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Doctors struggle to balance professionalism with the pressures of everyday practice

As practice pressures build, physicians are looking for ways to do right by patient care

From the April ACP Observer, copyright 2003 by the American College of Physicians.

By Phyllis Maguire

Talk to Bruce C. Smith, FACP, about professionalism, and he'll absolutely agree with all the ideals of professionalism like putting patients first.

But instead of just talking about what it means to act professionally, the Washington state geriatrician did something about it. Frustrated at having to limit patient visits to 10 minutes and making frail patients come back for what were almost always incomplete encounters, Dr. Smith and his partners founded a clinic that eliminates many barriers to geriatric care—including revolving-door office visits.

Behind that change was Dr. Smith's sense of integrity. "Professionalism is my 'doctor's heart,' as opposed to my 'businessman's heart,' and I ignore it at my own peril," he said. "If we don't maintain our sense of integrity, we have nothing."

That assessment comes during what many say is medical professionalism's toughest hour. Media reports bristle with stories of physician work stoppages to protest rising malpractice premiums, the growth of "concierge" medicine and deadly medical errors.

At the same time, physicians squeezed by anemic reimbursements are struggling to balance the realities of onerous health plan contracts and slipping fees with their professional obligation to patients. And although they are determined to maintain their professional integrity, they say it is a challenge to live by the ideals of professionalism in the real world of medical practice.

Scrutiny and renewed commitment

For many in medicine, professionalism took on new urgency in 1999, when the Institute of Medicine released its now-famous report on medical errors. Almost overnight, the media put issues of professionalism—particularly those related to patient safety—squarely in the public eye.

Since then, the media has continued to probe physicians' professional integrity in other areas. Much of that attention has focused on conflicts of interest arising from financial incentives physicians may receive from drug companies and health plans.

The new level of heightened scrutiny is even showing up in the exam room. Vinod N. Velakaturi, ACP Member, a general internist with Jackson County Medical Group in Independence, Mo., for example, said that some patients have asked him point blank whether he gets any kind of kickback for prescribing a new medication.

"I'm always shocked," he said. "I tell them, 'In fact, my life is a lot easier if I don't have to give you a prescription.' "

As patients begin to scrutinize issues of professionalism, physicians are doing so as well. In California, Kwabena O.M. Adubofour, FACP, said that his view of professionalism—"doing the right thing for patients"—has led him to make simple but key changes in office systems to enhance patient safety. He now makes sure, for example, that weekly safety meetings include staff who track lab tests and referrals.

Doing the right thing for patients has also led Dr. Adubofour—a general internist and medical director for Fifth Street Medical Center in Stockton—to take a much stronger leadership role in reducing what he called "the traditional gap" between research findings and their clinical applications. As part of that effort, he started holding grand rounds in local hospitals to help primary care colleagues understand their role in preventing cardiovascular disease in diabetic patients.

But Dr. Adubofour's embrace of professionalism may be most apparent in his sustained social advocacy. Because his inner-city clinic serves predominantly Hispanic and Southeast Asian patients overwhelmed by diabetes and asthma, he has worked with colleagues to create more community resources that bolster their clinical efforts. Those resources helped recruit bilingual nurses to serve in the city and trained medical assistants in diabetes management.

"The concept of an individual practitioner in an individual office, secluded from what's happening on the societal level, does not work any longer," Dr. Adubofour said. "It is not enough for me to be at the clinical end of things without putting in place some community efforts at prevention." It is that commitment to advocacy, he added, that "perhaps sets us apart from other professionals."

'Office manager' medicine

For many physicians, however, the challenges threatening medical professionalism are more subtle and insidious.

In the Seattle area where Dr. Smith practices, the media have scrutinized professional issues surrounding "concierge" practices. But for Dr. Smith, the real threat is more pervasive: a health care system that rewards physicians and groups for limiting patient encounters to short, repeated office visits.

