http://content.nejm.org/cgi/content/full/342/17/1284?ijkey=1cdZD.PCVPsgI
|
|
|||||
|
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
Medical Professionalism — Focusing
on the Real Issues
|
|
|
|||||||||||||||||||||||||||||||||||||
There
is considerable interest in reinvigorating medical professionalism.1,2,3,4,5,6
This interest reflects a profound unease with the seeming primacy of
economic factors among those currently affecting medical practice in
the United States. There is general agreement that patients'
interests must take precedence over physicians' financial self-interest
and that professionalism also entails service to vulnerable
populations and civic engagement. But as commentators focus on
managed care and other issues of the moment, many considerations are
entirely overlooked. These omissions may well subvert the effort to
make professionalism relevant to contemporary medicine.
Because the focus on the threats from managed care is so intense, the
thorny question of whether professionalism is more or less vibrant
or effective today than it was under fee-for-service medicine has
been slighted. Commentators do not consider whether professionalism
has to be revived or, more dauntingly, created. Why is there such
steadfast inattention to the past? Perhaps the reason is that an
analysis of the historical record would severely complicate the
agenda, forcing a shift of attention from managed care to the more
fundamental problem of professionalism in American medicine.
Take the question of how well physicians met the demands of professionalism
during the period from 1910 to 1980. Did they put their patients'
interests first? That some physicians did is clear, but given the
compelling evidence of overtreatment of patients and such practices
as self-referral and fee splitting, it would be difficult to
conclude that before managed care was introduced the profession as a
whole unequivocally gave precedence to the interests of patients.7 At
least since the inception of Medicare, which led to the
extraordinary rise in physicians' incomes, some (perhaps many)
physicians acted in ways that were designed to enhance their
financial positions.
Thus, to the degree that managed care does not pose the initial or
exclusive challenge to the precept of putting the interests of
patients first, it is necessary to examine the internal, not the
external, factors that have weakened professionalism. The problem
involves medical norms and practices more than reimbursement formulas
under managed care. The most pressing question is not how to redraft
contracts between physicians and health maintenance organizations
(HMOs) but how to reduce physicians' financial interests and better
monitor their behavior. Concepts of professionalism are particularly
relevant to this task, as a charge to physicians to make their
financial compensation secondary to the welfare of their patients.
In fact, professionalism may well require some financial sacrifices.
Discussions about professionalism before the introduction of managed
care involved other issues, such as technical expertise and
self-regulation of medical practice. These considerations, as
formulated by Talcott Parsons in the 1920s and 1930s, were once
understood as the foundation of professionalism. In fact, the goal
of maintaining technical expertise among physicians has been
exceptionally well met. Board certification has proved so effective
a mechanism that problems involving technical expertise have almost
disappeared from discussions of professionalism.
However, the record on self-regulation, particularly with respect to
incompetence and impairment, is replete with failures.8
Professional societies, with only a few exceptions, have not
effectively disciplined their members. By-laws may provide for
reprimand, probation, suspension, and expulsion of errant
physicians. But most organizations do not publish records of their
disciplinary actions. By all accounts, complaints against members
are few and rarely result in disciplinary action. The inadequacies
of self-regulation make it clear that an examination of
professionalism must go beyond questions of money and managed care.
To the extent that self-regulation is the focus, professionalism
today has to be invented, not restored.
This proposition is even more true of the current effort to make
civic and social obligations central to medical professionalism. Over
the past century, physicians have been extraordinarily reluctant to
enter the public arena. A few exceptions aside, most physicians have
not taken part in national politics (even when health care reform
was debated), let alone in state or local politics (e.g., serving on
school boards). If the historical record of civic engagement is so
bleak, how can it be changed? Why expect doctors to engage in public
service now if they have rarely done so in the past?
Just as the recent literature on professionalism ignores history, it
slights the structural barriers, apart from managed care, to the
accomplishment of the principles of professionalism. Most of the
authors, for example, pay little attention to the interactions
between pharmaceutical companies and physicians or the influence of
such companies on undergraduate medical education and residency
training. Despite the evidence that this influence is far-reaching,
the few analysts who do remark on the issue fail to convey its
importance. Pellegrino and Relman,1
for example, assert that contributions from pharmaceutical companies
should not dominate the budgets of professional associations. But
they do not cite the data showing how extensive these contributions are
or discuss what the associations might have to do to survive without
them.
