Presidential Address
Taking Charge of Health Care
Mark S. DeFrancesco, MD, MBA
This article provides a synopsis of Dr. DeFrancesco’s Inaugural Address from the 2015 Annual Clinical and Scientific Meeting of the American College of Obstetricians and Gynecologists, May 2–6, 2015, San Francisco, California. Financial Disclosure The author did not report any potential conflicts of interest. © 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/15
VOL. 125, NO. 6, JUNE 2015
“What is the future of obstetrics and gynecology as a specialty?” Dr. Reuben Peterson asked this question in 1920 in the Journal of the American Medical Association.1 At that time, obstetrics and gynecology were two distinct specialties, suffering from a major identity crisis. As we know, the ultimate resolution was to merge into one specialty, which obviously has worked very well and has advanced health care focused on women. Doctors combined the therapeutic armamentaria from both obstetrics and gynecology to provide care over the entire spectrum of a woman’s life. We provide prenatal care even when medical problems threaten the lives of mother and child, and deliver babies—healthy babies. When needed, we perform surgery that makes a difference—a real difference—in times of crisis or trouble. We provide care to help keep women healthy. Clearly, obstetrics and gynecology as a specialty has it all! How privileged we all are as obstetrician–gynecologists to have the honor and the responsibility of being entrusted by women with their health care. How amazing it is to witness the beginning of so many new lives, bringing such joy to so many families. Here we are in 2015, and we are again posing the same question asked by Dr. Peterson almost 100 years ago. Do times really change? Today let’s talk about our specialty, our patients, and our organization: the American College of Obstetricians and Gynecologists (the College). For many years, we have been debating the nature of our specialty. Are we “primary care” or are we “specialists”? We know what we are: We are obstetrician–gynecologists (ob-gyns)—and more importantly, our patients know what that means! So let’s just do away with the term “generalists” and simply call ourselves what we are: “ob-gyns.” During the past 30 years, our nation’s population has grown some 34%, with essentially no growth in the number of ob-gyns.2 Furthermore, more than a fourth of our graduates subspecialize in some manner and will not be practicing the comprehensive specialty of obstetrics and gynecology.3 So today there are fewer ob-gyns to provide care and more people who need it. If we don’t do something about this, who will provide the care? Who will deliver the babies? Well, let me be candid: I worry that the excitement and enthusiasm that I felt some 35 years ago, when I chose our specialty—the ability to provide a continuity of care for a women’s life needs and the privilege of witnessing the birth of a new family—are being thwarted by many external forces, resulting in significant physician dissatisfaction. The health care world talks about the “Triple Aim” of providing high-quality care, economically, while at the same time enhancing patient satisfaction.4 However, no one talks about physician satisfaction. Unhappy physicians cannot provide high-quality care. We need to expand the Triple Aim to the “Triple Aim Plus One” and include physician satisfaction as an important metric. A major study in 2013 surveyed 25 specialties for physician satisfaction—and our specialty was fourth from the bottom.5 This is not
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1279
surprising at all. The increasing burdens of regulatory guidelines, electronic documentation, and medical liability concerns, amid a worsening national economy, are all very depressing. Perceived loss of autonomy and decreased societal respect do not help. So to help our specialty, we will be asking our district and section leadership to help us assess the depth of this problem, determine its root causes, and develop strategies to cure the malaise so that we restore wellness to our doctors and our practices. Only then can we hope to keep our patients healthy. Keeping our patients healthy—isn’t that really why we are here at the annual meeting? To learn even more about how we can help our patients become or stay healthy? My two immediate predecessors began addressing how we can provide more care for more people. Dr. Jeanne Conry’s landmark task force on Well Woman Care defined the important elements of women’s health care, and Dr. John Jennings encouraged us to team up with collaborative providers to provide more care more efficiently. Now it is time to really take charge of health care by focusing on two problems that together contribute more to morbidity and mortality in this country than all of the cancers and specific diseases for which we routinely screen and treat: smoking and obesity. Smoking causes 480,000 deaths per year in the United States alone, or about one of every five deaths in this country.6 Obesity results in another 300,000 deaths annually. Combined, that is more than the total number of American deaths during World War II and represents about one third of the deaths in the United States each year. Think about it—that is three deaths every 2 minutes. In the 15 minutes or so it will take a reader to read this, more than 20 people will have died from the effects of smoking or obesity. By contrast, total annual deaths from cervical, uterine, ovarian, and breast cancers are estimated at fewer than 70,000.7 That is not in any way to minimize the critically important work we do in these areas, but to suggest how much more we can do if we can provide more comprehensive care. These two problems directly affect our care: we all know that obesity increases the cesarean delivery rate and other pregnancy-related morbidities. Even worse perhaps, we now also know that obesity in pregnancy may be condemning the newborn to a medically complicated life, as the fetus is programmed for life by the epigenetic influences of maternal obesity.8 The economic costs arising from all complications of smoking and obesity are astronomical and mind-boggling. Annual direct and indirect costs
