Thursday, September 6, 2007

Session 2: The "Crisis" in the Ethics and Profession of Medicine: A Historical Perspective

David Rothman, Ph.D.
Bernard Schoenberg Professor of Social Medicine and Director of the Center for Medicine as a Profession
Columbia University

CHAIRMAN PELLEGRINO:  Can I ask the Council members to be seated please?  Thank you very much.  We'll now resume our agenda.

The next topic for the rest of the day will be on the "Crisis" in the Ethics and Profession of Medicine.  And we begin with a very distinguished commentator and author in this area, Dr. David Rothman.

I have explained to Dr. Rothman, who understands clearly, of course, our custom which is not to provide long introductions, and he said he was relieved, and I'm glad.  And so I will ask him forthwith to address us and then the discussion will be opened when Dr. Rothman finishes.

PROF. ROTHMAN:  Thank you.  I can tease with Dr. Pellegrino.  If you can accumulate enough titles, you don't have to give your talk -

            (Laughter.)

            - particularly, you know, when you get these 20-minute versions of it.  I have longer today, and I very much enjoy the chance, [first], to appear before you and speak to you.  I know several of the members of this commission for some years.  And, secondly, it's a good subject, and I'm hopeful that the pleasure that I got in sitting down and doing this for you will be matched by your finding what I'm about to say interesting.

Dr. Pellegrino and I are both members of that generation that came of age well before PowerPoint.  Since I was in arts and sciences before going up to the medical school, I didn't even know from slides.  We just simply talked from notes or text.  Yet, I have converted and Dr. Pellegrino is suggesting to me9 maybe in [confidence]- I'm not sure0 - that he's beginning a little bit to convert to PowerPoint as well.  It's a very useful tool.     So I haven't used as many as I might otherwise have done out of respect for Dr. Pellegrino's bias.  On the other hand, it was hard not to at least be able to say something using the technology.

I'd like to open my analysis of the state of the medical profession, the putative crisis it faces, and the locus of responsibility for making change by recounting to this august group how another group responded to the very same issues.

The group whose experience I'd like to share with you is the Board of Trustees of the Institute on Medicine as a Profession, IMAP, a 501(c)(3) public charity of which I am the president.

IMAP itself was created through a generous gift from a noted philanthropist, George Soros, a man who made his fortune in the marketplace obviously, but a man who was totally convinced that marketplace values should not dominate all sectors of the society.  In particular, the professions, medicine and law, as the exemplars, have responsibilities that ought not to be driven by the market.  This was very, very much his position, a position that I share, and I suspect many, if not all, in this room will share.

Doing justice from the legal side and promoting health in our territory are obligations that go well beyond the bottom line.  It was that kind of thinking that led him to endow the Institute.  The Institute itself carries out its work through a center at Columbia College of Physicians and Surgeons.

IMAP has a board of directors, trustees, if you will, and the first meetings post the gift were devoted to defining its mission, the Institute on Medicine as a Profession.  As it would be expected, the group wanted to spend a certain amount of time defining professionalism, how it might promote it.  But what might not be expected in these early deliberations was a dialogue that we got into and actually stayed into for a surprisingly long period of time.  And it's that dialogue that I want to recount to you.

The first impulse of the group was to set out the challenge, medicine as a profession, and set it out in terms of a revival of professionalism.  We have to look back, recapture, restore, you know, if you will, all the "RE" words.  Recent developments have eroded professionalism, the opening hypothesis was, so our efforts should be revitalization, recovery.  You can fill in more and more synonyms.

But before we even could go very far down that path, we all recognized a fundamental inadequacy of framing a program in terms of restoring - and I don't mean it quite pejoratively, but perhaps there's a little inkling of it - restoring the good old days.

So as the slide shows, we called it and we began to talk about it in terms of the so-called good old days.  Did we really want to revive, restore, rediscover a profession that was all male, almost all white, and almost all upper-middle class?

I keep wondering.  You know those photographs, you've lived with them.  We have them at P and S [College of Physicians and Surgeons], too.  You know, the class of house staff from 1910 and 1912.  You know those photographs:  Lily white, [and all] male.  I mean, occasionally maybe a woman, maybe a person of color.  But those are stark white photographs.  And we do know the socio-economic origins, the upper-middle class, as well.  So before one got too rhapsodic about going back to the good old days, certainly we didn't mean to do that. 

And then we would go into financial issues, which we'll be talking about today.  Conflict of interest was certainly present; fee-splitting, an absolutely common habit.  The surgeon had to reward the referring physician.  He did it in a variety of ways, sometimes the charade of that surgeon bringing in the primary care provider to the operating room.  One way or another, they figured out how they could gift, if you will, the referring source.  The practice hasn't altogether disappeared.

I love California wines, saw an advertisement in The New Yorker for a kind of California wine-of-the-month club, was curious about it.  On home stationery, home stationery, I wrote and asked for the brochure.  It came back with a first-cover insert kind of thing which said, "The perfect way to thank the referring physician." 

            (Laughter.)

Somebody at that wine company knew how to market its product.  Fee-splitting isn't over.  But, I mean, again, my caution is, we're not going to get so rhapsodic about the good old days.

Direct dispensing.  A not uncommon practice. 

Fee-for-service.  In a group like this, I don't have to expound on the potentials of conflict of interest there.  But certainly, you know, returning the patient for a visit, it happened, part of the roster.

Drug company largesse, which we'll spend some time on this morning as well.  It's not a post-1990 phenomena.  It goes way back and was, if anything, perhaps - well, I shouldn't say that.  But it's effectiveness may have increased.  But it's certainly a phenomena as part of the good old days.

And even public complaints about doctors' income, which you see a lot of in the press, nothing really new about that.  The 1950s saw a spate of journalist accounts of doctors including one that I always tell my medical students that involved a child in a Midwestern town who fell down an abandoned well.          

He opens his book with this.  The town spent about a day and a half.  Everybody - you know, the fire department, the citizens - digging, you know, doing all the rescue operations.  They rescued the child.  They give the child to the physician for care.  The physician delivers the care, and then the physician has the audacity to bill the family.

Well, this became newsworthy.  How could you have billed?  It made its way to the AMA.  As I followed the story, I wasn't sure what the AMA would do.  The public uproar was so great that the AMA said the doctor was wrong.  I tell this story, not for the rights or wrongs of the charge, but that public complaints about physicians' income has a long history. 

Damned if you drive the Cadillac, damned if you don't.  Patients want their physicians to be "big men."  On the other hand, you know, I mean, the only reason that I'm playing this out for you is I don't want you to think that the current kind of critiques have anything unusual about them.

And the last two bullets are, of course, perfectly obvious to you.  The strong bias against group practice and the extraordinary bias against government intervention, the case in point, of course, being Medicare.  So before you get too rhapsodic about restore and rediscovery, we really don't want to go back to those good old days.

Then, you know, the dust would settle.  Everybody's outrage, you know, would calm down.  And then we would say to each other, "Okay.  So our task is to invent professionalism.  If we can't restore it, we should invent it."

But that was, again, a kind of frame that could not exist for very long.  Everybody in this room and everybody in that room knows it well.  The Hippocratic oath dates back and, you know, if you want to bring a laugh to a medical audience, all you have to say is, there is no Hippocratic oath for lawyers.  It's the medical students at commencements who recite, not the business school students.  You know the rest of that litany.  And it's a powerful document, obviously amended by almost all of the medical schools that use it.