To select one example from an organization that specifies in its
budget reports the contributions of pharmaceutical companies, all 21
major donors to the American Academy of Family Physicians in 1995
were drug companies.9 If
more professional societies divulged information about such
contributions, this example might be multiplied many times over.
There is also substantial evidence that gifts from pharmaceutical
companies (such as subsidies for meetings and travel) influence the
prescribing practices and formulary choices of physicians.10 A
discussion of threats to professionalism that does not address the
influence of pharmaceutical companies omits a critical
consideration, one that, unlike managed care, is largely subject to
the control of physicians.
Perhaps the most important omission from the recent discussions of
professionalism is the question of how to implement and enforce professional
standards. There are calls to expand the teaching of professionalism
in medical schools and in residency programs and to have
professional societies become more explicit about the norms they
espouse. But the limitations of these two approaches are apparent.
Ludmerer observes that lectures in the preclinical curriculum are no
match for the rough-and-tumble lessons of clinical training.3 The
rhetoric on respect for patients is too easily undercut by the
reality of exhausted residents teaching medical students how to
avoid a "hit." But Ludmerer does not suggest how to
implement a change. He is eager "to make the internal culture
of academic medical health centers less commercial and more service
oriented," but he has no more specific strategy for
accomplishing this goal than to appeal to the "courage" of
medical leaders.
Nor is it completely satisfactory to depend on a public declaration of
norms, whether through new oaths or ceremonies in which first-year medical
students are given white coats. Take, for example, the call for
greater social engagement through the provision of care to
underserved populations or greater civic participation. Professional
resolutions favoring such practices might have some effect on
individual behavior, but it is doubtful that they would have a
substantial collective impact. Lofty phrases generally do not change
customary ways of doing things. To put it another way, the burden is
surely on those who would rely on such strategies to demonstrate
that they would be successful.
In what other ways might professionalism be promoted and implemented? There
are a range of possible strategies, many requiring fundamental departures
from current procedures. First, professional and board-certifying
societies could require rather than recommend standards of behavior,
including service. One could imagine that, like continuing medical
education, service to vulnerable groups of people would be required
to maintain certification. A number of community organizations
already attempt to meet the medical needs of uninsured patients by
coaxing physicians, more or less successfully, to provide care to
such patients without charging fees. A minimal requirement to render
free care might improve the health of poor patients and promote
medical practice that exemplifies the precepts of professionalism.
The controversy that would greet such a proposal cannot be
underestimated, especially since physicians are under pressure to
see larger numbers of insured patients. But controversy may be the
price that has to be paid for taking professionalism seriously.
Second, professional associations could form alliances with consumer
groups to accomplish goals that neither can realize separately.11
Sullivan suggests that medicine might wish to "go public"
and become "much more of a partner to other fields and social
interests."4
This approach informs at least one program, Medicare as a Profession
(I chair the program's advisory board). Part of the Open Society
Institute, it funds joint efforts by consumer groups and medical
groups to improve the quality of care, implement professional
standards, and provide care to underserved populations. Although
physicians have traditionally refrained from joining forces with
consumer groups, the need for such alliances may break the
tradition.
Third, the medical school and residency curriculum should be altered,
not only by including lectures on professionalism but also by
inculcating the skills necessary to promote it. To the degree that
the profession accepts a commitment to social engagement, the
curriculum should teach advocacy skills along with diagnostic skills.
Once again, this would constitute a startling break with established
patterns. Medical school faculty would have to include persons
trained in advocacy and community organization. The clash of
cultures would be great, but so would the benefits.
