Thursday, June 28, 2007

Session 1: The Healing Professions

Patricia Benner, M.S.N., Ph.D.
Senior Scholar, Carnegie Foundation for the Advancement of Teaching

Arnold S. Relman, M.D.
Professor Emeritus of Medicine and Social Medicine, Harvard Medical School

CHAIRMAN PELLEGRINO:  Good morning, good morning, good morning.  Welcome to the members of the Council, the 29th meeting of the President's Council on Bioethics.

I want to welcome our guests as well.  We are in slight violation of my usual rule to start precisely on time, but we've had some difficulties with travel.  The weather is awful all over the country, and some of our initial speakers, as luck would have it, have not been able to make it right away.

So we will turn the agenda around just a little bit, and instead of having William Sullivan, who is stranded somewhere — where is he? — Chicago, and we're hoping he will get here this afternoon, but Dr. Relman has graciously agreed to be the first speaker, and our second speaker also has graciously agreed to the change in schedule.

I'm going to ask Dr. Lisa Day to open the program, if you wouldn't mind.  She has graciously undertaken the task because Dr. Patricia Benner was not able to come, and that was decided at the very last minute.  I want to thank you most sincerely for picking up the ball so rapidly and moving ahead.

It's customary in these meetings not to go into an extended discussion of the background of the speakers.  You have the essential facts in the program, and so I will not say anything further  than to introduce Dr. Day as Associate Clinical Professor at the University of California, San Francisco, in nursing, and you are, I believe, an Associate and a student as well of Patricia Benner's; is that correct?

DR. DAY:  Yes, indeed.

CHAIRMAN PELLEGRINO:  But you, of course, will be speaking on your own and giving your ideas on the question of the healing professions.

Just a word, and I don't want to keep you standing there long expectantly.  On the program this morning and tomorrow and tomorrow afternoon, we are opening up several new topics for the Council.  This is a consequence of previous surveys we've made of Council members and what their interests are and especially of individual conversations.

And people have expressed repeated interest in some of these problems, but we are not dedicated necessarily to taking up these issues unless it is the wish of the Council.  So this in some ways is exploratory.

The healing professions is a question you all know that's very much before all of us, the public, the academicians, the questions of professionalism, the questions of what has happened, if anything has happened, to the classical professions of medicine and nursing and ministry and the law.

We will be focusing on the healing professions, medicine, nursing, allied health, all of those that have direct confrontation with human beings who are in need or dependent and vulnerable, and the way in which we approach them and what our obligations are, particularly from a moral point of view, as well as sociological will be the focus of these presentations.

Without further ado then, Dr. Day, may I ask you to address us?

DR. DAY:  Thank you.  Thank you very much.

I'm quite honored to be here, to be asked to represent nursing in this discussion of the professions in society and of professional practice and the ethics of professional practice, and I'm honored to be here representing Patricia Benner, who is my mentor and teacher, and also to be representing my practice, which I'm very honored to have been a nurse since 1984 when I graduated with an Associate degree.

And in this discussion of practice ethics, nurses are directly engaged in and embody everyday ethics as they work with individuals, families, and communities.  In this presentation I want to take up two main themes.  First, I want to take up a consideration of practice ethics and what I think are the distinctive marks of nursing as a profession and as a practice, and then second, I want to discuss some of the impediments nurses face as they try to enact the goods of our practice.

So nursing as a profession and as a practice.  Nursing is a socially organized set of caring practices.  The practice demands that nurses develop concerns about how to meet, empower, protect, nurture and comfort those who are vulnerable and in need of care.  This is accomplished, in part, through advanced knowledge of nursing and medical therapies and also through practical skills that allow nurses to titrate these therapies according to particular patients' responses.

The margins between what is therapeutic and what is dangerous in this practice are often narrow, and the opportunities for errors in judgment are many, but the nurse when truest to her or his practice tradition does this work with an acknowledgement of the distinctiveness and separateness of the other and with the understanding that the need for care is universal and that we as helpers share in the same human possibilities and vulnerabilities as those we would like to help, we seek to help.

This stance is distinct from that of the technical expert who holds an external relationship to the object of craft or fabrication.  For nurses there is no durable product.  We're engaged in a process of relationship that Aristotle would describe as phronesis rather than techne.

The outcomes of our practice are not predictable, and we operate most often in under-determined situations that are changing constantly.

So the practice of nursing requires a knowledge base and rationality, but also embodied skill, know-how and ethical comportment.  Good nursing practice requires a commitment to a response-based ethic and depends on knowing the particular patient.  Nurses cannot coherently claim to apply a narrow rationality or technique that guarantees mastery over outcomes when good nursing practice really depends on caring relationships with concrete, finite and particular others.

The ethics of nursing practices inextricably connected to the daily clinical work that nurses take up.  Learning to be a good nurse requires one to develop not only technical expertise, but also the ability to form helping relationships and engage in practical ethical and clinical reasoning. 

So six aspects of skillful ethical comportment and clinical judgment are central to becoming an excellent practitioner.  First, the ability to link clinical and ethical reasoning.  So linking clinical concerns to a sense of the good.  What is good to our practice?

And then thinking and action and reasoning and transitions in this ever changing relationship that we form with patients and communities and families.  Nurses must develop response-based practice and a sense of their own agency in this practice.

In this view, ethical and clinical reasoning cannot be separated because the visions of what is good, bad or harmful dictates sound clinical judgments.  The moral sense of what is good to be and do in a situation guides problem identification, guides the selection of therapies and the evaluation strategies for those therapies.

So when we think about bioethics and health care ethics, we think often about procedural ethics and a justification of right actions, and a justification of right actions based on moral principles, while this is useful for institutional policies and procedures and for justifying ethical decisions in dilemma or quandary cases and also for insuring rights and justice, this type of ethics is not sufficient for discovering or enacting the good in concrete particular caring relationships, such as nurses make.

That nurses seek the good in situations of risk and vulnerability also requires more than a diagnostic armamentarium for fixing pathologies and deficits.  It requires that the good possibilities in actual concrete situations and concrete relationships be acknowledged and nurtured.

Nursing practice invites nurses to embody caring practices that meet, comfort, empower and advocate for vulnerable others.  Such a practice requires a commitment to meeting and helping the other in ways that liberate and strengthen and not in ways that impose the will of caregiver or impose dependency.

Helping that dominates, takes over or promises what is not feasible in an attempt to realize a static predetermined goal must be recognized as such and vigilantly resisted.  Notions of the good and ends of practice are essential to nursing.  Benner and colleagues have argued that clinical judgment cannot be separated from ethical reasoning because each clinical judgment is about what good is at stake and what to do in each particular situation.

If nurses do not have a good understanding of worthy ends in nursing practice, that is, goods internal to practice as McIntyre would describe it, then their clinical judgment will be faulty, and likewise, if nurses do not have a good grasp of the science of pathophysiology and medical nursing interventions and therapies, then they can make neither good ethical nor good clinical decisions because they cannot know what is good to do in this particular situation.

So good nursing practice also minimally requires the following moral sources and skills.  First, relational skills that allow the nurse to meet the other in his or her particularity and to draw on the life manifestations of trust, mercy, and openness of speech.  So this requires nurses to develop communication skills and an appreciation for  and ability to engage in narrative interpretation and narrative understanding.

