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Our Faculty | Residents: 1st Year | 2nd Year | 3rd Year | Guest Speaker: Dr. Antonia Novello

Amy Lovano

Antonia Novello, MD

14th Surgeon General
of the United States (1990-1993)

United Nations Children's Fund (UNICEF) Special Representative for Health and Nutrition (1993-1996)

Visiting Professor of Health Policy and Management at the Johns Hopkins School of Hygiene and Public Health (1996-1999)

Commissioner of Health for the State of New York (1999-2006)

Vice president of Women and Children Health and Policy Affairs at Disney Children's Hospital at Florida Hospital, Orlando (Current Title)

Commencement Address: Emergency Medicine Residents, UH/CMC - Cleveland, Ohio / Thursday, June 14, 2012

On Thursday, 6/14/2012, the inaugural class of the University Hospitals/Case Medical Center Emergency Medicine Residency Program celebrated it's graduation with a very close and intimate group of family and friends. Among us that day was or friend and colleague, Dr. Antonia Novello, who served as the 14th Surgeon General of the United States. In her Commencement speech to us (transcript below), she reminded us that, as emergency medicine physicians we must work beyond the emergency room to preserve our practice, our art and our autonomy. Her experience and expertise in the political arena of health care offer a sobering view of medicine today and tell us the need to remain politically active as a profession, and as individuals.

Good Evening.

Thank you, and welcome parents, friends, spouses, children, faculty, and of course, the 2012 Graduating class of Emergency Medicine at Case Medical Center. It is an honor for me to be here among all of you.

In front of you, you have a speaker who has been a little bit of everything. I have been a left-handed Puerto Rican medical school graduate; A winner of the Chamber Pot award at the University of Michigan Medical Center; A nephrologist at Georgetown with an I.Q. higher than my BUN; The first woman Surgeon General of the United States; The 13th Health Commissioner of the great State of New York; And most recently, the Executive Director of Public Health Policy at Florida Hospital. Like all of you, I am trying to decide what I am going to be when I grow up!

I am impressed that this class of 8 residents, 4 males, 4 females & 2 baby girls represents various different personalities and shares among them some very interesting traits.

For example:
Joseph Stone - academic chief resident, artist, always the gentleman, great in-service scores, married to Leslie with one daughter Birdie and will be joining the faculty here at Case Medical.
Kelly Tenbrink - current administrative chief resident, born in Kenya, engaging personality, a real charmer and leader. Most productive in clinical skills, great teacher - will move with wife to Florida
Justin Yax - The perennial student - enormous knowledge and a doctorate from the London School of Tropical Medicine and Hygiene. He has the amazing ability to never laugh at an unfortunate occurrence - Brought real style to the emergency department. Will be joining the faculty in emergency medicine at Case Medical, becoming Medical Director for International Emergency Medicine.
Stephanie Hunter - From NEOCOM Medical School and finished the 6 year program. Always a professional, always charming, with different hair styles and a smile that can light up a room. A real superstar. Joining the faculty at Case Medical.
Eric Goldblatt - Tenacious - will work under the most dire conditions. Never missed a shift, never late, has an incredible sense of responsibility. Great procedural skills with the crucially ill. Great lecturer and careful editor. Has a built in GPS. Will pursue further training in critical care.
Liliana Viera-Ortiz - Great clinical skills, always devoted to the poor and less fortunate. Won the leadership award from the national Hispanic Medical Association. Came to be trained in Emergency Medicine and ended up trained in love with Joel and Joelito. Will join a private group in Lakewood.
Rebecca Schulman - Loves EMS and has cross trained in firefighting. Incredible devotion to the pre -hospital care world. Great source of knowledge. Excellent computer skills. Will be pursuing a fellowship in EMS in Hershey, PA.
Jennifer Mitzman - Very determined, excellent clinician loves pediatric EM. Worked in “Teach for America” to close the gap between the “haves” and “have nots” regarding education. She is highly structured and organized. Has one daughter Naomi and is married to Brian. Will be pursuing a fellowship in Pediatric Emergency Medicine in Wake Forest.

