Category: Medical Professionalism;

Professionalism, the Invisible Hand, and a Necessary Reconfi… : Academic Medicine

Professionalism, the Invisible Hand, and a Necessary Reconfi… : Academic Medicine

Our third duty in the Charter on Medical Professionalism is to be good stewards of resources. This brief article makes the case for explicit and detailed education for medical students on this critical aspect of health care.

The first two months of medical school (with preexisting courses taxed to create this curricular space) will be devoted to the economics of care. This block will involve multiple pedagogical approaches from traditional didactics and problem-based learning to simulation and social networking. Instructors will range from topic experts to patients and members of the public whose lives are being bludgeoned by health costs. Preceptorships will be community based and will focus on student experiences in educating the public on the cost of both schooling and health care. Once this competency is mastered, students will begin to meet with patients upon discharge (clinic or hospital) to explain all charges. There will be no traditional “patient care” contact until students are fully able to decode and explain the highly cryptic billing statements that encumber patients. As students enter the biomedical side of their training, patient meetings will begin to add explanations of diagnoses and treatment options to those of cost. No student will be admitted to the care side of the educational continuum until he or she is fully able to explain to patients what has been done to them and why. As students move into residency training, they periodically will be shifted from their clinical responsibilities into the discharge process to recheck on their decoding and explaining competencies. National boards will reflect this new mandate. So, too, will CME requirements, which will include mandatory credits in cost competency. Cost will be defined as a major burden of treatment, with “burden of treatment” a major reframing of how we conceptualize and approach health care.3

We seek to provide a system of training that will produce true patient-centered practitioners, a bona fide revolution in what it means to practice medicine, a physician workforce prepared to lead, and a true profession willing and able to regulate itself on behalf of the public.

Medical Professionalism Charter Principles | ABIM Foundation

Medical Professionalism Charter Principles | ABIM Foundation:

Principles of the Charter

The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. The three fundamental principles below are a guide to understanding physicians’ professional responsibilities to individual patients and society as a whole. 1. Primacy of Patient Welfare 2. Patient Autonomy 3.Social Justice

Primacy of Patient Welfare
The principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.

Patient Autonomy
Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.

Social Justice
The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

We talk a lot about professional responsibilities within the medical profession. I think the first two principles of patient welfare and autonomy are uncontroversial (though not always easy!).

The last one, social justice, is just as critical, and I would argue largely uncontroversial around the world both within the medical profession and in societies as a whole. Only in America is this principle questioned, and only in a vocal and politically powerful segment of the population.

I think many physicians, especially our conservative fellow physicians, would be surprised (and disappointed) that every major medical organization in the US (and globally), and almost certainly their own specialty organization, have already endorsed the Charter, warts – social justice in their view – and all!

