Jordan J. Cohen, president and chief executive officer of the Association of American Medical Colleges, gave the commencement address for the the School of Medicine on May 7, at the Macon City Auditorium. Below is Cohen’s address:
The class of 2005! Wow! Let me be among the first to congratulate you, not only for your marvelous academic achievement, which we’re celebrating today, but also for the choice you made some time ago when your decided to spend your working life as a health care professional.
That choice, and the tangible symbol of academic success you will receive momentarily, have positioned you to contribute your talents to one of the most noble of human causes. Whether as a doctor, or as a public health professional, or as a family therapist, you will be positioned as few others are to advance the cause of human health.
Indeed, you will be armed with more powerful tools for doing your noble work than any generation before you has had at its disposal.
You are all familiar with the fact that medical knowledge has grown geometrically over the past several decades, and that that knowledge has fundamentally transformed our understanding of human biology and disease.
As a result, we are entering an era of unimaginable new scientific breakthroughs – breakthroughs that promise to make life better for everyone on the planet.
But I want to focus today on another kind of geometric transformation — one that has received less attention but one that promises to be equally, if not more important because it has the potential to actually bring those benefits of the scientific revolution to more people who need them.
I am talking about the geometric transformation that must take place – and that your generation must lead — in the relationships among health care professionals and between the health professions and the public they are sworn to serve. Using geometry as a metaphor, let me suggest that what we urgently need is a morphing of the geometry of health care from a triangle to a circle.
Can you guess why I have chosen to use the triangle as a metaphor for the current structure of American medicine?
It is because health care has evolved over the past many decades into a largely “top down”, triangular affair.
At the apex of the triangle sits the highly trained super-specialist physician on whose knowledge, experience, and judgment the entire system of health care has come to depend to deliver the most sophisticated care to the most critically ill patients.
Tucked up under the apex of our triangle — and sometimes barely visible in its shadow – are the generalist physicians — the family practitioner, the general internist, the general pediatrician — who have been subordinated to the specialist in prestige, relegated to lesser financial reward, and possessing less power to change the way the system works.
Along the sides of the triangle are all of the other health care professionals — the nurses, radiology technicians, respiratory therapists, cardiac bypass technicians, physician assistants, laboratory technicians, physical therapists, social workers, and others —
who have supported the apex at the top — who have kept physicians from slipping down the slope of inadvertent error, who have kept physicians from collapsing under a burden much too large for one profession to bear, and who have kept physicians from falling from the lofty perch on which they appear all-knowing, all-important, and indispensable.
At the base of the triangle, of course, are the patients and the public at large who, on the one hand, have supported the whole edifice of medicine with their hard-earned resources and who, on the other hand, have received enormous rewards as beneficiaries of the best health care available anywhere in the world, at least for those who can afford it.
To the shame of our civilized society, we have not yet found the will to make excellent health care available to everyone. So maybe I should use a dotted line, rather than a solid line, to draw the base of this metaphorical health care triangle.
In any event, this triangular structure I have tried to draw in your mind’s eye is meant to convey the reality that health care in America has been, in large measure, a hierarchical affair.
Doctors at the top, who set the standards of care and from whom other health care professionals take direction, as benefits rain down on the patients at the bottom who sustain the entire enterprise.
What’s wrong with this picture? After all, American medicine has set the standard of health care that is the envy of the world. Not a bad result for plane geometry.
· But what’s wrong with this triangular picture is that its pointy, sharp-edged, 20th century features are proving difficult to fit into the structure we need for 21st century medicine.
· What’s wrong with this picture is that we can no longer afford the inefficiencies and inequities inherent in such a system.
· What’s wrong with this picture is that it is ill-suited to deliver the high quality, technologically sophisticated, expensive care to everyone who can benefit at an affordable cost to society.
· What’s wrong with this picture is that people of all colors and income levels don’t have equal access to care — in fact, some have no access at all.
· And finally, what’s wrong with this picture is that it inhibits us from taking full advantage of the benefits that can flow from using teams of health care professionals rather than depending to such a large extent on individual providers.
Fortunately, an alternative to this outmoded triangular affair is coming into view. It has a new geometry, one based on the circle, with its much more contoured, well-rounded, egalitarian shape.
At the center of this developing health care circle is – hold onto your caps — the patient, still ultimately responsible for the resources needed to sustain the system, but no longer sitting at the bottom of the heap, powerless to determine what kinds of services are available and how much they will cost.
“Patient-centered care” is a mantra we in the health care game have been chanting for a long time, but it is only recently, thanks to a fiercely competitive health care marketplace vying for customers, that it may finally become a widespread reality.
Before that can happen, however, generalist physicians must emerge from under the shadow of the specialists and take their rightful place in close proximity to patients and their families at the center of the action. In equally close proximity to patients we must find room for other primary care providers so they can form teams with generalist physicians in a rich lattice of cooperative services at the hub of our circle.
Health care teams comprising an array of professionals with special skills are now universally acknowledged to be the proper paradigm for the future — not individuals working in splendid isolation and often in triangulated competition with one another — but teams of professionals organized in circular embrace and deployed to provide comprehensive, continuous care especially to the growing number of patients with chronic unremitting illness and disability.
Radiating in all directions from the center of our metaphorical healthcare circle, and no less important to the quality and effectiveness of the outcomes of the care provided, are the specialists and subspecialists who round out the team.
It will always be the case, of course, that some patients will require highly trained specialists in order to gain access to cutting-edge technology and highly sophisticated care. Such individuals are also indispensable for ensuring that advances in modern science are translated into cost-effective improvements in the quality of care available to everyone.
One of the most compelling features of this new circular conception of health care is symbolized by its outer bounds, its circumference.
The defining perimeter of concern, for which everything inside the circle is pushing outward to achieve, is improvement in the quality of life for individuals and in the overall health status of the public.
Although the need to constrain the rising costs of health care is unquestionably the most powerful force driving the near term shift from triangle to circle, the more lasting long term benefit will come from a shift in emphasis.
The historic stance of medicine has been reactive – waiting for something to go wrong and then trying to fix it. The challenge and opportunity for 21st century medicine is become prospective – to use our powerful new science to anticipate what might go wrong and to try to prevent it for happening.
Your job is to help flatten the geometry of health care from a hierarchical triangle overly concerned with maintaining the structure of the system, to an expanding outward-reaching circle striving to embrace everyone in the community.
In so doing, you will help create a better coordinated, more prospective, more collaborative system designed to improve the health of the public.
And by focusing on teamwork, by respecting everyone on the team who has something to contribute, by encouraging everyone to work together in the interest of quality care, you and your generation can complete the transformation of American health care to a more effective geometry, designed to give everyone the kind of health care they need.
The values and skills you have acquired here at Mercer have prepared you well to participate in this historic transformation of American healthcare.
