American College of Physicians: Internal Medicine — Doctors for Adults ®


Three milestones of change confronting internists

From the March ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By William J. Hall, FACP

While the last year has been characterized by many meaningful lessons, a few milestones stand out. I have chosen three quotations that identify concepts important to internists: systems, chaos and loss of professionalism.

These concepts are so important because they point to some of the external forces that are pressuring our profession to change. As these outside influences continue to escalate, they will test our adaptability to change and our collective sense of professionalism.


"The burden of harm conveyed by the collective impact of all of our health care quality problems is staggering."

Last April, the Institute of Medicine published its second monograph on patient safety and health care quality in America. The IOM message quoted above was blunt: We need to radically alter how we deliver care to fix long-standing quality problems.

The report went on to explain that meaningful improvement requires strong physician leadership. Physician leaders must understand a "systems" approach, a concept I admit I did not readily understand.

In terms more familiar to internists, a systems approach calls for physicians to embrace collaboration, teamwork and community. This can be difficult for some of us who were schooled to act independently.

This year, I have been privileged to meet many such leaders in both small and large communities across the country. These internists have two things in common: They tend to work locally and let their influence spread by reputation.

They are also very self-motivated and derive much personal satisfaction from their professional lives. They also still recommend that their children pursue careers in medicine. I hope we can find better ways to tap this reservoir of talent to solve two major challenges for our profession: improving health care quality and enhancing professional satisfaction.


"These acts of murder were intended to frighten our nation into chaos and retreat."

President Bush's choice of the word "chaos," taken here from his first public speech following the Sept. 11 terrorist attacks, is interesting. The term has subsequently been used frequently to characterize the post-September environment.

For years, physicians have had a fairly simple frame of reference: If only we know enough and work hard, we can care for our patients no matter what. In light of recent events, that notion seems naive. America's encounters with terrorism served as a startling reminder that the guild concept of medical training, in which apprenticeship prepares us for lifelong responsibilities and competence, has long since passed.

During the anthrax scare last fall, for example, we learned that our public health networks, drug distribution methods and hospitals are inadequate to meet the challenges of bioterrorism—or even more prosaic unanticipated health needs. Few had sufficient knowledge and skills to deal with biological threats, and fewer still knew where to find the information they needed.


"Physicians today are experiencing frustration as changes in the health care systems in virtually all industrialized countries threaten the very nature and values of the medical profession."

On Feb. 5, a landmark article, "Medical Professionalism in the New Millennium: A Physician Charter," was simultaneously published in Annals of Internal Medicine and The Lancet. This document, from which the above quote was taken, represents the consensus of the major medical societies of the West.

One of its main messages is that physicians must navigate in a world of complexity, even chaos, and that we increasingly seem to be professionally rudderless. At risk is the continuation of our social contract to maintain patients' welfare and to collectively improve the health care system. These concepts form our profession's high ground.

Backdrop of change

The concepts of systems, chaos and loss of professionalism form a backdrop of change that is impinging on physicians. Irrational reimbursement systems, paperwork that adds no value to patient care, and economic and time pressures all coexist in a health care system that is increasingly influenced by unthinkable and unpredictable events. Is it any wonder that some of us ask why we should uphold the ethos of Hippocrates and all those hoary traditions that are the foundations of our professionalism?

A former College Regent recently compared our efforts to improve medical care and maintain professionalism to rearranging furniture in a house built directly over two active tectonic plates. Social scientists, however, would describe our environment as characteristic of "complex, self-adapting systems."

They offer the optimistic view that even if we cannot predict the outcome of multiple simultaneous activities or define where ultimate control resides, we are not doomed to anarchy. I would argue that our complex environment offers great opportunities for innovation and change.

Immutable core values are not contraindicated, even in a chaotic universe. As internists, we must remember that the ultimate validation of our values occurs during face-to-face contact with patients. We should reflect on just how privileged we are to take part in this human interaction every time it occurs. Here is the place to validate our professional values every day.

Another area that we can exert some influence is the process of life-long education that we internists must direct. While we will always need some form of testing to satisfy external bodies, it cannot be the sole measure of our continuing capabilities as physicians. It is up to us, however, to change how we learn and are evaluated. If we don't, others will do it for us—poorly and more onerously.

While CME has traditionally focused on enhancing competence, it is merely a starting point. Every one of us must improve our ability to adapt to a changing world and remain open to new approaches. We must define our own learning goals and create opportunities for constructive feedback. Finally, any educational intervention that does not focus on improving or validating our performance in the real world may not be the best use of our limited time.

Making a difference

Over the past year, I have met many members and Fellows of the College who want to make a difference in this complex health care world. The College needs you and wants to work with you.

Hundreds of our members have made substantial, lasting improvements in health care through local and national College committees. Our profession is endangered, the need is great and you have the talent.

Sara E. Walker, MACP, a compassionate and wise physician, will succeed me next month as President. I know she will provide the College inspiring leadership.

I offer you all my sincere thanks for your support and inspiration this past year.


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