Envelopes: presidential address.

The fabric of medical care has been altered during the past 2 decades. Initially this alteration was furtive but it rapidly escalated, producing change that will be irrevocable. Physicians, dedicated to caring for their patients, frequently were found struggling in the wake of the changes in the health care system. In most situations they found themselves swept aside from crucial decision making because of timidity, practice obligations, and absence of knowledge related to "medical business." With about 600 managed care operations in the United States, physicians can no longer afford to sit in the stands and just watch the play on the field. Participation is crucial and must be accompanied by additional learning, such as masters degrees in business administration or MBAs. This will allow the new players to read the playbook of business medicine. Although on-the-job training is possible, it usually has a slow learning curve as a result of diluting the new assignment with practice obligations. Despite these formidable challenges, physicians must enter the local, state, and national arenas and participate. Despite change and reaction to change, physicians have an irrevocable trust that cannot be withdrawn or overlooked. It has been earned and pervades every facet of our professional careers. The physician has an uncompromising duty and privilege to care for his or her patient in the highest and most ethical manner, a duty that will remain forever. This will never change!