TMA President Josie R. Williams, MD: Installation Address

May 3, 2008

Good Afternoon,

As Bill Hinchey stated so eloquently last year … We are The Texas Medical Association!! It is with great honor and a humble heart that I assume the office of President of this awesome organization.

First, I want to recognize many individuals and groups for giving me this exciting opportunity. First let me acknowledge the Brazos-Robertson County Medical Society, and Dr. Dennis Schmidt, the Lamar County representative.

Would the entire Small Districts Caucus please stand and remain standing. Thank you Drs. Merian, Davis, Rohack, Thorstenson, Klawitter, Cardenas, Teuscher, and Lockhart and all of the Small Districts Caucus .Without you and your support I would not be here, please join me in thanking them.

As most of you know, I have lived in many places and met many individuals and associations who have influenced my incredible career. Twenty-five years ago Dallas County reached out to me to return to active TMA work. When I lived in Tarrant County you opened your hearts and took me in graciously. Travis County is like a second home to me and your style still influences me everyday.

I lived in West Texas early in my life. Those West Texas values stuck … hard work, integrity, and saying it like it is. I did most of my training right here in San Antonio, and since Harris County has given me so many mentors I couldn't leave you out either … even if I have never lived there!!

I want to welcome my dear friends Tanis and Don Hager from Paris, Bill Mercy from Frisco, and Pastor Fred Gerch and wife Gail from Fort Worth.

My family, representing my parents, is my paternal aunt Dorothy Drake of Sherman;
from Caddo, Oklahoma, my brother Bill, wife Donna and adopted sons/grandsons Tyler and Randall; from Wichita Falls, my brother Dan, wife Jan and their son, my nephew, Zachary of Plano.

From Burlington, Vermont, my sister JoAnne Davis, her youngest daughter Jennifer Finley with her son Levi, her middle daughter from Watauga, Deborah, husband Craig  Clark and sons Joseph (who was 9 Thursday) and Aaron, and JoAnne's oldest daughter who she has shared with me so often, "My Kids"-from Paris, niece Dee, husband Darrell T. Hawkes Jr., son Samuel, and the twins Nichole and Michayla.

Many of you will remember Grandma Radke who traveled with me in her wheelchair for years. She and grandpa helped me through so much in my life as has my adopted sister Naomi who has literally been the mainstay in my office and home-I have called on her so often for so much.

Thank you, Naomi would you stand and be recognized. Thank you so much for indulging me in the privilege of recognizing my family.

Among my friends and family are moms and dads, grandmothers and grandfathers, patients and ex-patients, as well as a banker, a realtor, obviously a pastor,  a health care executive for physician practices, a dental hygienist, a retired major oil company executive assistant, an aerospace engineer, a teacher, a nurse specialist, an entertainment specialist, a beautician, an architect who is also a business owner, a fireman, a lawyer, a software editor, a commercial construction supervisor, an accountant, a postal service retiree, and a farmer.

They have seen health care through their own experiences in many different ways. They and their perspectives keep me grounded and have taught me as much as my own experience about the reality of health care, about its successes and its failures. It is for them, for their children and for our great profession that I come today to ask you to reflect upon where we are and where we are going.

"Identity, experimentation and learning are watchwords for leading organizations in chaotic times," says consultant and author Margaret Wheatley.

We are a leading organization, and indeed we are in turbulent, troubling, and chaotic times. We have been successful in the past. I pledge to you we will continue the strong defense of our issues. Our defensive issues often dominate our time and energy. That will not change.

We will call upon you and your patients to make your elected officials aware of the thorny issues that comprise our dilemma and of how inaction is straining access to health care.

I must touch briefly a couple of those issues. Congress will jeopardize the promises they have made to our seniors regarding access to health care. Congress will continue to be missing in action after 8 years, with fixed, unfair and inadequate 1998 dollars for physicians. In June they will not have the political will to permanently fix the SGR. In spite of giving all Part A providers their annual cost of living or real increase, they will kick the can on down the road as far as adequate and fair payment for your services.

We strongly support the Texas Medicare Manifesto and a permanent fix. We will unequivocally defend the right of physicians to appropriate payment for services to ensure practice viability.

We will stand firm for your right to be responsible owners of hospitals and other health care delivery facilities. Dr. Carlos Cardenas' hospital, Doctors Hospital at Renaissance, comes to mind as an example for us to emulate. This physician-owned community hospital does all the right things. They put the patient's needs first as a matter of moral obligation, and this turns out to be a competitive advantage.

It is your job in the coming year to strengthen your relationships with your elected officials and patients.

2009 is a legislative year and we have begun to identify the threats and opportunities for our patients and our practices. Those relationships will help to better delineate and defend the need for better coordination of care, continuity and adequate supervision of non-physician practitioners for safe quality care.

Nurse practitioners, for example, are preparing to lobby to practice medicine as "independent collaborative practitioners" with prescribing authority under their nursing license and nursing board rather than under direct supervision of a physician. They and other allied practitioners desire to be recognized as doctors without the education or skills to warrant that privilege.

