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