Thursday, September 6, 2007

Session 3: The "Crisis" in the Ethics and Profession of Medicine: The Perspective of Medical Education

Jordan Cohen, M.D.
President Emeritus
Association of American Medical Colleges

David Leach, M.D.
Executive Director
Accreditation Council on Graduate Medical Education

CHAIRMAN PELLEGRINO:  This afternoon we will continue the discussion of professionalism, and we will begin the discussion with Dr. Jordan Cohen, who is Professor Emeritus of the Association of American Medical Colleges, and very much instrumental in the development of current ideas and contemporary directions in professionalism.

Jordan, it's all yours.

DR. COHEN: Thank you very much, Ed, and to the Council for the invitation.  It's really an honor and a privilege to be able to share some thoughts with you.  I was very much informed by the discussion this morning that David Rothman stimulated.  I think your comments and your questions were awe inspiring, I must say.  So I'm not sure I can answer the gauntlet that David threw down at me, but I will give it my best shot.

Anyway, how do I give my presentation?  If I just do this, something good will happen (indicating microphone).  Fabulous, good.

Well, I want to begin with a quote from a wise man that I once knew, who said, "Across history, culture, nation, ill persons are vulnerable, dependent, nervous, fearful, and perhaps most importantly, exploitable.  They are dependent upon physicians' technical knowledge and skill.  The physician invites trust" - and I would urge you to keep that word in mind" - and the patient is forced to trust.  Fidelity to this trust is the moral compass that must always be the profession's guide."  You won't be surprised who said that.

So Dr. Pellegrino not only has inspired much of the contemporary discussion about professionalism and the ethical and moral foundations of medicine, but I also, in the interests of full disclosure, have to tell you that he was my academic grandfather.

One of the medical schools he started at [State University of New York at] Stonybrook, I had the privilege of being the dean once removed from Ed's tenure there.  So I have had the privilege of knowing him and admiring him for a very long time.

Well, let me hearken back to your June Council meeting, because, again, I thank you for giving us the opportunity to review that session, and particularly the comments of William Sullivan, who presented the theoretical basis for the importance of professions, professional work and professionalism.

And I took away, at least his take-home message to me was, that society reaps essential benefits from professions as long as professionals adhere to the core principle of professionalism, that is, placing public interest ahead of self interest.

And then Arnold Relman, in a very impassioned recitation of his concerns, he detailed what many of us I think are concerned about, the contemporary threat to professionalism that is posed by commercialism and by the investor-owned enterprises that have proliferated over the last several years in our health care system.

His take-home message was we should purge the healthcare system of the alien profit-oriented value system of commercialism and restore the traditional service-oriented value system of professionalism.

Well, what David Leach and I have been asked to share with you today is the perspective of medical education.  And I'm going to take the medical school, the undergraduate medical education perspective, and David will follow with the second phase of formal education, the graduate medical education.

But from the medical school's perspective, and again, I have to confess this is as much my own personal perspective as the medical school's perspective - I'm not sure I can speak for the medical school perspective - but from my perspective, I think the threat that Dr. Relman highlighted is clearly real. 

At least in my professional lifetime, I don't think I've ever seen a period of time when there has been as much concern and assault on the basic fundamental commitment of professionals to their ethical foundations as is the case today.

And I often try to capture this in contrasting the models of commercialism, or the marketplace, with the motto of medicine.   The motto of the marketplace is "Caveat emptor," buyer beware.  When you enter into a commercial transaction, you have to assume that the person on the other side of that transaction is interested in his or her purposes and self-interest, not primarily interested in your interest and concerns.

The motto of medicine?  "Primum non nocere," "First, do no harm."  The first obligation of the professional, the medical professional, is to insure that that interaction is to the benefit of the patient, and certainly not to the harm of the patient.

So that, at least to me, captures the tension between the commercialism ethic and the professional, medical professional ethic.  And it's captured in a lot of the verbs, or a lot of the words that we use to describe those interactions.

We have "patients" rather than "customers."  We have "doctors" rather than "providers."  We have "care" rather than "profit."  So a lot of what is in the vernacular I think captures this important difference — and the degree. 

As Dr. Relman expressed extensively and very well, there is a real threat to the fundamental medical ethic by the commercial enterprises that are so much in evidence in medicine today.  So the threat is real. 

Trust in the medical profession does appear to be waning.  In fact, there are some studies that document, in terms of public polling, that the public is less confident about the profession.  They still express a great deal of confidence about their individual physician, but they have over time seemed to be less convinced that the profession as a whole is organized and behaving in a way that is to their particular liking or expectation.

So I do think, again, anecdotally, and again, Professor Rothman gave you a series of recent articles and they are coming, as he said, daily, that sort of document in the public press the concern that's being expressed in that arena about the lack of professionalism among some of our colleagues.

And clearly, I think, at least I would argue, that sustaining trust is absolutely critical for insuring safe and effective care.  And why do I say that?  Because I don't think that there is anything that can protect the patients like trustworthy physicians.

We can't depend upon the marketplace to have a primary interest in protecting patients' interest.  Nor do I think we can depend upon government to establish regulations that can prevent the potential dangers that entering the medical interaction poses. 

So, no laws, no regulations, no patient bill of rights, no watchdog federal agency, no fine print in an insurance policy, and certainly not even the President's Council on Bioethics, I think, can substitute for having a trustworthy physician who is honor-bound to act in such a way as to be in the best interests of the patients and of the public.

Now, what is professionalism?  Well, as has been discussed several times, it's been bandied about, there's lots of different definitions.  The one that I tend to focus on, the one that I use in my own teaching, is an articulation by a consortium of organizations, the American Board of Internal Medicine Foundation, the American College of Physicians Foundation, and interestingly, the European Federation of Internal Medicine.

This was an effort to try to see whether or not in the contemporary world of medicine one could articulate or identify a set of principles and responsibilities for physicians that were transnational, at least transatlantic in nature, and not just specific to the American circumstance.

So this group was convened with the representation of our European colleagues to see if one could come up with a statement that captured in contemporary vernacular the fundamental principles and responsibilities of professionals. 

And the Physician Charter that you may already have had presented to you in one form or another, but I want to briefly remind you what the Charter called for, because I do think it answers at least some of the issues that Dr. Kass mentioned earlier today about the difference between a healer and a professional.

The fundamental principles that this group identified were sort of the time-honored pre Hippocrates principle, the primacy of patient welfare.  I think that's the touchstone of every affirmation of professionalism that I've ever read.

A more recent, but I think, again, historically quite old view of professionalism is based on the principle of patient autonomy, that patients have individual rights and a sense of identity, that one cannot violate a competent patient's interests or desires. 

So one always has to be operating with the notion that the patient is an autonomous human being who has his or her own set of values and interests in that transaction.

As far as I know, there has been no previous formal statement of medical professionalism that has as explicitly included social justice as part of the individual physician's professional responsibility as a principle of those responsibilities.

But the Charter group felt that given the modern world with all its complexities and all of the difficulties that are involved in the organization of medicine and the financing and delivery of healthcare, that social justice was an important element of the commitment of physicians to professionalism.

And it went on then to identify ten categories of professional commitments that were called for under the three principles.

The first, professional competence.  Obviously, a fundamental requirement, and again, Dr. Kass, I think, this is the healer component of the doctor's responsibility, to be competent, to have the expertise that is advertised, and to deliver that competence and maintain that competence through a lifetime of a career.  And that is a fundamental commitment, to maintain that competence.

And I'm sure Dr. Leach will speak more about that, because that's a very important part of the modern challenge to professionalism, is to maintain that competence through a lifetime.

Second is to be honest with patients.  Again, a fundamental responsibility, commitment of physicians, always to be honest, to maintain patient confidentiality, to maintain appropriate relations with patients, not to abuse the power gradient that almost always exists between doctor and patient, to be sure that that gradient is not exploited at the disadvantage of patients with sexual abuse, other kinds of inappropriate relations.

Scientific knowledge.  A commitment to use scientific knowledge, evidence-based medicine, use the best science that's available for the decisions that are made.  But also to continue to support the advance of the scientific basis of medicine, continuing to explore new knowledge and develop new ways and better ways of delivering healthcare to our patients.

Professional responsibility.  Much of what Dr. Rothman spoke about this morning was the commitment of individual physicians, professionals, to maintain a professional set of organizational structures that can in fact interdigitate with society in such a way as to fulfill the professional commitments.  So individual physicians in this view should be committed to involving themselves in professional responsibilities in order to fulfill their obligations under the social contract.

Now, the next three are really under the rubric of social justice and getting into the issue of civic professionalism, if you will.  Improving the quality of care-something, again, that is terribly important, given what we now know about the errors that are rife in medical practice and some of the difficulties of maintaining a patient's safety in our systems, taking advantage of the knowledge that we now know from other walks of life about the way to improve, continuously improve the quality of care.

To improve access to care.  Again, individual physicians have a limited ability in their own individual practices to improve access to care, although that's always been a traditional commitment.  The AMA has called for physicians always to open up their practices to indigent patients.  But clearly it's a commitment that needs to go beyond the individual physician.

And a just distribution of resources.  Similarly, there's only so much individual physicians can do in their dyadic relationship with patients to insure the just distribution of resources.  But a commitment to involve themselves in a civic professionalism to accomplish this.

And finally, and I would say most importantly, clearly from the standpoint of our discussion today, is to maintain trust by managing conflicts of interest.  Again, the conflicts of interest that Dr. Relman spoke of and Dr. Rothman spoke of this morning I think are inevitable in our complex circumstance.  And our obligation as medical professionals and to fulfill the commitment of professionalism is to manage those conflicts of interest.  Eradicate them when possible, but recognizing that it's not ever possible to completely eradicate conflicts of interest. 

We all have conflicts of interest in everything we do, not just in our professional work.  And so it's not a question of eliminating conflicts of interest, but it's recognizing them, managing them, insuring that they do not overarch or trump our commitments as professionals when we're in that kind of relationship.

Well, that's sort of the framework in which medical educators now are trying to fulfill their obligation.  And I just wanted to say a few words about that.

So, sustaining trust is what fundamentally professionalism is all about.  It's maintaining this understanding between individual patients and their doctors and between the public at large and the profession as a whole that we can be trusted with this responsibility that we have to work in the public interest.

Professionalism in medicine is centered on the primacy of patient interest.  And we had an interesting discussion this morning about what patient interest is.  And I would concede that that is a very vague term, in terms of the kinds of interests that we're talking about. 

But in the context of this discussion, I think we're talking about what is in the best interests of insuring and maintaining that a patient's health is the interest that that patient has when entering this relationship.

What a professional does is choose voluntarily, and I think that's an important part of this notion, that this is an honor-bound commitment, a voluntary commitment, to place the patient's interest ahead of one's self interest.

Clearly, we all have self interest.  There is no denying that, or we should not shy away from that recognition.  But it's a question of how you balance one's own interest against the obligation of a professional to voluntarily concede that interest in favor of the patient's interest.