But the key values - confidentiality, do no harm, respect for the body of the patient even if the body of the patient - you'll remember that line - is the body of a slave.  I mean, that's startling in its way.             

So, I mean, invent when you have that kind of tradition? 

And medicine as we do know and we recognize had a long tradition of serving the under-privileged.  In pre-Medicare/Medicaid days, there was a Robin Hood quality about medical practice.  Well-to-do patients paid more.  Poorer patients paid less.  And many physicians to this day serve patients' well-being impervious to the clock, the day of the week, the nature of the holiday.  So "invent" seemed, if you will, totally presumptuous.

We went round and round this cycle of revive/ invent several times, and we soon recognized that the internal debate we were having matched up quite well with the academic debate that had gone on within the history and sociology of medicine over now almost the past 90 years.

In the 1930s, the major frame or analytic context for understanding medical professionalism was the work of Talcott Parsons, a famous sociologist.  I suspect some of you have read him as well.  Parsons treated medicine as the quintessential profession.  This profession, he argued, had a collective orientation, and he very, very clearly contrasted it to business, which was self-interested.

For Parsons, the financial self-interest that business characterized as normative was outlawed in ethics and the practice of medicine.  He was altogether confident in declaring that patients should put themselves in doctor's hands, do as they were told, commit themselves to recovering.  No patient activism there.  You listened to your doctor.  You did as your doctor told you.

Parsons did all his field work at Mass General.  A very sophisticated sociologist, he had no trouble thinking that Massachusetts General, MGH, represented the world of medicine. Startling as we read him but very, very much there, professionalism in his context and his influence, I think you appreciate.  Professionalism, doctors serving patients' best interest, was the hallmark of the field.

But in the 1950s and 1960s, a very different line of interpretation comes to dominate this territory.  Professionalism now becomes the synonym for guild monopoly.  Restrictions on entry to the profession, exams, licensing, these are not intended to maintain quality, the school argued, but to restrict the number of practitioners.  And why restrict them?  Obviously, so that those already inside would be able to protect and raise their incomes.

Self-regulation was a sham, variations on the fox guarding the chicken coop.  Physicians in this school had only one goal:  Protect their own and advance their own financial interests.

Well, those two rival schools, if you will, one succeeding the other, as you look at this over the past 10, 15 years, the wheel of interpretation has turned again, not all the way back to Parsons but quite close.

Professionalism now has become the best hope for resisting the demands of managed care or any profit-seeking managers and auditors.  The patient is to be represented and stood up for by the doctor.  Indeed, because the government was not only a payer but the payer, professionalism had to resist its intrusions as well.  And as I think everybody in this room recognizes, we've had a fabulously intense revival of professionalism, and we are almost back in the days of Parsons.

So two important findings.  I think I want to draw your attention to this little anecdotal survey:  One, there is no single historical line of interpretation that will resolve the question of whether past crises are more severe than current ones.  You know, whichever frame you prefer you may adopt, you can emphasize, you can stress.  But there is no one line of interpretation that will enable you to say "Back then, it was so good.  Now, it is ... don't go down that road, I would urge you." There is really no way of saying whether the profession has deteriorated in its performance, whether doctors are or are not less committed.

Second, in the case of my own organization, we found ourselves, after we went round the wheel abandoning the issue, trying not to resolve the past record, but defining ourselves in terms of future action.  We take as our fundamental challenge, leaving aside this historical context that I provided you with, our fundamental challenge:  What is the role for professionalism in the 21st Century?  Going forward, what does it mean to make professionalism a force for change?

Clearly, the practice of medicine is different today than it was 50 years ago.  It's different in what it can do.  It's different in what it should do in terms of best practices, fundamental differences in who does it, differences in practice conditions, and differences in reimbursements.

The assignment then becomes, given these changes, what do we do to enhance, promote, use professionalism as the guide for action?  What considerations, whether in medical education - which you'll hear from later today - in medical practice, in physician's behavior, in health policy, what difference should professionalism make?  And in the time I have with you this morning, I'd like to begin to suggest some answers to that question.

I've avoided until now, but it's not a serious issue, the definition of what we mean by professionalism.  Perhaps surprisingly, although not in a room like this, there's a good deal of agreement on just what its attributes are:  Altruism and commitment to patients' interests, the starting point for everyone; profession as self-regulating, clear to everyone; the obligation to maintain technical competence, again clear to everyone; civic engagement, which I'll only say a word or two about in a moment, a little bit more controversial.  But there are those of us, and I think you've heard from them, too, over the past several years who would put civic engagement in there as one of the attributes of the profession.

I'm going to come back to the key altruism point.  But I want to begin with the others because the altruism and commitment to patients' interests is so important and so complicated, if we begin there, I'm afraid we won't get out.

Professionalism's commitment to self-regulation.  The historical record is weak.  If I was going to more aggressive, I could say pitiful.

The tradition of passing on troublesome colleagues to the next institution.  Every major institution that I know of and have been affiliated with is totally scrupulous in terms of who gets to practice medicine under its umbrella.  I mean, you know, I know this.  I experience it.  And if there are lesser physicians in terms of talent, etcetera, etcetera, you know, a friend is going to go there, I will be told immediately, "Uh-uh, not there.  You go here.  Thank you."

As institutions, we are terrific at monitoring the capacity and quality of our fellow practitioners.  The problem though is that our loyalties are very institution-bound, and we have no difficulty often in passing on colleagues that we would not send our relatives to to the next institution.  Periodically, scandals will break out, and New York has had its share.  We don't do a very good job outside of our own turf.

Failure to police activities.  We just came off a fabulous scam in whole-body scans.  Right?  I mean, a useless, expensive, anything-but-evidence-based procedure, although it collects a good - collected, I'm happy I can use the past tense.  I mean, obviously the major professional societies did, you know, in the radiology world say uh-uh.  But very, very little concerted action taken to really put an end to this.  I mean, you know, let a scam come up.  You don't see a lot of organized action to take it down. 

Anti-aging clinics, cosmetic claims, the anti-aging claims.  Manhattan has several.  I'm sure Florida, Arizona, California beat us by the many.  It is a scam.  Many of us in this room have a real stake in anti-aging claims would that they were valid.  But I think most of us in this room would suggest that giving 75-year-old men heavy doses of testosterone might not be the thing you want to do.  And we've learned, despite all the complexity, etcetera, etcetera, giving 65-year-old women estrogen is not the thing to do.  Growth hormone - I mean, you know the litany. 

And yet you can walk on the East Side of Manhattan as well as in these other states, and there they are.  There's even now an anti-aging [specialty] - I don't know.  I think they call themselves that.  It's not recognized by the G and E [graduate medical education] world.  But there it is in medicine's record, so to speak, and taking these things down is not very great.

Maintenance of technical competence, reducing medical error.  There the profession has done a more credible job.  But the challenges it faces are going to be quite extraordinary.  The chart which was once thought of as, if you will, in private practice belonging to the doc, if not, in institutions, making the chart transparent, the use of information technology; sharing data, somebody looking over your shoulder; recertification - I think many of you in the room will know the stories of what happened of when the ABIM tried to put in recertification - resistance, but it may yet come through.  The younger generation is perfectly comfortable with it; and the evidence-based medicine debates, which are quite fierce. 

I've just finished reviewing Jerome Groopman's book [How Doctors Think].  The reviews didn't talk about this, but I certainly do.  It's a polemic in a variety of ways against evidence-based medicine.  It's going to ruin the clinical intuition, and he comes out very, very strongly against it.  He was worrying about clinical insight.  Many others, of course, worry about the failure to do what ought to be done, whether it's the use of beta-blockers or, you know, other interventions.  A major area, and one I think that's going to see enormous amount of activity.