"When I was an employed physician, an office manager constantly told me, 'You can spend only 10 to 15 minutes with patients, and they'll have to come back next week to deal with another problem,' " Dr. Smith said. "But in geriatrics, when mom takes a while to get down the hall with her walker and is taking eight to 10 drugs, that just isn't right."

If he wanted to spend more time with his elderly patients, the office manager in the big multispecialty clinic where Dr. Smith used to work had an easy solution: He could pay for that time out of his own productivity bonus.

Rather than shrug off the dilemma as a system problem, Dr. Smith decided to find another business model. Four years ago, he and two colleagues approached a local hospital and proposed establishing a geriatrics-only clinic that the hospital would have to be willing to run at a loss. They also proposed that the hospital pay clinic physicians a premium over what they bill.

Fortunately for Dr. Smith, he and his partners found what he called "an enlightened hospital administrator," who approved the plan.

The solution to his professional dilemma is an example of doing well by doing good: By subsidizing the clinic, the community hospital gets a dedicated base of loyal patients. The other physicians on staff are pleased because they "can shuffle their Medicare patients off to the senior clinic, and not have them tying up their primary care offices," Dr. Smith said.

He now earns more than he did in his previous employed position. And he is delivering the kind of care his patients—whose average age is 83—need. The minimum clinic visit is 30 minutes, and patients receive extra support from social workers and pharmacy assistants.

"It's a much more satisfying practice," Dr. Smith said. "If you do it right medically but can't do it right business-wise, it's a lot more frustrating."

'Contract' with society

Dr. Smith is not alone in finding that professionalism needs the right practice environment to thrive. Certain elements of organized medicine, for example, are shifting their view of medical professionalism to look at how outside influences shape physicians' clinical and business decisions.

A good example is the Medical Professionalism Project, begun in 1999 as a joint effort of the ACP Foundation, the ABIM Foundation and the European Federation of Internal Medicine. The initiative produced a charter that outlined the key components of medical professionalism. (For more information, see "The professionalism charter defines ethical principles and responsibilities.")

The charter contains many tenets that have long been part of mainstream medical ethics, like putting patients' interests first. But some of its language—working toward the just distribution of finite health care resources, for instance—marked a significant departure from previous notions of professionalism.

And analysts say the charter represents a significant shift in thinking about how medical professionalism relates to society. "The charter speaks specifically of a 'contract' between medicine and society in a way that other codes of ethics have never done," said Daniel P. Sulmasy, FACP, a member of the College's Ethics and Human Rights Committee, chair of ethics at New York's St. Vincent's Hospital Manhattan and director of the Bioethics Institute of New York Medical College.

The traditional language of professionalism, Dr. Sulmasy explained, has typically been "covenantal." That kind of language describes a relationship based on trust between two parties who may be radically unequal, such as a desperately sick person and a physician who has the knowledge and capability to help.

A contract, on the other hand, indicates a relationship in which both parties have obligations. "Contracts imply equality, autonomy, independence and mutual self-interest," Dr. Sulmasy continued. "That's a different take on what it means to be professional."

Instead of portraying professionalism as the ability to hold oneself above the social and financial fray—a position physicians 50 years ago were very comfortable with—the charter views professionalism as one factor among interrelated social and market forces, said Walter J. McDonald, FACP, executive vice president (EVP) of the Council for Medical Specialty Societies and former EVP and Chief Executive Officer of the College. Dr. McDonald worked on the task force that drafted the charter.

"In that sense, the charter has broken new ground," Dr. McDonald said. "It outlines principles we should try to practice by. But the charter also implies that society is obligated to make sure we're able to do that as much as possible."

Tough choices

When physicians and the public see professionalism as a contract, what happens when society—or another profession that affects how physicians practice—doesn't live up to its end of the bargain? That's exactly the situation that troubles many internists when it comes to payment for their services.

The four physicians at McDuffie Medical Associates in Thomson, Ga., for instance, struggled to care for patients from an HMO that paid less than Medicare and hadn't raised its rates in four years. Like most payers, the HMO expected physicians to make up for bare-bones reimbursements by seeing more patients.

