Sunday, June 28, 2009

David Rothman on Medical Professionalism

This summer I'm doing some writing on the ethics of medical professionalism. I reread an article by David Rothman, published in the New England Journal of Medicine in 2000. It stands up well nine years later and deserves attention today.

At a time of massive medical whining about managed care Rothman had the gumption to take medicine to the woodshed. Not only was managed care not the cause of the widespread concern about pallid professionalism - in large measure it was a response to failures of professionalism, especially failures in self regulation, advocacy for appropriate use of medical resources, and addressing multiple financial conflicts of interest.

Rothman made a series of recommendations for promoting more robust professionalism. They stand up well nine years later. And, happily, there's been some progress. What follows is Rothman's recommendations, followed by my comments in bold italics:

1. "Professional and board-certifying societies could require rather than recommend standards of behavior, including service. One could imagine that, like continuing medical education, service to vulnerable groups of people would be required to maintain certification."

To the best of my knowledge this hasn't been done at the post graduate level. But in interviewing residency applicants, the degree of community involvements of this kind on the part of medical students from all over the country appears to increase each year. Many high schools require specified levels of community service as a condition of graduation. (My oldest grandchild set off today to do a week of trail work for the Appalachian Mountain Club. He might have done it anyway, but the high school requirement was a useful prod!) Our specialty societies should do the same.

2. "Professional associations could form alliances with consumer groups to accomplish goals that neither can realize separately."

This is happening in good ways, but also in ways that have been corrupted. As a positive example, the American Psychiatric Association has formed a strong affiliation with the National Alliance on Mental Illness. The two groups work closely to promote services for people with serious mental disorders, lobby for legislation, combat stigma, and more.

Unfortunately, but not surprisingly, alliances with consumers have been co opted to advance commercial interests, most notably by vendors of drugs, devices, and specialized treatments, who provide financial support to "AstroTurf groups" (pseudo grass roots movements) who then express "consumer demand" for their sponsor's services.

3. "The medical school and residency curriculum should be altered, not only by including lectures on professionalism, but also by inculcating the skills necessary to promote it."

There have been some truly remarkable steps forward in medical education, organized around recognition that the "informal curriculum" (the messages delivered in unspoken ways by the organization's culture) is at least as powerful as what is said in class. As one example, Indiana University School of Medicine has conducted a carefully thought out, broad-based approach to changing its culture in ways that promote ethical professionalism in faculty behavior and student learning. If you're interested in the details you can read a full description here.

4. "Medicine in its organized capacity must encourage and protect whistle-blowers, so that the profession is not so dependent on outsiders to identify and publicize problems."

There has been more progress in this sphere than Rothman probably anticipated, but it's in large part due to the burgeoning of the blogosphere, not to any steps taken by organized medicine. As examples, blogs like Health Care Renewal, Hooked: Ethics, Medicine and Pharma, and The Carlat Psychiatry Blog (accessible by links from this blog), are written by physicians who regularly use their whistles to call attention to failures of professionalism.

5. "Professional societies, medical schools, and teaching hospitals should adopt policies to minimize the influence of pharmaceutical companies and their representatives."

The pace of change here has been dizzying. Several states have passed laws sharply curtailing physician-drug company interactions. Medical schools all over the country have prohibited students and residents from taking drug company gifts and eating Pharma provided pizza.

The concept of medical professionalism came under extensive attack in the last three decades of the 20th century as a rationalization for the promotion of guild self-interest. Leaders in the profession - in the U.S. and Europe - responded by convening expert groups to articulate professional ideals in new ways, as in "Medical Professionalism in the New Millennium: A Physician Charter." Rothman challenged the health professions to put their noble words more fully into action. There's been some real progress since he threw down the gauntlet!

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