Charter on medical professionalism addresses issues of finite resources
From the July 2001 ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.
By Phyllis Maguire
Your patient is sitting on the examining table, listening to you outline treatment options. As you help her decide how to proceed, do you think of the resources she’ll need as part of a finite pool? Do you consider how her individual care may affect the medical resources available to society at large?
According to a new charter on physician professionalism, that’s exactly the kind of inner dialogue physicians should engage in when caring for patients. The document, which was created by a team of American and European internists, tackles physicians’ responsibilities in some of medicine’s most sensitive areas, including disclosing medical errors and conflicts of interest.
The charter, which is scheduled for release later this year, affirms many principles that medicine has embraced for years, such as the primacy of patient welfare and the need to end racial and sexual discrimination in patient care. But its discussion of physicians’ duty to consider limited medical resources is already sparking debate among the handful of physicians who have seen the document.
Crisis in professionalism?
The Physician Charter on Medical Professionalism is the product of the Medical Professionalism Project (www.professionalism.org), a collaborative effort of the ACP–ASIM Foundation, the American Board of Internal Medicine Foundation and the European Federation of Internal Medicine (EFIM). (The EFIM includes internal medicine societies from more than 20 European countries.)
When the project first got underway in 1999, project members decided physicians needed a document that focused on the challenges and responsibilities of the profession. The driving force behind the charter was “a strong sense of professional crisis,” said Walter J. McDonald, FACP, the College’s Executive Vice President and Chief Executive Officer. “Professionalism is more threatened now than at any time since I graduated from medical school 35 years ago.”
Dr. McDonald, who participated in the project on behalf of the ACP–ASIM Foundation, listed several of those threats. Rapidly changing health care delivery systems have brought radical changes to physician autonomy. Physicians must now cope with a shrinking base of medical reimbursements and a growing arsenal of medical technology. And they are increasingly confronted by financial conflicts of interest that can undermine research and skew therapeutic guidelines.
Perhaps more importantly, Dr. McDonald said, discussions of professionalism often take a back seat to other pressing concerns. Physicians now are so busy trying to keep up with new clinical information and administrative hassles that they often do not have time to think about the larger responsibilities of their profession.
U.S. physicians aren’t the only ones experiencing these pressures. Project members said that they were struck by how these same threats are being played out worldwide, even in countries with government-sponsored health care systems.
“The challenges that we feel here are common to virtually all countries around the world today,” explained project member Robert B. Copeland, MACP, former Chair of the College’s Board of Regents and Chair of the ACP–ASIM Foundation Board of Trustees. “There is an increasing mismatch between the legitimate needs of patients and the resources available to them, whether those resources are determined by the government or the insurance industry.”
Social justice and finite resources
The new charter is far from medicine’s first attempt to grapple with professionalism. The College’s “Ethics Manual” (www.acponline.org/ethics/ethicman.htm) and the AMA’s “Code of Medical Ethics” (www.ama-assn.org/ama/pub/category/2503.html) address many professionalism issues. The charter, however, is the first document in decades that focuses exclusively on challenges to physician professionalism, a topic that many view as a subset of medical ethics.
The charter states that professionalism needs to be founded on the primacy of patient welfare and on social justice, including the fair distribution of health care resources. It also claims that physicians should advocate for just and adequate access for all patients; work to continuously improve the quality of clinical care; disclose and manage conflicts of interest; and promptly inform patients of medical mistakes.
While much of the language in the charter echoes the work of mainstream medical ethicists, its section on the just distribution of finite resources may prove to be controversial.
At press time, the draft of the charter said that while physicians must meet the individual needs of their patients, they must also “be aware that the decisions they make about individual patients have an impact on the resources available to others.” While the charter’s section on finite resources concludes that physicians must scrupulously avoid unnecessary tests and procedures, a position that few would dispute, some physicians wonder how the document will play out in practice.
At the Annual Session presentation where a draft of the charter was presented, for example, several physicians like William S. Aronstein, FACP, spoke out against the idea. In subsequent interviews, Dr. Aronstein said he supports the charter’s commitment to social justice and the fair distribution of health care resources. But he said that trying to juggle the care of individual patients with “finite resources” was an ethical contradiction. The worst case scenario, he said, would have individual physicians, not society, inconsistently deciding how to distribute medical resources.
“Trying to provide care while taking the needs of some abstract ‘society’ into account is no different from HMO medicine, where your job is to save money for the HMO,” he explained. Dr. Aronstein said that he left academic practice two years ago to do pharmaceutical research, in part to avoid the clinical constraints imposed by managed care. “When you introduce the concept of the cost to society, you confuse public health issues with individual medical care.”
Dr. Aronstein said he wondered whether the notion of balancing individual and public needs reflected input from European physicians, many of whom have learned to live with state systems that control the utilization of medical resources.
Troyen A. Brennan, FACP, JD, president of the Brigham and Women’s Physicians’ Organization in Boston and chair of the project, refuted that assumption. He explained that the problem of limited health care resources was just as apparent to the American physicians working on the project as their European colleagues.