They and others believe we have only given lip service to the supervision of allied health professionals practicing under us. I will work to preserve safe, quality care for our patients with adequate supervision. But for those physicians who let their colleagues and our patients down by abandoning their responsibility for appropriate supervision, we would encourage evaluation and remediation by the Texas Medical Board.

Speaking of the Texas Medical Board, we will work with officials to make that body responsive to the protection of the public. We will not however forget the physicians rights to due process. And, we will work with the Board to try to get them to be  responsive to our concerns over quality of care issues and moral misconduct. Not about crossing I's and dotting T's.

We will hold the line and be ever vigilant about the attempts to dilute our professional liability reforms. The reforms are working!!! Record numbers of physicians are coming from other states to practice in Texas. We have seen on average a 25-percent decrease in liability premiums.

Health care costs have exploded. We must pay attention to that. Resources are limited and reform is coming. There is no way to do it the way we've always done it. We cannot attempt to deliver 2009 medicine in a 1950 chassis. It's like trying to launch the space shuttle into orbit on the backs of the Kitty Hawk."

We only account directly for 20 percent of every health care dollar. But we control large quantities of the remainder, and we are being held accountable.

Change is imminent. Major businesses find themselves in an unpredictable, global marketplace. Big business, health plans, insurers and other payers are designing and implementing so-called solutions. They will no longer wait on us to find our way, devise our own solutions, and build better practice designs.

They are deeply involved with the government in crafting and orchestrating new and inventive ways to curb health care spending. They want to outsource more and more of our services to those with less training, or worse, to foreign countries, claiming that this will somehow cut costs and improve quality care and medical outcomes.

How we respond will be crucial to medicine as we know it.

We are faced with new and unfortunately flawed methods of economic credentialing disguised as "quality, transparency, and value." Our special committee working with Blue Cross Blue Shield of Texas has a report at this meeting that clearly delineates the issue. We are and have been on record opposed to this practice for several years.

The increasing demands of regulation, electronification, … (and remember EMRs and electronic prescribing are tools … not the answer) … and quality and accountability reporting will further stress our ever-decreasing bottom line. We must take charge of our profession.

We are a diverse bunch but collectively we must take charge of health care delivery. We can and must identify our commonalities and speak with one voice to be effective.

In our state, where one out of four patients has no health care coverage, where businesses are providing less and less health insurance for their employees, our diversity as a profession is more disparate than ever. A few are getting rich. Others are approaching poverty in practice to the extent they must choose to limit their practice, take early retirement, or close their doors to direct patient care and work in other capacities.

The majority of us labor on, wondering how much longer can we endure? How much longer can we tolerate the onslaught of critical changes in this honored profession that we love? The expectation of a bright, meaningful career filled with purpose and rewards, economic and non-economic, is dimmed beyond recognition.

I worry most about our ability to speak with One Voice. We are so much more effective when we do. We must find common goals. And I know we can.

If I could, I would wave a magic wand and decree that we will defend your right to practice medicine … as you see best … whatever style of practice you want … so long as you practice good, safe evidence-based medicine. But given the number of dollars at stake and our uneven record of outcomes, there is no chance of ever going back to "the good old days."

Make no mistake, we will not be soft on the injustices. However is it fair to ask if we have become too focused on our economic woes? Too focused on the ever increasing bureaucracy and complexity of the world that we live in?

That preoccupation, perhaps because of the injustices, has left patients and employers … and the payers … with a growing perception that we have forgotten our core values. The right care for the right patient, every time.

Our greatest weapon is our patient-physician relationship, so long as we put what is right first … so long as we continue to insist on patient-centered care and communication. That patient-physician relationship … when not abrogated to time pressures … is our greatest strength.

Much of our dilemma stems from the fact that we were taught to "do something" for our patients … to care for the individual in front of us … at all costs.

But the evidence suggests we are much more likely to do tests, technologies, surgeries, and procedures …   anything rather than sit and explain to our patients the alternatives. We take 2 to 4 years to introduce new procedures and technologies … but we wait 17 years to change our behavior based on the scientific evidence of other therapies.

It does not help our cause that we are predominantly rewarded and paid to "do stuff" rather than talk with our patients, provide support or palliative care.

Nor do most of us examine our practice and actively seek to participate in activities to improve the care we deliver in our offices and hospitals. We often leave that task to others.

In this world … with its complexities, bureaucracy, and interventions into health care delivery … defense is no longer sufficient. We can no longer afford to abrogate the direction of health care reform to others. We can no long afford to react with anecdotal data that we would not accept from others.

With only a defensive approach … no matter how good … we are left working with half the tools we need to effect change. Consequently others are doing it for us, without input from physicians … without input from men and women who have struggled in the day-to-day practice of medicine, lacking the resources or time to do the job right.

Years ago, we gave our control of hospitals, nursing homes, and home health agencies to others because we were too busy to continue to do it. In fact, we devalue that work. When Medicare came about in 1964, we allowed others to build the billing database because we didn't have the inclination, money, or time to build it ourselves.

