The Blue Ridge Academic Health Group

Getting the Physician Right: Exceptional Health Professionalism for a New Era

Report 9 November 2005 Report 9 November 2005

Mission: The Blue Ridge Academic Health Group seeks to take a societal view of health and health care needs and The Blue Ridge Academic Health to identify recommendations for academic Group health centers (AHCs) to help create Getting the Physician Right: greater value for society. The Blue Ridge Exceptional Health Group also recommends public policies to Professionalism for a New Era enable AHCs to accomplish these ends. Members and participants Contents

Members Invited Participants Report 9: Getting the Physician Right Enriqueta C. Bond, PhD, President, Eric B. Larson, MD, MPH Introduction ...... 5 Burroughs Wellcome Fund University of Washington; What is Medical Professionalism? Jordan Cohen, MD, President Center for Health Studies, Group Health What is a medical professional? Cooperative, Seattle, WA Association of American Medical Colleges Part I . The Internal Challenge ...... 7 Catherine DeAngelis, MD, Editor in Chief, Afaf Meleis Understanding, Forming and Leveraging Teams 10 Journal of the American Medical Association Dean, School of Nursing University of Pennsylvania Moving in the right direction 11 Haile T. Debas, MD, Executive Director, Teams as Microsystems 12 Global Health Sciences Institute David P. Stephens, MD University of California, San Francisco VP, Clinical Care Improvement, Health Systems Professionalism 12 Association of American Medical Colleges *Don E. Detmer, MD, President and CEO, Models of Innovation 13 American Medical Informatics Association; John D. Stobo, MD I. Innovation in Team Medicine and Patient-Centered Care Professor Emeritus and Professor of Medical President, University of Texas Medical Branch II. Adoption at Galveston Education, University of Virginia Barriers to Change 14 Arthur Garson, Jr. MD, MPH, Vice President The Health care Financing/Payment/Reimbursement System and Dean, School of Medicine, University of Staff Inertia and Ingrained Practices Virginia Janet Waidner, Executive Administrative Conclusion, Part 1 15 Michael A. Geheb, MD, Senior Vice President for Assistant, Woodruff Health Sciences Center, Part I – Recommendations ...... 19 Clinical Programs, Oregon Health Sciences Emory University University Part II – The External Challenge ...... 19 Concerning medicine’s internal professional challenge *Michael M.E. Johns, MD, Executive Vice Editor President for Health Affairs; CEO and Director, What is the Value of Medical Professionalism? 13 Jonathan Saxton, MA, JD The Robert W. Woodruff Health Sciences Center, Special Assistant for Health Policy Societal Context 13 Emory University Woodruff Health Sciences Center, The “Exceptional” American Physician 13 Peter O. Kohler, MD, President Emory University Exceptional Economic Expansion 13 Oregon Health Sciences Center Physicians: Professionals or Simply Experts? 22 Jeffrey Koplan, MD, MPH, Vice President for Design The Need to reassert Medical Professionalism and Leadership 23 Academic Health Affairs, Emory University Peta Westmaas Design Inc. Exceptional Efforts 24 Lawrence Lewin, Executive Consultant Leadership is Key Steven Lipstein, President and CEO, BJC The Need for “Exceptional Medical Professionalism” 25 HealthCare, St. Louis Arthur Rubenstein, MBBCH, Dean and Part II – Recommendations ...... 26 Executive Vice President, University of Appendix 1. Medical Professionalism in the New Millennium: A Physician Charter ...... 27 Pennsylvania School of Medicine References ...... 29 George F. Sheldon, MD, Chairman and Professor, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill; Reproductions of this document may be made with written permission of The Robert W. Woodruff Health Sciences Center by contacting Janet Waidner, Woodruff Health Sciences Center, Emory University, 1440 Clifton Road, Suite 400, Atlanta, GA 30322. Phone: 404-778-3500. Fax: 404-778-3100. E-mail: Scholar in Residence, BurroughsWellcome Fund [email protected]. Getting the Physician Right: Exceptional Health Professionalism for a New Era is ninth in a series of reports produced by the Blue Ridge Steven A. Wartman, MD, PhD, President Academic Health Group. The recommendations and opinions expressed in this report represent those of the Blue Ridge Academic Health Group and are not Association of Academic Health Centers official positions of Emory University. This report is not intended to be relied on as a substitute for specific legal and business advice. Copyright 2005 by Emory University. *Co-Chairs Introduction in “Getting the Physician Right” for the evolving The Blue Ridge Academic Health Group Report 9 health care system. The Blue Ridge Group believes that, at the dawn The Blue Ridge Academic Health Group (Blue Ridge Group) studies and reports on of the 21st Century, given the pace of change and What is Medical Professionalism? issues of fundamental importance to improve our health care system and enhance the ability the increasing complexity of systems of clinical of the academic health center (AHC) to sustain optimal progress in health and health care care and health care technology, medical compe- To frame discussion of “getting the physician tency and medical professionalism in the United right,” it is important to understand what is through sound research—both basic and applied—and health professional education. Eight States require renewed definitions. These defini- medical professionalism. We start with a defini- previous reports have described opportunities to improve AHC performance in a changed tions need to recognize population approaches tion of professions drawn from a wide review of health care environment and to leverage AHC resources in achieving threshold improve- in addition to the traditional focus on the indi- the literature: ments in health system access, quality, and cost. The Blue Ridge Group has sought to provide vidual patient. While physicians and other health workers have become increasingly sophisticated “A profession . . . is an occupation that regulates guidance to AHCs that can enhance leadership and knowledge management capabilities; aid “knowledge workers,” the future of medicine as itself through systematic, required training and in the adoption and development of Internet-based capabilities; contribute to the develop- a profession may be at risk. To some commenta- collegial discipline; that has a base in technical, specialized knowledge; and that has a service rather ment of a more rational, comprehensive, and affordable health care system; improve manage- tors and policy makers the demise of medicine as a profession or “privileged occupation” would than a profit orientation, enshrined in its code of ment, including financial performance; and address the cultural and organizational barriers be a positive development (Reich 2000). We hold ethics” (Starr 1982, 15). to professional, staff, institutional success in a value-driven health system, the need to reas- the opposite view. We believe that medical pro- This definition captures essential characteristics sess and improve the education of physicians and other health professionals, and the need for fessionalism is critical to the values, quality and future of health care and to the research, educa- identified by most scholars, including that a pro- comprehensive health care reform (Blue Ridge Academic Health Group 1998a, 1998b, 2000a, tion and training upon which it is founded. fession is: 2000b, 2001a, 2001b, 2003, 2004). The medical profession, like other health In this, our 9th report, the Blue Ridge Group reviews and recommends changes required care-related occupational groups, has for several n  based on required intellectual training in decades experienced rapid change both internally specialized knowledge; to revive medical professionalism and to get the physician of the future right. to the profession and in the external environment n  oriented towards public service; for practice. This rapid change has created major n  rooted in a code of ethics; For more information, visit our web site: http://www.blueridgegroup.org. stresses throughout the profession and the health n  not strictly profit-oriented; n  infused with common, collegial norms; occupations – as well as in the health care system as a whole. The pace of change continues unabat- n  authorized by society to operate as a rela- ed and more change is a certainty. tively autonomous, largely self-regulating ■ We describe changes required to Physicians are key in organizing and delivering occupation. revive medical professionalism and to care in every health system. Their competence get the physician of the future right. and performance, on the one hand, and their While variations on these elements of a profes- overall commitment to professionalism, on the sion have been offered, almost all discussions of other, in large measure define the values of the the nature of professions describe an essential ■ We present policy recommendations health care system and how clinical outcomes symbiotic relationship between the status and that AHCs and the health professions will be achieved. The changes and stresses that authority conferred by society on the occupation, and the occupation’s commitment to maintaining can pursue to lead our nation to an era have affected the medical profession create new challenges for physician performance and com- high standards of qualification, ethics and service of "exceptional" health professionalism. petence. They also test the commitment of the (Sullivan 2005). Through this “social compact,” profession to its larger social responsibilities. professions have evolved as guarantors of the The primary focus of national policy and integrity of the particular sphere of activity within debate has been on addressing growing health which they are engaged. For the law profession, this care-related costs, improving measurable health has meant commitment to maintaining the integ- care quality, and getting America’s health care rity of the laws, legal system and courts. For the system right. The Blue Ridge Group believes that accounting profession, this has meant assuring the an equally urgent priority is the work to be done integrity of financial accounting systems and stan-

  dards vital to public and private institutions. 4. Its singular beneficence and basis in charity. Part I. The Internal Challenge Exhibit 1 provides a fuller description of the For medicine, this has meant assuring the integ- (Silverman 2003) elements of professionalism required of candi- rity of the health sciences, and the appropriate- Osler roots his definition of medical profes- “Today, the medical profession stands at a cross- dates seeking certification and recertification ness of health care practices and the protection sionalism in a “noble” history and equally noble roads. The direction it takes depends largely on from the ABIM. and promotion of overall population health values. But his definition is particularly notable its collective willingness to abide by a standard of Overall, the ABIM Project revealed a profes- (Starr 1982). for how it rests on the profession’s “singular excellence and behavior that requires a commit- sion whose members had become more “self- A profession, therefore, has a two-part chal- beneficence and as one based in charity” (empha- ment to self-improvement and peer review.” interested” and less characterized by “altruism, lenge in securing its legitimacy and authority sis added). – ABIM, Project Professionalism Report, 2001 (1995) accountability, excellence, duty, service, honor, within the larger society. The first challenge is Osler’s early 20th Century conception of integrity and respect for others.” It proposed internal: the group must achieve cohesion and the profession seems at the same time both In 1992, the ABIM established “Project important curricular and evaluative tools to be near-consensus on its shared internal standards quaint and profound by today’s standards and Professionalism,” with a mission to enhance the employed in preparing and evaluating outcomes for training, qualification, and licensure and on is likely an idealized version. But Osler manages teaching and evaluation of professionalism as a of professionalism programming in GME train- the group’s role as the keeper of highly valued to identify essential characteristics of medical component of clinical competence within internal ing programs. “public goods.” The second challenge is exter- professionalism that most would continue to medicine. The Project conducted an extensive Along a parallel but even more comprehensive nal: to win and to maintain societal recognition acknowledge today: The first speaks to the inter- evaluation and found serious deficiencies: track, starting in 1998, the IOM undertook a of the group’s sphere of professional authority nal standards of the profession, “the critical sense wide-ranging series of studies of America’s health and social responsibility. and skeptical attitude of the Hippocratic School;” “The medical profession has long enjoyed a special system. Together, these reports have painstakingly position in society. In the last few decades, how- Two key questions for medicine (as for the and by “[I]ts progressive, scientifically-based and (and sometimes painfully) documented the “qual- ever, accelerating advances in medical knowledge other professions) are: forward looking character.” The second speaks to ity chasm:” the extent to which our health care and technology have placed greater pressures on the character, integrity and commitment of the physicians to absorb and communicate informa- systems and health professions under-perform 1. What is the status of medicine’s internal profession: that it is animated by a “remarkable tion to patients and other health professionals. In on their missions and capabilities (IOM 1999, cohesion as a profession? Is the medical pro- solidarity;” and “Its singular beneficence and basis the wake of these changes, demands and expecta- 2001, 2002, 2002(a), 2003, 2003(a), 2003(b), 2004, fession characterized by appropriate, shared in charity.” tions of the public and the medical community 2005). With perhaps unprecedented clarity, the standards of professional training, qualifica- But there is no doubt that a century has made have altered the perception of what being a physi- IOM called for replacing current systems of care tion and competence? And, a difference in how the medical professional is cian really means. Unprofessional behavior and with new systems that can meet six aims that are 2. Has the medical profession maintained its viewed and experienced. attitudes on the part of some physicians have not now being met. Health care should be: safe, external obligations to carry out key respon- For some time, the decline of medicine as a eroded medicine’s historically respected position.” timely, efficient, effective, equitable and patient- sibilities on behalf of the integrity of its profession has been the subject of widespread (ABIM 2001, 1) (emphasis added) centered (IOM 2001, 6). The Blue Ridge Group sphere of professional oversight, sufficient to commentary, analysis and proposed remedies, and others now refer to these as the “STEEEP” maintain societal recognition of its sphere of both within the profession and without. Within It is important to note that, while acknowl- goals, and the Blue Ridge Group embraces them. authority? the profession, the American Board of Internal edging changes in the external environment had The IOM’s 2001 report, Crossing the Quality Medicine and its Foundation (ABIM) and the created new difficulties for physicians, the ABIM Chasm, reviewed and proposed new approaches First, What is a Medical Professional? Institute of Medicine (IOM) have been at the Project directly implicates ”unprofessional” to health care training and practice. These are forefront of identifying and addressing the chal- physician behavior and attitudes in the erosion reproduced in Table 1. Perhaps the most elegant definition of the medi- lenge of maintaining professional values. The of “medicine’s historically respected position.” Table 1 captures the extent to which tradition- cal profession was offered by William Osler, who ABIM has made particularly strong contribu- What exactly have been these “unprofessional al training and practice have been built around suggested that medicine was characterized by tions defining the nature of the profession’s behaviors and attitudes?” the prerogatives of physicians and the organiza- four great features: societal obligations. The IOM has made espe- The short answer can be found in the ABIM’s tion of health care services largely according to cially strong contributions in defining the core prescription for renewing medical professional- academic and practice specialties rather than 1. Its noble ancestry, which includes the critical competencies needed for health care profession- ism: according to conditions. Likewise, professional sense and skeptical attitude of the Hippocratic als (IOM 2003). Together, they point the way performance expectations have been built “Professionalism in medicine requires the physi- School that laid the foundation for a modern towards the renewal and redefinition of medical around physician autonomy, responsibility and cian to serve the interests of the patient above professionalism in the 21st century. accomplishment within hierarchical operating medicine; his or her self interest. Professionalism aspires to systems, rather than around team performance 2. Medicine’s remarkable solidarity; altruism, accountability, excellence, duty, service, 3. Its progressive, scientifically-based and forward honor, integrity and respect for others.” (ABIM and accountability. Historically, accountability looking character; and 2001, 5) for outcomes and quality has been low and not systematically measured.

