 I'm delighted to have Dr. Winia join us for today's session. As you know, Dr. Winia is an internist who works here at the University in this section of infectious disease. In addition to that, at the American Medical Association, Dr. Winia directs the Institute for Ethics of the AMA, where he oversees a variety of subject areas, one of which is the topic of professionalism. And Dr. Winia got his MD degree at the Oregon Health Sciences University, did his residency in Boston at the Deaconess, his ID fellowship at Tufts, and then had a master's of public health from the Harvard School of Public Health. Today, Dr. Winia will speak on a topic that really fascinates me, the short history and tenuous future of medical professionalism, wither professional associations, and why. Matt, welcome. I do want to point out that it's wither with an H, not anyways. Wither. It's hard to pronounce a different word. So I'm really honored to be here, and I'm deeply distressed that I haven't been able to come to all of the other of these seminars, because the folks who've already spoken to you are such an illustrious crowd that I am really intimidated, and I wish I could be able to stand up and say, well, as you've heard, I am going to make some assumptions based on who has spoken so far and go through some of this talk kind of quickly. But I want to start with the fact that there's an ongoing debate in the field right now about whether professionalism is important in an exalted status, or whether physicians are more along the lines here, where the girl is saying, OK, you be the doctor. I'll be the secretary of the HHS. And that's kind of the outline of what I'm going to talk about is that tension about what is the role of the physician as a medical professional? What does it mean to be a professional in society? And I'm going to give you my own definition of what I actually think professionalism means. And I think there's really only two sort of take-home messages. So if you have to leave, I'll give you those right now. One of those is that professionalism, like other isms, capitalism, socialism, Catholicism, it's an ideology about how best to organize a good or a service in society. And so that's going to be message number one. And message number two is we have in front of us a very important discussion about what professional autonomy means in that regard. Does professional autonomy mean the right or the liberty of any individual doctor to establish their own practice standards and do what they want without meaningful social oversight, hang a shingle, and start up? Or does professional autonomy entail a set of group processes where the group establishes standards and then enforces those standards for practice? And it's an individual liberty versus communitarian orientation debate that is still ongoing. And you heard it last night in the president's state of the union and the Republican responses. So this isn't just happening within our profession. It's happening in a much larger framing as well. But I'm going to talk about it within our profession. Let me start with a disclaimer. And my disclaimer actually, I think, needs to go just a little beyond this. In eighth grade, I wrote a paper for my social studies class called The Unholy Alliance Between the American Medical Association and the Tobacco Industry. And in order to write this paper, I visited with a former senator from the state of Oregon. I lived in Oregon at the time, Maureen Newberger, one of the first female senators ever, actually. And she was an icon in Oregon. And she was very elderly at the time. But she consented to interview with me as an eighth grade student. And it was a really formative experience. I also read a series that had been done in Mother Jones about the AMA. And you can imagine, if anyone knows what Mother Jones is anymore, what that looked like. And so I say this because that's the background that brought me into medical school. And so when I was in medical school, and I'm putting this all on the table because this is personal disclosure, like this is my conflict of interest here. I walked into medical school and immediately was in the first year that Physicians for Human Rights formed. I was a member. I was on the board of trustees for the Physicians for Social Responsibility. I've been a member of Physicians for a National Health Plan since the day it was founded. So I'm liberal. And so I walked into medical school and I went through medical school and I went into residency as what I would now call a conscientious non-member of the AMA, which is to say I didn't just neglect to sign up. I would not join the AMA because I thought that organization did not represent the values that I thought were most important in medicine. I thought that organization did not pursue the aspects of medicine that were most important to me and, frankly, for all of society. During my year as a chief resident, a guy named Arnold Relman gave a talk. Bud Relman, he used to be the editor of the New England Journal of Medicine. And he was kind of a personal hero of mine. And so he was giving a talk at the Massachusetts Medical Society's resident section meeting, which happened to be right across the street from the hospital I was rotating in. So I planned to go to that meeting. At the end of his talk, someone stood up and said, well, don't leave yet because we're going to hold elections. And we're going to elect people to serve as representatives of the Mass Medical Society to serve at the AMA. And those who are elected will go to the AMA meetings this year, which will be in Chicago. There's always one in Chicago and in New Orleans. And I thought, well, I wouldn't mind a free trip to Chicago and New Orleans on the AMA dime. So I raised my hand and said, I'll run. And I stood up, and I made a little speech about why they should elect me. And lo and behold, I'm elected. And so the first meeting of the AMA I ever go to, so I join. And the first meeting of the AMA I ever go to, I bring with me, and this, by the way, is during the first year of the Clinton administration. So Hillary Clinton spoke at that meeting. I brought with me a resolution to the AMA to endorse a single-player health plan. And I just thought this would be fun, right? I knew for sure this wasn't going to pass. But I thought, what the heck, I'm going to a meeting. Someone else is paying for it. I'm going to throw out an idea here. What happened was actually kind of astonishing to me. It didn't pass. But I wasn't the only one in favor of this. And it got over two hours of debate, first in reference committee, and