Thursday, September 29, 2011

Our core principles

Lyle Swenson, M.D.,
2011-2012 MMA President
It was a great honor to be inaugurated MMA President on September 15. Afterwards, I even had a few requests for the text of my speech. So though it is long for a blog post, I wanted to include it here, since it addresses some of the key issues I hope to focus on as MMA President. 

Inaugural Address
 Our profession has its origins in antiquity.  The earliest known written records of mankind are found on Sumerian clay tablets from Mesopotamia, which are over 4000 years old.  These tablets contain the oldest medical manuscripts, and they give us some insight into the role of the asu, the physician, in this ancient society.

     From the Code of King Hammurabi, 1700 years before the birth of Christ, we find a detailed description of the rewards due to the surgeon for surgical procedures prevalent during that time.

     The foundations of our profession were most firmly established by Hippocrates, the Greek physician we call the Father of Medicine.  In his oath, we find the enduring principles that have guided us as physicians for over 2000 years. In the Hippocratic oath, and in the oaths now taken by all those who become physicians, we find the basis for the relationship that we have with our patients.  This commitment is a covenant, which is an agreement based on trust.  In our oath we also pledge to hold the health, well-being, and best interests of our patients above all else, and above our own interests.  We pledge to do no harm to our patients, and to hold all that passes between our patients and ourselves in confidence, in order to protect our patients, and to maintain their trust.

     In the second century after Christ, scientific medical investigation by Galen led to the realization that   anatomic accuracy and physiology are the basis for the understanding of disease. 1000 years later, the scholar, philosopher, scientist, and physician Maimonides further defined and shaped our profession.  In his physician’s prayer, Maimonides writes “Inspire me with love for my art and for Thy creatures.  Do not allow thirst for profit, nor ambition for renown, to interfere with my profession”.  As Dr. Carmel has so eloquently stated, this is what we call integrity. He has also reminded us that in the care of our patients, we must have compassion, we must have empathy.  The traditions of using scientific knowledge for the benefit of our patients, with integrity and empathy, have been growing for thousands of years.

     From the earliest efforts of the asu, to the scientific investigations of Galen, to the discovery of the double helix by Watson and Crick, our profession has seen profound changes in our ability to understand, diagnose, treat, and cure disease. With the tremendous growth in scientific knowledge and our improved understanding of disease, there have been great opportunities to improve the health of our patients.  With these opportunities have come great challenges, and the challenges of our time now threaten the very foundation and time-honored principles of our profession.
 With greater scientific knowledge has come the need and the desire for specialization, and the development of medical subspecialties has given us the potential for better care for our patients, but it has also led to disagreements between specialty societies and a lack of unity  within our profession.

     With the commercialization of health care, the potential for financial gain has led to worrisome conflicts with the principles of our profession. The business of health care has become politicized, and now political posturing and ideology threaten to drive us apart as physicians.

     Fundamental changes in the delivery and financing of health care have resulted in the rewards to our profession being doled out by large payers who are influenced primarily by economics and politics, with those rewards having little relationship to the value we bring to our patients and our communities.  Many physicians have understandably responded to these realities by changing their medical practice, and some of these changes have resulted in alliances and relationships which challenge, and threaten to alter, the covenant we have with our patients.  The conflict between economic survival and prosperity on the one hand, and the best interest of our patients on the other, is certainly not new, but our current conflict is unprecedented in its magnitude, and how we, as a profession, respond to this conflict will have profound effects lasting many, many years.

     As we recall the history of medicine, we recognize and cherish the abiding principles that give us hope and guidance in our professional lives today.  The supreme importance of our patients’ health and wellbeing; the covenant we have with each patient we care for; the continual quest to bring new scientific knowledge into our practice for the benefit of our patients, brought with integrity, trust, empathy, and compassion; these principles we must hold sacred.

     All challenges to our profession, whether great or small, must be faced openly and honestly, with courage, without restraint or hesitation, and without deference to politics, ideology, or commercial interest. We must renew our commitment to our profession.  We must renew our commitment to the principles of our profession.  We must be unwavering in their support, and we must resist the forces that threaten to drive us apart.

     It is now our time to do our part, as physicians have done for thousands of years, so that in the years to come, physicians will be free to practice the science and the art of medicine, with knowledge, integrity, empathy, and compassion, for the benefit of their patients.

Thursday, September 8, 2011

To Err is Human

Patricia Lindholm, MD,
2010-2011 MMA President

I believe that we all recognize the above title as a timeless adage, but also the title of the Institute of Medicine report that brought to public scrutiny the problem of medical errors in hospitals and the prevalence of harm that patients experience during their hospitalizations.  The report jump-started a nascent patient safety movement that now appropriately applies to outpatient care as well. 

An excellent article appeared this week in AMA News about physicians who have publicly acknowledged their medical errors.  They are using such disclosure as teaching opportunities for themselves and other health care professionals, and to highlight that systems improvement is the key to preventing errors.  The “I’m Sorry” legislation that has been discussed in various states reflects the need to provide transparency to patients and to make amends when they are harmed by medical procedures and decisions. 

The most interesting part of the article for me is a discussion of how to support physicians who have harmed patients through diagnostic or treatment errors.  I trained in the era of “shame and blame” when one person was assigned total responsibility for an error.  This led to a tendency to hide our errors from patients, hospitals and our colleagues.  Physicians judge themselves quite harshly and question their general competence or even their personal worth when faced with an error. 

In Boston at the Brigham and Women’s Hospital, a Center for Professionalism and Peer Support was created to reach out to physicians who are in the painful and lonely position of having acknowledged a medical error.  A number of physician peer advisors are available to reach out to their colleagues and ask about their wellbeing and offer support.  Similar programs have developed at medical centers around the country.  A compassionate and human approach to such colleagues can save careers as well as the lives of the physicians who are supported. 

Several years ago when I served on the board of MMIC (the professional liability company started by MMA some years back) we started the Physician Litigation Support Program.   Each physician facing a claim is personally contacted by a psychiatrist whose only purpose is to provide support and education to the insured.  We have received many thanks from recipients of this caring program.

If your training program or health care organization does not have a mechanism to support colleagues who have made errors or who face litigation, what can you do to get such a program started?  I suggest that the first step is speaking up and insisting that collegial support programs be proactive, supported and expected.  You should expect to hear from colleagues who want to work with you to make good work happen.  I suspect you will have richer friendships and happier patients as a result.