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Medical Professionalism in the New Millennium: A Physicians' Charter¹

¹ From the Medical Professionalism Project. The members of the Medical Professionalism Project are listed at the end of this article. Address correspondence to Linda Blank, ABIM Foundation, 510 Walnut St, Suite 1700, Philadelphia, Pa 19106.

To our readers: What does it mean to be a professional in the specialty of radiology? As busy radiologists, we are rarely able to pause to consider what it means to be a professional in medicine today.

Lawyers, the clergy, airline pilots—all are professionals. Each profession has its own body of knowledge, set of defining characteristics, underlying values, and obligations to society. In return, society allows professionals certain levels of autonomy and power, thereby creating a social contract.

For physicians, professionalism encompasses many attributes—such as medical knowledge, altruism, and accountability—all defined in relation to the medical care of their patients. Radiologists are challenged in that the highly technical aspects of our field remove us even further from our patients. We have "progressed" to the point where radiologists can supervise staff, review digital images, construct differential diagnoses, and make clinical recommendations, without ever seeing the human being from whom the images are derived.

The Radiological Society of North America (RSNA) is committed to promoting the highest standards of patient care and humanism in medicine. To help fulfill its commitment, the RSNA has created the Professionalism Committee. The role of this committee is to educate radiologists and allied health professionals about methods for improving the relationship that exists between us, our patients, our colleagues, and the health care team. The committee's educational topics include enhancing professional competence through life-long learning and Maintenance of Certification; methods for improving honest, clear, confidential communications with our patients and colleagues; and strategies for managing conflict of interest and promoting teamwork within "communities of learners" in our own institutions and practices. We focus on our profession not only because of licensing, certification, or external government pressures, but, most important, because it is the right thing to do for our patients.

As part of its educational mission, the Professionalism Committee is proud to introduce the RSNA membership to "Medical Professionalism in the New Millennium: A Physicians' Charter." This document originated as an international project of the American Board of Internal Medicine, the American College of Physicians–American Society of Internal Medicine Foundation, and the European Federation of Internal Medicine. Unique in its scope, timeliness, and broad appeal, the charter is a recognition of medicine's social contract, the obligations between us and the patients whom we serve.

The RSNA has now joined the more than 100 other organizations that have endorsed the Physicians' Charter. We trust that your review of this document will serve as a reminder of the very best ideals to which we as physicians, and as radiologists, aspire.

Steven K. Teplick, MD, Chair

Leonard Berlin, MD, Vice-Chair

Philip N. Cascade, MD

Marilyn Goske, MD

Alan C. Hartford, MD

Murray L. Janower, MD

John P. Livoni, MD

Carol M. Rumack, MD

Hedvig Hricak, MD, Board Liaison

The 2005 RSNA Professionalism Committee

Note: This document was prepared by the American Board of Internal Medicine Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine as part of the Medical Professionalism Project.

	PHYSICIANS' CHARTER

TOP INTRODUCTION PHYSICIANS' CHARTER PREAMBLE FUNDAMENTAL PRINCIPLES A SET OF PROFESSIONAL... SUMMARY

 
Physicians today are experiencing frustration as changes in the healthcare delivery systems in virtually all industrialized countries threaten the very nature and values of medical professionalism. Meetings among the European Federation of Internal Medicine, the American College of Physicians and American Society of Internal Medicine (ACP-ASIM), and the American Board of Internal Medicine (ABIM) have confirmed that physicians' views on professionalism are similar in quite diverse systems of healthcare delivery. We share the view that medicine's commitment to the patient is being challenged by external forces of change within our societies.

Recently, voices from many countries have begun calling for a renewed sense of professionalism, one that is activist in reforming healthcare systems. Responding to this challenge, the European Federation of Internal Medicine, the ACPASIM Foundation, and the ABIM Foundation combined efforts to launch the Medical Professionalism Project (www.professionalism.org) in late 1999. These three organizations designated members to develop a "charter" to encompass a set of principles to which all medical professionals can and should aspire. The charter supports physicians' efforts to ensure that the healthcare systems and the physicians working within them remain committed both to patients' welfare and to the basic tenets of social justice. Moreover, the charter is intended to be applicable to different cultures and political systems.