  Exhibit 1: ABIM: Project Professionalism Table 2: Inter-Professional Value Set –Geheb, et al Five value domains that integrate and incor- als must provide the best care possible The elements of professionalism required of Duty porate professionalism as described by nursing, irrespective of race, cultural background, candidates seeking certification and recertifica- is the free acceptance of a commitment to service. medicine, dentistry, pharmacy, and social work gender, and economic social class, recog- tion from the ABIM encompass: This commitment entails being available and respon- in the State of Oregon: nizing that the resources available to any sive when “on call,” accepting inconvenience to given patient vary considerably given the 1. A commitment to the highest standards of meet the needs of one’s patients, enduring unavoid- n Knowledge Acquisition and Application: inequities of the American social system. excellence in the practice of medicine and in the able risks to oneself when a patient’s welfare is at Each discipline is distinguished by the ac- generation and dissemination of knowledge. stake, advocating the best possible care regardless cumulation and application of the knowl- n Intrapersonal and Interpersonal 2. A commitment to sustain the interests and wel- of ability to pay, seeking active roles in professional edge base that defines it as a discipline. Communication: fare of patients. organizations, and volunteering one’s skills and Embedded in each discipline’s knowledge It is imperative that healthcare profes- 3. A commitment to be responsive to the health expertise for the welfare of the community. base is the commitment of professionals sionals learn to utilize respect, integrity, needs of society. Honor and integrity within the discipline to pursue self-direct- and compassion in self-reflection, self- These elements are further defined as: are the consistent regard for the highest standards of ed and life-long learning and the respon- management, and relationship manage- behavior and the refusal to violate one’s personal and sibility to inform and teach others. ment in regards to interdisciplinary team Altruism professional codes. Honor and integrity imply being functioning as well as caring for the is the essence of professionalism. The best interest fair, being truthful, keeping one’s word, meeting com- n Responsibility to the primacy of the pa- individual patient. Professional behavior of patients, not self-interest, is the rule. mitments, and being straightforward. They also require tient and also the larger social system:The must be responsible and sensitive to the Accountability recognition of the possibility of conflict of interest and second domain acknowledges that health- needs of individuals and social contexts in is required at many levels — individual patients, soci- avoidance of relationships that allow personal gain to care providers are charged with these dual patient care and training environments. ety and the profession. Physicians are accountable to supersede the best interest of the patient. and sometimes conflicting responsibilities. their patients for fulfilling the implied contract gov- The social system can be conceptualized as n Ethical Reasoning and Behavior: Respect erning the patient/physician relationship. They are having three levels: Micro (patients, fami- Healthcare professionals must be able to for others (patients and their families, other physi- also accountable to society for addressing the health lies, and teams), mezzo (the hospital and recognize, analyze, and manage ethi- cians and professional colleagues such as nurses, needs of the public and to their profession for adher- community), and macro (local, national, cal conflicts arising in clinical, teaching, medical students, residents, and subspecialty fel- ing to medicine’s time-honored ethical precepts. and world). Responsible management of and research settings. Familiarity with lows) is the essence of humanism, and humanism is resources includes people, money, time, ethical principles can aid understand- Excellence both central to professionalism, and fundamental to equipment, and other resources. ing of conflicting values and priorities. entails a conscientious effort to exceed ordinary enhancing collegiality among physicians. (ABIM 2001) Decisions and behaviors in these settings expectations and to make a commitment to life- n Access to Equitable Care: should reflect ethical reasoning. Ethical long learning. Commitment to excellence is an The duty to advocate for access to principles need to guide difficult deci- acknowledged goal for all physicians. equitable health care is fundamental to sion making especially in circumstances in our value of fairness and respect for all which resources available to an individual human beings. Healthcare profession- patient are constrained. Table 1. Simple Rules for the 21st Century Health Care System –IOM 2001

Current Approach New Rule The IOM has estimated that only between 2004). Such alignment could then enable what 1. Care is based on visits. 1. Care is based on continuous healing relationships. 30% and 50% of the time do patients get treat- is described as the development of inter-profes- 2. Professional autonomy drives 2. Care is customized according to patient needs and values. ment known to be effective (IOM 2001). It sional “systems competence” or “systems profes- variability. 3. Professionals control care. 3. The patient is the source of control. has described the embracing of systems and sionalism” (ibid). 4. Information is a record. 4. Knowledge is shared and information flows freely. accountability for quality, “ . . . the last best hope Geheb and colleagues discovered in their 5. Decision-making is based 5. Decision-making is evidence-based. on training and experience. of the medical profession” (IOM 2001). research that the professions lack a common 6. Do no harm is an individual 6. Safety is a system priority. The IOM has challenged the professions to grammar with which they can categorize and responsibility. develop a commonality of interest and values communicate values and competencies. The lack 7. Secrecy is necessary. 7. Transparency is necessary. 8. The system reacts to needs. 8. Needs are anticipated. that would fully enable new systems of care nec- of such a common grammar vastly complicates 9. Cost reduction is sought. 9. Waste is continuously decreased. essary to a STEEP health care system. As a first the goal of putting common values and compe- 10. Preference is given to professional 10. Cooperation among clinicians is a priority. step, Geheb and colleagues have set out to define tencies into practice, not to mention the goal of roles over the system. a “common inter-professional value set” (Geheb developing team approaches to practice.

  Table 2 reproduces the five professional value Ideally in such teams, each individual brings leveraged (www.improvingchroniccare.org). n “Students and residents work around the patient domains that Geheb and colleagues found com- important expertise that is leveraged within A related initiative is centered in the care system” must give way to “All members of mon to the health professions. The constructs and the operation of the team on behalf of patients. Association of American Medical Colleges’ the care team are part of a high performance vocabulary utilized in Table 2 is a first attempt to Leadership is taken and shared by those team (AAMC) Institute to Improve Clinical Care clinical microsystem” (Stevens 2004). develop an inter-professional grammar. member(s) with the best information and/or (IICC), directed by David P. Stevens. The aim of Related to this, as part of the effort to identify skills in the particular case or part of the case. An the IICC is to “unleash the full potential of the The Society of General Internal Medicine and catalyze new systems of care, in 2002, the interdisciplinary team refers to a group of profes- nation’s medical schools and teaching hospitals (SGIM) is another professional association that IOM convened a summit on health professions sionals and support personnel working together for promoting the continuous improvement of is actively exploring the types of new training education. This resulted in a report that sets a in a coordinated fashion to address an individual clinical care” (www.aamc.org/patientcare/iicc/ and competencies required of medical profes- consensus standard for professional competency. patient’s needs at a specific time and clinical cir- about.htm). A major aim is to find strategies by sionals. Its Task Force of the Domain of Internal In Health Professions Education: A Bridge to cumstance. which to seed and empower early adopters who Medicine (Domain Task Force) has developed Quality), the IOM recommends, can pioneer new models of training and prac- recommendations for the training and practice of Understanding, Forming tice that others can adopt. One strategy being general internists, a specialty with one of the most “All health professionals should be educated to and Leveraging Teams employed to reach such a “tipping point” is to daunting challenges in defining competency. deliver patient-centered care as members of an create programs that support medical students General internists must be capable of practice interdisciplinary team, emphasizing evidence- A large number of models, along with a burgeon- and residents as agents of change and innova- that is both broad and deep, encompassing care based practice, quality improvement approaches, ing scholarly literature, are exploring and devel- tion within teaching hospital and other aca- of people with common conditions, including and informatics” (IOM 2003, 3). oping a variety of innovative team approaches demic health center learning and care sites. The conditions that are acute, complex, and/or chron- to clinical practice and to professional training rationale is that, while more senior clinicians are ic, as well as across the Out of this summit, five essential competencies for such practice. The Society of Care is proficient in their particular skill sets and within fields of health promotion were identified. “Competencies are defined here Our nation’s aging demo- traditional clinical systems, younger physicians, General Internal and disease prevention. redesigned to as the habitual and judicious use of communi- graphic, for example has or even trainees, may be more “expert” in under- Medicine (SGIM) is Accordingly, the Domain cation, knowledge, technical skills, clinical rea- use open access, created broad interest in standing and adopting newer approaches to the Task Force recommends, another professional soning, emotions, values and reflection in daily group visits, and the increasing challenge organization of work. This initiative is being “Wherever they practice, association that is practice” such that all clinicians (and not just modern informa- of treating and managing piloted in 12 teaching hospitals. general internists should physicians) can: chronic disease. Edward actively exploring be able to lead teams and tion and commu- Wagner and colleagues Moving in the Right Direction the types of new be responsible for the nication systems, 1. Provide patient-centered care (Wagner 1999, 2000) have training and com- care given by their teams, 2. Work in interdisciplinary teams like electronic offered compelling working The IOM and ABIM descriptions of professional embrace changes in infor- petencies required 3. Employ evidence-based practice medical records, models for the develop- competencies and characteristics are designed mation systems, and aim 4. Apply quality improvement ment and success of team to lead to the development of systems of care of medical profes- to provide most of the care electronic pre- 5. Utilize informatics medicine and new ideas for that explicitly recognize the interdependence sionals. required by their patients” (IOM 2003, 3-4) scriptions, and better practice and learning of the skills and competencies of each of the (Larson 2004, 639). email. environments. They have health disciplines and support personnel. The In keeping with current thinking, the Domain The competencies identified and recommended described the essential ele- AAMC’s IICC also leads in this direction when Task Force also recommends that general inter- here respond to very much the same deficiencies ments of an ideal “Chronic Care Model” of coor- it describes how traditional principles that have nists develop and be trained to particular expertise in professional behavior and attitudes identified dinated care to manage chronic diseases (Wagner guided clinical learning must give way to new in team and systems practice, and in the capacity by the ABIMF. They represent new directions in 2000). Ideally, this involves a prepared practice principles to underpin redesign of care where to integrate this knowledge and practice with the physician training. It is now widely accepted that team using available health information, and students and residents learn: best of personalized and “high touch” medicine. such new direction is required in order to address working with an informed, activated patient. The much of the inefficiency, underperformance, patient is supported in self-management. Care is n “Care and Curriculum as separate silos” must “General internal medicine residency train- error and sub-optimal quality that persists redesigned to use open access, group visits, and give way to “Patient care and medical educa- ing should provide both broad and deep medi- throughout the health care system (Wennberg modern information and communication sys- tion are tightly coupled.” cal knowledge as well as mastery of informatics, 1982). tems, like electronic medical records, electronic n “Patient safety is on the radar screen” must give management, and team leadership. . . . Research To this end, most often proposed is the concept prescriptions, and email. Inter-professional care is way to “Patient safety is a key characteristic.” should expand to include practice and operations of the team player, the professional who learns systematic and seamless, evidence-based decision management, developing more effective shared and works as part of a interdisciplinary team. support is available and community resources are decision making and transparent medical records

