President's Message

Jacksonville Medicine At The Millennium

A. Allen Seals, M.D., President

In this new millennium it is a certainty that medicine will continue in an evolution, both as a science as well as a healing art. We will see the scientific progress of medicine shaped largely by the extraordinary expansion of technological and biogenetic sciences. These advances will provide unbelievable benefits to our patients. However, simultaneously, society will demand that we critically examine broad ethical and moral questions. Just as we can scarcely imagine what skills and tools the physician in the next millennium will have to utilize at his/her disposal, we can also scarcely imagine the bio-ethical challenges to medicine that these advances will encumber. Two present day examples allow us a limited extrapolation into the future.

The related clinical fields of infertility treatment and fetal surgery have perhaps given us our first glimpse into the tremendous potential of genetic research. In certain medical centers, physician/researchers have reported that families not only accept fetal surgery, but in fact are now demanding it. It is foreseen that in utero surgery will utilize ever-smaller laproscopic instruments with even the possibility of gene transfer therapy for multiple congenital abnormalities. However, related technology has permitted an escalation in the practice of in vitro fertilization with genetic material now viewed as a market commodity; prompting the practice of "egg-selling" by celebrity donors. Some health economists predict that we will soon see eugenics becoming a new medical industry with the possibility of detailed gene analysis, with potential partners scrambling for body specimens for DNA analysis on the first date.

A second example can be taken from the area of cardiovascular disease, still the number one cause of death in this country, and expected to be the primary cause of mortality worldwide early in the next century. Specifically, left ventricular dysfunction, clinically manifest most often as congestive heart failure is now not only the number one reason for Medicare hospital admissions, but is also projected to overtake heart attack as the number one cause of death in this country. A possible definitive treatment for CHF is being developed with the use of human pluripotent stem cells; stem cells offer an extraordinary and unique resource in that they can divide for indefinite periods in culture, and be genetically selected to develop into specialized cells and tissue (including heart muscle). While present day research utilizes cardiac catheterization catheters to inject specific growth factors into the heart muscle of CHF patients, future researchers dream of the potential of injecting stem cells programmed to develop into functional heart muscle. These injections may literally give physicians the ability to grow new heart muscle in areas of heart attack scars. However, widespread use of stem cells would also require the widespread harvesting of early stage embryos; possibly from in vitro fertilization clinics, or from non-living fetuses obtained from pregnancies that have been terminated. The bioethical questions raised by this research is not a futuristic issue, but is under current debate at the National Institute of Health, the National Bioethics Advisory Commission, and the American Heart Association on a national level as well as by the local Florida Affiliate.

While we can anticipate exceptional advances in medical science, the art of medicine will undoubtedly remain the most consistent aspect of the current practice of medicine. The inherent needs of humans is not likely to change significantly, with individuals continuing to be defined as patients in need of care. Society is still likely to give high priority and economic resources to not only the application of technologically advanced science, but also to insist on the time honored "healing arts" of communication, understanding, sympathy, care, and compassion. In fact, over all of recorded history, it is this dedication to the underlying humanitarian principles of medicine that has maintained the medical profession in its position of high respect that it has so deservedly earned.

We can see challenges to the humanities of medicine most clearly in the external economic pressures that we are all forced to battle on a daily basis. While some have predicted that the present day system of managed care is here to stay forever, others argue that we are already seeing cracks in the "Berlin Wall" of managed care systems around the country, with a popular outcry for more balance and accountability and the likelihood that private and governmental payors will come back into some form of balance with physicians and hospitals. One mechanism to encourage this transition in medical economics has been the widespread application of evidence-based medicine. In increasing numbers, both physicians and the public have embraced the concept that that evidence based science in the hands of the practioner is not simply "cookbook medicine", but rather a scientifically proven method to apply the best that science has to offer coupled with proven medical economic benefits. There are numerous published reports where payors have realized medical economic value by the application of medical guidelines including, for example: adoption of guidelines for treatment of hyperlipidemia, breast cancer screening, pediatric immunization, and emergency management of head trauma. Computer systems are now being developed by physicians to advance electronic medical records into the arena of medical decision making based on evidence based science. The era of managed care as the final dictator of medical care will fade away, and become a part of medical history along with hemlock and leeches.

Where is the Duval County Medical Society in the midst of this evolution, or is there even still a role for organized medicine? Can we best accomplish our goals as an organization representing all physicians, or should we divide ourselves into special interest groups, and delegate responsibility for political and social change advocacy to specialty societies, or regional based physician pacts based on shared hospital or third party payor interests? Some futurists have suggested that organized medicine is superfluous and that the individual physician will be characterized as a "health care provider"; functioning basically as a technocrat utilizing a small medical computer to determine the correct bedside diagnosis, (probably assisted by advanced imaging technology as well as genetic laboratory analysis), and then applying the most advanced medical or surgical treatment while simultaneously calculating risks/benefits derived from computer database analysis, accurately predicting results of treatment, automatically entering the patient and physician into a national outcomes database for on-line comparisons of short and long term results. All of this information would of course be instantly available from any one of multiple medical information websites.

