Courage, sacrifice, and internal medicine—a year in review

ACP's president reflects on his year of tenure and shares his convocation speech from Internal Medicine Meeting 2017.

This is the end of my year as ACP President, and it has been the honor of a lifetime. I cannot overstate the worldwide regard in which the College is held and the extraordinary talents and hard work of the staff, Governors, Regents, and leaders who will guide medicine in the 21st century. I particularly want to recognize Tom Tape, Chair of the Board of Regents; Doug DeLong, Chair of the Board of Governors; Robert Lohr, Treasurer; Wayne Bylsma, COO; and Darilyn Moyer and Steve Weinberger, EVP/CEOs, whose advice has been invaluable. I look forward to turning over the presidency to Jack Ende, who will do outstanding work. I will now be returning to private practice and await the next adventure and challenge.

On March 30, I gave the Convocation speech at Internal Medicine Meeting 2017 in San Diego to new Masters, Fellows, and awardees. In my final column, I thought I would share relevant portions with the entire membership.

I would like to talk about courage and sacrifice, gratitude, and authority. I will start with my parents, who emigrated from India nearly 60 years ago to seek opportunity for themselves and their children. My father was a biochemist and co-discoverer of the glycoprotein molecule but struggled to receive a tenured faculty position. My mother had a graduate degree in economics but had to work as a key-punch operator. They both endured professional and social discrimination based on the color of their skin, the accent of their English, and the pattern of their dress. There were many moments when they considered returning to their native land, but they didn't. They knew that this was a country of ideas, great opportunity, and promise. They sacrificed and were determined to make a life for themselves and for their children in America. I stand humbly before you today in their shadows.

Mine is not a unique story but one repeated millions of times around the world and perhaps in your lives. Perhaps you too have gained from the sacrifice and courage of your parents, your family, or friends or colleagues. You too have had to make choices in your careers and personal lives. So we celebrate that sacrifice and take pride in your accomplishment and the knowledge, skill, and empathy you bring to your patients.

As I traveled the world as ACP President, I was inspired and humbled by the talent and dedication of the internists I met. Some are practicing in rural and resource-poor areas; others are providing state-of-the-art subspecialty care; others are advancing knowledge through basic science research, teaching, or clinical trials; and some, like me, are caring for patients in urban or suburban settings. The common thread is the commitment to advance humanity, better lives, and seek a world where all lives have equal value.

I also saw the respect in which American medicine and the College are held. Internists around the world look to ACP to set the standards for ethics and professionalism in the practice of medicine. Some seek the same opportunities that my parents sought to create lives and careers in America, while others seek affirmation for their accomplishments with the honor of advancement to Fellowship and Mastership.

As I traveled the United States, I experienced the diversity of our country and witnessed disparities in health care delivery, as well as the demands on internists attempting to stay in private practice and sustain a work-life balance. But there was also a great sense of joy and reward in caring for patients and gaining knowledge over the course of their careers.

Our patients and profession face many challenges. Our patients seek access to high-quality affordable coordinated health care as a fundamental human right. They seek affordable prices for medications and medical and surgical services, and health insurance that is affordable for everyone.

They trust us to be current in our knowledge and offer our experience, judgment, and wisdom. Patients look to us to help solve the problems of prescription drug costs and opioid dependence, provide access to compassionate and ethical end-of-life care, protect against gun violence, provide adequate mental health care, and fight against any and all discrimination. They look to us to advocate for women's health rights and mitigate against the greatest health threat of the 21st century, global climate change.

But our profession is at a tipping point. We have the knowledge and skills to care for complex and chronically ill patients. We are master diagnosticians in addition to practicing disease prevention and population health. But we are struggling for identity within the house of medicine and society. General internal medicine is in crisis, with very few choosing it as a career. We are at risk for becoming just a foundation for further subspecialty training. We need to once again educate society on our unique and critical role. Medicine has changed, and we need to change with it.

We are burdened with disruptive EHRs, coding requirements for billing purposes, and prior authorizations for tests, medications, and medical equipment. In addition, we are now tasked with managing the cost of care and taking on risk in a for-profit medical-industrial complex, where attempts to control profits will be met with great countervailing forces. New payment initiatives may help improve both care for some chronic conditions and prevention strategies with decreased cost, but it remains unclear if these gains will be significant or sustainable.

The vast majority of health care costs are attributed to hospital care, surgeries, procedures, pharmaceuticals, advancing technology, the aging population, and unhealthy lifestyles. The needed fundamental change is the reevaluation of noncognitive and cognitive services to more accurately reflect the knowledge, skill, time, and value they bring to patient care.

We take pride in our thirst for knowledge and for learning new skills. We believe in standards for certification and Maintenance of Certification. But we need to make the acquisition and assessment of knowledge less burdensome, less costly, and more interactive, as well as ensure that it improves the quality of care. Leadership at ACP and the American Board of Internal Medicine have been working long and hard to make this transformative change.

The issue of resilience and wellness, or "burnout," looms large, especially among our trainees and early-career physicians. Several factors are contributing, including complex reporting requirements, administrative burdens, poorly designed EHRs, and lack of autonomy. The College in collaboration with other organizations has recognized this and is active in finding solutions.

One antidote to burnout that I have discovered is gratitude. As Marcus Cicero said, "Gratitude is not only the greatest of virtues, but also the mother of all others." We should have gratitude for the education we have received, the opportunity to serve humankind, lifelong learning, and the privilege of sharing in our patient's lives. You are members of an elite group to whom much has been offered, and you should take pride in the service you give back. Create balance in your lives with volunteerism, time with family and friends, physical fitness, varied interests, and mindfulness.

Things must change, and you have the authority, respect, and trust to make those changes. You must become leaders in setting policy that keeps the patient at the center of care and recognizes the importance of general internists as heads of the health care team. We need you to become leaders in setting the standards for uniform and meaningful quality measures and for an evolving payment system that values cognitive services, is value-based, and perhaps leads to payment for a demographically and complexity-adjusted global patient panel. We need you to be leaders in forcing governmental agencies and Congress to make vendors develop more functional, truly interoperable EHR systems. We need you to take back the profession and move it closer to utopia. The American College of Physicians is and will be there to help with this transformation.

Imagine a world of healthy lifestyles, 100% renewable energy and a healthy planet, minimal chronic disease, gene-base therapies, stem-cell research, universal access to high-quality and affordable care, information technology that is seamless and interoperable, time with patients, the excitement of making the correct diagnosis and instituting a treatment plan, adequate payment, and work-life balance. That world is a possibility, and you are charged with creating it. In the words of John F. Kennedy, "Our task is not to fix the blame for the past, but to fix the course for the future."

Our voices should be heard in boardrooms of companies and health care systems, academic institutions, practices, community centers, town halls and civic groups, the halls of Congress, and the White House. Perhaps you could run for federal, state, or local office, or set public health policy at the state and national level. It will take courage and there will be disappointment, but we must persevere for our profession and our patients. I challenge you to make one new commitment to your profession and to your personal lives that will improve the health of our patients, your profession, and your life.

My improbable journey could be yours. The thought of standing here before you today was once unimaginable. But you have the same opportunities to lead change through your values and vision for the future of health care. Become a leader. Use your authority to take risks, be courageous, and have gratitude. As Mahatma Gandhi said, "Be the change you wish to see."