then again on the floor of the house before it went down. But the seriousness with which people took this debate was striking to me. And between that meeting and the next meeting, which is the one in New Orleans which took place in November, I was contacted by a guy named Sid Wolf, Sidney Wolf, who runs Public Citizens Health Research Group, who said, you know, there's an issue that we'd like to bring to the AMA. Would you be willing to submit a resolution on this, having to do with the match, the residency match? At that time, the match algorithm, which is a kind of complicated thing, but the match algorithm, in the event of a tie between what the program wants and what the resident wants, the tie went to the program. And this was actually misleadingly presented in the materials so that it sounded like it was the other way around. But mathematically, it was true. It was going to the program. There was a mathematician at Stanford who'd done a series of simulation models, which were published in academic medicine. AMSA had been on this bandwagon for several years. They'd been trying to get the match at minimum to change the materials, the literature, so it was accurately reflecting what the algorithm was, and at best, to change the algorithm. By this time, I was evaluating people for our residency training program. And I was quite convinced that the difference for our training program between our number 78th pick and our number 79th pick was absolutely meaningless. But for a student, the difference between getting your top pick and your second pick could be quite momentous. This could mean New York versus San Francisco. Many, a lot of import there. So I felt it was wrong. Many people agreed. The match had been dragging its feet. Didn't want to change this for whatever reason. And this had been going on for several years. So at that meeting, I brought a resolution to the residents. A medical student brought the same resolution to the medical student section. Both sections passed the resolution and brought it forward as an emergency resolution to the full House of Delegates of the AMA, and it passed. And the algorithm changed that year. Before December, the match NRMP agreed that they should change the algorithm and the language. And it was at that point that I was hooked because it dawned on me that this organization, A, is a hyper-democratic organization which is incredibly frustrating because it means you have to get 50% of people on board in order to make a change. So it's inherently conservative. But it also means that if you can bring something through this difficult process and get 50% of the doctors at the AMA's house to buy in, that has real import. And this organization, the AMA, is a parent of the NRMP. It's a parent of the Joint Commission. It's a parent of the ACGME. It's a parent of ACCME. It's a parent of LCME. So all of these organizations that we use to establish the structures of the American medical profession have roots and tentacles attached to the AMA. And so I became more and more involved, and I'm still frustrated with the AMA sometimes because they don't take the same positions that I individually would like. But I believe in the process. I believe in democracy. And the AMA is what we have as a democratic body for the entire house of American medicine. ACP can't do that for me. I love ACP. I'm very involved. ACP is not a representative body that can say we are the voice of American medicine. We have to have the AMA for that. So that's my disclaimer statement. It's really long, I understand, but that's my disclaimer before getting started today. So let me tell you my understanding of the evolution of professionalism in medicine. And of course, like everyone, I suppose you've probably seen this year, I'll start with Hippocrates. And I start with Hippocrates to make a point that may or may not have been front and center in some of the other talks this year. But the point is, while the Hippocrates did a series of very important things, they did not professionalize medicine. And here's the reason I say that. So first, what the Hippocrates did was combine the scientific and ethical aspects of medical practice. The injunction to refrain from intentional harm was very important in the Hippocratic corpus. And it established a written versus an oral tradition for what it means to be a Hippocratic doctor. These all are very, very important things. In particular, I spend a lot of my time talking these days about quality improvement and patient safety. The Hippocratic corpus is laden with references to something like humility in practice. And the place you've seen this most famously is this aphorism, life is short, the art-long opportunity fleeting, experiment treacherous. And experimentum, the Greek word in this, didn't actually just mean an experiment, it meant any kind of treatment. So the recognition by the Hippocrates that this is dangerous business and we need to enter into our treatment relationships with a great deal of humility and caution about what we promise and so on. Very important aspect of Hippocratic medicine. But when you start to think about professionalism, the problem with saying the Hippocrates established professionalism is they were a minority sect. So Margaret Mead says that the Hippocrates famously separated the healers from the killers, the sorcerers, the people you could hire. But they failed in this. They didn't establish this as a profession-wide. It was really quite common for non-Hippocratic doctors to do many of the things, including hiring someone to knock off your husband, as Agrippina did when she wanted to kill Claudius. And this is 400 years after the Hippocratic era and this kind of a famous story, she calls the doctor and says, how can I knock this guy off? And the doctor gives her the poison. And goodbye, Claudius. So the Hippocrates did not establish professionalism. If by professionalism, we mean a uniform set of standards of ethical and practice-type behaviors. I'm going to jump forward 1,000 years through the Middle Ages into the Renaissance here and just note that the Middle Ages is a very interesting time frame, in part because of the relationship that evolves here between medicine and the church and the relationship between illness and sin and the doctor's role in both protecting society and in redeeming sinners and so on. But it's also interesting because of the loss, in one sense, of something that was really core to the Hippocratics, which was curiosity and humility in the sense of not knowing whether the way you're doing things is the best way. So a