10 11 and promoting the close personal connection that We might well ask whether many medical edu- The concept of building a new “health sys- has recently innovated again in creating new care both doctors and patients want” (ibid). cation and training programs or health care set- tems professionalism” captures well many of teams that are responsive to current trends and tings model these characteristics of the optimal the dimensions of the new professionalism that pressures in hospitals. Many teaching hospitals Teams as Microsystems microsystem? is evolving in both the literature and in prac- face tremendous pressure to reduce costs and find Throughout the literature on microsystems tice. Whether with respect to clinical teams or new efficiencies in the wake of reduced hospital At a more fundamental level, a great deal of and HROs is a strong emphasis on what might microsystems, to high-reliability organizations, payments and new limitations on medical residen- research is being conducted to understand what best be described as the requirement for a proper or to clinical or information systems, health cies and work hours, among many other factors. makes good teams and how they can approach culture within, and personal attitude towards professionals must now acquire a broad-ranging Starting in two subspecialty services, inpatient optimal functioning in a clinical setting. participation in, the system. “Mindfulness” is a “systems” competence. And the physician of the cardiology and vascular medicine, Mayo designed Pioneering here is the work of Weick, Reason, term of art often employed to describe this cul- future must be more than just a participant in new care teams utilizing “midlevel” health care Batalden, Nelson, Mohr, and others in the fields ture and attitude. Mindfulness means “Awareness health systems. He or she must also develop the providers (Cooper 1997). Instead of using medi- of systems theory, error and risk analysis, high of one’s work unit as a system is a matter of iden- skills and leadership capabilities to shape, man- cal residents and their supervising physicians, reliability and high complexity organizations, tity and is connected to age and mentor others within these systems. As these services were staffed by physician assistants, complex adaptive systems and microsystems. Pioneering here is purpose. . . . Mindfulness leaders, physicians will need to have a common nurse practitioners, and internal medicine hos- Most health care is provided within clini- implies “a radical pres- language to communicate with other interdisci- pitalists. Outcomes for these new service teams the work of Weick, cal microsystems. These are “small organized entness” . . . and a con- plinary team members. This language will need were comparable to those of traditional teams groups of providers and staff caring for a defined Reason, Batalden, nection to the actual to be based on the STEEEP aims of the IOM. (Costopoulos, et al. 2002). population of patients” that work within larger Nelson, Mohr, and requirements of the Additionally, an explicit understanding of how complex adaptive organizations (macro-systems) others in the fields current situation along the skills and competencies of each member of II. Adoption of Innovative Approach to (Mohr and Batalden 2002, 45). This work is with a chronic sense of the team contribute to good patient outcomes Utilization of Information Technologies -UTMB of systems theory, derived, in significant part, from the experience unease that something will be required. A commitment to performance The University of Texas Medical Branch (UTMB) of the military and other high reliability organi- error and risk analy- catastrophic might occur improvement will be necessary, measured at both in Galveston, Texas, provides a model of the zations (HROs) in organizing an extraordinary sis, high reliability at any moment” (Mohr individual and population levels. Absent these adoption and application of new information array of expert performance systems to a near- and high complexity and Batalden 2002, 46). characteristics, physicians will not be able operate technologies to the clinical setting. In 1996, zero failure rate. organizations, and This frame of mind is and effectively lead interdisciplinary teams. UTMB won the contract to care for approxi- In understanding the characteristics of optimal not self-referential, in mately 106,000 prisoners of the State of Texas, systems and teams, much has been learned about microsystems. the way that traditional Models of Innovation under a capitated payment model. Faced with the importance of training and orientation of team medical training would prisoners spread over a large geographic area and members. The operative principle for HROs is: “The dispose one to approach practice, but is instead Many current efforts in practice model innova- in multiple settings, UTMB developed a telemed- most important person at any given moment in a team- and system-referential. It comprises a per- tion are being made possible only with the help icine approach. The components of the UTMB high-risk organization is the person with the most sonal and professional orientation that disposes of philanthropic or other specially designated Telehealth Delivery System include: valuable information, regardless of rank” (Weick one to participate and collaborate in developing grants of financial support or through special 1995, Batalden 2002, Nelson 2003 and Mohr 2003). approaches and systems of optimal reliability, efforts with third-party payors willing to experi- n Telecommunication with multiple attach- Applying microsystems research and expe- safety, and effectiveness. Important for all team ment with new forms of reimbursement support. ments rience to the health care setting, Mohr and members is deference to knowledge and flexibil- We offer two examples of clinical innovation and n Pharmacy management Batalden have described eight characteristics of ity in sharing leadership with the person(s) best leadership. The first represents an innovation n Electronic medical record—HIPPA compliant optimal clinical microsystems. These include: trained or equipped for the particular activity, within the confines of existing reimbursement n Voice activated dictation whether on aircraft carriers, in air traffic control, policies and the second represents an effort in n Disease management/practice guidelines n Integration of information in nuclear power plants or in clinical settings combination with a third-party payor. Efforts n Measurement (Weick 1995). such as these are vital to the more complete Team medicine is practiced, with on-site nurses n Interdependence of the care team adoption of team approaches to health care and and staff who facilitate prisoner access to on-site n Supportiveness of the larger system Health Systems Professionalism deserve the broadest possible replication. and portable diagnostic and communications n Constancy of purpose modules, which are employed by other members n Connection to the community One way of characterizing these new competencies I. Innovation in Team Medicine and Patient- of the health care team at remote locations. Using n Investment in improvement has been offered by Geheb and colleagues (Geheb, Centered Care this method, UTMB physicians make an average n Alignment of role and training et al. 2004). The attributes are listed in Table 3. In team medicine and patient-centered care, the of over 3000 patient visits per month with prison- (Mohr and Batalden 2002, 47) Mayo Clinic has long been a leading innovator. It ers. With telemedicine, tremendous efficiencies

12 13 and savings are realized in everything from travel “customer service” from health care systems and some of these costs has largely been squeezed Conclusion, Part 1 time to conducting and communicating a variety they often come to the clinical encounter with out of the system. Payment systems continue to of diagnostic tests. Far more patients are seen and web-mined information concerning their condi- be inappropriate and inflexible, making change Our first question has concerned the status of with access to more technologies than would be tions and treatment options. Often this material to team care models financially challenging. This medicine’s internal cohesion as a profession. possible without the telemedicine capabilities. is branded by leading provider organizations, like is an ongoing and major impediment to reform To maintain its professional status, a profession Prisoners themselves report high satisfaction Harvard Medical School (through InteliHealth. and change. Pay for performance appears to be must be characterized by the active maintenance with this type and level of access to health care com) or, often, by the provider’s own organiza- a step in the right direction but payments must and promotion of appropriate, shared stan- and a variety of indices demonstrate that the sys- tion. Physicians and providers of all types must be sufficient to change behavior. The reform dards of professional training, qualification and tem is working well. now anticipate interacting with patients and of health care financing remains an urgent competence. Do physicians practice according families with a far more equitable orientation priority as a precondition for fuller adoption to appropriate, shared standards of professional n Prison treatment compliance under the tele- than the traditional paternalistic approach (See of needed innovations in medical practice and training, qualification and competence? What are medicine system has risen dramatically, from PatientSite.com). training. those standards? What 40% in 1995 to 96% in 2003; Young professionals and trainees are challeng- Professional associa- should they be if we n Inmate deaths are down; ing the traditional models in other ways. There Inertia and Ingrained Practices tions are increasingly are to get the physician n Asthma cases are down; is a trend, recently abetted by regulatory change, Many practitioners, professional societies, of the future “right?” realizing that they n Overall average clinical endpoints have towards trainees and younger physicians seeking regulatory organizations, provider organizations, Our answers, drawn improved, resulting in lower blood pressures, and expecting less demanding work hours, more and the professions themselves, remain rooted must set new stan- from both experi- blood glucose, and LDL levels; time off, greater flexibility to accommodate fam- in traditional autonomous training and practice dards and also work ence and an extensive n Drug costs are down 18.4% in four years. ily responsibilities and other priorities. They also models. Many are reticent to change and to adapt across specialties and review of the literature, seem more willing to exchange higher salaries for to the requirements of cross-disciplinary and are that physicians are disciplines to achieve Overall costs have been dramatically reduced: more satisfying personal lives with their spouses, team efforts. In academic medicine, and in other currently struggling it now costs approximately $2000 per year per children, and/or friends. Traditional training settings, such fundamental decisions as promo- the shared and com- within an environment prisoner, well below average for health care programs and practices struggle to accommodate tion and tenure continue to be characterized by plimentary values, that perhaps is best services per person these new developments. a widespread incapacity to develop standards to standards and compe- described as “creative nationwide. properly evaluate or value collaborative efforts, chaos” (Robinson, Telemedicine started at tencies necessary to UTMB as an innovative Telemedicine Barriers to Change unconventional or part-time time commitments 1999). Traditional started at UTMB as an or other deviations from long-accepted norms, collaborative care. models of training program designed to innovative program The Health Care Financing/Payment/ whether they be in research, education or care. and practice are being meet the needs of pris- designed to meet the Reimbursement System While there are many impediments to cite variously reformed and recast within a health care oners who traditionally needs of prisoners Many obstacles stand in the way of fuller when considering the possibilities for change, environment that demands better systems and have had significant who traditionally have adoption of better systems and team medicine. it is also possible to protest too much. Without more collaborative approaches to care for indi- had significant diffi- Probably the most daunting obstacle is the health a profession-wide near-consensus to adopt the viduals and populations. Physicians are learning difficulties achieving culties achieving access care payment system. Fee-for-service and most new standards for training and practice, train- that they must learn and practice seamless, inter- access and responsive- and responsiveness for other third-party hospital and physician reim- ing for the new team and systems competencies disciplinary “collaborative care” (Cohen 2002). ness for health care health care concerns. bursement practices are designed to pay for tra- will not be formalized, and existing care systems Professional associations are increasingly realizing concerns. The model has proven ditional medical practice that is focused around and organizations will have neither the guidance that they must set new standards and also work effective in improving individual medical practitioners. Even in settings nor incentive to change. Without professional, across specialties and disciplines to achieve the health and health care and in controlling costs where leaders and innovators would like to pur- regulatory and organizational buy-in, individual shared and complementary values, standards and and telemedicine is being rolled-out for other sue team approaches to health care services, it learners and practitioners will continue to find competencies necessary to collaborative care. populations, both within and beyond the United can be very difficult to devise methods or to find it difficult, if not impossible, to embrace these Taken together, the efforts we have described, and States. Yet, state medical practice restrictions have sources from which to pay for the efforts of many required competencies and sustain effective many others besides, are identifying and redefining inhibited multiple adjoining states from benefit- team members. Many, if noy most, reimburse- teams and microsystems. And, without profes- the basic competencies that are required of the health ing from the UTMB initiative (Stobo 2004). ment policies do not recognize or pay for other sional near-consensus on appropriate care sys- care professional, and in particular, the physician. Along with such early-adopter innovations, than physician efforts. With the intense ratchet- tems and models, payors can ignore pleas for New competencies that must be embraced and the status quo is being challenged in other ways ing-down of reimbursement levels for all health innovation and experimentation beyond those further elaborated not just by individual profes- as well. Patients’ expectations have changed. care services over the past two decades, what flex- that benefit their own financial models or mar- sionals, but by health professional organizations Patients and families have come to expect better ibility there might have been at one time to cover ket interests. and regulatory bodies more formally, include:

