Another of our unifying traits is our rigorous pursuit of science. This propels research. In the pursuit of science, we marvel at the rare and the commonplace.

A third characteristic is our desire to refine the art of the profession. We know science to be inadequate without compassion, devotion, and continuity of responsibility. We are the human face on a complex biological science.

Our purview is the whole person. We focus on personal histories, family, and social circumstance, ever aware of the forces that define the individual patient. We respect that individuality.

We tolerate uncertainty. Often, our conclusions must be tentative while we diagnose and treat disease that will not wait.

Our experience makes us ever aware that our patients are community. Our patients do not exist in isolation. We cannot restrict our inquiries to the confines of a single clinical setting. This is the public side of our responsibility.

Once, the public's health involved freedom from pestilence, from contaminated water, from smoke-fouled air. In our modern day, we must expand the list of public enemies to include poverty, violence, hunger, and homelessness-each as virulent as any bacillus, each as capable of destroying life and hope.

Many view physicians as aloof, disconnected, materialistic. In fact, we are isolated from our patients' lives by the very nature of our long and demanding training. Our academic medical centers, in pursuing technology, have in some instances lost sight of the broader view. We are shielded from the enormous economic burdens that our clinical decisions may impose on our patients. How can we become more sensitive members of our larger society?

We must begin to comprehend our larger communities. This demands our active participation in those communities, beyond being simply physicians. Our unifying principles, you see, are valid only if they inform our actions.

Our profession stands at the edge of an uncertain future. Medical schools and teaching hospitals confront severe funding cuts. Physicians worry about future employment, practice opportunities, and loss of clinical identity.

Three forces converge to shake the foundations of traditional practice, teaching, and research: runaway costs and technology, increasing inequity in health care, and the advent of managed care.

The technologic accomplishments of medicine are amazing indeed, but they have driven up the cost of medical care to a level that cannot be sustained without crippling education, social services, and business and industrial development. Hospital costs quickly soar into the multithousands per patient, per admission.

Technology and services are not equitably distributed. While radial keratotomies become a growth industry and elective cosmetic surgery abounds, many citizens cannot obtain even the most basic of medical services. Fifteen percent of our population and 40% of our legal immigrants have no health insurance. Will the inscription on the Statue of Liberty have to be updated to say "Send me your tired, your poor ... but have them bring their own health care insurance"?

Finally, we confront managed care. Managed care represents the latest efforts of business and government to control the costs of health care. Some plans have succeeded while still maintaining high standards of quality and accountability. Others seem more interested in generating hefty dividends for stockholders. A community's climate for medical practice can be radically altered in short order when competing managed care enterprises enter. Clearly, managed care will be a dominant organizing principle for health care in America for the foreseeable future.

How can we, as thoughtful physicians, address this uncertain, chaotic time?

Neither time nor politics has ever defined our principles. Rather, we are stewards of a tradition. We must avoid the language of political expediency, which would have society content only with incremental change in a status quo and, worse, erosion of care for the most vulnerable of our neighbors. Our heritage has always been to ask the tough questions and seek fundamental solutions. We must counter those narrow economic forces that would depersonalize the physician-patient relationship and the teacher-student relationship. Love of patient and devotion to the profession are not for sale. Excellent health care is not a luxury for the affluent, nor should it be denied to anyone. Not anyone.

The use of technology must be rationalized. Improved efficiencies in our health care system can save money and still enhance clinical outcomes. Mindless paperwork is inherently wasteful. Fraudulent care must be eliminated. Preventive care—such as reduction of tobacco use and control of handguns—must prevail. We physicians must be certain that the talk about medicine's future is wise, informed, humane. We must be partners to that debate. Should the immediate future in health care be unsettled, our responsibilities to our patients will intensify.

Last weekend, I sat at the bedside of a desperately ill patient struggling for breath as severe emphysema and cardiomyopathy ran their course. He said something that has stuck.

"Doc, I'm trying to make sense out of things. The only thing that makes sense to me now is Mildred [he nodded to his wife] and her love." I realized that, in a time of turmoil, the only thing that perhaps makes sense to us is our love for our patients. In addressing issues of cost, equity, and managed care, let's keep that uppermost in our thoughts.

We should be satisfied with nothing less than universal care compassionately practiced—care delivered across the full diversity of mankind—delivered in communities freed of violence, of fear, of hunger and poverty.

Idealistic? You bet.

Doable? You bet. United as a discipline and as a profession, we, and our sons and daughters, can catalyze its accomplishment.

We have no other option.

@copy; 1995 American College of Physicians