Nurses require the development of a perceptiveness in recognizing when a formal moral principle, such as justice, is at stake.  Nurses also require the development of skilled know-how that allows for appropriate action in particular encounters and allows for that to happen in a timely manner.  So nurses need to respond fairly quickly in certain circumstances.

Nurses need some skill at deliberation and communication skills that allow for thoughtful consideration and justification of actions and decisions and communicating among health care team members and communicating with patients and families.

Nurses require an understanding of the goals and ends of good nursing practice, and nurses are required to become participants in a practice community, and this will allow for character development of the individual and for the actualization and extension of good practice overall.

Practitioners will exercise distinct forms and qualities of moral judgment based on their relative knowledge and skills in these areas and based on the possibilities for practice that the community in which they are situated facilitates or impedes.

And next I'd like to take up the impediments to realizing and enacting good nursing practice.  So what stands in the way of us enacting the goods internal to our practice?

Well, first, the professional hierarchy in health care and the privileging of the biomedical model of disease and treatment.  Perhaps nowhere are crippling hierarchies and status inequities more evident than in health care sectors with the privileging of dense technology and the biomedical model over basic caring practices.  This dysfunctional arrangement shows up daily in nursing and doctoring practice as breakdowns in communication, medical error and in the current safety crisis in hospitals.

The concerns of nurses often take a back seat to medical diagnostics and treatments concerned with efficiently controlling diseases, and the institutions we practice in support this prioritization.  And although it is becoming more evident that medical interventions alone with little or no attention to basic human concerns, like the social well-being of individuals, families and communities or access to good nutrition, nature, exercise, and a safe environment, cannot produce sustainable good health.

Health care policy, economic and institutional structures are all set up best to support acute medical intervention for crises. 

This press for efficiency and cure in health care institutions is combined with a devaluing of the relational and caring practices of nurses, and institutional structures in many ways impede the best nursing practice.

Another impediment to best nursing practice is inadequate preparation of nurses.  Nursing education in many ways under-prepares nurses for the demands of practice.  Based on findings from our national nursing education study which has been conducted under the auspices of the Carnegie Foundation for the Advancement of Teaching, we conclude that there's a major under-education of nurses, given the complexity of medical nursing and biopsycho-social sciences.

For one thing, there are many different points of entry to professional practice as a registered nurse, and in the paper here, I had originally a slide which I decided to delete, but there are different degree types that allow one to enter practice as a registered nurse and become licensed in most states.  Most states will recognize an Associate degree, a diploma from a hospital-based school of nursing, a Bachelor's degree.

There are also second degree programs that are very popular now, and they're very much the cutting edge of new programs in nursing.  An accelerated Bachelor's degree for someone with a Bachelor's degree in another field; the accelerated Master's entry degree, these are all points of entry by which one might sit for licensing as a registered nurse and become a professional practicing nurse.

These multiple points of entry indicate disagreement over what education nursing practice requires.  The American Organization of Nurse Executives and the American Association of Colleges of Nursing have both called for a mandated baccalaureate degree as the point of entry to nursing practice.

The American Nurses Association first made this recommendation in 1965, but to date the profession has not had the will, the funds, or the political power to make this happen.  Each state legislature in this country seems to be strongly committed to their community college nursing programs, despite the fact that community colleges are under-funded for the very expensive, high faculty-student ratios required for nursing education and despite the fact that community colleges have not delivered on their promise of increasing the diversity of the nursing work force.

And although it seems like promoting a faster path to the R.N., such as a two-year Associate degree, should ease the nursing shortage by putting more nurses into practice more quickly, it is more likely to actually compound the nursing shortage.

First, the two-year Associate degree in nursing takes a minimum of three years and maybe as long as four to five years to complete, and this has to do with difficulty getting into prerequisite classes, credit creep so that more and more credits are added to programs without adding more time.

But also at the root of the current nursing shortage is a serious shortage of nursing faculty, and this is the true root of the nursing shortage.  We've turned away hundreds of thousands of applicants, qualified applicants, to programs of nursing for lack of faculty, for lack of educational facility.

Given this shortage of nursing faculty, reliance on community college nursing programs compounds the faculty shortage since the Associate degree does not qualify the graduate to take up an academic position and only about 15 percent of these graduates go on to complete a baccalaureate.  Fewer still go on to complete graduate degrees.

Thus, the huge numbers of community college graduates in nursing create a faculty bottleneck that compounds rather than eases the nursing shortage.  But even more serious than this disagreement over the appropriate point of entry is the quality gaps in the educational preparation of nurses and in the teaching development of nursing faculty.  And this is across all programs.  So diploma, Associate degree, baccalaureate, and even second degree Master's entry and accelerated baccalaureate programs.

Nurses are under-educated for the current demands of the practice and for the demands of the increasingly complex health care delivery systems.  So confronting the complexity of health care and being able to engage in policy discussions to generate changes, nurses are not being prepared for this.

Patient safety and well-being depend on nurses adjudicating, titrating, and adjusting therapies according to individual responses.  Teaching this practice requires clinical expertise, as well as excellent teaching skills.

When faculty lack the ability adequately to prepare students for the transition to work, new nurses find themselves unable to engage in a practice that realizes the goods internal to it.

So for all of this bad news, the impediments to practice and struggles that nursing is having, there is also some remarkably good news from our national nursing study, and this is despite the difficulties of finding good sites for students to engage in hands-on learning.  Our clinical training tends to be excellent and safe.  Nursing students maintain a strong desire and passion to do a good job and are committed to engaging in an ongoing self-improving practice.

The nursing students demonstrate a strong connection to the goods internal to nursing practice.  They are concerned and they talk about concerns that the practice that they learn allow them to meet the patient as a person, allow them to preserve the dignity and personhood of each individual patient, allow them to respond appropriately to substandard practice and act as advocates to patients, families and communities.

Students and faculty in schools of nursing are seriously engaged in an attempt to do good nursing practice.  What impedes this possibility is the lack of rigorous scholarship demanded of nursing students in the social and natural sciences and in the humanities, and a lack of connection of these sciences and humanities to the practice of nursing, so teaching for a practice, particular discipline-specific pedogogies and teaching strategies to connect the science to the practice.

At best, we as nurses struggle in our practice to achieve the level of attentive, relational, clinical care we seek to provide the public.  Our health care institutions have not been designed adequately for good nursing nor for good medical practice, but rather for efficiency and profit.

Health care institutions often focus on profit and growth rather than on health promotion and healing.  Nursing, doctoring, and all of health care must move from a commodified, expensive, crisis- and cure-oriented system toward a focus on public health, health promotion, illness prevention, and management of chronic illness.  Without such a fundamental change we will continue to bankrupt our economy and do little to improve the health of our citizens and communities.

A good society should provide its citizens with access to health and health care as a right.  Anything less diminishes the quality of our lives together.

Thank you.

(Applause.)

CHAIRMAN PELLEGRINO:  Thank you very much, Dr. Day.  Again, thank you for coming on such short notice, hopping on the plane in this emergency.  Thank you.

DR. DAY:  Yes.

CHAIRMAN PELLEGRINO:  Dr. Rebecca Dresser, a member of our Council, will open the discussion, and you and she can respond to whatever questions may arise.

DR. DAY:  Thank you.

CHAIRMAN PELLEGRINO:  Rebecca.

PROF. DRESSER:  Well, thank you.  That was very impressive for someone who had to step in at the last moment.

When I was asked to do this, I thought, well, I don't really know much about nursing.  I haven't taught students or written about it.  So I thought maybe I would ask some naive questions.

