"I feel both honored and humbled upon the initiation of my year of service as president of TAFP. A review of the names of those who have gone before me in this office reveals a list of physicians, all of whom I would be honored to be associated with and whose shoes I will be challenged to fill.

I am privileged to serve as your president for we are family physicians, specifically the family physicians of Texas, and before all else, we are the doctors that care about people. My remarks will concern what I see as the most critical factor facing family medicine and what I feel is the underlying origin of the issues confronting us. Issues like:

• Scope of practice
• Managed care
• Universal access and coverage
• Quality of care
• Lawsuit abuse

• Recognition for our specialty
• Collective bargaining
• Medicare issues
• Patient privacy
• And the list goes on

How will we respond to these questions? In these brief remarks, I can’t hope to address all of these issues, but I can express to you how I feel about our profession, where we are, how we got here, and what I think will help us get where we want to be in the future. Some of what I am going to say may not be easy or simple, but it will be sincere. And I am here because I believe that we as family physicians have the potential to overcome the challenges before us and move into a bright future for both our patients and medicine.

Nobody blushes today when someone says, "Medicine is a business." Twenty years ago, no one believed this, and today a whole industry has grown up around the idea of medicine as a business. The problem is, it just isn’t true. The modern medical system is built around this catastrophic misconception, giving us a cold, impersonal health care system where patients are covered lives and doctors are health care providers who are contracted to payers, and dependant on the payers for their panels. These payers look for ways to use cap checks and reimbursement schemes to change the way we practice medicine.

What a radical change. The world turned upside down in just the 15 years I’ve been in private practice. Fifteen years ago, medicine was caring for people and business was a small part of what medicine was. Fifteen years ago, I belonged to a private practice journal club. How many of those exist today? And when you went into the doctor’s lounge, your colleagues were discussing what new medicine had come out or what results they were getting with a new hip prosthesis. Now, all the discussion in the doctor’s lounge is about Medicare reimbursement and HMOs.

Who are these business people, third party payers, who are attempting to impose the all-American profit-driven business system on medicine? They are not evil people. They are our fellow citizens who have watched medicine change into an impersonal and analytical system of advanced technologies. The payer has de-personalized and quantified medicine and in an effort to control cost, which really means increase profits, the payer has attempted to place itself between the doctor and the patient to shift loyalty. The result has been a growing mistrust by patients and doctors of the whole health care system.

Vital Statistics: 

Dr. Van Winkle graduated from  UT Houston Health Science Center in 1982 and attended UTHSC Family Practice Residency Program.

Recently, in response to patient dissatisfaction, the government has taken legal steps to make payers legally responsible for their economic moves. The lack of viability of the current managed care system is reflected in the economic upheaval in these companies across the country. Every day, another news story reports on the bankruptcy of one of these businesses. The system is not working as it is currently structured. The doctors are disillusioned by these changes, changes in both the reimbursement system and more importantly, the doctor/patient relationship.

The American Medical News, the newspaper of the AMA, recently published the results of a survey reporting 38 percent of doctors 50 years of age or older plan to retire within three years, and another 16 percent said they plan to significantly reduce their practice or refuse new patients. The survey indicates that dissatisfaction with managed care was the primary reason for their retirement plans. Many others stated they would get out of medicine if they were financially able.

They are choosing to leave a medical system of intimidation, where a doctor can be arbitrarily dropped from a plan and lose 30 or 40 percent of his patients overnight. The article refers to an excellent family physician, Dr. David Abbott, who used to practice in San Antonio, Texas. It described him as finally becoming so disillusioned with the current system, that he gave up his practice and took a job in a government clinic. This was a fine physician whom I know and who precepted part of my residency training in his office where I saw the caring way he interacted with his patients. He taught me how to treat people like more than just organ systems. He quit when he could no longer practice medicine in that way.

This early retirement trend worries me because doctors who know what medicine was and who would be most able to lead medicine in its efforts to re-establish the personal doctor/patient relationship are those now giving up medicine. They are leaving behind younger doctors who have only read or heard about medicine the way it was—-about a time when a doctor might have families in his practice for 30 or more years, not just until the next insurance open season rolls around.

Imagine an employer offers in a company’s benefit plan an annual painted portrait by Rembrandt. This benefit really appeals to you and is a major factor in your desire to take the job. You go to work for this employer, and you are assigned to an artist’s gallery. At the gallery, a sign above the door reads "Rembrandt portraits for $20." You can’t believe the price. You go into the shop and instead of Rembrandt, you see me. You see that while I’m dressed like Rembrandt, clearly, I am not Rembrandt. I then point out that I use exactly the same paints and brushes as Rembrandt. On top of that, I can show you a study that concludes that my portraits contain all the same elements of a Rembrandt, and they cost much less. What’s wrong here?

Well, a Rembrandt isn’t just about knowledge of paints, pigments and brushes. It’s not just each portrait having two eyes, two ears and a mouth. Rembrandt knew all those things and he had a great knowledge of the mechanics of painting, but he took the knowledge, merged it with his personality and experience and created true art.