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Parsimony & Medicine

[This is cross-posted on Doctors for America’s Progress Notes and DailyKos.]
I wasn’t planning on writing about rationing of health care again, since we covered it in my last post prompted by Don Berwick’s resignation from CMS.
But two stories came up recently that prompt me to do it again. The American College of Physicians released their revised Ethics Manual this week, and included language regarding the use of cost effectiveness as a criteria for providing care, and even urged parsimony by physicians. In an accompanying editorial, Ezekiel Emanuel, lauds the ACP for this language, noting the physician’s obligation to society as a whole, and not just to individual patients. (As we noted last time, the Charter on Medical Professionalism  and the AMA Code of Ethics emphasize the physician’s duty to social justice in the distribution of finite health care resources.)
All well and good, but NPR did a story on the Manual, and out it came. Scott Gottlieb, MD, of the American Enterprise Institute noted the general acceptance of cost effectiveness data in medical decision making, but then followed up that parsimony “really implies that care should be withheld. There’s no definition of parsimonious that I know of that doesn’t imply some kind of negative connotation in terms of being stingy about how you allocate something.” (The definition I linked to above notes that parsimony can mean simply being careful with money or stingy.)
Daniel Callahan of the Hastings institute also got the vapors: “If you say certain things will not be cost-effective, they’re not worth the money, well that’s rationing, particularly if some patients might benefit or simply some might desire it whether they benefit or not, whether it benefits them or not. So that’s where this all becomes a real viper’s pit.”
As we noted previously, America rations health care ruthlessly, largely by income and inability to pay (yes, I know that’s a link to an NPR story), but also on quality of insurance, most acutely with private health insurance and Medicaid. I won’t run through all of this again, please reread the last post for the details, but I cannot help but find it exasperating that supposedly knowledgeable people, like Gottlieb and Callahan, act as if utilizing cost effectiveness strategies necessarily means “withholding care,” and, by extension, that all care, effective or not, cost-effective or not, is beneficial.
But more irksome is the implication that we don’t ration now, and that this new, threatened “rationing,” is somehow anathema to America. Which brings me to the second story that came up this past week, concerning money troubles in the British NHS and a regression in some areas to longer waiting times for certain procedures. The NHS had done quite a bit to repair their reputation and significantly shorten waiting times, but are apparently losing ground due to governmental austerity measures that (surprise!) actually effect people in real life. I noticed that conservative web site Townhall.com covered the story as an indictment of all health care, all over the world (and, of course, missing the irony that conservative austerity measures were the source of the problem). I pointed out over there with a flurry of comments that we’re not so hot on this score ourselves, but also noted that Germany and France, in particular, provide health care for all, far more frugally (parsimoniously, even) than we do, and have no waiting times, no significant rationing of services compared to us. We remain the only industrialized nation that thinks nothing of rationing health care – and I mean this more literally than usual – as many of us give no thought to those struggling and suffering and dying for health care.
A country that displays an almost ruthless commitment to efficiency and performance in every aspect of its economy–a country that switched to Japanese cars the moment they were more reliable, and to Chinese T shirts the moment they were five cents cheaper–has loyally  stuck with a health-care system that leaves its citizenry pulling out their teeth  with pliers. 
                    – Malcolm Gladwell, The Moral Hazard Myth

To Fix Health Care, Help the Poor – NYTimes.com

To Fix Health Care, Help the Poor – NYTimes.com:

IT’S common knowledge that the United States spends more than any other country on health care but still ranks in the bottom half of industrialized countries in outcomes like life expectancy and infant mortality. Why are these other countries beating us if we spend so much more? The truth is that we may not be spending more — it all depends on what you count.

In our comparative study of 30 industrialized countries, published earlier this year in the journal BMJ Quality and Safety, we broadened the scope of traditional health care industry analyses to include spending on social services, like rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support and other services that can extend and improve life.

We studied 10 years’ worth of data and found that if you counted the combined investment in health care and social services, the United States no longer spent the most money — far from it. In 2005, for example, the United States devoted only 29 percent of gross domestic product to health and social services combined, while countries like Sweden, France, the Netherlands, Belgium and Denmark dedicated 33 percent to 38 percent of their G.D.P. to the combination. We came in 10th.

What’s more, America is one of only three industrialized countries to spend the majority of its health and social services budget on health care itself. For every dollar we spend on health care, we spend an additional 90 cents on social services. In our peer countries, for every dollar spent on health care, an additional $2 is spent on social services. So not only are we spending less, we’re allocating our resources disproportionately on health care.

Our study found that countries with high health care spending relative to social spending had lower life expectancy and higher infant mortality than countries that favored social spending. While the stagnating life expectancy in the United States remains at 78 years, in many European countries it has leapt to well over 80 years, and several countries boast infant mortality rates approximately half of ours. In a national survey conducted by the Robert Wood Johnson Foundation, four out of five physicians agreed that unmet social needs led directly to worse health.

It is also well understood in the public health communities that health has far more to do with overall poverty than access to health care, per se. But we have this hard headed approach in America to “punish” the “undeserving” poor. Therefore we shoot ourselves in the foot economically in order to feel better about our “values.”
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The painful side effects of Obama’s healthcare reform – Los Angeles Times

The painful side effects of Obama’s healthcare reform – Los Angeles Times:

“Now, I’m well aware that having 47 million people who can’t afford medical care is a genuine social problem — although many of those millions are illegal immigrants, people between jobs and young folks who choose to go insurance-bare. I’m also aware that I can’t necessarily have everything I want, whether it’s a dozen pairs of Prada boots or a pacemaker at age 99. I know that Medicare is on the greased rails to a train wreck, and not just because of spiraling costs but because doctors are fleeing the system because they’re sick of below-cost reimbursements and crushing paperwork. There are ways to solve some of these problems: healthcare tax breaks, malpractice reform that would lower the cost of practicing medicine, efforts to make it easier to get cheap, high-deductible catastrophic coverage, steps to encourage fee-for-service arrangements of the kind that most people have with their dentists.

