[Congressional Record Volume 140, Number 54 (Friday, May 6, 1994)]
[House]
[Page H]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: May 6, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                       OBSTETRICS AND GYNECOLOGY

  Mr. COCHRAN. Mr. President, as we continue our review of the options 
for health care reform, one of the important areas for consideration is 
the quality of health care. In his Presidential address to the annual 
meeting of the members of the American College of Obstetricians and 
Gynecologists, Dr. Richard S. [Pete] Hollis, of Amory, MS described how 
the quality of care physicians' provide is at an all-time high. Dr. 
Hollis' commitment to excellence in a changing medical profession is 
commendable.
  Mr. President, I ask unanimous consent that a copy of Dr. Hollis' 
speech be printed in the Record.
  There being no objection, the speech was ordered to be printed in the 
Record as follows:

               [From Obstetrics & Gynecology, Jan. 1994]

               Caring: A Privilege and Our Responsibility

                      (By Richard S. Hollis, M.D.)

       When I chose to become a doctor 45 years ago, I had very 
     simple, perhaps even naive, reasons for choosing a career in 
     medicine. I wanted to help people; I wanted to make a 
     difference. Of course, I could have accomplished these things 
     a farmer or a teacher, but I chose providing health care as 
     my way of caring about people.
       The principles of medical practice are based on caring. 
     John Ring, past president of the American Medical 
     Association, in a commencement address at the Georgetown 
     University School of Medicine in 1992 noted. ``It is no 
     accident that two of the most important words in medicine--
     the word `patient' and the word `compassion'--come from the 
     same Latin root: the verb patior, which means to bear a 
     burden.'' It is the patient who carries the burden of 
     illness, but the compassionate physician shares that burden, 
     lifting it when possible and lightening it when that is all 
     that can be done. This sharing of the burden has always been 
     the hallmark of the medical profession.


                         changing medical arena

       Nearly everyone who enters medicine has a desire to help 
     someone in need, to be socially useful It is 
     this commonality, this shared commitment, that unites us 
     as physicians and Fellows of this College. However, there 
     is a dramatic difference between the world of medicine 
     today and when I first began seeing patients. My memory is 
     that of the individual doctor doing his or her best, held 
     in high esteem by a community that expected the 
     physician's commitment to excellence but was realistic 
     about what to expect. Lawsuits were very rare, and 
     liability insurance cost must less than the rent. There 
     was no ``doctor shopping.'' The ``hassle factor'' was 
     manageable. Complex, intrusive regulations and paperwork 
     never took priority over patient care.
       Please do not misunderstand my nostalgia. I am not calling 
     for a return to ``the good old days,'' especially when I 
     reflect on how advances in technology and treatments have 
     benefited our patients. I still remember how heartbreaking it 
     was to deliver an erythroblastotic infant. And there are ways 
     other than the technological in which things have improved. 
     When I note how different the College is now--with women 
     currently representing 24% of our membership and nearly half 
     the Junior Fellows female--there is no doubt in my mind that 
     we are better for the changes of the last few years.
       But there are some disturbing factors in this new 
     environment. In balancing the demands of practicing medicine, 
     it is too easy to lose sight of why we entered this 
     profession in the first place. Although the quality of the 
     care we provide is at an all-time high, the way we provide it 
     has suffered. I sense a growing frustration within the 
     Fellowship, and it is hard not to conclude that the two 
     trends are connected.
       In 1987, the American Medical Association surveyed more 
     than 4000 physicians who had been in practice at least 5 
     years. Forty-four percent said they would not choose medical 
     school again.\1\ Within our specialty, there are other 
     alarming signals evidenced by the increasing number of 
     Fellows who have stopped providing obstetric care, creating 
     serious access problems for women and sacrificing one of our 
     greatest joys, that of helping to bring a new life into this 
     world.
       Rightly or wrongly, the general public, and women in 
     particular, have begun to lose faith in us. According to a 
     1991 survey of public opinion by the American Medical 
     Association, 73% of women feel negatively about doctors in 
     general. The next year's survey reported that most 
     respondents did not believe doctors care as much as they used 
     to. And we've all heard the complaints about arrogance, 
     greed, and paternalism. Why is it that, although our patients 
     are living longer, healthier lives, they are losing 
     confidence in their doctors? What are we communicating to our 
     patients, in either words or actions, that leads them to 
     believe we no longer care about them? And why are we less 
     satisfied with what we can do for patients, even though it 
     far exceeds our wildest dreams in medical school?