"It was an ethical dilemma," said Jacqueline W. Fincher, FACP, a general internist with the group. "We were running patients through like cattle, practicing medicine in a way that did not feel comfortable."

Last year, after some serious deliberation, the group decided to terminate the contract—even though the plan covered almost 20% of its patients. The physicians took a 5% pay cut for two quarters to offset the resulting shortfall.

Many of the HMO patients who had a choice of insurance products opted for a more expensive plan that let them stay with the practice. Others began paying out of pocket to use McDuffie as an out-of-network provider.

Other patients, however, had to part ways with the practice and were displeased with the physicians, Dr. Fincher recalled. "Still," she said, "leaving that HMO was an ethical, professional decision."

The group's physicians have also labored over whether to limit their number of Medicare and Medicaid patients. So far, they continue to see established patients once they turn 65, and they accept Medicare patients who are family members of established patients—but those days may be numbered. Each month, the group has to sit down and decide how many patients with public insurance it can add to the practice.

"Because we're in a rural area, we have a huge Medicare population," Dr. Fincher said. And in the South, she added, many patients have family who moved north but now want to retire closer to children—and see the same doctor as their family members.

"Limiting certain patient groups is not what we went into medicine to do," Dr. Fincher said, "but it's a reality of practice."

Continuing the debate

Many physicians staunchly defend their decision to limit patients from specific payer groups, saying they have an ethical obligation to do so. While individual patients may be turned away, they say, physicians would have to turn their backs on a much larger group of patients if their practices go under, if they move elsewhere to practice—or if they burn out, and quit practicing all together.

Part of the problem, Dr. McDonald pointed out, is that while physicians struggle with how to uphold their end of the professional contract, the other half of the equation—society's responsibilities—is less clear.

No one has ever defined society's responsibilities to physicians, he said. "Society has fulfilled its role by giving physicians rights that others don't have, like the right to pry into patients' personal lives."

Now, however, the issue of society's responsibilities warrants some attention. A case in point, Dr. McDonald said, is medical malpractice. Society as a whole needs to define reasonable malpractice awards and contingency fees instead of just letting physicians and trial attorneys duke it out.

One group that intends to analyze the societal setting for medical professionalism is the newly-established Institute of Medicine as a Profession. The group, which is funded by the Soros Foundation and located at the Columbia College of Physicians and Surgeons in New York, is studying how physicians put professional principles into practice. (See "Physician work stoppages: professional or not?")

"You can't talk about what medicine has to adhere to and think about without also spelling out what public policy has to adhere to as well," said David J. Rothman, PhD, an author and social historian of medicine who is president of the institute. In the same way that various groups now scrutinize policies for their impact on the environment or on gender representation, he said, "We need to start thinking about a 'professionalism impact' statement that addresses different reimbursement systems and other policies."

The Medical Professionalism Project, which drafted the professionalism charter, has initiated a new phase to explore how physicians implement principles of professionalism in their practice. The project plans to produce a series of case studies over the next year.

"We want to start talking about how the charter can address controversial issues," said Troyen A. Brennan, FACP, chair of the project, chair-elect of the American Board of Internal Medicine and professor of law and public health at Harvard School of Public Health. "We won't be able to bring these relatively high-altitude principles to life for practicing physicians if the discussion remains overly academic."

To bring those principles to life, project members want to focus on specific practice examples where professionalism comes into play. "As we get more specific, it becomes easier to debate professional issues," Dr. Brennan said. "And that debate will help renew our notions of professionalism."

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Physician work stoppages: professional or not?

Medical professionalism has become a much more visible issue largely because of growing physician advocacy on issues that affect their income. Physicians' attempts to draw attention to the medical liability insurance crisis have been particularly controversial.

While physicians agree they need tort reform, they disagree about what tactics to use to bring reforms about. Recent work stoppages by physicians in several states have elicited a range of opinions about whether such actions are warranted—and if they enhance or erode medical professionalism.