Having just described all of you, now I must tell you; colleagues, that it is an honor for me to join you today and share your pride in these fine men and women who will carry the legacy of University Hospital Case Medical Center... the graduating class of 2012. This class is like your former Surgeon General - small enough to be personal, yet large enough to be powerful.

Colleagues, I stand before you today to do three things: to congratulate you, to counsel you, and to challenge you.

Congratulations: When you leave this hall today, you will be able to do two things; call yourself a true health professional, and start to pay off your loans.

I don’t have to remind you that your future, and that of medicine, will be filled with complex issues. Although much has been done, much more will be expected of you. Twelve years into the millennium, the problems facing health care will demand the collective might of us all.

As I look out into the sea of faces here today, I see some of the leaders who will help remold and shape our communities in a new image. An image that reflects the capacity for caring and commitment, that Case Medical Center graduates are known for around the Nation - but one that, however real, we must zealously protect. The challenges facing us are too great.

After all, today’s health care environment is different. Physician autonomy is being threatened and the way we practice medicine is being challenged. People who look from afar and obtain ideas from their committees are drafting our future and dictating our career paths! What Irony!

We know that precious dollars for health care, research and for the practice of medicine are dwindling. I’m sure you’ve heard by now that despite our efforts, not all patients are getting the health care they need. But lest you think that all has changed for the worse, I want you to know that there are still some touchstones in the health care profession that remain sacred - that remain unchanged from one generation to the next.

And the most important of these touchstone is the one undeniable fact: we who dedicate our lives to the health of our fellow citizens, are a pretty special breed... an extraordinary profession, indeed. We are blessed with the opportunity to enter peoples’ lives in a most intimate way. The trust placed in us is the legacy we have inherited from past generations of our colleagues. We must protect that trust, nurture it, and make it grow. It is both a blessing - and a blessed responsibility.

The single greatest challenge for health care professionals today lies in finding ways to control the pace of change, and yet still make sure that evolving delivery systems and shifting health priorities do not undermine the essential values of our ancient healing relationships.

We must remember that the therapeutic effects of machines and gadgets must be enhanced by the touch of a healing hand or the spoken word. And while we have an obligation to advance the technology and science of health care, we must always maintain the human element of the work we do. Because as much as our health care system has changed, the vulnerability and the need of the communities we serve has not.

So I urge you to keep up with new scientific discoveries, new political health policies and exploding technologies - without forgetting the faces behind the data and the names behind the statistics. For ours is a profession of service.

As it has been said, Service is the Rent We Pay for Living - and that service will set us apart. Service to ourselves, and our families, service to our country, and service to God. The importance of this service attitude is painfully obvious in today’s world. My friends, there is a spiritual vacuum in America’s society today.

There is too much of “what can I get?” rather than “what can I give?” We must remember that, the test of making a living is how much you get. The test of making a life is how much you give.

In order to succeed, we must rediscover the true practice of medicine - which is much greater than the treatment and prevention of illness alone - or we will be practicing health care and medicine in a vacuum. I submit that our God -given vocation goes beyond our ability to cure!

So, while I congratulate you most warmly today. I urge you to embark upon a lifelong quest of learning, of healing... but above all, of caring.

And now, my counsel: Colleagues, we must remember that our work as professionals defines us as human beings. As it has been said, “much of the good and the bad you will ever do in this world will come through your work.”

How will you view your work? The author Robert Bella describes three types of work: First there’s the Job, where the goal is simply earning a living and supporting your family.

Then there’s the career, where you trace your progress through various appointments and achievements.

Finally, there’s the calling, the ideal blending of activity and character that makes work inseparable from life.

