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American Medical Students Association Annual Convention

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March 9, 2012
Houston, Texas

You have all taken different paths to get here today.  Some of you are the children of doctors.  Others are the first in your family to go to medical school, or even college.  Some of you have dreamed of wearing a white coat and stethoscope since you were little.  Others dedicated years to another career before realizing medicine was your true calling.  You come from big cities and small towns and will train in dozens of different specialties and sub-specialties.

But you also have something in common.  You are members of a generation used to instant gratification, yet you have chosen a career path that promises the exact opposite.  The path of problem sets and weekend labs, 16 hour hospital shifts and hours spent memorizing mnemonic devices.  A path that will require you to study and train for as much as a decade – and take on tens or even hundreds of thousands of dollars in debt – before you’re finally handed the reins to your own career.

When I talk to student doctors and ask them why they are willing to make these sacrifices, they all say the same thing: they want to help people.  They want to serve.  They want to be healers.  They know that being a doctor will help them support their families.  But it’s not about that.  There are other fields that offer a bigger, faster paycheck.  What drew them to medicine is the unique opportunity to make a difference in people’s lives. 

As your careers progress, you will have plenty of opportunities to do that.  You will move out of the lab and library, and into the clinic and wards.  You will be the one who soothes a scared patient, who delivers good news to the parents of a sick child, who follows a clinical hunch that saves the day.  You will help deliver a newborn, tell family members the surgery was a success, and hear over and over again, “Thanks, doc, for being there.” 

But I know I am not telling you anything you haven’t heard before when I say you will also have a different kind of experience: the feeling of helplessness when you discharge a patient who doesn’t have enough social support, knowing you will likely have to readmit them soon; the frustration of having to make seven phone calls just to piece together a patient’s health history; the sinking feeling after your patient tell you she skips medications because she can’t afford all the ones she needs.

We often hear about how these breakdowns and gaps in our health care system affect patients, but they also hurt doctors.  They keep you from practicing the way you were taught and force you to spend hours fighting with insurance companies and filling out paperwork instead of being with your patients.  They’re why older doctors, when asked for career advice, will sometimes say: “Go to law school.  There’s never been a worse time to be a doctor.”

If you take only one thing away from my remarks today, I want it to be this: the people who give this advice are looking at the past.  The truth is: there has never been a better time to go into medicine than right now.  Yes, there are real flaws in our health care system.  Yes, they will affect you and your patients.  But today for the first time ever, there is a real shot at fixing these problems.  There is a brighter future on the horizon.

You are entering medicine at a time of historic change.  The combination of a wave of health innovation across the country and the most important health legislation in over forty years has created a unique opportunity for progress in health care.  For the first time in decades, it’s possible to imagine making big strides towards a true 21st century health care system – one in which patients get the right care at the right time, Americans live longer, healthier lives, and doctors have more freedom to practice medicine the way they want to.  And no one is in a better position to shape that future than you.

So what will that health care system of the future look like?  The details have yet to be filled in, but we already have a sense of the big picture.

First, there will be a new national focus on prevention, both inside and outside the doctor’s office.  There is a growing body of evidence that people’s behaviors outside the health care system – what we eat, how much we exercise, whether we smoke or not – affect our health just as much, if not more, than the treatments and medicines we get when we visit a doctor.

For doctors, this meant experiences like designing the perfect regimen for your patient with diabetes, only to see them go home to a neighborhood where the lack of healthy food options meant their chances of sticking to that diet were almost zero. 

So over the last three years, we’ve launched what is probably the most ambitious effort in our country’s history to help people make healthy choices: funding innovative local programs for reducing chronic disease to be models for the rest of the country; new laws to make sure kids get healthy school lunches; and historic legislation to make it harder for tobacco companies to market their products to kids, since we know that every day, 3,800 young people smoke their first cigarette.

We’re also making it easier for you to promote good health in your practices.  A key benefit of the health care law is that recommended preventive services like cancer screenings and vaccinations are now available for Medicare beneficiaries and many Americans at no additional cost.  So you’re no longer going to have to worry about those patients skipping their mammograms and checkups because they can’t afford the co-pay or deductible.

The health care system of the future will also have a greater focus on primary care.  I want you to raise your hand if you’re thinking about going into primary care.  Now, raise your hand if you’d consider primary care if there was a smaller pay gap between pediatricians and specialists. 

Primary care is too important to be treated as if it was of secondary importance.  That’s why through the Affordable Care Act, we’re increasing reimbursement rates for primary care.  And we’ve added thousands of slots to National Health Service Corps, a Peace Corps for health workers.  If you go and practice primary care in an underserved community, we’ll help you repay your loans – a win/win.