But I have had the experience last year of being treated for cancer and really appreciating what a huge impact a skilled and humane nurse can have on the patient's experience.

So you've said some things that allude to the different ethical — I don't know — principles, guidelines, approaches that distinguish nursing and physician practice.  I wonder if you could highlight that a little bit more because I know as a patient there was certainly some overlap, but there were some clear differences.  So I don't know if you can articulate those more for us.

Also, I wondered about — and again, you've alluded to this — but if you were to describe central ethical issues for the nursing profession today, what might some of those be?

And then relationships with members of the medical profession and other clinicians, ethical aspects of that.

And finally, as you were speaking, I thought of an issue that has struck me just reading about it, which is the U.S. is increasing importing nurses from places like the Philippines and other countries, which probably have medical needs.  How do you see that as perhaps an ethical issue?

DR. DAY:  Wow, these are great questions.  Related to your first question about the overlap and interaction between medical practice and nursing practice, that's what I understand it to be.  I am very much unqualified to speak to medical practice.  I've been in nursing for my entire career.

I think the best doctoring, the best nursing, there is a great deal of overlap and there's a great deal of collaboration that happens.  There are different concerns, I think, in terms of meeting a patient and discovering what concerns a nurse has, what concerns a doctor has.  I think you'll find some distinctions there.

And this sort of leads into one of, I think, the biggest ethical problems nurses are faced with: this hierarchy that privileges the question of cure over basic caring practices.   Nurses are continually devalued and not taken seriously as members of the health care team.  There  are institutional impediments to this, and when we think about different practice venues like hospital based practice, there are a lot of blocks to nurses taking a full role in the team.  There are teams of physicians who round on patients and manage the medical care and treatment, and nurses change shifts every eight hours and then, you know, work three days a week and take, you know, the rest of the time off.

So it's difficult to create a cohesive team kind of practice in light of those kinds of issues.

The other thing, I think, that feeds this as an ethical problem is nurses being inadequately prepared academically to step forward and take a full role in a team of this sort.  I mean, I think that we could work out the difficulties with shift work and everything else that happens if we had some sort of momentum behind it, but I think nurses in a lot of ways are too complacent with the system as it is.

And so I think those are ethical issues because I think the patient — you know, enacting the goods of my practice, of our practice as nurses, meeting the patient and responding to the patient's needs, this can't happen in the best way that it could if we don't work as a team as health care providers.

And then could you repeat your last question, just the gist of it?

PROF. DRESSER:  I think it was the one about the U.S. bringing in nurses from other countries.

DR. DAY:  Oh, yes.  So thinking of health care internationally, there is a nursing shortage everywhere, and this importing nurses from other countries takes away from the health care infrastructure in places that have even fewer nurses than we have.  So I think it's a desperation kind of move.

The other issue with that is that the training and education that nurses receive internationally differs from that that this health care system in the United States demands.  There's an even bigger gap sometimes between the training and education nurses receive in other countries and what's demanded of them when they enter the health care system in the United States.  Different relationships with other health care providers expected; different types of communication happen here that are very culturally bound.

So I think there are lots of issues with importing nurses from other countries, and we have to begin to think about it.  I've talked with some colleagues in hospitals thinking about forming some sort of educational program or cultural development program for nurses new to the United States.  So if we could somehow enculturate them sort of quickly into this practice that has a very specific communication style, especially in hospitals, but I don't know how much success we'd have in that and then still remaining the issue of taking nurses away from places that need them as much if not more than we do.

PROF. DRESSER:  Yes, I wonder if, as you say, the shortage of nursing professors is a big part of the shortage here.  Could one argue that training more professors from here would be a more just way of handling our nursing shortage?

DR. DAY:  Yes, I think that's absolutely the root of it, and I think that putting more attention towards nursing education in many respects increasing the attention to rigor in the sciences and humanities and liberal arts education for nurses, and then making that connection with practice, and this is going to require discipline-specific teaching strategies and pedagogies.

So putting some attention towards developing the education infrastructure for nursing, and there's a faculty shortage for many reasons, and I think one of which is that there are so many options for nurses with graduate degrees.  You know, they're running clinical trials for pharmaceutical companies instead of teaching in academic settings.

And you know, the salary discrepancies and the sort of what do you get as a reward for going into academic teaching; there's very little faculty development going on in schools of nursing.  There's almost no attention paid or research going on to develop the best teaching strategies for patient outcomes.

So you know, this is a very neglected area of research.  What kind of teaching strategies will develop nurses that will then impact patient outcomes in the best way?  That's an area that's just not being attended to.

PROF. DRESSER:  Thank you.

CHAIRMAN PELLEGRINO:  I'd like to open — I'm sorry.  Any Council members desire to speak?

Dr. Carson.

DR. CARSON:  First of all, thanks for that presentation.

As a physician, I'm a big fan of nurses.  I always say they're the infantry of medicine, but a couple of things that I've noticed in medicine in recent years surrounding nursing.  First of all, there's an enormous amount of pressure now placed on nurses for documentation of everything to create the trail of virtually every case.

You know, as a surgeon, I find now in the operating room that you virtually don't even have a circulating nurse anymore because they're spending their whole time, you know, documenting everything.  And I'm not sure that this is something that's particularly useful for the patients.

And I wonder if this is something that you've noticed and that anybody is trying to address.

The other issue, of course, being one of the greatest components of good medical care is experienced nursing, and yet having nurses that stay in a particular location long enough to become experienced is becoming more and more difficult.

What do you believe are the pressures that are creating that type of situation which is very detrimental to health care?

DR. DAY:  Well, in answer to the question about documentation, it is becoming quite cumbersome, and it always has been.  There have always been discussions in nursing about how can we streamline documentation so that we don't spend all of our time writing instead of doing the care of patients.

But I think the explosion in documentation is a sign that we've lost our way in terms of professional practice because we're just trying to cover all of the bases and trying to, like you're describing, create a paper trail rather than communicate more directly with one another as providers, you know, sort of charged with the same duties and the same sort of concerns.

But I think that there are just more efforts going towards streamlining documentation, and this new thing of nurses documenting on computers is really rough on some nurses' practice, and I think it disrupts the flow, the work flow, and so getting used to that kind of new technology and new ways of doing that.

There's some discussion of having hand held computers that you can use as if it's a clipboard.  I don't know if the technology is going to allow us just to write and have it become a computerized record.  That would be really ideal because that's what nurses of my generation and older are used to, and I think maybe the new generation coming out will have more answers for us related to the documentation question.

Nurses staying in a job long enough to develop the expertise, this is one of Dr. Benner's — a seminal work in nursing practice is Dr. Benner's work applying the novice to expert model of skills acquisition to nursing and to describe nursing practice.  The development of skill from the beginner level when someone graduates from nursing school requires experiential learning over time, and so to gain expertise in the practice, to gain competence and then expertise requires one to confront similar situations repeatedly and have the sort of turning around of your assumptions in order to gain experience.

So this is a huge problem in nursing, this rapid turnover.  Nurses enter a job.  They leave after a year.  They go into a different area of practice.  They leave that place after a year, and it's a sign that nurses are not taking up their practice seriously as the self-improving practice that I described in the paper.  They're not taking seriously the importance of committing to a self-improving practice.