Rampant commercialism in today's health care system does in fact, I think, offer unprecedented temptations to physicians to yield to self interest.  And here I want to make the point that I think is obvious to all of you, namely, that we've never, in the history that I know of in medicine, been free of temptation to violate this ethic of primacy of patient interest. 

There's always opportunity.  There always have been opportunities for physicians to express their self interest, in how often they see a patient, what tests to order, what diagnoses to make-all kinds of ways in which the relationship between a doctor and a patient can be exploited for self interest.  And that's never been absent from medicine in time out of mind. 

What is, I think, changed in the modern era is the magnitude-the extent of those opportunities and the magnitude of those opportunities for temptation.  So Relman's answer to this dilemma, or this reality of the temptations that are so much in evidence, is to reduce those temptations.  And I don't think one should discount the absolute importance of that effort. 

Whatever we can do to restore a better balance between the temptations that are always there and what physicians have to confront in fulfilling their professional obligations is clear.  But clearly, to reduce those temptations to the extent possible is a very important part of the effort to try to sustain professionalism under the modern circumstances. 

And I would say as a quick and dirty summary of what medical education's answer to this dilemma is, is that we are responsible as educators to bolster the resolve of future physicians so that they can withstand the inevitable temptations that are there.  So we don't see the job of education as addressing these larger societal issues, although I will come back to that at the end of my talk.

But rather, our focus is recognizing that those temptations are always going to be there in some form or another, no matter how successful we are in reducing them, but that we want to be sure that our trainees, our students and our trainees, are sufficiently fortified with their commitment to this fundamental ethic so that they can withstand these temptations and maintain their resolve to keep the patient's interest uppermost.

So, how do medical schools go about doing that?  And again, I was very taken with the article in your agenda book by Coulehan, who talked a lot about the current ability and mechanisms that are at play in medical schools to try to bolster professionalism.  And I think he's right, that we haven't yet done an adequate job. 

We have a lot more that we can do and should be doing in order to make this more of a reality.  And I think some of his suggestions are extremely well put.  Another Stonybrook graduate, by the way, just to give proper acknowledgment to Dr. Pellegrino's legacy.

In any event, the first thing, and perhaps the most important thing that medical educators at the medical school level can do is to insure that the students who are accepted into medical school, as best we can, have the requisite character traits in order to provide the substrate to develop these professional commitments.

And this is, I think, a task that medical schools have understood for a long time.  We recognize that, given the fact that - I don't know what the figure is currently - but something like 97 percent of medical students who are admitted to medical school receive the M.D. degree.  Many of those who don't graduate choose to leave medical school, for reasons that they just made the wrong choice.

So it's very difficult to flunk out of medical school.  It takes a lot of effort to flunk out of medical school.  So the upshot of that is that the medical school admissions committee is really the entry point to the profession.  They are the gatekeepers, if you will.  That's where people get from laity into the priesthood, is through the door of the medical school admissions process.

So there's a tremendous amount of importance that's laid at the doorstep of the admissions office in order to develop whatever techniques they can to insure that those students who do gain entrance to medical school have the requisite character traits. 

And as I'm sure you know, there are now over twice as many students applying to medical school as there are places in our current medical school classes.  So this is a daunting task, to try to select among those very talented people, those that have not only the intellectual and academic backgrounds that are predictive of success, but they also have the evidence of these character traits.

Now, how do you measure that?  What sort of tools are used?  We all recognize that we have very imprecise ways of identifying students who are truly committed to these professional norms and the moral basis of the profession.

But I think by and large, admissions committees do a very good job.  There are very few students who turn out to be psychopathic or really fall far short of the expectations of the profession, not to say that there isn't a great deal more that we could and should be doing in order to sharpen that requirement, and sharpen that decision-making so that we can even more certain that these students that we admit do in fact have these requisite traits.

My own anecdotal observation - and I'd be interested in you all's view of this yourself - I think we are admitting an exceptionally talented, idealistic, committed group of students.  And I would credit some of that to the fact that we now have as many women as we have men in the entering class.  I think the women have done a lot to improve the atmosphere of the profession and have, I think, contributed to this sense of service, sense of obligation to others. 

In any event, whether that is a reality or not, the fact is - or at least the impression I have, the strong impression I have, is that the students that are now coming into the profession are endowed with a very rich resource of personal characteristics that I think ensure that if we can keep that alive - and that's the big challenge-that we will have a future cadre of physicians that will in fact be resilient to the threats and the temptations that are out there.

Well, secondly, it's clear that at least one of the things medical schools need to do is to organize their formal curriculum so they can address not only the rationale for professionalism, but also be sure that our students understand what the barriers and the threats to professionalism are as they go through their professional lives.

Again, I agree with Dr. Foster that the formal curriculum is important, but clearly not the be all and end-all.  It's nowhere near as important as the role modeling and the kind of experience that students have going through particularly their clinical education.

But nevertheless, I would like to underscore the fact that there is a need for some formalism, some didactic experiences, some knowledge base and cognitive understanding of what professionalism is about, its historical underpinnings, and, again, particularly the threats that our students and residents will eventually encounter during their professional life, to maintaining a commitment to those fundamental responsibilities.

And here's the issue of the informal curriculum, or the hidden curriculum, as it's been called.  And I don't think there's any question about the fact that many of our learning environments, particularly in the clinical settings, are not emblematic of the kind of professionalism that we'd like to see communicated to our students.

There is also no question about the fact that students take away much more strongly the lessons from what they see rather than from what we say.  And we need to recognize that our behavior, our interactions with each other as professionals, our interactions with our patients, the way the institutions operate in terms of their commitment to institutional ethics-all of those things contribute to an environment that presently is not nearly as conducive to bolstering this commitment to professionalism as it needs to be.

We need to recognize that we have crucibles of cynicism, as I've called them, that we have many learning environments in which our students are not exposed and witness the kind of level, the standard of care, standard of interaction, standard of relationships that we would like to see.  We need to convert those into cradles of professionalism, recognizing that that is where professional identity is truly established in this educational context.

And finally, I think we need to be much more objective, much more precise about what we expect physicians, future physicians, to exhibit before they graduate.  We need to give them a prospective understanding, not only of the knowledge and the technical skills that they need to demonstrate, but also the attitudinal and behavioral attributes that define professionalism. 

And we need to have much better ways of evaluating the achievement of those professional objectives, just as we evaluate the achievement of a certain degree of knowledge and technical skill.  We need to be willing and able and strong in our evaluations to sanction bad behavior, to not pass on from one class to the next students who we know have fallen short of this aspect of their professional responsibilities as well as their academic performance. 

So sanctioning bad behavior is part of the responsibility of the institution.  As important in fact, I think probably more importantly, to celebrate exemplars of professionalism, to have ways in which we can identify and hold up as exemplars the kinds of individuals and their individual performance that does give visibility to these values that we're trying to inculcate. 

So there are many obstacles in medical schools, and I've identified some of these in passing.  But just let me repeat that one of the issues is cynicism among faculty role models. 

We have faculty that are very stressed under the present time, by and large, with lots of responsibilities, lots of expectations that take their attention and their time and their commitment away from their fundamental obligation as faculty, namely, to teach and to pass on to the next generation these values that we're talking about.

And to the degree that our faculty have been frustrated in their attempts to maintain their professional identities, that's very easily communicated to the next generation. 

So we need to understand that faculty are a key element here, and we need to help them maintain their commitment to professionalism, to honor that commitment, and to insure that what they are responsible for achieving in their multiple roles does not undercut and undervalue their function as role models for future physicians.  It's a huge undertaking. 

Again, a lot of what is going on, as I'll mention in a moment, is far beyond what the profession and what the school can really get its arms around, because so much of this is embedded in the system of healthcare that we are involved with that we have very little opportunity to directly influence. 

But nevertheless, I think we have to recognize this as an issue and redouble our efforts to try to insure that faculty are not converted to cynics in the process.

Conflicts of interest in clinical research is another barrier.  We've had, I think, a very interesting period in our country over the last several decades, where we've recognized the really very important public purpose that's served by academic institutions involving themselves with commercial entities and translating basic science discoveries into useful services and products for the public. 

And this interaction, again, serves a very important public purpose.  But it has a very important caveat, and that is the degree to which conflicts of interest, financial conflicts of interest in particular, can become embedded in those relationships to the degree that at least there's the perception, and I think clear evidence of some actual threats, to not only the objectivity of the research results, but more importantly, the safety of patients in clinical research when there is conflict of interest that overrides the fundamental commitment to maintaining patient safety in these clinical research enterprises.

So the fact that those conflicts of interest are evident in our institutions and in some instances not well managed I think again contributes to an atmosphere where professionalism is difficult to sustain, for students. 

And as Dr. Rothman mentioned this morning, in detail, the intrusion of industry into the educational process in so many different ways, in terms of direct support for education, obviously, mostly continuing education, but increasingly in undergraduate and graduate medical education as well, there are attempts by industry, and some successful ones in fact, to involve themselves in a direct way, at least, again, with the potential of introducing bias into the educational process. 

The gifting, the detailing, the faculty involvement in speaker's bureaus, in ghost-written articles and that whole gamut of issues that

Dr. Rothman detailed, I think again, [what] poses a clear obstacle to maintaining a focus on professionalism. When the institution and those involved, particularly in leadership in the institutions, are not adherent to these fundamental commitments, it does make it difficult for us to sustain the importance of professionalism among our students and residents.

And finally, I would mention the debt burden of graduates.  I think somebody mentioned this morning that a graduate that they had talked to had a $300,000 debt.  That's a little bit extreme, but not greatly extreme. 

The average indebtedness now of students who are graduating from medical school - and over 80 percent of students who graduate, by the way, have educational debt - and among that group, the average now is well in excess of $100,000.  Many students have $150,000, $200,000 of debt.

The degree to which that challenges their fundamental commitment to service is, I think, speculative.  We don't have an awful lot of hard evidence about the relationship between debt and, for example, specialty choice.  But I think it is reasonable, and a lot of anecdotal evidence [suggests] that this in fact does influence physicians' choice - or students' choice of career.

Certainly, once they are involved in having to repay that debt, it does put a higher value on remunerative activities that they may engage in.  And I think clearly the implicit message that we send to students by burdening them with this debt is not a salutary one from the standpoint of nurturing the future generation of physicians in a compassionate and understanding way.  So I think this is an issue that is worth some discussion. 

So, let me conclude by saying that medical schools clearly recognize the urgency of strengthening students' resolve to maintaining this primacy of the patient's interest by emphasizing professionalism, much more - there's just much more discussion of these topics in medical schools now than was the case even just a few years ago, stimulated again by a lot of the things that you've already heard about. 

And I think the fact that there's now a recognition of the importance of this topic, it's being talked about, it's being debated, I think is obviously a very, very positive sign. 

There have been clear, significant curricular innovations that are trying to address what many of us feel has been a deficiency in the educational activities in terms of trying to introduce not only a didactic, but also trying to address some of these issues in the hidden curriculum.

Stronger policies governing conflicts of interest - Dr. Rothman, again, mentioned several schools that have adopted very strong policies, managing conflicts of interest within their institutions, both at the level of clinical research as well as in the educational involvement.