1280
DeFrancesco
Taking Charge of Health Care
attributable to smoking and obesity are estimated to range from $500 billion to $1 trillion per year. That exceeds the amount of money needed to fund health care reform. Let’s do something about this! Look at the College seal. We are indeed, “women’s health care physicians.” Remember, before we were ob-gyns, we were doctors. For most of us, the decision to become a doctor was based on an altruistic desire to serve and to save lives. I don’t need to tell you that we are the only regular contact many of our patients have with the health care system. We meet many of our patients when they are very young, often before they become obese, certainly before they build up 20 or 30 or more pack-years of smoking. We can prevent it—we really can—and we should. We must challenge our patients to stop smoking. We must challenge our patients to lose weight. Seventy percent of smokers do want to quit, and more than 40% of smokers at least made an attempt to quit in the past year.6 They want to do the right thing, so let’s help them. It begins with talking with our patients. Do you ask your patients to stop smoking and lose weight? Do you offer local or technical resources to help? If not, you may be tacitly condoning their unhealthy life choices—and you will not be alone. Many of us don’t do this for our patients, and we owe it to them to start. To help you help your patients, I will ask the College’s standing committees to develop a toolkit specifically designed for ob-gyns to address obesity and cigarette smoking in their daily practices. First do no harm? Let’s go way beyond that: let’s do even more good than we do right now. Now let’s talk about the College. Today is not about me, but about the College moving forward. Our organization, now 64 years old, includes almost every board-certified ob-gyn in the country, virtually every ob-gyn resident and Junior Fellow in practice, and many members from other countries. The mission has always been to advance women’s health through education, advocacy, and support of our members. Yes, our world is certainly changing, but our commitment to remaining relevant and dedicated to our mission will never change. Regardless of how successful we have been, in the spirit of continuous quality improvement, we can and must always do better. We have an obligation to the College as an organization, to the many thousands of ob-gyns who have preceded us, to the newly inducted members, and to those who will join us in the future to ensure that we hand down to you an organization of which you can continue to be proud, an organization that continues to advance women’s health, an organization
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
that will so inspire you to get involved that one day one of you will be giving your own inaugural address! For that reason, the last initiative that I announce today will be introspective, something for ACOG: “ACOG 2020.” We will re-assess our Strategic Plan, with emphasis on governance and operations, to ensure that we continue upholding our mission and values, both at home and abroad, for our members and for the women we serve. Finally, I want to leave you with a few words about the future. This year’s annual meeting has revolved around team care: Teaming up for Women’s Heath. It’s about providing more care for more people. More than ever, we must collaborate with other providers, use new tools such as electronic medical records, smart phone apps, and secure patient portals to provide more integrated care for our patients. Although not yet perfect, the electronic information systems we are using today were in fact envisioned by Dr. Fred Frigoletto in his 1996 inaugural address. Almost 20 years ago, Dr. Frigoletto grasped the relationship between data and quality, and predicted that one day we would be using these tools.9 Less than a decade ago, Dr. Ken Noller focused on changing practice in the 21st century and exhorted us to “Practice Smarter, Not Harder.”10 This has never been truer than it is today. We need to work in teams. As health care changes and we move into team care, we, the doctors, must lead it. The sacred trust immortalized in the Hippocratic Oath that we all took when we became doctors is threatened today by the pressures placed upon us by a system that is growing ever-hostile to the doctor–patient relationship. Regulatory and administrative systems should enable, not obstruct, good health care. Our patients know that we, the doctors, are the true experts, and they want us to take charge of health care. Like it or not, health care is now an industry, but with all due respect to the business people, the administrators, and the accountants in the health care industry, there would be no health care industry if we, the doctors, were not dedicated to caring for our patients. Along with our patients, we, the doctors, must always be the ones making the health care decisions for our patients, not the administrators and certainly not the politicians. Although there has been a need to come together in larger groups and integrated health systems in many areas, these new models should always be centered on the patient, not on the investor.