	PREAMBLE

TOP INTRODUCTION PHYSICIANS' CHARTER PREAMBLE FUNDAMENTAL PRINCIPLES A SET OF PROFESSIONAL... SUMMARY

 
Professionalism is the basis of medicine's contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession.

At present, the medical profession is confronted by an explosion of technology, changing market forces, problems in healthcare delivery, bioterrorism, and globalization. As a result, physicians find it increasingly difficult to meet their responsibilities to patients and society. In these circumstances, reaffirming the fundamental and universal principles and values of medical professionalism, which remain ideals to be pursued by all physicians, becomes all the more important.

The medical profession everywhere is embedded in diverse cultures and national traditions, but its members share the role of healer, which has roots extending back to Hippocrates. Indeed, the medical profession must contend with complicated political, legal, and market forces. Moreover, there are wide variations in medical delivery and practice through which any general principles may be expressed in both complex and subtle ways. Despite these differences, common themes emerge and form the basis of this charter in the form of three fundamental principles and as a set of definitive professional responsibilities.

	FUNDAMENTAL PRINCIPLES

TOP INTRODUCTION PHYSICIANS' CHARTER PREAMBLE FUNDAMENTAL PRINCIPLES A SET OF PROFESSIONAL... SUMMARY

 
Principle of Primacy of Patients' Welfare
This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.

Principle of Patients' Autonomy
Physicians must have respect for patients' autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients' decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.

Principle of Social Justice
The medical profession must promote justice in the healthcare system, including the fair distribution of healthcare resources. Physicians should work actively to eliminate discrimination in healthcare, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

	A SET OF PROFESSIONAL RESPONSIBILITIES

TOP INTRODUCTION PHYSICIANS' CHARTER PREAMBLE FUNDAMENTAL PRINCIPLES A SET OF PROFESSIONAL... SUMMARY

 
Commitment to Professional Competence
Physicians must be committed to lifelong learning and be responsible for maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care. More broadly, the profession as a whole must strive to see that all of its members are competent and must ensure that appropriate mechanisms are available for physicians to accomplish this goal.

Commitment to Honesty with Patients
Physicians must ensure that patients are completely and honestly informed before the patient has consented to treatment and after treatment has occurred. This expectation does not mean that patients should be involved in every minute decision about medical care; rather, they must be empowered to decide on the course of therapy. Physicians should also acknowledge that, in healthcare, medical errors that injure patients do sometimes occur. Whenever patients are injured as a consequence of medical care, patients should be informed promptly because failure to do so seriously compromises patients' and societal trust. Reporting and analyzing medical mistakes provides the basis for appropriate prevention and improvement strategies and for appropriate compensation to injured parties.

Commitment to Patients' Confidentiality
Earning the trust and confidence of patients requires that appropriate confidentiality safeguards be applied to disclosure of patients' information. This commitment extends to discussions with people acting on a patient's behalf when obtaining the patient's own consent is not feasible. Fulfilling the commitment to confidentiality is more pressing now than ever before, given the widespread use of electronic information systems for compiling data on patients and an increasing availability of genetic information. Physicians recognize, however, that their commitment to confidentiality must occasionally yield to over-riding considerations in the public interest (for example, when patients endanger others).

Commitment to Maintaining Appropriate Relationships with Patients
Given the inherent vulnerability and dependency of patients, certain relationships between physicians and patients must be avoided. In particular, physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose.