learning-oriented humility is actually kind of lost during the era of the Middle Ages. And this is largely because of this outsized reverence for the ancients, right? So Galen had it right. Even though Galen couldn't dissect human beings and had to dissect monkeys and pigs, fortunately, he chose a couple of animals that look a lot like human beings, but he still some things wrong, right? Humors don't work the way he thought they did. The blood doesn't work the way he thought, the heart, and so on. But I love this anatomy lesson, in part, because this is 1632. But look at where all of their eyes are. No one is actually looking at the body. They're all looking at the text, which is kind of illustrative of this time frame up until the Renaissance, that people revered the masters and thought they got it right. And even went so far as when they found something that contradicted what was in Galen's text, they would try and figure. They would say, well, this is an abnormal specimen, obviously, that kind of thing. Thomas Percival, I know you've heard something about in earlier talks and is often thought of as the father of medical professionalism, in part because he used this term, medical professionalism, for the first time. He recognized an important aspect of what makes professionalism relevant, which is the increasingly complex practice environment, the fact that we operate within social structures and not just as individuals. He invented the inverse hierarchical method that we still use today in medical rounds, where the lowest person on the totem pole gives the story first. It's then checked by the resident or the fellow, and then so it goes sort of up the chain, if you will. And that's basically what he described is still the way rounds are often conducted. And it's this notion of teamwork and everyone practicing to the top of their ability, that kind of language is actually present in Percival's work. He coined the terms medical ethics and professional ethics. And he talked about professions tacit compact with society. The problem with saying, and this is a nice quote from his medical ethics in 1803, talking about a patient registry basically, where you track mistakes and errors and try to learn from what happened, what went wrong. The problem with dating medical professionalism to Percival is that like the Hippocratics, he failed in getting his entire profession to adopt his code. He actually brought his code to the British Medical Establishment, who rejected it. They explicitly said, we don't want no code ethics. Well, they may not have used exactly that language, but they explicitly said, we do not need a code of ethics because doctors are gentlemen. We are virtuous individuals and a code of ethics, and this is a quote actually, a code of ethics is useful only to those who lack decent moral character and wish to pretend they have one. So it's a guidebook for someone who is deeply immoral to know how to act as though they're moral. So we don't want that, it is disparaging on us as doctors to think that we might need a code of ethics. And in fact, it would be counterproductive as a social construct, because it might allow people to fake it when in fact they're not virtuous and shouldn't be members of the group. So have a seat, Kermit, when I'm about to tell you, might come as a big shock. This next slide is the shocker for many audiences. Now I've given you a lot of background about why I already believe this, but the AMA created medical professionalism. And I know that sounds like a really atlantic statement, but the AMA essentially adopted Percival's work, verbatim, in many instances. The entire of medical ethics can be found, his book, Medical Ethics, can be found in the original AMA Code of Medical Ethics of 1847. What was different is the AMA succeeded. Where Percival had failed, the AMA got most, if not all, over the next 50 years doctors to sign on to this code of medical ethics and to agree that these are the professional standards that govern what it means to be a doctor. So this tacit compact becomes an explicit social contract with the creation and adoption of the AMA's Code of Medical Ethics. So it's an explicit set of reciprocal obligations between doctors and patients. So it has three chapters. The first chapter is on the doctor's responsibilities to patients and patients' responsibilities to their doctors. And it's set up that way. Second chapter on doctors' responsibilities to each other. Again, reciprocity, very simple philosophical framing here. And then third is on the doctor's responsibilities to the community and the community's responsibility to the doctors. And this is where you see things like it's the physician's responsibilities stick around during epidemics, even without regard to personal threat and without regard to remuneration. So we see an explicit social contract created and adopted and to one degree or another enforced and I'll come back to that in just a moment. Because this is the point at which I wanna give you my definition of professionalism. There are a number of really wonderful definitions of professionalism that I've seen over the years. I'll show a few of these, Dean Roscoe Pound, a group of men, one could say women, pursuing a learned art as a common calling in the spirit of public service and no less a public service because it may incidentally be a means of livelihood. A nice list of the criteria by which one might judge whether a profession exists. Similarly, Louis Brandeis, an occupation for which the necessary training is intellectual in character involving knowledge and learning and distinguished from mere skill, pursued largely for others, not merely for oneself, et cetera. Herb Swick, one of my favorites and one of the simplest, professionalism consists of those behaviors so he doesn't list them out but he says instead what their point is, what's the purpose of these behaviors, these promises essentially. They are ways that we demonstrate we are worthy of the trust bestowed on us by our patients and the public. And here's the one I'm sure you've all seen which is the medical professionalism project definition, the professionalism charter as it's become known which has the three principles and 10 commitments my favorite of which is number 10, the garbage bag of everything else we think is important. Setting that aside, all of these definitions of professionalism I think have one problem. And that problem is these are all approaches to defining professionalism that are based on making a list of the criteria. And if you can check off these four criteria you have a profession