But I think also it's a sign that things are not going well in hospital practice, and I think that's another impediment that I didn't emphasize.  The nursing shortage itself creates an impediment because when nurses get out into practice and realize there aren't enough nurses to support me, there aren't enough colleagues for me to turn to; there's no one here who has been here more than a year.  Who am I supposed to go to with my questions?  And, you know, who am I supposed to bounce my judgments off of as a beginner?

This creates a sort of panic in the beginner because they absolutely need that in order to develop their practice.  So leaving a clinical area to jump to another clinical area, that's one thing that's happening, but another thing that's happening is leaving the practice entirely or moving out of direct patient care entirely.

And I think this is a sign that we're sort of in a crisis situation in terms of how nurses are relating to their practice and how institutions are supporting that practice.

CHAIRMAN PELLEGRINO:  Dr. McHugh.

DR. MCHUGH:  I very much enjoyed your discussion and your answers to these questions, some of which I am going to repeat a little bit in my comment to you.

And perhaps, first of all, I should tell you that I'm, like Dr. Carson, absolutely indebted to and rest upon the caregiving enterprises of the nurses at my hospital and on my unit.  We run a multi-disciplinary team that has a nurse on it, psychologist on it, occupational therapist, and it's part of the responsibility of the physician in directing that multi-disciplinary team to appreciate and to teach to others just what each of those professions will do.

And if he or she cannot do that, then the multi-disciplinary team so needed in contemporary medicine will fall apart.

But perhaps I want to come back to the idea that you presented us, that there is this problem of morale amongst nurses, and this morale derives from a number of sources that you've mentioned.  But on a multi-disciplinary team with us, at any rate, the things that become quite clear in the communications between us and our patients are, for example, the fact that only the nurse in her caring or his caring role has a sufficiently longitudinal view of the patient over the time — we're talking now in hospital — that can add to and, in fact, often correct the cross-sectional view that the doctor gets walking in saying, "Hi, how are you?" and walking out.

The person in the form of the nurse knows this and to a considerable degree the multi-disciplinary team is helped not only by the visions that they have, but by the tools that nurses can bring to quantitatively demonstrate these matters of improvement or deterioration in the patient.

And I was struck by the fact that in part what you were saying is that in the caring role that to some extent — well, I don't think you used exactly this word — but you didn't mention the importance of empirical and data driven aspects.  After all, Florence Nightingale was the first person to bring empirical work to hospital services and demonstrate how the environment and aspects really fundamentally carried by nurses made tremendous differences in morbidity and mortality.

I'm struck often by how that side of nurses' history doesn't get emphasized either in their education or in their practice.

By the way, you  make the point that the education today of nurses doesn't prepare them for practice.  I wish the education of doctors prepared them for practice.  For a great deal of our time we realize that medical school prepares us for something, but that only when we're in practice on the wards as interns, residents, and the like do we tend to realize not only what we don't know and what we need to learn, but of course where we fit into the system of interaction.

So I'm interested in what you're thinking about how the longitudinal views of nurses can be strengthened in their communications back to the team, the issue of what you're saying is that the concerns for the caring and the environment that the patients are imbedded in is very much a nursing and traditional nursing role, should be articulated.  Everyone should know about that and appreciate it.

And finally, it seems to me that the support for nurses in these enterprises should be broadly based and should involve everybody on the team in both the hierarchy of administration, as well as the doctors as well.  Otherwise you lose them.

I early learned that if I wanted to maintain a team that worked functionally, I had to be sure that I supported the enterprises of the nurses in every way, not only the enterprises of their daily work, but even the sense of their achievements, announcing them broadly to people as to what was happening.

So I'm concerned about this morale problem that seems to come forth in what you're saying, and ultimately I suppose the question I want to put to you is that if there is a multi-disciplinary team needed on a unit, whether that unit be an in-patient or an out-patient, but just take an in-patient as a model, how does authority flow in your view in this way?  Does it flow hierarchically or does it flow interactively as equals?  What is expected?  How are we sure that the things which people know get employed properly for the benefit of the patient in relationship to the issues of diagnosis, to the issues of treatment plans, issues of care delivery and the like?

DR. DAY:  Okay.  I'll try my best to follow the thread here.  I think in relation to your most recent question about the hierarchy and how does authority flow, in my vision I think it depends.  I think that it could flow different ways depending on patient need, and whichever service comes forward as the most pertinent, and that's going to require very fluid communication among team members and including patient family as participants and as members of the health care team.

I think that nurses' position, as you described, having this longitudinal access to patient changes over time, there are a couple of ways that nurses engage in hospital practice, and I'll just use hospital practice because it's what I'm most familiar with, but I'm sure it happens across different points of practice.

But nurses engage in hospital practice as the bedside staff nurse, and this is the shift worker who works eight or 12 hours on a shift, days, nights, evenings, and then there's the nurse practitioner who often works with a medical or surgical team as a member of that team, has a group of patients that she or he sees and practice is structured very much like physician practice.

So I just want to make the distinction that the nurse who has the access you're describing is the one who's the staff nurse working the shift and seeing the patient over 12 hours we hope for more than one day in a row.

So nurses developing these skills of discernment, patient changes over time, this is the thinking and action, the skilled know-how to pick up these changes, and then it can't stop there.  Nurses also need skills to articulate these changes and describe them in ways that other providers can understand.

And this is what we talk about the need in nursing education for more rigorous humanities because this is where nurses could begin to engage with these skills.  They need rhetoric, and they need to be able to describe in a way that's compelling when the situation is compelling.

So one of the issues that I think contributes to the core morale among nurses is notifying a physician team of a change in a patient's condition, getting that heard in a way that the nurse thinks it should be heard and that, you know, there are different things going on in hospitals to improve this right now because it's a big source of medical error, medical and nursing error when physicians don't hear the serious concerns of nurses related to a patient, to a change in a patient's condition.

So improving communication between nurses and physicians and educating nurses such that they take seriously their responsibility to provide the narrative, to really provide the imbedded narrative of where this patient has been and where they're likely to be going.  So that will get heard more and increase the visibility of the nurse's position as sort of the keeper of the day.  So seeing this patient over the hours that we see them.

And then your concern about the lack of attention paid to empiricism in nursing.  I think there's a push now towards evidence based nursing practice, and from the way I've described nursing practice as response based, we have to develop a relationship with the patient such that we get close enough that we know what's appropriate in this situation, and evidence based practice, research is part of it.  So the empirical studies, the control trials that tell you which intervention is the better intervention for the population, that's one piece of it, but also knowing when to choose something different based on patient preference or family concerns or this particular patient's place at this particular time.

So ultimately being responsive to patients, but, yes, I mean nurses in their education, what we found in the Carnegie study is they are very much lacking in any kind of training, in accessing empirical evidence, in doing things like searching literature, searching standards of practice, finding out what the recommendations are for standards that are based on the research evidence.  They're sort of lacking in this kind of training.

So, yes, it definitely needs to be improved, and I think by improving those skills, we'll open up nursing practice even more to be able to make these kinds of discernments.  Like is it appropriate to implement this standardized practice, or is it appropriate to deviate from that?

CHAIRMAN PELLEGRINO:  Dr. Hurlbut and then Dr. Foster.

DR. HURLBUT:  So our subject in this session is healing, and it strikes me that the whole notion of healing is a conceptual framing of reality.  It starts with certain assumptions about the nature of human life, of our meaning and purpose in life, and our whole relationship with natural process.