“In short, as someone who’s not getting any younger, I’d like to be the one who makes the ‘difficult decision’ as to whether I can afford — and thus really want — that hip replacement in my extreme old age. Sorry, President Obama, but I don’t want ‘society’– that is, government mucky-mucks — determining that I’ve got to go sit on an ice floe just because I’m old and kind of ugly, no matter how many fancy degrees in medicine or bioethics they might have.”

Nothing like folksy wisdom for understanding and dealing with the complexities of health care reform and modern bioethics. The usual right wing disinformation and misdirection are especially tiresome. So, to the rebuttal:

First pillar of fear mongering on health care reform: rationing. Be afraid, be very afraid. Ignore the rationing (by income and economic class) that’s already going on. Ignore rationing by private health insurers. Ignore spiraling costs that will soon have all but the top tiers of income earners on shoe-string insurance plans. Forget all that, just worry about the potential for rationing.

The point of Ms. Allen’s piece is that health care will be rationed by using arbitrary clinical parameters to deny care based solely upon costs. Or, she also warns, that some procedures will be denied based upon scientific, non-arbitrary clinical parameters, specifically along the lines of England’s National Institute for Health and Clinical Excellence which publishes guidelines and does medical and economic analyses of medical treatments to determine whether they are worth it to individuals and to society as a whole. I’m sure Ms. Allen finds it infuriating that some all other societies consider how utilization of finite resources affects everyone, not just the well off.

Interesting thing, that concept of “allocating scarce resources.” It is actually one of the centerpieces of medical professionalism developed by the American Board of Internal Medicine, the American College of Physicians and the European Federation of Internal Medicine and adopted by the American Medical Association and many other physician organizations. The Charter states, “The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.”

This brings up fear mongering pillar two, always frame the debate as a choice between our current “system” or, the systems of either Canada or England, two countries that, while providing universal health care, because of their parsimony, have performed in international health care outcomes research almost as badly as does the United States! It seems genuinely ludicrous (but convenient for generating insecurity among the under-informed) to set as the benchmark for improving our health care system two countries who only do a bit better than we do. I have yet to see an opinion piece from a conservative decrying the inferior care and long wait times in France or Germany, the top performing countries in the world. That’s because they provide excellent care to all of their citizens, have no longer waiting times than our own, have much more satisfied physicians and patients and do it all at a sizeable discount to ours.

Another classic tactic is blaming the poor, the unhealthy, the “other.” On one hand, Ms. Allen laments the imposition of the 47 million uninsured onto our system, and forecasts that it will lead to unacceptable waiting times for those of us already “in.” A few paragraphs later she notes her understanding of the seriousness of the issue of the uninsured, but then posits that many of these 47 million don’t really need or deserve health care insurance as they are illegal immigrants or between jobs, etc. My brother was nearly bankrupted by being “between jobs” and having an illness in his family.

Back to our story. Ms. Allen makes a troubling conflation by muddling together limiting the amount we spend on health care in the last months of life with limiting health care to the elderly. There is a HUGE difference.

Ms. Allen cites the example of the hip fracture treatment President Obama’s grandmother received before her death and the pacemaker placed into the 99 year old mother of a town hall audience member as cautionary tales, indicating the “government run” healthcare would allow these patients to simply die because some intellectual, academic physicians in their ivory towers will give the thumbs down sign and demand their euthanasia. How sad that the public’s opinion of physicians and medical professionalism has deteriorated so badly that this is their expectation. Or, if not their expectation, but their cynical gambit that others will think this rings true.