14 15 n Dedication to patient-centeredness, In Table 3, we further characterize and com- Current State Future State n Systems competence, including change pare current/traditional models of professional- management, and ism and competence with what would charac- Patient-centered Health systems organized around Health systems organized around the n “Mindfulness” or vigilance in achieving terize a new patient-based, health systems/team care needs and wishes of providers. clinical needs and wishes of patients. Providers are the “center of control.” Patients are the center of control. Au- systems reliability and safety professionalism. Getting the physician right Autonomy highly valued. tonomy is diminished. depends upon how aggressively, how well, and Whereas several medical societies and pro- how extensively physicians, organized medicine, Institutional and individual interests Institutional interests align with com- override community interests. Focus munity and patient interests. Health fessional organizations have made significant and its training infrastructure adopt the mission on incidents of care and acute clinical and prevention focus while maintaining progress in identifying these competencies and that the IOM has perhaps best summarized: intervention. competence in incidents of care and promulgating revised standards for training and acute clinical intervention. competent practice, the medical profession as a “All health professionals should be educated to whole has yet to fully appreciate or embrace these deliver patient-centered care as members of an Interdisciplinary Work “culture” defined by individual “Culture of quality” recognizes the new competencies. Early adopters are model- interdisciplinary team, emphasizing evidence- teams discipline with rigid work-rules for unique contribution of each discipline support personnel. and the importance of support person- ing new team training and practice, but the vast based practice, quality improvement approach- nel in continuously improving the pa- middle majority has yet to do so. es, and informatics.” (IOM 2003, 3) tient experience and clinical outcomes. Communication channels are very Critical information is exchanged easily hierarchical with frequent misses for recognizing the “the most important “Make everything as simple as possible—but not simpler.” –A. Einstein critical information exchange. “Hand- team person at any given moment in a off” risk is high. high performance high risk organization is the person with the most valuable The physician gives the orders and information regardless of rank.” “Hand- Table 3 Defining Health Systems Professionalism and Competence others presumably follow off risk” is eliminated. Current State Future State Team members work as individuals. The physician develops a care plan with Professional values “Noble Values” defined independent- “Noble values” align, with a common “Working harder makes it better.” an interdisciplinary team that monitors its ly for each health discipline, although value set that incorporates the lan- Marked by high burnout rates and performance. Each team member knows compatible with each other. guage of the IOM aims. (Table 2) unbalanced lifestyles. Individuals “when to lead and when to follow.” are available “24/7” to meet clinical demands. Interdisciplinary teams build on individu- Disciplinary Multiple organizations in multiple A common language embracing IOM al responsibility with clear role defini- competencies jurisdictions define competencies in- aims and competencies is used to tions for each member. The team focuses dependently. Little common language define interdisciplinary competen- on improving results. There is high or understanding of interrelationships cies. Explicit understanding of how individual and team satisfaction. Team of skill and competency among disci- individual discipline competencies members have balanced lifestyles. The plines. No reference to or definition complement each other (synergistic health system and its teams are available of “interdisciplinary care.” Competen- competencies). Clear definition of “24/7” to meet clinical demands. cies are “disharmonious.” “interdisciplinary care.” Competencies are “harmonious.” Individual professional models are Operations Disparate human resources systems Clearly articulated and aligned human “siloed.” Teaching models are “addi- Interdisciplinary education occurs—with- are “siloed” for physicians, nurses resources systems with clear definition tive” as knowledge grows—taught in a “learning” community of profes- and other professionals, trainees, and of roles, responsibilities, and evaluation within rigid time constraints. sional disciplines. As knowledge grows other personnel. systems for interdisciplinary care, apply- and changes, it is substituted within ing to all personnel who work in systems Rigid “regulatory models” of educa- educational time frames, with skills for Poor provider, employee, and patient that “touch the patient” in any way. tion. life-long learning being taught. satisfaction. Continuously improving provider, em- Educational time frames (undergradu- Great variability in clinical outcomes, ployee, and patient experience. ate, graduate, and continuing educa- resource use and costs—nationally, tion) are viewed as a flexible con- regionally, and institutionally. Continuously improving clinical out- tinuum. “Just-in-time certification” comes, resource use and cost—nation- would be available making mid-career Continuous adding of “layers” of ally, regionally, institutionally. transitions easier. Crew management people and process to provide care techniques with clear communication (i.e. 80 hour work week for residents). Defining team structure and flexibility in standards are used centering around Rigidity in team structure with chaotic team organization based on the task, IT clinical episodes. work hours – increasing possibility for aids for “getting the right information, error with complex hand-offs of re- to the right people, at the right place and Flexible “learning models” are ori- sponsibility for care. “Work arounds” the right time.” Continuous reduction in ented toward the maintenance and abound. errors. “Work arounds” are eliminated. improvement of knowledge and skills.

16 17 With respect to the first challenge for profession- 8. Invest in information and record systems that Current State Future State alism, that of the integrity and quality of internal are accessible to all key players and proven to be Erratic and slow adoption of evidence Rapid adoption of evidence based clini- professional standards, we are convinced that effective in enhancing communications, including based clinical practices by discipline. cal practices on an interdisciplinary team across cultures and continents. Erratic team learning with incon- basis. Use of valid internal and external medicine desperately needs increased leadership sistent use of internal and external benchmarks of quality to encourage and stronger championing of the new patient- benchmarks. team learning. centered, systems competencies. The decline of Commitment to Quality Assurance Quality assurance transitioning to Qual- medical professionalism is well documented. To Part II. The External Challenge and regulatory model for Quality. ity Improvement. All professionals have reverse this trend, the medical profession must some working knowledge of quality summon the internal leadership necessary to The second challenge for medicine is the external Financial indicators are the “lead” improvement tools and their appropriate indicators for performance. application—when do you use what tool advance itself to the “tipping point” where profes- challenge: to maintain societal recognition of (focus/PDCA, lean, six sigma, etc.)—and sional standing, and, crucially, each professional’s medicine’s sphere of professional authority and Information technology (IT) not de- where does one find the help. identity, is rooted in the embrace of the new responsibility. In this regard, the renowned social ployed strategically. Leading with integrated patient-cen- team and systems value and competencies, and scientist, Karl Polanyi observed that the strength tered, clinical and operating indicators patient-centered care models both in training and of status groups depends “upon their ability to of performance with improving financial in practice. win support from outside their own membership, indicators following. which again will depend upon their fulfillment IT deployed to improve patient centered of tasks set by interests wider than their own” business processes, information flow, (Polanyi 1957, 152). decision support and patient centered Part I. Recommendations clinical quality. Outcomes measure With respect to this second challenge, the key would include error reduction, improved Concerning medicine’s internal professional challenge: question for medicine is: Has the medical profes- experience and patient and employee satisfaction metrics, improved clinical 1. Embrace, develop and promote the new interdisci- sion maintained its external obligations to carry outcomes, and reduced cost/unit work. plinary team and systems professionalism in health out key responsibilities on behalf of the integrity care, as described above and as summarized by of its sphere of fiduciary oversight, sufficient to Finances Continuous increases in healthcare Health care costs in line with growth of the IOM: maintain societal recognition of its sphere of pro- costs—outstripping inflation and GDP and inflation. “All health professionals should be educated to deliver fessional authority? growth in GDP. patient-centered care as members of an interdisciplin- Pay for performance rewards “best per- Medicare (& other) payers punishes formers” and recognizes infrastucture ary team, emphasizing evidence-based practice, quality What is the Value of Medical “best performers.” costs. improvement approaches, and informatics.” Professionalism? (IOM 2003, 3) Decades of accumulating evidence and com- Financial incentives generally align to Patient and providers are incentivized contribute to increasing costs by: to appropriate (avoidance of over and 2. Review and revise job descriptions, performance mentary on the decline of the professions and the n Promoting over utilization. under) use of resources: reviews and reward systems to embrace quality and proliferation of “unprofessional behaviors and n No incentives for health and n Providers rewarded for outstanding outcomes accountability and reward team/systems attitudes” suggests that this is not a narrow or prevention. and measurable patient centered n Individually patient based and clinical outcomes. professionalism. medicine-specific issue, but a broader sociologi- not population based reimburse- n Providers are rewarded and have 3. By the year 2010, understand and commit to defin- cal problem, and a long-standing one. There is ment. disincentives for variability in clini- a growing body of scholarship that suggests that n Violating principles of equitabil- cal outcomes. ing and developing the practice models and sys- ity with uneven access to clinical n Health and prevention on a popula- tems needed for care to approach near-zero failure the value of professionalism is no longer clear care. tion basis are paid for. tolerance. and that the risks to medical professionalism, n Promoting variability in out- n Access to essential preventive and comes at a national, regional and acute services are guaranteed. 4. Reform training programs to meet the goals of may be increasing (Sullivan 2005). institutional level. n Incentives for rapid adoption of evi- team and systems professionalism. n Proliferating regulatory burden dence based clinical care and best 5. Develop evaluation tools that assess and recognize Societal Context and costs due to concern over practices using benchmarking. “quality” and “escalating costs” n Decreasing regulatory burden and high functioning interdisciplinary teams and the The medical profession is an example of the tumul- costs linked to improving patient performance of individuals in these teams. tuous development of professionalism in American Variable quality associated with un- centered clinical outcome metrics. 6. Develop common training curricula built around society over more than two centuries. Given an even, often precarious operating and long-term capital position. Improving measurable quality associated interdisciplinary values and competencies. almost innate national suspicion of class or other with improving operating margins and 7. Assure that the relevant accrediting and certifying forms of social privilege, most historians agree that long-term capital position. agencies by discipline engage and formalize these the development of professions in America was by reforms. no means inevitable. Historians also agree that the