We have, I think, a much more explicit reinforcement of the humanistic values of caring, compassion, altruism, empathy, that are character traits that we want to support.

I'm involved with the Arnold P. Gold Foundation for Humanism in Medicine, which is dedicated to trying to support the professional development of the humanistic qualities in the medical education arena. 

The White Coat Ceremony that some of you may know about is a signature program of that foundation, again, at the beginning of medical school, trying to underscore the transition that is occurring from laity, if you will, into the profession, to ratify the importance of that transition, and the meaning that that has in terms of their future commitments.

We have, I think, to recognize that whatever success we may have in medical schools in terms of reinforcing these commitments that are largely there in the students that we've admitted, as I mentioned before, does depend upon the ability of graduate medical education and beyond to continue to develop those professional identities, and to bolster that commitment to professionalism throughout the subsequent phases.

I think we have the easiest job in undergraduate medical education.  I think the residency, as Dr. Leach will document, I'm sure, is a much more difficult issue.  That's where much of the cynicism, much of the unprofessional attributes that we worry about, I think, are in fact in evidence.  So we need to recognize that we can only have a certain amount of success at the undergraduate level.

But even more important, I think success in maintaining and bolstering this commitment to professionalism depends absolutely and exclusively on improving the environment of medical practice, because that's the fundamental problem, again, that Dr. Relman emphasized and I think we have to come back to - that much of what hinders professionalism is clearly beyond the control of physicians or of the medical profession as a collective.

Again, I mentioned the Physician Charter.  The Physician Charter has been endorsed by over a hundred medical organizations throughout the world.  But a very strong feedback, a criticism of the Charter, is that it calls on physicians to do things that are beyond the physician's control. 

Many of the things, as I'll mention in a moment, that the Charter expects physicians to fulfill as responsibilities are very difficult if not impossible to do given the circumstances of medical practice, certainly in this country.  It's not true only here, but in the United States the system of medical care is antithetical in many respects, as I'll mention in a minute, to what needs to be done.

So if you accept the assertion that I mentioned at the beginning, and again, that Professor Sullivan emphasized in his remarks in June, if you believe that the public has a real stake in maintaining medical professionalism because of its fundamental safeguard to patients and the public, far beyond what can be accomplished by the market or by government regulation or any other mechanism, if professionalism and the voluntary commitment of physicians to this ethical code is in fact of public value, then it seems to me that we must have a joint effort between the profession and the broader public to address these system-wide barriers to professionalism that the profession itself cannot alone manage.

And just to underscore what those might be, how are we going to manage conflicts of interest with a payment system misaligned, as it currently is-again, Dr. Rothman mentioned this this morning - that the current way in which we compensate or pay physicians for their services is in many respects antithetical to maintaining the primacy of patients' interests. 

We need to address the inequities in the payment system and the mechanisms in that payment system and align them better with what we really want physicians to do in the final analysis.

Maintaining professional competence provides adequate support for the education and training of physicians.  And burdening physicians with this much debt when they leave medical school is something that I think needs to be addressed. 

And other supports of the medical education enterprise to ensure, for example, that faculty has sufficient time to devote to the professional development of trainees and students is critically important, and given the current circumstances, very difficult to accomplish.  So we need a recognition in the broader public that that is an issue.

Maintaining scientific knowledge, obviously, giving adequate support for medical and health services research has always been acknowledged to be a public responsibility.  But I think we have to continue to advocate on behalf of medical research so that our public policymakers and lawmakers understand the importance of that issue.

Maintaining honest with patients is very difficult under the present circumstances of our liability system, where physicians are always threatened with lawsuits when they make what is perceived to be an error, or when an error occurs and when a misadventure occurs.

Maintaining a liability system that fosters frank discussion of those errors is the only way we are ever going to get to the point where we can identify the errors and improve the systems.  Most of the errors, as you know, are related to system level problems, not individual malfeasance.

And unless we can frankly discuss those errors in an atmosphere that is free of the threat of personal professional liability, it's going to be very hard to get a handle on that issue. 

So we've got to construct a liability system that fairly compensates individuals when they are injured by the system, which will inevitably be the case, but which doesn't at the same time squelch the ability to make improvements in the system.

We've got to improve access to care.  Obviously, individual physicians in the profession can only do so much in providing adequate medical care to individuals who lack financial wherewithal, either because of their own personal resources or because they lack insurance for a basic set of preventative and medical care services.  That's a clear example of where we need to have a partner with the broader public to achieve. 

And finally, improving the quality of care.  We've got to establish standards of inoperability for the electronic health record.  We've got to have a regime of privacy laws that ensures that we can have access to the relevant patient level data so that we can in fact make improvements in the system.

All of these things, again, are fundamental commitments of the professional, the individual physician, that can only be achieved, I think, in partnership with the broader public.

So, with that I will end my remarks, and hope I haven't taken too much time.  Thank you, Ed.

CHAIRMAN PELLEGRINO: Thank you very much, for a very complete and very, very incisive presentation on the whole range of issues involved in professional education. 

With the indulgence of the Council , I've asked, and I will ask, Dr. David Leach to continue the discussion, and then the Council itself can put questions to both of the speakers simultaneously.

Dr. Leach is the Executive Director of the Accreditation Council on Graduate Medical Education, that area of medical education where really the habits and attitudes of physicians are most frequently and most strongly formed.  Dr. Leach.

PRESENTATION BY DAVID LEACH, M.D.

DR. LEACH:  Let me begin by thanking the Council and its distinguished members for the opportunity to share my thoughts and observations about medical professionalism, especially as it applies to the formation of resident physicians.

Medicine, unlike most professions, requires a period of formal supervised training after graduation.  These educational programs, called residencies, are accredited by my organization, the Accreditation Council for Graduate Medical Education, the ACGME.   There are about 8,600 residency programs in the country, programs that in aggregate house about 106,000 residents in 122 different specialties and subspecialties.

Residency is an intense experience.  There is probably no steeper learning curve in physician formation.  The differences in knowledge and skill between a first-year and chief resident is profound.  The resident's journey is one in which they learn both the practical skills of medicine, the clinical wisdom, but also they learn about themselves.

They are seeking to become authentic physicians.  It's a journey that is surrounded by external drama, but which actually proceeds from the inside out.  It is a journey that calls on their intellect, but also on their will and their imagination.

Residents learn to discern and to tell the truth and to make good clinical judgments in very complex clinical situations.  Because of the intensity and importance of this most formative phase in physician development, and because the habits of a lifetime are developed during this period, we pay attention not only to the resident's progress, but also to the context in which residency occurs.

The learning environment is crucial and is monitored by ACGME's Institutional Review Committee.  Residents in the residency programs offer a particular view of the issue you are studying - professionalism and whether there is a crisis in the medical profession.

One of my mentors, Parker Palmer, a sociologist in Madison, Wisconsin, has said, "Hope is not the same as optimism.  An optimist ignores the facts in order to come to a comforting conclusion.  But a hopeful person faces the facts without blinking, and then looks behind them for potentials that have yet to emerge, knowing that the human experiment would never have advanced if it were not for the possibilities, however slim, that lie behind the facts."

Using Palmer's definition, I can say that I am cautiously hopeful, but definitely concerned.  In May of 2002, he facilitated a retreat for residency program directors who had received the ACGME's Parker Palmer Courage to Teach Award.

During the retreat, a case was presented, a case in which a liver transplant donor had died while in intensive care.  He died despite the fact that the surgery had gone smoothly, and despite the fact that his wife, who was with him throughout the entire postsurgical period insisted repeatedly and to no avail that her husband was going downhill fast.

Three months later, the state health commissioner issued an incident report saying the hospital allowed the patient to undergo a major high-risk procedure and then left his postoperative care in the hands of an overburdened mostly junior staff without appropriate supervision.

On the day the donor died, a first-year surgical resident, having been a resident for three months, and having been in the transplant unit only 12 days, had been left alone to care for 34 patients.  She could not and did not monitor every patient with the care and precision required.

I present this case as an example, perhaps an extreme example, of abandonment - not only of the patient but of a very junior resident.  I also present it because of the response it evoked from a set of doctors analyzing it.

The doctors at the Courage to Teach retreat discussed the case in small groups, and almost universally came to the conclusion that system issues were to blame.  The analysis was impersonal and abstract.  The culpable parties were the hospital leadership, the clinical department chair, the system of supervision, inexperience in staffing.

During the debriefing, Parker Palmer asked the question that brought the group into deep silence, "Who is the moral agent of this story?"  We were not used to thinking in terms of moral agency.  The group agonized over the question, and the fact that by habit we had avoided asking the question.

Parker then inquired, "What if residents were expected to be the moral agents of the institutions in which they work and learn?"  He suggested that young learners not yet acculturated by prevailing institutional mores offered a more pure look at the moral issues in health care than those of us who by experience and habit had developed a ready list of explanations to cope with such failings.

I realize that one topic of interest to this Council is the effect of various external forces on professionalism.  For example, investor-owned interests in health care money and its influence, and even its influence on educational programs.

I share Dr. Relman's concerns.  He has spoken and written eloquently, and I cannot add to his comments.  Commercial support has some, but so far limited, direct influence on residency education. 

We do have a position paper and guidelines on the topic, but I think it is fair to say that compared to commercialism's influence on the larger healthcare system, its role and influence in graduate education is quite limited.

Instead, I speak today more to the internal influences on the developing professional.  I think of medical professionalism as more potato than lettuce.  Lettuce rots from the outside in; a potato from the inside out.  I put commercial support of education into the lettuce category.  It should not happen.  Fixing it might involve removing some of the outer leaves of the lettuce that appear brown and slimy.                      

For me and for many who take residency education seriously, the question of professionalism is deeper.  How do we preserve and nurture authentic human moral reflexes in our young learners?  How do we foster authentic professionalism and moral development in young people, when the context in which young people are being formed is itself challenged morally?

ACGME has identified professionalism as one of six general competencies used in the accreditation of residency programs.  ACGME requirements about professionalism include this language:  "Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. 

"Residents are expected to demonstrate respect, compassion and integrity, a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society and the profession; and a commitment to excellence and ongoing professional development.

"Residents are expected to demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent and business practices.

"To demonstrate sensitivity and responsiveness to patients' culture, age, gender and disabilities."

As this definition makes clear, medical professionalism depends heavily on the quality of the physician's inner life.  Transcendence of self-interest is not a technique; it is a way of being.  The resident, in addition to learning the science and art of medicine must also learn a new way of being in the world in order to become a fully developed professional.

Their journey is an inner journey.  We have a heavy obligation to help them.  Though the journey is deeply personal and inner, it is heavily influenced by context, both institutional and societal context influence the development of professionalism.

Is it possible to model and teach professionalism in institutions that do not demonstrate professional values?  Is it possible to teach and model professionalism in a society that does not demonstrate social justice, a society that accepts limited access to health care for the uninsured, and that tolerates demonstrably worse healthcare outcomes for the poor?

No, the current context in which healthcare and resident formation occur does not make the task of fostering medical professionalism easy.  Relentless pressures of time and economics, fragmentation of care and the relationships supporting care, increasing external regulation, exciting but disruptive new knowledge and technologies, and above all, the broken systems of healthcare dominate conversations and characterize the external environmental context.