Here’s the difference: Obama’s grandmother was terminally ill with cancer. The questions surrounding her surgery boiled down to whether it would improve her comfort in her last months and whether the surgery would ultimately shorten her life. As it turns out, it appears to have done both, making this a difficult case to slice down the middle as black and white. That’s why decisions like this cause ethical dilemmas: there are pros and cons to the decisions. There are sometimes non-operative decisions involving immobilization, aggressive pain management and other palliative measures that avoid the pain Mr. Obama was rightly concerned about. And sometimes these measures, especially in extremely frail elderly patients, are the right measures, because they avoid the very high mortality associated with surgery and other aggressive measures in this population.

The medical team, had they made the decision not to operate, would not have been bureaucrats determined to painfully end the life of an elderly cancer patient, but a compassionate team of professionals, balancing the patient’s quality of life in her last months (pain, hospitalization, removal from family and home, etc.), with her wishes and goals – perhaps to see her grandson elected President! When we strive to provide excellent end-of-life care, we balance all of these issues and we counsel our patients and their families as best we can because it is the right thing to do, not because it saves money. We would do it if it cost more: that is apparently the decision arrived at in this case. The calculation was made, as it should always be, based on the goals of the patient and family, not on a corporate balance sheet and potential executive bonus.

The second case, of the 99 year old requiring a pacemaker, is actually not much of an ethical problem. I agree with President Obama that these decisions should not be made based on “spirit,” but they certainly can be made based upon clinical guidelines and the individual patient’s health status. Regardless of this woman’s spirit, if she was a frail 99 year old with advanced chronic heart or lung disease, or with advanced dementia and a feeding tube for nourishment, one would be hard pressed to justify placing an expensive pacemaker or defibrillator into her, but a healthy 99 year old is another matter. It is important to note that Medicare did not deny either of these patients care, as a private insurer may have.

The other inappropriate conflation is the issue of limiting the amount we spend with limiting the amount we spend on treatments without proven benefits or with benefits so limited as to make them frivolous in most senses. If we presume that any guideline that determines a treatment not useful to be rationing, we will be in a world of economic hurt. This is actually the point of Comparative Effectiveness Research (CER), to try to figure out what we do that is costly but adds no value to patient care on one extreme, and figuring out what is relatively inexpensive and saves lives on the other.

Her assessment of the inherent inferiority of screening mammograms every three years compared to annually demonstrates precisely the need for CER: The automatic assumption that more testing means better outcomes. This is actually one of the bigger problems with American medicine, the automatic assumption that doing something, and not just something, but the newest latest most expensive something, is always best. Should the 99 year old patient get the latest greatest pacemaker? Maybe, but having some CER to help us make intelligent judgments should be lauded, not reflexively ridiculed by the anti-intelligentsia.

Update: a link to this item on my dailykos diary and a lively discussion.

AMNews: June 29, 2009. AMA meeting: AMA reaffirms stance in health system reform debate … American Medical News

AMNews: June 29, 2009. AMA meeting: AMA reaffirms stance in health system reform debate … American Medical News:

“Chicago — Addressing what has become the hottest flashpoint in this year’s health system reform debate, the American Medical Association House of Delegates at its Annual Meeting in June renewed its existing reform policies rather than declare a position on whether lawmakers should establish a new national federal health insurance plan that would compete with private insurers.

“Delegates agreed that the AMA should ‘support health system reform alternatives that are consistent with AMA principles of pluralism, freedom of choice, freedom of practice and universal access for patients.’

“Both supporters and opponents of the public plan concept wanted the Association to take a definitive stand on the issue. But after AMA Immediate Past President Nancy H. Nielsen, MD, PhD, warned that such a move could handicap the organization as it tries to influence the health reform debate, delegates backed away from those resolutions.

“Dr. Nielsen said the resolution that ultimately passed would allow her and AMA President J. James Rohack, MD, to keep the AMA engaged in the debate without restriction but with a clear directive to advocate for choice for both physicians and patients.”

An encouraging sign for progressives at the AMA House of Delegates. I am pleased to be wrong in expecting the conservatives to win the day and the resolution that passed gives wiggle room to the AMA leadership.

It is worth pointing out that there will be much struggle throughout this process. AMA policy language stands largely against any reforms leading to any expanded role for government in health care and specifically declares that an “Unfair concentration of market power of payers is detrimental to patients and physicians,” and labels single payer as such and calls for continued opposition by the AMA.