and if you can't then you don't. So they are in that respect good. They comprise a list of the shared promises of health professionals but they are not professionalism as such. So let me go to the next slide here and just walk you through and you're gonna think this is way too simple when I'm done but professionalism starts with profess which means to speak. So to profess is to speak out in public. So I profess my love to my wife at the time of our marriage. A professor is someone who stands in front of a classroom and speaks presumably with some degree of knowledge but it's an open declaration of something is a profession. So a profession is a group of people speaking out together about their shared standards and values and professional is as a noun that would be a member of this group and the other way we use this is as an adjective. So something is or is not professional if it is in conformance with the explicitly stated standards and values of the profession. That's what makes something professional or unprofessional is whether it matches up with the professions stated standards and values. Professionalism is an ism. I mentioned before you can think of any number of isms. They're ideologies. Professionalism is the ideology which says the best way to organize health care is to entrust at least certain aspects of it to professionals who will make promises about what you can expect and they will make sure that those promises are lived up to and that's a good way to organize medical care. It's a belief system about how best to organize medical care by authorizing a professional group to have a great deal of power in how that service, good, is delivered and allocated in society. So it is a set of promises but it is really the belief that making those promises and living up to them is important and why it's important, right? So let me talk now for a moment. This is not all obviously my own thinking. Some of this is straight out of Elliot Frydson who was probably the foremost critic of professionalism for 30 years. So Friesen talks about ideal types. I would have probably just used the word ideologies but he talks about ideal types as ways to organize the delivery of health care but you could also imagine this as ways to implement justice, as ways to do teaching. Anything that where a profession is in the mix and you can imagine thinking of these ideal types, right? So there is a market option and in a market option, which we call often consumerism, the way you assure quality is through competition. The ethics of the market and there is an ethics of the market it is to ensure transparency and truth telling, right? So people are on an equal footing in terms of making their choices. Resource allocation using the market is according to value and it's not quite the kind of value you and I might think of in medical care where we often think of value as quality over cost. This is willingness to pay, value as defined by what someone is willing to pay for the service. So value can be quite different from one person to another but that's how markets allocate resources is according to value as defined by willingness to pay. And healthcare in this conceptualization in this ideal type is a normal good just like shoes and paper clips and computers and any number of other goods and services. You could also imagine medicine being delivered by the state. This is called socialism, maybe communism and here you've got regulation as the way in which you ensure quality. You've got an ethics that emphasizes equity across all of society, right? These are ideal types. I'm not saying any of this plays out exactly as stated but this is the ideal, this is the ideology that I'm describing. The resource allocation is in its ideal form supposed to optimize benefit across society and healthcare here is seen as a common good more like the environment or the transportation infrastructure or national defense. It's something that affects all of us and where all of us participate in decisions about how to use the resources and so on. And then there's professionalism. In professionalism, quality assurance is not through state regulation nor through competition. I'll make quick note of this. In professionalism, we share all our knowledge. We don't have trade secrets. We don't have a secret sauce. We're not allowed to. If we learn something new that helps us to do things better, we publish that. That's an ethical responsibility. So we can't have trade secrets and still say we are a medical profession. So we ensure quality through collegial review. Our ethics emphasize the fiduciary responsibilities of doctors to their clients, to the patients and other stakeholders in society. It's a complex fiduciary set of fiduciary relations that we hold. And resource allocation is derived from these fiduciary obligations and it balances individual and social needs. So the profession is empowered to make resource allocation decisions that take into account both the needs of the individual patient and stewardship of society's limited resources. So we're given the power to write someone a note to get them out of work. And we are trusted to use that power in a responsible way. So I am not allowed by my professional ethics to write someone a note to get out of work if it's not a health related issue and they don't really need to get out of work. Just because they come in and say, I would pay you $200 for a note, I can't do that because I have responsibilities not just to that patient but larger social responsibilities as well. So it's that complex balancing of responsibilities and healthcare here is seen as a service. So it's not exactly a common good. It's definitely also not exactly a normal good. It's a service good. Now the reality of course is that we use all three of these models all the time. They're all mixed up in the real world. So here just thinking of, whoops, just thinking about quality improvement or patient safety. We use peer review. We use ethics and socialization. These are professional methods to ensure the quality of care we deliver. We also use delivery of information to patients through quality monitoring and quality measurement and public reporting. These are methods of consumerism allowing consumers to exit from those providers that they don't wanna, that are not providing a good quality care by their lights. And we use things like licensure, malpractice litigation which are fundamentally political and state mechanisms to ensure quality. But it's also a nice way to see that these all even get mixed up. So malpractice cases are often contingent