As health care professionals, with a very visible responsibility to uphold the public trust, I hope that you are not just looking for a job, and I hope that you are not just planning a career. I hope each and every one of you has a calling - an altruistic calling. I know that you will do well. Your faculty has seen to that. But I pray you will do good.

One word of caution, though - from one who sat where you are sitting just 42 years ago - the world owes you nothing! To expect the world to treat you fairly because you’re a good person and a graduate of Case Medical Center is like expecting a raging bull not to charge you because you’re a vegetarian!

This is why, while I fervently wish you much happiness in your work, I caution you not to seek happiness for happiness’ sake. If you do good, happiness, believe me, will seek you.

It will creep silently into your lives from many sources; the heartfelt “thank you” from a grateful patient, the quiet discovery in a laboratory, the well-crafted lecture, the scientific paper, the book, the public policy, or the community intervention that may affect the lives of millions.

The profession of medicine, you see, offers many paths to happiness. So I counsel you not to be just good doctors. First and foremost, be good men and good women.

Do not forget to put balance in your lives: family, friends, leisure time, hobbies, social causes, volunteerism, and above all religion.

Only by maintaining your own health - physical, mental and spiritual - will you be able to look after the lives and well-being of those entrusted in your care.
So work hard, and beware of those enemies of tranquility: avarice, ambition, envy, anger and pride; and avoid Kuschner’s pillars of despair: complacency, mediocrity, and above all, indifference.

Now, allow me to challenge you: I am reminded of some very simple, yet profound observations of Mark Twain, who said: “Good judgment comes from experience. And where does experience come from? Experience comes from bad judgment.”

I can tell you that if we are going to meet the Nation’s complex and difficult health challenges, we’re going to need healthy doses of both: experience and judgment.

It is well known that today we are witnessing a staggering demographic, medical and political revolution - and like it or not, we will all be swept into its currents.

So, although it may be impossible to determine precisely what the true challenges of this revolution will be, allow me to share with you three challenges that I see along the way... challenges that might have a direct effect on the way we deliver care, and, in addition, might have an impact on the way we respond as a health care community.

Challenge No. 1: The challenge of changing demographics
In today’s world, we must respond to the changing demographics in this diverse nation of 310 million people - with more than half of the population women, with close to

  • 13 percent of our population African -American,
  • more than 16 percent Hispanic, 4 percent Asian or Pacific Islander,
  • nearly 1 percent native American and Alaskan native,
  • more than 1 in 10 over the age of 65,
  • 1 in 5 below the age of 12,
  • 80,000 people over the age of 100,
  • nearly 7 million (2 percent) being multiracial and
  • 1 out of every 10 speaking Spanish.

We simply cannot afford to cling blindly to values and perceptions that are out of touch, or to follow rigidly outdated practices accepted by the mainstream. Old time conservatism, should not make a mockery out of our humanity. The world is changing, and tomorrow’s health care providers’ skills must also change, in order to accommodate the special needs of America’s emerging communities and minorities. We must move toward designing programs for communities where we have walked in their shoes and on their streets. In the future, we all must learn not only the language of the people we treat but their culture as well.
Colleagues, I suggest that we learn to view our patients as partners in health care. Too often, patients complain that they are viewed as supplicants of care who are seen at the convenience of the provider, where the overall atmosphere at some medical care facilities is not conductive to a patient’s self worth, to the care of the poor, to the needs of working mothers, and/or to the tolerance of the language illiterate. Let’s go back to understanding what Franklin D. Roosevelt alluded to: “The test of our progress is not whether we add to the abundance of those who have much. It is whether we provide enough to those who have little.”

Challenge No. 2: Challenge of Access to Care
This challenge threatens to shake American medicine to its core: the challenge of access for all our citizens to adequate health care. Care that is comprehensive, family-based, community-centered, culturally sensitive, and under one roof.

A health care system that is portable, efficient and secure, and meets the five “A’s” - Available, accessible, affordable, accountable and to be sure-affable as well.