18 19 privileges afforded professions are neither writ in members according to local or family tradition, as a refuge from rigid “old world” political, class Exceptional Economic Expansion stone nor guaranteed for all time. or “common sense.” Eighteenth and 19th century and religious systems resulting in the American As the 20th Century progressed, increasingly, By virtue of a variety of particular historical attempts to create and enforce minimum stan- independence movement. This exceptionalism the trusted solo practitioner and local hospital factors, professional standing has been achieved dards of medical practice and state licensure has been variously described, but certainly con- were being changed by the new national invest- for several fields of expertise, such as law, were regularly repulsed in the Jeffersonian spirit tains strong doses of the ”rugged individual” and ments in biomedical research and health care, accounting, education, engineering, and medi- as an unjust check on the freedom of both occu- “entrepreneurial” character (Hoover 1928). by third-party payment systems, new technolo- cine. However, professional standing does not pational and “consumer” choice (Starr 1982, The development of American medical pro- gies, new training opportunities, and new patient maintain itself. History provides many examples Duffy 1993). fessionalism must be viewed through this lens. expectations. In the post-World War II era, bil- of periods where a profession may thrive and oth- Nevertheless, the need for something like a Unlike in most of Europe, American medicine lions of new dollars flowed into health care and ers where its survival is put at risk (Perkin 1996). medical profession continued to be raised by did not take root first as an occupation of the the health sciences. Many large employers began reformers as the American society and economy socially elite, homogeneous and well-schooled. offering health care insurance as an employee A Case Study in the Eclipse of evolved into larger-scale commerce. The occupa- Furthermore, America did not develop a form of benefit. Medicare and Medicaid were enacted in Professionalism: Arthur Anderson tions of law, medicine, teaching and accounting nationalized, universal health care as a basic ele- the mid-1960s -- the first truly government-spon- and the Accounting Profession grew increasingly important to the establishment ment of a larger social welfare system. In Great sored health programs (outside of the military and maintenance of rules and moral boundaries Britain and in most European countries, national and Veterans Affairs system). The establishment The clearest and most dramatic example of the within the spheres of law, care, learning and in health systems evolved. These largely public sys- of the National Institutes of Health (NIH) and neglect and abandonment of professionalism the marketplace. tems employed the majority of physicians as sala- the National Science Foundation (NSF), as well occurred recently in the accounting profession. The assertion of a professional ethos and stan- ried professionals. Professionalism became rooted as new interest in health care and biological war- In 2002, Arthur Anderson, the world’s largest dards in medicine gained ground with the advent in a traditional class-based “noblesse oblige.” fare in the Department of Defense (DoD), drove accounting firm, was found guilty of obstructing of the foundations of modern biology, especially Professional medical societies were essentially unprecedented increases in government-spon- justice in association with the “Enron Scandal.” with the germ theory of disease. Medical practice fraternal branches of the larger privileged social sored funding for biomedical research. Riding a tide of corporate greed and fraud, became rooted in science, formal education and class system. An elite group identity and connec- By the 1980’s, physicians were less connected Arthur Anderson ignored its higher obligations to training, responsibility to patients, and service tion to a charitable and beneficent heritage and in the traditional ways to their communities and society. The firm’s shocking loss of focus on the to society. Medicine achieved internal consensus societal mission were not difficult to establish to the patients they served. “Physician extenders” role of accounting in safe-guarding the integrity on universal standards for training and practice. or maintain. appeared. Time and staff devoted to managing of the business and finance processes for the Important new public health measures were American physicians, by contrast, evolved pri- the growing regulatory burden grew. Physicians public good, caused the firm to lose virtually all enacted. Society came to realize that properly marily as self-employed solo practitioners. They trained longer and became more specialized in of its clients. The firm was effectively dissolved. trained and credentialed practitioners could be were far less homogeneous as a group and more their practice. Their incomes, particularly in some But even more significantly, the entire account- trusted with your health and life. likely to associate and refer to one another for fields and sub-specialties, grew rapidly. Health ing profession has been transformed. With the In this context, medicine grew as an esteemed consults according to local or training ties. From care costs grew at rates that were increasingly Sarbanes-Oxley Act of 2003, Congress acted practiced and “calling.” Equally important dur- the start, American physicians operated more like costly to individuals, families, governments, and to largely strip the accounting profession of its ing this time is that hospitals were transformed traditional guild tradesmen than did their British corporations alike. Overall, physicians reported capacity to regulate itself and placed such regula- from “ . . . places of dreaded impurity and exiled and European counterparts. being less happy and less satisfied in their work tion in the government’s hands. Accounting as human wreckage into awesome citadels of science While often idealistic and oriented towards ser- (Blumenthal 2001). a self-regulating profession is on the verge of and bureaucratic order . . .” (Starr p. 145). vice, American physicians largely evolved as small In the early 1990’s, the Clinton Administration extinction (Beltran, et al 2002). businessmen. Like other small businessmen, they (like others before it) attempted, but failed, to The “Exceptional” American Physician were rooted in their communities and served a craft a major reform of the U.S. health care sys- While the value of medical science and profes- relatively local clientele. They had suppliers and tem. Public policy instead encouraged the rise By virtue of a variety of particular historical fac- sionalism was eventually established during the staff to pay and budgets to make; and they had to of the nascent “managed care” industry as the tors, professional standing has been achieved for 20th Century, it is important to understand the adapt their businesses to changes in the economy agency of health care reform and cost contain- several fields of expertise, such as law, accounting, extent to which its value came to rest on a set of and society. As a result, the American version of ment. A new “health care marketplace” drove education, engineering, and medicine. particularly American characteristics. medical professionalism developed less out of a significant and rapid change both in the organi- Until early in the 20th Century, medicine had It has often been observed that there is a so- social class system or any overall planning than zation of patient services and in the culture of been a virtually unregulated field of practice, called “American exceptionalism” that results in out of the activities of solo and small-group prac- medical practice (Glied 1997). Providers of all where formally trained practitioners shared the unique American approaches to all manner of life titioners/tradesmen and independent hospitals types adopted market-driven strategies. These field with self-proclaimed healers, apothecaries, choices and public policy. This exceptionalism is within an evolving health care market place. included the re-engineering and consolidation of and surgeons. Most care was provided by family attributed in large part to the legacy of America health systems, practices and services to achieve

20 21 increased efficiency and productivity that could association that is in large measure self-regulated group practices. The newest trend is now for – and potentially or actually rife with conflicts of drive patient throughput and revenue growth through values and principles incorporated in health systems to hire increasing numbers of spe- interest that have troubling implications for stan- (Herzlinger 2001). training and articulated and enforced in a code of cialists, particularly in the specialties that support dards of professionalism. These changes in both the medical profession ethics or conduct. While the knowledge worker their most profitable inpatient and outpatient We have said that the second challenge for and the external environment contributed to a is responsible primarily to him- or herself and/or services. This includes especially cardiologists, car- medicine as a profession is the external challenge growing sense that medical professionals, like oth- to an employer or client, the professional is con- diothoracic surgeons, neurosurgeons, orthopedic of maintaining societal recognition of medicine’s ers (in particular, lawyers), were becoming more nected through the professional association to surgeons and general surgeons, and hospitalists sphere of professional authority and responsibil- market-driven and self-centered – and less benefi- broader societal obligations and expectations. The (Beckham 2005). ity. To meet this challenge, the medical profession cent (Linowitz 1994). The decline of medicine as a professional is responsible to his or her peers and Other physicians are engaged in a wide variety must uphold its end of its social compact in exer- favored and revered profession was the subject of their common associative professional standards. of entrepreneurial and business schemes designed cising society-wide responsibility in the sphere of widespread commentary and analysis, as discussed Professional values and standards are explicit in large measure to increase or maximize their health care and the health sciences. Absent active in Part I of this report. and are explicitly recognized and sanctioned by incomes. vigilance in its societal responsibilities, the justifi- society. The professional, by education, social cation for professional status and privilege disap- Physicians: Professionals or Simply Experts? compact, and calling, is a socially conscious actor. n New ”surgicenters” and other specialty centers pears. As the example of the accounting profession The knowledge worker, where not also a profes- have proliferated as physicians, especially surgeons has shown, there are public and private entities Helpful “sociological” perspective on the inter- sional, may be accountable only to a client and/or and “proceduralists” in high-margin specialties, that can be empowered to take jurisdiction away play of society and the professions is provided informal peer groups, and is only accidentally, have left hospital-affiliated practices to form new from a profession that fails to live up to its societal by Peter Drucker, who has authored some of the incidentally, or episodically an actor or fiduciary practices and centers that compete directly with responsibilities. most accessible discussion of complex issues in the on behalf of larger societal values or social goods. hospitals for patients (Casalino 2003). development, organization, and management of Within Drucker’s framework, the knowledge The Need to Reassert Medical work in modern society (Drucker, 1989). worker is a natural adaptation and vital contribu- n Many physicians and practices of all sizes have Professionalism and Leadership According to Drucker, in the decline of profes- tor to the modern information society. Unlike the brought into their practices scanning and other The recent resurgence of public policy in support sionalism, we are seeing the effects of the emer- socially conscious professional, the non-profes- specialized technologies. While having such of free enterprise and unbridled competition is gence of a new type of workforce. In modern, sional knowledge worker functions as a relatively capabilities in-house can be more convenient for not unlike the type of policy that served in the post-industrial society, great value is placed on unencumbered agent of Adam Smith’s “unseen patients, a further benefit is additional income 19th Century to catalyze and justify the establish- the acquisition, organization and application hand” of the marketplace. This gives the non- to the practice. A troubling recent study shows ment of professions in the first place. However, of knowledge. New types of knowledge indus- professional knowledge worker an advantage in a that practices with such in-house capacities uti- today, American professions, including medicine, tries, services and organizations have spawned highly market-driven environment. Organizations lize them with patients at a rate 10 times the rate have largely failed to publicly articulate or cham- a new type of worker, the “knowledge worker.” and corporations striving for maximum produc- of practices that do not have these technologies pion values or standards that would distinguish Knowledge workers are distinct from manual tivity, market-effectiveness and flexibility greatly in-house (Pham, et al. 2004). Yet, other studies professionals from other knowledge workers. laborers and other skilled and non-skilled work- value such un-encumbered knowledge workers. show that, because of the irrationality of the From a societal perspective, organized medicine ers. They are relatively independent, adaptable and It is easy to see how the professions, and indi- payment system, without the revenue generating has become another “special interest.” It has, in self-directed. They are highly educated and often vidual professionals themselves might tend to act capabilities of such technologies, many practices significant measure, ceded its moral authority as highly skilled and their work is based in specialized or perform in such ways as to accentuate their would not be economically viable (Pear 1991). guardian of the common goods that medicine, as knowledge. Knowledge workers are mobile, often knowledge-worker attributes and minimize their a profession, exists to protect. In turn, and despite entrepreneurial, and tend to be continuing learners professional obligations in order to be as competi- n Physicians are leaving or avoiding specialties that some initial resistance to strictures imposed under so that they can adapt to new knowledge and to tive and highly valued as possible in such a mar- are lower-paying, require call duty, or that have managed care, society has become quite receptive new employment and economic markets. They are ketplace. relatively high expenses for malpractice insur- to public and private regulation of the medical motivated in large part by being “expert”: effective It should not be surprising, then, that physicians ance (Berenson 2003). professional’s scope of authority and prerogatives in applying their specialized knowledge. (ibid). would increasingly behave like other, non-profes- (Friedson 1994; Stevens 2001). Using Drucker’s framework, it is important to sion knowledge workers. More and more physi- In short, physicians continue to exist and to Nevertheless, as described earlier, there are understand that a professional is a knowledge cians are taking employment as salaried workers practice as they traditionally have in America: organizations within medicine that work val- worker, but a knowledge worker is not neces- within group practices and in larger hospital or as members of a privileged occupation who iantly to define and energize professionalism. sarily a professional. The professional shares the managed care organizations. This began in a big must also be entrepreneurial and business-savvy. The American Medical Association, for example, traits of the knowledge worker, but he or she also way in the early 1990’s when hospitals and health However, in our increasingly market-driven envi- has promulgated principles of medical ethics has one other overarching characteristic: The systems of all types began to hire primary care ronment, this behavior appears to have become and promotes professionalism through a range professional is a member of a guild or common physicians and to acquire and assemble larger more intensive, entrepreneurial and profit-seeking of programs. All professional specialty societies

