Alliance Between Society and Medicine: Title and subTitle BreakThe Public's Stake in Medical Professionalism

In 2002, the American Board of Internal Medicine Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine published A Physician Charter: Medical Professionalism in the New Millennium, which articulated a set of professional responsibilities that physicians were considered honor-bound to fulfill.^{1 - 2} On close reading of the charter, it is clear that the institutional and organizational settings of contemporary medical practice pose significant impediments to achieving several of the responsibilities to be assumed by physicians. Moreover, many of those impediments are so deeply imbedded in all health care systems that they are beyond the control of physicians. Only those in a position to effect system-wide changes (eg, elected officials, ministers of heath) can eliminate these structural impediments. Consequently, if the public is to continue to enjoy the unique benefits that medical professionalism can offer, some form of a functional alliance between the medical profession and society (medical-societal alliance) is necessary.

This Commentary highlights those professional responsibilities called for by the charter that are achievable only in alliance with society and discusses the critical importance to the public of working closely with the medical profession to preserve professionalism among physicians.

Ensure that all members of society have access to a basic set of preventive and medical services.

Society has an abiding interest in having health care services available to all. The charter affirms that physicians must strive both individually and collectively to reduce barriers to equitable health care, eg, physicians must provide care to individuals who lack access to sufficient financial resources. In countries with large numbers of such individuals, it is unreasonable to expect individual physicians to carry a burden that rightfully rests with the broader community.

As a matter of principle, every country should ensure that all residents have ready access to a basic set of preventive and medical services. This requires the availability of adequate financial resources, sufficient numbers of trained health care professionals, and a systematic plan that embraces everyone. A medical-societal alliance is needed to define a minimally acceptable set of services and convince policy makers to fulfill this fundamental responsibility.

Provide the infrastructure necessary to foster improvement in the quality and safety of health care services.

Patients have a right to the safest achievable health care services of the highest possible quality. The charter affirms that physicians have key roles in advancing the quality of health care and in reducing medical errors. However, much of what is required lies outside the control of individual physicians or the medical profession. Some of the most promising opportunities for quality improvement reside within the infrastructure underpinning the complex systems in which modern health care is rendered globally.³

For example, access to accurate measurements of health care outcomes is essential for identifying opportunities for improvement and for crafting appropriate interventions. Modern clinical information systems have the ability to fulfill this purpose but require broad agreement on data standards to ensure interoperability and on privacy laws to ensure access to relevant patient information. Such infrastructure needs are best defined by an effective medical-societal alliance.

Construct and maintain a medical liability system that encourages wide dissemination of lessons learned from medical errors.

Individuals seeking medical attention have a right to know the truth about their condition and any adverse occurrences in the course of their care. The charter affirms that physicians must be honest with patients, including acknowledging mistakes. In some countries, however, a seemingly unbridled legal system frequently sanctions clinicians for mistakes occurring in the course of patient care, even when the mistake is the consequence of failure of the complex system to provide adequate safeguards. In these circumstances clinicians are often reluctant to report mistakes. As a consequence, numerous opportunities for improving patient safety and reducing medical errors are lost.

Legal systems determined to find fault also have the unwelcome effect of encouraging physicians to practice defensive medicine in an attempt to avoid lawsuits. The result is unwarranted risk and added costs from unneeded tests and procedures.⁴

A medical-societal alliance is needed to advocate a medical liability system without perverse incentives and to protect the right of injured patients to fair compensation. At the same time, the liability system must foster frank discussion of medical errors and wide dissemination of lessons learned so that proper steps can be taken to prevent recurrences.

Align payment system with professional values and performance.

Society is best served by physicians who consistently place the needs of patients before self-interest. In recognition of this reality, the charter's core principle affirms that professionalism entails a commitment by physicians to place patients' interests first. But even with the best intentions, physicians cannot be expected to abjure self-interest when the economic circumstances in which they function provide overpowering incentives to attend to their own welfare.