                     CARING IN A TECHNOLOGICAL ERA

       Part of the reason lies in our increasing reliance on 
     technology. I believe we have become more comfortable with 
     high-technology procedures than with our patients. After 
     World War II, we entered an era of research that produced 
     unprecedented advances in technology. Gradually our skills 
     have shifted away from the beside. But have we sacrificed our 
     ``nice ways'' in the name of scientific discovery? Perhaps we 
     have forgotten, as James\2\ tells us, that ``success is not a 
     destination we will ever reach. Success is the quality of the 
     journey.''
       Our patients should not have to choose between the 
     ``traditional'' doctor who spends time with them and answers 
     their questions, and the ``high-technology'' physician whose 
     reputation in state-of-the-art procedures is as legendary as 
     his or her abrupt style. When 71% of the public says it 
     believes doctors keep patients waiting too long, and when 63% 
     do not believe doctors involve them enough in deciding about 
     treatment,\3\ we had better be listening. Whether we are 
     ready or not, the ``times they are a-changing.'' We need to 
     do more than just sit back and wait to see what others decide 
     for us.''
       The obstetrician-gynecologist is a critical advocate for 
     women's health, and advocacy has never been more important 
     than it is right now. Our health care system has been biased 
     against women. Research has been inadequate, not only in its 
     failure to give women's health issues their rightful 
     attention, but also in its assumption that the male is the 
     norm. Until recently, most drug testing was done on men, with 
     the results extrapolated uncritically to women. There are 
     many examples of how women have been left out of research, 
     such as the frequently cited Harvard study\4\ which 
     established the value of aspirin in the prevention of heart 
     disease. Initial research on antidepressants focused 
     exclusively on men, although women are twice as likely to 
     suffer from clinical depression. The Baltimore Longitudinal 
     Study on Aging did not include women during the first 20 
     years, even though women live an average of 7 years longer 
     than men and are more likely to be affected by osteoporosis 
     and arthritis.
       The health insurance industry has excluded payment for many 
     preventive measures for women, such as mammograms. Many 
     third-party payers require a woman to practice two-stop 
     shopping for health care. More than half of all women of 
     childbearing age consider their obstetrician-gynecologist 
     their principal physician, but the insurance industry often 
     does not,\5\ making it difficult for women to get the care 
     they need from a physician they know and trust.


                       need for a new specialty?

       There is new interest in a women's health specialty. 
     Critics say that internists are not taught enough about 
     female reproductive problems; family physicians are too busy 
     with men and children to be up to speed on women's needs; and 
     obstetrician-gynecologists are ill-equipped to treat problems 
     unrelated to reproduction. This new specialist would be 
     trained in women's reproductive biology and the effects of 
     certain diseases and treatments specific to women. He or she 
     also would have studied psychological and social issues, 
     eliminating fragmentation of care.
       Such a proposal appeals to women who are frustrated with 
     the way they receive care, but many fear that creating a 
     specialty devoted to the health care of women is just another 
     way of ghettoizing women's issues. They predict that such 
     specialists will earn less, and training programs will 
     attract few residents. Others, myself included, feel that by 
     creating yet another specialty, we would be sending the 
     message that the responsibility for improving women's health 
     is someone else's job. I have never believed in the 
     ``separate but equal'' solution. It does not work in 
     education or housing, and it does not work in medicine.


                          commitment to Caring

       What is the answer? It may be an oversimplification, but I 
     believe we need to go back to the basics, to rethink what it 
     means to care, to take a hard look at ourselves and how we 
     deliver health care.
       In 1968, the Council on Resident Education in Obstetrics 
     and Gynecology issued a definitive statement on our 
     specialty:
       At present time, many of our society's most serious 
     concerns lie in the discipline of gynecology and obstetrics. 
     The quantity and quality of the next generation, the 
     degeneration of family life, teenage pregnancy, the rising 
     illegitimacy rate--these and many other of our social 
     concerns are intimately bound up with the subject matter of 
     the obstetrician-gynecologist. These concerns have given the 
     discipline a sense of social responsibility that is perhaps 
     unique among the medical specialities.\6\

