A young lion went out for a walk, not sure of his past or of his future. He knew he couldn't change his past. Where was he to go in the future? And then the monkey appeared. He was just your average ordinary monkey. But the monkey began to taunt the lion, and the lion, becoming frustrated, asked "Who are you?" The monkey replied, "The question is, who are you?" And the lion looked dejected and said "I thought I knew." The monkey replied "Well I know then who you are. You are the son of the King and it is time." 

It's time my friends. We have to start speaking up for ourselves. We have to start defending ourselves. We have to start telling the world what physicians do, what physicians are, and how medicine needs to be practiced. I'm truly tired of hearing people say that so and so in the HMO told us that I have to discharge my patient tomorrow and she's not ready. It's just not fair, it's not right. 

The practice that I introduced you to earlier was an independent family practice for 60 plus years when I bought it in 1991. Within two years I made a decision that I had to sell the practice. We were busy. We were seeing 70-80 patients a day. Now why in the world couldn't we make a go of it? Because the HMO's weren't reimbursing us fairly and we were trying to provide good quality family practice that our consciences saw fit to provide. As time has gone on, we found that we cannot do lab work in our offices. We have all the equipment. But we have to draw blood and send it to a reference lab. Recently we were told by one of Milwaukee's HMOs that we could no longer do x-rays in our office. Now this is a particularly interesting catch 22. This HMO tells us not to send people to the emergency room because that's too expensive and we need to access them in our offices but we can't x-ray them in our offices. So if someone comes in with what appears to be a broken arm, ankle, or head, we have to send them to the hospital, and what that accomplishes is, allegedly, according to the HMO, a savings for them, but it doesn't provide the right care to the patient. Now what has to happen is that I have to have the patient come back to my office, or I have to call the patient and give them their results and then phone prescriptions in or send them to the durable medical equipment supplier on the other end of town for their crutches. It makes no sense! I had to sell my practice to a large system because under this system I would be able to negotiate better rates with the HMOs so that we could practice the kind of family practice that we need to practice, and that I felt in my heart I had to practice. And they're still trying to change it. 

Managed Care. What are they managing? Are they managing care or are they managing money? I would argue that they are managing money, because they really don't care. I had a patient with hepatic encephalopathy present to the emergency room recently and the HMO told me that he didn't meet the criteria for admission because the treatment was oral. The man was comatose, but he didn't meet criteria for being admitted to the hospital. 

There was an article in the Cincinnati Enquirer that I am going to read briefly to you because I feel that it says it all. I will preface this by telling you that I was angry when I read this article I felt how dare she say this? It's not my fault, it's not our fault, it's the HMOs, it's the insurance companies. The title is "How Could All Those Brilliant Docs Wimp Out?" 

Memorandum to: Physician

From: A person who accession gets sick.

Subject: Health Care.

Isn't it about time you rescue medicine from the questionable mercies of business and politics. You were the smartest kids in your class. So what happened. Why are you letting everyone else tell you how to do your job. Most of us are acquainted with dullards who became journalists and lawyers and insurance executives. But I can't think of a single instance where I heard someone say: "Gees, did you hear that Barry Binkly became a doctor? I always thought he was a little slow." You people who became doctors were the good students, the book worms, the merit scholars, the brains, the eagle scouts, the hall monitors. You were the ones whose homework the rest of us copied because you had the answers. You were the people who had an arrogance so magnificent that you could put your hands around a pulsing human heart. You were the people with the grit to triage on one battlefield to decide who will live and who will die. You were the voice that gives the bad news. You were the ones we trust with our babies. Only for you would we have worn those drafty paper robes sitting on your cold examining tables. Only for you would we have waited in a roomful of sick people and old magazines. So what's the problem? Are you scared of a bunch of bean counters? You whipped their butts on the SATs and now they're making medical decisions in consultation with you. Consultation? Why aren't you running the show? Why have you allowed insurance companies and managed care to demand that young couples leave the car running when they enter the maternity ward? I'm not saying that all new moms need to hang around the hospital for 3 or 4 days. I'd just like for you to be the one to decide when they go home. Now, in addition to shorter stays, hospitals are planning to use fewer nurses. Are you going to let hospitals cheap out on the people who care for us when you're not there. Of course hospitals are simply doing what they have to do, compete, cut, downsize, stay alive. At least they have a plan. What's your plan? Have you sent your best and brightest out to do battle, attend the meetings, work on the committees? Is it the money? Is it us? Are you tired of taking care of us and our untidy illnesses? Does it cork you off that Shaquille O'Neill will get $120 million to dunk round balls and you still owe on your med school loans? So maybe business is not your cup of tea. Maybe you hate meetings. Maybe you don't want to become a personal expert or crunch numbers. Fine. That's okay. You can hire someone to do that. But when I get sick, I still like to know that there's a doctor in charge, not some MBA, not a benefits manager at Procter or Gamble or Kroger. I sure don't want Hillary Clinton or Newt Gingrich or Ted Kennedy taking my temperature. You will notice that I have a lot of questions. Do I have the answer? Of course not, I was not smart enough to be a doctor.

