Physicians' self-regulation and professionalism is under intense scrutiny—much of it from inside the profession, as a remarkable series of JAMA opinion articles makes clear
If you're old enough, you can remember the doctor as part demigod, the sage Marcus Welby, MD, who always knew what was best. And drove a Chrysler.
But those days, like the TV show, are long gone.
Today,the would-be Dr. Welby stands—or rather, kneels—in a purgatorial circle, surrounded by accusations and suspicion from the public and his peers. Medicine's 50-year-old godly pedestal of self-regulation built on professionalism and integrity is cracking, or at least in need of major foundation repair. And doctors are very afraid of the flying debris.
That's the takeaway from this week's issue of The Journal of the American Medical Association, which is themed on the topic of "Professionalism and Governance." The issue contains 22 opinion pieces, an unprecedented number for a single issue in recent memory, says editor-in-chief Howard Bauchner, MD. All of the commentary focuses on the fermenting ire over the adequacy of our nation's standards for physician education, training, certification, staff credentialing, and discipline, many written by some of the biggest names in healthcare, like former CMS administrator Don Berwick, MD, and Joint Commission president Mark Chassin, MD.
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The articles delve into how doctors do or don't learn what they need to know, what the public should expect, and the myriad impacts from dramatic changes in how they're paid and how they work. For example, the burdens and potential of electronic health records conversion and the public reporting of their performance on quality measures.
Today's Dr. Welby is surrounded by accusations he has not implemented new knowledge into practice, is overly obsessed with making money while unaware of cost's huge burden on the nation's healthcare system or his patients, and that he repeatedly overprescribes opioids without checking patients' drug-seeking histories.
From within their own ranks, doctors are charged with being beholden more to the needs of a corporate employer or a cost reduction strategy than to those of their patients, or that they practice in referral networks based sometimes on a you- scratch-my-back-I'll-scratch-yours philosophy rather than who is the best doctor to treat the disease.
Take this passage from one Viewpoint by Ezekiel Emanuel, MD, author and chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania's school of medicine:
"Many of the important physician-driven problems affecting the U.S. healthcare system today relate to money: conflicts of interest of clinical researchers, physician evaluations based largely on the generation of relative value units, upcoding of services provided, the creation of physician-owned specialty hospitals that select and focus on caring for paying, healthy patients, the shift of sites of care not to improve patients' outcomes but solely to enhance reimbursement, the extensive use of medically unnecessary interventions, and providing highly reimbursed medical interventions when lower cost interventions are just as clinically effective."
Emanuel continued, "The real concern about professionalism is that money is corrupting the practice of medicine—that the pursuit of monetary gain for the physician is distorting judgments about what is best for the well-being of patients. All other threats to professionalism pale in comparison."
Failed expectations for doctors to keep up with state-required continuing medical education coursework prompts this Viewpoint from Steven Nissen, MD, chair of Cleveland Clinic's Department of Cardiovascular Medicine:
"Considerable evidence suggests that CME is unevenly applied within the U.S. healthcare system, and relatively ineffective in achieving the desired goals. … Physician knowledge of guideline recommendations for many important diseases is fair to poor, and adherence to these guidelines even lower.
"In a study of primary care physicians … who commonly treat patients with chronic obstructive pulmonary disease, only 33% knew the correct criteria for diagnosis," and in heart failure, only 27% of patients got guideline recommended therapies, Nissen wrote.
Nissen questions the sincerity of two-hour morning CME courses that take place in "resorts," allowing physicians to "enjoy recreational activities in the afternoon," and quoted a "highly critical" Josiah Macy, Jr. Foundation report that found 60% of the $2.4 billion spent on CME in 2006 was commercially funded, presenting "potential for bias" because of nonexistent firewalls that are supposed to be in place.
In his Viewpoint, "Professionalism, Self-regulation, and Motivation; How Did Health Care Get This So Wrong?" James Madara, MD, CEO of the AMA, rhetorically asks, "What is the role of professional organizations and societies in the medical profession's long-standing tradition of self-regulation, and what actions and influences might enhance the ability of the medical profession to operate effectively and responsibly?"
In a chart included in one JAMA editorial, authored by editors Bauchner, Phil Fontanarosa, MD, and fellow Amy Thompson, MD, readers are reminded that practitioners have been largely self-regulated by any of 17 nongovernmental, nonprofit standards and payment-setting organizations composed mainly of their peers.
They include the American Medical Association which establishes Current Procedural Terminology (CPT) codes; the American Board of Medical Specialties and its 24 member boards; The Joint Commission; the 70-member Federation of State Medical Boards; the National Board of Physicians and Surgeons; and numerous other groups that set minimum requirements for medical education curriculum and testing.
Much of the rancor of late, and the impetus for this themed issue, comes from new Maintenance of Certification requirements that physicians in 24 medical specialties must demonstrate to patients, payers, and the public to show continual learning in two-year cycles, Bauchner says. MOC requirements upended the old system, in which doctors merely passed an exam each decade and older doctors received lifetime exemptions after passing their first test.
New and extremely controversial requirements imposed by the largest professional certification board, the American Board of Internal Medicine, amid cries of profiteering and coercion, "have spilled over to other boards," raising the volume on the issue, Bauchner tells me.
"For me, and many others at JAMA, that issue led us to think about professionalism and self governance with respect to the entirety of medicine and not just recertification. We thought the best way of looking at undergraduate, graduate, and post-graduate training and other issues around professionalism was to solicit viewpoints by leading individuals in those areas.
"We also know that medicine is undergoing a fundamental change with more interest in value-based care and physicians being employed," he says. "It's possible that Medicare officials, or some other organizing authority, might step in to lay down rules that end doctors' self-governance."
Bauchner admits he is "worried that unless there are some very robust debates and discussion, medicine will lose what it's always prized, which is the very concrete, very substantial importance of self-governance."
"We're moving to far greater transparency than ever before. We know much more about physicians' conflicts of interest and where they get funds from. We know much more about physicians who bill Medicare and Medicaid at very high levels. That's absolutely in everyone's interest. But with that may come lack of clarity about what all that means. … It goes to the heart of what is professionalism."
Bauchner ended our conversation saying he hopes the themed issue will stimulate debate in a way that produces a solution to the rancor and noise. "Most of the organizations that formally oversee governance have no legal standing, so it really is a self-governing structure. And I think some questions need to be raised about whether this is the most effective governance structure."