The internal context of the system of care is also daunting.  We lie regularly.  Justifiable lack of trust pervades the system.  Beth McGlynn estimates that only 54 percent of the time do patients receive care that is known to be best - a number that falls to 2 to 3 percent of the time when evidence-based guidelines are bundled.

Hospital websites proudly announce that the hospitals they promote provide the best care with the best doctors, the best technology, et cetera.  Some are so detached from acknowledging human suffering that they make it seem as though a hospital might be a fun place to visit.

As a profession, we have tolerated that messaging, forgetting Hannah Arendt's adage that every time we make a promise, we should plan for the forgiveness we will need when the promise is broken.               

The hospital bill offers another example of a breach in professionalism.  It is frequently not interpretable, even by the hospital's own administrative staff, let alone patients and their families. 

Paul O'Neill has said that he knows of no other industry that regularly accepts a 38 percent reimbursement on amounts billed, a percentage that he states is the national average.

We all know how the number is derived.  Hospitals actively negotiate with several insurers in ways designed to cover costs.  Inflated bills and discounted deals result.  This system, while cumbersome, works from the hospital's perspective as long as aggregate reimbursements cover expenses and some margin.

The system works fine, that is, until a patient shows up with no insurance.  With no one to negotiate for a discounted rate, then the undiscounted fees are billed to those least able to pay.  The hospital bill is about as far away from respect, compassion, and integrity, a responsiveness to the needs of patients, as one can get.

It's hard to foster professionalism when incongruities between espoused and evident behaviors are so apparent.  I call this the "Abraham Verghesse problem."  At a spectacular forum sponsored by the American Board of Internal Medicine in the summer of 2005, the audience was, with some justifiable pride, celebrating the accomplishments of the Physician Charter on Medical Professionalism.

This very well-written document endorsed by many clarifies principles and commitments in a very important way.  And yet, in the midst of the celebratory speeches, Abraham Verghesse stood up and said that his medical students shrugged that the principles espoused in the Charter were self-evident, it was why they went into medicine.  Why were so many making such a fuss about it?

Dr. Verghesse then said, "Perhaps we pay so much attention to the words because there is no other evidence that the phenomenon exists."  Everyone became silent.  In spite of these examples, I remain cautiously hopeful, using Palmer's definition.  Why?

There is a deep hunger for a return to classic professional values.  Many good people are seeking clarity about how to best do that in the modern world.  And because, as Parker says, "in looking for the potentials that have yet to emerge, and at the possibilities hidden behind the facts," we can find allies that help us move this particular human enterprise forward.

Dee Hock has said, "Substance is enduring; form is ephemeral.  Preserve substance; modify form; know the difference."  The task before us is to be faithful stewards of the moral foundations of medical professionalism, while adapting to the new and emerging forms of medical practice.

If in fact medical professionalism is like  a potato and not just lettuce, our response to the new forms of medical practice will either reveal deeper lesions of professional values or not.  How can we best proceed?

I think it's best to work with rather than against human nature.  Residents, their teachers and all humans come equipped with three faculties that are naturally aligned with the goals of professionalism:  the intellect, the will, and the imagination.

The object of the intellect is truth; that of the will, goodness; and that of the imagination, beauty.  The job of a good doctor boils down to discerning and telling the truth, putting what is good for the patient before what is good for the doctor, and making clinical judgments that harmonize-harmonize in ways that are creative and sometimes beautiful - the particular needs of a patient with the generalizable scientific evidence at hand.

This construct invites a new frame, or rather a very old frame, for organizing experiences.  How good a job did I do in discerning and telling the truth, in putting the patient's interest first, in accommodating the particular realities of the patient's situation in my clinical judgments?

While we have a long way to go, some hospital websites are beginning to tell the truth about their clinical outcomes.  If you go to the Dartmouth Hitchcock website, you will find a list of several clinical procedures and diseases and Dartmouth's performance for each displayed in three columns:  Dartmouth's performance, national average, and national best performance.

While still unavailable for most hospitals, Dartmouth is not alone in its transparency.  Others are beginning to follow.  If you look at the Cystic Fibrosis Foundation website, you can get comparative outcome data for each of the major cystic fibrosis treatment centers in the country.  While not yet true for other diseases, that inevitably will be.  As a profession, we are beginning to tell the truth.

We are also beginning to tell the truth about medical error.  Many hospitals now have formal programs in which patients are told exactly what happened, are given an apology, and some evidence that the hospital staff are working to reduce the probability of that error occurring again.

To do this work we must acknowledge that we the teachers of medicine must attend to our own inner landscape.  Teachers who take resident formation seriously find that both resident and teacher are changed.  The journey to authenticity is not being taken by the resident and faculty alone.  The profession of medicine is on the same journey.

For that matter, our American society is on a journey to authenticity as well.  To the extent that our profession discerns and tells the truth about healthcare, to the extent that it puts what is good for the patient and the public before what is good for the doctor, and to the extent that it is creative and generative, it is an authentic profession.

Authenticity in this sense is a verb, not a noun.  It is not a state of rest.  It requires constant vigilance.  Residencies and the institutions that house them should be built on the bedrock of the intellect, the will and the imagination, and offer experiences that strengthen and test these capacities.

We must debunk the myth that our institutions are external to ourselves.  We tend to accuse others of our own sins.  We tend to blame the nebulous "they" for violations of standards that we alone and together must defend.

This from Parker Palmer:  "Professionals who by any standard are among the most powerful people on the planet have the bad habit of telling victim stories to excuse behavior.  'The devil made me do it.'  The extent to which institutions control our lives depends on our own inner calculus about what we value most.

"These institutions are neither external to us nor constraining, neither separate from us nor alien.  In fact, institutions are us.  The shadows that institutions cast over our ethical lives are the exterior manifestations of our own inner shadows, individual and collective. 

"If institutions are rigid, it is because we fear change.  If institutions are heedless of human need, it is because something in us is heedless as well."

In our journey to authenticity as a profession, we must call institutions to account as we call ourselves to account.  We may pay a price; we may be marginalized, demoted or even dismissed.  But the price we pay for continuing to pretend that we are helpless victims, the price we pay for living professional lives in conflict with our deepest values, is greater.

We must resist unprofessional institutional behavior not because we hate our institutions, but because we love them too much to allow them to fall to their most degraded state.  Perhaps we should take seriously Palmer's suggestion that we create a system in which residents and other early learners could function as moral agents.

Like the canary in the coal mine, they could detect and warn others when institutional conditions and relationships are toxic to professional values.  They could keep us honest about how we are dealing with the sick.

This approach would require that we both listen to and validate residents' feelings, and that we train them to use the human heart as a source of information.  This, of course, is problematic.  Embedded in the higher education process is a systematic discounting of the subjective.  It is thought to be a source of bias and unreliability.

And yet, good physicians do more than simply pay attention to objective details.  Compassion, empathy, and deep respect are all dependent on truths revealed by the human heart.  Perhaps the heart, like the mind, can be taught to discern truths.  Perhaps when the heart is uneasy, we should listen more carefully and mind the information it is giving us.  Perhaps a disciplined approach could enable moral agency to develop.

Lacking a disciplined approach, we too frequently socialize residents to cope with, rather than to master, the systems in which they work and learn.  They live in the cracks of a broken system; they are the glue that hold it together.  They get things done. 

Yet, as many have said, they are renters and not owners.  They can identify system issues but don't feel empowered to fix them.  Coping with systems in which patient safety depends on individual vigilance rather than design is wearing and dangerous, and we will fail every hundred or thousand times, well below what we know is achievable in other sectors of our society today.

It also inhibits the formation of true professionalism.  The solution requires attention to group as well as individual formation.  We have assumed that professionalism is an attribute of individuals alone.  It is not.  It also marks communities.

The assumption that the doctor-patient relationship is a one-to-one relationship is flawed.  In fact, it is more like a twenty-to-one relationship, with several different types of doctors, nurses, and other healthcare professionals interacting with the patient and each other in ways that are variable and frequently disorganized.  Needed is clarity about the roles, authorities, and functions of the various members of the healthcare team.

Cultivating communities to discern and tell the truth to each other, to enable and facilitate altruism, to make good promises and to seek forgiveness, and to harmoniously integrate true hospitality into care plans depends on paying attention to small group as well as individual formation.  It will help us respond to society's call for respect.

Lastly, we must not stand passively by when our country violates fundamental principles of social justice.  Every resident physician encounters the poor.  Many academic health centers include care of the poor as part of their mission, and are frequently the backbone of such care for their communities.

Yet widespread disparity exists across the larger society even within academic centers.  The profession has been ineffective at best and silent at worst about healthcare disparity.  We would be well served to have a bias toward rather than against the poor.  The larger society judges us over time by our response to their needs.

We live in a society in which truth is viewed as nothing more than a social construct.  Spin doctors rather than real doctors prevail.  They can construct a view of social justice that will serve their master. 

Medicine in its very nature functions under a different set of assumptions.  Rather than a postmodern socially constructed view of truth, doctors deal with things like gallstones and brain tumors.  Medicine accepts that there is a truth and that it can be known, although sometimes with great difficulty.  A gallstone is not a social construct.

A doctor may or may not be able to detect it, but ultimately, truth trumps opinion.  If we by habit discern and tell the truth, we can offer the larger society an approach to truth that conforms with reality, rather than mere social constructs that attempt to create reality.

Good doctors are humble.  Even the arrogant ones encounter failure.  Postmodernists lack that corrective and can become quite proud, marked by hubris and convinced that they are right.  Flannery O'Connor has said, "In the absence of the absolute, the relative becomes absolute."  This is the source of all fundamentalism, religious, political or other.

We cannot accept socially constructed views of social justice.  This is not an issue of conservative or liberal.  It is deeper than that.  We are called upon to provide health care for all of our citizens.  It is their due.  In a society with resources and know-how, failure to care for the sick is a breach of professionalism. 

Further, we must respond to the needs of all of our citizens in ways that offer an exemplar for our young learners.  They, too, will judge our words and actions and grade us on professionalism.  When idealistic young people are told to adjust their values downward in order to accommodate our accommodation, we have a problem.

If we get this right, the crisis in professionalism will fade, and we will have achieved the next step on our own journey to authenticity.  We can deal with external threats once our internal values are sound and our courage is found.  Thank you very much.

CHAIRMAN PELLEGRINO:  Thank you very much, Dr. Leach.  Dr. Carson has consented to open up the discussion.

DR. CARSON: I want to thank both of you gentlemen for your discussion and for the very long-term contributions you've made to the training of physicians in this country.  Now, this is a very, very in depth type of discussion that needs to be had about this.  I don't know that it can be actually done in the amount of time that we have, because it really is a problem.

I don't know if it's crisis or if it's just a problem, but it certainly does need to be addressed.  Our whole concept of how do we make patients' welfare the most important agenda item - I think that's perhaps the most important part of professionalism.