“The sense that we’re not going to be able to do everything possible in every circumstance is widely evident in this country, as is the fact that cost constraints in health care will continue to exist,” Dr. Brennan said. He pointed out that as the baby boomer generation ages, health care costs in the United States are expected to skyrocket during the next 20 to 25 years, further straining resources.
Yet Dr. Aronstein said that considering finite resources while treating individual patients seems to work against the concept of social justice included elsewhere in the charter. He cited indigent patients, many of whom he used to treat in his former practice.
“Is it really cost effective to give them medical care at all?” he asked rhetorically. “They’re just going to be out on the street and not taking their medicines, so who do you think will be the first people cut out by this sort of analysis?” By having physicians consider clinical resources when treating individual patients, Dr. Aronstein said, the charter might actually victimize many of the groups it seeks to protect.
Not everyone at the Annual Session presentation opposed the idea of taking finite resources into account. Nephrologist Virginia L. Hood, FACP, who attended the presentation, said later that she agrees with the charter’s language on limited resources.
“Many conflicts arise in terms of how we distribute resources according to need, merit and the free market,” said Dr. Hood, Governor for the College’s Vermont Chapter and professor of medicine at the University of Vermont. “We’re dealing with all of those conflicts within the medical profession all the time, and I don’t think it hurts us to acknowledge that.”
Far from letting an awareness of limited resources lead to care rationing, Dr. Hood explained that she tries to openly draw patients into the decision-making process. “I point out the cost differences between a widely advertised drug and another one that’s cheaper but just as effective,” she said. The needs of individual patients and of the larger society may indeed clash, she continued, “but they can meld under some circumstances, and I think we have to find ways to make that happen.”
The economics of patient care
Discussions with some of internal medicine’s leading thinkers and ethicists echoed both concerns and support for the new charter.
Faith T. Fitzgerald, MACP, former Governor for the College’s Northern California Chapter and assistant dean of student affairs at University of California, Davis, pointed out that physicians must differentiate between two very different views of economics and care.
“One is, ‘How can I do this study or therapeusis in the most efficient way possible?’ ” she said. “The second and more pernicious question is, ‘Do I think this patient is worth it?’ ”
Physicians’ commitment to providing efficient care is “a laudatory goal and should be explicitly stated,” Dr. Fitzgerald continued. “Physicians can say, ‘This test is too expensive for the good it does.’ They cannot say, ‘This patient is too expensive for the good he does society.’ ”
Internist Daniel P. Sulmasy, ACP–ASIM Member, a member of the College’s Ethics and Human Rights Committee, pointed out that there is a major difference between using resources carefully and rationing at the bedside. While prudent stewardship of resources may save money, he said, it does not attempt to balance the needs of individual patients with the needs of society. Carefully considering resources is an ethical obligation of physicians because doing so is in the best interest of individual patients.
“Using only the number of treatments or diagnostic tests necessary helps avoid potential iatrogenic complications, and it is part of the physician’s traditional role of serving the patient,” said Dr. Sulmasy, who is chair of the ethics department at St. Vincent’s Hospital in New York and director of the Bioethics Institute of New York Medical College.
The litmus test of prudence, Dr. Sulmasy said, is whether or not treatments exemplify what he called “the inherent rationality of medicine” and whether a physician’s care is also just. “The essential aspect of justice is that similar patients are treated similarly across the board, not according to idiosyncratic judgments made at the bedside on how to allocate resources,” he pointed out.
But as the population ages and health care resources may become increasingly constrained, he continued, the decision of how to dole out resources will need to be made by society, not physicians.
“It’s not just up to me as a doctor to decide to limit the use of scarce medical resources,” he said. “It’s up to people in government, in industry and everyone else who has a stake. If we all agree that we can’t afford to give anyone PET scans and the rule applies fairly to everyone, then I will be able to act in the best interest of my patients within those parameters.”
Distributing the document
Even as they debate its content, most physicians agree that the charter provides a forum to discuss the issues they face in practice today. To promote that discussion, project members want to give the charter as wide a distribution as possible.
In addition to presenting at Annual Session, project members discussed the charter with European physicians at a May meeting of the EFIM in Edinburgh, Scotland. At press time, project members were still incorporating physicians’ comments from both meetings into the final version of the document.
The College’s Board of Regents is expected to consider the charter for endorsement. During the next year, project members plan to present the document to other medical societies in North America and Europe for consideration.
The professionalism project wants to inform the public about the charter by networking with consumer groups and other philanthropies. And a large-scale international mailing will put the charter in the hands of medical students and residents.
Providing students with an explicit framework for considering professionalism is overdue, said Jordan J. Cohen, MACP, president of the Association of American Medical Colleges and a project member. “We have for too long assumed that students simply acquire an understanding of the norms of our profession through observing and working with role models,” he explained. He added that a declaration from both American and European physicians will send students and practicing physicians an important message.
“This is not just an abstract set of ideals from their own school or medical society,” he said. “It represents a very broad-based, longstanding tradition that is common across cultures.”
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