Early in my medical training it struck me that as I got into the clinical wards, I noticed that nurses were doing a lot of what I had seen medicine as being about in a way that even the physicians weren't in the sense that they were encountering the patient at the most sensitive and vulnerable moments and delivering a kind of compassionate care and a very human element of healing that transcended in some sense even the technical dimensions of healing that physicians were more assigned to.

So it struck me even then that this is a very difficult encounter.  It's an encounter with disorder, disease and death itself, and in fact, was an emphasis of life that's very different to the prevailing preoccupations of our entertainment oriented, consumer culture; that whereas the emphasis in — and I understand it — in much of our lives is toward the bright and the happy and the easy and the exciting, this was an encounter with something of difficulty and depth, a kind of intensity.

And I began to realize that this was very draining on the people who were closest to it, and it struck me that the nurses were actually closer to it even than many of the physicians.

So what I want to ask you is if you'd comment broadly a little on that.  It strikes me that you say that nurses move quickly out of their roles, I guess moving on to different jobs, a kind of restless dissatisfaction.   I would imagine nurses also leave practice probably more than people expect.

And would you comment a little on the whole prevailing question of cultural values and the difficulty of being a nurse and encountering something that we barely have a culture to contain anymore?

What I'm thinking of here, not to put words in your mouth, but to ask you seriously about:  is there an emphasis in our culture that does not face fundamental realities?  And is there an emphasis that doesn't set the proper frame for medicine in its deepest and most difficult role, that being the compassionate engagement with those in need of healing?

And just one little point I want to add on this.  It strikes me as rather fascinating that even as our culture does not emphasize those qualities of personal vocation, it is interesting that even in our entertainment oriented world there is a new and growing emphasis — it's been around a few decades — but a growing emphasis on entertainment through medical drama; that there is a strange intensity and authenticity to this encounter that actually is missing in much of our daily life.

So I guess what I'm asking is could you just comment broadly on this and perhaps give us some reflections on how we might integrate these deeply meaningful realities in a broader sense culturally, whether that might reinforce and encourage the important role of nursing.

And if you have a statistic on how long nurses actually practice once trained, I'd be interested to hear that.

DR. DAY:  I'm afraid I don't have the statistic, and it varies institutionally.  The most concern about this comes up in hospitals where they see a rapid turnover.  They put a lot of effort into new graduate orientation and training, and then they see a turnover.  So there are lots of efforts being made now in hospitals to retain new nurses.

In terms of the cultural turning away from what nurses sort of steep ourselves in, this is something that student nurses encounter when they take up the practice and they realize that what they talk about isn't what most people want to hear about.  So they form very strong bonds with one another because other nurses are who you can talk about this with and probably physicians also and others in health care practice in this sort of intense way.

But yeah, it's interesting.  I had a student once who told me that she used to watch the TV program "ER" religiously.  She loved this program "ER" until she started nursing school and began to actually immerse herself in the realities of this.  Then "ER" no longer sustained her.

So engaging in this reality and the real sort of suffering and vulnerability, I think it's confronting your own vulnerability, and this is, you know, what I described as we share with those we seek to help.  So it's a frightening thing, and to find ways to cope with that and to support one another around it, I think I don't know.  I don't have an answer about how we could begin to spread this or permeate this seriousness into the rest of society.

I think it would be a really good thing for many reasons and also to think about health in a much bigger sense than just the absence of disease.  That social well-being and connection to the natural environment in ways such as good nutrition and farming practices.  These kinds of things, it seems as though there may be something happening at a sort of more grassroots level, but I don't know how we can change the cultural penchant to entertainment, and I think the fascination with medical practice and surgical practice, you know, these reality TV shows that show you the plastic surgery or whatever that are happening now, I think that there's a fascination with the power of the biomedical model and the curative model, and there's less interest in things like caring for people over time who are living with chronic disease and illness.

That's much less interesting to people.  So I think this kind of rescue mentality, and this feeds the way our health care system is structured.  I don't know which came first, but we've got a definite over balance of cure, and much neglect of helping people cope with the day-to-day life with chronic illness, and this is where I think the shift needs to happen in health care and also less attention to public health.   Environmental health concerns are being neglected.

So shoring up the infrastructure, shifting the balance, shifting the emphasis away from dramatic cure because that's less and less feasible with the kinds of health issues we confront.

CHAIRMAN PELLEGRINO:  Dr. Foster.

DR. FOSTER:  I want to say to the visitors here that Council members tend to ask lots of question.  I was counting all of the questions that come to you from each speaker, and I couldn't even keep up with them myself.  So I'm only going to make a comment and not ask you any questions at all.

You've talked a lot about education, and it's a problem.  You say, "Well, we've got to learn about ethics and humanities and then the technical things," and I'm sure the Carnegie group and everybody else is going to have to come to the grips that all of us have to come to grips with, is that we have to prioritize what we can do in a limited time of education, whether it's four years of medical school of nursing or college.  You just can't do everything.

I addressed the new interns at Southwestern this week, and I pointed out that in 2004 — I think I mentioned this in the Council once before — there were 550,000 papers published in the 4,000 journals at the National Library of Medicine Archives.  That's a paper a minute.

Now, let's say that one out of 1,000 are important.  That's still a huge number of papers that you have to do.  So you have to make a prioritization, and one of the things I told them — Bud Relman will faint on this — that rarely read a whole paper.  You don't have enough time.  Read the introduction and the thing.  I tell them to read your journal.  That will keep up with everything that's going on.

But we have to prioritize about what we can do.  We can't become an expert in ethics or an expert in nursing, and I think that's one of the critical problems to do.  It's just too much information.

The second thing I want to say is that my observation is that people are happy in what they do if they get a sense that they're doing something important.  You know, Kierkegaard developed the concept of like for like.  What you give you get, and Emerson once said in a graduation address that there is a justice that is instant and inevitable; that if we do a noble thing, we're ennobled, and if we do a mean thing, we contract.

There has to be a sense that what one is doing is humanly important.  I mean, in nursing it's humanly important.  They have to get that sense, and that way the assets to the job markedly override the liabilities.  I've got to keep documentation of everything.  If you get a sense that what I've done is actually to help somebody go through what Bill Hurlbut knows they've talked about their difficulty.  We've got to better show that by the teachers and so forth that they can do that.  So they get a sense.

I use a little homely thing.  There's a floor cleaner in Parkland Hospital, which is where I work, which is a big charity hospital, and he cleans and polishes the floors on the wards, and if you look at his polisher, the chrome on it is shining, and he cleans the floors and I've gotten to know him.  He and his wife have put two kids through college and so forth working two jobs.  He said to me one time — I stopped and I said, "Mr. So-and-so, I'm really impressed at how you keep these floors polished."

And he said, "Well, the hospital is not going to work if it's not clean."  He polished the floor, but he thought that he was part of the curing and healing and comforting business.  He had a sense of what this was about.

And if we don't get that, salary won't make up for that.  That has to be, too.  So I just want to say I think that with nursing leaders like yourself, just like the academicians in medicine are going to have to prioritize what they can teach in a fixed period of time.

And secondly, we have to have this sense of being important.  What I say to the interns is there are only two things important in your life.  One is to be competent.  If you're not competent, you may have the greatest heart in the world, but you're unethical if you're not competent.

And secondly, you have to comfort.  Those are the two Cs is what we need.  Okay.  So I just think this is not an easy thing, but they've got to feel, we have to feel that this is really important, humanely important as well as technically important.

