Remarks to Physicians, Oregon State Board of Medical Examiners, Portland, Oregon
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61 (2,057,047 Bytes)
1989-10-06 (October 6, 1989)
Koop, C. Everett
This item is in the public domain. It may be used without permission.
Medical Subject Headings (MeSH):
Health Care Costs
Health Care Economics and Organizations
Health Care Reform
Reproduction and Family Health
"Reflections on Health Care: Oregon State Board of Medical Examiners [and] Oregon Foundation for Medical Excellence, Portland,
Oregon" and "Remarks to Physicians, Oregon State Board of Medical Examiners, Portland, Oregon" [Reminiscences]
Reflections on Health Care: Oregon State Board of Medical Examiners [and] Oregon Foundation for Medical Excellence, Portland,
Oregon (October 6, 1989)
Box Number: 9
Folder Number: 1989 Oct 6
Remarks to Physicians
Oregon State Board of Medical Examiners
October 6, 1989
C. Everett Koop, M.D.
It still surprises me, but I have become a recognizable fellow. Walking along the street, in the New York subway, [give example
of this trip to Portland], people come up to me: "Hi Doc!", or "Keep up the good work!" or, "I know you!
You're the attorney general. Keep after those tobacco companies."
If my plane is delayed, I often end up holding office hours in the airport waiting area. "You are the one who finally
made me stop smoking!" Or even, "Say, I hate to bother you, but it got this pain in my elbow . . . "
On several occasions I've been recognized, and then both pleased and saddened by someone saying to me, "I want to
thank you for making me proud, once again, to be a doctor." I'm pleased, of course, because I've given my life
to this profession, and it has been good to me. But I'm saddened to hear from so many of my colleagues who've lost
the pride, the joy of being a physician. Recently, one of my friends, quite accustomed to spending his time with other doctors,
found himself with a group of lawyers instead -- yes, the two can get together! The attorneys were congratulating themselves
on what they were able to do for their fellow citizens. It had been a long time since my friend and her doctors speak in that
vein. If lawyers can feel good about writing a will, can't we feel proud about postponing its use?
American medicine is at a crossroads. Our health care system is being torn apart by the struggle between society's aspirations
for health care and our resources to achieve them. America's high expectations are fast out-running the nation's ability
to pay for them. In other words, we have a clear gap in our society today between what we would like to see happen in health
care . . . and what can realistically happen in health care. The struggle between our aspirations and our resources has come
at the worst possible time, a time when demographic trends are running against us.
In a climate of scarcity Americans will have to work out equitable sharing of needed medical resources between one population
group that is growing -- that is, the elderly, people over the age of 65 -- and the population group that is comparatively
shrinking -- that is, children under the age of 18. Over the past 8 years I've dealt with advocates for children and I've
dealt with advocates for the elderly. They are both very dedicated and very persuasive groups. And both will be quite rightly
competing for a larger piece of smaller pie.
This has chilling ethical implications, and we must guard against letting our ethics be determined by economics, and not the
other way around. As I said earlier today, to a group of your civic leaders, when I or other people talk like this, our critics
come back at us and say that things really aren't that bad . . . that all we need to do is put a reimbursement cap on
this . . . or change the eligibility regulations for that . . . or cut back a little here . . . or prune back a little there.
During 8 years as your Surgeon General, I've listened to these debates and I thought about the true human cost associated
with that kind of a patchwork approach.
And today I'm more convinced than ever that our whole health care system needs to be studied with an eye to making a number
of very major corrections. Now, I can already hear the critics saying, "Wait a minute, Dr. Koop. The system ain't
broke, so don't fix it." To which I would reply, "You're wrong. The system is broken . . . and it must be
fixed." Band-Aids won't do. I say there's something terribly wrong with a system of health care that spends more
and more money to serve fewer and fewer people.
Our problems resulted in a three-tier framework of health care. We've always said we never wanted even a two-tier system.
But we have it . . . and a third tier, also. In the first tier . . . the bottom tier . . . are upwards of perhaps 30 million
Americans -- about 12 percent of the population -- who fall between the cracks and have no health insurance coverage . . .
no high options . . . no low options . . . no options at all. They're not old enough for Medicare and not poor enough
What, then, does this "health care system" of ours do for the uninsured? In the vast majority of cases the answer
is . . . very little . . . or nothing. And they are suffering the consequences. As you know, study after study indicates a
correlation between no medical insurance and increasing health problems. The health problems of the lowest tier, if ignored
by society now, will be borne by society later.
