More Questions Than Answers: "Will professionalism be a casualty of MODERN MEDICINE?"

A day-long sesquicentennial symposium on professional values in medicine accomplishes its goal, stimulating thoughtful exchanges and beginning a dialogue that many say was overdue.

The bold question chosen for the title of a day-long symposium on the medical campus in early June as part of the Medical School's sesquicentennial turned out to be every bit as thought-provoking as its framers intended. As participants — about 135 in all — contemplated the future of a profession about which they all care deeply, a note of deep concern, with overtones of disappointment and despair, pervaded the day, especially as they related to forces seen as weakening the doctor-patient relationship.

Deb Stern, wife of moderator and symposium organizer David Stern, and Thomas Stern, M.D., father of David and a practicing cardiologist in Memphis, Tennessee, with James Woolliscroft, executive associate dean of the Medical School.

Invited speakers represented academic medical institutions from coast to coast, including the Columbia University College of Physicians and Surgeons, the University of California at Los Angeles and at San Francisco, and Stanford, as well as many faculty members of the University of Michigan Medical School and a leader of the Association of American Medical Colleges. Panelists also represented the range of medical media, from the New England Journal of Medicine to ER, the popular show produced by Warner Brothers Television. The insurance industry was represented by a director at Aetna and the pharmaceutical industry by a researcher at Parke-Davis.

Also participating were Joe Palca, a National Public Radio correspondent, and Gretchen Berland, M.D., a former producer of the PBS series, Nova, who became a physician herself and is now a Robert Woods Johnson Clinical Scholar at UCLA. Her recent video, Cross-Cover, a compilation of edited clips of residents' video recordings of each other on the night shift at Barnes Hospital in St. Louis, Missouri, was part of the program.

The unexpected presence of Atul Pande, Ph.D., a research scientist in psychotropic drug development at the Parke-Davis Pharmaceutical Research Division of Warner- Lambert in Ann Arbor, served as an ironic symbol of at least one of the participants' expressed laments of the day — mergers and acquisitions. Speaking on the panel for "Challenges to Professionalism in Practice," the discussion which elicited the day's most vibrant and heartfelt comments, Pande was there as a last-minute substitute for Peter Corr, Ph.D., president of Parke-Davis, who could not attend because he was involved in the final negotiations of Warner-Lambert's merger with Pfizer.

Pande, who had served on the Michigan faculty before joining Parke-Davis, noted the advantages and disadvantages of academic-commercial collaborations as he has experienced them. "The focus and means of the pharmaceutical industry, combined with academic medicine, have led to advances that would not otherwise be possible," he said.

But he also noted the "potential problems" in the relationships between individuals and the industry. In the case of the clinical practitioner, "the hazard arises from the inability of average practitioners to distinguish between the promotional and the educational," i.e., their reliance on drug company representatives for information about pharmaceuticals. In the case of researchers, he observed, "when you're on the faculty, easy access to funding from the pharmaceutical industry is alluring. The danger is if that's the only or prime consideration." And then there is the "academic physician delivering 50-100 talks a year on behalf of the pharmaceutical industry. This is an area where some caution may be advisable."

An ascerbic "Will it be a casualty?" was the question posed by Jerome P. Kassirer, M.D., editor-in-chief emeritus of the New England Journal of Medicine, referring back to the title of the symposium to make the point that the question had been answered long before. "That's ridiculous. The question is how big a casualty?" he said. "It's a casualty in so many ways; where do we begin? Having 44 million uninsured in this country is an unethical system. The marketplace runs it; that's unethical. It biases the information we're getting; that's unethical. Dr. Pande told it like it is."

"I misread the title," said Rita Charon, M.D., Ph.D., associate professor of clinical medicine at Columbia University College of Physicians and Surgeons in New York. "I thought it said, 'Will professionalism be a causality of modern medicine?' I thought that was a terrific question. Whether it's altruism or greed, service or privilege, there always is a professionalism, whatever its nature. Without professionalism, medicine is mechanical, a trivial pursuit."