This duality is what distinguishes the artist physician from the materialist health care provider. No where does this become more clear than in family practice. For it is in family practice that a personal doctor/patient relationship is encouraged. We don’t just care for our patients, we care about our patients.

Every art contains in it multiple known and unknown elements brought together in an ever-evolving manner by the person practicing the art. Medicine has to do with nothing less than the principle of the preservation of a human life and the growth of passion and compassion for our fellow man in a heart of the practitioner.

Vital Statistics: 

Dr. Van Winkle is serving his second term on the AAFP Commission on Communications and is currently the Chair of the Subcommittee on Awards.

The father of four, Dr. Van Winkle lives and practices in Castroville, Texas.

"Here we are in the medicine-is-a-business model, where you need "X" number of patient encounters and "Y" number of referrals to get "Z" bonus dollars at years end. And it is in this system that medicine becomes just another job."

Those who would hope to practice that art of medicine must first, it is true, gain a broad knowledge of science, but then immerse that knowledge into his or her own passion and personality. This synthesis is the process whereby a medical student becomes a physician. You may not have ever thought of it that way before, but that’s what happens to each of us. We all know that there was a day at some point in our lives when our doctor persona merged with our private persona and we truly become physicians.

However, with no understanding of his beautiful and mysterious aspect of medicine, business number-crunchers have statistically decided that some number of hours of study makes a person without medical training as good as a physician—a health care provider. They do this because they believe medicine is only science and numbers, while in truth it is an art, an art that should be practiced with passion. They give no recognition, no value to passion or compassion because those factors cannot be analyzed and put down as a numeric value on an accounting spreadsheet, and they feel that must be done if medicine is to be managed like a business.

Here we are in the medicine-is-a-business model, where you need "X" number of patient encounters and "Y" number of referrals to get "Z" bonus dollars at years end. And it is in this system that medicine becomes just another job.

If that were the end of the story it would be a sad state of affairs, but it’s not. I believe it is possible to educate the public concerning what is being lost and to regain that passion, the true practice of medicine, the art of medicine.

In polls it is fascinating that our patients, in spite of all that has happened, still give us high marks for trust—-a trust that must be maintained. For, if we lose that trust, we lose our most effective weapon in this battle, the patient.

We are a privileged group and society sets us a part. They honor and respect us, they reward us financially and all they want is for us to be loyal to them, to care about them, to be worthy of their trust. They want to know we put them first, before annual contracts, before formularies, before dollars and cents.

We must, with every person we talk to, with every student we have in our offices, teach first and foremost, we care not just for, but about our patients. They are important to us as people, not just covered lives or cap payments. Take the extra minute to talk with your patients about medical issues, or their son making Eagle Scout, or their daughter’s illness. Let them know that you are concerned.

I suggest we can learn something about our current situation in a study of the Hubble space telescope. As you remember, scientists had dreamed of a day when they would have an instrument that would allow them to look deep into the mysteries of our universe. It took years in research and development, and the Hubble space telescope was, they assured us, the ultimate instrument for the study of space. Its launch into orbit was flawless. Once there, it was tested and all of its electronic systems performed perfectly.

Then the day came to remove the cover from the telescope lens. The pictures were blurry. The scientists in charge of the Hubble initially felt the problem was one of programming, a software snafu, or caused by some undetected damage incurred during launch. They felt that given time they could solve the problem, but eventually it became clear that the impossible had occurred. The focusing mirror of the telescope, its most critical component, which had been checked and rechecked to insure perfection, had been ground to the wrong focal length. It had been the last thing they thought could be the problem because no one wanted to consider that they could have been wrong about something so basic to success of the mission. The telescope worked fine, but all the information it produced was out of focus.

Today, I suggest, the mirror in the telescope of medicine has been ground to the focal health that matches the concept that medicine is a business and as a result, everything in medicine today is out of focus and the businessmen don’t want to see that. No one wants to consider that we could have made such a fundamental error in our thinking about medicine. But, I believe there is a remedy, a cure, and it means recognizing that our view is blurred by this underlying error. If we can just replace the phrase "Medicine is a business," with the key phase, "We care about people," I believe the picture of medicine’s future will come into focus and it will be a bright one.

I’m not going to suggest that business has no place in medicine, but not first place. And I’m not saying that if we change our approach that all the problems of medicine on the table today are going to just evaporate overnight, but we will have our direction back. We and our patients will have the same goal, that of quality medicine. Quality medicine not just because it is good science or good economics, but quality medicine because it’s good care provided by passionate, compassionate physicians who put their patients first.

I don’t know what the next year will hold for TAFP, but I’m excited to be where I am today because I believe, we as family practitioners are uniquely qualified and positioned as the physicians dedicated to the well-being of the people of Texas, and committed to the delivery of quality, compassionate health care. I promise all of you that everyone I come in contact with while representing this fine organization will hear from me that before all else, family physicians care about their patients.