Fourth, medicine in its organized capacity must encourage and protect
whistle-blowers, so that the profession is not so dependent on
outsiders to identify and publicize problems. Whether the problem is
specific instances of conflict of interest or abuses by managed-care
companies, journalists and government officials have taken the lead
in uncovering abuses and providing remedies. Thus, when HMOs imposed
restrictions on the length of hospital stays for new mothers and
women recovering from mastectomy, the press — not organizations
representing obstetricians or oncologists — spearheaded the protests
and brought about corrective legislation.12
Journalists have been especially active in ferreting out instances
of conflict of interest. To be sure, many medical journals have
reported on the overall dimensions of the problem, and universities
and medical schools have established useful oversight procedures.
But it is the press that continues to highlight the failures of the
existing system to control the behavior of physicians. A recent
article in the New York Times on the development and testing
of new cardiac devices is a telling case in point.13
Fifth, professional organizations must be persuaded to expand the
agenda for which they lobby and advocate. Nearly all these organizations
engage in extensive lobbying, with many spending over $500,000
annually on such activities.14
Through lobbying firms or their own staff, they attempt to influence
legislation on various matters, including health insurance, drug
regulation, managed care, antitrust violations, and liability
reform. But in most, if not all, cases, these efforts conform to the
special interests of the organization's members.
Thus, the American Academy of Dermatology has fought to maintain direct
access to specialists because it is the "most efficient and
cost-effective method of providing quality dermatologic services."15
By the same token, the American Academy of Ophthalmology has
strongly opposed the creation of "centers of excellence as they
apply to cataract surgery," as well as "single surgery payment
provisions,"16
apparently because they would reduce earnings for ophthalmologists.
And when Medicare benefits were being debated by Congress, the
American College of Gastroenterology lobbied to include screening
for colorectal cancer as a benefit.17
Imagine what could have happened if these societies had advocated for
the well-being of patients without regard for their own special
interests. Support by dermatologists and ophthalmologists for
colorectal-cancer screening would carry great weight in the debate
over whether to include it as a benefit. Again, the barriers to such
activities are formidable. Members of professional organizations do
not want their dues spent on advancing the other fellow's specialty,
and they may believe that only subspecialists can determine what
patients need. But think of how the public might respond to advocacy
that was driven not by narrow self-interest but by a broader
professional vision of patients' welfare.
Sixth, professional societies, medical schools, and teaching hospitals
should adopt policies to minimize the influence of pharmaceutical
companies and their representatives. If professional societies
raised annual membership dues and registration fees for meetings,
they would reduce their dependence on underwriting and advertising
by drug companies. At the very least, these organizations should
refrain from such practices as identifying drug-company donors in
programs for meetings according to the level of support (platinum,
gold, silver, and so forth); this suggests a degree of venality that
is inconsistent with professionalism.18
Societies may not wish to ban drug-company booths from annual meetings
on the grounds that such a restriction might hamper the spread of
new information, but no educational purpose is served by allowing
the booths to dispense such "brand reminders" as pens,
note pads, briefcases, flashlights, and golf balls.19
In the same spirit, medical schools should adopt formal rules that
prohibit all gifts from drug companies to students, whether books,
stethoscopes, or meals. Medical training should not include acquiring
a sense of entitlement to the largesse of drug companies. Finally,
teaching hospitals should enforce these same restrictions, proscribing
drug-company sponsorship of lunches, conferences, and travel for
house staff, and should also make it clear that accepting birthday
presents, Christmas gifts, or food and drink off the premises from
drug-company representatives violates the ethical norms of the
profession.
However fanciful, impractical, or misguided these suggestions may
seem, they make it clear that physicians have avoided the admittedly
tough question of how professionalism is to become more central to
their thinking and behavior. A general call to embrace the ethic may
be appealing and may even exert some influence in the long run, but
it is not sufficient to bring about substantial change in the near
future. Professionalism is too important for an exclusive reliance
on such tactics. An infusion of strength and relevance is needed. By
one means or another, professionalism must become a vital part of
American medicine today.
David J. Rothman, Ph.D.
Columbia University College of Physicians and Surgeons
New York, NY 10032
References
- Pellegrino ED,
Relman AS. Professional medical associations: ethical and practical
guidelines. JAMA 1999;282:984-986.[Medline]
- Swick HM, Szenas P, Danoff D,
Whitcomb ME. Teaching professionalism in undergraduate medical education.