DR. DAY:  I completely agree, and I think that when we think about prioritizing what can we teach, I think too often we go to content, and this is what we've seen in nurse educators in the classrooms with nursing students.  The content overload, just how many facts does one person need to memorize before they can go into the hospital and meet a patient?

I think we focus too much on the number of facts, and we have to add things about genetics now and we have to add things about, you know, just different facts and different content areas.

But I think that we can't pass over the formation of the developing nurse, and that's instilling them with the sense of importance, the sense of the seriousness of the task at hand, and this kind of engagement and access to the practice doesn't seem to be happening in the education.  We need to develop educators who can open this up for students better because students find that they don't learn anything in the classroom.  they learn it all in the clinical arena, and in the clinical arena, they have hit and miss role models.  Some nurses are pretty disenchanted with the practice, and they're not good people to introduce new nurses to the seriousness and the importance of the work that we're doing.

So making sure that students get a sense of the importance of the work that we're doing and carry that forward, I think that is the essential aspect.

Competence and a knowledge base, having some skilled know-how and ability to develop clinical judgment in practice is essential, and having a knowledge base that allows you to do that is essential, but when we focus too much on what content should I include or not include in my lecture, I think that's where we get into trouble.  We need to be thinking about the formation and the access to the practice that we're affording with all of our teaching.

CHAIRMAN PELLEGRINO:  Dr. Meilaender.

DR. FOSTER:  If I can respond in one quick way to say that the constant error in all teaching didactic is putting in too much and not having too little.  I mean you see that in every grand rounds, and so forth, every biochemical lecture.  The error is most often too much rather than not enough.

PROF. MEILAENDER:I thought we needed someone other than a doctor to say something to you.

I've been sitting here kind of trying to figure out what we have to contribute, what the Council on Bioethics has to contribute, and it's not your job, of course, to tell us that, but I'm still not clear entirely, but I'd like to just press a little bit.  This in a way follows up on Dan Foster's comment, but maybe pushes it a little harder.

Because I don't think the issue at least as I listen to you, I don't think that the issue is simply the sheer mass of information, which I acknowledge and which is obviously going to create problems, but it seems to me as if you've got a couple different things going, and I'm not sure they're compatible.

On the one hand, you want better attention to formation, to nurses who are able to enact the goods internal to the practice of nursing and so forth, and I mean, one learns to enact the goods internal to a practice by practicing.  It's not simply a theoretical undertaking.  It's an experiential one.

And on the other hand, there's a need for more scientific knowledge and so forth driven, it sounded to me — now you may wish to correct me — but driven it sounded to me by the sense that this is needed if we're to redress the imbalance in the professional hierarchy that pervades medicine.

But, I mean, maybe the practice of nursing needs to think about kind of what kind of practice it primarily is and maybe it doesn't need to worry so much about redressing the hierarchical imbalance.  I mean, I'm sure that I understand that creates problems sometimes.  All of the doctors who spoke are very careful to appreciate nurses and so forth, but I mean, these are a couple of different kinds of learning, and you even want to toss in you want these nurses to be well trained in the liberal arts as well.  You know, they should read Plato, too.

I think, you know, there be just a kind of incoherence of desire here in what you're looking for.  These are different kinds of learning.  They're not separate entirely, but they're still different kinds, and maybe the practice of nursing needs to think about what sort of learning it primarily is.

Now, I may have put that too strongly, and yet it just seems to me that there is the kind of tension in your wanting everything, and the problem is not just that it's too many things.  That's partly the problem, but that it's the different things, and one needs to think about kind of what primarily you're up to, if that makes sense.

DR. DAY:  Yeah, it does, and it helps points out a way in which I think I haven't been clear.  I think there are different ways of thinking that nurses need to engage with, and so when I think about nurses reading Plato, I don't think about them engaging in the same way that a philosopher would engage with reading Plato, but I think about them gaining something valuable for their practice in reading this dialogical method.

And a nurse — this is why I say the liberal arts specifically geared towards the undertaking of the practice of nursing so that if I were to assign a reading from Plato in my class, I would specifically have some specific ideas about how that would lend itself to the practice of nursing, what kinds of skills and knowledge nurses would gain that would be valuable to them as nurses.

And I think there are all sorts of things like this that nursing education neglects, and in terms of the breadth of knowledge needed for the practice, I think there is a huge breadth of knowledge needed for the practice, and I think engaging with what nurses need to know, it depends on what area they decide to practice in, and that's another big issue in nursing education is how much specialization should go on early on, but in terms of just a general practice of nursing, to think about that nurses may not need the same kind of science that a bench scientist needs, you know, a biochemist who's working at bench science, nurses don't need the same kind of understanding of chemistry as that person needs.

But there has been this sort of tendency in nursing education to what's called dumb down the science and not give nurses the kind of rigorous training that we need in sort of thinking about science in the way that we need to think about it.  So it's not that I'm saying that we need to train as if we're going to go into a life of biochemistry, but we do need to have a grasp of what's happening in this sort of current model for understanding disease.  Nurses need a fluent grasp of that.

And in what I've seen in nursing education, they are not necessarily getting that.  So it is a way, and I see it as a way to address the hierarchy, the problem with hierarchy of medicine and nursing being in the sort of very unequal status in hospital practice, but I don't see that as the ultimate point of giving nurses this more rigorous education.

I see the point of giving nurses the rigorous education to better prepare them to address the patient care issues that they're confronting and also to confront the system that they're working within.

A nurse that we interviewed who had come back to school, she had graduated from a community college with an Associate degree and then gone back to school for a Bachelor's completion program.  She described the world that opened up for her, the possibilities it opened up when she learned how to write grammatically correct sentences.  And she could finally write the letter to her supervisor to explain exactly why it was a problem not to have the adequate staffing in the area she was working in.

So these kinds of basic skills are being neglected in nursing, and to address this sort of when I say humanities, things like English, basic writing, being able to make an argument, being able to convey, to evoke a situation for someone else to understand it.  I think nurses are in many ways not able to do that adequately.

So this is the kind of education that I'm calling for, is not to take nurses down the path of, you know, studying philosophy and being able to write a dissertation on Plato, but taking up Plato.  Look at the dialogues.  Look at what is happening in this dialogue and how the argument is being built, and how could you use that in your practice?

PROF. MEILAENDER:That's all.  I don't quarrel with any of that.  I just, as somebody who has spent his life teaching undergraduates,  one, I just want to say that's not really liberal arts education.  that's a certain kind of training in the service of professional competence, and that's fine.  I have no quarrel with it.  It's just not really liberal arts education.

DR. DAY:  Yeah, and there really are two things, and this is a discussion that we've had within the Carnegie team as well.   There really are two things that we're calling for.  One is the liberal arts as a way of opening up thinking that's not related to the practice.  So not taking up reading Plato for Plato, and I think there's a lot of that for nurses.

And then, you know, when nurses get into practice, realizing you know, what I read in that philosophy class really has opened up some different possibilities for me here, but reading it with a philosophy professor who's not concerned with the practice of nursing but is giving future nurses, those who maybe haven't even decided on nursing school yet, but giving them some foundation in different ways of thinking, different ways of approaching others.

CHAIRMAN PELLEGRINO:  Thank you very much, Dr. Day.  More, I want to thank you for responding so promptly and also for your stimulating discussion.

We have a schedule.  Dr. Kass, go ahead.