Suggesting that physicians must listen to medicine itself as well as they listen to their patients, she shared the unhappy comments she herself has heard from her colleagues: "It breaks your heart to hear what medicine tells us, of the researcher whose work is interrupted because it's not patentable, of the internist seeing 20 patients in half a day. We must recognize these voices as the lament of medicine. What is it saying? Are we brave enough to hear? What is it that our medicine is and what is it supposed to do? We haven't even begun that conversation."

The symposium, perhaps, was such a beginning. There was much conversation, both talking and listening, among the panelists and speakers, and between them and audience members. "We should have made it a day and a half," commented James O. Woolliscroft, M.D., executive associate dean and director of graduate medical education at U-M, in his closing remarks. "I feel like a weaver with many different yarns, trying to make a tapestry. I'm glad Dr. Kassirer noted that professionalism has already taken some hits. This is not theoretical; we are dealing with a wounded profession."

So what, then, is meant by professionalism? How is it jeopardized by so-called modern medicine, which is increasingly in the thrall of giant insurance companies, HMOs and the pharmaceutical industry? And what is to be done, both by physicians already in practice and by those who train the physicians of the future?

Allen S. Lichter (M.D. 1972), dean of the U-M Medical School, and David T. Stern, M.D., U-M assistant professor of internal medicine and the symposium organizer, addressed the first question in their opening remarks.

Stern noted that "a professional has command of a special body of knowledge or skills, is given specific rights not generally provided to the public, and has specific responsibilities or duties not generally expected of the public," adding that "professionalism is not simply the adherence to an abstract list of values. It is, in addition, the ability to negotiate between two equally worthy values, such as honesty and efficiency, when they come into conflict."

A profession, Lichter suggested, is "a calling, not simply an occupation; a way of life with a moral value." Sharing his concern that "medicine is losing its distinctive voice," particularly as the doctor-patient relationship erodes, he also lamented the chipping away of public trust at the intersection of business and medicine. "Medical schools invest in these companies and take an equity interest," he noted. Universities have royalty arrangements under which they get money if the companies succeed. It is pervasive, and does not do us proud."

For most of the participants, the key to professionalism is in the doctor-patient relationship, and that is precisely what they see as under siege.

Darrell A. Campbell Jr., M.D. (Residency 1978), U-M professor of surgery and associate chair of clinical affairs, cited a survey showing 65 percent of patients dissatisfied with their physicians, 50 percent feeling their doctors didn't care, and 26 percent reporting a loss of respect for doctors. "The doctor-patient relationship is the cornerstone of medicine," he said. "Why aren't competency requirements and humanistic qualities intersecting as they used to? Part of it is the environment doctors practice in."

In addition to the conditions already cited, that environment includes "uncertainty for residents due to mergers and bankruptcies, academic medical centers under fire, reductions in workforces, HCFA regulations, and less time to teach," said Lynn Chen Jeffers, M.D., U-M surgery resident. Moreover, said Neal Baer, M.D., the ER producer and a pediatrics resident at Children's Hospital in Los Angeles, "attending physicians are now doing procedures themselves because of fears of lawsuits and government intervention."

"My father practiced medicine for 52 years out of his house," said Lawrence M. Tierney, M.D., professor of medicine at the University of California at San Francisco and associate chief of the medical service at the San Francisco VA Medical Center. "He was on call every night, and never burned out. Does that tell us something?" What it tells us, he suggested, is that however primitive Dr. Tierney's father's therapeutic resources may appear to us today, he never had to cope with the kind of external pressures that confront contemporary clinicians. Campbell quoted the results of a survey of surgeons that cited three principal factors in burnout: emotional exhaustion, feelings of depersonalization and cynicism, and a sense of low personal accomplishment. All have been exacerbated by the conditions of recent years, he noted, suggesting that may be why burnout now surfaces more frequently among younger doctors than their older peers.

"Will unions, managed care, consumerism and the pharmaceutical industry challenge the professionalism of tomorrow's physicians?" asked Susan Hershberg Adelman, M.D., U-M clinical associate professor of surgery, trustee of the American Medical Association, and president of Physicians for Responsible Negotiation. "Yes, yes, yes and yes. That's why this is such a problem for us: 90 percent of today's residents will become employees, and 50 percent of all physicians under 40 are employees. Employed physicians no longer have autonomy; they no longer have control of the conditions of patients, or of what they can give away to the poor."