22 23 promote standards and maintain codes of eth- the European Federation of Internal Medicine, to paramount, as long as those decisions are in keeping Nevertheless, it has to be admitted that the ics. The American College of Surgeons (ACS), for create and promulgate a new physician charter. with ethical practice and do not lead to demands for Physician Charter has had only limited impact instance, has a long history of attention to devel- Their joint statement, “Medical Professionalism inappropriate care. within the United States. As with many other oping professionalism and professional standards. in the New Millennium: A Physician Charter” is recent attempts to gain the attention and enthusi- It founded the Joint Commission on Accreditation an extraordinary two-page document describing The principle of social justice. The medical profes- astic embrace of reform by professionals nation- of Hospitals and the Trauma certification program the principles and responsibilities to which physi- sion must promote justice in the health care system, wide, the Physician Charter has yet to have an in 1928, and the Residency Review Committees cians should strive as professionals (ABIM 2004). including the fair distribution of health care resourc- obvious impact on the overall behavior of the in 1952 (Sheldon 2002). The Association of The Physician Charter is a solid foundation upon es. Physicians should work actively to eliminate dis- medical profession or its public profile. It is to be American Medical Colleges (AAMC) is a strong which to build a new medical professionalism. crimination in health care, whether based on race, hoped that this is young document and its message advocate of ethics and professionalism in train- gender, socioeconomic status, ethnicity, religion, or will likely acquire more influence in the near term. ing and of establishing the highest standards in The Physician Charter begins: any other social category (ibid). hospital practice and management. Many medical “Professionalism is the basis of medicine’s contract Leadership is Key societies have supported public efforts to expand with society. It demands placing the interests of The Physician Charter then describes ten funda- Neither the IOM reports, the Physician Charter access to affordable health care for all (Sheldon patients above those of the physician, setting and mental professional commitments: statement nor any other policy statements alone 2005). In every state, medical licensing boards maintaining standards of competence and integrity, can effect significant change in the professional and medical societies monitor and enforce profes- and providing expert advice to society on matters of n To professional competence. standing of medicine. Driving change requires sional ethics and standards. All of these efforts, health. The principles and responsibilities of medi- n To honesty with patients. not just inspired vision but relentless leadership. and more, continue to develop and enforce pro- cal professionalism must be clearly understood by n To patient confidentiality. And one of the unfortunate and not well under- fessional standards in medicine. Yet, the overall both the profession and society. Essential to this n T o maintaining appropriate relations with stood characteristics of the recent, tumultuous impact of these efforts is not enough to dispel the contract is public trust in physicians, which depends patients. era in health care is the relative dearth of identifi- impression that the profession as a whole is more on the integrity of both individual physicians and n To improving quality of care. able or bold leadership in medicine on behalf of self-interested than public interested; and that it the whole profession” (ABIM 2004). (The Physician n To improving access to care. what Osler more than a century ago described as is more concerned with protecting its prerogatives Charter is reproduced in full in Appendix 1.) n To a just distribution of finite resources. medicine’s “progressive, scientifically-based and than in protecting the common, health-related n To scientific knowledge. forward looking character, and “Its singular benef- goods that medicine, as a profession, exists to It would be hard to state the external challenge n T o maintaining trust by managing conflicts icence and basis in charity.” protect. for medicine more clearly or forcefully. of interest. The Blue Ridge Group believes that good and Then the document articulates and annotates n To professional responsibilities (ibid). broad-based leadership from academic health Exceptional Efforts three fundamental principles. The first two are centers is key to salvaging the future of medical Over the last several years, the Institute of rooted in the profession’s traditional commitment The Charter ends with the following admonition: professionalism. Medicine and the ABIM and its Foundation stand to the primacy of the interests of the patient. The out as organizations that are successfully devising third refers to the profession’s larger social obliga- To maintain the fidelity of medicine’s social contract The Need for “Exceptional Medical programs and approaches that address the public tions, centered, in this rendering, on the principle during this turbulent time, we believe that physi- Professionalism” obligations of medical professionals. The IOM’s of distributive justice in the health care system. cians must reaffirm their active dedication to the recent series of reports on quality, safety, train- principles of professionalism, which entails not only “In a well arranged community a citizen should feel ing and other important public policy aspects of The principle of primacy of patient welfare. their personal commitment to the welfare of their that he can at any time command the services of a health care and professionalism have helped to The principle is based on a dedication to serving patients but also collective efforts to improve the man who has received a fair training in the science create a renewed public dialogue about the role the interest of the patient. Altruism contributes to health care system for the welfare of society (ibid). and art of medicine, into whose hands he may commit of health care and health professionals in society the trust that is central to the physician-patient with safety the lives of those near and dear to him.” (IOM reports). relationship. Market forces, societal pressures, and Altogether, the Physician Charter is a remark- The ABIM Foundation, too, has had a signifi- administrative exigencies must not compromise this able document – an international manifesto –William Osler (The Growth of a Profession. Can cant impact on the public debate. The ABIM’s principle. – that captures and promotes the highest ideals of Med Surg J 1885-86;14:129-55) Professionalism Project, discussed earlier, was just physician competence, practice and professional a first step in its ongoing focus on re-defining The principle of patient autonomy. Physicians responsibility. It is composed in such a way as to As previously described, American medical pro- and reviving professionalism. One of the most must have respect for patient autonomy. Physicians be virtually universal in scope and applicability. It fessionalism did not develop within a pre-existing impressive recent achievements in redefining pro- must be honest with their patients and empower is not just an American document, but resonates class and status regime or within an emerging fessionalism has been the ABIM Foundation’s ini- them to make informed decisions about their treat- with international, cross-professional and cross- social welfare consensus. American medicine tiative, in concert with the ACP Foundation and ment. Patients’ decisions about their care must be cultural experience and values. developed within a far less well-defined societal

24 25 commitment to social welfare supports and one program and policy underscores the legal profes- are generally considered unsustainable rates of 5. Health Care Services largely based on the primacy of private, market- sion’s commitment to promoting fair access to the growth of health-related costs. Hospitals, health Exceptional Professionalism would address the based initiative. To this day, publicly sponsored courts and the legal system for all and to the larger systems, group practices, and individual practi- poor organization of health care services. All pro- social welfare policies and programs in the United cause of upholding our nation’s justice system. tioners should work aggressively to organize care viders and provider organizations should work States remain the focus of tremendous conflict The Blue Ridge Group believes that American delivery so that it is cost effective. The health to achieve the IOM’s STEEEP aims, adopting and controversy. medical professionalism must develop similar and professions should also work with health care these publicly and adopting public measures for It is in this context that the role of profes- even more robust programs in support of its soci- industry, including drug, device, and medical accountability for achieving specific milestones. sionals in the United States must be defined and etal roles. Medicine must engage its larger social equipment manufacturers and suppliers and with championed. Without the European-style overlay obligations not with just inspiring principles but federal and state governments, to deliver evi- 6. Heath Care Conflicts of Interest of historical commitment to publicly sponsored with inspiring actions. And these must be shared dence-based, cost-effective health care. Exceptional Professionalism would address social welfare, American professionalism requires in the public sphere where they can be under- the growing issue of conflict of interest in the an “exceptional” commitment to the integrity stood and appreciated. 4. Health Care Training health care industry. With the current societal of the common goods within the fiduciary pur- Exceptional Professionalism would address the emphasis on technology transfer, and in the view of a profession. For professions composed Part II. Recommendations well-documented shortcomings of professional current environment for maximizing competi- not primarily of career public servants, but of education and training. The health professions tive and market advantage, there are extremely entrepreneurial salary workers and small busi- The Blue Ridge Group recommends that must undertake systematic re-evaluation and important and sensitive issues of conflict of inter- ness-people, the commitment to performance on Medicine, and all of the health professions, adopt reform of education and training programs that fail est that must be addressed and clarified through- the implied social contract of fiduciary respon- a robust and public “Exceptional Professionalism” to prepare the health care workforce for interdisci- out the health professions and in the public and sibility for “common goods” must be made very that would address, with proactive, relentless and plinary team and systems-integrated health care. private health sectors. publicly explicit. And the ability of individual entrepreneurial vigor, well-known problems that professionals to perform or “make good” on that threaten the integrity of our nation’s health system social contract must also be made easy to fit the and that inhibit the provision of the best possible circumstances of their work and lives. care to all who need it. Appendix 1 American medicine has displayed an “excep- At a minimum, we recommend that the follow- 2004 • ABIM FOUNDATION • ACP FOUNDATION • EUROPEAN FEDERATION OF INTERNAL MEDICINE tional” entrepreneurialism and business acumen ing society-wide issues should be addressed: that most distinguishes it from the professional- Preamble eral principles may be expressed in both complex and ism found in other nations. American medicine 1. The Uninsured Professionalism is the basis of medicine’s contract subtle ways. Despite these differences, common themes with society. It demands placing the interests of patients emerge and form the basis of this charter in the form of Exceptional Professionalism would address the must embrace and leverage that well-developed above those of the physician, setting and maintaining three fundamental principles and as a set of definitive exceptionalism in the cause of renewing the crisis of the uninsured with entrepreneurial vigor. standards of competence and integrity, and providing professional responsibilities. performance of its societal professional respon- It should entail a nationwide, professions-wide expert advice to society on matters of health. The prin- sibilities. The renewal of medical professionalism effort targeting the creation of new hospital ser- ciples and responsibilities of medical professionalism Fundamental Principles requires a newly proactive professional posture: vices, new programs and interventions in commu- must be clearly understood by both the profession and Principle of primacy of patient welfare. The principle society. Essential to this contract is public trust in physi- is based on a dedication to serving the interest of the nities and populations, and a high profile public an “exceptional” professionalism. cians, which depends on the integrity of both individual patient. Altruism contributes to the trust that is central Medicine and all of the health professions must effort to solve the problem of uninsurance. physicians and the whole profession. to the physician-patient relationship. Market forces, so- have concrete and highly public programs that At present, the medical profession is confronted by an cietal pressures, and administrative exigencies must not publicly and explicitly address their societal obli- 2. Health Care Payment Systems explosion of technology, changing market forces, prob- compromise this principle. gations. In the legal profession, for example, the Exceptional Professionalism would address lems in health care delivery, bioterrorism, and globaliza- tion. As a result, physicians find it increasingly difficult Principle of patient autonomy. Physicians must have American Bar Association and virtually all state the irrationality of current payment systems. Academic and non-academic health centers to meet their responsibilities to patients and society. In respect for patient autonomy. Physicians must be hon- Bar associations have well-publicized public poli- these circumstances, reaffirming the fundamental and est with their patients and empower them to make in- cies either requiring or strongly recommending should model new forms of team and systems- universal principles and values of medical professional- formed decisions about their treatment. Patients’ deci- participation in and support of pro-bono pro- integrated medicine with government and private ism, which remain ideals to be pursued by all physicians, sions about their care must be paramount, as long as grams by both organizations and individual mem- payors, insisting on standards of care driving pay- becomes all the more important. those decisions are in keeping with ethical practice and The medical profession everywhere is embedded in do not lead to demands for inappropriate care. bers of the bar. These policies are reinforced with ment rather than payment driving the organiza- tion of care. diverse cultures and national traditions, but its mem- Bar-sponsored programs that raise money from bers share the role of the healer, which has roots extend- Principle of social justice. The medical profession lawyers and law firms, run programs that enable ing back to Hippocrates. Indeed, the medical profession must promote justice in the health care system, includ- 3. Health Care Costs lawyers to easily volunteer their time for such must contend with complicated political, legal, and ing the fair distribution of health care resources. Physi- Exceptional Professionalism would address what market forces. Moreover, there are wide variations in cians should work actively to eliminate discrimination pro-bono work, and publicize such efforts. This medical delivery and practice through which any gen- in health care, whether based on race, gender, socio-