Interestingly enough, however, the AMA has endorsed the principles of Medical Professionalism of the ABIM, ACP-ASIM and European Federation of Medicine. This Charter unequivocally advocates the physicians role in promoting social justice, fair distribution of finite resources and promoting fair access to care.

I am sure my conservative colleagues would argue that this can all be achieved by a more libertarian/Randian approach to health care, but I think, finally, that the number who believe that is growing smaller by the week.

Certainly polls indicate that most physicians now recognize that our system is broken and that the cure is not rearranging the deck chairs on this sinking ship and clinging to a heyday that hasn’t offered us or our patients much “hey.”

Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker

Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker:

A damning look by Atul Gawande at the way we pay for medical care in America. The final three paragraphs of this must read article.

“Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.

“In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen’s lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ ”

“As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.”

I went to the Dartmouth Atlas web site myself and found this interesting tid-bit:



I think it fits in well with the ethos described in Gawande’s article.

It is much easier to continue aggressive treatment rather than spend time having an honest discussion about the benefits and burdens of continuing treatment.


Thanks to whoever put the link up on the Howard Dean Webinar tonight!



UPDATE: This recent Archives of Internal Medicine article is particularly apporpriate:
http://archinte.ama-assn.org/cgi/content/short/169/10/954

This also, perversely, can make the hospital statistics in mortality look good, as well. As an intensivist, I can get almost ANYONE out of the the ICU and subsequently out of the hospital if I ignore the true outcome for the patient and the family: additional suffering, minimal prolongation of a life at its end, and so on.

My colleagues who do practice best EOL practices know that our ICU and hospital mortality numbers suffer, but I have no doubt that having honest discussions with my patients and families is the right thing to do. You may have heard this for your patients, “Thanks for the straight talk, Doc,” or “Nobody talked to me about my prognosis before.”

Of course, this is not new information, but we still need to do better as physicians:http://www.chestjournal.org/content/128/1/465.full?ck=nck

Arch Intern Med — Abstract: Discussions With Physicians About Hospice Among Patients With Metastatic Lung Cancer, May 25, 2009, Huskamp et al. 169 (10): 954

Arch Intern Med — Abstract: Discussions With Physicians About Hospice Among Patients With Metastatic Lung Cancer, May 25, 2009, Huskamp et al. 169 (10): 954:

“Background Many terminally ill patients enroll in hospice only in the final days before death or not at all. Discussing hospice with a health care provider could increase awareness of hospice and possibly result in earlier use.

“Methods We used data on 1517 patients diagnosed as having stage IV lung cancer from a multiregional study. We estimated logistic regression models for the probability that a patient discussed hospice with a physician or other health care provider before an interview 4 to 7 months after diagnosis as reported by either the patient or surrogate or documented in the medical record.

“Results Half (53%) of the patients had discussed hospice with a provider. Patients who were black, Hispanic, non-English speaking, married or living with a partner, Medicaid beneficiaries, or had received chemotherapy were less likely to have discussed hospice. Only 53% of individuals who died within 2 months after the interview had discussed hospice, and rates were lower among those who lived longer. Patients who reported that they expected to live less than 2 years had much higher rates of discussion than those expecting to live longer. Patients reporting the most severe pain or dyspnea were no more likely to have discussed hospice than those reporting less severe or no symptoms. A third of patients who reported discussing do-not-resuscitate preferences with a physician had also discussed hospice.

“Conclusions Many patients diagnosed as having metastatic lung cancer had not discussed hospice with a provider within 4 to 7 months after diagnosis. Increased communication with physicians could address patients’ lack of awareness about hospice and misunderstandings about prognosis.”

First, having these conversations with patients is the right thing to do for a multitude of reasons, not the least of which is our duty to help our patients weigh the benefits and burdens of medical treatment. The reduction of unwarranted suffering is hard to over estimate.

Second, imagine the economic impact of doing the right thing. No rationing, just having the appropriate conversations with our terminally ill patients.