And I'm going to ask a series of questions in response to what's been said and what's been written here, just to get us started.  The whole concept of can we actually select out people who are prone to act in a professional way, or can we take people who perhaps aren't prone to acting that way and train them to act in that way?

That's a very profound question.  Which one of those is true?  Are they both true?  Perhaps not.  How good are we at determining who is going to be a good physician? 

I can remember in my own case, when I was a first-year medical student, after the first six weeks having a comprehensive exam and not doing very well on it, and being sent to see my counselor, who looked at my record and said, "You seem like a very intelligent young man.  I'll bet there are a lot of things you could do outside of medicine."

And he encouraged me to drop out of medical school.  He said I wasn't cut out to be a doctor, and I'd only invested six weeks, so why waste everybody's time, just drop out.  Well, obviously I didn't listen to him.  I must say I was looking for him when I went back to my medical school as the commencement speaker, because I was going to tell him he wasn't cut out to be a counselor.

But, you know, in so many cases we actually do think that we know, and it may be more complex than we think.  Now, no one can deny that there are a lot of problems.  One of the problems is, is medicine able to attract the best and the brightest anymore?

I think that may have something to do with the change that we see in the demographics of people who are going into medicine.  Maybe that's good; maybe that's bad.  It's probably something that needs to be discussed.

Are the liabilities of practice too great?  Are the tangible rewards too small for the time and the effort commitment?  If the answer to that is yes, are there things that we should be doing to address that, and are there consequences if we fail to do that?

Are there models that we can look at around the world, of places where the tangible rewards for medicine were removed, and what happened in those situations?  Need we learn from those things?

Now, in terms of some of the many ethical issues, new knowledge and technologies are certainly going to bring some new moral issues.  For instance, because we can keep people alive for 150 to 200 years, should we do it?  These are issues that the new professional is going to have to face.

Should we choose a baby's sex because we have the ability to do that?  As medical professionals, are we servants of the client?  Because they decide they want to have a boy and we have the ability to insure that they have a boy, should we do that, knowing what the long-term consequences of those kinds of things are?

I think those are major ethical issues that we need to address with students.  Should we create organs, spare parts, and if so, to what extent?  Is it okay to create an eyeball but not a face?  A kidney but not an entire abdomen?  I mean, where do we draw the line with these kinds of technologies that will become available to us?

When we have the ability to bring a fetus to term outside of the uterus, will we have to redefine viability?  Another big one, when all information is electronically and digitally available to us instantly, what will be the role of memorizing things in medical education?  That's coming.

Now, there was a time also, just moving to another area here, when most physicians gladly provided care for the poor.  But that was a time when they were fairly reimbursed by insurance companies, and there was the ability to spread costs over a number of different people.  That's no longer the case.

I'm reminded of a case just two weeks ago, a little girl from Maine who had a very, very complex spinal condition.  She has achondroplasia, has been operated on a couple of times, and the problem is not going away.  It's going to require some very, very intricate surgery.  But it's going to require both my services and pediatric orthopedic services.

The patient has Medicaid of Maine.  Their reimbursement is 5 percent of the charge.  I said I would accept the 5 percent.  The orthopedic surgeon involved said, "Forget it," not happy.  And I don't particularly blame him. 

But, you know, there was a time when if there was somebody who was indigent, you could just say, "Write it off.  No problem."  And you wouldn't have a problem from the hospital because there was enough of a pot of money, and nobody really got bent out of shape.  It doesn't happen anymore.

Medicare was supposed to help solve that kind of problem, and maybe initially it did.  And someone made mention of the fact that physician reimbursements went up significantly when Medicare was first established.  That perhaps was the case, but at that point, reimbursements from Medicare were significantly higher than they are now.  They've continued to go down, and then other reimbursements have been indexed to that.

So those are issues that can't just be discarded and not looked at in terms of the impact that they have.  And is there so much emphasis on professionalism that we in the medical profession have dropped the ball on finances, and allowed that to be taken over by other people, instead of, you know, trying to take charge of that ourselves and perhaps making sure that things are more equitably distributed, as opposed to putting it in the hands of people who are business-oriented and are interested in making money for themselves and really could care less about what happens to patients.

And I would be the first to admit that the medical profession has dropped the ball on that.  But it may be not too late to pick it up again.

Now, in terms of outside influences, research dollars are getting harder and harder to find.  And of course, that has led to the alliance with industry-drug companies, device companies, in a very significant way.  And there's no question that that can have a deleterious effect.

But, can we just say, "Stop it," and not have anything to replace it with?  And is there maybe a larger responsibility towards society to say, you know, what those dollars from the drug companies are providing is something that is important. 

And is there another way that we can provide those dollars for that research for the various things that need to be done?  I don't think we can just say, "You guys are bad, all of you are bad, a curse on your houses," and let it go away.  It doesn't work that way.

Now, I'm going to come back to the idea of our social responsibilities momentarily.  Now, there is significant blame to go around.  Most physicians find repugnant the incredibly large fees exacted by liability attorneys, particularly malpractice attorneys. 

But isn't it really just as bad from a moral and ethical point of view for physicians to collect fees for treatment of hopelessly terminal patients, when it's known that those are hopelessly terminal patients?  Doing procedures on them and collecting fees I believe is reprehensible, something that we frequently just don't talk about.  And I believe those things need to be talked about, particularly in terms of looking at the way that we can more equitably distribute resources.

Someone mentioned this morning - no, it was actually mentioned in one of the articles that we need to coax physicians into seeing uninsured patients.  Now, you know, that sounds nice.  But we also have to look at the practical reality that the people who are most likely to bring lawsuits are those very indigent patients, looking at the statistics.  If we're going to be coaxing people to see these patients, we clearly are going to have to reform medical malpractice.

Now, also, one of the articles talked about the importance of getting the media to take a role in this.  But the media, you know, I have mixed feelings about the media and their responsibility. 

I wrote a column for the Washington Post a few years ago about medical liability and the fact that it always gets through the Congress, but whenever it comes to the Senate - it gets through the House, and whenever it comes to the Senate, even though there's enough votes to pass it, it never gets voted on because of a couple of filibustering senators who are in the hip pocket of certain special interest groups.  And that the media has responsibility to shine the light on those filibustering senators.  But they haven't done it.  So, you know, I just wonder how reliable they would be in helping us with these various problems.

Now, getting to the pharmaceutical companies, they're not all horrible people.  Some of them actually produce pretty good products, actually.  But I wonder if maybe they should be publicly graded, the same way hospitals are, in terms of their relationships with the medical profession.

They are exquisitely sensitive to public scrutiny and to their reputations.  And there may be ways that we can take advantage of that.  The ones who don't bribe physicians get an "A"; the ones who bribe everybody get an "E," you know.  If this was done on a regular basis, I think it could probably have some impact.

Now, moving to the residency issue, a few years ago, I think most of us are aware of the fact that there was a major change in the hours.  And residents are now only allowed to work 80 hours a week.  In certain specialties they get an exemption and work 88 hours a week.  That, along with some other types of changes, have resulted in large part to a different type of mentality when it comes to identifying patients as "my patient."

And there's more of a "This is my shift" than there is "This is my patient" type of mentality.  Now, I don't think that's going to go away.  But what we need to figure out is a way to work within that framework to try to reestablish that relationship that I think was so important.

When I was - if I had a patient who was having a problem, there was no way I was going to leave.  I mean, I wanted to deal with that situation.  And I think most of us in the older generation probably felt that way.  And we're dinosaurs in that regard.  But is there something that we can do to help foster that type of relationship once again?

And another thing, physicians in training do tend to model what they see.  If you look at most surgical interns, they're very nice people - considerate, reasonable.  And by the time they're chief resident, most of them are not like that anymore. 

Now, what happened during those years?  Watching people yelling, throwing instruments around and acting like they're God reincarnated.  You know, this is craziness.  And yet, I see it tolerated, and it really should not be tolerated. 

We in medicine fall down when we do not call people on that kind of infantile behavior, which is then re-modeled by those coming along.  It becomes sort of a rite of passage.

Also, should we continue to teach emotional detachment?  We tell doctors, we tell nurses in training, "Don't become emotionally attached to your patients, because you're going to burn out and because it's going to be harmful to you in the long run."  Now, I've never discovered how to do that, myself.

And does it hurt when something happens to one of your patients?  Absolutely.  It's extraordinarily painful.  But you can get over it if you know you've done your best.  And, you know, I think we need to reexamine that whole concept.

And finally, making healthcare affordable and available to everybody is perhaps the biggest ethical issue facing our nation today.  And I think for a Council like ours, in terms of having some real, tangible recommendations to make for the President and for the Congress, we really need to be looking at what's wrong with a system that has plenty of money in it, but has so much disparity in terms of the way that it's distributed.

And, once again, thank you all for what you've presented.

CHAIRMAN PELLEGRINO:  Thank you very much, Dr. Carson.  I will now open the discussion - Diana, you had your hand up first.

PROF. SCHAUB: I just want to say I'm sort of surprised by the emphasis on transcending self interest.  I admit that there can be a conflict between the patient's interest and the doctor's interest, but only when the doctor isn't really a doctor.  And I have a wonderful little story that Booker T. Washington tells that I think illustrates this point.  It's just a couple of paragraphs.

"In a certain community there was a colored doctor of the old school who knew little about modern ideas of medicine, but who in some way had gained the confidence of the people and had made considerable money by his own peculiar methods of treatment.

In this community there was an old lady who happened to be pretty well provided with the world's goods, and who thought she had a cancer.  For 20 years she had enjoyed the luxury of having this old doctor treat her for that cancer. 

As the old doctor became, thanks to the cancer and to other practice, pretty well-to-do, he decided to send one of his boys to a medical college.  After graduating from the medical school, the young man returned home and his father took a vacation.

During this time, the old lady who was afflicted with the cancer called in the young man, who treated her.  After a few weeks, the cancer, or what was supposed to be the cancer, disappeared, and the old lady declared herself well.

When the father of the boy returned and found the patient on her feet and perfectly well, he was outraged.  He called the young man before him and said, 'My son, I find that you have cured that cancer case of mine.  Now, son, let me tell you something.  I educated you on that cancer, I put you through high school, through college, and finally through the medical school on that cancer.  And now you, with your new ideas of practicing medicine, have come here and cured that cancer.  Let me tell you, son, you have started all wrong.  How do you expect to make a living practicing medicine in that way?' "

Now, if the father is right and there really is this sharp conflict between the patient's interest and self-interest, then it seems to me our only hope would be to cultivate altruism.

But the father isn't right, and the point of the story is that the father isn't right.  The son is right.  The son is truly a doctor, a healer.  And for the son it seems to me there is no conflict between the good of the patient and his own self interest, because his self-interest is the self-interest of the doctor.

The quack, which is what his father is, lives often uneasily by duping a few; the good doctor makes a reputation for himself, and by his healing he lives securely and prosperously by serving the many.           

So I guess I'm just a little uncertain about all the emphasis on withstanding temptation.  It seems to me it's not really necessary if you understand yourself to be a healer.  In that case, your self-interest would not be at odds with your patient's interests; they would coincide.  You're guided by love. 