26 27 economic status, ethnicity, religion, or any other social care resources, and optimize the outcomes of care. Phy- fessional duties and activities. Relationships between Summary category. sicians must actively participate in the development of industry and opinion leaders should be disclosed, es- The practice of medicine in the modern era is beset with better measures of quality of care and the application of pecially when the latter determine the criteria for con- unprecedented challenges in virtually all cultures and A Set of Professional Responsibilities quality measures to assess routinely the performance of ducting and reporting clinical trials, writing editorials or societies. These challenges center on increasing dispari- Commitment to professional competence. Physicians all individuals, institutions, and systems responsible for therapeutic guidelines, or serving as editors of scientific ties among the legitimate needs of patients, the available must be committed to lifelong learning and be respon- health care delivery. Physicians, both individually and journals. resources to meet those needs, the increasing depen- sible for maintaining the medical knowledge and clini- through their professional associations, must take re- dence on market forces to transform health care systems, cal and team skills necessary for the provision of quality sponsibility for assisting in the creation and implemen- Commitment to professional responsibilities. As and the temptation for physicians to forsake their tradi- care. More broadly, the profession as a whole must strive tation of mechanisms designed to encourage continuous members of a profession, physicians are expected to tional commitment to the primacy of patients’ interests. to see that all of its members are competent and must improvement in the quality of care. work collaboratively to maximize patient care, be re- To maintain the fidelity of medicine’s social contract ensure that appropriate mechanisms are available for spectful of one another, and participate in the processes during this turbulent time, we believe that physicians physicians to accomplish this goal. Commitment to improving access to care. Medical pro- of self-regulation, including remediation and discipline must reaffirm their active dedication to the principles fessionalism demands that the objective of all health care of members who have failed to meet professional stan- of professionalism, which entails not only their personal Commitment to honesty with patients. Physicians must systems be the availability of a uniform and adequate dards. The profession should also define and organize commitment to the welfare of their patients but also ensure that patients are completely and honestly informed standard of care. Physicians must individually and col- the educational and standard-setting process for current collective efforts to improve the health care system for before the patient has consented to treatment and after lectively strive to reduce barriers to equitable health care. and future members. Physicians have both individual the welfare of society. This Charter on Medical Profes- treatment has occurred. This expectation does not mean Within each system, the physician should work to elimi- and collective obligations to participate in these pro- sionalism is intended to encourage such dedication and that patients should be involved in every minute decision nate barriers to access based on education, laws, finances, cesses. These obligations include engaging in internal to promote an action agenda for the profession of medi- about medical care; rather, they must be empowered to geography, and social discrimination. A commitment to assessment and accepting external scrutiny of all aspects cine that is universal in scope and purpose. decide on the course of therapy. Physicians should also equity entails the promotion of public health and pre- of their professional performance. acknowledge that in health care, medical errors that in- ventive medicine, as well as public advocacy on the part jure patients do sometimes occur. Whenever patients are of each physician, without concern for the self-interest injured as a consequence of medical care, patients should of the physician or the profession. be informed promptly because failure to do so seriously compromises patient and societal trust. Reporting and Commitment to a just distribution of finite resources. References analyzing medical mistakes provide the basis for appro- While meeting the needs of individual patients, physi- ABIM 2001. Project Professionalism. Philadelphia. probation, $500,000 fine and possibly its own end. priate prevention and improvement strategies and for cians are required to provide health care that is based on American Board of Internal Medicine. 2001. CNN/Money, June 16, 2002: 4:43 PM EDT Available at: appropriate compensation to injured parties. the wise and cost-effective management of limited clini- ABIM 2002. Medical Professionalism in the New http://money.cnn.com/2002/06/13/news/andersen_ver- cal resources. They should be committed to working with Millennium: A Physician Charter. Annals of Internal dict/. Accessed online 6/2/05. Commitment to patient confidentiality. Earning the other physicians, hospitals, and payers to develop guide- Medicine Vol. 36, No. 3, February 5, 2002. Benedetto AR. 2003. Six Sigma: Not for the Faint of trust and confidence of patients requires that appropri- lines for cost effective care. The physician’s professional Heart. Radiology Management. March/April 2003. ate confidentiality safeguards be applied to disclosure of responsibility for appropriate allocation of resources re- Agich GJ. 1980. Professionalism and ethics in health patient information. This commitment extends to dis- quires scrupulous avoidance of superfluous tests and pro- care. J Med Phil. 1980;5:186-199. Benson JA. 1991. Certification and recertification: One cussions with persons acting on a patient’s behalf when cedures. The provision of unnecessary services not only Anderson K. 1992. The purpose at the heart of man- approach to professional accountability. Ann Int Med. obtaining the patient’s own consent is not feasible. Ful- exposes one’s patients to avoidable harm and expense but agement. Harv Bus Rev. May-June 1992, pp. 52-62. 1991;114:238-242. filling the commitment to confidentiality is more press- also diminishes the resources available for others. Berenson R. 2003. Medical Malpractice Liability Meets ing now than ever before, given the widespread use of Basch PF. 1990. The International Health Profession. Textbook of International Health. Oxford U Press. New Markets: Stress in Unexpected Places. Issue Brief no. electronic information systems for compiling patient Commitment to scientific knowledge. Much of medi- 69. Washingtoon: HSC 2003. data and an increasing availability of genetic informa- cine’s contract with society is based on the integrity and York. 1990. tion. Physicians recognize, however, that their commit- appropriate use of scientific knowledge and technology. Bashshur RL. 2002. Telemedicine and Health Care. Berwick DM,Ware JE. 1990. Patient judgment of ment to patient confidentiality must occasionally yield Physicians have a duty to uphold scientific standards, Telemedicine Journal and e-Health. Vol. 8, No.1. No- hospital quality: Conclusions and recommendations. to overriding considerations in the public interest (for to promote research, and to create new knowledge and vember 2002. Medical Care. 1990;28:S39-S44. example, when patients endanger others). ensure its appropriate use. The profession is responsible Batalden PB, Nelson EC, Edwards WH, Godfrey MM, Berwick DM. 1989. Continuous improvement as an for the integrity of this knowledge, which is based on Mohr JJ. 2003. Microsystems in Health Care: Part 9. ideal in health care. New Engl J Med. 1989;320:53-56. Commitment to maintaining appropriate relations with scientific evidence and physician experience. Developing Small Clinical Units to Attain Peak Per- Betz M, O’Connell L. 1983. Changing doctor-patient patients. Given the inherent vulnerability and dependen- formance. Joint Commission Journal on Quality and relationships and the rise in concern for accountability. cy of patients, certain relationships between physicians Commitment to maintaining trust by managing con- Safety. Vol. 29, No. 11. November 2003. Social Problems 1983; 31(1):84-95. and patients must be avoided. In particular, physicians flicts of interest. Medical professionals and their orga- should never exploit patients for any sexual advantage, nizations have many opportunities to compromise their Bazzoli GJ. 2004. The Corporatization of American Bledstein BJ. 1978. The Culture of Professionalism: personal financial gain, or other private purpose. professional responsibilities by pursuing private gain or Hospitals. Journal of Health Politics, Policy and Law, The Middle Class and the Development of Higher Edu- personal advantage. Such compromises are especially Vol. 29, Nos. 4-5, August-October 2004. cation in America. New York. Norton, 1978. Commitment to improving quality of care. Physicians threatening in the pursuit of personal or organizational Beckham D. 2004. New Twist in Employing Physicians. Blue Ridge Academic Health Group. 1998a. Academic must be dedicated to continuous improvement in the interactions with for-profit industries, including medi- Hospitals and Health Networks Online. Health Forum, Health Centers: Getting Down to Business. Washington quality of health care. This commitment entails not only cal equipment manufacturers, insurance companies, and Inc. 2004. Accessed online 11/05. DC: Cap Gemini Ernst & Young US, LLC. maintaining clinical competence but also working col- pharmaceutical firms. Physicians have an obligation to laboratively with other professionals to reduce medical recognize, disclose to the general public, and deal with Beltran L, Gering B, Martin, 2002. A. Andersen guilty Blue Ridge Academic Health Group. 1998b. Promot- error, increase patient safety, minimize overuse of health conflicts of interest that arise in the course of their pro- Once grand accounting firm now faces five years ing Value and Expanded Coverage: Good Health Is Good

28 29 Business.Washington DC: Cap Gemini Ernst & Young Brewster M. 2003. Unaccountable: How the Accounting Drucker PF, 2001. The Next Society. The Economist, Batalden PB. 2003. Microsystems in Health Care: Part 3. US, LLC. Profession Forfeited a Public Trust. Hoboken, NJ. Wiley, November 3, 2001, 2-20. Planning Patient-Centered Services. Joint Commission Blue Ridge Academic Health Group. 2000a. Into 2003. Duffy J. 1993. From Humors to Medical Science: A His- Journal on Quality and Safety. VOl 29, No. 4. April 2003. the21st Century: Academic Health Centers as Knowledge Brock DW. 1991. The ideal of shared decision-making tory of American Medicine, 2nd edition. Urbana, IL. U. Hoover H. 1928. “Rugged Individualism Speech.” Leaders.Washington DC: Cap Gemini Ernst & Young between physicians and patients. Kennedy Institute J of Illinois Press. 1993 October 22, 1928. available online: http://www.pinzler. US, LLC. Ethics. 1991;1:28-47. Eckhert NL. 2002. The Global Pipeline: Too narrow, com/ushistory/ruggedsupp.html. Accessed11/1/05. Blue Ridge Academic Health Group. 2000b. In Pursuit Brook RH. 1994. Health care reform is on the way: too wide or just right? Medical Education. 36(7):606- Huber TP, Godfrey MM, Nelson EC, Mohr JJ, Campbell of Greater Value: Stronger Leadership in and by Academic Do we want to compete on quality? Ann Intern Med. 13, 2002. C, Baltaden PB. 2003. Microsystems in Health Care: Health Centers. Washington DC: Cap Gemini Ernst & 1994;120:84-86. Edelstein L. 1943. The Hippocratic Oath, text, transla- Part 8. Developing People and Improving Work Life: Young US, LLC. Brundtlandt GH. 2004. The Globalization of Health. tion and interpretation by Ludwig Edelstein. Baltimore: What Front-Line Staff Told Us. Joint Commission Jour- Blue Ridge Academic Health Group. 2001a. e-health Seton Hall Journal of Diplomacy and International Johns Hopkins Press, 1943. nal on Quality and Safety. Vol 29, No 10. October 2003. and the Academic Health Center in a Value-driven Relations. 4 (22) 7-12, 2004. Eisenberg L. 1977. The social imperative of medical Institute of Medicine, 1999. To Err Is Human: Building Health Care System.Washington DC: Cap Gemini Ernst Burstin HR, Kipsitz SR, Brennan TA. 1992. Socioeco- research. Science. 1977; 198:1105-1110. A Safer Health System. Washington, D.C.: National & Young US, LLC. nomic status and risk for substandard medical care. J Academy Press. Emanuel EJ, Emanuel LL. 1992. Four models of Blue Ridge Academic Health Group. 2001b. Creating a Am Med Assn. 1992;268:2383-2386. the physician-patient relationship. J Am Med Assn. Institute of Medicine, 2001. Crossing the Qual- Value-driven Culture and Organization in the Academic Casalino LP. 2003. Focused Factories? Physician- 1992;267:2221-2226. ity Chasm: A New health System for the 21st Century. Health Center. Washington DC: Cap Gemini Ernst & Owned Specialty Hospitals and Ambulatory Surgical Washington, DC: National Academy Press. Young US, LLC. Enthoven AC. 1993. The history and principles of man- Centers. Health Affairs Nov/Dec 2003: 56-67. aged competition. Health Affairs. 1993;24-48. Institute of Medicine, 2001a. Coverage Matters: Insur- Blue Ridge Academic Health Group. 2003. Reform- Casalino LP. 2005. Disease management and the ance and Health Care. Washington, D.C.: National Fagin CM. 1992. Collaboration between nurses and phy- ing Medical Education: Urgent Priority for the Academic organization of physician practice. JAMA. 2005 Jan Academy Press. Health Center in the New Century. Atlanta, GA: Emory sicians: No longer a choice. Acad Med. 1992;67:295-303. 26;293(4):485-8. Institute of Medicine, 2002. Care Without Coverage: University. Federman D. 1992. Professional accountability and Christakis DA, Fedutner C. 1993. Ethics in a short Too Little, Too Late. Washington, D.C.: National Acad- certification in internal medicine. J Gen Int Med. Bluestone N. 1993. A piece of my mind: The bottom white coat: The ethical dilemmas that medical students emy Press. line. J Am Med Assn. 1993;329:2580. 1992;7:225-227. confront. Acad Med. 1993;68:249-254. Institute of Medicine, 2002a. Health Insurance is a Fleck LM. 1992. Just health care rationing: A demo- Blumenthal D, Laffel G. 1989. The case for using Cohen, JJ, Gabriel BA 2002. “Not Just Another Busi- Family Matter. Washington, D.C.: National Academy cratic decision-making approach. U Penn Law Rev. industrial quality management science in health care ness”: Medicine’s Struggle to Preserve Professionalism Press. organizations. J Am Med Assn. 1989;262:2869. 1992;140:1597-1605. in a Commercialized World. Obstetrics & Gynecology Institute of Medicine, 2003. Health Professions Educa- Blumenthal D, Meyer GS. 1993. The future of the aca- 2002;100:168-169 Fletcher JC, Hoffmann DE. 1994. Ethics committees: tion: A Bridge to Quality. Washington, D.C: National Time to experiment with standards. Ann Int Med. demic medical center under health care reform. NEJM. Cooper RA, 1995. Perspectives on the physician work- Academy Press. 1993;329:1812-1814. 1994;120:335-338. force to the year 2020. JAMA 1995;274:1534-43. Institute of Medicine, 2003a. A Shared Destiny: Com- Flint A.1983. Medical ethics and etiquette: Commentaries Blumenthal D. 1997. The Future of Quality Measure- Cooper, R.A. 1997. The Growing Independence of munity Effects of Uninsurance on Individuals, Families on the National Code of Ethics. NY Med J. March 1983. ment and Management in a Transforming Health Care Non-physician Clinicians in Clinical Practice. JAMA. and Communities. Washington, D.C.: National Academy System. JAMA 278(19):1622-25. 1997;277:1092-1093 Flexner A.1915. Is social work a profession? School Press. and Society. 1915;1:902-911. Blumenthal D., Causino, N., Campbell E.G., and Core Committee, 2002. Institute for International Institute of Medicine, 2003b. Hidden Costs, Value Weissman, J. S. 2001. The relationship of market forces Medical Education. Global minimum essential re- Fox DM, 1991. Leichter HM. Rationing care in Oregon: Lost: Uninsurance in America. Washington, D.C.: Na- to the satisfaction of faculty at academic health centers. quirements in medical education. Medical Teacher. 24 The new accountability. Health Affairs. 1991;2:7-27. tional Academy Press. American Journal of Medicine 111 (4): 333-340. (2):130-5, 2002. Foa RP. 1986. Are physicians professionals? Pharos. Institute of Medicine, 2004. Insuring America’s Health: Bodenheimer T, Wagner EH, Grumbach K. 2002. Im- Costopoulos, M.G., Mikhail MA, Wennberg, PV, Summer 1986, pp. 21-23. Principles and Recommendations. Washington, D.C.: proving primary care for patients with chronic illness. Rooke, TW, Ewolt Moulton, LL, 2002. A New Hospital National Academy Press. JAMA 2002, Oct 9; 288(14):1775-9. Freidson E. 1994. Professionalism Reborn. Chicago, Patient Care Model for the New Millennium: Prelimi- IL.1994. Institute of Medicine, 2004a. Academic Health Centers: Bodenheimer T, Wagner EH, Grumbach K. 2002(a) nary Mayo Clinic Experience. Arch Intern Med 162; Leading Change in the 21st Century. Washington, D.C: Improving primary care for patients with chronic ill- March 25, 2002 Geheb MA, Dickey J, Gordon G, Beemsterboer P, National Academy Press. ness: the chronic care model, Part 2. JAMA 2002 Oct 16; Flaherty-Robb M. 2004. Looking Towards a Model of Delbanco TL. 1992. Enriching the doctor-patient rela- Kagarise MJ, Sheldon, GF. 2000. Translational Ethics: 288(15):1909-14. Organizational Performance: Can Health Systems Pro- tionship by inviting the patient’s perspective. Ann Int fessionalism and Competence be defined?A ugust 2004. A Perspective for the New Millenium. Arch Surg, vol. Bogdanich W. 1991. The great white lie: How America’s Med. 1992;116:414-418. ACGME Bulletin, 3–7 135:39-45. hospitals betray our trust and endanger our lives. Simon Detmer D, Steen E, eds. 2005. The Academic Health Kaplan RM. 1992. The Hippocratic predicament: & Schuster. New York, 1991. Gellhorn A. 1991. Periodic physician recredentialing. J Center: Leadership and Performance. Cambridge U Am Med Assn. 1991; 265:752-757. Affordability, access, and accountability in American Boyarski S. 1990. An MD-JD’s responses to the medical Press 2005. medicine. Academic Press. San Diego 1992. malpractice crisis. Pharos. Winter 1990; 16-21. Glied S. 1997. Chronic Condition: Why Health Reform Drucker PF, 1994. Post-Capitalist Society. New York: Fails. Cambridge, MA. Harvard U. Press. 1997. Krause EA. 1996. Death of the Guilds. Professions, Harper Collins; 1994. States and the Advance of Capitalis: 1930’s to the Pres- Godfrey MM, Nelson EC, Wasson JH, Mohr JJ, ent. New Haven: Yale University Presss.1996.

