Solyom, Antal E. MD, PhD, MA
Committees convened by the Institute of Medicine (IOM),1 the Commonwealth Fund,2 and others,3 have noted that needed improvements in the quality of health care in this country require fundamental reforms in medical education. A more recent report from the Ad Hoc Committee of Deans4 —commissioned by the Institute for Improving Medical Education of the Association of American Medical Colleges (AAMC) to inform about the agenda of that association—outlines specific systemic shortcomings that represent obstacles to reform and offers a vision of the ideal medical education system. That report also states that the AAMC intends to assume a leadership role in achieving the necessary changes toward the ideal system and its associated educational objectives. These objectives encompass the whole spectrum of undergraduate, graduate, postgraduate, and continuing medical education programs.
The reports cited above, which call for needed changes in medical education, are derived almost entirely from concerns about the quality of health care provided in this country. The general question regarding quality, as exemplified by the study of McGlynn et al.,5 seems to be: how appropriate is the care provided to those who have access to it? Thus, the assessment of quality appears to reflect the application of available clinical know-how to the care of individual patients who receive it. But here I call attention to the contrast between the concerns and goals about the quality of the care provided to those who have access to care, as opposed to concerns and goals about those individuals who are without appropriate access to health care, and the impact of this on the quality of care provided to the population as a whole.
In my view, there are two issues that require special consideration regarding the leadership role and responsibilities of physicians—particularly the educators among them—in bringing about changes in medical education to improve health care. First, in terms of systemic changes, it is essential to recognize that there are significant problems not only with the quality of health care that this country’s physicians provide but also with the quantity of health care they provide. Second, in terms of educational objectives, it is important to clarify what kind of education is to be provided to what kind of physicians. Does it matter whether future physicians will regard the practice of medicine as a job, a business, or a vocation? I argue that different kinds of internal morality, social responsibility, professional identity, and integrity are involved when medicine is practiced as a vocation with emphasis on service, and that medical educators have a responsibility to be mindful of these when designing medical education programs.
Quality versus Quantity of Health Care: The Unresolved Moral Problem
There are glaring inequalities and injustices in the U.S. health care system due to unfair health care policies and insurance arrangements.6 The harsh quantitative reality is, according to the recent report by the IOM7, that about 18,000 inexcusable deaths are due to lack of health insurance. Those are but a fraction of the countless millions who suffer from not having access to adequate health care because they are uninsured or underinsured or unreliably insured.8
The above statistics confront us as a society and as members of the medical profession with a moral plight for at least two reasons. First, more than half a century ago, in 1952, the President’s Commission on the Health Needs of the Nation9 stated that “access to the means for the attainment and preservation of health is a basic human right” and that “the same high quality of health services should be available to all people equally.”
Although not acknowledged and implemented as a moral and legal dictum, this recommendation probably facilitated the establishment of Medicaid and Medicare as a partial recognition of the importance of universal health care. Three decades later, in 1983, the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research10 watered down the basic human right claim of 1952 by stating that “society has a moral obligation to ensure that everyone has access to adequate care without being subject to excessive burdens.” Today, after an additional 20 years, not even this obligation has been fulfilled. Yet in my view, there is a prerequisite right to health care because the inalienable human rights to life, liberty, personal dignity, and the pursuit of happiness cannot be guaranteed without adequate (not exceptional!) physical and mental health. Therefore, it is unethical to sell and profit from health care on the marketplace as if it were a commodity.
Second, during the second half of the 20th century—the same era in which the above statements from presidential commissions were made—the phenomenal advances and successes of U.S. biomedical sciences and clinical medicine have made it possible to deliver exceptional services to many members of our society. At the same time, the noble vocation of being a physician has, to a significant extent, been transformed into a component of a health care industry in which the health care of people is treated like a commodity on the marketplace. Thus, our society and the medical profession have turned away from confronting the fundamental moral problem of unrealized rights and unattained justice with the consequence of explicit harm to the health of a large portion of the citizenry.