DR. KASS:  Thank you.  Much of what you say about sort of the institutional emphasis on cures, the neglect of chronic illness, public health, environmental health, nutrition, and so on, would be part of a speech made by someone who wants also to reform the medical profession and the way medicine is practiced and how we think about the new problems of medicine now, some but by no means all of the efforts of curative medicine that have succeeded.

But the one difference would be that the doctors would not complain about the hierarchy question, and my good friend General Carson spoke of the nurses as the infantry.  This is a complaint that one has heard for years.  It's in a way partly built into the system, and these are complicated matters, but I wonder whether one doesn't sort of have to acknowledge that while every member of this team has not only special skills but possibly special insights into what's needed for the well-being of the patient, someone has to be primarily responsible, and it has to somehow, I think, be understood, unless you want to disagree with this, that both as a matter of law, as a matter of responsibility, as a matter of competence that this has to be a team which is led by physicians.

Now, it might be there are certain areas in which one really says, "Look.  Nurses do this vastly better.  It should be their area."  But I wonder whether the emphasis on the hierarchy question is the right one.  If everyone, as Dan said, thought their work was somehow valued and appreciated, the resentment of where one is in the overall chain of responsibility might disappear unless this was a question of envy and resentment for the inequality as such.

So I really wonder what you'd say about that.

DR. DAY:  Well, I think it's interesting because I do agree that there has to be some sort of accountability.  I mean, there has to be a person who's accountable ultimately.  The issues of hierarchy that I'm thinking of are the ones that don't make sense, and so some attention to at what point does it make sense for this person to take the lead and at what point does it make sense for this other person to take the lead.

And I think the assumption is made that the physician always takes the lead, and I've run into this in things like, for example, family conferences.  There came a question in the hospital where I was practicing that when we have family conferences the physician always takes the lead when at times the nurse is the one who has been more closely communicating with the family on an hour-to-hour, day-to-day basis, and why is it that the physician always takes the lead in these settings?

And so those kinds of hierarchy concerns that I have are not really about who's ultimately accountable or who's sort of running this treatment while the patient is hospitalized, making decisions about what treatments will go forward, but it's more this kind of day-to-day like how are we communicating.  Who's listening to whom?  And who's being devalued and discounted and ignored?

And I think that nursing concerns are often ignored.  One of the things that I point out to my students is that they have an experience in an intensive care unit where they always are so impressed by the collaboration between physicians and nurses in intensive care units, and that has to do with a lot of different things, but I think one of the things it might have to do with is the very clear concern that everyone has for physiologic stability in the intensive care.

I mean, patients are very on the edge in that environment.  So medical and nursing concerns very much line up, and we're all looking towards the same thing.  We need to titrate vasopressors.  We need to wean this person off the ventilator or make changes, all geared towards physiologic stability.

The patient moves out of that intense environment to an acute care unit where the vulnerability for physiology is not so desperate.  Nursing and medicine concerns diverge much more, and now what happens is nursing gets ignored, and there is no longer any collaboration among the team members.

So that's sort of what I'm thinking of as hierarchy, not so much who's making decisions but who's listening and what kind of input are decision makers getting, and does it make sense for this person to be the decision maker in this situation or would it make more sense for someone else to be?

CHAIRMAN PELLEGRINO:  Thank you very much. 

I'm sorry for the quick foot on the accelerator.  I didn't see Dr. Kass' hand.

Thank you, again, and I'm going to take the Chairman's prerogative of going on with the agenda in a modified way because what's coming this afternoon.  We're trying to get everything in.  So I'm not going to have a coffee break.  For those of you who need the stimulus of a little coffee and other related agents, feel free to go out and get a cup and come back, but I'd like to move on to the next speaker so that we can accommodate Dr. Sullivan when he comes in and move into the panel and give everyone a chance we promised them to speak.

So I will now ask Dr. Relman to address us.  Again, I point out that the credentials and background of all the speakers is in the agenda and the agenda book.

It is often said that some people do not need to be introduced.  It doesn't always apply, but it surely is the case here with Dr. Relman.  He was an emeritus professor at Harvard of medicine and also is the former editor of the New England Journal of Medicine.

Bud, thank you very much for joining us.

DR. RELMAN:  Thank you very much.

It's an honor and a privilege to be here and to talk about medical professionalism, a subject that is much discussed, but yet I believe, as I will point out, much neglected.

I believe that medical professionalism in this country is facing a crisis just as serious as the crisis facing our health care system itself, and that's profound, and I believe the two crises are interrelated.  In this presentation I want first to explain what I mean by "medical professionalism," why it is being threatened, and what is at stake.

After that,  I will briefly suggest what I think needs to be done and what I think this Council might contribute by dealing with the problem.

Now, to understand the crisis of medical professionalism we need to remind ourselves of what a profession is and what role it plays in modern society.  There's a huge literature on the subject, but in my opinion the late Eliot Freidson, the distinguished sociologist at NYU, wrote one of the most insightful analyses of the professions.

He considered a profession to be one of what he called three options modern society has for controlling and organizing work.  The other two options aside from a profession are, one, the free market and, two, management by organizations, such as government or private business.  He believed that medical work was totally unsuited for control by the market or by business or government.  So in his view the practice of medicine could only be conducted properly as a profession.  It had to be a profession.

Well, what does it mean to be a profession?  According to Freidson, a profession has certain distinguishing characteristics.  Its work is highly specialized and grounded in a body of knowledge and skills that is given special status in the labor force.  Its members are certified through a formal educational program that is controlled by the profession itself, and qualified members of a profession are granted exclusive jurisdiction and a sheltered position in the labor market.

Finally, and most important of all according to Freidson, professionals have a ideology that assigns a higher priority to doing useful and needed work than to economic rewards, an ideology that focuses more on the quality than the economic efficiency of the work.

In my view, this ideology is the essence of medical professionalism.  More than almost any other profession, the practice of medicine is based on an ethical commitment to those it serves, i.e., its patients, and to society.  The threatened loss of this commitment is what concerns me here.  That's the crisis.

And I use my words carefully.  I believe it is a crisis.  What is endangered, it seems to me, well, let me say that the science and technology of medicine and the special place that medical practice holds in the labor market are not at risk.  What is endangered are the ethical foundations of medicine, and by that I mean the commitment of physicians to put the needs of their patients ahead of their own personal gain, to deal with their patients honestly, competently, and compassionately, and to avoid conflicts of interest that could undermine the public trust in the altruism of medicine.

It is this commitment, what Freidson is pleased to call the soul of the profession, that is eroding before our eyes, even while its scientific and technical base grows stronger.  It's ironical, but medical science and technology are flourishing as never before while the moral foundations of the medical profession lose their influence on the behavior of physicians.

This undermining of the ethical underpinnings of medical practice is an integral part of the sea change in the scientific, economic, legal, and social environment in which medicine is now being practiced.  The coincidence of all these events is a story too large for full exposition here.  I've told it and documented it as well as I could in a little book that I've just published called A Second Opinion.  So I'm going to mention only a few points here.

In the book, I argue that one major reason for the decline of medical professional values is that medical care in the United States has become so commercialized.  I noted with interest that Dr. Day, who preceded me with her excellent talk about the nursing profession, identified profits and the economic behavior of the health care system as one of the impediments to the nursing professionalism.

The health care system in the United States can be described not inaccurately and not in any sense of exaggeration as an over $2 trillion industry largely shaped by the arrival and growth of innumerable private, investor-owned businesses that sell health insurance and deliver both in-patient and out-patient medical care.

