It is not our imagination that 2010 was a tsunami in health care. I do not pretend to have answers to the health care question and what will happen, but we can all make some educated guesses about overall trends. What are some of these coming changes? What are some ways we can meet them or at least cope?

But first, let me ask you the following question: who is the most admired Canadian of all time? No, it is not Wayne Gretsky; it is not Don Cherry, who by the way, has better name recognition than the prime minister, and it is not Pierre Trudeau. The most admired Canadian of all time by a recent Canadian Broadcast Corporation poll of >1 million Canadians is Tommy Douglas, the father of the Canadian Health System. This is probably actually a vote for universal access, rather than for the actual plan, because that system has some well-known problems. Tommy Douglas, an immigrant Scottish minister, first introduced universal health care when he was premier of Saskatchewan. Physicians struck for 18 days and then caved. I think that universal health care in the United States is also inevitable, although it has been very slow in coming and so far messy and confusing.

We are the only developed nation without some form of universal health care. It was a 1945 goal of Truman’s presidency, yet 65 years later we still do not have coverage for everyone. As of this month 50 million Americans have had no health care coverage sometime in the past year. Coverage for all has gone slowly; we now only have Medicare and Medicaid and the Department of Veterans Affairs. Why a slower development? We are a very large and diverse nation with strong conservative and religious elements and a hesitation about depending on the government. We now have a law that increases the number of covered Americans. However, it is buried in 2000 pages of regulations, and no one really knows how it will work out.

Another change in process: Universal health care in most countries is paid for partially by decreasing payments to physicians. I believe that it is inevitable, unfortunately, that physician compensation will decrease gradually, probably more for specialists than primary care physicians, but at least some for all. What makes this a hard pill to swallow is that, in this country, the government does not pay for medical school; the average debt after medical school now is in the range of $160,000-200,000. Our training is also longer than in most other countries, and we also have large liability costs.

Because of costs and manpower problems, there will be an increase in nonphysician providers. We see this at our very large hospital; physician assistants do admission physicals. Who takes the veins out of your legs for your bypass procedure? Physician assistants. Physicians will need to share power and decision-making with these nonphysician providers.

The electronic medical record has come into its own recently; this new system has been creeping up on us gradually, but suddenly it is here. It is hard to switch to and can be cumbersome, hard to learn, and expensive. But we will get used to it. When its problems are worked out, we will look back and wonder how on earth we used paper all through the years. Remember the last days of wards in hospitals. Our young physicians will tell everyone they remember when records were kept on paper.

We will soon have a shortage of available residency spots in all specialties if new medical schools keep opening and the number of training spots does not increase. There are strains on training programs as hours are cut back. Specific to our specialty, we have a changing workforce, decreasing work hours for obstetricians in training, and a soon to be decreasing workforce.

On top of all this, medical liability continues to be a problem.

Decreasing expenditures by pharmaceutical companies will mean less support for continuing medical education and for journals. The good side of decreased pharmaceutical support for physicians is that our professionalism will improve; hopefully, we will not be provided junkets or “consulting” positions with pharmaceutical companies.

Maintenance of certification will likely be mandated by states, not just by our boards.

That is the list of problems and challenges. How to cope? What to do? I recently heard Gloria Steinem speak about women’s problems in the world. They all seemed so overwhelming. Where to start? “What can we do?” she was asked. Her reply: “Do just 1 thing within the next 24 hours, however small.” Then select another. Here, too, the key is not to think about everything at once but to take action on at least 1 item.

Learn the electronic medical record if you can; do not retire unless the expense is too great. There are physicians at our hospital who are retiring rather than learning it; if you are smart enough to get through medical school, you are certainly smart enough to learn how to use an electronic medical record. It seems awkward at first; but when you watch our residents float through it, you know you will too.

Change is much more palatable if we are a part of it. We do not need to let change happen without our guidance. We need to be active in our local medical organizations and the American College of Obstetricians and Gynecologists. If you do not have time to actively participate now, pay dues and resolve that you will help when you have more time. Unfortunately, advocating for our patients does not in itself make laws. Lobbying and legislation need money. Remember that lawyers donate an average of $1000 per person to political action committees; we physicians donate $11 per person. Pay your dues and, when you see that added line, think that it is a good investment in your profession and patients. They are not unions out only for our welfare; the American College of Obstetricians and Gynecologists is focused primarily on what is good for women.

Some things cannot be compromised in; we are adapting to all the changes around us. We must maintain professionalism and not sink to an occupation that involves continuing to put patient interests before our own, to respect their trust in us, and to be honest with them with no conflict of interest. A recent commentary in JAMA talked about how policies will be established, depending on the perception of physicians as knights, knaves, or pawns.

You can probably guess which is the most desirable. A knight practices to save and improve lives; financial gain is secondary. Knights read because they love learning and want to provide the best care. Knights perform research to advance scientific knowledge. The role of government then would be to get out of the physicians’ way and to let them do their jobs and to seek their advice when policy affects the health of the public.

If they see us as knaves, then policy will be designed to combat and work against us. If physicians are interested in themselves and their financial well-being first and their patients second (if at all) and if they learn new techniques and procedures and order tests for personal gain and if research is driven by self-glorification and narcissism, then the system will work in spite of them. The public must be protected by regulation, and physicians must then be given incentives to get them to do what is right by their patients.

If they see us as pawns, then the government will design the system to make sure that physicians will do what is right. The physicians are seen as a function of their environment and must then be given guidelines to follow; policy makers and regulators will decide clinical priorities.

