effort – I always knew my journey was part of many support teams. Through the dedication of AMA staff – of the members of state and specialty societies I met in my travels – to my friends and colleagues in this House of Delegates – and the insights and inspiration I received from everyone in my travels – and especially the support from my wife Debbie – each one of you was right alongside me.

The degree to which successes are possible during an AMA presidency are as much the result of your efforts as mine. One of the most uplifting moments of this past year was giving the commencement address at my alma mater, the University of Illinois-Chicago medical school, just across the Loop from where we’re gathered today. The faces of these bright young graduates and the many languages they spoke – told me we’re well on the way to enhancing diversity among physicians and being better equipped to tackle disparities.

And I saw JAMA Executive Editor Dr. Phil Fontanerosa hood his own son, who graduated with an MD/PhD. I also had the honor to hood my own son Ethan and my daughter-in-law Melissa. These are moments when one generation is blessed by the next. As parents, we must have done something right.

I’m also happy to tell you, at this meeting Ethan debuts as a new delegate from the American Society of Bariatric Physicians. Way to go, Ethan – and welcome! Your determination and talent is helping patients get off medications for diabetes, hypertension and cholesterol and restoring a hopeful future to their lives. You are making a difference and I’m very proud of you.

Just like all of you sitting here – at every age, at every stage of career – who work every day to improve the health and lives of your patients. The passing of years gives us more than grey or thinning hair. It also brings clinical advances, new technologies like electronic health records and increasingly complex administrative requirements.

For those who pursue a career in medicine, it can be a lot to juggle and maybe more than was bargained for. But for all of the challenges and frustrations – medicine above all is a profound calling – one that helps people when they need help the most. That, dear friends and colleagues, is something worthy of pride and optimism at any age, or any stage – in one’s career. And I can assure you that we all have even something more to offer.

For me, these past 12 months through airports, countries and Capitol Hill, the winding road of medicine has been an incredible journey. Though sometimes lonesome and sometimes uncharted, it presents some pretty spectacular views along the way. And for that, I will always be very grateful.

Now it’s up to you to keep on running. Our profession is worth it. This country needs us to be our very best, and together, this generation and all that follow, will cross every finish line together!

Thank you.