I won't spend much time on civic engagement except that the data is overwhelming that physicians do not participate in community affairs, and I'm allowed to say, even pediatricians who lead the pack don't lead it by a lot.

You don't find physicians participating often in public discussions.  It's a much more reclusive profession except for many of its professional medical associations.  But most of them spend their lobbying money on protecting members' interests.  They are member-interest driven rather than advocating for the public good.  This is not always true.  Pediatrics, some of the medicine groups can escape it. 

In the New England Journal of Medicine piece that is in your packet, I said something which brought me more shouts and screams than most things that I say.  I was dealing with this question of advocating for more than pocketbook interests.  And there's a quip in there, "would that ophthalmologists rather than GI guys advocated for colonoscopy."  Well, I mean, I meant it in just this frame.  You can't imagine the invective that I got.  Don't you know the difference between an eye - you know, you can fill in the rest. 

I was tempted to remind some of my writers that ophthalmologists to the best of my knowledge had received MD degrees and might be perfectly competent to review colonoscopy-funding decisions.   But what I was trying to do was to get out of the box.  It was not a particularly well-appreciated line.

Let's come to the core issue, altruism and commitment to patients' interests:  money versus medicine, the HMO/hospital/group  practice/financial incentives, the drug company gifts and payments.           I mean, I've already given you a frame that says it ain't quite as new as some of those who worry about this may believe, but it is certainly hot on the public agenda.

I use this slide for a purpose, and it's not simply to wake up a sleepy audience, which is not this.  A physician:  "Try this.  I just bought a hundred shares."  All right, now this appeared in The New Yorker about a year and a half ago if I remember.  I don't want to spend a lot of time deconstructing it.  But just do the thought process of the presumptions among those who edit The New Yorker and its readers, you know, that this will be understood, will be seen as funny.  This builds on a lot of assumptions that suggest that ultimately the professional is really money-driven.  Parsons notwithstanding, this is what it's about.  That this is seen as understandable and humorous suggests a quite jaded public view of exactly what's going on.

This slide comes from The New York Times as you see.  On the weekend, she's a cheerleader.  During the week, she's a drug rep.  When I'm lecturing the medical students, I remind them that once upon a time in the '60s and '70s - Dr. Pellegrino will probably agree - the anatomy course would, you know, throw in pictures like this even a little racier to wake up students.  Now we're at '05.          

And, again, what does this say about the profession to the public? 

I will share quickly a humorous story.  I had been doing some work in China on issues of professionalism.  They were interested in it for a variety of reasons, and I sent this slide.  And then I had some second thoughts about it, did I really want a Chinese audience to deal with this?  And I wrote to the convener of the meeting and said, "Look, take that slide out."  And he e-mailed me back very quickly, "Yes.  We will take this slide out and we're delighted that you made this decision.  Our translators couldn't figure out what a postage-stamp skirt was," the dangers of doing cross-cultural work.

(Laughter.)

The press coverage.  For a project that I'll tell you a little bit about later, we had one of our researchers just cover the press, you know, over July, the extent of it, a lot of it in The Times, a lot of it in The Journal.  But it goes out to The San Jose Mercury News, "Science critics ... Financial Ties", "Financial Ties to Industry ...", "Hospital Chiefs Get Paid for Advice on Selling to Hospitals," "Indictment of Doctor Tests Drug Marketing Rules."  I mean, again, it goes on, "... Conflicted Medical Journals."  Look, this is the reading public.  A week?  You know, I keep a pretty extensive file.  There can't be a week when I don't add to it on conflict of interest, and it's almost every day between The Wall Street Journal, The New York Times, The L.A. Times, The Philadelphia Inquirer.

Many of these reporters, by the way, are not in the health section but in the business section.  So the public is getting a pretty steady accounting of conflict of interest, and it's very, very much on the public mind.

It was knowing this that the ABIM Foundation, at that point in time headed by Harry Kimball, and my organization got together to see what we might want to say about conflict of interest questions given their extraordinary prominence.  In the room is one of my colleagues who worked on this, Susan  Chimonas.  You'll be hearing later from Jordy Cohen.  You know many of the other names on here from Troy Brennan to Neil Smelser, Jerry Kassirer. I mean, you know these people.

We spent several years, two to three, doing this piece and found our task - well, we found two things.  One, we had to create, so to speak, a table of contents which I'll show you in a moment.  What were the major issues that ought to be on the table?  And simultaneously we really tried to give an account of what we thought should be done.  You know, what are our recommendations to deal with these issues?

I will say here that the group began very moderate in its posture.  Given my training, I would call them, if you will, moderate abolitionists, gradual abolitionists, don't move too fast.

The more the group stayed with the issue and the more the analysis went on both in terms of information about the practice, the impacts of these various practices and our own sense of what should be done, we became, if you will, Garrisonians, immediate abolitionists. 

And this is a fairly consistent, if you will, abolition document.  It's had, I mean from our perspective, a wonderful more neutrally-put extensive impact, maybe even more because we set out the table of contents in the left-hand column, the activity that, you know, we worried about.  I mean, the left-hand column has now become, if you will, the checklist as more and more institutions review their own policies on conflict of interest.

We limited ourselves incidentally to academic medical centers because we could find no easy way to influence community physicians.  That seemed beyond us.  But at least academic medical centers, centers which did all the training, centers of influence, there we could speak to them.

Gifts, meals - eliminate.  You can read this.  Samples - indirect, not in the doctor's office.  Speakers' bureaus and ghostwriting - I mean, scandalous.  The ghostwriting, it's hard to imagine anybody accepting this.  This is what we throw kids out of college for.  I mean, where we come from, it's plagiarism or something of that sort.

Speakers' bureaus - we're not talking about honoraria.  That's a separate list.  We're talking about joining the speakers' bureaus and becoming the hired hand of the drug company - shill, commercial sex work, I don't know what terms you want to use - infamous.  And there we had no problem saying eliminate.

Payments - okay, but get it out of direct support for CME, get it out.  Don't let the division chief or the chairman pick up the phone to call the drug company to say, "I need $20,000 for...," that sort of thing.

Consulting, honoraria, and research contracts - we did not say no.  I mean, we recognize fully well that, if you will, pharmaceutical companies are not tobacco companies.  We appreciate that.  You can't end all the nature of the relationship.  And the cheap shots that were taken at us were, "You're demonizing the pharmaceutical company."  We're not trying to demonize the pharmaceutical company.  We were trying to eliminate as far as we could conflict of interest in this arena.

Consulting, speaking honoraria, and research contracts have to be maintained.  But we do ask for transparency, but real transparency.  Specify the terms of the service, make them available for public inspection, let it be known how much.  You know, you'll see the disclosures in journals.   Consultant to X drug company - $100, $500, or $500,000?  It does make a difference, and that urge on our part to render it transparent we think is crucial.

Formulary and other purchasing decisions - decision-makers must be conflict-free. 

After the appearance of that article, I received a phone call from Pew Charitable Trusts who read the piece, saw the press coverage of it which was extensive, and then asked an embarrassing question:  What did your committee think to do the week after the report was released? 

Our committee in truth, as I told them, had not spent five minutes on what we would do after the release.  Here's our view, but, I mean, we spent not a moment on what we might think about in terms of implementation.  Pew Charitable Trusts is many things, but it's not the IRS.  So when it says, "Think about it, and we'll help you," we were prepared to start thinking about it and we did.

