At the dawn of the 20th century, medical professionalism began a transformation. This refinement of traditional principles was based on increasingly rigorous training standards, growing scientific discovery, and new technical applications. Medical school education became a four-year immersion in clinical and basic science, hospitals became the site for teaching and surgically treating disease, postgraduate hospital-based residency training became the model for advanced medical learning, specialties proliferated, and those practicing medicine and surgery acquired a social position unknown in the 19th century.
But it was still “traditional” professionalism, based on an individual doctor-patient relationship and a code of ethics meant to create a public and personal trust in the physician’s motive and competence. The physician had an obligation to individual patients to advise and act in their best interest, to be knowledgeable and competent in the craft of medicine or surgery, and to be discrete, honest and compassionate.
The concept of professionalism changed in the last half of the 20th century, with the doctor no longer simply the Hippocratic oath-taker employing fancier tools. Technical complexity, growing effectiveness of medical care in combating disease and prolonging life, evolving concepts of social welfare, and steadily climbing costs all conspired to alter the responsibilities associated with professionalism.
The 1960s and 1970s saw uncomfortable challenges to the traditional concepts and image of professionalism. Accusations of physicians acting as part of a profit-seeking monopoly altered the public’s perception of physician altruism. The presumption of scientific evidence as the basis for medical care was assailed by claims of idiosyncratic physician practice patterns, variable and undependable healthcare quality, and failure to ensure oversight of physicians by their peers.
At the same time, the advent of multihospital corporate chains, pharmaceutical giants, billion-dollar academic centers, an explosively expanding medical device industry, and health insurance consolidation burst the illusion of medical care as a charitable or altruistic service. Healthcare assumed the demeanor of a profit-making business, associated with a buyer-beware caution rather than an altruistic assurance. Medical schools, accrediting bodies, and medical professional organizations were regarded by the Federal Trade Commission as price-fixing monopolies rather than agents of public interest and welfare.
The battered concept of professionalism sparked an identity crisis for physicians. The underlying issues were exposed in an exchange of letters during 1984 and 1985 between Arnold Relman, MD, former editor of the New England Journal of Medicine, and Uwe Reinhardt, James Madison Professor of Economics at Princeton. The letters, subsequently published in Health Affairs in 1986, debated the role of professionalism in modern healthcare. Dr. Reinhardt questioned whether healthcare “providers” were any different than other “purveyors of goods and services” in the competitive, commercial healthcare system; whether medicine’s conflicts were an inevitable result of its traditional entrepreneurship; and whether the profession’s concept of a “social contract” was disintegrating under commercial strains, or was simply an illusion, a self-justifying rhetorical device posing as a pseudo-bargain struck in a seller’s market. Dr. Relman’s defense of traditional professionalism was spirited, but unconvincing.
Responding to the perception of professionalism adrift in an increasingly commercial culture, the American College of Physicians, the American Board of Internal Medicine, and the European Federation of Internal Medicine proposed a new social contract in 2002, the Charter on Medical Professionalism. Notable in the proposal was a shift in the emphasis of physician responsibilities. In addition to the traditional commitments to competence, honesty, confidentiality, appropriate relations with patients, and managing conflicts of interest, the charter plowed new ground, asserting a commitment to scientific integrity, improving quality of care, improving access to care, and ensuring a fair distribution of finite resources. These last four responsibilities are public and social duties, not solely individual patient interactions. They imply an expanded professional responsibility to influence public policy for the general good.
Modern healthcare is a megalithic melange provided in a social framework that involves a triad of actors with differing roles: government, business, and the medical profession. Government adopts public healthcare policy, business drives the economic engine by which healthcare is delivered, and medical professionals ensure that the core values of healthcare are preserved in policy-setting, financing, and healthcare delivery.
Therefore, professionalism in the 21st century requires involvement in public policy, including legislation, regulation, and terms of contracting, to ensure that patient welfare is the foremost consideration and the highest standards of quality are maintained. Neurosurgery must adapt to this expanded concept of professionalism. We cannot provide service adequately when public policy threatens 40 percent cuts in fee levels. We cannot provide optimal service if public policy disallows payment coverage of the service. We cannot provide scientific proof if public policy prevents research by underfunding it. We cannot ensure optimal training if the time permitted for training is reduced beyond workable levels. Neurosurgery must be able to influence national legislative and regulatory policy for these and other issues to ensure that standards of care are preserved or improved, and not lowered.
The access to public policy for neurosurgery is through our Washington office and the AANS/CNS Washington Committee. Both have steadily increased in size and expenditure over the past 18 years in proportion to growth in their responsibilities. The Washington staff monitors all health-related legislation, proposals and actions by dozens of federal agencies, works with coalitions of medical specialties, organizes neurosurgery’s own quality and guideline initiatives, and coordinates position and policy proposals among neurosurgical organizations. There is no returning to simpler times, when healthcare primarily involved a physician advising and treating a patient.
Professionalism continues its transformation, and we are living through the process. Neurosurgeons today have a dual professional responsibility: the traditional responsibility to treat individual patients, and a contemporary charge to formulate public policy that ensures that the population as a whole enjoys the optimal benefits our science, training, and technical advances can provide.
This column and the AANS Annual Meeting will conclude my 2008—2009 term as president of the AANS. I want to thank the members of the Executive Committee and the entire AANS Board of Directors for their support and work throughout the year, making my task inexpressibly easier. I wish to thank every AANS member who served the organization on a committee or in another position this year. Commitment and personal sacrifice such as theirs have made the AANS the successful and highly regarded organization it has become over the years. And I must thank the AANS staff members for their reliability, commitment, and professionalism in keeping the association functioning smoothly and dependably, whatever the momentary challenge.
It has been an honor and a privilege beyond description to serve. I have every confidence that the AANS will thrive under my successors, reach everhigher planes of success, and meet the inevitable challenges of the future with equanimity and resolve. Neurosurgery will continue to be a profession like no other, worth the commitment of a lifetime of dedication and effort.
James R. Bean, MD, is the 2008-2009 AANS president. He is president and managing director of Neurosurgical Associates PSC in Lexington, Ky. The author reported no conflicts for disclosure.
For Further Information
- American College of Physicians, American Board of Internal Medicine, European Federation of Internal Medicine: Medical professionalism in the new millennium: a physician charter. Ann Intern Med 136(3):243-246, 2002
- Latham, SR: Medical professionalism: a Parsonian view. Mt Sinai J Med 69(6):363-369, 2002
- Relman, AS, Reinhardt UE: Debating for-profit health care and the ethics of physicians. Health Aff 5(2):5-31, 1986
- Stevens, RA: Themes in the history of medical professionalism. Mt Sinai J Med 69(6):357-362, 2002