As a result, in today's age of information, we are at the mercy of the government and the insurance companies to give us information … albeit skewed, inadequate and inaccurate information … regarding our own practices, and our own outcomes.

In short, colleagues, we have been reduced to "providers" attending to "consumers." We are no longer "doctors … physicians" caring for our "patients."

That is why I want us to focus this year on the fourth of our TMA 2010 strategic tenets - that of "trusted leader." We must become the leaders of patient care in and out of our facilities. Our professionalism, our pride in our profession, and our profession's relationship with our patients are our most effective forces for change.

I have a vision … some will see it as a mirage … that we must and can improve the architecture of health care delivery. That this great change will be led by physicians and our patients. Until we all believe this can happen, we will remain at the mercy of others at best … and at worst, we will preside over the total collapse of this time-honored profession.

Mahatma Gandhi once said, "You must be the change you want to see in the world." Our healthy vision of a better future for our patients is paramount to our success. TMA stands for "Physicians caring for Texans."

With all the evidence that we do not do what we know to do, want to do, and try to do, isn't it time we examined the existing practice of medicine? Isn't it time we had actual hard data to measure what and how we do things in this complex world … if for no other reason than to legitimately question accusations of poor quality of care? If for no other reason than we are physicians caring for our patients? If for no other reason than it is the right thing to do?

My private practice motto was "take care of the patients, the patients will take care of you." I still believe that.

We have nothing to fear in knowing our practice.
We have nothing to fear in explaining and defining our structures and processes.
We have nothing to fear in discussing our shared outcomes.
Evidence suggests we need to improve our care, and we will do so only with adequate and accurate data. The trouble now is that our image of ourselves … our belief in who we are … does not allow us to examine truthfully … to measure … how well we do.

We need to be the trusted leaders of the team. We may also need to identify ways to collaborate with other sciences such as industrial engineers, safety engineers, health care architects and others who can shorten our learning curve … who can help us design and build systems that work for patients and doctors.

We, in short, need to lead the team that will develop an ever-improving health care delivery system for our patients.

Remember again what Margaret Wheatley said: "Identity, experimentation, and learning are watchwords for leading organizations in chaotic times."

This year, we will begin to ask the hard questions regarding appropriate experimentation and learning for this organization.

We can build our practices upon a patient-centered delivery system. Yes, the incentives are wrong and we don't have the resources … but we must find a way.

We must find a way to leverage the resources to build information databases that will give us the information on our own practices that make sense for our own patients. We must control that data for accuracy and relevance. The data can give us the information and knowledge we need to make meaningful, efficient and effective change in how we deliver care.

We must look at how each of us individually contributes to the outcome of the system … even when our individual numbers are so small they seem imperceptible.

We must have the will to do this important work because it will allow us to return to caring for all patients as if they were our parents or children. It will allow us to return to being physicians … rather than expendable health care commodities.

We must approach this new science of Health Care Delivery with the same rigor that we would devote to implementing the latest procedure or developing replacement body parts or new genomic interventions. We can no longer stand by and watch as safe, quality care is taken from our patients.

We may lose some of the battles, but we will win the war. We will save and perhaps renew our profession.

We must deny others who would take the leadership from us by getting serious about our desire to reform … yes, even transform … health care. It must be all about patient-centered, safe, effective, efficient, timely, evidence-based care.

We … our TMA … needs to develop a research plan that sorts the known from the unknown. Our councils and committees need to evaluate the mountains of reports and isolate the successful systems. Give us the white papers, define the terminology, the structure, the processes that will lead us to the outcomes we so desperately need. We urgently need to honestly evaluate what we do not know … and to learn what we must.

In this complex environment, personal vigilance is no longer sufficient to make sure we do what we know to do, what we think we do, what we don't have time to do. We can no longer rely on our prodigious memories.

These reforms and changes may mean giving up some of our long- standing practices. In doing so, however, we ensure our right to peer review ourselves and our practices and protect the patients we serve today and into the future.

Together we are stronger, to borrow from the AMA, and we are the ones to lead a better tomorrow. I stand today on the shoulders of so many great leaders.

Men and women such as Hippocrates, and Albert Schweitzer, and Drs. Osler and Earnest Codman … Drs. May Owen, Betty Stephenson, and Ruth Bain … Drs. Sam Nixon and Gordon McGee. They have paved the way and shown me how to be active and to support good patient care.

These giants of our profession would expect us to meet the challenge head on as physicians. I challenge you … I challenge our great Texas Medical Association to do just that.

For if not us it will surely be others, and I don't want us to be accused of "kicking the can on down the road." I know that together we can design a better tomorrow for our profession and our patients, even in chaotic times, regardless of how hard it is, if we have the will. And I believe we do.

I come arm in arm with many strong TMA and AMA leaders, committed to establishing this new science of health care delivery. Together we will begin a journey that may span years. But this is a journey we must lead.

I call upon you Texas physicians, our trusted leaders , for support this year as we toil to improve your practice and the health of all Texans.

Thank you very much.

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