The prescription project, funded handsomely by Pew, is working in a variety of areas, the two areas most central to our conversation today and really most central to the project, to see what we can do to change conflict of interest policies at academic medical centers.

There are some lead groups out there:  Stanford, Yale, Penn - you'll read tomorrow about BU - Wisconsin, Michigan, Kaiser.  It means a lot of forward action.  The wind is to our back and we'll see what we can do in that territory - translate prescriptions into practice and the very same thing with professional medical societies.

I give you this and tell you this background to it because you are obviously quintessentially in the formulation area.  It was unusual for us - we were not prepared for it - but we are finding it very exciting to look at actually changing practice in an area that we have been studying.

Where do we go from here?  I worry.  I worry a lot about "professionalism lite."  I hear a lot about this.  I get anxious when professionalism gets equated or swallowed up by good manners.  Look, good manners are very, very important.  I don't want to discount them in people or in doctors.  But that's not the sum and substance of professionalism. 

Humanism is important.  Look, I come out of the social sciences and humanities, not out of medicine.  And, you know, the humanistic spirit, god knows, is important.  Again, I don't want to - you know, I think it's important that medical students read literature, although I will tell you as you already know and can remember, there are professors of literature that I would no more trust to be good-mannered or acting in my best interest than anybody else.  But humanism is important, but they are not substitutes for substance.

My last slide is probably my most controversial slide.  Professionalism lite is easy to put down.  At least, I think it's easy.  I think it's really important to talk about what it really means to advocate for professionalism. 

Put patients' interests first, but don't coddle that.  That really is meaningful.  Look, you may have to take a financial hit.  That's what it may mean.  You know, speakers' bureaus are fabulous.  They'll send you to Hawaii and they'll pay you X-teen thousand. 

One dean has mentioned to me that as he put in a ban on this sort of activity an angry colleague came up to him and said, "You are now depriving my children of their college education."  Okay?  I mean, rhetoric, not rhetoric?  I don't know.  But you certainly can get the heat up.  If you mean it, this is what it means.  You know, if you're really going to talk about it, this is what it means.

Technical competence?  Sure.  But it means you're going to have to let people look over your shoulder.  None of us like having people look over our shoulder.   That's not the most pleasant activity, but that's what it really means.

Self-regulation.  You're going to have to say something.  From my context, you know, the guy who is handing out testosterone, you know, like it's life-savers, do something.  Report a colleague.  It's not comfortable.  None of these is comfortable.  But ultimately I think they're crucial.

The last slide, you know, the last bullet, physicians will campaign for public benefits, not private reimbursement.  Change the orientation of professional societies.  Members may not like it, but that may simply make the issues all the more important.

Thank you for listening.  I've enjoyed the chance to present, and I look forward to the discussion.

CHAIRMAN PELLEGRINO:  Thank you very much, Dr. Rothman.  Dr. Dan Foster, a member of the Council , has graciously agreed to open the discussion.  Dan?

DR. FOSTER:  I didn't really agree.  I was just told to do it.

            (Laughter.)

CHAIRMAN PELLEGRINO:  But you were told graciously.

DR. FOSTER:  Well, I think that, I mean, there are many things that one could comment on in the report and very little that I think that I would disagree with.

The first comment I want to make is that the good old days of all-white males are completely gone in most academic centers, I'm sure.  I was at Columbia not too long ago.  White males are an endangered species in medicine.  We have 55 new interns and four are white men.  I mean, it goes back. 

There are no, almost no, white males going into medicine anymore and for complicated reasons.  There are many women and, of course, a huge number are of second-generation persons from Oriental and other [ethnic backgrounds].  But that one, we don't have to worry about anymore.

Secondly, the traditional views of professionalism, as you pointed out, go back a very long time and were much narrower than the social issues that you have talked about here.

Osler in 1902 gave a great talk in which he started off - he had four things to say about medicine and what it should be.  He said it had a noble heritage, that there was a long line of true physicians that went back to the founders like Maimonides and Hippocrates and so forth, and that he was asking the guild, as he called it at the time, to take their place at the end of this long noble line.  He believed that it was a noble profession.         

And if you go back and read the history, that term "noble" enters very often.

Secondly, he said that it had a remarkable solidarity to track to their sources the causes of disease and to make these new findings available to everyone.  It was not a solidarity of race or sex or political meaning.  It was to fight disease.  It was to prevent premature death and cure disease when that was possible, that it was to alleviate symptoms when cure was not possible.  It was to comfort always, the priestly function.

Third, he said it had a progressive character.  In his day, they were shifting from magic to science, and they did it.  They made that change.  That meant that one was a life student.  It has to do with your issue of technical competence, which is not easy.  I'll comment in just a second.

And, finally, he said, it had a singular beneficence.  He said the relief of human suffering was such to make the angels sing.  We don't talk like that anymore.  But this was the core of professionalism in Osler's view, and I think that still holds very much.

The technical issues are not solved by evidence-based medicine.  One of the real problems is that you have very good studies by very good people who come to different conclusions.  For a long time, we believed that estrogen replacement would be helpful in terms of heart failure and so forth in women.  Everybody agrees that this was a solid statistically-wonderful study, and then it changes.  And they change in different parts of the country, so it's not - and then you worry about a challenge to the nature of journals that 35 percent of their statistical analyses were no good and they didn't believe it, and they reproduced this from the Spanish statisticians that challenged it, and it turned out it was true.

So oftentimes the - and the meta-analyses that everybody pays attention to about, you know, whether this - I think most scientists are really skeptical about that because you don't know.  You're giving equal comment to studies of all sorts of things, old people versus young people, all sorts of things of that sort, so it's a problem.

And then in the traditional sense, Joe Goldstein in his last career award - I can't remember whether I mentioned this before sometime.  But in 2004 - and I didn't check it - there were 550,000 papers published in the biomedical literature in the 4,000 journals that the National Library of Medicine archives in PubMed and so forth. 

550,000 - that's more than a paper a minute.  Now let's say that only one of 1,000, Goldstein said, if only 1 of 1,000 is important, that's still 500 major papers that a practitioner and a scientist has to keep up with to do it, and that has nothing to do with this issue of somebody looking over and what best practices are.  It's much more complicated than that, I think, and much more difficult than to be dedicated to try to learn those things.

And I think the last thing that I want to say is that it's very easy to recommend to others that their income ought to go down.  As Bud Relman said last week, "You can't go to any major city in the country and find an internist for an aging patient."  People won't take Medicare anymore. They don't follow their Medicare patients, because their income goes down.

I have a son who is a general internist, and he's very good.  He admits his own patients to Baylor Hospital and so forth, and he has a wonderful group.  His income has gone down every year for the last four years.  And he doesn't do anything shady.  I mean, he doesn't give Botox or anything like that.

But I'm not talking about big money.  I mean, there are some people that make big money.  I'm talking about trying to make $100,000 a year as a general internist.  I get $40 for seeing them.  I'm a professor, but I get $40 for seeing a patient for Medicare.  We still see them...   Internists are very demoralized these days because of these changes in money and so forth and the fact that it goes on here.  And we had taken our dog to the veterinarian, two dogs we took for a bath and shots.  And it was $250 cash upfront.  And I get paid months later $40 for seeing a patient.

So there's a worry about that.  And then to say, "Well, you're going to have to take a hit financially if you're honorable" - that's sort of what it says.  And that's probably true.