It's okay if you don't want to be a political activist. It's okay if you don't want to go to the meetings. It's okay if you don't want to be a manager. But, what you can do and what you do do every day is you teach your patients. We have to educate our patients about what's going on. They don't know. My patients, by and large, are told to sign on the dotted line because the shop steward tells them to. They don't know what they're signing up for. "It's all covered." What's all covered? We have to tell them, we have to educate them. It's not about gag rules, it's about education. It's about teaching, and physicians are teachers. 

HMOs are accounting for every dollar and they're making us account for every dollar that we spend. So why aren't they accounting for the dollars they spend? Why is the John Hancock Tower in Chicago one hundred stories tall? Why do we have to account for every dollar and not them. I think that we have to start responding to that and we have to start standing up for ourselves. We need to start telling them how things are going to be and retake medicine. 

When our youngest child was born we received a package containing a beautiful embroidered baby blanket and it said "Welcome to XYZ HMO's Brand New Patient." We were kicked out of the hospital in a day. We had a seventeen month old toddler at home. I had a wife who had gone through a long labor and we had to go home after 24 hours. There was no staff to help train the new mother how to nurse or take care of the baby. 

California, which has brought us a lot of changes in medicine, actually seems to be leading the battle in helping us regain our rightful place. There are two propositions that will be on the ballot in November: Propositions 213 and 214. One will prohibit managed care companies from offering financial and other incentives to doctors to induce them to deny or delay care, and specifically with health care providers ordering physicians not to tell patients about alternative and possibly more expensive treatment. The initiative also would require a second opinion from a doctor before a company could deny care. It's a little bit of a start. 

I am not an angry President, but as the monkey said: It is time. Where do we go from here? We are in the business of patient care. We care for people. We don't care for dollars. Unfortunately, the cynicism in America and some of medicine's past makes people think that we're in it for ourselves, that we're in it for lining our pockets. We have to educate people that this is not the case. This is our job. This is not somebody else's job. We can't expect Joe down the street to do it, because if we let someone else do it, it's not going to be done. We care for people. We don't care what kind of insurance they have. We don't care how much money they have. And that's basic to all physicians. We make up the same personality profile. That's why we went into medicine. 

Another way that we can make change is through political activities. We do make a difference. I participated in the AAFP's Visit to the Hill in April of this year and I spoke to Senators and Congressmen and their aides and they really don't know what we want. They're listening to spokespeople for special interests groups and if we don't speak up for ourselves and let them know what we want, they're not going to know. You've got to write a letter. "I don't have time to write a letter." You do have time to write a letter. It takes a minute on your Dictaphone to write a letter. They really do want to hear from us. Go to their fund-raisers and go to their town meetings and meet them. You don't have to travel to Washington or Madison to participate. They do come to your area. 

I dedicate my presidency to activism. Speak up. Let them know who we are. Teach. This is what we are supposed to do. We are teachers. As part of teaching we teach people how to care for themselves, keep themselves healthy and make themselves responsible for their health care decisions. We need to show others that we are the ones whose homework they wanted to copy and that they were right. We have to be careful not to sit back and enjoy the glory. Family Practice is at an all time high in this country. We've really got it made. But if we sit back and don't stay active and teach and let the country know what we're about, we're going to lose it just as fast as it came up. This is all about empowerment. You have the power. Just go out and do it. It is Time.