VOL. 125, NO. 6, JUNE 2015
No matter how large or complex the health care system grows, it doesn’t begin to approach the complexities of the human body, and we’ve spent our lives studying and understanding that we can do this, too! Only doctors will really put the patient first. Doctors must take charge of health care. We are in a time of great disruption in health care, but I do have equally great expectations for the future. No question it will be difficult, but I have no doubt that we will not only survive, but thrive. You know how to collaborate, you know how to work as a team, and you are leaders. When doctors like you lead the teams, patients will win. So today I’m challenging you all to take charge of health care. I’m challenging you to step out of your comfort zone of Pap tests and pelvic examinations and provide care for the whole patient. I’m challenging you to be a good team player and at the same time lead our women’s health care teams to victory. For us, a victory means saving many, many lives.and that’s why we became doctors! REFERENCES 1. Peterson R, The future of obstetrics and gynecology as a specialty. JAMA 1920;74:1361–4. 2. Rayburn WF. The obstetrician/gynecologist workforce in the United States: facts, figures and implication. Washington, DC: ACOG; 2011. p. 1–2. 3. Gilstrap LC. American Board of Obstetrics and Gynecology subspecialty divisions, 2014. College Clin Rev 2013; 18:2. 4. Institute for Healthcare Improvement. The IHI Triple Aim Initiative. Available at: http://www.ihi.org/Engage/Initiatives/ TripleAim/Pages/default.aspx. Retrieved December 1, 2014. 5. Medscape. Physician compensation report 2013. Available at: http://www.medscape.com/features/slideshow/compensation/ 2013/public. Retrieved December 2, 2014. 6. U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress. A report of the surgeon general. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014. 7. American Cancer Society. Cancer facts and figures. 2013. Available at: http://www.cancer.org/research/cancerfactsstatistics/ cancerfactsfigures2013/index. Retrieved December 1, 2014. 8. Obesity in Pregnancy. Committee Opinion No. 549. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:213–7. 9. Frigoletto F. CPR: can we be resuscitated? Obstet Gynecol 1997;89:1–4. 10. Noller K. We are the champions (of women’s health). Obstet Gynecol 2007;109:1268–9.
DeFrancesco
Taking Charge of Health Care
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1281
Taking Charge of Health Care
Mark S. DeFrancesco, MD, MBA
This article provides a synopsis of Dr. DeFrancesco’s Inaugural Address from the 2015 Annual Clinical and Scientific Meeting of the American College of Obstetricians and Gynecologists, May 2–6, 2015, San Francisco, California. Financial Disclosure The author did not report any potential conflicts of interest. © 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/15
VOL. 125, NO. 6, JUNE 2015
“What is the future of obstetrics and gynecology as a specialty?” Dr. Reuben Peterson asked this question in 1920 in the Journal of the American Medical Association.1 At that time, obstetrics and gynecology were two distinct specialties, suffering from a major identity crisis. As we know, the ultimate resolution was to merge into one specialty, which obviously has worked very well and has advanced health care focused on women. Doctors combined the therapeutic armamentaria from both obstetrics and gynecology to provide care over the entire spectrum of a woman’s life. We provide prenatal care even when medical problems threaten the lives of mother and child, and deliver babies—healthy babies. When needed, we perform surgery that makes a difference—a real difference—in times of crisis or trouble. We provide care to help keep women healthy. Clearly, obstetrics and gynecology as a specialty has it all! How privileged we all are as obstetrician–gynecologists to have the honor and the responsibility of being entrusted by women with their health care. How amazing it is to witness the beginning of so many new lives, bringing such joy to so many families. Here we are in 2015, and we are again posing the same question asked by Dr. Peterson almost 100 years ago. Do times really change? Today let’s talk about our specialty, our patients, and our organization: the American College of Obstetricians and Gynecologists (the College). For many years, we have been debating the nature of our specialty. Are we “primary care” or are we “specialists”? We know what we are: We are obstetrician–gynecologists (ob-gyns)—and more importantly, our patients know what that means! So let’s just do away with the term “generalists” and simply call ourselves what we are: “ob-gyns.” During the past 30 years, our nation’s population has grown some 34%, with essentially no growth in the number of ob-gyns.2 Furthermore, more than a fourth of our graduates subspecialize in some manner and will not be practicing the comprehensive specialty of obstetrics and gynecology.3 So today there are fewer ob-gyns to provide care and more people who need it. If we don’t do something about this, who will provide the care? Who will deliver the babies? Well, let me be candid: I worry that the excitement and enthusiasm that I felt some 35 years ago, when I chose our specialty—the ability to provide a continuity of care for a women’s life needs and the privilege of witnessing the birth of a new family—are being thwarted by many external forces, resulting in significant physician dissatisfaction. The health care world talks about the “Triple Aim” of providing high-quality care, economically, while at the same time enhancing patient satisfaction.4 However, no one talks about physician satisfaction. Unhappy physicians cannot provide high-quality care. We need to expand the Triple Aim to the “Triple Aim Plus One” and include physician satisfaction as an important metric. A major study in 2013 surveyed 25 specialties for physician satisfaction—and our specialty was fourth from the bottom.5 This is not