But that's very easy to say when you're not - and I'm not speaking about you at all, you understand.  But it's very hard to find people to even go into general internal medicine anymore to get people who will take care of real patients, not subspecialty.

And the last thing I would say is that I don't think - I know you're not attacking drug companies.  But almost everything that happens, one has to look for somebody who must have some interest to give significant money. 

I'm the president of the Academy of Medicine, Engineering, and Science in Texas.  That's all the people who are members of the national academies that live in Texas.  And in response to the gathering storm report of the National Academy about the failure of their - there's a great editorial in Science this week about stem and so forth. 

But we took on at the request of Senator Kay Bailey Hutchinson, our senior senator, the Academy is going to study the teaching of math, science, and technology in the Texas schools.  This academy has no money, I mean, really.  I mean, the university presidents give us about $250,000 total a year, you know, to keep up with.

So we have to say, this is a very great thing to do.  How are you going to do it?  Well, the first gift we got was from Dow Chemical.  They didn't put any [conditions] - they just said, "We're very interested in this" and so forth.  But everything that you want to try to do, you have to have somebody that's got some sort of an interest unless they're purely altruistic that they just want to give money.  And the pressure from their stockholders is very hard, you know, if you're going to give a lot of money to support the study of Texas schools.

So, I guess I'm a little worried about the idea that the involvement of big businesses and so forth has to be always completely pure without any interest.  I mean, nobody in the government does anything without some interest that they have, and I think we have to be careful about the terrible things that your group on professionalism has said.

But I think it's going to be a little hard to say, "Well, we can't receive."  There's always an implication that nobody gives money unless they have a self-interest.  Well, if you give money to the symphony in Dallas, you have a self-interest because people will think American Airlines is good if that do that and so forth.  But, anyway, I think it's a terrific thing here.

The last thing I would say is that I think it's hard to teach ethics or to teach professionalism by papers or by lectures.  There's a statement that I gave that I found that I thought was very interesting, and it was about the contract between teachers and students, what do they owe each other?  This person who writes about this a lot said, "Great teachers don't teach.  They help students to learn."  That's a profound statement.  "Great teachers do not give lectures," he says.  "Great teachers do not teach.  They help students to learn."

It seems to me most of the time the lessons of individual professionalisms of the Osler type and so forth almost always occur because of a role-model who is professional and where they see. 

So I'm fairly skeptical about the - I think it's good to get a structure of what ethics means and so forth, and probably somebody should have a lecture of that.  But I don't think we're going to transform people to working in the public interest and so forth, let's say, for health unless there are people who do it that a student can identify with.           So I'm not sure that one can teach in a didactic sense what professionalism is about.

So I think this is a wonderful effort that one has made.  But I think that one has to be - and maybe the prescription thing is an excellent way to go.  I mean, I don't know.  But I think it's really, really hard, and I wouldn't want to think that it's a simple thing to deal with, and I know that you don't think that because you do this all the time.  I don't do it at all, but, I mean, except that - I would say I don't want to sound self-serving.  But I do try to show it, you know, on the wards and so forth.

And I've been very active in public.  I ran for the Presbyterian Church all the inner-city work for four years in Dallas, Texas.  I've been involved in all these things, so I'm not being critical about it.  But you have to be motivated to want to do that, I mean.

I rented the Dallas Auditorium for the first Martin Luther King celebration without permission from the Church.  I thought I was going to get ex-communicated, but they actually thought it was a nice thing to do.  So you just have to have a model.  I served on the Dallas School Board.  I was a trustee during the desegregation case.  But you have to have somebody who does this that says, "Well, maybe I could do this."

And the last thing I'd say, I'm very touched by the AIDS work that a drug company is sponsoring in South Africa and Africa where all these young physicians - I think there are 50 or 60 now - that are sent there for two years.  I have a bunch, a number, that are over there.  They are paying their salaries.  They're building the clinics.  And these young people, these young people where they're right in the middle of their careers, you know, that haven't finished their fellowships and so forth, are giving two years of their - and so you see these sorts of things.  Now they're an inspiration to me to do that.

I didn't mean to talk so long about this, but it's something that I feel very strongly about.  And as I say, I think that it's going to be hard to universalize this and I think it's going to be awfully hard to get people to say, "Well, I'm going to cut my salary" when nobody else does it.  I think that's going to be hard.

CHAIRMAN PELLEGRINO:  Thank you very much, Dan.  Dr. Rothman, did you want to make a brief -

PROF. ROTHMAN:  I think it would be more helpful to hear the others.

CHAIRMAN PELLEGRINO:  Very good.  Thank you. 

DR. CARSON:  I identify very, very strongly with Dan's comments.  They're right on target.  You know, I've spent my entire career in academic medicine where there has not been as much of a drive to enhance one's income.  Sort of automatically, one takes the altruistic road when one decides to go into academic medicine.  Nevertheless, those people that do still have pressures.

I'm reminded of the story of the neurosurgeon who had some plumbing work done at his house and the plumber gave him the bill, and it was $2700.  He said, "$2700?  I'm a neurosurgeon.  I don't make that much," and the plumber said, "I didn't make that much either when I was a neurosurgeon."

(Laughter.)

But, you know, the fact of the matter is that there always has been sort of this feeling that doctors make too much money.  It may even stem back from when people were in grade school.  You know, people who went on to become doctors were always the ones who sort of changed the curve and made you get a bad grade and, you know, people feel resentful of those kinds of individuals. 

But one has to take into consideration the enormous amount of money that it takes to pursue a medical career.  I was talking to a fourth-year student not long ago, a medical student.  I said, "What's your debt up to?"  He said, "$300,000," you know, when you still have internship and residency to go through and you're not going to be paid very much money during that time and all of your friends who have gotten their MBAs and their legal degrees are, you know, leagues ahead of you, and then you get into the profession and people say, "You shouldn't make any money.  You should be a good guy," you know, that doesn't compute.

So, you know, we need to actually address those issues rather than just, you know, making little platitudinous statements about you guys ought to not really be interested in a financial remuneration.

CHAIRMAN PELLEGRINO:  I have Dr. Hurlbut and Dr. Meilaender after him.

DR. HURLBUT:  So you articulated certain dimensions of the problem well, but I want to explore something that's implicit in what you were saying.

In the first comment you made, you spoke of the dominant culture that governed medicine in the past, and it wasn't really the good old days only.  I mean, obviously if the physicians are all male, white, and upper-middle class it indicates a lack of opportunity for some people, but also perhaps more seriously a kind of limited perspective engaged in the practice of medicine, a kind of prevailing culture.

And so basically what I want to ask you is, what limitations are subtly and maybe unconsciously being imposed by today's prevailing culture?  And just to unpack that a little, we are, at least by some critics, a materialistic consumer-driven society.  Maybe that's influencing physician's values and their codes of conduct and self-justifications as you've said.

But could it also be that there are some other dimensions?  You mentioned enhancement technologies.  Without really giving much articulation to it, you dismissed some practices that physicians do as being not physicianly. 

So what I'd just like to get at is, what do you think the role of the physician really is?  What are our purposes?  What are the limits of our prerogative?  And what kind of service are you really calling us to be?

And I know that's a very big question and very broad, but just if you could make some comments about what dimensions of the prevailing culture might be perverting medicine today and how we might more specifically articulate the professional role in the face of those.