A Health care system where there is an appropriate balance between meeting the health care needs in a cost-effective manner, without jeopardizing the number of health professionals, the access to the health care provider or where teaching and/or research are curtailed to an unnecessary degree.

To do this we have a battle looming in front of us. Many of us in this audience can remember in the mid-1970s , when the public held physicians in high esteem, right next to members of the clergy.

Confidence in the ability to make a decent living was always assumed - all we had to do was to “hang up a shingle” and patients would come.

Academic medicine seemed to offer the best of both worlds: plenty of time for research, some teaching, and limited practice responsibilities.

Today, it all appears to be somehow jeopardized: the independence, the time, the easily acquired grants, the life-style, even the security.

Today, we face a complexity of health care options and health plans unprecedented in human healing history - almost as many and as varied as patients and health care professionals themselves! Today we have an image of fast-paced, high-tech, dollar-conscious medicine - that sometimes seems to leave little room for the needs of the human equation.

The business of medicine has grown leaner. Sometimes meaner. Yet we know this is happening because the marketplace is looking for value—which translates into high quality, cost-effective care, but from the patient’s perspective, not necessarily good old time health care delivery.

Regardless of what eventually plays out in Washington, there is no doubt that the healthcare landscape is transitioning; and the future of medicine and emergency medicine is transitioning as well. The reality is that, we have the most expensive healthcare system in the world. We fail to insure 48 million citizens (many of whom are working), and according to the World Health Organization, the United States ranks #37 (between Slovenia and Costa Rica) in quality. Simply put, we pay more for healthcare than any other country in the world, and in terms of maintaining a healthy population our system is ineffective at best.

I look at all of these issues and believe that if the American health care system were a patient, its vital signs would suggest that it is very sick, and that the disease is spreading throughout the body. The reality is that the twin goals of the new health care reform - providing health coverage to 32 million and limiting health care costs - will require increased primary care access and reductions in the overuse of what government considers inappropriate interventions.

I ask you how do you emergency room doctors see your role in this plan? We know that the emergency department provides acute care access for all patients and nonemergency care for those patients unable to find other sources of care.
I believe that if no one understands what role you play, the implementation of marketplace reform in order to limit health costs may direct patients away from Emergency Departments to other primary care sites and reallocate residency positions now available for training of emergency physicians to other primary care specialties. These two negative effects may endanger the viability of the Emergency Room as the safety net system of the nation.
We also know that with the goal of decreasing healthcare spending, comes the challenge of increasing prevention and quality. So today government and private payers are devising strategies and demonstration projects with the expressed goal of rewarding value rather than volume. It is known that, currently payers reimburse providers for volume and intensity of services. Providers get paid their share regardless of outcomes. In the new healthcare reform, this will change. The new world order is Value Based Purchasing, premised upon payment reform as a strategy to maintain a healthy population. Value Based Purchasing based payment strategies reward outcomes, coordination of care, quality and population health, not volume. Payment policy will be driven by prospective pricing tools that are based on outcomes, resource utilization and attainment of certain quality markers.
Again, I ask you how does this affect the Emergency Department?
If you are the professionals that are the safety net, that provides a community service (not unlike police) If you are the folks that provide immediate assessment and treatment for time sensitive presentations, like stroke, sepsis and major trauma, then you must start getting involved in the deliberations regarding healthcare.
As I look at the future of emergency departments in the new healthcare reform, it seems, (as Dr. Beck from Beacon Medical Services has suggested) that Emergency Departments do not have many friends in the healthcare reform arena. In the eyes of some bureaucrats, you have become the poster child for everything that is wrong with healthcare today.
So what are you planning to do, to change this perception?
- -In the movies the mantra was “If you build it, they will come.”
- -In the Emergency Department, today’s mantra in Washington translates to: “Keep all those unnecessary visits out of the Emergency Room and the system will save a ton of money.”
In the recent past, it seems that every politician, analyst and policy maker has incorporated this mantra enough that it has become an accepted axiom. Reducing Emergency Room visits is about the only aspect of emergency care that has made it into any Value Based Purchasing proposals. In fact, in Massachusetts - they now have universal coverage, and not surprisingly, Emergency Department use did not decrease, but instead increased by 7%. This is no revelation, given the shortage of Primary Care Specialists and the safety net role.

