Conflict of duty

One more challenge for physicians in the 21st century is addressing the quandary emerging over the concept of medical professionalism within an evolving healthcare system. At the heart of this debate is the conflict between the traditional Hippocratic ideal of clinical loyalty to individual patients and the broader managed care focus on the health of entire populations. Given this disparity, how do physicians rationalize the concept of medical professionalism with an industrial model of medicine and make it relevant for contemporary healthcare delivery?

The terms of the contract between physicians and their patients are defined by medical ethics, while the enforcement of the contract is assured through professional accountability.

The medical ethics component of professionalism is far too complex a topic to address here. However, the medical professionals bound by this social contract must be monitored for observing whatever behavior is deemed ethical at the time.

Such accountability lies at the very core of any profession, and the responsibility for that accountability must be clearly and effectively established.

Physicians have clearly expressed their dissatisfaction with any external responsibility for this accountability imposed by insurance companies and managed care organizations. Indeed, a study published in the March issue of theJournal of the American Medical Association found that 81% of surveyed physicians believe that changes in the healthcare system over the past 10 years have diminished their accountability to their patients.

On the other hand, physician preference for such accountability is merely a return to the self-regulation that has been woefully ineffective in the past.

State licensing boards, hospital medical staffs and peer review organizations have been reluctant to discipline anything less than the most egregious physician conduct. Yet on an individual basis physicians may ignore advances in clinical practice; abuse drugs and alcohol; overstep professional boundaries in physician-patient conduct; succumb to the financial temptations of fee-for-service reimbursement; or defraud third party payers in their billing and coding practices.

Therein lies the challenge for medical professionalism in the future, since neither self-regulation nor external accountability has resulted in the desired professional behavior. However, by virtue of being a profession, self-regulation is presumed, since everyone outside that profession lacks the knowledge or experience to do it appropriately. While that was certainly well demonstrated by the failed attempts of managed care to regulate physician behavior, what options for self-regulation remain?

The problems with self-regulation result from placing responsibility for behavioral accountability with individual physicians. Obviously, expecting each physician to be responsible for his or her own behavior is inadequate because not all physicians accept such responsibility. Even when placing the responsibility with groups of physicians, like medical staff committees or peer review organizations, many physician members function from an individual perspective, while each maintains personal liability for their own decisions.

However, three options exist for collectively accepting responsibility for medical professionalism, so that the perspective is broadened and the liability mitigated. They are professional associations, trade associations or physician unions, and physician organizations.

Professional associations are typically specialty-focused and may offer the accountability needed. For example, the American Board of Family Practice influenced physician clinical behavior when it required re-examination every seven years in order to maintain board certification. Unfortunately, the natural constituency of these associations is their specialty members, not all patients or physicians, so their focus may be too limited for comprehensive oversight of medical professionalism.

In a similar manner, the agenda for trade associations and physician unions tends to be the protection of its physician members from the vicissitudes of the marketplace, rather than holding the behavior of its members accountable to that marketplace. Furthermore, while lip service may be provided to patient advocacy, the constituents of these organizations are clearly physicians and not patients.

Thus their oversight of medical professionalism is precluded by a substantial conflict of interest.

Physician organizations include academic faculty practice plans, IPAs and medical groups. Medical staffs, peer review committees and quality oversight committees do not qualify as true physician organizations, for while comprised of physicians, their agenda and constituency often serve other organizations, like hospitals or state licensing boards.

In truly effective physician organizations, like the Mayo Clinic or the Cleveland Clinic, individual physicians assume collective responsibility for both clinical and business decisions of their organization. This allows them the breadth and objectivity required for overseeing medical professionalism, while their organizational status insulates them from any personal liability for their decisions. However, their ability to function optimally will ultimately be determined by the organizational integrity of their structure.

The physician organization model for accountability avoids the interference of nonphysicians in medical care delivery, while allowing collective responsibility to the organization to overcome the inherent weaknesses of self-regulation. Such collective self-regulation, in which the whole is greater than the sum of its parts, would appear to be an effective model for the accountability in the future. While the debate over medical professionalism continues, it remains to be seen whether physicians can make the sacrifices of personal autonomy necessary to preserve their professional autonomy through an organizational model of their choosing.