Medical professionalism faces new challenges, opportunities

For many of us, the start of a new year provides an opportunity for self-reflection and to set new goals to improve our personal lives. The new year is also a good time to look at our professional lives.

Medical professionalism is the basis of our profession's contract with society. The privilege of professional status with the opportunity for self-regulation comes with the obligation to provide care for the sick and maintain high professional standards. The core of this contract is trust, which is critical because the practice of medicine involves investigation and treatment of physical and mental conditions that are often fraught with fear, anxiety and doubt, and many decisions are made in the face of uncertainty. Medical professionalism is the set of values, behaviors and relationships that helps us maintain this trust.

In 2002, the ACP Foundation, the American Board of Internal Medicine Foundation and the European Federation of Internal Medicine developed a physician charter to confront the health care challenges of a new millennium and to reaffirm the importance of medical professionalism. As well as restating the principles of “primacy of patient welfare, patient autonomy and social justice,” it outlined a set of professional responsibilities. It emphasized commitments to professional competence, improved quality and access to care, patient confidentiality and respect, just distribution of finite resources, integrity and use of scientific knowledge and management of conflicts of interest.

Since then, 130 organizations worldwide have endorsed the physician charter. Ten years after it was published, as medicine faces challenges that threaten the professional ideal, the tenets of medical professionalism are more necessary than ever.

Challenges to medical professionalism permeate all areas of medicine. An increased demand for services, fewer physicians providing comprehensive coordinated services, an aging population and more chronic disease threaten the provision of altruistic care. Such forces can lead to denial of care to the sick and poor.

Changing market forces such as profit-centered systems of care can lead to deselection of patients, overtreatment of other patients and use of high-cost technologies and treatments, all of which contribute to increasing health care costs. Undervaluing cognitive services compared to procedures can decrease respect for those who provide the former.

The primacy of patient welfare is challenged by an increase in the treatment of patients by multiple clinicians, resulting in a fragmentation of overall responsibility as each one focuses on limited aspects of care.

The physician-centered challenges are also varied. Maintaining knowledge competency is an ordeal, with more than 6,000 new articles published every day in the English medical literature. New technologies and treatments appear without clear guidelines or information on comparative effectiveness. Electronic medical records provide an enormous amount of unsorted information, often without appropriate patient context. Institutions and insurers require ever increasing amounts of information to process payments and assess performance. The ingoing and outgoing information physicians must process is so overwhelming that it threatens a sense of control and stems the capacity to focus on improving patient well-being.

Increased patient autonomy and access to information are undeniably beneficial, as patients want and need shared decision making, but can challenge the physician's monopoly on knowledge and the mystique of a learned profession. Decreasing membership in professional societies, where collegiality helped reinforce professional identity and maintain standards, tends to undermine a collective sense of obligation.

However, with these challenges come opportunities to strengthen medical professionalism's influence in shaping policy and practices that can promote better patient outcomes, as well as better experiences for patients and physicians.

As internists, we are skilled at education and persuasion. We must use these attributes to give our patients what they need for shared decision making (autonomy), also emphasizing their shared responsibility. We must convince payers that they too should follow the tenets of medical professionalism as they share responsibility for patient outcomes. At a minimum, they must provide physicians with the needed infrastructure to support their work.

As we try to address inequities in distribution and stewardship of limited resources, we must consider cost, not to deny effective care but to ensure that we recommend care with proven value and avoid overuse and misuse. We are responsible to patients to provide safe and effective care and to society to conserve resources.

ACP is leading these efforts with support for the patient-centered medical home and neighborhood, development of rational performance measures and promotion of the high-value, cost-conscious care initiative. We have begun working with other professional organizations and consumer groups to promote these efforts but must continue to develop and strengthen partnerships with patients, payers, the public and policymakers.

A focus on medical professionalism will not solve all these problems. But if we

• remember to put patient interests above self-interest by providing patient-centered care,
• avoid unproven or harmful treatments, including overuse and misuse of high-cost diagnosis and therapies,
• teach our patients to share responsibility and become partners in shared decision making, and
• advocate for public health policies and programs that reduce disparities in health care access and receipt of quality health care.

We can use these values to influence health care policy and ensure that ethical, medical and economic factors will be appropriately considered in decisions about the best health care for individuals and populations. These efforts will go far toward reaching our personal and professional potential as we celebrate the 10th anniversary of the physician charter.