In striking this theme, I want to credit James Reinertsen and Richard LeBlond, who have suggested that the fundamental nature of the transaction that takes place between physician and patient, as complex, multifaceted, and enigmatic as it is, can be captured in just three questions that people seek answers to when they are sick [1]. They suggest that people basically look to their physicians to 1) explain nature: "What's happening to me?"; 2) predict nature's future: "What's going to happen to me?"; and 3) alter nature's future for the better: "What can be done to improve what happens to me?"

In western civilization, at least over the past century or so, physicians have played the dominant role in answering these questions. We have classified the answers we give with fancy words such as diagnosis, prognosis, and therapeutics, and we've earned great respect for the quality of the answers we give.

But it's important to recognize that people sought answers to these same questions long before there were physicians with fancy words. Consider the prehistoric shaman, faced with a feverish child, casting bones to predict the illness's future course, and administering some herbal concoction in the hope of improving his patient's outlook. He was being asked to answer those same questions, and he, no less than today's physician, was using the limited knowledge at his disposal to do so.

Physicians Have No Monopoly Here

Similarly, it's important to recognize that, despite the dominance that today's science-empowered medicine men enjoy as providers of answers to these questions, we physicians do not have a monopoly on the field. This most fundamental quest for answers by people who are sick, or who believe they are, still supports a thriving enterprise outside of medicine. Americans make more visits to practitioners of so-called unconventional medicine-which includes some truly outlandish practices-than they do to primary care physicians [2]. And the balance may be shifting even further away from traditional medicine as many in the United States express a diminishing faith in science and as many more express a growing desire to control their own destiny. It is too easy to ascribe the mounting skepticism about science just to society's inadequate attention to fundamental education. As critically important as that attitude is to fix, we must acknowledge that medicine itself also has some accountability here. Evidence the highly publicized, albeit rare, instances of fraud by medical scientists, and the widely reported, not so rare, instances of just plain arrogance on the part of physicians. Most troubling in this connection, though, is the perception that today's medicine has placed science ahead of humanism at the core of the physician-patient relationship. Consider, for example, how ardently people feel about the necessity of advanced directives for fear that physicians cannot be trusted to treat their patients humanely at the end of life.

But the lesson I want to extract from these observations runs much deeper still: Physicians, as we know and love them, do not have a God-given, automatic, uncontested hold on this question-answering business. Just because people have always sought, still seek, and will always seek the answers to these questions does not, ipso facto, mean that they will always choose physicians to get their answers. They will go to whomever they believe can best address their burning questions. And I submit that the future of internal medicine, and of medicine in general, is wholly dependent on how skillful we are in answering the age-old questions and on how well we understand that others are positioning themselves to fill the void created by medicine's perceived shortcomings in addressing this fundamental quest of human nature.

Fighting the Battle in the Marketplace

The medical marketplace, in which so many physicians now feel enslaved, is, like it or not, the place where this battle is being fought. Ultimately, people will express their preferences in the increasingly open competition of the marketplace. As competition opens up-competition among physicians, between physicians and nonphysicians, among a variety of health care delivery systems, between traditional and nontraditional philosophies of healing-people will have many choices. And they will choose whom they wish to direct their questions to in accordance with their perceptions of who provides the most valuable answers in the most convenient, friendly, and least costly fashion. Ignoring this fundamental truth about the marketplace is a sure road to oblivion.

Please don't get me wrong here. I'm not saying that medicine is or should be viewed as a simple, marketable commodity, or that medical professionalism, with its ethical devotion to both the healing power of scientific medicine and the supremacy of the patient's interest, should be abandoned in favor of the unprofessional, mercantile philosophy of "buyer beware." Quite the contrary. I contend that the only hope we have of preserving our ethical heritage, of retaining our special relationship with patients, is to understand the marketplace and make it work for us in our role as patient advocate.

Guidance to Answering Age-Old Questions

Let me turn back to Reinertsen and LeBlond's age-old questions and see what guidelines we can extract to help steer physicians out of the wilderness into which so many fear that medicine has wandered. Recall the first question: "What's happening to me?" When people think that something is wrong with them, the first thing they want to know is, What's going on? What's causing this pain? Where did this lump come from? Why do I feel so weak? Until this question is answered, anxiety is bound to persist. But what does literally every poll tell us is the most common complaint that people have about physicians? "My doctor doesn't listen to me and doesn't talk to me!" Clearly, if physicians-internists in particular-are to strengthen their position in the market, they have to satisfy this yearning and give more acceptable answers to the question, "What's happening to me?"-acceptable, that is, to their patients. Basic to this task is skillful communication. The importance of the medical interview in meeting patients' expectations cannot be overstated. But just when we need it most, we find the medical interview seriously undervalued by the lure of fancy technology and, as a result, too often deemphasized by medical educators at both the undergraduate and graduate levels.

