To unify internal medicine, look to professionalism
By Charles K. Francis, FACP
ACP's overarching goals have always emphasized high clinical standards, ethical ideals, education, advocacy, research and recognition of excellence. Recently, however, the College added a seventh goal to respond to recent developments that threaten the very fabric of our specialty. This newest goal calls for ACP to "unify the many voices of internal medicine and its subspecialties for the benefit of our patients, our members and our profession."
Modern American internal medicine evolved from the consultant-generalist ideal of the 1800s to encompass not only the general internist, but also academic internists, hospitalists, medical subspecialists, clinical investigators and basic researchers. More recent labels like gatekeeper, primary care provider and doctors for adults reflect the very central role that internists envision for their specialty.
However, market forces, technology and scientific advances have all created more narrowly defined functions for internists, threatening the traditional bonds between specialists and subspecialists. The best way to respond to these challenges is to unify the many voices of internal medicine.
Given the multiple roles played by internists and the fragmentation of the American health care system, what common themes can unite all of internal medicine? One solution may be to turn to the specialty's core values.
Professionalism is not subject to the vagaries of a payment system, market-driven policies or unprecedented scientific advances.
The Physician Charter on Medical Professionalism, created in 2002 by the ACP Foundation, the American Board of Internal Medicine Foundation and the European Federation of Internal medicine, outlined several "core values" of internal medicine that are embodied in the concept of professionalism.
The notion of professionalism is key to this discussion because professionalism is not subject to the vagaries of a dysfunctional payment system, market-driven health policies or unprecedented advances in biomedical science and technology. As a result, applying the principles of professionalism may give us the foundation we need to unify the specialty.
Moreover, professionalism serves as the foundation for the social contract we maintain with the public. It is therefore essential in building and maintaining public trust.
Here is an overview of the core values as outlined by the Physician Charter:
Patient welfare. Fundamental to professionalism is the primacy of patient welfare. While physicians face a dysfunctional payment system, practice hassles, spiraling medical liability costs and increasing demands from society, reaffirming our commitment to high quality care is a prerequisite to solving many of the problems facing internal medicine today. If we are ever going to forge the political will to change our health care system, the public must trust the integrity of individual internists.
Patient autonomy. The charter identifies respect for patient autonomy as a second fundamental core value.
As reliable health care information becomes increasingly available to the public, we need to help patients make more informed decisions about their care. Internists also need to learn to work with a growing number of cultures, races and ethnicities, and to become familiar with the role culture plays in medical decision-making. We need to appreciate the impact of different beliefs, attitudes (of both providers and patients) and health care-seeking behaviors.
Internists also need to gain knowledge of other cultures, become adept at assessing our patients' cultural beliefs and learn how to empower patients from different backgrounds to make health care decisions.
Social justice. Promoting social justice and the fair distribution of health care resources is the final fundamental principle of professionalism outlined in the Physician Charter.
The first two principles, primacy of patient welfare and commitment to patient autonomy, focus largely on the interaction between physicians and patients. The third principle, however, focuses on medicine's social contract, stressing the responsibility of the medical profession to promote social and distributive justice.
There is abundant evidence that racial, ethnic, cultural and socioeconomic disparities exist in access to care, health status and health outcomes. Internists should work to eliminate those inequities.
The Physician Charter identifies a set of professional responsibilities that have been adapted for internal medicine. The following responsibilities will not only help unite internal medicine as a specialty, but improve our overall system of health care.
Professional competence. Beginning with its roots in the Royal College of Physicians, internal medicine and ACP have been distinguished by a commitment to the highest intellectual standards and academic excellence. Internists should be exemplars of life-long learning, the maintenance of knowledge of the latest advances in the science and art of medicine, and the practice of the highest quality care.
Honesty with patients. Efficient and effective communication between patient and internist must be based upon honesty, trust and respect. We can help foster this trust by candidly discussing diagnostic and therapeutic outcomes, both favorable and unfavorable.
Patient confidentiality. In part because of recent federal regulations protecting the confidentiality of patient health information, internists must ensure the privacy of electronic medical records. And while this can be challenging, internists are best prepared to serve as leaders in "genetically informed medicine" and in translating new scientific insights (knowledge of the human genome, for example) into clinically applicable preventive, diagnostic and treatment modalities.
Doctor-patient relationships. Because of their dependence on physicians, patients are vulnerable to exploitation. As we are reminded by Hippocrates and the oath recited by new ACP Fellows, internists must not take advantage of patients for their own personal financial gain or private benefit.
Quality of care. Concerns about care quality have been fueled by reports on medical errors. Internists should work toward implementing evidence-based practice, improving reporting systems for errors and adverse events, and participating in continuous quality improvement initiatives.
Access to care. Lack of health insurance remains a problem for more than 40 million Americans. While most uninsured patients come from non-minority families with at least one member who works, low-income adults and minorities are more likely to lack insurance. Internists need to advocate for expanding coverage to low-income families to help reduce racial and ethnic disparities in access to care.
Distributing finite resources. Internists need to balance their concern for individual patients with a commitment to ensuring that resources are distributed equitably throughout society. We need to more effectively use information systems and avoid unnecessary tests and treatments, such as antibiotics for viral infections.
Scientific knowledge. As the specialty that spends a significant amount of time teaching medical students and training physician researchers (both clinical and basic), internal medicine has a responsibility to maintain the centrality of science and research in life-long learning and continuing professional development.
Conflicts of interest. Well-publicized concerns about errors and the quality of care have only reinforced the criticism that physicians and their professional organizations are more interested in their own well-being than the public good.
As a result, it is particularly important that internists avoid any perceived conflicts of interest. Relationships with industry and other for-profit entities should be "transparent" and free of conflict of interest or commitment.
Fulfilling the public trust
The medical profession has been given the trust and respect of the public because it places the public good above individual interest and advantage.
To truly function as professionals—and to unite the specialty—the various segments of internal medicine must come together to agree on a self-definition hat unifies all of internal medicine.
We need to establish specialty-wide standards for continued clinical competence. We need to assure the public, third-party payers, government agencies and policy-makers that physicians who call themselves internists not only have the appropriate training, but also meet the highest clinical, academic and personal standards.
Meeting these standards may not be easy, but it is the right thing to do. Internal medicine and its subspecialties are ideally positioned to play a prominent role in leading the medical profession to improve the health care system.
The core values and responsibilities outlined in the Physician Charter can help show us the way to improve U.S. health care—and unite the many branches of internal medicine.
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