PROF. ROTHMAN:  I know I promised Dr. Pellegrino that I wouldn't comment until all, but your question is so specific so I'll address it.  It's a truly wonderful question.  I won't comment on the first part of it, but I promise you the next time I get to talk about that I will. 

What did it mean?  What did it mean that it was an all-male, all-white, upper-middle class profession?  That's a great question.  And there are things that it did mean, but we'll save that for another time given the limits of time here.

But your second question - and it's actually helpful given the comments, you know, that came before you.  I'll give two examples.  Remember in the old days, you know, in the rationing debate when Oregon did its rationing scheme and it limited it to, you know, Medicaid patients, many of us said, "When it comes to rationing, it's really easy to ration the other guy's medical care."  Right?  I can tomorrow ration Medicaid.  Right?  But, you know, if you're going to start rationing my medical care, etcetera, etcetera. 

And I was not intending to have physicians take a vow of poverty.  You know, that's not my theme, and your question enables it.  What do you think the problems are?  I'll give you two examples from The New York Times - but then please respond back - a story within the past week.

It will take you approximately - don't hold me to the exact numbers.  It will take you 30 days to get a dermatologist, the Times wrote, to take off a suspicious-looking wart to see if that wart is cancerous.  It will take you four days to get Botox.  Okay? Something's wrong.

Now this is not a vow of poverty, and I'm not trying to do a number on dermatologists.  But there's something going on that you can get your Botox - and we know what's going on.  Dr. Foster, your comments.  You think it's hard to get into medical school?  Try to get your kids into veterinary school.  I mean, the word is out.  I mean, you know, people understand this.  The plumbers aren't lining up quite so much.  That's humor.  It's not real.  But the vets are real.  So a profession in which you get Botox quicker than you can get a biopsy.

A story about a year ago of a guy coming out of oncology who self-reported, you know, was making $300,000 or $400,000 goes to Goldman Sachs, works for Goldman Sachs and now is making, you know, $3,000,000 to $5,000,000, I mean, and was quite proud of it, by the by, and when asked whether he felt any twinges, etcetera, etcetera, he said, "No.  Sooner rather than later I'll become a philanthropist."

So the question is, you know, it's not a vow of poverty.  Nobody intended that, although I will also just add parenthetically until the middle '60s the profession was not particularly well-paid.  Then procedures and Medicare came in and changed the income distribution, procedures particularly by detaching reimbursement from time.  That's really another subject.

But it's a profession.  And the meaning of the profession taught, modeled - I have no problems with that - somehow or another communicated.  Jordy Cohen will be talking about medical education in a little bit. 

You know, Botox is really neat.  But, you know, biopsy first.  That kind of message.  I'm not saying - you know, if you want to run a little thing on the side to make some money, all right.  But don't bump biopsy for Botox.  It's like a car sticker.  Right?  Don't bump biopsies for Botox, somehow or other by modeling, by freeing medicine up from the more obviously marketing ploys, from trying to give a sense of value that this is not a marketplace activity.

But please respond back.

DR. FOSTER:  Let me just make one comment in the Botox thing.  What's wrong with that article is that the Botox is done by technicians and not by the doctor, and so it's very easy for them to just schedule somebody to come in.  You know, you don't even have to be an MD to give Botox.  At least in Texas, you don't.

So I think one of the problems is that you have a physician assistant or somebody who can do things faster and that may be one of the reasons.  I'm sure it's money.  Don't misunderstand.

PROF. ROTHMAN:  The Times piece didn't draw that distinction.  I don't know if it was in their story.

DR. HURLBUT:  What I'm really getting at is - I mean, you've partly answered this - what you might call prevailing cultural values.  They're almost unconscious to the culture.  It's so close to you that you can't see it.

PROF. ROTHMAN:  Yes, yes.

DR. HURLBUT:  And here I'm thinking of things like the emphasis on autonomy and individuality that prevails in our culture, the sense that there's a new relationship, not patient/doctor but client/provider, where we're serving the patient's aspirations and ambitions and not necessarily more profoundly articulated purposes and values.

Just to give two very obvious and extreme examples, physicians have been expected to become executioners at death penalties and in some cases implicitly expected to serve patients' personal desires for gender-selection abortions.  And so I'd like you to comment a little on this. 

These are worrisome things because if the physician's role is socially-constructed and socially-defined, then are we somehow in need of a deeper root, both intellectually and specifically articulated in our code of conduct?

It seems to me that physicians are in danger of becoming agents, not just of individual patient's desires, but of larger unarticulated purposes of the society as a whole including almost becoming tacit social scientists and engineers for the kind of society that we want to get and, strangely, even ultimate authorities on matters of what defines personal responsibility, what defines acceptable species' conduct, what even defines human purpose.

These are really new roles for the physician, it seems to me, and it seems a lot of this is very unconscious.  A lot of it is just our not being aware enough of how we as a society are actually imposing certain values onto medicine itself.

PROF. ROTHMAN:  But then - and just a response, because there's so much more, but these are fabulous points.

I taught a couple of years ago with a colleague in the law school.  We taught a course to law students and medical students.  And I don't mean this as a putdown of lawyers.  The lawyers really define themselves as client-driven.  Hired guns is not, you know, etcetera, etcetera.  The medical students to their credit were much, much more conscious - I mean, they could go overboard, too - much more conscious of the fact that, although they had duties, they also had professional obligations. 

I mean, the gorgeous case that you raised:  The AMA to its credit and others not allowing for the physician participation in capital punishment.  It's a very - I mean, that was well-done.  You are not the handmaiden of the criminal justice system.  The criminal justice system may decide to do capital punishment.  You, as physicians, don't belong there.  And that was done and said very, very well.  You're not the hired guns.

I mean, yes, I know.  And this notion of physician-patient partnership, I have a lot of difficulty with that.  I mean, I didn't go to medical school.  I hope my doctor went to medical school.  I don't want to deal with all the stuff that he knows.  I don't have to find that out.  It's a complicated relationship.

But you're not a hired gun, and I think that has another aspect of professionalism.  Indeed, it's what, you know, I think in many ways drove Soros and others to say, "The state doesn't control you."  The government says, you know, a gag rule on abortion discussions.  Medicine got its back up.  We're not here to take orders on what we say to our patients.  We're not here to be servants in your criminal justice system.  We have an ethic and an ethos apart from the society. 

Now it's tricky and hard to teach it, and it's tricky and hard to model it.  But you're really at what I think are core issues of professionalism. 

CHAIRMAN PELLEGRINO:  We have Dr. Meilaender, Dr. Dresser, Dr. Kass, and Dr. George.  And before you launch into your comments, thank you.  We'll start with Dr. Meilaender.

PROF. MEILAENDER:  Yes.  I'm not sure whether this is a question or a comment, but I've been trying to think about sort of what a body like this is to make of your presentation.

And for me at least, I'm more persuaded by certain examples.  That is to say, when you're lower to the ground and you give an example of a particular conflict of interest or something, I'm more persuaded by that than by the theory of professionalism which seems to me to need - I don't know - to need work in a lot of ways.            

I'll just tick them off.  I won't try to defend them at length right now. 

But it's not clear to me why a professional, simply because he or she is a professional, is to be civically engaged.  There may be other reasons why they should, but.  Nor is it clear to me why I should pay particular attention to them when they're civically engaged just because they have professional expertise.  That's one sort of thing.

Second, putting patient interest first - and this relates to Bill Hurlbut's comment - I mean, this needs a lot of sorting out.  By patient interest, do we mean patient's desires?  Do we mean the good of the patient?  The health of the patient?  Patient interest covers a whole range of sorts of things there and, in fact, blurs some important arguments that it seems to me need to be made.