Admittedly, what patients need is hard to deliver in the limited time most physicians are allowed (or choose to take) with a given patient, and harder still as the ever-increasing racial and ethnic diversity of our patients erects additional barriers to effective communication. But there are steps that can be taken to overcome these temporal and cultural difficulties. Choosing not to take these steps is to invite obsolescence as others do find the time and display the ability to listen to the varied voices of patients, to hear their troubling questions, and to explain in understandable and believable language what nature is doing to make them sick.

Aligning with Patients' Needs

As for having enough time, physicians simply must have the courage to stand up to those who are driving a wedge of clock-punching between them and their patients. I know that the economic pressure to be more productive is severe and that the cost-conscious market seems to be forcing us toward an assembly-line structure for health care delivery. But in the final analysis, the ultimate architect of how medicine will shape up in the future will not be the accountant concerned about cost containment; it will be the people concerned about their well-being. And as people become progressively more dissatisfied with the way their questions are being answered by assembly-line medicine, they will force a change. In the long run, they will not be denied. If physicians-internists-wish to remain their patients' advocates and wish to escape their present bondage, they must align themselves with this irresistible force, with human nature's fundamental need for an explanation of ill health, because that force is destined to overwhelm what seems at the moment to be the immovable obstacle of clockwork medicine.

In my view, physicians have not yet pushed back hard enough. They have not exerted the enormous latent power available to them by acting in concert to defend their patients' interests. Opportunities are at hand to do so. One way is to exploit the newly available mechanism of provider-sponsored organizations. I would encourage physician groups to position themselves, with others as necessary, to contract directly with those who purchase health care services on behalf of potential patients. Proving increasingly redundant is the middle-man function of those managed care companies that merely dole out to independent providers a portion of the premium paid by purchasers of health care. Another way for physicians, both individually and collectively, to push back is to assert their rightful leadership roles in those managed care organizations that do operate their own delivery systems. Physicians must insist on setting the policies and priorities for those organizations so that they are more in line with medicine's ethical and professional obligations. As risky as these and other assertive tactics may be, I believe it is essential for physicians to take such risks if we are to free our profession from oppressive practices contrary to patients' best interest.

In fact, physicians may find it easier than they might think to re-exert their rightful leadership role. Many players in today's medical market seem to be ready to rally around a call on behalf of patients. The press is weighing in with a rash of horror stories about overly managed care. Numerous consumer groups are beginning to voice their outrage. And the president, Congress, and state legislatures all are actively considering ways to regulate managed care to protect the consumer. Who better to lead this advocacy effort on behalf of patients' best interest than the patient's best advocate-physicians.

The Challenge of Racial and Ethnic Diversity

Now, what about the challenge of communicating effectively with an increasingly diverse patient population? I'm afraid that physicians will need more than courage to grapple with this one; what they need is a more diverse group of colleagues. This topic deserves a much longer discussion than I have space for here [3]. However, as the United States becomes rapidly more racially and ethnically diverse (predictably reaching the point, in about 2050, at which most Americans will be members of one of the minority groups that are currently vastly under-represented in the medical profession), we must find the means to ensure that our minority populations gain appropriate entrance to the health professions. Access to health care-access to answers to our three age-old questions-simply cannot be achieved unless the medical profession looks more like the United States. A profession dedicated to serving the needs of the public must overcome the shameful legacy of generations of discriminatory practices that have culminated in our being a predominately white male elite. But much more effort is clearly needed, beginning with our duty as community leaders to improve the early education of those still denied access to quality schooling because of their race and ethnicity, and including our vocal support for the use of affirmative action as a critical, if only temporary, tool for achieving diversity among medical students.

Providing More Accurate Predictions

Let me move on to the second of our patients' age-old questions: "What's going to happen to me?" We've gotten pretty good at prognosis over the years, given the wealth of critical observations that clinical investigators have made to document the natural history of disease. But, as everyone knows, we are on the threshold of a whole new realm of unimaginably powerful prognostication. I mention just two examples. The first is the information emerging from the Human Genome Project, information that will transform our ability to tell our patients, in some instances with uncanny precision, precisely what nature has in store for them. In understanding how best to answer this question, I believe that internists have an unusual opportunity to reinforce their position as the most authoritative source of reliable information on the natural course of disease. Internal medicine and its subspecialties, with their strong tradition of scientific rigor and deductive brilliance, are uniquely positioned to convert the powerful genetic data so near at hand into both intelligent and intelligible answers to some of the most fearsome questions patients will soon be asking.

