Henri Carter, M.D.
Arizona Medical Association
Inaugural Speech
June 6, 2008

As previously stated I am a general surgeon in private practice in Yuma, Arizona and have been for over twenty years. I am originally from Phoenix as was my father and grandmother. Camelback Road ended at our ranch on the west side of Phoenix. My family moved to Yuma in the mid 1960's where I attended high school. I bounced around a bit in college before completing a degree in Agricultural Science at Arizona State University. I attended medical school at the University of Arizona and trained in general surgery at the University of Louisville. After the completion of my residency I spent almost two years on the faculty at the University of Queensland in Brisbane, Australia. This was somewhat different than the "socialized medicine" I experienced during residency but it did offer, particularly in retrospect, insight into the differences between "socialized medicine" in America and elsewhere. I joined ArMA in 1991 and was elected Southwest District Director in 1996. I served in that capacity until my election to vice President two years ago.

I am grateful for the efforts of Dr. Farmer, Dr. Jasser, Dr. Ditmanson, and those Presidents before them in providing outstanding stewardship for this organization. I hope I can approach their standards. In particular I have been very impressed this past year with Dr. Farmer's quick thinking and ability to analyze and react to a situation. I would also like to acknowledge the Arizona Medical Association staff whose total number is less than what a handful of physicians might employ yet who provide ongoing support and continuous advocacy for over 5,000 members.

2009 will mark the ten-year anniversary of a publication we have all heard about; The Institute of Medicine Report, TO ERR IS HUMAN. I am not sure I have met an individual who has actually read this report despite the fact that it is referenced at least once in almost every journal and is quoted more frequently than the Bible. You have each been supplied with a piece of paper to write down all the major improvements, and I would emphasize improvements, in health care that have resulted from this report. I don't mean countless committee meetings, reams of paperwork, nor onerous regulation, institution of somebody's "best practices" or compliance monitoring of those practices. I mean real improvements in clinical medicine. If you have too much paper just tear it in half or even quarters. By the way, has anyone received their pay for performance check?

"TO LOSE ONE'S HEALTH RENDERS SCIENCE NULL, ART INGLORIOUS, STRENGTH UNAVAILING, WEALTH USELESS, AND ELOQUENCE POWERLESS."
- Herophilus, Greece 300 BC

If I had studied Greek instead of agriculture in college and happened upon this quote to translate, I might have interpreted it as "the only thing that matters about being sick is getting well."

"…WHAT BINDS OUR PROFESSION TOGETHER THROUGHOUT THE WORLD IS NOT SO MUCH THE FACTS WE AGREE UPON OR THE KNOWLEDGE WE SHARE, AS THE EXPERIENCES WE HAVE ALL GONE THROUGH… OUR PERSONAL HISTORY HANGS TOGETHER BECAUSE THE CARDINAL EXPERIENCES OF THE DOCTOR WITH DEATH, BIRTH, RESPONSIBILITY AND CONFIDENCE, FEAR AND COURAGE, IGNORANCE AND LEARNING, POWER AND POWERLESSNESS, HAVE REMAINED SO LITTLE CHANGED THROUGH THE CENTURIES…"
Alan Gregg, 1954

The brotherhood of physicians as defined by Dr. Gregg over 50 years ago is as eloquent as that of physical and mental despair Herophilus described 2000 years earlier. Both speak to the soul of medicine, illness and the experiences of those who alleviate suffering. Dr. Gregg's comments, while modern, are from a different era. Polio was about to be conquered, heart transplants were only attempted in animals, DNA was just a model and Viagra was only a dream.

Physicians can identify with the clinical experiences that bind us together. At present many non-clinical experiences within the practice of medicine are shared and regarded as common ground but the net effect has been disenchantment rather than unification. Facts and testimony highlight this professional malady. For example, 132,000 pages of Medicare regulations, physicians who state publicly that they would not encourage their children to go to medical school, and a Merritt-Hawkins survey that found 50% of physicians age 50-65 (our most experienced clinicians) will either reduce or stop practicing in the next 1-3 years. The soul of medicine has not changed but the practice has.

2008 will mark five years since residents were restricted to an 80-hour work week. I believe this mandate is the most serious trespass against the sovereignty of our profession yet. At a time when individual physician development is at a critical stage our best and brightest must concern themselves about documenting that they went home. The preference of a young physician to choose a specialty must include the opportunity for maximum achievement. Instead, doctors in training across all disciplines have been lumped into a one size fits all model. There is an old joke that the worst thing about every other night call is missing half the good cases. While most of us would rightly scoff at that notion, I presume we all know more than one driven individual who was and/or is consumed and passionate about the art and science of medicine.

There are two subjects I would like to address regarding the practice of medicine in 2008 and finally one issue about the viability of this organization.

PHYSICIAN SHORTAGE

The first subject has to do with physician shortage. A series of policy decisions through the 1980's and 1990's where physician surplus seemed inevitable led to a voluntary stabilization of allopathic medical school admission rates, and with the Balanced Budget Act of 1997, a cap on residency positions which qualified for Federal funding. Prior to that time residency positions were increasing at a rate of 400-500 per year. The 1996 recommendations by the Council on Graduate Medical Education which led to this freeze in residency positions were supported by a number of organizations. This graph by Richard Cooper, a urologist, was originally published in 2002. It demonstrates a 70-year trend of physician supply relative to economic and population growth. Beginning in the year 2000 - three years after the freeze in residency positions - the supply and demand curves began to separate. What did not reproduce on this slide is the "effective" supply of physicians which is actually a downward slope. Cooper attributes this to a host of unanticipated circumstances. Even with 1,000 new residency positions added every year for the next ten years these curves will not merge again. Cooper estimates the shortage of physicians in 2020 to be in the range of 200,000. The Council on Graduate Medical Education reversed their previous assessment in a 2005 report that anticipates a physician shortage of 90,000 by the year 2020. The effects of physician shortage are quite evident even today. Two examples are the outsourcing of radiology services and the large expansion of locum tenens positions in multiple specialities. Physician pay for emergency room call can be attributed to a host of factors but physician shortage among them. Twenty years ago I would have believed gas at $10.00 a gallon more likely than outsourcing of physician services by the United States.