And then third, and sort of most importantly and most central to your presentation on the issue of altruism - I mean, Dan Foster said everybody has interests.  I think that's true.  We need a lot more work on what we mean by "altruism" if this is to be theoretically helpful, it seems to me.  You don't want people who lack interests.  That would be to lack projects in life, sort of.  Nor is it necessarily a bad thing if my interest and the interest of the others should coincide in various ways.  I mean, this is not a bad thing.    

So whatever altruism means, it doesn't mean the obliteration of self-interest, at least I'd like to see the theory worked out that persuasively argued that.  I doubt if it can be done.

So at the theoretical level, it seems to me - I'm just not sure - I'm not entirely persuaded and I'm not sure kind of where to go though a lot of your particular examples seem to me, you know, fairly persuasive.

CHAIRMAN PELLEGRINO:  Dr. Dresser?

PROF. DRESSER:  Thank you.  I really liked the JAMA article because it went beyond hand-wringing and really some, I think, concrete and reasonable recommendations.

I wondered if you had thought much about the internal challenges in academic medicine to being a good professional.  I see my colleagues at the medical school torn in a million directions.  Should I spend more time teaching with students?  Should I see more patients?  Should I spend more time in the lab and on research and getting published?       

And to me those conflicts really certainly affect patients and students and the contribution to knowledge. 

So in some ways it seems to me at least the academic medical profession needs to think about, well, what does it mean to be an academic medical professional today?  Is everyone supposed to do everything?  Are there different classifications?  Because it seems to me when I see so many people trying to do everything and they're suffering and the patients are suffering, I would hope that that could be a component of this work.

PROF. ROTHMAN:  That's very interesting.

CHAIRMAN PELLEGRINO:  Dr. Kass?

DR. KASS:  Thank you.  This picks up, I think things that Gil and, to some extent, Bill Hurlbut were saying.

I don't doubt for a moment the seriousness of the kinds of threats to medicine as a profession that you've identified here, but they mostly seem to be the temptations connected with money and have to do really with these external matters that tend to corrupt.

And it seems to me the emphasis on professionalism, which I find an extraction and not terribly helpful, quite frankly, gets to be defined as the opposite of the trade because the problem seems to be the corruption that the trade element introduces into what it is you think should be going on and, therefore, the language of interests as opposed to altruism seems to come out to the center.         

Are you serving your own self-interests defined in terms of being a tradesman rather than the interests of your patients?  And I think that's what sorts of skews the presentation.

I don't think Hippocrates would have understood himself as a professional.  He would have understood himself as a healer.  And it seems to me - I would be interested to know how one begins to think about the special aspects of that kind of professing which is the activity of healing and whether we worry slightly wrongly if we think simply about the deformations that occur at the margins and don't think enough about the positive definition of what it means to undertake the vocation of being a healer, and that's to begin really not with some abstract notions of profession and worry about the deformations and the misconduct, but to talk about the professional formation concretely in terms of what is this work, and we'll talk about it. 

And Dr. Pellegrino's paper, I think for my money, comes a lot closer at least to those internal questions of the character of the profession, and I wonder whether you've thought about those things which are internal to medicine having nothing to do with money that are every bit as much of a challenge to doing this work well as are these kinds of deformations.

Dan Foster landed on one of them simply talking about what it really means today to try to be technically competent.  And a small piece of that also is a drive towards specialization which isn't simply money-driven, but it's very, very hard for anybody comprehensively to serve the patient's well-being in this kind of age when so much is needed. 

And similarly with technology.  I mean, we would not want to do without some of these things notwithstanding the fact that their abuses are commercially-driven.

So I'm really wondering about the presentation of the model of a healer in an age of hyper-specialization and massive increases of knowledge and to not let go of the fundamental meaning of what it is to reach a hand out and accept the reach for help on the part of someone who is ill and wants your loyal service.

PROF. ROTHMAN:  A quick question back to you, although the Chairman is probably going to disallow it, but let me just do it very quickly.

There is a common ground.  I mean, you know, how you deal with the practice, how you deal with competence given these articles and, you know, and the role, you know, given those numbers.  That's been one of the things that the evidence-based crowd says.

My problem with "healer" is that it individualizes.  The term itself seems to render the practice.  It's not necessarily integral to it, but it, so to speak, turns it back one-to-one.  And those of us who worry about the profession really want to think much, much more about - I hate to use this word and don't hold me to it much - the collective organized responsibilities that, in fact, the profession has responsibilities.

"Healer" seems to put it - and maybe you missed my reading of it, so it's really a question back to you.  "Healer" seems to put it back in that kind of examine room one-on-one where those of us who are worried about the profession are really thinking about organized collective responsibilities, really as was being said.  But you're smiling, so I think I may have touched something, but I'm not sure.

DR. KASS:  Mr. Chairman, can I have 30 seconds?  If it's out of order, tell me.

CHAIRMAN PELLEGRINO:  No, go ahead.

DR. KASS:  No.  Look, I don't deny that there are systemic things from how medicine is paid for to how the professional societies organize themselves that are important.

But it seems to me that if one wants to form physicians who understand what it means to do the work, one has to really take absolutely seriously that their work is encountered one-by-one and these other things are constraints which sets the boundaries.

But how you model what it means to actually - I mean, Hippocrates says, "I will apply dietetic measures for the benefit of the sick.  I will keep them from harm and injustice."  And that's a kind of - that's a vocation.  And without that, the rest of the stuff, it seems to me, can't do the work.

CHAIRMAN PELLEGRINO:  Thanks, Leon.  I have Professor George and I also have Dr. Carson, and then I think we'll give Dr. Rothman a chance to respond.

We're going to be discussing this subject this afternoon, and I think some of these questions will be recurrent and you'll have an opportunity to discuss them in more extent.  So Robby?

PROF. GEORGE:  Thank you, Ed. 

Dr. Rothman, thank you for your presentation.  I was impressed by your wonderful moral passion and by the almost prophetic stance that your organization takes toward holding physicians as professionals to very high moral standards.  We can debate, you know, whether they're the right moral standards.  But the idea, I gather, really is to hold people to high standards.

Now, of course, that presupposes that we can know something about morality.  We can know something about the truth of these matters, about moral truth which, of course, raises the question, how do we know such things?  And in questions of disputation among serious people, how do we decide whether it's a good thing or a bad thing for doctors, for example, to be involved in capital punishment?

Obviously, the decision has got to be made.  It's a moral question.  I think you're presupposing that we have some way of knowing these moral answers to these moral questions, so I'm kind of curious about where you and your organization come up with what you think the moral truth of the matter is.

Secondly, I'm impressed in the willingness of the organization, like advocacy organizations across the spectrum irrespective of ideology, right or left and so forth, to be willing to impose or see imposed on people adherence to these norms.  They're not just putting them forward as optional.  You want to see them imposed, like, for example, the norm that I gather you would like to see imposed that has been imposed that physicians may not participate in capital punishment.

So it's not just an ideal or a proposal to people.  It's an imposition.  And physicians who would dissent from this, who would want to make a few bucks or believe that they're doing a good thing and perhaps even something that justice requires in participating in capital punishment, they could lose their license to practice medicine or their standing if they deviated from this.  So obviously you don't have a problem with norms, moral norms, being imposed on people.