For instance, in health systems in which physician compensation is significantly below that of other professionals or well below average for their level of education and expertise, physicians may be hard pressed to avoid activities that can enhance their income even when those activities are not in their patients' best interests. Some systems offer such tantalizing financial rewards for discretionary services that physicians are tempted to perform tests and procedures that patients may not need Similarly, some systems offer physicians large financial rewards for controlling expenditures to the point that patients are put at risk of substandard or inadequate care.

Recognizing these dangers, the profession has a dual obligation: to bolster the commitment of individual physicians to the fundamental values of professionalism and sanction those who fail to adhere to those values, and to work with the public to ensure that payment systems do not provide incentives for physicians to behave unprofessionally. Payment systems that offer physicians financial inducements for providing fewer necessary or more medically unnecessary services can confront physicians with unreasonable temptations to violate their commitment to patient welfare.⁵

Government and private purchasers of health care services have a legitimate right to provide financial incentives for physicians to render care of the highest possible quality for the lowest possible cost. A medical-societal alliance is best suited to find the right balance between proper incentives for physicians to optimize their performance and improper temptations for physicians to act contrary to their patients' interest.

For those arrangements that include financial rewards for physician performance, a medical-societal alliance is also best suited to ensure that payers use reasonable and validated measures of quality and cost-effectiveness in establishing payment mechanisms that promote professionalism and patient-centered care.

Provide adequate support for the education and training of physicians.

Most countries recognize the social good from having a highly educated, well-trained, and socially diverse cadre of physicians. Given the cost and length of medical education, few aspiring physicians can afford to bear the full financial burden of their own education and training. Accordingly, governmental support has generally been provided for medical schools and teaching hospitals to encourage qualified students to pursue a medical career. However, as educational institutions experience mounting financial pressures, and as students accumulate mounting educational debt, a medical-societal alliance is needed to advocate adequate governmental support for both predoctoral and postdoctoral medical education.^{6 - 7}

The interests of society are served best by physicians who are not only well-trained but who also remain highly skilled throughout their careers. Thus, the charter affirms that physicians and the profession must be committed to maintaining the knowledge and skills necessary to provide high-quality health care. In fulfilling this commitment, physicians must take personal responsibility for continuing medical education (CME) and must participate in credible periodic evaluation of their performance to demonstrate that they are competent to practice. Professional organizations, for their part, must establish and enforce high standards of performance for their members and be publicly accountable for those standards.

Provide adequate support for medical and health sciences research.

Society has a vital interest in continued scientific advancement to improve the quality and length of human life. The charter affirms that physicians have a duty to uphold scientific standards, promote research, and create new knowledge. Moreover, physicians have an obligation to use the best available scientific evidence in their practice. However, support for the basic research that underpins advances in medical science is beyond the capability of the medical profession alone and has long been recognized as a public responsibility. A medical-societal alliance is needed to advocate appropriate public investments in medical research and to ensure that scientific merit alone governs the allocation of public resources. The profession has an obligation to be accountable for these resources by ensuring that they are used wisely and in the best interest of the public.

Recognize and minimize opportunities for conflicts of interest.

Patients are best served when medical care is based on available scientific evidence. The charter affirms that physicians and the medical profession must oversee the integrity of scientific processes that create new knowledge and must ensure that available scientific information is properly incorporated into patient care.

Sophisticated commercial enterprises (eg, pharmaceutical companies, medical device manufacturers) have economic interests in promoting their products and services, both to physicians and directly to the public. As a consequence, innumerable opportunities exist for a commercial entity's interest in economic gain to conflict with the public's interest in scientific objectivity. Such conflicts have the potential to introduce bias and thereby compromise the integrity of information needed to ensure safe and effective medical care.

Notable examples of activities in which the involvement of individuals with conflicting interests can have an adverse effect on the delivery of sound medical care include (1) the design and conduct of CME programs, (2) the preparation of scientific reports for medical journals, (3) the development of guidelines purporting to convey the best available evidence for the diagnosis or treatment of disease, and (4) decisions about the safety and efficacy of new pharmaceutical agents and medical devices before release to the public.

