College of Medicine Commencement 2011

Remarks to the Graduating Class of 2011,
University of Illinois College of Medicine, Chicago, IL May 6, 2011

By Arnold S. Relman, M.D.
Professor Emeritus of Medicine, Harvard Medical School, and
Former Editor-in-Chief, New England Journal of Medicine

Arnold S. RelmanThank you, Dean Flaherty. I am delighted and honored to be here in Chicago to greet and congratulate the 185 members of the graduating class of the University of Illinois College of Medicine. I also want to congratulate all those who are receiving Masters or Doctoral degrees in the medical sciences from the College of Medicine. This is a significant day in the lives of all of you. You should be proud to share this happy, auspicious occasion with your family and friends and with the assembled school faculty. Without their help and support you could not have come this far.

Although I salute all those receiving degrees today, I want to address my remarks particularly to the graduating medical school class, that is to those who are about to enter what is without doubt not only the most esteemed of the learned professions, but the most demanding and rewarding. It is a career that calls for commitment and hard work, but one which, if pursued with integrity, compassion and skill, provides unique personal satisfactions. In its essence, medicine is a profession that offers the opportunity to do well by doing good. By "doing good", I mean caring for people when they are sick or injured and urgently need help that no other profession can provide. Their health and well-being, and even their survival, may be at stake. And by "doing well", I mean being reasonably assured of a comfortable economic future. Competent and ethical medical practitioners should not expect to become rich, but they can usually count on earning a good living, without competing with or threatening others in the same profession. The practice of medicine is a "win-win" relationship that benefits both parties involved—patient and doctor. So it is a great privilege to become a physician. But it is a privilege that carries great responsibilities.

After you receive your medical degree, which presumably will soon allow you to become a state-licensed practitioner of medicine, U.S. society is in effect offering you a contract. As a licensed medical practitioner, the state will grant you unique privileges and powers, and patients will confide in you and trust you to protect their life and their health. In return society will expect you to give your first and highest priority to the medical needs of your patients. You will also be expected to avoid financial arrangements that create conflicts between the best interests of your patients and your own economic interests. The patient's medical interests must always be your primary concern.

Beyond all these established and generally well-recognized responsibilities, a new obligation of the medical profession has arisen as a result of the deepening crisis in our health care system. Society needs you to help our health system become more efficient and sustainable—to help rescue a medical care system that is coming close to bankruptcy. This is the most important part of my message to you today. But before I discuss it any further, I must say a word about the remarkable demographic changes that have been reshaping the medical profession itself and explain how these changes will affect what I believe the profession should do in the years ahead.

Consider first, the demography of the profession. Sixty-five years ago, when I graduated from the College of Physicians and Surgeons of Columbia University in New York City, the vast majority of the class were white men. Among the113 graduates there were only four women—reflecting the fact that in those days physicians were almost all men. And, among the men in the class there were only two Latinos (both citizens of Puerto Rico), and one American black. There were no students at all from Asia. That kind of demography was pretty much typical of the entire population of students entering the profession in those days.

Since then, beginning during the cultural revolution of the 1960s, there has been an extraordinary transformation in the gender and in the racial and ethnic origins of U.S. medical students. Your graduating class well illustrates this point. Your class is half female and, only forty percent white. Your non-white members are largely Asian in origin, but ten percent of you are U.S. blacks. That half of your class are women is typical of U.S. medical graduates nationwide, but you have a larger than average representation of non-whites. In any case, it is quite clear that the demography of the U.S. medical profession, rather than being an exclusively white male domain, will soon resemble the demography of the U.S. population as a whole. Half of all practicing physicians will soon be women and many races and ethnic origins will be represented. That is the way it should be if physicians in this country are going to deliver the kind of medical care through the kinds of medical organizations, our country now so urgently needs.

This now brings me to my central theme—the currently perilous state of our medical care system and how young physicians can help solve its problems.