on a professional standard of care. Licensure boards in many states have on the board a number of doctors often from the state medical society. The state medical society appoints people to the licensing board in many states. So these, even trying to separate these out like this gets complicated because these are, well, as I've got here, this is a balancing act about how to organize and deliver medical care. There is an important role for professionalism, but stateism and market-isms also come into play. And the question facing health policymakers is constantly how do we balance these various mechanisms of regulating and enforcing and ensuring the quality and safety of care that's being delivered and the value of the care that's being delivered to the American people? Now I put up this other quote which I assume you'll get more of next week, but Friedson later in his career actually became much less of a critic of professionalism and in fact became something of a promoter of professionalism. Once he started thinking through, and I'm projecting now, but once I think he started really thinking through, what would it mean to have a medical care system that was governed by the state or governed by the free market and would either of those work as well as one that has a primary role for professionalism? Because it's not a matter of establishing a perfect system here. It's not like you can establish one system based on one ideology and it's gonna work perfectly. All of these have weaknesses and the question again is this balancing act. So this raises the point that there are inherent tensions so I'm not gonna talk anymore about state and market. I'm now just gonna sort of focus on professionalism for the last part of this. Early on in the history of the AMA, this notion of establishing practice standards was very prevalent and so that was the role of the AMA. The reason the AMA was initially created was to establish a code of ethics and a set of training standards for medical schools. That's what brought the group together was out of control, unregulated medical schools that and nostrums and quacks and all that kind of stuff, right? And it was created in a time when there were a number of other competing ways of delivering medical care. Homeopathy was very prevalent, Thompsonians, eclectics and so on. So there was also a sense of what I'll call professional closure. That's the sociological kind of term or economic term I guess. There was a sense of wanting to clearly define what a scientific practitioner looked like and what they promised to society. So you've got on the one hand a series of committees setting increasingly stringent quality standards. On the other hand, the AMA code for a long, long time said, you know, these are really important, but there's really no real tribunal other than your own judgment as to whether you're adhering to all of these. Which always makes me think of this great line from the Pirates of the Caribbean that the code is more what you call guidelines than actual rules. And that tension still exists in spades within the profession. The degree to which we are willing to set standards and ensure that we all are living up to those standards. To say nothing of what other people get to do, can we make sure within our club that we're all living up to the standards we've established and what standards are we capable of establishing and then enforcing in some meaningful way. This is just an example and I'm sure many of you know this face, this is Ernest Codman. Codman is often called the father of modern quality improvement. He said that every hospital should follow every patient it treats long enough to determine whether the treatment's been successful and to inquire if not why not with a view to preventing similar failures in the future. This was not really a new paradigm but it was at that time even called a new paradigm for medicine. It reflects the Hippocratic beliefs. It reflects Percivalian beliefs. It reflects others, Thomas Bard and a number of others before him. But the important thing is he tried to actually implement this at Mass General Hospital and was basically fired because he said we should track the outcomes of the doctors here and those with bad outcomes should not get promoted and people didn't like that. And I don't have to tell you all the various reasons why people might not have liked that idea but that is the basic tension of facing our profession still today. And it reflects in a deeper way this question about the science and the art of medical practice. This is the prevalent view in the progressive era so the late 1800s, early 1900s when the belief was that science was on the ascendance and it was going to be possible to define good practice and to monitor whether good practice was taking place and that we knew how to cure people. And this is John Musser, president of the AMA in his acceptance speech saying with the incoming of scientific precision, this is, we have stethoscopes, we have sphingmonometers, we're checking blood for glucose, we're doing CBCs at this point, there are tests for syphilis, right? So lots of science now setting up a doctor's office radically changes between 1850 and 1900. You need not only more books, but you need a microscope, you need equipment, you need tools so it becomes much more expensive to become a doctor. All of this has ramifications for the role of the association representing doctors and setting standards for them. So I mentioned all of these committees that were established. In medical education, the AMA, and this is a little known fact because the AMA didn't want it known, but I'll tell you now, because it's 100 years later. So the secret is out. The AMA actually asked for the Flexner report. The AMA's committee on medical education, renamed the Council on Medical Education in 1904, had already been doing exactly the same thing that Flexner did. Traveling, visiting the medical schools, they had a set of criteria. They were ranking medical schools and they were being beaten up by the medical schools for having, well, for seeking professional closure, for trying to close medical schools, trying to reduce the number of doctors, increasing salaries for doctors, all of that stuff. And so they weren't seen as an honest broker and so they went to the Carnegie Foundation and said, would you be willing to sponsor an independent assessment? The chair of the Council on Medical Education went with Flexner, as far as we can tell, on every single one of his site visits, and Flexner wrote the report here in Chicago at the AMA headquarters. But this