Have you seen the articles about Chinese hospitals? The Chinese see their physicians as dishonest and unqualified. When the World Health Organization ranked China as 1 of the world’s most inequitable health care systems (188/191 nations), 2 of 5 sick people went untreated. Only 1 of 10 people had health insurance. China has since poured billions into their health care system. But in most of China, care is still inadequate. One-half of the doctors have no better than a high school degree, and many did not make it past junior high school. Public hospitals have very high fees and needless surgery; 1 in 2 Chinese newborn infants is delivered by cesarean section. Prescriptions are hospitals’ second biggest source of revenue. Some link doctors’ salaries to what they generate from prescriptions and diagnostic tests. In 2006, 5500 medical workers were injured by patients or relatives in China. One in 4 physicians experiences depression, and most are afraid of their patients and the patients’ families.

On the good side, we should keep in mind that medicine is still the most respected profession in the world; even in countries where doctors earn very little money, parents want their children to become doctors. If the usual monetary awards are not as good as in the past (and they probably will not be), we still have the collegiality of medicine, the intellectual challenge, the honor of mentoring students and residents, and the privilege of helping our patients in social and medical ways. On days when things seem routine, I pick up journal articles to remind myself of how interesting medicine is and how much each of us can improve by being well read. I remember my husband’s college reunion at which corporate lawyers gathered all around him asking about medicine as a career. It all apparently was much more interesting to them than the law as they practiced it, and the envy was palpable. If we have less money, well, it is less stressful to have a small house and basic cars than it is to work harder and harder to afford elective luxuries. I always tell residents to try to spend a lot less than you earn.

Speaking to the young women in the audience, many of whom think that they have to do it all: you do not! Delegate or trade off. Do not do the grocery shopping, cleaning, and drug store runs if you do not have to or do not enjoy them. Have someone else do it. Expect kids, spouse, or household help to do it. Exercise or read instead. Order online; even drugstores have standard shopping lists you can use. Teach your spouse or children to cook. Children should be able to prepare part of dinner or at least set the table and clean up.

What else adds to our stress? A study of oncologists found that the amount of documentation and the amount of time in the office increase stress, as do poor clarification of job responsibilities, lack of enough time to get the job done, conflicting demands on time, the ringing of the phone, and night work and weekends with no compensation for long hours. That tells me as a manager what I need to do to decrease stress for my colleagues.

Some coping strategies are harmful. Lemaire and Wallace found that keeping stress to oneself, going on as if nothing happened, and concentration on what to do next were associated with emotional exhaustion, whereas talking with coworkers, taking a time out when particularly stressed, humor, exercise, quiet time, and spending time with family were correlated negatively with emotional exhaustion.

Dealing with expectations of different generations can be stressful, but I think we have something to learn from the younger generations. Deal says, in her book, that generational differences are not as great as thought. Family, respect, trustworthy leaders, the opportunity to learn, and feedback are common wishes among the generations, as is aversion to change.

Not spending all your time at work, getting enough sleep, not chasing money, and getting outside are all things that help us cope. It has even been found that people who jog inside on a treadmill are not as relaxed as people who run the same distance outside in greenery.

Demand to be included in decisions. This is the time to be persistent. Our 1100-bed hospital suddenly has become headed by a physician with an MBA from Wharton College. Our administration now consists of a physician-in-chief with support from nursing and administration. Our board now has many more physicians than in the past. This came from requests and pressure.

A Swedish study showed that department heads had less anxiety and were more satisfied when they had influence over their work, when compared with nondepartment heads. The difference? The department heads received clear work directives and more feedback on their performance. More than 50% of physicians could not state the overall mission of their hospital, including goals and strategies. Those physicians who were aware of the overall mission rated their opportunity to influence departmental goals 2-3 times as high as physicians who were not aware of the mission. Although all heads had annual performance reviews, only one-half of all other physicians had performance reviews.

When telecommunications engineers and 3 seniority levels of Swedish physicians were asked about their jobs, the physicians rated their work environment as being more mentally demanding, with a higher workload, less control, and a lower degree of intellectual discretion than the engineers did. High workload and not enough time to finish assigned duties made their jobs very stressful. Job satisfaction was also related to performance feedback, a high degree of participatory management, and a reasonable workload. Take note chairs and division chiefs!

German physicians are also under great stress; 80% of those who were polled in a study of surgical specialties, which included obstetrics and gynecology, said that the amount of stress they experienced interfered with their home lives. Those who were employed by hospitals perceived more stress because they had great demands with little control. A disparity between responsibility and reward also increased stress. With 1 of 6 physicians now employed by hospitals and the number soon to increase, this can give you an idea of what kind of job to accept and what kind to reject.

Be a part of decision-making by considering doing outcomes research. There is too much variation and waste in health care because so much of it is not based on evidence.

Physicians who spend more time keeping up-to-date report less emotional distress and greater job satisfaction. Choudry et al have shown that years of experience do not improve care; the number of years in practice actually sees a decline in care. We must keep up to date and read.

Some of this material illustrates the reason that meetings and groups like the Central Association provide much more than continuing medical education, which we can obtain by a number of other sources. They provide a network of people who are doing similar jobs, time to talk about problems, a forum where you find out that you are not alone; they provide active, rather than passive, learning. They are an important time-out from the routine of work, a professional renewal, and at least in the case of the Central Association, they also provide fun family time. So you see, the Central Association is good for you and for your mental health. I hope that you continue to support it and that you tell others about it.