Commitment to Improving Quality of Care
Physicians must be dedicated to continuous improvement in the quality of healthcare. This commitment entails not only maintaining clinical competence but also working collaboratively with other professionals to reduce medical error, increase patients' safety, minimize overuse of healthcare resources, and optimize the outcomes of care. Physicians must actively participate in the development of better measures of quality of care and the application of quality measures to assess routinely the performance of all individuals, institutions, and systems responsible for healthcare delivery. Physicians, both individually and through their professional associations, must take responsibility for assisting in the creation and implementation of mechanisms designed to encourage continuous improvement in the quality of care.

Commitment to Improving Access to Care
Medical professionalism demands that the objective of all healthcare systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable healthcare. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.

Commitment to a Just Distribution of Finite Resources
While meeting the needs of individual patients, physicians are required to provide healthcare that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician's professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes patients to avoidable harm and expense but also diminishes the resources available for others.

Commitment to Scientific Knowledge
Much of medicine's contract with society is based on the integrity and appropriate use of scientific knowledge and technology. Physicians have a duty to uphold scientific standards, to promote research, and to create new knowledge and ensure its appropriate use. The profession is responsible for the integrity of this knowledge, which is based on scientific evidence and physicians' experience.

Commitment to Maintaining Trust by Managing Conflicts of Interest
Medical professionals and their organizations have many opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage. Such compromises are especially threatening in the pursuit of personal or organizational interactions with for-profit industries, including medical equipment manufacturers, insurance companies, and pharmaceutical firms. Physicians have an obligation to recognize, disclose to the general public, and deal with conflicts of interest that arise in the course of their professional duties and activities. Relationships between industry and opinion leaders should be disclosed, especially when the latter determine the criteria for conducting and reporting clinical trials, writing editorials or therapeutic guidelines, or serving as editors of scientific journals.

Commitment to Professional Responsibilities
As members of a profession, physicians are expected to work collaboratively to maximize patients' care, be respectful of one another, and participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards. The profession should also define and organize the educational and standard-setting process for current and future members. Physicians have both individual and collective obligations to participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all aspects of their professional performance.

	SUMMARY

TOP INTRODUCTION PHYSICIANS' CHARTER PREAMBLE FUNDAMENTAL PRINCIPLES A SET OF PROFESSIONAL... SUMMARY

 
The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges center on increasing disparities among the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform healthcare systems, and the temptation for physicians to forsake their traditional commitment to the primacy of patients' interests. To maintain the fidelity of medicine's social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the healthcare system for the welfare of society. This Charter on Medical Professionalism is intended to encourage such dedication and to promote an action agenda for the profession of medicine that is universal in scope and purpose.

Members of the Medical Professionalism Project:

ABIM Foundation: Troy Brennan (Project Chair), Brigham and Women's Hospital, Boston, Mass; Linda Blank (Project Staff), ABIM Foundation, Philadelphia, Pa; Jordan Cohen, Association of American Medical Colleges, Washington, DC; Harry Kimball, ABIM, Philadelphia, Pa; Neil Smelser, University of California, Berkeley, Calif. ACP-ASIM Foundation: Robert Copeland, Southern Cardiopulmonary Associates, LaGrange, Ga; Risa Lavizzo-Mourey, Robert Wood Johnson Foundation, Princeton, NJ; Walter McDonald, ACP-ASIM, Philadelphia, Pa. European Federation of Internal Medicine: Gunilla Brenning, University Hospital, Uppsala, Sweden; Christopher Davidson, Royal Sussex County Hospital, Brighton, UK; Philippe Jaeger, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Alberto Malliani, Università di Milano, Milan, Italy; Hein Muller, Ziekenhuis Gooi-Noord, Rijksstraatweg, the Netherlands; Daniel Sereni, Hôpital Saint-Louis, Paris, France; Eugene Sutorius, Faculteit der Rechts Geleerdheid, Amsterdam, the Netherlands. Special consultants: Richard Cruess and Sylvia Cruess, McGill University, Montreal, Quebec, Canada; Jaime Merino, Universidad Miguel Hernández, San Juan de Alicante, Spain.

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