was all agreed in advance that it would not come out as an AMA report. It would come out as a Flexner as the Carnegie Foundation's report. Carnegie was also, at this time, they had been thinking about doing a similar set of reports on other professions. So this all sort of was a nice confluence of events. Food and drug safety. The AMA is a major proponent for the Pure Food and Drug Act of 1906 and subsequently a series of amendments. The Council on Pharmacy and Chemistry prints out there's a very famous series of essays in colliers about food and drug safety that they distribute to basically every doctor in the country. And this tension is very common at this time. It's true with vaccinations as well, by the way. The AMA is really paternalistic in this era. The Progressive Era is one in which we believe, as a profession, that if we come together and decide that something is the right way to go, we should enforce that. So mandatory vaccinations, that kind of stuff, we're very much behind in this timeframe. It also raises these questions about professional self-interest. And you can imagine the folks in the community saying, wait a minute, the reason you want mandatory vaccinations is because we have to go to your office and pay you to get a vaccination. So you're just trying to drum up business. So that tension between standard setting, legitimate public health promotion activities and what is perceived as professional self-interest is ever present since the founding of the AMA right until today. Now, scientific medicine works, right? I don't have to prove this to all of you, but scientific advances were really, really important. And this is obviously well before the development of antibiotics, much of this takes place, because of public health interventions, the germ theory of disease really pays off. And as a result, through the 20s and the 30s, doctors become heroes. There's a great book called The Microbe Hunters, which really is a hagiography of a series of doctors and microbiologists about cures and their own experiments on themselves and so on. It's a terrific book, William DeCreef, 1927, I think. I read it to my son, actually, when he was about your age. It's actually that fun that these stories, they're relatively short 10 or 15 page descriptions of these here, you know, Lou and Hook and Pastor and Marie Curie and so on. Anyways, terrific book. Doctors become heroes throughout this time frame. And doctors become incredibly arrogant. This is obviously a quote from well before this time period, but I think it, as well as anything, illustrates some of the problems that arise as a result of all of this tremendous success. We lose our customer service orientation, because after all, people don't need to listen to us anymore. They just need to show up and we'll give them a shot and they'll be better. So getting the patient engaged in decision making, you know, if you're taking out their sick gallbladder or when you can cure someone, that's the pinnacle of your ethics right there. All the rest of ethics becomes subservient to the cure. So we become very paternalistic. There's a great deal of loss of the sort of civic obligations that had arisen earlier. The whole notion of the responsibility to stay and treat patients during epidemics essentially collapses in part with the collapse of major infectious diseases. When it's actually removed from the code of medical ethics, which takes place in the early 80s actually, late 70s, early 80s, the statement that describes why we're taking this responsibility out of the code is that it has become anachronistic. Doctors taking care of patients during epidemics isn't irrelevant these days, because there aren't epidemics. Of course, you all know that 1983 is also when we start seeing AIDS, which is a different talk. There's unquestioned professional closure, right? You cannot any longer, through this timeframe, become a doctor without passing through the professional sanctions mechanisms, right? You can't just hang up a shingle. Our self-regulatory mechanisms are adopted by the state. And so we succeed beyond probably anyone's wildest dreams at professional closure. And we have increasing emphasis on professional autonomy. And this brings me to my last question, which is this one about what does professional autonomy mean? Because during this timeframe, from roughly the 40s or 50s through to about 10, 15 years ago, it seemed pretty clear that what professional autonomy meant was the right of individual doctors to practice as they wished. And that conflation of professional autonomy and personal individual liberty was very prevalent, and it was tied, and I'm not gonna get into all the details on this, but it's tied very much to a series of other social things that are going on around individual liberty and autonomy and the rights of individual patients. And this notion that the doctor is an advocate for the individual person sitting in front of them, period, full stop. No other considerations whatsoever. So this is best illustrated perhaps by this piece from the New England Journal from Norman Levinsky. Physicians are required to do everything they believe may benefit each patient without regard to costs or other societal considerations. This is not the original sense of what professional ethics meant. It was a much more nuanced relationship because the doctor had important relations with other doctors, with the community. It was very explicit in the AMA's Code of Medical Ethics in 1847 that doctors had these varying relationships which could come into conflict, and our job as a professional was not to always say one thing, always trumps. It was to say, this is why we get paid the big bucks, is to make these difficult balancing decisions. We rejected that for about 40 years. And the consequence of that is the adoption of this sort of zealous advocacy agenda, what I would call lawyerly ethics. So now I'm no longer a doctor with medical ethics behind me. I'm acting more like just your advocate, Mr. Patient, Ms. Patient. What has to happen if we do that? Because that doesn't function for all of society. That only works for here. I'm now gonna have to establish some mechanism by which me as the advocate for you go into a system where there's an advocate for the other parties that are affected by my decision and I don't get the final say in this anymore as the doctor. There has to be a judge. There has to be opposing counsel. That's why lawyerly ethics work for lawyers. Lawyerly ethics cannot work for doctors if we are also the judge. And we wanna be the judge. And patients want