In some specialties this problem is extraordinary as illustrated by a recent study presented at the Southern Surgical Association in 2007. In general surgery there are approximately 1,000 chief residents who finish their training every year. In 2007 80% of those chief residents indicated plans for fellowships with the potential to restrict the patient population they would otherwise serve upon entering the workforce. Thus of 1,000 chief residents in general surgery only 200 broad based surgeons will be available to enter the work force each year under the present circumstances. In November 2007, the National Association of Physician Recruiters listed 758 general surgery positions in 47 States. Even if half of the surgical sub-specialists in hand, vascular, oncology, thoracic, colorectal, pediatric or trauma were to include traditional general surgery as part of their practice there is still a 25% shortage in just those positions identified by recruiters. The implications for physicians are obvious. Individuals need to be much more deliberate and discriminatory in negotiations to allow them to practice medicine rather than be purveyors of paper work. As a reminder, Medicare has a 10% fee schedule reduction set to take effect July 1, 2008 - 25 days from now.

LIABILITY

The second issue on the practice of medicine has to do with liability. Medical care is not perfect nor do I ever see a time when it will be. A colleague who is currently in the midst of a lawsuit relayed the following story to me The tort system in this country has become an institutionalized lottery which benefits only the regular participants; plaintiff and defense attorneys. Courts serve neither to compensate injured patients nor protect physicians from meritless claims. The closed claim study by the American College of Surgeons was undertaken to determine patterns and potential remedies of the liability nightmare. Among the findings was the absolute benefit of clear and effective communication. Still, 42% of plaintiffs who received timely and appropriate care received awards. Almost as perverse, 23% of patients injured due to negligence and/or poor care received no award. Thus, at least in this analysis, two out of three verdicts were incorrect.

"I'm sorry" legislation to facilitate effective communication without reprisal exists in Arizona law due to the efforts of the Arizona Medical Association. Similarly, the requirement for an affidavit of merit as well as expert witness qualifications in medical liability cases has had a favorable and noticeable impact. It was the Arizona Medical Association that led the charge in an attempt to amend the State Constitution to allow for caps on non-economic damages. We are all familiar with this. Despite this there is no hospital in the State of Arizona which allows staff privileges without a minimum of $1,000,000.00 in medical liability coverage. Individual assets are at risk regardless of the exposure. Physicians don't necessarily carry $1,000,000 worth of automobile insurance.

The concept of joint and several liability appears to be an overriding concern for hospitals on this issue. The Law was changed over 20 years ago to comparative negligence where in the event of liability involving more than one party each individual and/or entity is responsible only for their proportionate damages as determined by the Court. The constitutionality of this law was upheld unanimously by the Arizona Supreme Court six months ago.

With our tort system run amok of its purposes, physicians should consider other means of reducing their exposure. In Texas, where tort reform is more comprehensive than Arizona, hospitals in a single county began allowing physicians the option of reduced liability limits for staff privileges. What started in isolation spread to most hospitals across the State within two years. This type of action requires neither legislation nor referendum. Physicians must be engaged in dialogue with their respective hospitals and medical staff colleagues to explore the opportunity to choose what level of coverage is operational. This may become a significant consideration as the recruitment and retention of physicians becomes more difficult with each passing year.

MEMBERSHIP

Finally, I would like to address an issue which impacts the viability of this organization. ArMA needs members. My personal goal in the next 12 months is to improve membership numbers. As the only organization which advocates on behalf of physicians across all disciplines throughout the State I find it difficult to understand why 4 out of 5 practicing physicians in Arizona are not ArMA members. Do our non-member colleagues fail to realize or understand that the Arizona Medical Association, among many other things, is at the Legislature every day in session, every year on a mission of physician advocacy? This year alone there were over 180 health related measures before the State Legislature, many with onerous if not frankly stupid implications. There is a flyer in the materials for this meeting indicating in money saved the tangible benefits physicians across Arizona have realized through the efforts of the Arizona Medical Association. Non-members need to be enlightened as to the source of this benefit; it is an ideal talking point for members to recruit new members.

I have tried to figure out how to target recruitment (identify non members) especially in Maricopa and Pima Counties. As a surgeon and with our present resources the plan had to be direct and simple. If ArMA members are unsure as to whether a colleague is a member or not JUST ASK! Unfortunately, the odds are at least 50/50 the physician colleague is not a member or in many cases has failed to renew their membership.

Among the many changes in medicine, County Medical Societies have been evaporating across Arizona. Later today you will hear a resolution on the need for ArMA to change our bylaws to reflect this reality. Large group practices were targeted very successfully by Dr. Jasser. The Faces of ArMA program has had some success with individual recruitment. Hospital medical staff meetings are one venue I see as an opportunity to speak to groups of physicians representing multiple disciplines akin to the County Medical Society meetings at least demographically. As your President it would be my privilege to address these groups but I will need the assistance of our membership in securing ArMA as an agenda item and enough advanced notice that I can arrange my schedule appropriately. The only asset of the Arizona Medical Association is the physician membership. In this case bigger is clearly better.

Thank you.