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1279
surprising at all. The increasing burdens of regulatory guidelines, electronic documentation, and medical liability concerns, amid a worsening national economy, are all very depressing. Perceived loss of autonomy and decreased societal respect do not help. So to help our specialty, we will be asking our district and section leadership to help us assess the depth of this problem, determine its root causes, and develop strategies to cure the malaise so that we restore wellness to our doctors and our practices. Only then can we hope to keep our patients healthy. Keeping our patients healthy—isn’t that really why we are here at the annual meeting? To learn even more about how we can help our patients become or stay healthy? My two immediate predecessors began addressing how we can provide more care for more people. Dr. Jeanne Conry’s landmark task force on Well Woman Care defined the important elements of women’s health care, and Dr. John Jennings encouraged us to team up with collaborative providers to provide more care more efficiently. Now it is time to really take charge of health care by focusing on two problems that together contribute more to morbidity and mortality in this country than all of the cancers and specific diseases for which we routinely screen and treat: smoking and obesity. Smoking causes 480,000 deaths per year in the United States alone, or about one of every five deaths in this country.6 Obesity results in another 300,000 deaths annually. Combined, that is more than the total number of American deaths during World War II and represents about one third of the deaths in the United States each year. Think about it—that is three deaths every 2 minutes. In the 15 minutes or so it will take a reader to read this, more than 20 people will have died from the effects of smoking or obesity. By contrast, total annual deaths from cervical, uterine, ovarian, and breast cancers are estimated at fewer than 70,000.7 That is not in any way to minimize the critically important work we do in these areas, but to suggest how much more we can do if we can provide more comprehensive care. These two problems directly affect our care: we all know that obesity increases the cesarean delivery rate and other pregnancy-related morbidities. Even worse perhaps, we now also know that obesity in pregnancy may be condemning the newborn to a medically complicated life, as the fetus is programmed for life by the epigenetic influences of maternal obesity.8 The economic costs arising from all complications of smoking and obesity are astronomical and mind-boggling. Annual direct and indirect costs
1280
DeFrancesco
Taking Charge of Health Care
attributable to smoking and obesity are estimated to range from $500 billion to $1 trillion per year. That exceeds the amount of money needed to fund health care reform. Let’s do something about this! Look at the College seal. We are indeed, “women’s health care physicians.” Remember, before we were ob-gyns, we were doctors. For most of us, the decision to become a doctor was based on an altruistic desire to serve and to save lives. I don’t need to tell you that we are the only regular contact many of our patients have with the health care system. We meet many of our patients when they are very young, often before they become obese, certainly before they build up 20 or 30 or more pack-years of smoking. We can prevent it—we really can—and we should. We must challenge our patients to stop smoking. We must challenge our patients to lose weight. Seventy percent of smokers do want to quit, and more than 40% of smokers at least made an attempt to quit in the past year.6 They want to do the right thing, so let’s help them. It begins with talking with our patients. Do you ask your patients to stop smoking and lose weight? Do you offer local or technical resources to help? If not, you may be tacitly condoning their unhealthy life choices—and you will not be alone. Many of us don’t do this for our patients, and we owe it to them to start. To help you help your patients, I will ask the College’s standing committees to develop a toolkit specifically designed for ob-gyns to address obesity and cigarette smoking in their daily practices. First do no harm? Let’s go way beyond that: let’s do even more good than we do right now. Now let’s talk about the College. Today is not about me, but about the College moving forward. Our organization, now 64 years old, includes almost every board-certified ob-gyn in the country, virtually every ob-gyn resident and Junior Fellow in practice, and many members from other countries. The mission has always been to advance women’s health through education, advocacy, and support of our members. Yes, our world is certainly changing, but our commitment to remaining relevant and dedicated to our mission will never change. Regardless of how successful we have been, in the spirit of continuous quality improvement, we can and must always do better. We have an obligation to the College as an organization, to the many thousands of ob-gyns who have preceded us, to the newly inducted members, and to those who will join us in the future to ensure that we hand down to you an organization of which you can continue to be proud, an organization that continues to advance women’s health, an organization