A lot of policy makers in Washington; however, are looking to Massachusetts as a potential national model, to prove “that if you limit Emergency Room visits, healthcare costs will drop.” Nothing farther from the truth.

A 2011 study by 3 major medical schools published in the New England Journal of Medicine; compared the rate of Emergency Room usage - both in and outpatient service over 5 years in Massachusetts, Vermont and New Hampshire and neutralized the negative perception regarding Emergency Room visits and cost increases. The study found that Emergency Department use in Massachusetts after their health reform, did increase; however, it also increased by similar amounts in New Hampshire and Vermont, states that had not implemented insurance expansions.
The point here to ponder after all of these discussions, is that in the current environment of reform and Value Based Purchasing, emergency medicine as we know it and practice it today might be facing its greatest crisis since becoming a specialty.
Today, it seems that all specialty practices are being engaged and are actively pursuing Value Based Purchasing strategies to protect their interests. I urge all of you, Emergency Room physicians to devise strategies that demonstrate your value as well. Your duty now is to protect members of the team and patients from intended and unintended consequences of reform, and Value Based Purchasing efforts, and also think of developing payment strategies that demonstrate the value of emergency care.
How are you going to do this? I believe that you need to become more than Value Based Purchasing or bundle payment experts, you need to instead develop something altogether new along the lines of an Emergency Room episode of care. I ask you, do you need to get involved in identifiable targets like reducing admissions, or do you base yourselves only on risk adjustment.
Perhaps you need to look again deeply into tort reform - Especially geared at emergency rooms with adherence to guidelines and preset awards for unexpected bad outcomes. Talk to your societies and to your lobbyists. Get started! You are more than a cost containment specialty - You are the life link in medicine. Share it with the world!
I recommend that in the interim, start debunking the myths associated with the Emergency Room - Do it frequently and publicly. Start with:

  • Emergency medical care is expensive and inefficient - Reducing emergency care will control our rising health care costs.

The fact is that the 120 million annual visits to the Emergency Room account for only 3% of all health care spending. Although the fixed cost of being open 24/7 are high, the valuable costs for seeing patients in the Emergency Room are the same as anywhere else where care is provided.

  • Emergency departments are crowded with patients seeking non-urgent care.

The fact is that according to the CDC, only 12.1% of Emergency Room patients have non urgent conditions that could wait 2 to 24 hours for medical care. The truth is that the crowded conditions and longer waiting times are primarily caused by patients being “boarded” in the Emergency Room, often on gurneys, long after they have been seen and admitted to the hospital.

  • Your local emergency department will always be there when you need it.

The fact is that hundreds of emergency departments have closed nationwide because of an overburdened emergency care system, and those remaining open must accommodate an average increase of 3 million more patient visits each year. Similarly, it has been reported that every 60 seconds emergency care is delayed when an ambulance is diverted to another hospital, when the nearest one is unable to accept more patients.

  • The need for emergency care will decrease when healthcare reform is enacted.

