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What can physicians do to regain the public's trust?

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

By Munsey S. Wheby, FACP

Are physicians trustworthy? While that may seem like an impertinent question, it has gotten me thinking about professionalism in a new light.

I first heard the question posed last June at an AMA meeting during a presentation by Rosemary Stevens, PhD, professor emerita of health policy at the University of Pennsylvania. In a compelling presentation, Dr. Stevens described the medical profession's current predicament. She questioned whether public trust in our profession will continue to decline, or if we can restore this trust and grow it anew.

One of her main messages: The outcome rests not so much with the public as with us.

Eroded trust

In March, I had the opportunity to revisit the theme of rebuilding public trust at the 2003 AMA Presidents' Forum. AMA president Yank D. Coble Jr., MACP, asked me to plan one of the sessions. I chose the topic of public trust and professionalism.

Leaders from many medical organizations, including national specialty societies and state and county medical associations, gathered to discuss issues affecting physicians. An especially popular topic was the threats facing medical professionalism.

Jordan J. Cohen, MACP, president of the Association of American Medical Colleges, set the tone for our discussion. He examined the erosion of public trust in many areas of our society, particularly in the wake of scandals involving publicly traded corporations, the accounting profession and the Roman Catholic Church.

Surveys show that patients have not lost trust in their individual physicians, Dr. Cohen pointed out. Most patients still believe their own physicians act in their best interests.

Nevertheless, medicine today encompasses more than patient-physician relationships. It has become a complicated industry in which many interests converge and financial concerns loom large on all fronts. Physicians' behavior in this larger arena has hurt the public trust, Dr. Cohen said.

Managed care organizations seeking to control health care costs have routinely used financial incentives to get physicians to limit patient access to services. At the same time, many physicians have fought valiantly for their patients, sometimes resorting to ethically dubious subterfuge to convince health plans to approve lifesaving treatments.

Such scenarios raise eyebrows among our patients. Already wary of physician self-interest, they further lose faith in us when they hear new reports about physicians' incompetence, greed, arrogance and deception about conflicts of interest.

According to Dr. Cohen, our only real means of repairing and preventing further damage to public trust is to renew our commitment to professionalism. In doing so, he said, we can assure the public that their well-being is medicine's foremost concern.

He issued a sobering challenge to our profession: If we are to merit and maintain public trust, we must keep our concern for society ahead of our concerns about the profession and personal gain.

A positive response

How should we respond when professional lapses come to light? Hazle S. Konerding, MD, president of the Medical Society of Virginia, offered a specific example of how her organization used a media attack on physician self-regulation to make needed changes in the profession.

Two leading Virginia newspapers published a series of articles alleging that the profession failed to remove from practice some physicians accused of practicing incompetently and egregiously harming patients. The state legislature soon began considering reforms that would have gutted the state's peer-review process in hospitals.

The state medical society responded by meeting with the newspaper publishers, members of the state legislature, state medical board leaders and the state governor's staff. During these meetings, Dr. Konerding didn't try to defend or excuse the physicians whose obvious problems had garnered all the attention. Instead, she focused on physicians' professional obligation to regulate and discipline themselves.

By emphasizing the medical profession's commitment to patient welfare and safety, Dr. Konerding said, she helped the newspaper publishers better understand medicine's position. The tactic eventually won over some legislators as well.

In the end, the state medical society was able to work with the state legislature to draft a bill that allowed the state medical board to exercise discipline more effectively.

Taking initiative

Dr. Konerding's story had a good outcome, but it highlights the fact that as a profession, we're often in a position of reacting to problems after the fact. We need to take more initiative to build and maintain professionalism among our ranks.

The profession has taken an important, proactive step in that direction by developing a document known as the charter on medical professionalism. I spoke at the AMA forum about this document, which was created to serve as a framework for understanding professionalism.

The Medical Professionalism Project, a joint effort of the ACP Foundation, the ABIM Foundation and the European Federation of Internal Medicine, drafted the charter, which was published in the Feb. 5, 2002, Annals of Internal Medicine. To date, more than 70 national and international medical organizations have endorsed it.

The charter's preamble states that professionalism is the foundation of medicine's contract with society. The charter lists the primacy of patient welfare as one of its fundamental principles, stating clearly that physicians' primary responsibility is to their patients.

The patient-physician covenant published in the May 17, 1995, Journal of the American Medical Association voices a similar commitment. It says, "We believe the medical profession must reaffirm the primacy of its obligation through national, state and local professional societies; academic, research, and hospital organizations; and especially through personal behavior. Only by caring and advocating for the patient can the integrity of our profession be affirmed."

Simply put, valuing service to others over personal reward is something we must never compromise, as difficult as it may sometimes be. As John A. Benson, MACP, former president of the American Board of Internal Medicine, has noted, "Evolving and often transitory financial and delivery arrangements in health care can and do perturb these convictions, but must not subvert them."

After discussing the charter at the presidents' forum, I used my closing remarks to call on the attending leaders to promote discussion of the charter and commitment to its spirit. After all, the charter is a call to action. It should and will arouse debate, which we hope will help physicians better understand and accept it.

Welcoming different points of view about the charter, Faith T. Fitzgerald, MACP, former Governor of ACP's Northern California Chapter, observed, "We hope abrasive opinions polish rather than lacerate one another."

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