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
that will so inspire you to get involved that one day one of you will be giving your own inaugural address! For that reason, the last initiative that I announce today will be introspective, something for ACOG: “ACOG 2020.” We will re-assess our Strategic Plan, with emphasis on governance and operations, to ensure that we continue upholding our mission and values, both at home and abroad, for our members and for the women we serve. Finally, I want to leave you with a few words about the future. This year’s annual meeting has revolved around team care: Teaming up for Women’s Heath. It’s about providing more care for more people. More than ever, we must collaborate with other providers, use new tools such as electronic medical records, smart phone apps, and secure patient portals to provide more integrated care for our patients. Although not yet perfect, the electronic information systems we are using today were in fact envisioned by Dr. Fred Frigoletto in his 1996 inaugural address. Almost 20 years ago, Dr. Frigoletto grasped the relationship between data and quality, and predicted that one day we would be using these tools.9 Less than a decade ago, Dr. Ken Noller focused on changing practice in the 21st century and exhorted us to “Practice Smarter, Not Harder.”10 This has never been truer than it is today. We need to work in teams. As health care changes and we move into team care, we, the doctors, must lead it. The sacred trust immortalized in the Hippocratic Oath that we all took when we became doctors is threatened today by the pressures placed upon us by a system that is growing ever-hostile to the doctor–patient relationship. Regulatory and administrative systems should enable, not obstruct, good health care. Our patients know that we, the doctors, are the true experts, and they want us to take charge of health care. Like it or not, health care is now an industry, but with all due respect to the business people, the administrators, and the accountants in the health care industry, there would be no health care industry if we, the doctors, were not dedicated to caring for our patients. Along with our patients, we, the doctors, must always be the ones making the health care decisions for our patients, not the administrators and certainly not the politicians. Although there has been a need to come together in larger groups and integrated health systems in many areas, these new models should always be centered on the patient, not on the investor.
VOL. 125, NO. 6, JUNE 2015
No matter how large or complex the health care system grows, it doesn’t begin to approach the complexities of the human body, and we’ve spent our lives studying and understanding that we can do this, too! Only doctors will really put the patient first. Doctors must take charge of health care. We are in a time of great disruption in health care, but I do have equally great expectations for the future. No question it will be difficult, but I have no doubt that we will not only survive, but thrive. You know how to collaborate, you know how to work as a team, and you are leaders. When doctors like you lead the teams, patients will win. So today I’m challenging you all to take charge of health care. I’m challenging you to step out of your comfort zone of Pap tests and pelvic examinations and provide care for the whole patient. I’m challenging you to be a good team player and at the same time lead our women’s health care teams to victory. For us, a victory means saving many, many lives.and that’s why we became doctors! REFERENCES 1. Peterson R, The future of obstetrics and gynecology as a specialty. JAMA 1920;74:1361–4. 2. Rayburn WF. The obstetrician/gynecologist workforce in the United States: facts, figures and implication. Washington, DC: ACOG; 2011. p. 1–2. 3. Gilstrap LC. American Board of Obstetrics and Gynecology subspecialty divisions, 2014. College Clin Rev 2013; 18:2. 4. Institute for Healthcare Improvement. The IHI Triple Aim Initiative. Available at: http://www.ihi.org/Engage/Initiatives/ TripleAim/Pages/default.aspx. Retrieved December 1, 2014. 5. Medscape. Physician compensation report 2013. Available at: http://www.medscape.com/features/slideshow/compensation/ 2013/public. Retrieved December 2, 2014. 6. U.S. Department of Health and Human Services. The health consequences of smoking—50 years of progress. A report of the surgeon general. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014. 7. American Cancer Society. Cancer facts and figures. 2013. Available at: http://www.cancer.org/research/cancerfactsstatistics/ cancerfactsfigures2013/index. Retrieved December 1, 2014. 8. Obesity in Pregnancy. Committee Opinion No. 549. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:213–7. 9. Frigoletto F. CPR: can we be resuscitated? Obstet Gynecol 1997;89:1–4. 10. Noller K. We are the champions (of women’s health). Obstet Gynecol 2007;109:1268–9.
DeFrancesco
Taking Charge of Health Care
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1281