Art Caplan Lecture – Society of Critical Care Medicine

SCCM – Society of Critical Care Medicine:
“Max Weil Honorary Lecture
Arthur Caplan, MD
University of Pennsylvania
Philadelphia, Pennsylvania, USA
Beyond Band-Aids: How to Cure America’s Ailing Healthcare System
Arthur Caplan, MD, argued that the United States healthcare system is broken, and it is important to evaluate the various healthcare reform proposals and their political feasibility. Healthcare professionals should have a prominent place in the discussion to ensure ethical and meaningful reforms.”

Dr. Caplan spent the bulk of his time making the ethical case for healthcare reform. He based his argument on the right to opportunity, or equal opportunity, of all citizens to be free from the encumbrances of illnesses untreated due to lack of personal resources or lack of resources from our social safety net.

Fair enough, but I think this argument will fall flat, of course, to those who oppose health care reform of any stripe, but I think it rings peculiarly hollow to most others as well, including the most fevered advocates for reform.

I will be flagging my ignorance of formal ethics and bioethics here, as I am, like most, simply an amateur (but nonetheless opinionated) ethicist. (But, I am an intensivist, so maybe I am semi-pro?)
I think in addressing health care professionals, it is reasonable to appeal to their professionalism. In the Charter on Medical Professionalism, we are called to advocate for Social Justice:

“Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category. “

And this argument does need to be made to specialty physician organizations. Repeatedly. Many of our organizations have devolved into glorified trade organizations, only springing into action when income or clinical territory are threatened. We need to call ourselves and our colleagues to the better angels of our nature.

But this is really only the tip of the iceberg required to make the ethical case for universal healthcare. The real case rests on our common humanity, our common respect for the dignity of man, The Golden Rule.

A recent program aired on Bill Moyers Journal called “Beyond Our Differences”, which explored the common themes of all world religions. It is a terrific program and I advise everyone to watch it, preferably with your family.

Is there a moral philosophy on the planet that does not require us to care for the least among us? Is there one which does not require us to care for the poor, the sick, the hungry to the best of our ability? Is there one that does not require us to respect the dignity of our fellow humans?

I like to joke that there is such a philosophy, Ayn Rand’s Objectivism. Maybe there are other philisophical schools of thought that also reject these tenets, I will let the real philosophers out there correct me. But all religions, east and west, and secular humanism all carry forward this strong ethical mandate. As I look through my “Social Justice” subject tag, quite a lot are covered: Catholics and the Jesuits, Charles Dickens (and Protestants and humanists), physicians, Jews, and even the self-intersted. The “Beyond Our Differences” program covers these and more.

So, how to make the ethical argument? I think we must rely on our common humanity, our common philosphy of honoring the dignity of our fellow humans and doing our duty as citizens of a great country to “promote the general Welfare”.

But better yet, let me sum it up as Uwe Reinhardt would, “Go explain to your God why you cannot do this, and he will laugh at you.”

Medical Professionalism in the New Millennium: A Physician Charter — Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine* 136 (3): 243 — Annals of Internal Medicine

Social Justice and a commitment to a fair distribution of finite resources has always been a core of who we are as physicians and as human beings. With the renewed emphasis on professionalism in medicine, it is being reintroduced as part of the core of our values as physicians. This is very welcome, but does not sit so well with some of our more conservative colleagues, as you’ll see below.

Medical Professionalism in the New Millennium: A Physician Charter — Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine* 136 (3): 243 — Annals of Internal Medicine:

“Fundamental Principles:

“Principle of primacy of patient welfare. This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician–patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.

“Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.

“Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category. “

In the next section, A Set of Professional Responsibilities:

“Commitment to improving access to care. Medical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.

“Commitment to a just distribution of finite resources. While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one’s patients to avoidable harm and expense but also diminishes the resources available for others.”

Response Letter in Annals of Internal Medicine, by Christopher Lyons, in part:

“In the charter’s preamble, the concept of medicine’s contract with society is discussed. To a large extent, the obligations of physicians to society in that contract are nicely laid out in the subsequent discussion. Given that a contract is usually created between two parties and each party has an obligation to the other, what is society’s responsibility to physicians? As highly trained, caring members of society, aren’t physicians entitled to certain assurances of financial stability? Should we be expected to withstand ongoing efforts to politicize the health care industry in attempts to garner votes while balancing the federal budget? Must we continue to withstand repeated attacks from trial attorneys who have little interest in the facts of a medical case and are interested only in the payoff? “

