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| Vol. 22, No. 21 |
| November 15, 2000 |
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TACKLING TOUGH TERRITORY By RONDA WENDLER Texas Medical Center News
Dr. Randolph D. Smoak Jr. has had it with smoke. As president of the American Medical Association, Dr. Smoak has become the lead spokesperson for the AMA's anti-smoking campaign, and advocates a plan of action to "wipe the scourge of tobacco from the face of the earth." On a recent swing through Houston, Dr. Smoak shared his impassioned views in a speech presented to the Harris County Medical Society and the Rotary Club of Houston. "Tobacco companies have deceived the American people for years, and they're continuing to do so," Dr. Smoak says. While ads for tobacco products are prohibited on television and radio, the tobacco companies are now running ads that promote themselves - not their products. "They run ads that pull at your heartstrings, showing how their employees help poor souls or kids in need in the community. This is all designed to help people feel favorably toward the tobacco companies, and it's dishonest," Dr. Smoak says. "They're 'sneaking in through the back door' to get their names on television again." He sees through this "smokescreen," and hopes television networks will follow suit by pulling such ads from the air. Although he hails from South Carolina - a tobacco state, Dr. Smoak has no qualms about imposing strict penalties on the tobacco industry. He advocates spending tobacco lawsuit settlement dollars for smoking cessation and prevention programs, and for other health-related activities that benefit underserved and uninsured patients. He wants the tax on tobacco boosted, he says, because higher taxes make it harder for young people to afford cigarettes. Dr. Smoak gets steamed when he sees cigarette-puffing musicians and actors who are role models for young people. These public figures are influencing minors who are not yet equipped to make intelligent choices, he says.. As the acknowledged leader of the AMA's anti-smoking campaign, Dr. Smoak also is the AMA representative to the U.S. Department of Health and Human Services on smoking matters, and vows to carry his anti-tobacco platform to those in policy-setting positions.
A POWERFUL VOICE A board-certified general surgeon from Orangeburg, South Carolina with advanced training in oncological surgery, Dr. Smoak is the 155th president of the AMA. His easy-going manner and southern charm resemble that of a favorite uncle, yet he's one of America's most powerful and influential voices in medicine. His year-long presidency is devoted to hard-hitting issues, including tobacco reform, health care for the uninsured, equality of care, and uniform accreditation of physicians. Dr. Smoak, whose term as AMA president runs from June 2000 to June 2001, has served the AMA in virtually every leadership position imaginable including board chair, vice-chair and secretary-treasurer. He has been an influential figure on the AMA's Political Action Committee, and currently serves on the Board of Directors for the Campaign for Tobacco Free Kids. A founding member of the South Carolina Oncology Society, Dr. Smoak also is a fellow of the American College of Surgeons and a diplomat of the American Board of Surgery. After graduating with an M.D. degree and completing his residency training at the Medical University of South Carolina, Dr. Smoak traveled to Houston, where he completed a senior surgery oncology fellowship at The University of Texas M.D. Anderson Cancer Center from 1966-67. Though invited to remain at M.D. Anderson, he and his wife Saundra returned to South Carolina to start a family in familiar surroundings. "Home and roots are important," said Dr. Smoak, the father of four girls. "They keep me grounded and remind me every day of what's important." He now heads Orangeburg Surgical Associates, a flourishing private practice made up of seven surgeons, including himself. Dr. Smoak is a clinical professor of surgery at the Medical University of South Carolina -- his alma mater -- and a clinical associate professor of surgery at the University of South Carolina School of Medicine. Growing up 17 miles south of Orangeburg, Dr. Smoak enjoyed a rural American childhood, complete with simple pleasures like trout fishing in the local pond and weekend trips into town for ice cream and movies. His mother taught piano and seventh-grade English, and his father worked at the post office. Dr. Smoak recalls that the town's only doctor officed in a back room of the local drug store and made house calls. That doctor, who in the 1940s inspired Dr. Smoak to follow in his footsteps, wouldn't recognize the chaotic world of medicine today. Managed care, genetic advancements, and the provision of health care in an ever-changing multicultural and multiethnic society -- all have a major impact on Dr. Smoak's term as president.