JAMA 1999;282:830-832.[Medline]
- Ludmerer KM. Instilling
professionalism in medical education. JAMA 1999;282:881-882.[Medline]
- Sullivan WM. What is left of
professionalism after managed care? Hastings Cent Rep 1999;29:7-23.
- Wynia MK, Latham SR, Kao AC,
Berg JW, Emanuel LL. Medical professionalism in society. N Engl J Med
1998;341:1612-1616.
- Casalino LP. The unintended
consequences of measuring quality on the quality of medical care. N Engl J
Med 1999;341:1147-1150.[Full
Text]
- Rodwin MA. Medicine, money,
and morals: physicians' conflicts of interest. New York: Oxford University
Press, 1993.
- Derbyshire RC. How effective
is medical self-regulation? Law Hum Behav 1983;7:193-202.
- AAFP Foundation corporate
members. Bull Am Acad Fam Physicians 1995;10:4.
- Chren MM, Landefeld CS. Physicians'
behavior and their interactions with drug companies: a controlled study of
physicians who requested additions to a hospital drug formulary. JAMA
1994;271:684-689.[Medline]
- Cleary PD, Edgman-Levitan S.
Health care quality: incorporating consumer perspectives. JAMA
1997;278:1608-1612.[Medline]
- Kassirer JP. Our endangered
integrity -- it can only get worse. N Engl J Med 1997;336:1666-1667.[Full
Text]
- Eichenwald K, Kolata G.
Hidden interests — a special report: when physicians double as
entrepreneurs. New York Times. November 30, 1999:A1.
- Washington Representatives
(a directory of lobbyists and organizations) 1996, pursuant to 1995
Lobbying Disclosure Act (Public Law 104-65). The Center for Responsive
Politics maintains a file on each organization. (Or see: http://opensecrets.org/lobbyists/98lookup.htm.)
- American Academy of
Dermatology Web site. (See: http://www.
aad.org.)
- American Academy of
Ophthalmology Web site. (See: http://www.
eyenet.org.)
- American Academy of
Gastroenterology Web site. (See: http://www.
acg.gi.org.)
- Program and abstracts of the
32nd Annual Meeting of the American Society of Nephrology. Washington,
D.C.: American Society of Nephrology, 1999.
- Wazana A. Physicians and the
pharmaceutical industry: is a gift ever just a gift? JAMA 2000;283:373-380.[Medline]
|
|
|
|||||||||||||||||||||||||||||||||||
Related
Letters:
Medical Professionalism — Focusing
on the Real Issues
Hoskins H. D., Ruane T. J., Rothman D. J.
N Engl J Med 2000; 343:739-740, Sep 7, 2000. Correspondence
This article has been
cited by other articles:
- Hoskins, H. D., Ruane, T.
J., Rothman, D. J. (2000). Medical Professionalism -- Focusing on the Real
Issues. N Engl J Med 343: 739-740
[Full Text] - Smith, R. (2001).
Maintaining the integrity of the scientific record. BMJ 323:
588-588
[Full Text] - Angell, M. (2000). Is
Academic Medicine for Sale?. N Engl J Med 342: 1516-1518
[Full Text] - Wolfe, S. M. (2002). The
Destruction of Medicine by Market Forces: Teaching Acquiescence or
Resistance and Change?. Acad Med 77: 5-7
[Full Text] - Yarborough, M., Sharp, R. R.
(2002). Restoring and Preserving Trust in Biomedical Research. Acad
Med 77: 8-14
[Abstract] [Full Text]
|
HOME | SEARCH |
CURRENT ISSUE | PAST ISSUES | COLLECTIONS | HELP Comments
and questions? Please contact
us. The New England Journal of
Medicine is owned, published, and copyrighted © 2002 Massachusetts Medical Society. All rights
reserved. |
ALL
INFORMATION, DATA, AND MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR
GENERAL INFORMATION PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE
KNOWLEDGE OR OPINIONS OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED
AS PROVIDING MEDICAL OR LEGAL ADVICE. THE DECISION WHETHER OR NOT TO
VACCINATE IS AN IMPORTANT AND COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU
ALONE, IN CONSULTATION WITH YOUR HEALTH CARE PROVIDER.