Other than Joe Palca, the NPR correspondent who moderated the afternoon panel discussion, the only speaker who was neither an academic nor a physician was Nancy Gould, a board member of the U-M Women's Health Resource Center, who brought a ray of sunshine to the proceedings with her positive descriptions of her experiences as a patient, her admiration for physicians, and her desire to give them more power over their lives.

After recalling the "esteem in which doctors were once held," Gould said she got "the first glimmer of change in the system in 1992, when my surgeon said he just got a call from the insurance company saying it was time for me to go home (from the hospital). I thought that was outrageous-someone in New York or Chicago telling my doctor what I should do." In her work at the resource center, she said she often hears from patients that "what they want is a choice. They say, 'I can buy any car I want, I can pick who cuts my hair, I can get groceries where I want, but I have to take a doctor out of the phone book.' I'm an amateur," she acknowledged, "but I'm a mom, I'm a patient, and I want to help."

Absent a repeal of recent history, what measures will help both patients and doctors alike? In Adelman's view, one way for the latter to reclaim some of their autonomy, and thus in part their ability to advocate for the former, is through organizing. "It's essential for doctors to have some control over resources, some negotiating power," she said. She spoke positively about AMA initiatives aimed in this direction, and suggested that doctors also must gain control over situations in which ethical questions loom large. She noted the recent closings of three Detroit hospitals that largely served the poor and asked, "Is it professional for doctors to back away (in such situations)?" In addition to preserving jobs, she said, "We have an ethical obligation to fight for what the patient needs."

Several participants said the learning of those qualities deemed to comprise "professionalism" could no longer be left to the "hidden curriculum" but must be explicitly taught and rewarded. Indeed, David Stern cited a study showing that medical students' cynicism climbed dramatically from their first year to their fourth, along with negative attitudes toward, in particular, cancer patients, geriatric patients, the suicidal, the alcoholic, and the emotionally ill. As one of the residents in Gretchen Berland's video said regretfully, "I don't feel as sincere anymore."

"Faculty need to learn the same things students need to learn," said Stanford Professor of Medicine Kelley Skeff. "There is an environment now that requires new skills and behaviors to be taught simultaneously to faculty, residents and interns." Academic medicine must meet this challenge, agreed Jordan J. Cohen, M.D., president of the Association of American Medical Colleges. "Trust is earned, not owed," he said. "Is there evidence that trust in the medical profession is eroding? My perception is we are dealing with more examples of unprofessional behavior: greed, arrogance, abuse of power, misrepresentation, lack of conscientiousness, and undisclosed conflicts of interest.

"Graduate medical education must require the attainment of behavioral objectives," Cohen added, calling for comprehensive evaluations of professionalism, enforcing limits on resident work hours, re-balancing service and education, honoring the "E" in GME, and recognizing the power of the hidden curriculum. As for the faculty, "some conflicts of interest are unavoidable," he said, "but we must require full disclosure (an absolute minimum requirement), place strict limits on financial interests in research, prohibit the conduct of clinical trials by investors (a no-brainer, in my mind), hold faculty to high professional standards, and celebrate examples of professionalism."

In his closing remarks, James Woolliscroft mused about one of the overhead transparencies Darrell Campbell had used in his talk. It was a photograph of Campbell's grandfather, also a physician, dating from a century ago. "In 1900, doctors could do relatively little compared to today, but they were there for their patients and recognized the human elements," he said. "As science grew, we gave it great homage, but we didn't give as much homage to the art of medicine, and were sometimes disparaging of it."

A hundred years later, he said, we need to remember that "the death rate is still one per person," that medicine is experienced personally and individually, not scientifically. While acknowledging that managed care has no doubt brought some overdue financial discipline to the medical profession, Woolliscroft argued that economics cannot and must not be at the center of the enterprise. "Much of being a physician," he said, "is around the human-to-human interaction. As educators, we must focus on the constants." He closed the symposium with an unanswered question that summarized the deeply troubling issues shared during the day of discussion: "Is our responsibility to the patient, to society, or to corporate entities?"