The medical profession, through its various organized activities (eg, accrediting bodies, licensing authorities, specialty societies), has a responsibility to alert physicians to circumstances in which troubling conflicts of interest commonly arise, to monitor the adverse impact of conflicts of interest, to adopt policies and procedures to manage such conflicts effectively, and to ensure public accountability of their oversight activities.⁸ However, given the damage to public trust that can stem from unbridled conflicts of interest, appropriate laws (eg, restricting self-referrals) and regulations (eg, requiring investigators to disclose financial relationships with research sponsors) are required to bolster the efforts of the profession. A medical-societal alliance is needed to advocate a balance of government and professional oversight to minimize the adverse consequences of conflicts of interest.

Importance of an effective medical-societal alliance.

Virtually all countries face significant challenges in providing appropriate preventive and medical services to their population. To meet these challenges, many if not most countries rely on a combination of government regulation, market forces, and an unwritten but crucial “social contract” with their physicians. The term “social contract” in this context describes the tacit understanding that permits physicians to receive a high degree of autonomy in their professional affairs in return for vowing to use their medical and scientific expertise solely to promote the interests of their patients and the welfare of the public.⁹ The term professionalism, the hallmark of which is the primacy of patient interest, connotes the means by which individual physicians fulfill the obligations implied by their social contract.

Society has a keen interest in fostering medical professionalism. Physicians who are committed to the tenets of professionalism, and hence who choose as a matter of principle to subordinate their self-interest to their patients' welfare, provide patients and the public at large with the greatest assurance of safe, effective, and compassionate care. No regulatory scheme or marketplace arrangement has the potential to provide comparable assurance of high-quality, ethically sound health care. But many of the contemporary circumstances under which physicians practice, and over which they have limited or no control, frequently thwart their ability to fulfill their responsibilities to patients.

For this reason, a strong, purposeful medical-societal alliance is needed to address those features of the health care system that hinder the full expression of professionalism and that the medical profession alone cannot affect. Neither individual physicians nor the medical profession as a whole can guarantee universal access to care; establish the technological infrastructure and legal arrangements needed to support patient safety efforts and enable robust quality-improvement activities; provide the financial and policy conditions necessary for effective medical education and research; create a financing scheme for the health care system that supports evidence-based decision making and discourages waste; or fully safeguard patients from the damaging effects of conflicts of interest.

To be effective, the kind of working alliance envisioned must interrelate in some meaningful way with the country's policy and decision making apparatus. For example, a recognized entity is needed to convene the relevant stakeholders and to initiate the reforms the alliance eventually advocates. The primacy of public welfare, public accountability, and social justice are the principles that should animate the alliance's efforts. In some jurisdictions (eg, Great Britain, Canada), quasi-governmental medical councils already exist that could serve as a starting point for the envisioned partnership. In other jurisdictions (eg, the United States), no national forum exists to spawn the development of an effective medical-societal alliance.

Absent a functional forum to satisfy this need, it is incumbent on the leadership of the medical profession to convince key stakeholders and opinion leaders that an erosion of medical professionalism poses a major threat to the health of the public. Where no such forum exists, professional organizations must exert leadership to protect the public interest by mounting a coordinated effort to secure the establishment of an effective public-private entity tasked to foster medical professionalism. Even in circumstances for which a suitable forum does exist, a targeted dialogue between the medical profession and patient advocacy groups, government officials, business leaders, insurance executives, media outlets, and others will be necessary for the creation of an alliance with sufficient influence to effect needed changes.

The urgency of establishing a working medical-societal alliance cannot be overstated. If professionalism among physicians is not sustained, it is doubtful that its ethical norms, once lost, could ever be reestablished. The result would likely be a replacement of the traditional patient-physician relationship with one more characteristic of a purchaser-vendor transaction. Such devolution would leave society without adequate protection from the vicissitudes of 21st-century medicine and would leave patients without individualized care devoted to their best interest.