Wednesday, December 12, 2007

Relman in JAMA on Threats to Physicians' Core Values

The purpose of the Health Care Renewal blog is to address "threats to health care's core values," as noted in our side-bar.

The latest issue of JAMA contains an important article by Arnold Relman on this topic.(1) Much of its content will be very familiar to Health Care Renewal readers.

Relman's first point is that physicians' core values are threatened:

Endangered are the ethical foundations of medicine, including the commitment of physicians to put the needs of patients ahead of personal gain, to deal with patients honestly, competently, and compassionately, and to avoid conflicts of interest that could undermine public trust in the altruism of medicine.

These threats arise from "the growing commercialization of the US health care system." This has been abetted by physicians who accept "the view that medical practice is also in essence a business." Thus, "the vast amount of money in the US medical care system and the manifold opportunities for physicians to earn high incomes have made it almost impossible for many to function as true fiduciaries for patients."

Relman also the growth of specialization, and the "greater economic rewards of procedural specialties," although he did not address why procedures have come to be better rewarded.

I think Relman's most important insights were about how legal changes in the US have undermined professionalism.

The law also has played a major role in the decline of medical professionalism. The 1975 Supreme Court ruling that the professions were not protected from anti-trust law7 undermined the traditional restraint that medical professional societies had always placed on the commercial behavior of physicians, such as advertising and investing in the products they prescribe or facilities they recommend. Having lost some initial legal battles and fearing the financial costs of losing more, organized medicine now hesitates to require physicians to behave differently from business people. It asks only that physicians' business activities should be legal, disclosed to patients, and not inconsistent with patients' interests. Until forced by anti-trust concerns to change its ethical code in 1980, the American Medical Association had held that 'in the practice of medicine a physician should limit the source of his professional income to medical services actually rendered by him, or under his supervision, to his patients' and that 'the practice of medicine should not be commercialized, nor treated as a commodity in trade.' These sentiments reflecting the spirit of professionalism are now gone.

Finally, Relman blames the "growing influence of the pharmaceutical industry," noting that the industry

uses its enormous financial resources to help shape the postgraduate and continuing medical education of physicians in ways that serve its marketing purposes. Physicians and medical educational institutions aid and abet this influence by accepting, sometimes even soliciting, financial help and other favors from the industry, thus relinquishing what should be their professional responsibility for self-education. A medical profession that is being educated by an industry that sells the drugs physicians prescribe and other tools physicians use is abdicating its ethical commitment to serve as the independent fiduciary for its patients.

It is striking that the notion that physicians core values are under external threat is now becoming mainstream.

Hearing from multiple physicians about their central concern "with the abandonment of the core values of medicine,"(2) prompted us to start planning for what eventually became this Health Care Renewal blog. In my European Journal of Internal Medicine article, I summarized these values from some prominent codes of medical ethics: they required "that the physician put the patient's interests first, and then require that the physician practice with honesty and integrity, to uphold the confidentiality of information about individual patients, and to be responsible for the education of the next generation of physicians." The more modern codes also required the physician "to commit to scientific medicine."

However, I wish this essay had considered a broader formulation of the causes of the current crisis.

On one hand, Relman did not discuss how the government runs its part of health care could have some responsibility for the current crisis. In particular, on Health Care Renewal, we have discussed, most recently here, how the US Medicare system allows its physician reimbursement, which heavily favors procedures over primary care, to be determined by a secretive committee, the RBRVS Update Committee, or RUC, dominated by proceduralists and sponsored by the AMA, the same organization that once condemned the commercialization of medicine. It turns out that Relman has just written a book (reviewed here) about how to reform health care, in which he advocated for a government run single-payer system. The notion that Medicare, our current government run single-payer system (albeit only for the disabled and the elderly) may be to blame for much of the current system's problems makes this position harder to defend.

On the other hand, although Relman decried the commercialization of health care, he focused on only one sector, the pharmaceutical industry. Although pharma has had its share of abusive leaders and practices, other sectors, including biotechnology, medical devices, health care insurance and managed care, health care information technology, etc, etc have not done much better (just page through Health Care Renewal for examples.)

On the third hand (oops), Relman came close to excusing the conduct of not-for-profit organizations within health care. He wrote only, "to survive in this new medical market, most nonprofit medical institutions act like their for-profit competitors, and the behavior of nonprofits and for-profits has become less and less distinguishable." Again, Health Care Renewal (and many others) have noted incompetent, conflicted, and even outright criminal leadership of many not-for-profit health care organizations, including some of our most revered. Relman's book, however, advocates that health care delivery be turned over to not-for-profit organizations. Doing so might provide little benefit unless we take drastic steps to improve not-for-profit governance, an issue which I am not sure the book addressed.

In summary, Relman's commentary should help shake awake those who keep thinking that US health care is the best in the world. It should also remind us how different things were only a generation ago. If only physicians still agreed that "'the practice of medicine should not be commercialized, nor treated as a commodity in trade," and that "'in the practice of medicine a physician should limit the source of his professional income to medical services actually rendered by him, or under his supervision, to his patients." (For more discussion of the history of the AMA's former opposition to commercialization of medicine, see Money-Driven Medicine by Maggie Mahar.)


1. Relman AS. Medical professionalism in a commercialized health care market. JAMA 2007; 298: 2668-2670. [link here]
2. Poses RM. A cautionary tale: the dysfunction of American health care. Eur J Int Med 2003; 14: 123–130.


Anonymous said...

Roy, I could not access the JAMA article, so perhaps my comments are redundant. I would ask you--did Dr. Rehlman address issues of arrogance/lack of hubris within the profession? I wonder how often patients actually hear the words, "I don't know, but I'll try to find the answer"?

Perhaps doctors have acute hearing problems since most seem unable to HEAR their patients' complaints. I know listening and hearing are not synonymous . . . but many doctors seem to posses neither.

Do doctors wonder about the diminishing esteem with which they are regarded? Do they wonder about the lack of trust they engender? Or are they satisfied that big bucks and sheer authoritarianism are all they need for fulfillment?

DDx:dx said...

I happened to agree with Dr. Relman's point, that professional ethics need to be emphasized and the business model solutions widely touted will lead back to the Pre Flexnerian days...Snake oil and nostrums. Which is honestly some of what we have now, with rampant over treatment, over scanning, over medicalization of the human condition.
But we have done it to ourselves and probably will continue to do so.
In response to ANON above, I think I hear patients complaints well. But they often come to me expecting "cures" when they are experiencing life...And this distance between what medicine can offer and what is expected(and doctors subsequent attempts to approximate what is expected, knowing we will fall short) can lead to increased suffering...When, in reality, it is our duty to listen and kindly tell the truth, not support the patients unreality.
I find the majority of physicians are quite troubled by the "moral hazard" issue of universal care. But we haven't reflected on our own moral hazard of fee for service.

Anonymous said...

Good review and good comments. I am currently reading the book, and find it resonating with some of my concerns, but offering, as you say, a conflicted solution.

He does not mention Illich's criticisms (which preceded his). (And Illich's answers, ironically, were similar to Relman's.) But the hubris of medicine seems to be the greater problem, bordering on idolatry.

There is a moral hazard to both approaches suggested. But that does not mean "damned if you do, damned if you don't." Rather, it means love your neighbor as yourself, and mutually submit to one another.