The man who loves his wife doesn't have such a problem with the temptations of adultery.  So it seems to me that what we need to think about is, you know, how do the institutions have to be structured to make sure that they don't undermine that love? 

So calling on doctors to be professionals doesn't seem to me to be the answer.  I mean, no kid grows up wanting to be a professional.  I can't think of anything more deadly than being a professional.  Kids grow up wanting to be a doctor, wanting to be a teacher, wanting to be a fireman. 

So we need to figure out how to let doctors be doctors.  And it may be, you know, that there are all kinds of things in the institutions that are interfering with that.  But it seems to me when I listen to the doctors here speak, when I listened to Ben Carson, when I listened to Dan Foster or Paul McHugh, they really do embody this love.

CHAIRMAN PELLEGRINO: Do you want to answer?

DR. COHEN: A very interesting comment.  With all due respect, I think it's a semantic issue that you're raising.  In your vernacular, I would phrase it this way:  what we want to do is convert doctors' sort of original self interest into the self interest of a doctor.  So I don't care whether you call it self-interest or patient interest. 

And I agree with you, I think doctors should have that motivation internally, strongly felt, voluntarily devoted to the doctor's sort of profession.  And that's what we're trying to do.

So I think it's a confusion of words here.  I don't think we're trying to avoid self interest.  We're trying to convert the doctor's self interest into being in harmony with what the patient's interest is.

PROF. SCHAUB: Yes, I guess - I mean, it is a matter of words, but I think the words really matter, and that you can actually undercut what you're aiming at.  I mean all the talk, for instance, about assessment.  I'm in teaching, and we are also talking a lot about assessment and all of these regimes of assessment.

It seems to me that in many ways that really undermines the enterprise.  I mean, I was struck by - at one point, at page 614, you talked about the bad apples, right?  That there may be some way to sort of figure out from a pretty early point which doctors, which future doctors, are going to be problematic.

It seems to me it might make sense to put some real emphasis there.  You know, are there things that you could do to really figure out who doesn't belong in this enterprise?  But the other kind of assessment, you know, constantly filling out forms and looking over people's shoulders and all of that might actually undermine the love that real doctors feel for their enterprise.

CHAIRMAN PELLEGRINO:  Dr. Meilaender and Dr. Bloom, and Peter.

PROF. MEILAENDER:  I'm next?  I want to express - this is really in a certain way a continuation of a comment I made in the previous session.  But I want to express just a certain frustration as I try to think about what this Council could think about or could do.  I'll try to do this as compassionately and empathetically and so forth as I can.

But I'm just puzzled by a lot of things.  Doctors are supposed to place the public interest above self-interest.  Now, I mean, I'm not going to go the entire way with Diana's point, because a doctor is not only a doctor.  A doctor is many other things and so has other interests.  I understand that.

But Professor Rothman this morning told us how medical education, medical practice, were being changed by the presence of so many more women who weren't about to be told it was a 24/7 calling, and that was evidently a good thing, I think, as far as I could tell.

But that didn't sound in some simple way like placing patient interest ahead of self-interest; it sounded more like kind of sorting out life in such a way that I looked after my own interests.  But it was evidently a good thing.

So I just think that this whole talk about interest is not clear.  It's muddied by, as I said in my comment in the earlier session, the kind of language of altruism that hasn't been sorted out, hasn't been thought through carefully.  And we're not going to get anywhere until we get clearer on what that is.  That's one sort of comment.  And until we can do that, I don't know what it means to make patient welfare - give primacy to it.  I just don't know what it means.

The loss of trust, which is evidently sort of the primary problem - and it may be.  I don't know.  I haven't done sociological studies.  Maybe it's the loss of trust in physicians.  But what's the evidence for thinking that the primary reason for the loss of trust is some tendency of physicians primarily to pursue their own commercial interests?  I mean, maybe there is evidence, but I haven't seen any.  What is it?

My hunch would be that specialization has a lot more to do with it, in the fact that you don't deal with the same physician over time and therefore don't have the same kind of relationship that leads to trust.  Or it might be - I mean, if I found out that my physician was thinking that one of the primary aspects of his profession was a commitment to social justice, I might start to worry that he was going to think about somebody else's needs a lot more than mine, and I might begin to lack trust in him.

So that these several claimed aspects of professionalism just don't fit together for me.  And then finally, it may be that we need to restructure society in fundamental ways.  And probably you always need to restructure society in fundamental ways.  But we've got to have arguments about this, and about how it's supposed to be done, not just general claims or assertion. I just don't see where we as a Council are going to get anywhere with just some sort of general assertion.  I mean, the same thing is true with respect to education.  There is an enormous disparity between the wealth that we have there and the distribution of it.  No doubt it should be altered in some way.  But how to go about that - I mean, I can't imagine that just asserting the fact is very helpful.

So I just think that there are a lot of particular examples we've been given that are persuasive and compelling, but I don't see that theoretically we're getting anywhere or making progress towards something that - well, that we'd have a contribution to make about it.

CHAIRMAN PELLEGRINO: Dr. Bloom.

DR. BLOOM: I'll try to be brief, because I think we've had three very eloquent, well reasoned and clear discussions of what the issues are in re-establishing a professionalism in the medical profession. 

But it seems to me that if you listen with a filter for what is the recurrent element that each of the three speakers spoke to, it's the healthcare system that is causing the problem, and frustrating the young physicians and developing the cynicism of the maturing physicians, and in beating down those physicians who have dedicated their lives to taking care of the poor. 

The system is overwhelming the professionalism that was there at the start.  And unless we do something about the healthcare system, it's going to be like the old joke about the honor system.  The administration has the honor, and the students have the system. 

In this case, society has put us into a position where we cannot do what we think is right.  And if we don't stand up for telling the public that what we're doing is pulling the wool over our own eyes by tolerating a system that will not allow us to promote the health of our countrymen, we're not doing good service. 

We're in an election season.  Healthcare has to be on the agenda for the nation as a whole, and this Council ought to make statements about the hypocrisy of our healthcare system.  We have to acknowledge not only that certain sectors do it better than others, but that we're not allowing the huge investment we make in healthcare to contribute to health.  We spend more of our gross domestic product on health than any other nation in the world, and yet we rank very poorly on the health of our country. 

That, it seems to me, along with the .789 in Jordy's talk about access to care and universality of care and quality of care, is a much bigger issue than trying to give pep talks to residents to maintain a professional attitude in a system that we have tolerated for 25 years that we know is going in the wrong direction.

CHAIRMAN PELLEGRINO:    Thank you, Floyd.  Dr. Schneider.

PROF. SCHNEIDER: First a quick word on trust.  The trust that patients have in their physicians remains quite high, possibly because patients have no choice but to trust their physicians.  The trust in leaders of medicine has gone down. 

Of course, the trust in every human being in the United States has gone down - every profession, every business has lost trust.  And if you ask people, "Do you trust people generally?" they will say, "Less than I used to."

So, I think that looking for reasons in medicine for the decline in trust in medical leaders is probably not a very fruitful activity.  I confess that I have tried to read these materials and some of the supplementary materials that were referred to in the materials, and I've listened to the conversations this time and last time.  And I feel as though I am swimming in cotton candy.

This conversation is being held at a level of such abstraction that I have no idea what's going on.  I passionately agree with a lot of the things that people have said about how wonderful the ideals of medicine as a profession can be, and for that matter, of lots of other professions.

And yet I find the conversation taking place in terms of this word "professionalism," which has no meaning at all.  It is used by every group that wants to be better regarded and better compensated.  And it is used as a way of fighting all kinds of battles without actually coming to grips with what's actually going on.

In search of guidance, I read the Physician Charter, and I have to say that I found it absolutely incomprehensible.  It, too, is phrased at such a level of abstraction that you can't disagree with anything in it, but you can't tell what anything in it is actually going to mean when the rubber hits the road.

I find myself confused because the conversation is at such a level of abstraction that I don't know what the actual evidence is that things are so bad or things might be so good. 

I read the description of what life is like in medical schools because of the abominable way that many faculty members behave, and I looked to see what the citation for that proposition was, and it was another article that didn't have any actual evidence, but just said, "Things are terrible."  So I don't know what the actual empirical dimensions of things are.

Then we have been talking in terms of another set of abstractions, this abstraction about the contrast between commerce and professionals.  And it seems to me that that discussion has been made almost exclusively in caricature.

I know lots of business people who have better ethics, a better sense of responsibility, and care more for their clients than a lot of members of professions do.  And a number of people have said about professions that they have behaved in ways that have caused them to lose trust.

I do want to say about the trust, remember that in 1909 Bernard Shaw said, "The medical profession has not a high character; it has an infamous character."  In 1978, a political scientist wrote, "There are widespread complaints against the medical profession on the grounds both of failures in the realm of service to the public and of defects with regard to effective self-regulation.  This is 1978, remember.  "The public dislikes the way physicians often seem to be concerned more for science than for caring, to have turned their means into ends, to have become authoritarian and unresponsive," and finally, "to care too much about their money income."

So, this idea that somehow, if we just abandoned this bad thing that is called commerce and went to this good thing that is called professionalism, then all would be well, I find operating at a level of caricature that I don't think is very helpful.

I also think that it's important that we be more precise about the historical moment and about something that I think we have almost not heard discussed at all, which is the role of the organized profession. 

And I keep saying "profession" instead of "medicine" or what have you, because I regard all professions as conspiracies against the laity, as Shaw said some years ago.  I know of no profession that runs itself in a way that we ought to admire.

But let me talk more particularly about the role of organized medicine.  The definition of professionalism we hear is a definition that talks about the importance of service to others and to the welfare of the patient. 

But organized medicine, which ought to be more interested than in anything else in seeing to it that all Americans actually have some way of acquiring medical care - organized medicine has fought proposal after proposal after proposal for some way to fund it.  They, you remember, opposed Medicare and Medicaid.  They called it socialized medicine.

And organized medicine continues to play a role in these professionalism issues that seems to me to be highly destructive.  The conversation that we're implicitly having seems to me to be in large part about managed care.  When we talk about how hard it is now to practice medicine properly, I take a lot of that conversation to be a conversation about managed care.

And it may well be that managed care is a dreadful thing.  But let's remember how we got into managed care.  We got into managed care because after Medicare and Medicaid, the fee for service system got more and more out of hand, and it became impossible for us to feel that we could continue to pay for medical care.

And in an attempt to try to control those costs, we moved to managed care.  It may well be that managed care isn't the right way to do it.  But the difficulty that I have here is the difficulty that I have in many aspects of the way that organized medicine has dealt with these problems.

Organized medicine has not come up with a good substitute for managed care.  It has said, "Things are bad.  Stop hassling us."  Organized medicine has not come up with a good way of providing care for poor people.  It has just said, "We're against every proposal that you have put forward."

I not only looked at the manifesto for-that's not a good - the charter for medical professionals, I looked at the article about the alliance between society and physicians, which amplifies the charter.  And it seems to me to carry on in this vein. 

It says, "Yes, we're in favor of all of these altruistic things, but you've got to remember we need to have enough salary or enough income so that we're not unduly tempted."  I find that deeply embarrassing.

