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President's Column 5/6/10
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The Unchangeable Certainty of Change
Mark B. Johnson, MD, MPH, FACPM
(With help from the quotes of a cast of millions.)

"The one unchangeable certainty is that nothing is unchangeable or certain." John F. Kennedy

"Anything that is in the world when you're born is normal and ordinary and is just a natural part of the way the world works. Anything that's invented between when you're fifteen and thirty-five is new and exciting and revolutionary and you can probably get a career in it. Anything invented after you're thirty-five is against the natural order of things."  Douglas N. Adams

Things are changing way too fast in the world of preventive medicine! I believe it's against the natural order of things. Then again, I'm over thirty-five.

Here are just a few examples of how bizarre things have gotten in our world:

  1. The Residency Review Committee for Preventive Medicine (PM-RRC) is threatening our way of life by proposing radical new specialty requirements for our residency programs that don't include an MPH degree and call for more clinical training;

  2. The American Board of Preventive Medicine (ABPM) is desecrating the sanctity of our specialty by allowing a new pathway for members of the medically great unwashed to more effortlessly join our ranks;

  3. Subsequent to years of unsuccessfully appealing to the government for funding for preventive medicine, the U.S. Congress finally put the words "money" and "preventive medicine" in the same bill only to trigger a stampede of diverse groups to suddenly appear, all claiming that they, too, do prevention;

  4. While we are in the midst of fighting an obesity epidemic and trying to vilify the fast-food industry, McDonald's and Kentucky Fried Chicken made it onto an Internet's Healthy Dining Finder site (www.healthydiningfinder.com); and,

  5. After warning the world that a potentially catastrophic virulent disease was on its way, we had an influenza pandemic that probably saved more lives than it killed. (www.philly.com/philly/health_and_science/90723119.html?cid=xem-emc-nd)

How is one to cope with all of these strange and radical events and changes?

I do not like those who say change is inevitable. I, for one, am a dues-paying member of the group that Sydney J. Harris described when he said, "What we really want is for things to remain the same but get better." I much prefer advice like that of W. Edwards Deming, when he said, "It is not necessary to change." That was until I read the next part of the quote, which says, "Survival is not mandatory."

I certainly want preventive medicine to survive. I am very sympathetic to Winston Churchill's sentiment when he said, "I have not become the King's First Minister in order to preside over the liquidation of the British Empire." It is definitely not my intention to preside over the liquidation of the specialty of preventive medicine while I am serving as the president of its specialty society.

I suppose there are several ways to approach the challenges and threats of change. One way would be to deny that change is taking place. This appears to be the approach being taken by those who do not wish climate change to cause a modification of their lifestyles. But "facts do not cease to exist because they are ignored," as Aldous Huxley said.

Another approach would be to use all of ones available resources to fight the impending changes. At times this would seem to be the most logical and valiant pathway to pursue, especially if the changes are clearly detrimental. Of course, it would also help if resources are adequate for the approaching fight.

A third alternative would be to follow Octavio Paz's advice, and see that "wisdom lies neither in fixity nor in change, but in the dialectic between the two." Unfortunately, the word "dialectic" sounds too communistic, and I can't figure out what Octavio is saying, so I'll ignore this option.

To my way of thinking, the best approach to imminent change is to follow R. Buckminster Fuller's advice, and "build a new model and make the existing obsolete." To choose this option, however, I believe the first step is to determine if the proposed change is detrimental or not. Perhaps there is another way of looking at a couple of the examples I've listed above.

Preventive medicine is currently one of the twenty-four medical specialties in this country that is recognized by organized medicine as providing a "gold standard" level of board certification. This is a recognition that is viewed by most American medical practitioners as being almost priceless. To gain such recognition, however, a medical specialty loses some of its autonomy. It must live up to the standards and requirements of both the American Board of Medical Specialties (ABMS) and the Accreditation Council for Graduate Medical Education (ACGME). Neither of these organizations allows a member medical specialty to remain at status quo. Truly, change is inevitable - we must either continue to live up to the changing standards and requirements or give up this priceless recognition. We do have a choice. I would submit, however, that giving up this recognition would be an extremely ill-advised and foolish choice.

The changes being proposed and made by the PM-RRC and the ABPM are the direct results of pressure that is being put on organized medicine by state and federal governmental agencies, insurance providers and business clients to ensure that the provision of quality medical services and patient safety are paramount in American medicine today and in the future. Resistance to such pressure is not only futile, it is impolitic. It also goes against the very principles and values of preventive medicine.

I am reminded of comments that were made to the Colorado Medical Society House of Delegates several years ago by Dr. Joseph S. Bujak, the Vice President of Medical Affairs for the Kootenai Medical Center in Coeur d'Alene, Idaho, and a nationally known speaker and consultant on health care. "Substance is what you believe and what you are trying to accomplish. Form is just the current method of trying to provide your substance. Too often we try to preserve the form and lose sight of the substance. As the form changes, don't give up the substance of what it means to be a physician. What we do is going to change. How we do it is going to change. But why we do it must never change," he said.

Let me repeat that. "What we do is going to change. How we do it is going to change. But why we do it must never change."

I believe we must open our arms to change, but never let go of our values. Those values include being precise in the knowledge, skills and competencies that are required in the quality practice of preventive medicine. They do not include, nor have they ever included, the attainment of one specific degree. Our values have also included providing the widest dissemination of the knowledge and the principles of prevention in the medical community as possible. They have never included the hoarding away of that knowledge or those principles to be shared only with those who are deemed to be members of an exclusive group of initiates.

I am proud of being board certified in preventive medicine. I believe we need to continue to advocate for the funding of high quality training programs for resident physicians in the principles and practice of this specialty. I am also convinced that if we provide that high quality training, there will always be positions in organized medicine and the health care system for our diplomates. But I also believe that "only in growth, reform, and change, paradoxically enough, is true security to be found," as Anne Morrow Lindbergh so eloquently put it.

Unfortunately, I have also found that Woodrow Wilson was correct when he said, "If you want to make enemies, try to change something." I congratulate the PM-RRC and ABPM members on their valiant attempts to "build a new model and make the existing obsolete." It is in that direction that true security, as well as quality medical care and patient safety, will be found.


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