Thursday, April 5, 2012

There's a Physician Charter on Medical Professionalism?

Who knew? A friend sent me the link to an article in the New York Times entitled "Doctors Have Feelings Too" by Danielle Ofri. The subject matter of the article was interesting but what really caught my eye was the author's reference to a document entitled "The Physician Charter on Medical Professionalism" that was created in 2004 by the American Board of Internal Medicine, the American College of Physicians Foundation and the European Federation of Internal Medicine. This document has been endorsed by numerous medical associations including my own, the American Board of Family Practice. So how is it that I've never heard of it? 

The Charter catalogues the essential elements of my profession. The Preamble begins with the obvious, that the physician's contract with society demands that the needs of our patients are placed above our own needs. Judging by the stories I hear from patients who come to me and the letters I receive from specialists, this first responsibility is frequently lost in the noise of the economic, legal, political, technical and pharmaceutical messages that bombard us. Yesterday I saw the daughter of an 88-year old woman who broke her femur two weeks ago and had her leg stabilized with a metal plate. The plate has now slipped due to her severe osteoporosis and her orthopedist recommended that she undergo a total knee replacement. This recommendation was made in the context of a less than ten minute discussion with the daughter (her mom is too demented to participate). Thankfully, one of the nurses at her mother's nursing home was horrified enough to suggest that this line of treatment be reconsidered. I can't say what the orthopedist was thinking--my guess is that he is outrageously busy and therefore did not realize how demented the woman is, that the woman was unable to walk without assistance BEFORE she broke her leg and rehab following a knee replacement would likely be near to impossible. He didn't ask if she was having any pain (she isn't), he didn't ask about her mobility before her fall, he didn't think too hard about the morbidity associated with doing a knee replacement on this woman, he didn't go over the pros and cons of this type of surgery with her daughter, in short, he did not fulfill the first clause of the above mentioned contract. I wish I could say this is an unusual occurrence but unfortunately, it is not. Oh, and yes, his professional society has endorsed this charter. He's probably never seen it either.

After the Preamble is recorded the Fundamental Principles:
Principle of primacy of patient welfare. The principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.
Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.
Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.
The first two of these are obvious but how many of us, myself included, are working hard enough on the last one? Just judging by the political slogans and candidates endorsed by the bumper stickers on the cars in the doctor's parking lot, I'm guessing that most of them are not all that interested in actively eliminating health care discrimination. It might cause some change in the distribution of their own private resources.

The next area addressed by the charter is Professional Responsibilities which include:
  •  a commitment to life-long learning (seems obvious-who wants to go to a 20th century physician in the 21st century)
  • honesty with patients (the topic of the NYT article mentioned above)
  • upholding patient confidentiality (another obvious one but in today's world of social media and HIPAA it can be tricky. Sometimes the hardest thing is getting information necessary to treat from other providers who are terrified of breaching PHI)
  • maintaining appropriate relations with patients (another straightforward responsibility--don't sleep with your patient or otherwise take advantage of him/her)
  • commitment to improving quality of care and access to care. Quality of care seems straightforward but what about when doctors are seduced by peer-reviewed articles that encourage the use of pharmaceuticals that later are found to be no more improved than older medications or worse, more dangerous (see conflict of interest below)?
  • commitment to just distribution of finite resources. This responsibility addresses cost-containment issues. Really? Not only did I not realize there was a charter, but in it is addressed cost-containment! Amazing and it was written eight years ago. I said, most physicians don't know it exists.
  • managing conflict of interest. We are supposed to make clear all interactions with for-profit entities. Apparently this remains a problem in even our most prestigious journals--for example the BMJ which had to discredit a widely publicized article on autism and vaccines. There is ongoing evidence that big  pharmaceutical companies routinely suppress or fail to publish data that does not look favorable on their drugs. Another link...As mentioned above, this impacts quality of care.
  • a commitment to self-regulate. This concerns remediation, disciplining of failing physicians, and participation in the educational process both before and after a medical degree is conferred. 
Wow, this is a very complete document written by individuals who put a lot of thought into what our profession is about. I wonder if medical students are taught about it? Residents? I wonder if it was ever disseminated by my professional society, the AAFP. To repeat...who knew? Who knows? 

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