The U.S. medical care system that you are about to enter is in crisis. Although the quality of our best medical schools and teaching hospitals and the technical expertise of our best physicians are unsurpassed, our health care system is failing. While patients seeking the most advanced and sophisticated medical services still come to the U.S. from all over the world, our country lags behind many others in providing accessible and affordable care for all its citizens. Yet we spend more than twice as much on health care as most other advanced countries and our costs are rising at an unsustainable rate. Government expenditures on health care are the single largest contributor to the growing deficit in our federal budget, and the health reform legislation passed last year will make this deficit even larger. Costs of health care are at the center of the great national debate on government expenditures.

The new health legislation provides federal support for greatly expanded private health insurance coverage and for expansion of state Medicaid programs, but does very little to control the unsustainable growth in health care costs. Health care costs largely reflect the volume and types of medical services, i.e., the use of hospitals and other medical facilities, the number of office visits, and all the diagnostic and therapeutic procedures that are provided to patients. Almost all of these things are controlled by physicians. They order or perform the tests and procedures and they determine the use of medical facilities. Physicians are paid only about twenty percent of the health care dollar, but their decisions and recommendations determine how most of the rest of the money is spent.

Most physicians are still in solo or small partnership practices and they are paid fees for each service they personally provide or supervise. This encourages physicians to provide many unnecessary services, particularly since most of the costs are reimbursed by insurance, which rewards them for doing more. The system also encourages physicians to refer patients to medical facilities because they are paid fees for the services they render to patients in these facilities. For their part, most medical facilities are now run like businesses looking to increase their income, so they market their services and encourage physicians to refer patients to their facilities and share in the income generated.

Two different philosophies are now contending for influence over the national policy debate on controlling medical costs. One side believes that responsibility for paying costs should be shifted from insurance plans to individual patients, because this would make patients more concerned about the costs of unnecessary or elective services, and would stimulate price competition among insurers and medical care providers, thus resulting in lower costs. This is the view of most Republicans and of those who see medical care as just another business. They see no need to change the way medicine is practiced or paid for.

The other philosophy considers medical care to be a social service quite different from a business, and it thinks the relation between patient and doctor is not the same as exists between a customer and a vendor in a commercial market. It believes that physicians have a moral obligation to serve the needs of patients and that the best way to control costs is not by market competition, but by changing the way medical services are paid and the way physicians are organized to practice. In my opinion the best way to do this is to have a single, tax-supported insurance plan that would pay for comprehensive care on a per capita basis, instead of piecework payment for each item of service. Salaries should replace fees for service as payment for physicians, and multi-specialty group practices should replace independent solo practices.

Now this is precisely what young physicians—especially women—are looking for these days. They do not want the hassle of setting up their own office practice and struggling with insurance plans and professional competitors to earn their livelihood, and they do not relish being on call all the time, seven days a week. More and more young physicians—particularly women, but many men as well—are looking for salaried positions in medical organizations that offer shared responsibilities and defined hours of work. More of them are accepting salaried positions in hospitals, but what is more encouraging, many more are joining multi-specialty group practices, owned and managed by physicians.

I believe that salaried physicians, working in not-for-profit group practices that can accept responsibility for comprehensive care of patients on a capitated payment basis are the key to providing good medical care at a cost we can afford. If physicians continue to choose to join such groups, and this becomes the major form of medical practice, federal and state governments will finally be able to enact the reforms in health insurance payment that can solve our health care crisis. Already nearly a third of practicing physicians are employed in group practices and their number is growing rapidly.

This, I suggest, is the future you should work to establish because it promises to yield better medical care at lower costs, and it offers a professional lifestyle that is more rewarding for physicians. You will do well by doing good, and that, as I said at the beginning of my little sermon, is what the practice of medicine should be about.

So I conclude by congratulating you again on entering this great profession. I hope that you will help to preserve its values by joining in the national effort to reform our health care system. If you do that, you have a good chance of getting as much satisfaction from your medical career as I have had.

All the best to you, and thanks for your attention.