Another, by Jerome Arnett, in whole:

“I read with interest the article on medical professionalism in the new millennium (1), which proposed a new code of conduct for physicians comprising three principles and 10 responsibilities. As a proposed code of ethics, the charter is untenable for several reasons. Two of the three principles conflict. Patient welfare is predicated on individual rights while social justice is based on group rights (those of “society”). Since individual rights and group rights are mutually exclusive, the physician can follow one of these two principles but not both (2). In addition, at least 2 of the 10 responsibilities (public advocacy and just distribution of finite resources) place the interests of others ahead of those of the patient. Physicians will be less likely to subscribe to an ethical code that does not have the welfare of the patient as its highest objective.

“Equality of outcome is an undesirable and unattainable vision that invariably results in the loss of patients’ rights. Only under socialism (government medicine or corporate socialized medicine) are health care resources finite, so that they must be rationed or justly distributed. Under other circumstances, the provision of services”necessary” or “unnecessary”to one patient does not diminish the resources available for others.

“The commitment to maintaining trust by managing conflicts of interest forbids physicians to pursue private gain or personal advantage. How then is it ethical for a group of physicians such as the Medical Professionalism Project to weaken our code of ethics in order to promote a political agenda (improving “the health care system for the welfare of society,” promoting “the fair distribution of health care resources,” or ensuring social justice)? These proposed changes in our time-honored, patient-centered ethics will worsen, not improve, the dilemma of today’s physicians, who already are challenged by new technology, changing market forces, problems in health care delivery, bioterrorism, and globalization. But even more ominous, medicine without effective, patient-centered ethics is no longer a profession but merely a tradewhich was its status in ancient Greece before the Oath of Hippocrates.

Reference number 2 is:
2. Vazsonyi B. America’s 30 Years War: Who Is Winning? Washington, DC: Regnery; 1998:79.

Two of the authors, Drs. Cruess and Cruess, reply, very diplomatically:
“IN RESPONSE:

“Although Dr. Arnett’s points are well taken, the charter is not a code of ethics, nor is it intended to detract from or supplant the Hippocratic tradition that has long enriched medicine’s history. It is a statement of contemporary responsibilities—medicine’s understanding of its obligations under today’s social contract. We strongly disagree that individual rights and group rights are mutually exclusive and that “the physician can follow one of these two principles but not both.” We do not underestimate the difficulty of reconciling the two sets of responsibilities but believe passionately that medicine must attempt to do so. The alternative is for someone without medical knowledge or expertise to determine the societal rights in health care and how they are to be reconciled with the rights of individual patients. Do we really wish this to occur, or do we believe that it is better for individual physicians and their organizations to use their expertise to try to achieve the proper balance? The charter suggests the latter course. It does, however, state that physicians must put the welfare of the individual patient first, thus reaffirming our traditional fiduciary responsibilities. Our duties to individual patients must be carried out with a knowledge of the impact of our own decisions on the wider society, which we also serve. We also disagree that the allocation of resources to one patient does not diminish the resources available to others under a market-driven system. The attempts at cost containment seen throughout the world, no matter what the nature or structure of the health care system, indicate that this is not true. There is no question that contemporary physicians are expected to serve both their patients and society.

“A second point of some importance refers to “equality of outcome.” We are not sure that equality of outcome can be termed “undesirable,” as Dr. Arnett stated, but certainly such an objective is unrealistic. Nowhere does the charter advocate equality of outcome as an objective.

“Dr. Arnett interprets the charter as forbidding physicians’ pursuit of private gain or personal advantage. Nowhere does it so state. The conflicts of interest section states that physicians must deal with these conflicts in an open and transparent way. We cannot eliminate conflicts of interest, but we must ensure that our integrity is preserved as we cope with and manage them and recognize the consequences of our decisions.

“We agree with Dr. Arnett that without effective patient-centered ethics, medicine is no longer a profession. As already mentioned, the charter is not a code of ethics but a freely given statement of medicine’s commitments and responsibilities, essentially outlining where we should stand in complex times. It is aimed at restoring the feeling of pride in the profession and public trust that all observers have agreed is so essential to the proper functioning of a profession and distinguishes it from a trade.”