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


Charter calls physicians to work toward social justice

From the December ACP Observer, copyright 2006 by the American College of Physicians.

By Lynn Kirk, FACP

The U.S. has, arguably, the best health care system in the world. Yet, despite spending more on health care than any other country—almost $2 trillion annually and approaching 16% of our gross domestic product—we rate at or near the bottom among developed countries on such important measurements as infant mortality and longevity. And while access to advanced health care technology is easily available to most Americans, over 46 million Americans have no health insurance.

The resulting poor access to quality care has significant repercussions for patients, their families and their communities. All too often, the uninsured cannot access needed services until they have reached advanced stages of their disease. Meanwhile, physicians annually face Medicare fee cuts that discourage younger physicians from pursuing careers in primary care and threaten older patients' access to quality care, especially in remote and rural areas.

The U.S. health care system's emphasis on new treatments and technologies has yielded significant personal benefits in terms of health, longevity and quality of life. However, as the Institute of Medicine has pointed out, the system is prone to medical errors that can take a heavy toll on patients. Other investigators have documented significant gaps in providing evidence-based care and shown that spending more on health care often fails to improve outcomes.

What can we, as individual physicians, do to solve any of these problems? The answer is in our own Professionalism Charter, which was developed collaboratively by the American College of Physicians Foundation, The European Federation of Internal Medicine and the American Board of Internal Medicine (ABIM). The Charter sets forth three fundamental principles of professionalism, the primacy of the patient, patient autonomy and social justice.

Of these, the third has been the most controversial and has sparked significant discussion as other physician organizations have considered or adopted the Charter. The Charter further explains this third principle by stating that "physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category." The Charter links three commitments directly to this principle: improving quality of care, improving access to care, and a just distribution of finite resources.

A particular challenge we face as physicians is balancing our obligation toward individual patients with our more global responsibility to help steward the nation's finite medical resources. In an individual physician-patient encounter, our goal is always to deliver the best care possible—evidence-based whenever such data exist—consistent with the patient's wishes and values. However, one can argue that appropriate use of finite health care resources is the best way to ensure access to appropriate care for all of our patients.

The ABIM Foundation convened leaders of several organizations in its Summer Forum to discuss this and other issues related to the Professionalism Charter (see The group's recommendations included:

  • Physicians should provide professional leadership and citizenship in quality, efficiency and equity in the health care system in the U.S.
  • Physicians should know and report their clinical performance and resource use.
  • Physicians should inform and influence their patients to change the paradigm that "more is better."
  • Physicians should advocate for a more effective and efficient delivery system, with a strong emphasis on primary care.

These recommendations are a good starting point for discussion and action. We can take first steps locally in our own practices and health care systems by collecting and analyzing the data necessary to assess the quality of and the resources used in the care of our population of patients. These data reveal areas where we need to improve and provide us with a baseline for measuring the impact of changes we choose to make in our practices.

Generating and analyzing these data take time and resources not accounted for in our current fee-for-service health care reimbursement system. Thus, we also need to work within the system and through the College and other physician organizations to advocate for the necessary resources.

Providing the best quality care today includes both individual patient interactions and what we do for our entire population of patients. We have a responsibility toward judicious allocation of resources, so that all patients can receive the best possible care and benefit from all that our health care system has to offer. My hope is that over the next decade the U.S. will rise in important rankings such as infant mortality and longevity, and that our outcomes will reflect the high quality of health care we all strive to provide.


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