Part of the reason we need more primary care doctors is that they’re the key to care coordination – something we’ll need a lot more of in the health care system of the future.

Thanks to the medical breakthroughs of the last 50 years, millions of Americans today are living with chronic conditions that would have killed them fifty years ago.  It’s good news that we’re living longer.  But it also means we have a new group of patients who often suffer from multiple, complex chronic conditions. 

You may see a patient with congestive heart failure.  But she also has chronic asthma, uncontrolled diabetes, and is a smoker.  Good care for this patient has to be a team effort, with primary care doctors and specialists, but also nurses, community health workers, and substance abuse counselors.  As the doctor and author Atul Gawande likes to say: today, we need pit crews, not cowboys

And now, the health care law is changing the way we pay for care to support this kind of coordination.  For example, we’re bundling payments so that the hospitals that follow-up to make sure patients don’t get readmitted get rewarded.  And we’re supporting Accountable Care Organizations, led by health providers, that will get paid for keeping their patients healthy and not just how many tests and procedures they do.

To provide this coordinated care, doctors need new tools.  And the good news for you is that you are entering medicine at the same time as the file cabinets are leaving.  Thanks to a law signed by the President in 2009, there are powerful new financial incentives and supports to help practicing doctors and hospitals switch to electronic health records.  And after decades of talk, we are seeing some dramatic results.

In the last three years alone, the share of primary care doctors switching to digital records has almost doubled from 20 percent to 39 percent, and it's on pace to exceed 50 percent by the end of the year.  By the time many of you are practicing, electronic health records will be the rule, not the exception, bringing with them fewer errors, less paperwork, and lower costs.

But the biggest difference for both you and your patients will be the changes happening to the health insurance system.  In the past, far too many health decisions were dictated not by what a patient and their doctor thought was best, but by what an insurance company or patient’s finances would allow.

Too many people showed up in the emergency room with a health crisis that could have been prevented.  Cancer patients had to abandon chemotherapy regimens because they hit a lifetime limit on their insurance policies.  Parents of sick children lived in fear of being dropped from their insurance or having their child branded with a pre-existing condition that could be used to deny him coverage for the rest of his life.

 Now, for the first time, we have a health care law that’s getting rid of the worst abuses of the insurance industry.  The new Patient’s Bill of Rights makes it illegal to impose lifetime limits on care or cancel someone’s coverage when they get sick because of a paperwork error.  And in 2014 when many of you begin your residencies, for the first time in our history, every American will have access to affordable health coverage.

The result will be a health care system in which you will be able to begin far more conversations by saying: what can I do to help?  Not asking: what coverage do you have?

This 21st century health care system is already taking shape in cities and towns across the country.  Earlier today, I visited Ben Taub General Hospital right here in Houston.  They told me that in the short time since they installed their electronic health care system, they’d reduced avoidable hypoglycemic events by a third.  And they said were putting a new focus on prevention, from sponsoring farmer’s markets to using mobile vans to reach patients in their communities.

What’s happening in Ben Taub is happening across the country.  And all the innovative hospitals and health centers that I’ve visited have one thing in common. 

Many of them use electronic health records like Ben Taub, but some do not.  Some do outreach to help patients manage their chronic conditions, but others don’t.  It’s common for them to put an emphasis on primary care, but it is not universal.  The one thing they all have in common – the one indispensable ingredient for improvement – is physician leadership.  And I can’t imagine anyone who’s better prepared to provide that leadership than those of you in this room.

For one thing, you’ve grown up around the technologies that will play a key role in the health care system of the future.  I also hear from older doctors that you understand intuitively that health care today must be practiced as a team.  And simply by being here today, you’ve shown that you have already learned an important lesson: that your work as a clinician is just one of the ways you can help your patients.  And that perhaps the best way you can help them is by working to build a better health care system for all Americans.

So this afternoon, I want to urge you not to give in to cynicism or complacency when you have those frustrating experiences I mentioned earlier.  It will not be easy.  When you’re working 14 or 16 hour shifts in the hospital, there will be a temptation to jut put your head down and finish your assignments.  When you see the same error happen again and again, you may find yourself wanting to say “that’s not my job to fix it.”  When you try out a new model of care and it doesn’t work, it will be easy to just go back to the old way of doing things.

But we need you to persevere.  We need you to remain focused on that brighter future.  We need you to be leaders.  And you should want to be leaders too.  After all, we are talking about a health care system that many of you will spend the next three to four decades of your life working in.

If we can seize the opportunity in front of us, I believe you can be the generation of doctors that helps us usher in a new day for health care in America: one in which our communities are healthier and more prosperous, patients get better care and have greater satisfaction, and forty years from now, you can tell medical students when you talk to them that this is the best job in the world. 

Thank you.