SERVING THE MOST VULNERABLE One of Dr. Smoak's main priorities is to resolve once and for all the problem of the 42 million Americans who currently have no health insurance -- the working poor, Dr. Smoak calls them. "These are good people who work hard, do a great job, but are not paid very handsomely. The counter clerk at the dry cleaners, the fast food cook who makes your hamburger ... these people live from pillar to post when it comes to getting health care," Dr. Smoak says. A handful of states require companies, regardless of size, to provide health insurance to employees, with the government covering some of the cost. But the vast majority of states have no such mandate. "We must ensure and we will make certain that the uninsured -- the most vulnerable of Americans -- receive health care coverage like everyone else," he states. The new Children's Health Insurance Program, funded with federal and state dollars, has helped one million children become insured so far, but that small number is just a "blip," Dr. Smoak says, considering that 10 million children remain uninsured. There are those who advocate solving the problem with a government-funded health plan such as Canada's, but Dr. Smoak doesn't believe such a program will work in the United States. "Remember Canada, population-wise, is the size of California. The Canadian population is much more homogenous than ours, and people there are willing to accept more restrictions than our culture will permit," he says. To understand, Dr. Smoak suggests observing Canadian and U.S. citizens at bus stops. "Canadians queue up in an orderly line, but Americans look like a covey of quails flocking to the bus all at once," he says. Canada is suffering serious problems with its health care system, Dr. Smoak cautions. The country has failed to refurbish its existing hospitals, build new hospitals, and update medical equipment. Instead, money has been spent largely on patient care, and now the health care system is in a real crunch, he explains. "The cost of updating equipment and facilities is an overwhelming $1.74 billion," Dr. Smoak says. "Intense discussions aimed at finding a resolution are under way, but it won't be easy." To make matters worse, Canadian doctors and nurses are migrating south in favor of working in the United States, creating a shortage of skilled caregivers in Canada. "Ninety percent of Canadians live within 100 miles of the U.S. border. They have a 'pop-off' valve, so to speak -- an escape mechanism if necessary," Dr. Smoak says. "Health care workers can cross the border for better jobs, and Canadians who can afford to pay can find superior health care in the United States," he explains. "The AMA believes it is imperative to keep the American health care system in the private sector, with government programs available as a fallback for those who slip between the seams," Dr. Smoak says "because government programs have traditionally not run well or efficiently." Take, for example, the National Health Services Corps, a government program that subsidizes physicians and other health care practitioners who serve in medically underserved rural and inner-city areas. The program is in trouble due to insufficient government funding. "The Clinton administration and Congress allowed the program to languish," Dr. Smoak says, "and the neglect in the form of insufficient funding has taken its toll." The AMA will bring this issue to the attention of the new administration, Dr. Smoak promises, and the program ultimately will be not only restored, but expanded. "We will be relentless in our advocacy until this program receives the support of the president, Health and Human Services and Congress," he vows. "This urgently needed program needs all the help it can get right now."
ONLY THE BEST While access to care is enormously important, quality of care deserves equal attention when addressing the problem of the uninsured, Dr. Smoak says. The AMA has worked for six years to pass through Congress a Patients' Bill of Rights, a simple piece of legislation assuring all Americans the right to receive the highest quality of health care. The bill made it through the House, but lobbying efforts on behalf of insurance companies have tied up the bill in the Senate. "The insurers have fought us every step of the way. The House overwhelmingly passed the bill because it actually protects patients, and holds insurance firms accountable. But the Senate keeps passing legislation that protects HMOs," Dr. Smoak says. The latest twist has the Senate considering a compromised version of the bill that seeks to strike a balance between patients' rights and insurers' concerns. Until truly meaningful legislation is passed, Dr. Smoak vows that the AMA will remain focused, disciplined and aggressive in getting patient protections passed. "We have a moral covenant in advocating for our patients' rights, including the right of all Americans to receive the highest quality of health care," he says. Along those lines, Dr. Smoak this month begins serving on an AMA committee charged with developing an action plan to combat increased health risks among ethnic and racial minorities in this country, such as lower life expectancy, higher infant mortality, and higher levels of disability. Dubbed the "Initiative to Eliminate Racial and Ethnic Health Disparities," the members include representatives from the American Public Health Association, the Surgeon General, and a number of public and private organizations. "Our group will put together a reality-based plan to wipe out the disparities in health status that divide our nation and endanger our patients," Dr. Smoak explains. "One size doesn't fit all in a country as diverse as ours," he says, "so expect the plan to have many tailor-made features." The AMA, he adds, supports pending legislation for a new National Center for Research on Domestic Health Disparities to be located in the National Institutes of Health in Bethesda, Maryland.
FORMS, FORMS AND MORE FORMS One of the most frustrating chores confronting physicians today, Dr. Smoak says, is credentialing, the approval process a physician must go through to be listed as a provider on a managed care plan. The average physician has 10 managed care contracts. Not uncommonly, each insurer has different standards for verifying physicians' credentials, professional behavior, completeness and confidentiality of records, and general patient friendliness. Paperwork soars as contracts multiply. In a practice like Dr. Smoak's, with eight managed care contracts and seven surgeons, each physician undergoes the process eight separate times. Then each of the eight managed care plans demands an annual or biannual site review. Hospitals and other organizations ask for duplicate information. "You absolutely would not believe the nightmare this creates," Dr. Smoak says. To tame the runaway credentialing process, Dr. Smoak was instrumental in creating the American Medical Accreditation Program, the AMA's national benchmark for physician quality. Though discontinued in February due to opposition from physicians who were wary of "grading," the program bestowed an AMA "seal of approval" on physicians who met the standards for accreditation. Among the criteria considered were a physician's initial and continuing education, board certification, peer review, and self-assessment of performance. Two years ago when the progam was new, Dr. Smoak offered himself and his practice as guinea pigs, and earned the programs's first certificate. Dr. Smoak continues to defend the program and lobby for its return. "All we're saying is, here is the standard, if somebody measures up, great. We're not going to grade physicians, and this is not anything that involves public or federal standard setting," he explained. "The AMA is very much opposed to federal licensure. That is a states' rights issue." The AMA continues to fight an uphill battle in trying to achieve industry-wide acceptance of its standards. Whether the setback is temporary or permanent remains to be seen. But as far as Dr. Smoak is concerned, uniform accreditation is one more tough but necessary change in a profession that has exploded from a cottage industry into a mega-business. "With so many pulls in different directions that threaten to erode the doctor/patient relationship," Dr. Smoak said, "physicians must remember to embrace the initial reason they chose medicine as a profession." "Think with your head, feel with your heart. That makes it all worthwhile," he advised.
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