Right now, house-sitting for us is one of my neighbors.  I live in a working class community, and my neighbors would feel very lucky to make the average American household income, household income, not individual salary, which is about $50,000.

And my neighbor is sitting in my house, and I expect him - he seems to be operating under much more temptation than a physician has.  I expect him not to steal from me.  And I think we expect the maids of this hotel not to steal from us.  And I think that it's clear that there are people who live under much greater kinds of temptation.

So to begin this discussion by talking about the need to pay doctors enough that they're not tempted to behave unethically strikes me as very troublesome.  The alliance paper then goes on to talk about in extremely colorful terms how impossible the legal system has been, and it talks about the need for doctors to be able to maintain individual and professional autonomy.

If you look at that through the kind of historical lens that I'm talking about, what it looks like is another attempt by a profession to say, "Do not regulate us, but let us continue to control ourselves." 

Now, that leads me to what seems to me to be one of the most egregious failures that all professions display, which is a failure to deal with their incompetent and unethical members.  It is absolutely plain that no profession I've ever heard of is willing to take that job seriously. 

And one of the problems I have with the discussion we've been having and with the charter of professionalism and all the rest of it is that nobody has ever talked about how it is we're actually going to enforce any of these ideals.

We are supposed to be moved by the loftiness of the ambitions, and I am, but I want to know how it is that we're actually going to deal with people who don't do the right thing. 

That leads me - and I'm coming to a close pretty soon - that leads me to what seems to me to be a temptation of all professions-it happens in law - to say, "Oh, my God.  Things are terrible here.  What we have to do is to tell the medical schools and the law schools that they have to educate people better and all will be well."

The first thing that's wrong with that is that I don't think I'm going to live long enough to have all of the unethical doctors and lawyers pass through the system to be replaced by the newly educated doctors and lawyers who understand how to behave ethically.

The second problem I have is that it is just grossly implausible that any kind of activity in a professional school is going to make professionals behave well if they get out into a world in which bad behavior is beneficial to them and good behavior is costly.

If there is one thing that psychology has discovered about human behavior, it is that character matters surprisingly little, and that the circumstances in which you find yourself matter a great deal. 

I'm sure you all know about the Milgram experiments, where they took perfectly normal, decent residents of New Haven and induced them to, in the understanding of the research subjects, to give terribly painful shocks to apparently perfectly innocent people.

And this kind of experiment has been duplicated all over the place, and it represents a very standard understanding that you can make people virtuous in character all you want, but that their actual behavior is going to be very strongly influenced by the circumstances in which they find themselves.

Let me suggest one way in which education, if it really wanted to take professionalism seriously, might do it.  And that is by disciplining their students.  If it is true that 97 percent of the people who enter medical school leave with MDs, then it is clear that that is not what they are doing, that they are not taking this seriously.

And I'm certainly here to tell you that law schools do not deal with their inadequate students in any way that suggests an actual interest in encouraging professionalism or in deterring misbehavior. 

I actually spent last semester visiting at the Air Force Academy.  And one of the interesting things about it was that that is an organization that actually does care about professionalism - being a military officer being one of the original professions.

But they believe that in order to make education effective in encouraging professionalism, you have to make that a primary activity.  So the motto of the Air Force Academy is "Integrity first."  "Service before self," second.  "Excellence in all we do," third.  But integrity comes first.

And "Integrity comes first" for them means that if you lie, cheat or steal, or tolerate somebody who does, you throw them out of the Academy.  And it is by that kind of clear statement that you really mean this and you're not just adjuring them to behave better that you have any hope of having education make any kind of difference.

So I wind up truly hoping that if we move in some direction that we speak with enough concreteness and clarity that we do not become one more statement of high ideals.

CHAIRMAN PELLEGRINO:  Let me mention that we're reaching the end of our time, and what I will do is the following.  Peter, obviously, you make your comment, and if anyone wants to make one more comment, then we'll have a break and we'll come back and give our speakers an opportunity to respond.

And I don't mind cutting into time allotted to me.  So don't worry about that.  And I'm sure you're not worried about it anyhow.  You wanted to get on the list, Dan?  Okay.  And we'll open the list again when we come back.  But I'd like Peter to make his comment if he would, and then if you don't mind, we'll take a break and you both respond.

Are you in a rush?

DR. COHEN:  I've got a 6 o'clock flight.

CHAIRMAN PELLEGRINO: All right.  We'll give you a chance to respond, if the group doesn't mind.  Peter.

PROF. LAWLER:  All right.  I'll make this as brief as I can.  I certainly can't follow that.  And I'm not an M.D., and on all of these issues I don't have a strong opinion.  I am though, in the profession, such as it is, of political science.  And here are some irritating words that have snuck into the profession of political science, coming from academic administrators.

"Civic engagement," "social justice," "social activism."  Now in the opinion of deans and other administrators, the most important thing in political science is to inculcate in students passion and purpose.  In other words, get them out there being all activist about everything in some sixties manner, without asking the question, "Do they have any idea what they're talking about?" 

So actual education is subordinated to activism and engagement.  So when I think about a physician, I wonder how much this really has to do with the job of a physician.  In my county - quickly-we're a regional medical center.   We have more physicians than any other county in the country per capita.

Not only that, studies have shown that physicians in our county enjoy the highest standard of living, relative to the local standard of living, of any county in the country.  So our physicians are as happy as physicians can be nowadays.

As a result of that, many of our community leaders are physicians, and they do many admirable philanthropic things, as Dan does and as so many of our-as Ben does, and the other physicians on our Council do.  But I'm not sure they do these things as physicians.  They do these things because they're good guys, they make the big bucks, and have some extra time.  I'm for them doing this.

And some of them are involved in politics.  Some of them get elected to office.  They have all sorts of political opinions.  But their political opinions are not particularly good because they really weren't trained to have good political opinions, nor would an extra course in their medical education really have helped out there all that much.

In fact, many physicians in my area disagree with many of the things that have been said here.  They are radically libertarian.  They believe that the problem of access could be solved through a lot more market, not less.  I tend to think they're probably not right, but I don't think they really know whether they're right either.

So our physicians have all sorts of political opinions.  They're all over the map.  But some of the writing - and I think in a certain sense some of the presentations-suggest that physicians as physicians have a particular conception of social justice that unites them together in this particular agenda they should push together as physicians.  I just doubt that this is really so.

DR. FOSTER: I just want to make one sentence in defense of physicians and residents.  I've just come off the wards at Parkland Hospital.  I think that this crisis in professionalism is at least something that I don't see working on the wards.  I think the students that we have now are enormously admirable, both in terms of their talents and dedication to science and in their kindness in taking care of the poor. 

And I'd say one other thing.  Almost every one of the - I would be happy to have almost every one of the senior residents at Parkland Hospital take care of me now, or my family.  I just want to say a word about - I don't think that - it's just not the picture I have of the crisis of loss of altruism or anything. And I'm only talking about one place, and maybe you might think that I'm too much of an optimist.  But I just got through with this, and I'd let them take care of me right now.

CHAIRMAN PELLEGRINO:  Jordan?

DR. COHEN: Well, let me make a few comments, if I could, in response to some of the things that have been said.

Let me start with Dr. Carson's comments.  Two things I want to comment.  First of all, I think your notion about the selection of students is right on target, as I tried to mention.  And one of the things I didn't mention that I think is important is the way in which schools project what they're interested in to prospective students. 

And I think there is altogether too much - the perception is that we're interested only in grade point average and MCAT scores and not interested in these issues of character and commitment to service and what have you.

As a consequence, I think - and again, I have no evidence for this but this is my strong perception - that a lot of students who I would very much love to see in medicine would even be more impressive to you, Dan, than the ones that you are now dealing with, never even choose to apply to medical school because they don't think that's what we're interested in, that we're interested more in what's in their head than in their heart.

So I think one of the jobs of medical schools is to be more explicit-to the degree that they believe this, which I think they do-but to be more explicit about what they really are looking for in applicants, that these are as important characteristics as long as they have the scholarly and intellectual capability to meet the challenge.

And several of the points you made and several of the points I think that Dr. Meilaender made as well I think relate to this issue I ended my comments with, namely, that to the extent, again - and you may not agree with this; from your comments I'm not sure you do - that the public does have a stake in doctors and the profession adhering as best they can to this ethic of service to the public. 

That to the extent that there is a commitment to that kind of service-oriented value system, the public gains a great deal.  In the absence of that, there would be much to be lost.  Now, you either accept that premise or not. 

But if you do, then it seems to me that one has to take cognizance of the fact that there are a number of things, as I tried to indicate, and which that alliance paper spells out, that the profession cannot grapple with unilaterally.  It requires some kind of interaction with the policymakers or the lawmakers in order to address the access issue. 

We can't solve the uninsured problem as a profession.  It requires that we convince the policymakers that they've got to get in bed with us and lead with us and solve it.  We can't behave the way we want to behave in the absence of access to care, in the absence of the ability to do the quality of things and all the other things I mentioned.

And again, on this topic, Dr. Meilaender, I'm really sorry that I think you misread that aspect of the alliance paper that spoke about physician payment.  It's not that we're looking for more money; it's the mechanism of the reimbursement system that is not properly aligned. 

I wouldn't have any problem with there being no more or even less money available for physician services.  But the way it's currently committed to the profession, it doesn't reinforce the attitude of patient interest primarily.  The fee-for- service system in my view is antithetical to a profession that truly is acting in the interests of the public and patients.

You can't expect doctors, particularly with the disparity in the fee-for-service as it currently exists, to avoid that temptation.  It seems to be more than one can honestly expect even of a highly motivated physician, to adjure self-interest when they're faced with that kind of temptation.

So that's the point that I was trying to make there, not that doctors want to make more money.  It's just that the mechanism of payment is not properly structured to deal with these issues.

CHAIRMAN PELLEGRINO:  All right.  I think we'll take a break until 4:20, and then return and give Dr. Leach a chance to respond, and further questions you may want to raise or contribute.

(Whereupon, the proceedings in the foregoing matter went off the record at 4:10 p.m. and went back on the record at 4:25 p.m.)

CHAIRMAN PELLEGRINO:  What we'll do from this point on is ask Dr. Leach if he wishes to respond.  If others of you have other questions, let's not repress them.  We'll continue, as I think the discussion is going in a very - how shall I put it - interesting manner, and we should continue it and try to explore some of these issues further.

Don't worry about cutting into my time.  I'll get a few one-liners in somewhere along the line.

DR. LEACH:  Thank you very much.  I'll be brief.  I have to, not for lack of interest, but because I have a plane to catch.  Something very practical that you've been calling for has occurred, and I have to catch my plane.

I would encourage all of you to listen to Dr. Carson.  I agreed with everything he said.  He mentioned information systems and what patients would do when abundant reliable data became available.  I've thought about that a lot.  And it seems to me there are three reasons why a patient would continue to go to a doctor. 

One is that unlike the computer, the doctor shares a human vulnerability with the patient.  Both are going to die; both are going to suffer.  And that's comforting when you're sick, to be in the presence of a fellow human.  If that's true, then the educational programs should encourage one to become more fully human. 