us to be the judge. We want to be able to say if I say that you need this, that's what's gonna happen. The only way we can make that promise is if we also say and I'm taking into consideration a series of issues that have to do with the rest of your family and the rest of your community and not just you. This is very, very difficult for people to grapple with and this will be the defining issue of our profession for the next decade. We're coming out of, just to be very blunt about this, there are good reasons why we adopted this lawyerly zealous advocacy professional ethic. We saw what happens when doctors fail to serve as advocates for their individual patients and see themselves only as looking out for the good of the larger community, society, eugenics, right? We watch that roll out. So there are very strong reasons why doctors want to say I look out for you, period, full stop. I have no other considerations in my mind. The problem is that professional ethic doesn't work. In the long run, it falls apart and it falls apart because of out of control spending. We get erosion of public trust. We get weakening of professional closure. We'll start to see other people coming in to fill the gaps. It gives us ambiguity in our ethical standards. We've really come to rely a great deal on the red face test rather than rules and the problem with the red face test is some people don't embarrass that easily. And there is a very strong argument to be made to say look, there are some things where even though you disagree, this is the professional standard for what it means to be a doctor. And you may disagree with this, but if you do, you should recognize at minimum you are standing up to the profession and saying I don't think you're right about this and I'm willing to argue it out. This, by the way, I think is really relevant to the AMA's role because the reason the AMA matters is because it is the forum where every specialty society and every state are represented in debates about what our professional standards should be. And so if you are a medical student and you say, well, I'm not a member of the AMA. I don't like the AMA. I don't adhere to their code of ethics. Well, that's all fine except that if you later in your career get brought in front of a judge, that judge is gonna say these are the professional standards. They were adopted by a representative body of doctors. So you better be prepared to explain why you chose not to follow the standard. So you don't have to be a member of the AMA to have the code of medical ethics used as a way of gauging what the professional standard is. And in fact, there are seven states in which the code of medical ethics is written into the State Medical Practice Act. So it's very explicitly part of the standard of care. I'm actually gonna stop because I want a couple minutes for questions. And I'll just let you read this, but I think it's kind of obvious. If we don't have doctors who are engaged in the AMA, and by the way, most of you, whether you know it or not, are engaged in the AMA because you're a member of a society, whether it's a state society or a specialty society that has representatives in the AMA House of Delegates. So just speaking as an individual here, not as a spokesman for the AMA, I don't think it matters that much whether individual doctors join. The AMA is an organization of organizations. It's really not, and it shouldn't be, an organization that is seeking to further the interests of every single doctor who's a member. Our role is to ensure the trustworthiness of the medical profession, writ large. Now I'm not saying you should drop your membership. I wish everyone were a member. It would be great, but the AMA works not because it has a bunch of individual members. It works because it is a representative democratic body with representatives from all the states and all the specialties in one room fighting. And I will tell you it is fighting about what it means to be a doctor. So for those who think the decision to endorse health system reform two years ago, that was fought tooth and nail and it was voted on and it got better than half of the votes. That's why the AMA endorsed it. It wasn't some cabal, it was a bunch of conservative doctors by the way who voted to endorse and continue to support today the reforms that were put in place. And these are smart people. I don't like all of them, but they're smart people. I don't agree with all of them I should say. But they are smart and they are by and large well-intentioned and they take these issues very seriously so the better we all can engage with them the better and I'll just end with two quotes. One from Osler who was asked once by a medical student whether he should attend the state medical society meeting saying why should I go? What will I get out of it? Osler said do you think I go for what I can get out of it or what I can put into it? A little Kennedy-esque. And if that doesn't convince you I'll give you Plato who said the punishment of wise men who refuse to participate in the affairs of government is to live under the rule of unwise men. So if you don't like some decision the AMA is making or has made you have only yourself to blame if you're not involved. So I'm happy to stick around. I know we're right at one o'clock so we're just very close. In the slide that flashed by near the end which you called the professionalism get spiral. I had a sense that your answer to the question with a professional associations is that their future is not robust and that you're worried about them. So my question is whether that really is your view and if it is where will the voice of medicine and the voice of professionalism come from in the future? Well I think what's happening right now because of the weakening of in particular the AMA. I can't say the same by the way is true of many of the specialty societies which are doing well as far as memberships. So ACP has its highest membership in ever last year and the proportion of membership in some of the specialty societies is also very high. The problem there is that it establishes an environment of at least the potential for internecine warfare and we see that. And I don't think you can have a really well functioning profession without a legitimate forum for working out those kinds of issues and to some extent coming to consensus on shared standards for certain things. So I think the days of the AMA as an individual membership organization are probably limited, that's my own personal view. I'm not that worried about it. What I'm more worried about is the loss of credibility