30 31 Kronman A. 1993. The Lost Lawyer: Failing Ideals of the Osler W. 1885. The Growth of a Profession. Can Med Future. Presentation to Blue Ridge Group Meeting July ment programs: Are they consistent with the literature? Legal Profession. Cambridge, MA. Harvard U. Press. 1993. Surg J 1885-86;14:129-55. 2, 2004. Managed Care Quarterly. 1999;7(3):56-66. Larson EB. 2003. General Internal Medicine at the Pear R. 1991. Study says fees are often high when doctor Sullivan, WM. 1999. “What Is Left of Professionalism Wagner EH. 2000. The role of patient care crossroads of prosperity and despair: Caring for has stake in clinic. The New York Times. August 9, 1991. after Managed Care?” Hastings Center Report 29, no. 2 teams in chronic disease management. Br Med J. patients with chronic diseases in an aging society. Ann Perkin H. 1996. The Third Revolution: Professional (1999): 7-13. 2000;320(7234):569-572. Intern Med. 2001; 134:997-1000. Elites in the Modern World. New York. Routledge, 1996 Sullivan, WM. 2005. Work and Integrity: The Crisis Wagner EH, Glasgow RE, Davis C, Bonomi AE, Pro- Larson EB. 2003. Medicine as a Profession – Back to Pescosolido BA, Martin JK. 2004. Cultural Authority and and Promise of Professionalism in America, 2nd Edi- vost L, McCulloch D, Carver P, Sixta C. 2001. Quality Basics: Preserving the Physician-Patient Relationship in the Sovereignty of American Medicine: The Role of Net- tion. San Francisco, CA. Jossey-Bass. 2005. improvement in chronic illness care: a collaborative ap- a Challenging Medical Marketplace. Am J Med. Vol 14: works, Class and Community. Journal of Health Politics, Swick HM. 1998. Academic Medicine must deal with proach. Jt Comm J Qual Improv. 2001 Feb;27(2):63-80. 168-172. February 1, 2003. Policy and Law, VOl. 29, Nos. 4-5, August-October 2004. the clash of business and professional values.Acad. Wasson JH, Godfrey MM, Nelson EC, Mohr JJ, Medicine 73:751-755,1998. Batalden PB. 2003. Microsystems in Health Care: Part Larson EB, Fihn SD, Kirk LM, Levinson W, Loge RV, Pham, HH, Devers, KJ, May, JH, Berenson, R. 2004. 4. Planning Patient-Centered Care. Joint Commission Reynolds E, Sandt L, Schroeder S, Wenger N, Williams Financial Pressures Spur Physician Entrepreneulialism. Taplin S, Galvin MS, Payne T, Coole D, Wagner E. Journal on Quality and Safety. Vol 29, No 5. May 2003. M. 2004. The Future of General Internal Medicine: Health Affairs, 23:2, March/April 2004. 1998. Putting Population-Based Care Into Practice: Report and Recommendations from the Society of Real Option or Rhetoric? J Am Board Fam Pract. Weick KE. 1995. Sensemaking in Organizations. Thou- Polanyi K.1957. The Great Transformation. Beacon General Internal Medicine (SGIM) Task Force on the 1998;11(2):116-26. sand Oaks, CA. Sage. 1995. Domain of General Internal Medicine. J Gen Intern Press, Boston 1957. Veblen T. 1963. The Professions. Daedalus, 92: 1963. Wennberg JE, Gittlesohn A. 1982. Variations in Med 2004; 19:69-77. Reich R. 2000. The Future of Success: Working and Liv- Medical Care among Small Areas, ScientificA merican Larson EB. 2004(a). Health Care System Chaos Should ing in the New Economy. New Yor, Vintage, 2000. Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. 1999. A survey of leading chronic disease manage- 246:120-134, 1982. Spur Innovation: Summary of a Report of the Soci- Reiser SJ. 1992. Consumer competence and the re- ety of General Internal Medicine Task Force on the form of American health care. J Am Med Assn. 1992; Domain of General Internal Medicine. Ann Intern Med. 267;11:1511. 2004;140:239-243. Reiser SJ. 1993. Doctor-hospital competition. Heal Man Blue Ridge Academic Health Group Report Ordering Information Linowitz, SM. 1994. The Betrayed Profession: Lawyer- Quart. 1993;15:22-5. ing at the End of the Twentieth Century. New York. Scribners, 1994. Relman AS. 1988 Assessment and accountability: The If you would like to order copies of this publication—or any of the others listed below—please contact third revolution in medical care. New Engl J Med. 1988; Ludmerer KM. 1999. A Time to Heal: American Medical 319(18):1220. Education from the Turn of the Century to the Eve of Janet Waidner Managed Care. New York. Oxford U. Press 1999. Ring JJ. 1991. President’s Address: The right road for Woodruff Health Sciences Center medicine — Professionalism and the new American Emory University Merry MD. 2003. Healthcare’s Need for Revolutionary Medical Association. J Am Med Assn. 1991;266:1694 Change. Quality Progress. September 2003. 1440 Clifton Road, Suite 400 Rodwin, MA, 1993. Medicine, Money, and Morals: Atlanta, GA 30322 Mirvis DM. 1993. Physicians’ autonomy: The relation Physicians’ Conflict of Interest. New York: Oxford U. Phone: 404-778-3500 between public and professional expectations. N Engl J Press, 1993. Fax: 404-778-3100 Med. 1993;328:1346-1349. Rothblatt S. 1995. How ‘Professional’ are the Profes- [email protected] Mohr JJ, Batalden PB. 2002. Improving Safety on the sions? A Review Article, Comparative Studies in Society Front Lines: The Role of Clinical Microsystems. Qual and History, 1995 37(1), 194-204. When requesting publications, please refer to the report number and title and provide your full name, Saf Health Care, 11:45-50. 2002 Sheldon GF. 1995. The health work force. Generalism organization name, business address, city, state, zip, telephone, and email. Mohr, JJ, Barach, P, Cravero, JP, Bilke, GT, Godfrey, and the social contract. Annals of Surgery 1995;222 MM, Batalden, PB, Nelson, EC. 2003. Microsystems in Health Care: Part 6. Designing Patient Safety into the Sheldon, GF. 1998. Professionalism Managed Care, and Report 9: Getting the Physician Right: Exceptional Health Professionalism for a New Era the Human Rights Movement. Bulletin of the American Micro System. . Joint Commission Journal on Quality Report 8: Converging on Consensus? Planning the Future of Health and Health Care and Safety. Vol 29 No.8. August 2003. College of Surgeons.vol.83, Number 12, December 1998. Report 7: Reforming Medical Education: Urgent Priority for the Academic Health Center Moreno JD. 1988. AIDS and the caregiver: The mean- Silverman ME, Murray PJ, Bryan CS, 2003. The Quot- ing of professionalism. Am J Hosp Phar. 1988;45:642. able Osler. Philadelphia. American College of Physi- in the New Century cians – American Society of Internal Medicine. 2003. Nelson EC, Splaine ME, Godfrey MM, Kahn V, Hess A, Report 6: Creating a Value-driven Culture and Organization in the Academic Health Center Spivey BE. 2001. Professionalism, Specialization, and Batalden P, Plume SK. 2000. Using Data to Improve Medi- Report 5: e-Health and the Academic Health Center in a Value-driven Health Care System cal Practice by Measuring Processes and Outcomes of Care. Competition. AM J Opthal. VOl 110, No. 6.1990.Stevens, J Qual Improvement. Vol. 26, No. 12. December 2000. RA, Public Roles for the Medical Profession in the Unit- Report 4: In Pursuit of Great Value: Stronger Leadership in and by Academic Health Centers ed States: Beyond Theories of Decline and Fall. Malden, Nelson EC, Batalden PB, Homa K, Godfrey MM, MA. The Millbank Quarterly Vol. 79,No.3, 2001. Report 3: Into the 21st Century: Academic Health Centers as Knowledge Leaders Campbell C, Headrick LA, Huber TP, Mohr JJ, Wasson Report 2: Promoting Value and Expanded Coverage: Good Health Is Good Business JH. 2003. Microsystems in Health Care: Part 2. Creating Starr P. 1982. The Social Transformation of American a Rich Information Environment. Joint Commission Medicine. New York. Basic Books, 1982. Report 1: Academic Health Centers: Getting Down to Business Journal on Quality and Safety. Vol 29 No.1. January 2003. Stobo, JD. 2004. Modeling Health Care Delivery of the 32 For more information, see our website: www.blueridgegroup.org 33 34