Then we have a second tier. This tier receives a narrow range of basic medical and health services with more or less fixed
levels of reimbursement. This is low-option coverage . . . Medicare and Medicaid coverage . . . with the patient paying many
costs out-of-pocket or with the help of some form of supplemental insurance, which is -- in my book -- just another kind of
Finally, we have the third tier, the top tier. The people in this tier receive a full range of medical and health services.
They are covered by high-option health insurance and also have a few dollars left over to pay the 15 or 20 percent difference
between the actual bill from the doctor and the check from the insurance company. But business is finally coming around to
understand that it cannot continue to bury inflated costs of health care in the price-tags of their goods and services.
Since 1984 the average premiums for employer-provided health insurance have approximately doubled . . . to $3,117 per year,
and have risen from 8 percent of business payroll costs to 13.6 percent this year. Businesses can't absorb these costs
and also expect to be competitive.
This situation, this disparity between resources and aspirations, the sense of costs out of control, has placed American medicine
under the gun. Momentum is building for restructuring the financing and delivery of healthcare in the United States. Even
business leaders who cringe at the thought of government intervention are asking for a system of national health care as a
solution to rising insurance costs. A surprising and very significant event took place at the beginning of last summer.
Two groups, unlikely partners in this sort of issue, each called for a national health service. The first was one of the major
automobile manufacturers, and the other was the Heritage Foundation, a most conservative body. Never before have there been
so many voices clamoring for radical reform of the American healthcare system. In Congress, in labor, in business, in physician's
offices, people agree: something must be done.
We need to get away from the consumer-provider mentality. We need to restore the doctor-patient relationship. Each of us.
"Consumer" brings to mind someone shopping for groceries or checking out the features of the new car. "Provider",
on the other hand, sounds like a garage attendant pumping gas. If the patient thinks of himself primarily as a consumer, getting
the most for his money, he automatically puts the doctor in the role of the seller, getting the most for his time.
If the doctor is primarily concerned with collecting his fee, he automatically arouses the consumer mentality in his patient.
The next time people refer to you as a "healthcare provider", correct them. Remind them you are a doctor, and that
you work, not with consumers, but with people who are your patients.
Of course, medicine is not alone in its rapidly rising costs. But our prices make people angry. Recently, I asked the contractor
building the new house to move the outlet for overhead light 1/2 feet -- before the ceiling was finished. The contractor wanted
to charge me $450! When people hear that, they may laugh knowingly, or groan in sympathy, but they don't get angry.
The same is true for the escalating costs of private education. Although no one is happy about the rising cost of college
education, it does not create the same anger or resentment as the rising medical costs. Students pay the price for private
higher education because they feel they are getting quality in return, even though the expectations in education are lower
than in health, and the failures more frequent. The student-teacher relationship has not become one of consumer-provider.
That is because students do not see teachers as the direct beneficiaries of the rising costs, the way patients see doctors.
A high-quality education, students and professor like say, is something you can't evaluate in dollars and cents alone.
Patients used to feel the same about restored health. But now they are angry.
Part of the anger, the dissatisfaction may be unavoidable. No one wants to be sick, and to have to pay for it makes it worse.
But part of the anger is of our own making. Last week I read an article in the newspaper of my old hometown, Philadelphia,
which pointed out that while the president of the University of Pennsylvania might be trifle overpaid at $220,000 a year,
five professors of surgery raked in between $440,000 and $620,000.
The public has a hard time swallowing that. Let me say it again, that the restoration of the doctor-patient relationship is
most essential. Many things would have to change in order that it be restored, but once restored, many other things would
fall in place. Doctors and patients must stop viewing each other as an economic threat. We can't have patients wondering
if doctors make bedside or emergency room decisions on care based upon insurance coverage. We can't have doctors wondering
if the patient on the examining table will next meet him in court, surrounded by malpractice lawyers. And deeply saddened
when doctors tell me that this new adversary relationship has made them dislike their patients.
I am more than saddened when a physician brags that he talked his son or daughter out of going to medical school. I need not
explain in great detail to this group the sorry relationship between rising costs and the malpractice mess.
Before is imperative, but it may be impossible in the face of entrenched interests, doctors protecting doctors, lawyers defending
lawyers. Perhaps a blue-ribbon panel of retired attorneys and physicians, men and women without a personal financial stake
in the system, could serve the public interest by adjudicating claims, deciding whether or not the case should go to court.
There are other things we can do, as doctors, each day we practice.
We must you are patients as human beings, as allies, working with us in the struggle against disease. This includes prevention
as well as treatment and rehabilitation. The dentists have done a much better job in this than we have, joining with their
patients in preventive dental habits, even though this has the effect in some ways of working themselves out of a job. Most
Americans really feel that their dentist wants them to have fewer cavities.