and understanding of the process among doctors. I think doctors need to know how the AMA works and be engaged in the functioning of the AMA in its role as a voice for the medical profession. That doesn't mean everyone has to come to the meetings, but if you don't even know who your representative is to the AMA House of Delegates from your specialty, if you've got a complaint, where are you gonna go? I think there are a series of things that I keep arguing for within the AMA. I think we should have every member of the Specialty Society House of Delegates on the website, very prominent, so that you can just look on and say, oh, I'm an anesthesiologist, there's the four people from the American Society of Anesthesiology who sit in the AMA House. They should be elected from within your membership. Sometimes they are for some specialty societies, they're appointed by the board or appointed by the president, that's an honorary kind of position. That, in my view, is the wrong way to do it. This is a democratic body. We should treat it that way and make sure people understand how it works. Matt, I'm interested in the roots of the advocacy view of professionalism. You suggested, maybe there was a response to much state influence and the possibility of reaction to eugenics and things like that. And it seems to me, if that were the case, it probably would have started 30s, 40s, 50s, maybe, but I think that that idea probably starts later than that in the late 60s, early 70s. And that would suggest to me the possibility that it's more the consumer, no, that it's part of the consumerism movement and a reaction to the consumerism movement on the part of patients, that I will be your advocate for getting the resources that you need because otherwise, and with the decline of the sort of professionalism part of the triangle that you talked about at the beginning. Does that sound reasonable to you? I think that does sound reasonable. And certainly insofar as professionalism is also tied to public trust in a number of other social institutions, right? So trust in the army, trust in government, trust in the police force, there are a lot of social institutions that lost credibility through the 60s and 70s. And the extent to which that is a follow-on to the Vietnam War versus a follow-on to the Holocaust versus a follow-on to attempts in the teens and 20s to really socialize, truly socialize medicine in the US, you can go back at least into 1912 when the AMA first put into the code of medical ethics the notion that the doctor should not be the employee of anyone except the patient. So group practices, Kaiser, those kinds of arrangements were seen as unethical because they pitted the doctor against potentially the patient when some of these things came up. So in some ways, this tension is inherent and has always been present. And the scales tipped in a series of events, I would say starting, I've sometimes had 1912 was one point. And then another time with Truman and then another time after World War II and then another time with what I think of as the bioethics revolution and individual autonomy. And then at the same time is the whole resource allocation problem, the God committee, that kind of stuff. I think that falls into the same bucket of influences that made doctors move further and further away from the more nuanced understanding of professionalism and towards this lawyerly advocacy way of thinking about how they do their work. One of the major potential strengths of the AMA is that it's the one nationally representative medical organization. But I'm wondering if that also makes it so that it's very difficult, if not impossible for it to really come up with cogent positions and thoughts on some of the healthcare reform structural issues that do require sort of a level headed view. So in other words, you take something like the Ruck in terms of like payment to physicians where if like 25 out of 27 slots or especially slots, well, primary care is always gonna get hosed, you know. Or some way, ACOs and medical homes have just mentioned. Well, my sense is that AMA has really been reactive that unless it had been the employers, unless it had been some of the primary specialists, for example, driving the issue, AMA probably would have been pretty silent. And so now, because of- On ACOs? If it wasn't for like healthcare reform and sort of the political move towards ACOs, then I have a hard time seeing the AMA sort of being sort of at the forefront of pushing those. I mean, it's more reactive. But I guess the wider question is, because again, you have them, it's not necessarily democratic in terms of having to represent all the different specialties. The financial self-interest in particular, really, how can you overcome that in terms of coming up with positions on these fundamental healthcare policy issues which do think about the common good as opposed to initially individually individual or specialty self-interest? Yeah, this is not unique to the AMA, by the way. I think it really comes up strongly if you start talking even to the specialty societies about scope of practice issues, right? And, you know, without being too inflammatory, you know, there are probably areas where scope of practice could be expanded for non-physician practitioners, but you will not see the specialty societies that are entrenched in those areas endorsing that no matter what the studies are, no matter what the data show, no matter what, you know? So there is a sort of fundamental way in which all of us are trapped in the way we think and the interest that we hold. And the AMA is just a blown up version of the ACP in this regard, right? ACP struggles with this, because it includes American College of Physicians, includes both primary care doctors and cardiologists and pulmonologists and GI docs, right? So they face this as well in policymaking. It's, we're, I think we're just a little bigger than that with even more, you know, people at the table, but the conversations have to take place, you know? And to a certain extent, I think we have to, we have to figure out how to speak respectfully to each other and acknowledge differences and figure out where the common ground is. And this is, you know, maybe this is one of the places where a focus on professionalism and recognizing, you know, that we are here talking about a compact with all of society and not just amongst ourselves, maybe more transparency in some of the deliberations would help. I think there are ways to, there are ways to, it's never gonna be perfect. Matt, should we, yeah. Thank you. Thank you.