Because this is true, we in the profession of medicine must face several questions:
* Is part of our failure to provide adequate leadership addressing this problem due to failed medical education?
* Have we neglected only our social responsibilities or shortchanged our professional integrity as well?
* Should the education of physicians entail the affirmation of a moral position on the right of everyone to health care?
* Should physician education clarify the measures of professional integrity in the context of our professed commitment to the patient first and foremost,11 and also in the context of the declaration that humanity is our patient?12
* Should physician education confront the dichotomy and contradiction that often exist between what we preach and what we do?
* Would it be important to clarify in the course of medical education whether the practice of medicine is a moral activity because responsibilities and decisions about life, health, and death are moral issues?13
I answer the above questions in the affirmative, realizing that others may have different views.14,15 Yet, these and related questions must be confronted; the answers to them will have a bearing on the future content and direction of medical education and health care. For example, in describing the ideal medical education system, the report of the Ad Hoc Committee of Deans4 states that such a system will promote, among others, “an understanding of the organization, financing, and delivery of health care in the United States.” The question is, for what purpose? To buy into the current highly unjust nonsystem of health care? Or instead, to understand how that system is a major obstacle to the goals of medicine and how to become leaders and advocates in changing it?
What Kind of Education for What Kind of Physicians?
The IOM report of 20011 recommends that physician education should emphasize patient-centered care, evidence-based practice, and performance of integrative tasks within interdisciplinary teams, as well as informatics, new technologies, and other new approaches. The report of the Ad Hoc Committee of Deans4 makes these elements part of the proposed ideal medical education system, but also stresses that the new goals of medical education can be achieved only by ensuring that physicians acquire the attributes necessary to meet their professional responsibilities: “knowledge, skills, attitudes, and values.”
Lumping together these four attributes suggests that all are important parts of an integral whole. Yet, it is instructive to recognize the two subsets of the attributes, or the two sides of the same coin: (1) knowledge and skills, and (2) attitudes and values. One may see them as the scientific versus the humanistic side of medicine, corresponding roughly to what used to be called the science and art of medical practice. The latter determines how the former is applied, particularly in a clinical situation, no matter whether it is clinical practice or research or teaching. The former has to do with the scientific–technical know-how of the physician, whereas the latter is about the person of the physician. So, the question of “What kind of physician should medical education aim to produce?” tries to elucidate those personal qualities, including integrity, that will determine how and for what end the power of knowledge and skills will be used.
In terms of leadership role and responsibilities, the emphasis has to be on the attitudes and values of physicians. The underpinnings of these are the personal and professional philosophies that may originate in individuals’ childhoods but could be modified and become ingrained during professional training. The challenge seems to be that the development and modification of attitudes and values may result in markedly different kinds of medical practice, even while the knowledge and skill base remains the same. Some who were “idealists” when they decided to become physicians may convert to “cynics” before they graduate, whereas others may make that conversion later in their training or career, without any change in their knowledge and competence. The opposite may happen as well. Some who were initially interested mainly in scientific and technical competence may become swayed by the humanistic aspects of medical practice. Many midcareer physicians reportedly say they would not choose to become physicians again if they started over. But there are also some who decide to become physicians at midlife. My own observations over the past few decades in U.S. medicine suggest a gradual transformation of physicians’ disposition toward medical practice—representing both a change during the careers of many physicians and a difference between successive generations of physicians—along a trajectory from vocation through business to job.16
Do physician educators adequately understand, and are they sufficiently mindful of, what brings about such changes in the attitudes and values of some medical students and physicians, so that they can address the appropriate issues as they educate future doctors? It seems fair to say that the ingredients for the development and modification of attitudes and values of physicians come from the ideas and concepts they are taught, the behaviors they observe, and the events and predicaments they personally experience. These form the basis of their personal and professional morality and identity in the context of being a physician. One may then be able to identify an internal morality that orchestrates the physician’s attitudes and values in the pursuit of the goals of medicine. Medical educators must ensure that the educational program they are most directly involved with fosters the development of the appropriate attitudes and values needed to serve the goals of medicine.
