American Medical Student Association

The theme of the American Medical Student Association convention in March was “Win Back Our Profession.” In his welcoming message, then-president Dr. Brian Hurley said: “It is time to reclaim the profession in the name of our patients.” I want to examine, briefly, the basis of that theme.

First, let’s consider what a profession is, or should be, and what role a profession like medicine plays in U.S. society. As the late Eliot Freidson wrote in his insightful book, Professionalism: The Third Logic, a profession is one of the three basic ways of organizing important work—the market and the government being the other two. A profession values expert knowledge, competence, integrity and service to others more than per-sonal gain. A profession is responsible for educating and defining the qualifications and monitoring the performance of its members, but its members are also licensed by government because a profession has a de facto contract with society. Professionals are expected to serve the public interest in exchange for privileges bestowed by society.

Medicine is the prime example of a profession. It cannot thrive if controlled by external nonprofessional forces, and its services to society are essential. Physicians are given unique authority and responsibility, and much public assistance with their education and work, in the expectation that they will faithfully meet their commitments as professionals. Government should not control the actual practice of medicine, nor should the marketplace. But to justify this independence, and its privileges as a profession, medicine must be altruistic, competent and trustworthy. And it must always consider the best interests of patients as its highest priority. That is why all of us take an oath when we enter the medical profession.

Then why the current concern about “winning back” the profession “in the name of our patients”? Who or what has been controlling medicine lately, and why is this issue so important right now? The answer, in short, is that our profession has been too much controlled—or more accurately, has allowed itself to be too much controlled—by business interests. As a consequence, it is in danger of forgetting its ethical foundations, and this has caused us to lose the public trust and come under greater government scrutiny.

Health care in the United States is now a huge, competitive industry. To generate profits for providers, in-vestors and managers, our health care system has been misusing the remarkable scientific and technological advances that have been made in medical practice. Rather than using these advances to deliver needed med-ical care in the most effective and efficient manner possible, our health system has been exploiting modern technology for private gain. The system has become a business that considers profits to be at least as impor-tant as service to patients.

Our profession has been devalued by a business ideology that promotes profitable procedures and frag-mented, specialized care while neglecting a more integrated and patient-centered approach simply because the latter is less profitable. Financial conflicts of interest are becoming ubiquitous, as physicians accept pay-ment from industry to help test and market its products. Continuing medical education is now largely funded by industry and serves commercial interests at least as much as professional purposes.

These changes are at the heart of our current health care crisis because they increase the cost of care at an unsustainable rate. Employers are being forced to reduce their health insurance benefits to employees, and states are cutting back on Medicaid coverage. As medical costs and unemployment rise, the number of uninsured and underinsured citizens grows. The Obama administration is planning to spend huge sums to expand insurance coverage, but can do relatively little to slow the rise in costs unless it radically reforms the health industry to eliminate investor-ownership and reorganizes the practice of medicine to reduce the perverse incentives of fee-for-service reimbursement.

While the failure of our health care system is due in large part to its capture by business interests, it has surely been abetted by a failure of physicians to defend professional values and resist the temptations of profit-making and commercial exploitation. If our country is ever to find a solution to this crisis, we will need reform that includes some type of “single-payer” government-funded universal insurance. We will also need to restructure medical care to eliminate for-profit providers and encourage physicians to join organized multispe-cialty groups in which capitated prepayment replaces fee-for-service. Physicians in these groups should be well-paid but they should have no financial incentives to do more or less than is medically appropriate for their patients. The best way to accomplish that objective is by paying them salaries. The insurance system should be tax-supported and government-regulated, but the delivery system should be private and not-for-profit, and should be governed by professional values and the needs of patients.

This kind of reform is politically unlikely now, but sooner or later it will become clear to policymakers and to most of the public that nothing less than a major reorganization will save the U.S. health care system. Over the next few years, our political leaders will be struggling to legislate extensive health reforms that will control costs while ensuring all citizens access to good quality medical care. The active participation of physicians will be needed, but that won’t happen unless they rediscover their professional values and free themselves from the influence of industry. The new generation of physicians should be in the vanguard of this movement, to “win back” the great profession they have chosen.

Dr. Arnold S. Relman is professor emeritus of medicine and social medicine at Harvard Medical School and former editor-in-chief of the New England Journal of Medicine.