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!


Dan said...

Nearly half of the budget of the APA comes from big pharma, who I believe are promoting unnecessary psychotropic drugs.

Same with NAMI and their budget. Both budget sources are not publically disclosed.

What also is not disclosed is that NAMI, and other perceived non-profit support groups are essentially front groups for their budget sources.

CHADD and NAMI, for example, do disease state screenings upon direction of their pharmaceutical sponsors- arguably for diseases and disorders that do not require pharmacological intervention.

Psychiatrists receive the most cash from the pharmaceutical industry.

The DSM-V is being created right now. The secrecy is allowed with the creation of this very powerful manual, instead of the transparency that is needed to protect the health of the public.

Most who are responsible for the creation of the next DSM have financial incentives from psychotropic big pharma, and coerced directives from the APA, who dictates the creation of the APA.

All toxic forces such as these likely cloud the judgement of those responsible for creating the next DSM,

Dan Abshear

Jim Sabin said...

Hi Dan -

Thanks for your fiery comment!

I don't go as far as you do in your critique of/wariness about the APA and NAMI, but critics like you play an important role, holding organizational feet to the critical fire!

If you look under the psychiatric ethics heading in this blog you'll see that I've been rather critical of my own professional organization (the APA). I hope I'm not being too optimistic in saying that I think the criticism - internal to the APA and from the outside - is having an effect. The organization is weaning itself from depending on Pharma support. There's much more awareness of conflict of interest. From public officials like Senator Grassley to private individuals like Dr. Danny Carlat there's been a steady, and healthy, stream of critical attention. It's important to keep that stream flowing!

Keep up your own good work!



eric said...

Jim--Point one brings out the crank in me. In my opinion, I served by doing my job. In my last job, a third of the time that I spent in direct patient care was not compensated. Same for my private practice, which I had to close. I was the final common pathway for a lot of poor and sick patients, who required a lot of extra help to cope with the system of care. Furthermore, one of my best teachers had to close his practice for similar reasons. He and his wife worked in their home office. Their family practice was the only doctor's office on their peninsula. They provided clothes for some and food for others. They set bones, did minor surgery, and gave high-quality life-cycle care. Medicare and other third party payors didn't see the "value" of their "service," so they had to leave.--Eric

Jim Sabin said...

Hi Eric -

As always, it's good to hear from you!

Your comment brings out a problem with the kind of advocacy Rothman is conducting - it is vulnerable to offending the choir and to being ingnored by those to whom it is directed.

The kind of practice you and your teacher did is just the kind of socially responsible activity that Rothman wants to encourage. Rothman would want to use these practices as exemplars of what the profession should foster. He would go on to challenge organized medicine by saying something like - "how can you claim to be an ethically responsible profession when you allow high end specialties to earn as much as they do and allow socially responsible physicians to be driven out of business? Don't ask for more money for our bloated system - redistribute what we're already spending!"

Our payment system is a disgrace!