     Twenty-five years later, I believe that this is still true.
       We must focus today on improving the health of the women we 
     will serve tomorrow. I urge you to join with me in committing 
     to five goals. First, let us renew our commitment to caring. 
     Caring comes from the heart. Call it empathy, compassion, 
     understanding, or friendship. It is time to put the patient 
     first. This means we must endow caring with a tangible value 
     so it can compete in the same realm with technical expertise.
       In our training, we must ask if there is an overemphasis on 
     methodology. We may need more course work that involves 
     ethics and discusses the values and traditions on which our 
     specialty is based. To broaden our perspective, a review of 
     the history and philosophy of medicine would be helpful. I 
     recommend the following reading to every resident: The Cry 
     and the Covenant, a biography of Ignaz Semmelweis; The 
     Woman's Surgeon, a biography of J. Marian Sims; and ``A Way 
     of Life,'' the 1913 Sillman Lecture, delivered by Sir William 
     Osler, at Yale University.
       Many of our training programs have already recognized the 
     need to return to the humanistic model. Today, more than 70% 
     of medical schools use real-life models who simulate 
     specific, standardized symptoms to provide students with 
     actual experience in dealing with patients. Other programs 
     provide lessons in empathy in which doctors become the 
     patients. Still others require students to teach preventive 
     health courses and serve as mentors to distressed families. 
     These efforts are to be celebrated, but we can do more.
       Second, we must learn the skills to communicate better: to 
     use open-ended questions, not to interrupt, to answer 
     questions and explain procedures, and to make the patient 
     feel part of the decision-making process. To have her simply 
     sign the consent form is not enough.
       Do you greet your patient warmly by name or by looking at 
     her chart? Do you avoid eye contact and use jargon? How do 
     you respond to being questioned? Do you recognize the 
     different language and cultural factors that could affect how 
     you and your patient interact?
       We need to be concerned with the total patient, not just 
     with why she presents herself on a particular visit. That 
     means taking the time to listen--to her domestic problems, 
     her stress at work, her financial worries, and her basic 
     difficulties in coping with day-to-day living. We also must 
     try to understand what is meant when we're told, ``You just 
     don't get it.''
       Third, each of us needs to become an aggressive advocate of 
     women's health issues. The government has been reluctant to 
     support research focusing on issues unique to women. We must 
     labor for equal time for areas in obstetrics and gynecology 
     where our lack of knowledge is enormous. Questions such as 
     what can a young woman do to prevent breast cancer later in 
     life and what triggers the onset of labor need to be answered 
     to improve the care we provide. We must never allow gender--
     any more than race, religion, ethnicity, or social status--to 
     play a role in setting the agenda for health care research.
       Fourth, we must place greater emphasis on prevention care. 
     For most women ages 18-44 years, the obstetrician-
     gynecologist is her primary, and often her only, health care 
     provider. Preventive health care is an important aspect of 
     the care we provide.
       We can do a better job in helping our patients make the 
     behavioral changes often required for improved health. It is 
     not enough to tell a woman not to smoke; when she says ``show 
     me how'', she is telling us what we should do. It is not for 
     us to set the timetable for an abused woman to pack her bags 
     and leave her husband. Our role is help her find a shelter 
     when she decides it is time to leave, or to support her if 
     she chooses not to leave.
       How many of us get involved with safe-sex discussions? Do 
     we offer sexually transmitted disease testing to all of our 
     patients, or do we select certain women because we think they 
     may be a particular risk? If we do not provide these services 
     to women, who will? The reality is that there simply are not 
     enough other primary care physicians to meet the needs of 
     women.
       Finally, we must promote access to quality health care for 
     all women, especially those most vulnerable and least served 
     women in our society. We need to go beyond the rhetoric and 
     become active at the community, state, and national levels to 
     assure access to high-quality care for all women. The ACOG 
     Executive Board's approval of a plan for universal access to 
     maternity services is one step in making our commitment 
     clear.
       Call me old-fashioned, but I believe we were put on this 
     earth for a purpose. For those of us who chose medicine as 
     our life's work, the number of opportunities to make a 
     difference far exceeds the number of challenges we must face. 
     Our patients deserve no less than the best we have to offer.
       As we look to the future, let us aim high and strive hard. 
     Let us never cease in the quest for knowledge. And let us do 
     this with concern, caring, and heartfelt love and compassion.


                               References

     1. Schroeder A. The troubled profession: Is medicine's glass 
     half full or half empty? Ann Interim Med 1992;116:583-92.
     2. James J. Success is the quality of your journey. New York: 
     Newmarket Press, 1986:7.
     3. American Medical Association. Survey of public opinion on 
     health care issues, 1992.
     4. Steering Committee of Physician's Health Study Research 
     Group. Preliminary report: Findings from the aspirin 
     component of the ongoing Physicians' Health Study. N Engl J 
     Med 1988:318:262-4.
     5. American College of Obstetricians and Gynecologist. 
     Patient attitude surveys, 1982-88. Washington, DC: American 
     College of Obstetricians and Gynecologists.
     6. Council on Resident Education in Obstetrics and 
     Gynecology. Gynecology and obstetrics: A definitive 
     statement. May 1968.

                          ____________________