As we enter this, the first year of the "brave new world" of the next millennium, I remain steadfast in my confidence that the Duval County Medical Society will not only survive, but will adopt an ever-increasing and vital role for both the individual physician as well as for the public utilizing health care services. To this end, the Duval County Medical Society has already identified many important areas to fill our "Year 2000 agenda". These are efforts that will affect all area physicians, and will again require the effort of multiple extremely knowledgeable and dedicated individuals. At the perilous risk of omission, I would like to summarize some key areas that will require focused effort by the DCMS.

The Legislative committee will again occupy a central importance during the first quarter of this year. Under the guidance of this year's committee, I am confident that the DCMS will continue in a leadership role in public advocacy by maintaining outstanding relationships with local political figures through our key contacts as well as promoting our members in active participation in FLAMPAC and the 1000 club. This committee has already begun work to coordinate with the FMA on proposed legislation, as well as to personally take this agenda to each area legislator. While we emphasize our positive agenda for the upcoming 2000 legislative session, we have come to expect, there are numerous self-serving individuals and groups who see the Florida Legislature as their means to gain economic gains at the expense of the safety and well being of our patients. We must be willing to assist with any last minute efforts needed by the legislative committee to help block adverse and harmful bills if introduced.

We have established an ad hoc committee to evaluate working relationships with other county medical societies. In Florida, as well as in most states, county medical societies are under distinct economic pressures. The Florida Medical Association has suggested that county medical societies work together to find key areas of common interest and explore creative methods of consolidating administrative functions to improve overall effectiveness and efficiency. The DCMS is committed to being responsive to the needs of surrounding county medical societies, and will devote considerable effort to assist with this development.

The managed care committee has the opportunity to establish an important dialogue with the leadership in managed care in our city. As we are seeing significant changes occur rapidly in the third party payors, I feel the DCMS has the obligation to work harder on behalf of our membership to realistically define areas that we can agree, and in the areas where we have honest disagreement, to work toward some common ground of constructive compromise. For example, in the specific areas of drug formularies, procedures for pre-certification, and providing a forum for resolving potential conflicts between individual physicians and MCOs, I feel the DCMS should have a prominent role.

Physician education has always been a high priority of the DCMS. Under the excellent guidance of recent editors and editorial committees Jacksonville Medicine has achieved much deserved recognition and awards. As most of you are aware, Jacksonville Medicine provides our members with a valuable CME tool of a focused topic monthly (including domestic violence and acquired immunodeficiency disease), while also providing updates from the activities of the DCMS and FMA, all available on-line. I am certain that our new editor and editorial committee will continue in the production of our outstanding journal.

The website committee has a complementary role with Jacksonville Medicine and has a similar educational mission to our members, but also has the added challenge to provide comprehensive information about the DCMS and area physicians on a website format for the general public. Physicians have never before enjoyed a technology that potentially allows us to so thoroughly and completely display our best positive efforts for our patients on a wide spread media. With creative and visionary leadership, we can expect to see significant expansion and improvements in our website.

With respect to public relations, we have been reminded recently of the power of the press, both published as well as electronic to provide important medical information, and unfortunately to act in unprecedented ways to provide medical misinformation. Let me state categorically for the record, that we physicians do not meet late at night in smoke filled rooms to cover up our ill-fated deeds, and with certainty there is no "code of silence". In addition the media has consistently ignored the exemplary efforts of area physicians in patient care as well as basic and clinical research. We cannot, and should not sit idly by while the media for the sake of increased ratings, publish/voice the most outlandish medical stories without an opportunity for comment from the DCMS. The DCMS Public Relations Committee has worked extremely well to establish our voice and image to the community at large as the organization that best speaks to issues related to physicians and public health in general.

The DCMS Alliance has continued to evolve into a highly effective coalition of medical spouses, with a mission parallel to the DCMS. They have earned our respect and admiration for their past accomplishments, and deserve much more of our continued support for their efforts in the future.

In addition, the high importance and key roles of WE CARE, the Academy of Medicine, and other special projects cannot be understated. It is impossible in the space allotted to point out the integral and vital role of all of our DCMS committees; and it should be stated clearly that each of these committees offers the uninvolved member the opportunity to roll up your sleeves, jump into the waters, and begin to contribute your knowledge and expertise.

It is impossible to occupy a position of leadership in this role as President of DCMS without recognition of the outstanding examples of excellence in leadership established by my predecessors, of whom I humbly follow in their footsteps. In addition, extremely dedicated DCMS members among us represent this organization in a number of specialty societies, key FMA committees, the FMA Board of Directors, as well as hold high committee and officer roles in the AMA. I am honored to work shoulder-to-shoulder with many of these individuals that I regard as mentors in the very highest sense. We were reminded earlier tonight of the selfless dedication of Dr. Francis Wellford, and I consider myself extremely fortunate to know some present day "Wellfords".

The new millennium has begun. As physicians we must maintain our dual focus on the patient, while putting forth our best efforts to improve the future health care system that we all participate. Effective leadership has been defined as the ability to delegate with authority and principle. The authority is an honor I hope to earn, and the principles are the ideals that have characterized the 147-year history of the Duval County Medical Society. I would ask for your assistance this year in working in a collaborative manner to continue in our accomplishments, with an acknowledged respect for the past, and with a renewed hope for the future.

January, 2000/ Jacksonville Medicine

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