I think a second reason is that I have a friend, David Stevens, whose wife is a musician, who is a physician.  And he woke up with severe pain in his joints and a little rash in his popliteal fossa.  His wife, with no medical knowledge, got on the computer and discovered that the rash on his popliteal fossa looked exactly like Lyme disease. 

So, totally naive, she said, "I think you've got Lyme disease and we should get some doxycycline."  And she marched him to the internist and walked in and said, "David's got Lyme disease.  He needs doxycycline." 

And the intern said, "Well, that's very interesting.  We'll have to do a few tests."  And she said, "Tests are not helpful in the early phases of Lyme disease.  He needs doxycycline."  And he got it and was cured. 

Well, that reminded me of a second reason why people would go to doctors.  "I think it's Lyme disease, but I don't know.  Perhaps you've seen a case.  Maybe you can recognize this pattern."  So, in addition to training doctors to be human, we should train them to reflect on their practice, accumulate their experience, and learn how to discern early pattern recognition. 

And lastly, if you're going to have your brain operated on, not everybody can do that or prescribe certain drugs and so on, and they would go to actually get that done.  So those are three reasons why patients would continue to see doctors in the information age. 

I think the system should acknowledge the importance of those three things and pay attention to them.  Right now, you know, it is said that every system is perfectly designed to produce the results it's producing.  And the system is producing the results it's producing.  It's producing things we like and things we don't like. 

So, the inordinate expense, the inadequate results, it's designed to do that and so it's doing that.  Now, you could - perhaps it's dignifying healthcare to call it a system.  It is so fragmented, it's not really a system.  But the thing that we do call "healthcare" is demonstrating abundant opportunities to improve, that are going to require redesign.  And perhaps some of those issues are important for this Council . 

Residents became stressed, as did the whole healthcare system, when basically three things happened:  one, because of DRGs, time was compressed.  When I was trained, I had typically two weeks to get to know the patient, and that was all.  It was a true relationship.  Now they're in and out in a day and a half.  And the resident's life consists of admitting, discharging, admitting, discharging, admitting, discharging, on a treadmill.  It's a different lifestyle, one that challenges ethical principles.  There's more to do. 

When I was a resident, if you wanted to know how the patient was doing, you had to go and talk to the patient.  Now you fill out forms to get tests done that are helpful, but it consumes all of the available time, and you don't talk to the patient.  It's part of the system. 

And lastly, there's less help.  There are fewer nurses.  So residents are doing more in less time with less help.  And, in that environment we're trying to say, "Be ethical."  It's a stress. 

Someone mentioned, you make residents virtuous.  That's not the way it works.  It's educing virtue; it is taking what is latent and encouraging and allowing it to emerge.  It's tapping into their fundamental human goodness and creating an environment that that happens.  And I think it's important. 

And lastly, I think this Council is wonderfully diverse.  And there's a price with diversity, and that's conflict.  And vision is a physiologic hallucination.  So there are billions of photons hitting my retina right now.  I can't possibly process all of them equally.  I would go insane.  Based on my background and my experience, what I have discerned in the past is important or not, I scan a room and see things, and then there's a whole bunch of stuff I don't see, because I have not thought it important.  As I heard your comments, I was reminded of that. 

When two smart people who care about an issue are arguing, it's not that one is right and one is wrong; it's that both are blind.  And this Council and your report is going to help do something.  You have to honor and deeply understand each other's perspective, and that's, from my point of view, the work before you. 

I have to go catch a plane.  Thank you very much.

(Applause.)

CHAIRMAN PELLEGRINO:  Any comments, questions?  Robby, you look like you're about to ask one.

PROF. GEORGE:  Well, I was struck, as I'm sure many were, by the powerful condemnation that Dr. Leach offered in his prepared remarks of the postmodernist view of life as denying any objective basis, denying that there is any moral truth. 

And anyone who has spent any time in universities in the last couple of decades knows that that is not only a prominent view, but in very many places, almost an established orthodoxy from which dissent is remarkable. 

Now, if Dr. Leach is right, and I have every reason to believe that he is, that this has an impact on how young people who are educated and socialized in our system, both in our high schools and colleges - because it's now filtered down into high school certainly - if he's right, that that has an impact on how people come to terms with the demands, the ethical demands of their professions, then it is a serious problem. 

And it's not a problem that can be dealt with by professional ethics courses in medical schools or law schools or what have you.  It's a socialization problem from the beginning.  And what it does is, I think it - again, if Dr. Leach is right - it means that we're not going to solve this problem unless we take seriously the problem of a certain ideology having such powerful standing in the intellectual culture.           

Now, I'm sure this Council doesn't want to get into the question of postmodernism and its ideological hegemony or anything like that.  But it might be that anything else is really kind of tinkering around the edges or rearranging the chairs on the deck of the Titanic. 

I know Dr. Leach has to be right, it seems to me, about this.  You cannot preach to young people that there is no truth, that it's all socially constructed, that all we have are moral opinions, there's no such thing really as right or wrong on one set of issues, issues about sexual morality or drug-taking or the sanctity of human life or whatever, and then turn around and, with respect to questions of social justice or professional responsibility, there is an objective truth that is rationally accessible and which can be imposed on people if they are recalcitrant about living up to it in their professional lives.  I mean, that kind of a mixed message just can't possibly work. 

So I was very powerfully moved by what you said.  It certainly resonated with my own experience with 22 years of college teaching and a few years before that in the universities as a student.  But it does leave me deeply wondering whether our problem is not deeper than what can be addressed by any systematic shifting of systems and rules.  That it's really a deep problem in the intellectual culture.             

And I thank you for what was really powerful testimony in two senses.

CHAIRMAN PELLEGRINO:  Thank you, Robby.  Do I see a hand?

DR. HURLBUT:  Do you have time for a question, or do you have to run to catch your plane?

DR. COHEN:  Ask me your question and I'll let you know.  No, no, we have a couple of minutes.

DR. HURLBUT:  Just briefly.  You talk about the outer leaves of the lettuce, and my question this morning is the same basic question.  Is it possible that the role of medicine, the deep professional purposes, the star we navigate by, is somehow lost? 

Is it because of just what Robby has affirmatively said, that because we were criticized for being overly paternalistic, we shifted toward relativism, that we gave up some of the longstanding principles of our code in the face of the rising social acceptance of practices like euthanasia, abortion, the confusions of modern biotechnology?  I just - give me one minute. 

I'll read something that troubles me very much, and I'm just putting this out.  This is a quote from Margaret Meade, taken from a book called The New Medicine by Nigel Cameron.  He says that at the time the oath was articulated - and there may have been a period of time obviously - that the practices such as euthanasia and abortion were common.  These were accepted practices; they were not just considered evil, that there was a real revolution in the Hippocratic oath. 

Margaret Meade, who is not generally considered to be a conservative Republican or whatever you want to say, she says, quote, "The Hippocratic oath marks one of the turning points in the history of man." 

She writes, "For the first time in our tradition, there was a complete separation between killing and curing.  Throughout the primitive world, the doctor and the sorcerer tended to be the same person.  He with the power to kill had power to cure, including specifically the undoing of his own killing activities.  He who had power to cure would necessarily also have the power to kill. 

"But with Greek Hippocratism, the distinction was made clear.  One profession, the followers of Aesculapius, were to be dedicated completely to life, under all circumstances, regardless of rank, age or intellect.  The life of a slave, the life of the emperor, the life of the foreign man, the life of a defective child."               

And then she goes on to say, speak of this as a "priceless possession which we cannot afford to tarnish."  Now, I just threw that out because, as Ben articulately said, we are facing challenges, projects like fetal farming and so forth.  If we're really going to get down to questioning professionalism, it seems to me we have to look at - you said it very directly.  Is it deep hunger to return to classical medical values? 

Is it possible that some of the outer layers on the lettuce are modern aberrations of understanding of what professionalism really is, and that the core problem in our profession may not be commercialism, self interest, or all of these things, but that we have lost the guiding principle that is fundamental to our profession? 

I really didn't put that out with an agenda of assertion so much as a question.

DR. LEACH:  I think that's exactly the right question.  And I think the substrate of medicine, seeing people when they're sick and vulnerable, you either support human life and its dignity or you go into some other profession.  I mean, it is a fundamental human activity. 

And that is why I think the great strength in response to this - I don't know whether this is a crisis or not.  I think that there's been erosion of some traditional values.  Young people and faculty live in a postmodern world.  It has had a set of assumptions that have not always been carefully examined. 

Having said that, I do not think this is a political argument, you know, for abortion/against abortion.  I think that justice and mercy kiss.  And I think a good doctor defends life and has mercy and has great compassion for the patient's circumstances and doesn't compromise or increase the patient's vulnerability by a political agenda.  It's deeper than conservative or liberal. 

And to me, yes, I think - and of course, this is a horribly mixed metaphor - the lettuce leaves are brown, a few of them.  It's not strip them away.  The potato may or may not be sound.  That is the question.  If the potato is sound, we will get through all kinds of this and many other changes in the forms of medicine.  If the potato is not sound, we're dead. 

And so to reinforce that at all levels of the educational system and the practice world means you have to have an understanding of what a healthy human set of values looks like.  And that has to be the organizing principle, as you adapt to the thousands of unique patients that come with particular problems. 

You can't look that up in a rule book.  You have to have a good heart to manage that.  And that's what professionalism is all about.

CHAIRMAN PELLEGRINO:  Further questions?

DR. ROWLEY:  Would you comment again on one of the things that Ben said, which was that physicians are trained to be emotionally withdrawn, or detached from patients, and that maybe this is a bad thing?  I'd be interested in your views on that.

DR. LEACH:  And don't forget that he also said he could never do that.  Which I think is the mark of a good doctor.  But it is true, and I think - I mean, it began long before Osler.  But Osler said equanimity is what you have to offer patients. 

So when the world is coming to an end and everything is panic, if a doctor can stand in full equanimity, which does require a wonderful honoring of both arms of a paradox - detachment enough to have equanimity, engagement enough to actually help.  And you cannot dishonor either arm of the paradox. 

But you do have to hurt people sometimes to get them better.  I mean, when Dr. Carson operates, it hurts.  I wouldn't want an operation on my brain.

DR. CARSON:  We have anesthesia.

DR. LEACH:  But then so you have to be able to say, "Yeah, I'm going to cut your head open, take the bone out and put it - yeah, I'm going to do all of that."  And you have to do it well, and you have to do it in a balanced way.  And so you have to be a little detached to do that.  You wouldn't do that with your neighbor on a Saturday afternoon. 

But you also, if you're a good doctor, don't let the detachment get to the point that you don't give a damn.  You constantly are supporting the needs of the patient.

CHAIRMAN PELLEGRINO:  Again, thank you very much for joining us.  Well, there are a few minutes left.

DR. ROWLEY:  Well, I was just going to say that since this is an area in which you have thought about a great deal, speaking for myself, I would really like to hear what you have to say on the issue.  And I don't think you should cut your remarks short.  I am perfectly happy to go to dinner later or whatever.