They don't view their relationship with their doctor in the same way. For example, if over the last decade, doctors had
quizzed their patients about smoking, and then had given sound advice, we might enjoy that same alliance and prevention. After
all, it has been known for many years that the most likely cause of smoking cessation is for a doctor to look his or her patient
in the eye and tell him, "Smoking is going to kill you." Treating our patients like allies in the fight against their
disease means being clearer and more complete about informed consent.
That may mean telling more about what we know in some cases, sharing our uncertainties in others. Early in my own pediatric
surgical practice, I determined that I would make my patients and their parents my allies with me against their child's
surgical problem. I did this simply because I thought it was good medical practice, but also had the unforeseen dividend of
having no one sue me when I was in practice. We also must do better in policing our own profession.
For a variety of complex reasons, the normal competition of the market place does not always operate in medicine to get rid
of the bad apples. As physicians, as well as citizens, we need to do something for those Americans who, under our present
system, are denied access to reasonable care. While we wait for national or even state legislative solutions, we can do our
part by revitalizing the practice of offering free care to appropriate patients. I'm disturbed when I read those advertisements
in a county medical society bulletin, pleading with doctors to give half a day each week at a free clinic. In my day -- I
guess I sound, and look, like an old timer -- I found myself extraordinarily fortunate if I got paid for 40% of what I did.
But I was happy in my practice, my patients appreciated what I did, and I certainly enjoyed what I did for them.
But once entitlements came along, doctors who had been very happy to perform a certain amount of free service began to feel
that they had to be paid for everything. Giving, charity, has always been part of our calling. Finally, in addition to all
we must do, we need to make clear what we cannot do.
In a modern society, the practice of medicine has become complicated. It involves not only diagnosis and treatment, but also
the relationship between health and socio-economic factors. Increasingly people look to medicine to solve these deeper problems,
problems that are beyond the ability of medicine or doctors to solve. Doctors cannot eliminate the property from which patients
come; they cannot keep patients' children off drugs; they cannot bring back the husband who has deserted their patient
. . . a year or two ago I was asked to take grand rounds in pediatrics at a major teaching hospital. When I was finished listening
to three cases, having done the best I could with the problems, I had to remind the resident staff when the audience left
that I would not have gotten away with presenting those three patients when I was in their position because they were not
strictly medical problems: -- what they had presented to me were socio-economic problems that had come to the hospital because
the patient had an illness. Finally, let me remind each of you, that in this critical hour for American medicine, each of
you, each of us, carries the entire profession on his or her shoulders.
Just last week, after I had finished an appearance on CBS and was about to do a piece for National Public Radio in connection
with Critical Care Week. I was speaking with two young women, both bright, knowledgeable, articulate health reporters. I asked
them each the same question: "Are you satisfied with your health care?"
One said she was; one said she wasn't. I asked why. The one who said she was satisfied said, "My doctor listens to
me, and he tells me what the problems are, what he'll do, and I have a lot of confidence in him."
The one who was dissatisfied said, "I'm furious at my doctor. In order to have some surgery done, I saw him 7 times
in 2 weeks, had various tests and consultations, and when I called him to ask a question, he said, 'now remind me who
you are and why I know you.'" I said to them both, "In other words, when I asked you 'Are you satisfied with
your health care?', One of you said "yes", one said "no", but what you really were saying is that one
of you liked your doctor and one of you didn't. One had confidence in your doctor, one did not." If any of you saw
the two-part series of Golden Girls, September 23 and September 30, you got the public's view of what we are facing.
You would have seen a stereotyped expensive specialist fail to understand a patient's complaint, with utter lack of empathy
or compassion, a stereotype I hear about so frequently that it must be based on fact. You also would have seen a patient with
chronic fatigue syndrome telling her doctor off in a manner many patients wish they could.
Whether or not this is reality -- this is certainly the public perception. Therefore, my message to the doctors in Portland
is: when you are dealing with the patient, you are representing American medicine, you are representing American health care.
We have much to do, but let's not lose our positive energy. The message we have to share with their cells with the American
people is a positive one. We don't need the past tense, nostalgia about the "the good old days"; nor do we need
some futuristic manifesto promising what we intend to do. We need clear and persistent affirmation of the many good things
we do, day in and day out, to make our system of medicine -- once we take things in hand -- potentially the best in the world.
I have never regretted going into medicine. I'd do it again tomorrow. And I tell that to any youngsters who are considering
it. Ours is a calling. It is not a business. We could have made money doing other things.
We chose medicine because it combined a quest for knowledge with a way to serve, to save lives, and alleviate suffering. We
have to convince the public we still mean it.