The nature of the doctor–patient relationship
The goals of medicine17,18 grow out of the human experience of illness. The suffering sick person requires professional intervention.19 The physician may provide care, may cure, or may heal. In everyday medical practice, the primary goal is to try to cure the disease. This curative medicine does not mean that the disease will be eliminated, but that it will at least be contained and controlled. Healing implies the restoration of the wholeness and integrity of the person who is ill, whether the disease is cured or not. Care denotes the committed and concerned attention to the person who is sick. Caring may be the default function of medicine when the curing of the disease, or the healing of the person, are not possible. Thus, the healing function subsumes curing and caring, and addresses the goals of medicine most comprehensively. The ideal identity of the physician as healer entails all the functions of caring, curing, and healing that are applied according to what is appropriate and possible in particular clinical situations.
The above goals are internal to medicine and, with the associated duties and virtues of physicians, are the ingredients of the moral framework of professional activities conceptualized as the internal morality of medicine.20–23 In other words, the internal morality of medicine consists of values and virtues that guide the attitudes and behaviors of physicians. The most important virtues are probably the integrity of the physician and the discernment of the best interests of patients.24 The latter implies that patients are seen as persons,25 which is the prerequisite to aiming one’s professional prowess at the restoration of the health (that is, wholeness) of the individual. This connotes that the healing activity of physicians attends to the physical, mental, social, and spiritual dimensions of the health of the patient as person. It appears that the pivotal factor defining the morality involved in the practice of medicine is the physician’s disposition toward patients. Because different dispositions toward patients are inherent when medicine is practiced as a job or business or vocation—such as employee–client, businessman–consumer, or healer–patient—the moralities involved are different as well.16
The question must, however, also be raised whether the morality of medicine should be confined to the doctor–patient relationship and to the healer identity of the physician. In other words, is it appropriate to narrow the ethical responsibilities of physicians to their relationships with individual patients? I suggest that a doctor–society relationship also exists within which the integrity of the physician requires a moral position on the right of everyone to health care. Accordingly, I call attention to the morally based civic responsibilities of physicians that they fulfill by being teachers and leaders in the social sphere. These functions and responsibilities entail clinical research, public health, and preventive health measures; the latter have and will increasingly become a part of the practicing physician’s domain. In other words, due to the great advances in medical science and technology, the goals of medicine today and in the future do not just revolve around attending to the suffering sick person, but also entail preempting and minimizing upfront such sufferings and disabilities, as well as preserving and maximizing the well-being of individuals. Thus, I argue that the morality of medicine entails both the doctor–patient and doctor–society (or doctor–community) relationships, that the latter partly stems from the former, and that the ideal identity of the physician is the tripartite healer-teacher-leader.26 (In my view, the teacher and leader qualities of the healer may be recognizable in the doctor–patient relationship as well.)
The nature of the doctor–society relationship
Once we acknowledge that the internal morality of medicine guides the attitudes and behaviors of the physician-as-healer—a physician who considers the physical, mental, social, and spiritual dimensions of the health of the patient as a person—it would be arbitrary to exclude from the physician’s roles and responsibilities the concerns about those aspects of the community or society that have a bearing on people’s health. Thus, in the doctor–society relationship, the moral activity of medicine is extended to the health concerns of the public at large. The moral basis of this civic responsibility is that the physician is endowed by privileged knowledge in matters of health and disease. Therefore, the physician should identify and promote action to minimize or eliminate those aspects of public life and policy that are injurious to the health or aggravate the disease of individual members or certain segments of the population and which, in turn, may be detrimental to the well being of the society at large. Accordingly, the doctor–society relationship has its foundation in the doctor–patient relationship with the proviso that the healer of the individual becomes the teacher and leader of the many in issues of individual and communal responsibilities in health care (as I will explain below).
