The College's roots as a vital foundation for its future
As the largest medical specialty organization in the United States, ACP is one of the most successful and influential organizations in American medicine.
However, the College and internal medicine are both confronting external and internal forces that promise to transform health care. In the face of these challenges, it may be worthwhile to explore the foundations not only of the "College of Physicians," but also of the medical profession.
Understanding the roots of the term "physician," the origins of medical ethics and the history of the "College of Physicians" can inform our current efforts to revitalize internal medicine and help ACP meet the health care challenges of the 21st century.
Ancient roots of "physician"
The term "physician" dates from antiquity and antedates its usage in England to designate an elite class of non-surgical medical scientists. It is derived from the Greek word physikos, which means "natural" or "according to the laws of nature."
The ancient Greeks included both biological sciences and medicine in their view of natural sciences. Physikos encompassed the teaching of the natural sciences, including medicine, and its practitioners were designated as physicians.
Our modern understanding of the role of medicine and of the physician's role in society has been derived largely from the mythic traditions of the Greek physician-hero/physician-god of medicine, Asklepios (or Aesculapius) and his priestly followers. Many of the "priests" who followed Asklepios were essentially physicians who practiced healing in the temple. They included the ancient physicians Galen and Hippocrates.
In the Asklepian tradition, Hippocrates introduced many of the original tenets of medical ethics, including beneficence, altruism, relief of suffering, integrity, honesty and respect for patient autonomy.
The Asklepian principles of equally serving princes, slaves and paupers—without regard to personal risk, self-interest or financial gain—form the foundation of our contemporary expectations of the medical profession.
Defining a "College of Physicians"
The American College of Physicians was modeled on the Royal College of Physicians of London.
The Royal College was chartered in 1518. Sir Max Rosenheim, in the May 1986 Annals of Internal Medicine, quoted from Sir George Clark's history of the Royal College on that first College's purpose: "it was a vocational body, charged with the repression of unqualified practitioners, with examining and licensing those who wished to practice, and with some kind of supervision over medicines. It set high ethical and intellectual standards for its members."
The Royal College helped establish a physician elite by granting fellowship only to licentiates who earned a medical degree from the universities of Oxford or Cambridge. In early England, the prestige of "Physicians" exceeded that of "Surgeons," whose early status was less than that of the Barber-Surgeons.
Prescribing medicine to be taken "internally" was the sole privilege of physicians. The Royal College held the power to grant licenses to practice, allowing it to protect physicians' professional prerogatives against incursion by apothecaries or surgeons. The designation of the Royal College of Physicians as the standard setter for medical practice established the distinction between "Physicians" (with a capital "P") and "Surgeons," which continues in the United Kingdom to this day.
Our American beginnings
In 1913, Heinrich Stern, MD, a prominent New York physician, attended a meeting of London's Royal College. After observing the educational and professional impact of the Royal College, Dr. Stern was convinced that American physicians needed a similar organization to help raise the standards and ideals of American medicine.
In 1915, he helped form ACP (which was first called the American Congress of Internal Medicine). At the time, ACP was envisioned as the counterpart of the Royal College, providing leadership in medical education and clinical quality assurance, and protecting the public from incompetent, untrained practitioners.
The Royal College of Physicians was established because of the need for an organization dedicated to protecting the interests of the profession and the public. In the same tradition, the modern American College of Physicians is called on to assure the public that physicians continue to meet the highest academic and ethical standards.
What does this brief look back at the beginnings of the College and the specialty have to do with American medicine in 2004? First, it serves as a reminder that we are, first and foremost, "physicians" in the tradition of Asklepios and Hippocrates.
As "physicians," we are pledged to the immutable ideals—now known as "professionalism"—of our ancient progenitors. As a "College of Physicians," we are united by a tradition of academic excellence, of high clinical and scientific standards for our members, and of advocacy for internal medicine.
Like our early English counterparts, internists in the United States still need to define and regulate our specialty. Whether we are generalists, hospitalists or medical subspecialists, we must constantly demonstrate to each of our patients and to the public at large that we are committed to the traditional medical ethos that distinguishes the healing professions from all others.
In this way, we may restore the public's trust in physicians and develop the political will to implement substantive changes in health care and health care financing.
An historical perspective also serves as a reminder that Colleges of Physicians also protect the interests of our profession and of internal medicine, even as we, once again, attempt to redefine our specialty. What distinguishes internal medicine's role in primary care, in the care of complex disease and in the management of chronic disease? What is the relationship of general internal medicine to its related subspecialties?
How do we resolve pragmatic issues such as practice hassles, administrative burdens and declining reimbursement? And how do we design more effective approaches to training future "doctors for adults"?
'Looking back reminds us that, throughout its history, internal medicine has confronted ambiguity and conflict, but has prospered nonetheless.'
Looking back also reminds us that, throughout its history, internal medicine has confronted ambiguity and conflict, but it has prospered nevertheless. The success of ACP within the medical profession has been strengthened by the mix of generalists and subspecialists.
The College has been enriched by a continuing quest for consensus of purpose and mission, in a turbulent and changing environment. Perhaps we can learn from the lessons of the past as we respond to society's demands to improve patient safety, enhance the quality of health care and reduce racial and ethnic health disparities.
We must also address forces put in play by the marketplace, government regulations and political realities, while adjusting to advances in technology and the human genome. And we must contend with the continuous interweaving of old and recurring themes: primary care versus consultants, generalism versus specialism, internal medicine as an elite versus a democratic profession.
In the October 1986 Annals of Internal Medicine, medical historian Rosemary A. Stevens, PhD, pointed out that internal medicine has long been characterized by intrinsic inconsistencies.
However, she offered four reasons for preserving internal medicine. Those reasons, which I list here, also form a compelling basis for the continued vitality of the College:
Internal medicine has long served as the conscience of the medical profession.
There is a need for organizations that can encompass all medical points of view, from primary through tertiary care.
With the growing incidence of chronic disease and major surgery, the internist's role as arbitrator between the patient and other physicians is becoming more necessary and compelling.
Internists have experience in dealing with uncertainty and a history of willingness to change.
Keeping these reasons in mind, Sir William Osler's advice in his essay, "Internal Medicine as a Vocation," in "Aequanimitas," is worth remembering: "bear without reproach the good old name physician, in contradistinction to general practitioners, surgeons, obstetricians and gynecologists. I have heard the fear expressed that in this country the sphere of the physician proper is becoming more and more restricted, and perhaps this is true; but I maintain ... that the opportunities are still great, that the harvest truly plenteous and the labors scarcely sufficient to meet the demand."
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