The fact is that, with a growing and aging population, your role in providing care to the sick and injured any time day or night, and your front line responsibility in responding to natural and man-made disasters, will be in even greater demand in the future. Lets remind everyone about the Massachusetts experience. Since enacting its universal health care legislation, Massachusetts, different from what was expected, has experienced an increase not a decrease in emergency department patients.
Colleagues, instead of allowing unsubstantiated myths regarding Emergency Rooms to be believed - the time has come for you to share with the world what you truly believe in and what you deserve as the essential community service that you provide to this nation.
This country needs to be reminded that Emergency Room doctors are the only physicians in the country required by federal law to treat all patients regardless of their ability to pay. It is a responsibility you embrace proudly. With so much at stake, America can no longer ignore the crisis in its emergency medical care system or make decisions based on myths. You deserve better than that! So get going, if not now, when?
May I suggest, that irrespective of what the future of health care might bring, that you, the healthcare leaders of the future, become men and women who are concerned not only with discovering where your patients come from, but also with challenging and modifying the healthcare policies, intended to change the way you practice the art of medicine, especially when you have not been invited to the solution table. I am afraid that today, technological specialization is driving out the “exquisite reward for human needs” essential to our prime goal - the relief of suffering, and substituting it with more paperwork and unattainable directives.

So, I urge you to become a voice not only for the disenfranchised - the young, the poor, the disabled, the elderly, the immigrant - those who have been shut out of the health care system through no fault of their own, but also a voice for yourself and your future. I urge you to use this voice in Washington, your State Houses, and local communities as well.

Colleagues, politics is too important of an issue to be left only to politicians. This rings true more so today when the health care reform bill is on the front burner of the Supreme Court and in the minds of all our patients. If the law survives the court, we must become very knowledgeable about it, and become part of its implementation, not just help aspiring politicians become reelected.

I do not want to leave you, without covering
Challenge No. 3:
This challenge strikes at the very core of what we do and who we are. It is the challenge of professionalism.

Simply put - the degree to which health care reform succeeds or fails for patients and caregivers depends on the answer that only we can provide. And that is:

Can we, health care providers, maintain the traditional humanistic qualities necessary within an increasingly corporate structure? I say we can!

So, what are we to do about it? The answer I believe is medical professionalism. Something that reminds us that we must have the courage to put our patients first!

To have that opportunity is a privilege, but one that does not come without a price.

And that price is not only doing all we can to improve the health of those we treat, but to do so in a manner that is deserving of their trust and respect.

So, let’s approach our work with a professionalism that keeps the health profession a sacred institution - not only for those of us who work in it - but more importantly - for all those who depend on it.

But above all, colleagues, uphold the high ethical standards on which the medical profession was founded. Live by the standards and encourage, even demand it, from others. More than anything, light a path so that others can so that we can continue to protect the autonomy and credibility of our medical profession.

I believe you are ready to meet these and all the other challenges that lurk in wait for you.

But in order to effectively address the challenges I have outlined, you must learn to work effectively with other members of the health care team - for in the health care world that is about to unfold, you will no longer be the sole proprietors of the state of American’s Health.

As it stands, we must not only collaborate, but we must also cooperate, because health care will be improved if we work as a team.

And you must also learn to communicate effectively not only the language, but the culture as well because you will be a guide, a voice, an advisor, as well as a person of considerable power - in helping the needy make correct decisions.

So, speak up - and listen well. Believe me, you will listen your way into people’s lives much more meaningfully than you will ever talk your way in.

Colleagues, today, it has been my distinct honor to congratulate, counsel and challenge. The rest is up to you.
As you leave here today, may you seize this day and all others that are to follow to bring honor to your hospital, joy to your family and friends, comfort to your patients, and true happiness to yourselves.

Above all, I pray that you do not lose your sense of who you really are, where your roots are, where you came from, and who helped you getting to this point. Most importantly, do not forget the impact of this great institution in molding your life and professional future.

Graduating Medical Class of 2012 remember:

Yehuda Bauer said it best: “Thou shall not be a victim. Thou shall not be a perpetrator. But above all, thou shall not be a bystander.”

Don’t ever be said that a graduate of Case Medical Center was a bystander!

Thank you, congratulations and God Bless.

Department of Emergency Medicine Residency Program
University Hospitals Case Medical Center
11100 Euclid Avenue, Cleveland, OH 44106
Phone: 216-844-3610 Fax: 216-844-7783