Internists must take seriously the challenges of preparing for this role. High on their priority list of continuing education should be in-depth understanding of the genetic basis of human health and disease and of the myriad ethical quandaries created by novel genetic insights. Equally high on internal medicine's priority list of public education should be an all-out effort to redress the appalling ignorance of science, even among otherwise well-educated people. The irony of our entering an age of matchless scientific power to alleviate human suffering, at a time when the United States is still enamored of parascientific and blatantly unscientific thinking, is astounding. If medicine is to shepherd the public toward the rewards of the genetic revolution, all physicians, and internists especially, must find ways to hook the public back on science. Success at doing so will further strengthen the medical profession's claim as patient advocate and as the authentic source of answers for human ailments.

The second, albeit less celebrated, tool that has the potential to greatly enhance our prognostic power is predictive modeling. This novel technique couples readily available computer technology with formidable statistical analyses to yield what promises to be highly reliable predictions about the future course of disease in individual patients. Early results from the application of this modeling are encouraging. As with genetic information, however, physicians must begin now to prepare themselves if they are to exploit this new tool to full advantage. Understanding the theoretical basis for predictive modeling and becoming facile with computer applications are prerequisite to maximizing the utility of this approach in addressing their patients' concern about what's going to happen to them.

Improving Patient Outcomes

Finally, let me say a word about our patients' last age-old question, "What can be done to improve what happens to me?" The truly remarkable advances in medical science (often coupled, unfortunately, with excessively optimistic claims by the media and occasionally by our own colleagues) have conditioned much of the public to expect routine miracles from physicians. Here again, internists, armed with an unexcelled foundation in clinical science, have great opportunities for enhancing their value to society and, in so doing, for solidifying their claim to be doctors for adults. Building on their traditional role as a dependable gateway to cutting-edge medicine, internists should be well positioned not only to deliver those miracles of science that have, in fact, become routine but also to ensure that their patients understand the realistic limitations that will doubtless continue for the foreseeable future to frustrate everyone's high expectations.

Equally important is for physicians to understand what really works. In choosing diagnostic and therapeutic strategies, physicians have in the past relied too much on tradition, anecdote, and deference to "authorities." The standards of evidence are, happily, becoming more rigorous as we become more concerned about the effectiveness of what we do and as we become armed with more authoritative information on the outcomes of our choices. All physicians, but internists especially, can improve the outlook for their patients by ensuring that their practices are evidence based. Use of computer-assisted literature searches and well-researched clinical guidelines are but two of the techniques now available to physicians in their role as evidence-based practitioners.

But there is yet another role that internists can play to improve the outlook for everyone. We have known for years that many of the most common and serious causes of disability and premature death are self-inflicted: smoking, obesity, lack of exercise, unhealthy diet, neglect of immunizations, unsafe sex, preventable trauma. Some regard these matters as falling outside of medicine's domain of responsibility. I disagree. To be sure, we are first and foremost advocates for our individual patients. But as leaders among the healing professions, physicians are also charged with enhancing the aggregate health of the public. What better way to do so than by greatly escalating our efforts to provide sound information and advice about eminently preventable hazards? Are we to leave so much of this vital work to the government, or to churches, schools, the advertising industry, or, pray tell, other health professionals? All of them have a part to play, but physicians and their professional organizations surely should take the lead in telling people what they can do themselves to improve what otherwise is going to happen to them. Taking on the task of providing public as well as private answers to this last of our three age-old questions will uphold medicine's traditional platform of public service and help to position our profession for a safe passage to a better place.

Summary

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My message, in summary, is quite simple. Physicians can escape from the allegorical bondage so many seem to be experiencing at the hands of today's pharaoh-the alien market-by focusing on how best to answer the three fundamental questions all human beings pose when they are sick. Explain. Predict. Improve. Internists can lead the way out of the wilderness to a more promising future by aligning themselves thoroughly with these natural concerns and by defending vigorously the rights of patients to receive the answers they seek. Natural laws are at work here. Human nature will prevail. Making an ally of Mother Nature is a time-honored strategy for success. After all, look at how successful the Israelites were when they got Mother Nature to part the Red Sea.

Adapted from the keynote address delivered at the American College of Physicians Annual Session, 22 March 1997.