But then where do we draw the line and why do we, why would you, for example, have a problem with the government telling physicians that, "Look, we don't want you promoting abortions.  We think that's a bad thing, not a good thing.  We've made a moral judgment.  If you do that, you're violating what we think doctors ought to do, the moral norms doctors ought to stand up to"?

So obviously you don't think - you're not a hypocrite.  You don't think it's all a question of whose ox is being gored.  But how do you handle those admittedly very difficult questions when it comes to proposing the exercise of power to coerce people to conform to these norms?

CHAIRMAN PELLEGRINO:  Thank you.  Dr. Carson?

DR. CARSON:  I want to thank Dr. Rothman for that wonderful presentation and for a willingness to try to take on such a big topic in such a small period of time.

PROF. ROTHMAN:  I do get to teach a course, literally -

DR. CARSON:  Basically, you need one.

PROF. ROTHMAN:  - on professionalism.  But that's a semester you've been spared.

DR. CARSON:  You know, I wonder in academic medical centers where the breakdown of professionalism is in terms of individual clinicians versus administrations, when it comes to advancement in academics because, you know, having been in academic medicine for such a long time, I've seen an enormous number of absolutely top-notch clinicians, people who put patients first, who everybody absolutely loves, but they get the boot.  Why?  They haven't published enough papers.  They haven't done enough research. 

CHAIRMAN PELLEGRINO:  Thank you.  Dr. Rothman?

PROF. ROTHMAN:  Since there's so little time and I am between you and lunch, it's a relief that there's so little time.  So to both you and Professor Dresser, Jordy Cohen is back there.  He's going to have to take on these issues. 

All I can tell you is that it ain't different at 168th Street than 116th Street where I come from.  Oh, yes, we really want good teachers.  And every ad hoc will, on promotion, say, "Oh, yes.  We're really interested in teaching."  I just can't remember the last time somebody who taught and didn't publish got a promotion.

And it's the same at the medical schools.  At the medical schools it's times - look, since I went from 116th to 168th, I was stunned.  I mean, you know, we had a first book for assistant professors, a second book for associate professor.  And then I get up to the medical schools, and these - well, you know what that means, and they've started to change it - 97 articles of which he is first author on 69.  You know, where are these numbers coming from?  It was kind of unbelievable.

Now there are these - the majority I'm talking more about.  There are these new positions of, you know, clinical educator and even Columbia which is a rather traditional place has adopted some of them.

But I think, you know, Dr. Cohen, you're going to take all this on later and deal with it.

The relief of time is to be able to avoid your question of the moral bases for doing this.  The cop-out response is to say that in both of the instances that were raised, both capital punishment and the abortion, the profession itself rose to the position so that the question is really not so much directed at me.  Although, do I have a problem with it?  You know, no.  But it's interesting.

It was the profession that took on the capital-punishment issue and responded, it thought - we won't have to parse out all the "it" - and it was the docs who were furious about the gag rule rather than it being, so to speak - it wasn't cases of me urging medicine to, although I would have, but I was irrelevant to this.  The profession defined these as intrusive and violative.

Now, I mean, I'm sure there are some examples which I wouldn't be quite so happy - well, okay.  The earlier ones that I used where the profession stood up and said, "We will not have government support of, you know, healthcare for the elderly," I mean that sort of thing.      

But in those two cases that you raised, the profession did it. 

I am not a philosopher and, you know, would probably not satisfy you even at my best as to why I thought both capital punishment and government intrusion into the examining room are inappropriate.  I'd probably do better on the government-intrusion side.  But, you know, I like the fact that the profession took on this stand.  I mean, that spoke to its values, not my values.

PROF. GEORGE:  But do you like it because of the outcome they reached?  What if the medical profession would have said, as the medical profession once did, "Abortion is an evil thing.  We do not want you involved in this.  We will take your license away the way we will if you're involved in capital punishment"?  Is it whose ox is being gored?

PROF. ROTHMAN:  That's when we went to the courts.  You're right.  No, no.  I'm with you all the way.  It's horribly complicated, horribly complicated.  And, look, this committee, you know, now we're really more on your turf than on mine thankfully.  I mean, my line is "how nice," and I don't have the test case, although I did use the Medicare.

Let me just close with one last comment because I think I haven't given it - actually two comments which I haven't given justice to. 

One, although we spoke mostly today and I spoke mostly today about the profession's obligation to itself, I equally and on other occasions have spoken at length about public policy's obligation to the profession, and that is serious and every bit as important.

The easiest example to use is payments systems.  Sometimes when I talk about this at length I can talk about we really know how to raise a screwed-up kid.  I mean, we know how to do that.  You know, reward one thing one day, punish it the next.  I mean, we can really teach you how to screw up your kid.  How to raise a good kid is much more complicated.

We know how to set up a payment system that will be most subversive of professionalism.  We witnessed this in managed care.  Set a system up that rewards physicians absolutely to 70 percent of their salaries to the degree that they don't send patients on to specialists.  I mean, we know how to do it badly.

The challenge:  How does public policy treat the profession the way the profession should be treated?  I mean, so don't hear me as only charging the profession.  The issues of payment, for example, are infinitely complicated.  But how do you pay professionals in ways that promote professionalism rather than subvert it - that kind of exercise?

The last point which we didn't get into although it's been intimated a little bit, and I just want to throw this out for your consideration and others will do it, and Dr. Foster raised this a little: The extraordinary change in the workforce.

Columbia, again, is not of the most advanced on this.  But 50 percent of the medical school class is now women.  When you said, by the by, that there are no white men, what was the field?  I mean, I didn't know if you were talking about ob-gyn or peds.

PROF. ROTHMAN:  Internal medicine.  Well, it's not quite that way at Columbia and New York.  But the predominance of women - and that raises another kind of fascinating issue in professionalism that I'm just going to drop with you as closing.

A lot of the "good old days" boys talk about medicine as 24/7.  You've got to be ready all the time, etcetera, etcetera.  And I've been in rooms where young women professionals have said, "Don't you dare define medical professionalism as requiring me not to have children, not to pay attention to my children, not to be married, not to be able to," you know.  And the conflict of interest, which is not only financial, but, you know, "My kid's in a play today," or, you know, "It's my anniversary," those sorts of issues, which I think again are very, very important, and I'm not sure that looking back will give us all the answers.

I guess what I was trying to do mostly today, and then I'll stop, is we're really into some interestingly novel new areas.  And although the look back is useful and it can tell us some things, the interesting challenges are the changes in the profession, the changes in the society, and in the context of the practice of medicine and how does professionalism become relevant to those new developments, whether it's women, whether it's the kind of financial incentives that you describe, or the other issues that we've described today.

It's exciting, and I'm comfortable thinking about it more collectively.  Look, a lot of people think about that doctor-patient relationship.  Less of us are thinking about the larger context of the profession.  And it's been exciting to do it and it's actually been fun, and I thank you for making it even more interesting and challenging. 

I've enjoyed this question and answer period and discussion enormously, and my gratitude to you for having me here.

CHAIRMAN PELLEGRINO:  And we thank you very, very much, Dr. Rothman.  Your contribution was spirited, informative, stimulating, provocative, and not always right.

            (Laughter.)

PROF. ROTHMAN:  I accept all of that.  Thank you.

CHAIRMAN PELLEGRINO:  We will return at 2:00 o'clock.  I think we can make that even with the overrun.

(Whereupon, the proceedings in the foregoing matter went off the record at 12:20 p.m. and went back on the record at 2:00 p.m.)