"Can you justify work stoppages?" asked Walter J. McDonald, FACP, the College's former Executive Vice President and a member of the task force that produced the Medical Professional Project's charter on professionalism. "In an ideal world, the answer is 'absolutely not,' but this isn't an ideal world, and principles can't be absolutes."

A case in point is what was billed as a one-day "strike" of several hundred physicians in Illinois in February to call attention to liability insurance problems. The Chicago-based AMA did not support the move, nor did the Illinois State Medical Society. Although the state medical society has endorsed past physician rallies on the issue, a society spokesperson said the group shied away from supporting a "strike" because the label has unprofessional implications.

Similar activities in other states have garnered the support of local organized medicine groups, but the efforts of the Florida Medical Association (FMA) perhaps underscore organized medicine's desire to tone down the rhetoric. While the FMA sponsored a weekday physician demonstration in the state capital to advocate tort reform in late March, it called the event a "rally" and urged medical staff and patients to participate as well.

These kinds of advocacy efforts enhance physicians' professionalism, according to an FMA spokesperson. "They teach physicians the need for political activism and the skills to speak with legislators," she said. "They also enhance professionalism by letting physicians have a dialogue with patients and legislators about issues that have an enormous impact on their ability to practice."

Vinod N. Velakaturi, ACP Member, a general internist in Independence, Mo., added that such tactics are certainly effective in helping the public understand physicians' frustrations. "The average patient used to look at [the liability insurance issue] as 'rich doctor vs. rich lawyer,' " he said. "Now they see it as 'rich doctor vs. rich lawyer, except I can't go see my doctor,' and that's made a tremendous difference."

But others are troubled by the direction of some advocacy efforts. Troyen A. Brennan, FACP, chair of the Medical Professionalism Project and professor of law and public health at Harvard School of Public Health, said he would prefer to see physicians broaden their demands for reform beyond just premium relief.

"I wish people would think about full reform, recognizing that we need to focus more on patient safety and appropriate compensation for people who have been injured," he said. "From a point of view of professionalism, we should advocate for significant reform in the way we deal with medical accidents, not just rolling back premiums."

And while Daniel P. Sulmasy, FACP, a member of the College's Ethics and Human Rights Committee, said he strongly endorses the need for physician advocacy, he does not believe the answer is work stoppages—which, at the very least, inconvenience patients. "Stoppages look like physicians are only out to protect their own incomes, instead of acting genuinely for patients as a political force," he said.

Dr. Sulmasy said he looks forward to the day when massive numbers of doctors demonstrate in Washington (on a Saturday, when they don't have office hours) to call attention to disparities in health care among racial groups, access problems in inner-city and rural areas, and inadequate support for the uninsured and undocumented.

"But apparently, the only thing that will mobilize us is tort reform," he added. While that mobilization gets the public's attention, he said, he does not believe it reflects well on the profession.

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The professionalism charter defines ethical principles and responsibilities

The Medical Professionalism Project's professionalism charter has received a robust international response. Soon to be translated into almost a dozen languages, the charter has been endorsed by more than 70 national and international medical organizations—including virtually all American professional societies and medical education associations.

Established in 1999, the Medical Professionalism Project—consisting of members of the international internal medicine community, including representatives of ACP and the American Board of Internal Medicine—set out to draft a charter that could serve as a framework for understanding professionalism.

Published in the Feb. 5, 2002, Annals of Internal Medicine, the charter claims medical professionalism is founded on three principles: primacy of patient welfare, patient autonomy and social justice.

The charter also identifies the following 10 professional responsibilities:
1. Commitment to professional competence;
2. Commitment to honesty with patients;
3. Commitment to patient confidentiality;
4. Commitment to maintaining appropriate relations with patients;
5. Commitment to improving quality of care;
6. Commitment to improving access to care;
7. Commitment to a just distribution of finite resources;
8. Commitment to scientific knowledge;
9. Commitment to maintaining trust by managing conflicts of interest; and
10. Commitment to professional responsibilities.

The charter is available online.

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