One such crucial issue is the provision of adequate and equitable health care for all members of society, as discussed above. It must be particularly obvious in the context of the doctor–society relationship that to participate in and thereby support the manipulation and exploitation of people’s health care by for-profit insurance companies, health maintenance organizations, managed care organizations, and the pharmaceutical industry undermines the integrity of physicians and of the profession of medicine. Thus, I agree with Dell’Oro’s27 lamentation about the fate of the intrinsic morality and integrity of medicine due to its commodification. And I read Kao’s28 view as a warning: “How the medical profession mobilizes to address the national and global crisis of disparity in health and other challenges to the welfare of humanity will largely determine the vitality and robustness of medicine’s social contract with civil society.”
Therefore, we in the profession of medicine should reaffirm our moral standing as healers, teachers, and leaders24 serving individuals and society via a not-for-profit health care system that ensures equal access to high-quality services for everybody. To teach and lead society about these issues of morality and professional integrity—and to train future physicians to do so—is, I argue, a responsibility of physicians within the doctor–society relationship. An important aspect of this consideration is the fact that the illness and treatment of individual patients may have important social ramifications. These may include unintended and unrecognized harm to members of the family and/or community.29 In other words, I view the concerns for the well-being of others that transcends the commitment to particular doctor–patient relationships as a part of the doctor–society relationship. I do not mean, of course, any disrespect or harm to the doctor–patient relationship. Instead, I mean that the physician has an additional teaching role to help the patient realize and accept the implications of his or her specific health situation and its treatment for family members and/or for the community or society.
Another aspect of physicians’ responsibility within the doctor–patient–society relationship is clinical research, in which the major emphasis is on benefiting the health of certain segments of the population (according to particular diseases). Clinical research is an example of how the doctor–patient and doctor–society relationships are part and parcel of the responsibilities defined by the morality of medicine.
Of course, the most obvious areas of the doctor–society relationship are the public health functions related to infectious diseases, sanitation, pollution, environmental and occupational hazards, as well as issues such as smoking, gun violence, obesity, and similar preventable problems. Although there are specialists in many of these fields to do the bulk of the teaching and leading, all physicians need to be mindful of these matters. A special form of the doctor–society relationship is in the area of national defense, such as in the field of military medicine.
The issues I have raised in this essay are intended as contributions to the important efforts undertaken by the AAMC toward reforming medical education in this country to improve the quality of health care provided by physicians. My approach comes from how I view the morality of medicine and the leadership role and responsibilities of physicians.
First, I point out that physicians need to confront the challenges not only about the quality but also about the quantity of health care. The latter is about the moral plight that thousands die and countless millions suffer unnecessarily in this country because they are uninsured or underinsured or unreliably insured. Does this have to do with the ways physicians have been educated about civic responsibilities, leadership, and professional integrity?
Second, I discuss the related question of what kind of education is to be provided for what kind of medicine and for what kind of physicians. In terms of leadership roles and responsibilities, the emphasis has to be on the values and virtues that guide the attitudes and behaviors of physicians. All of us in the profession of medicine, but particularly the educators of future physicians, have to face the fact that physicians in this country today may practice medicine either as a job, a business, or a vocation. These represent different dispositions toward the patient, and thus entail different moralities. To the extent that the nature of the doctor–patient relationship is different in the three types of medical practice, and that the doctor–society relationship can be seen as a derivative extension of the doctor–patient relationship within the moral framework of the physician’s activities, what direction should medical education take?
In my view, the practice of medicine as a vocation would best achieve the goals of the humanistic, patient-centered, and culturally sensitive approach to health care and quality of life issues envisioned by the AAMC’s proposed ideal medical education system. However, it is highly unlikely that the existing organization, financing, and delivery of health care—that treat it like it is a commodity on the marketplace—can be compatible with a humanistic, patient-centered, and culturally sensitive approach to the health needs of the public. Therefore, the necessary changes I envision require that medical education be reformed to challenge and prepare physicians of integrity who can take on the responsibilities of moral and professional leadership in working toward a health care system that ensures equal access to high-quality services for everybody.
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