To survive in this new medical market, most nonprofit medical institutions, and they constitute — it's very hard to get accurate, quantitative numbers, but my best estimate is that the nonprofit institutions still slightly outnumber the for-profit medical institutions in the country, but not by much, by less and less.

But the point is that to survive in this new medical market most nonprofit medical institutions must act just like their for-profit competitors.  So the behavior of nonprofits and for-profits has become less and less distinguishable.

There are notable exceptions, and I tip my hat to them.  There are very notable exceptions, but by and large, the not-for-profit health care institutions in this country are more and more being driven by the same bottom line considerations as the for-profits, and in no other health care system in the world do investors and business considerations play such an important role.  In no other country are the organizations that provide medical care so driven by income and profit generating considerations.

This uniquely American development is an important cause of the health cost crisis, the health cost crisis, that is destabilizing our entire economy, and it has played a major part in eroding the ethical, professional commitment of our physicians.  That's what my book is about.

Physicians for their part have contributed to this transformation by accepting the view that medical practice, like the organizations that provide the venue and the resources for the delivery of care, is also, in essence, a business.  In this view, it is a very technical business, to be sure, one that certainly requires adequate credentialed education and great personal responsibilities, but a business nevertheless.

Business people consider profit and income as a primary end, but medical professionalism should require giving even greater primacy to the needs of patients.  It is not that physicians haven't always been concerned with earning their living.  I'm sometimes accused of being unrealistic and not recognizing that even in the good old days when I started out in medicine physicians were always worried about earning their living, and in a certain sense behaved like businessmen.

Of course they were.  They had to be.  Those are the realities.  And there were always some physicians, even in the good old days, who were far too driven by greed and acted unethically because of that.

But the current focus on money making and the seductions of monetary reward have changed the climate in U.S. medical practice at the expense of professional altruism and the moral commitment to one's patients.  The vast amount of money in play in our medical care system and the manifold opportunities for physicians to make money has made it difficult, almost impossible for far too many physicians to function as moral agents, as true fiduciaries for their patients.

Now, I think that's unassailable, and I would be willing to defend that proposition against all comers with innumerable examples of the fact that medicine has become far too commercialized, and that's a sea change.  It didn't exist 30 or 40 years ago or 50 years ago when I was a young physician.

Let me be clear though that I do not consider business to be inherently immoral or even amoral, although some would challenge that.  I certainly don't consider it inherently immoral.  I am no beef against business, and I'm not arguing for a socialistic ethic.  God forbid.

I am simply saying that the essence of the practice of medicine is so different from that of ordinary business that the two are inherently at odds.  Yes, business concepts of efficiency and effective management may be useful in medical practice, but only to a certain point.  The fundamental ethos of medical practice is different from that of ordinary commerce and market principles cannot adequately describe the relation between physician and patient.

In 1963, economist Kenneth Arrow, later shared a Nobel Prize, was among the first to recognize that fact.  But those insights didn't stop the advance of the medical-industrial complex, as I termed it in those days, and the triumph of market ideology over professional values in the practice of medicine that now characterizes the U.S. health care system.

Other forces in the new environment have also been eroding medical professionalism.  The growth of technology and of specialization, a great blessing, may increase the power, the curative and the preventive and the healing power of medicine, enormously.  The growth of technology and of specialization is attracting more and more physicians into specialties and away from primary care, thus further weakening the personal bond between doctor and patient.  The episodic involvement of the specialist with the physician is different from the ongoing personal caring, long term commitment of the classical view of the physician as healer.

The vastly greater economic rewards of procedural specialties are particularly appealing to new graduates who enter practice burdened with very large educational debts.  Specialization is not incompatible with ethical professional practice, but it often reduces the opportunities for physicians and patients to interact in ways that kindle the relations upon which moral behavior depends.

It is all too easy for even the best of specialists to act simply as highly skilled technicians, to do their thing as competently as they can and then move on.

The law, too, has played a major role in the decline of medical professionalism, and the more I think about it the more outraged I get at this fact.  When the Supreme Court in 1975 ruled that the professions were not protected from the thrust of anti-trust law, it undermined the traditional restraint that medical professional societies had always placed on the more crassly commercial behavior of physicians.  Having lost some key legal battles after that, after the Supreme Court decision, organized medicine now fears, is terrified to require that physicians behave differently from business people.  It asks only that physicians' business activities should be legal, disclose to patients, and not inconsistent with the patient's interest, a far cry from the earlier moral strictures placed upon the doctor-patient relationship.

Until forced by anti-trust fears to change its ethical code in 1980, the American Medical Association had always held that — and now I quote from the ethical guidelines of the '50s, '60s and '70s — "in the practice of medicine a physician should limit the source of his professional income to medical services actually rendered by him or under his supervision to his patients."

It also had said that "the practice of medicine should not be commercialized nor treated as a commodity in trade."

These fine sentiments reflected the spirit of professionalism that motivated medicine when I was a young physician, but they are now gone, along with the unthinking universal description of the physician as a man.

Very shortly, to the enormous benefit of medicine, very shortly about half of all practicing physicians will be women.

Yet another de-professionalizing force has been the growing influence of the pharmaceutical industry on the practice of medicine.  This industry now uses its enormous financial resources to shape the postgraduate and continuing medical education of physicians in ways that serve its marketing purposes.  Physicians and medical institutions for their part aid and abet this influence by accepting, sometimes even soliciting financial help and other favors from the industry, thus relinquishing what should be their own professional responsibility for self-education.

A medical profession that is being educated in the practice of medicine, at least in the practice of pharmacological medicine, by an industry that sells the drugs and other tools that physicians prescribe is abdicating its ethical commitment to serve as the independent fiduciary for its patients.

I should say that there's been a recent backlash against this, but it's just starting and a few courageous institutions, students and faculty and administrators are saying, "Stop.  We're not going to allow the pharmaceutical industry to take over our educational responsibilities in pharmacotherapy, and we're going to draw some barriers.  We're going to set some walls between the sales representatives of the industry and our academic institutions."

More power to them, but they've got an uphill struggle against enormous financial resources that are being involved here.

Well, given all of these anti-professional forces and given the historical change I have described, why not accept what appears to be the judgment of history?  Why is the preservation of professional commitment in medicine still so important?

I believe the answer is because physicians are at the center of our health care system and the public must be able to depend on and trust the altruistic motives of its physicians.

Now, it is currently fashionable to be concerned about the paternalism and elitism of medicine, and certainly there's plenty of that.  I do not defend the paternalism and the elitism of medicine.  I've argued against that for a long time.  And it's certainly fashionable now to champion the notion of so-called consumer directed health care, and I'm all for educating and empowering consumers as much as possible, as much as practical.

But while there is undoubtedly a need for more information and responsibility to be given to patients, the fact remains that without trustworthy and accountable medical professional guidance, our health care system can't work.  A medical profession not motivated by a strong ethical commitment to patients simply cannot fill that role.  Without such commitment, health care becomes simply another industry, and we continue along the present course that is increasing the influence of market forces and the role of business corporations and government.

I didn't emphasize, but Freidson is quite right.  If the medical profession itself is not going to assume the responsibility for monitoring and directing the professional behavior of its members, then either business and/or government is going to step in for sure.  This trend is inevitably heading toward the bankruptcy and collapse of our health care system, along with the de-professionalization of medical practice.

I argue in my book that we simply can't afford to accept the industrialization of our medical care and that we must work toward major reforms that restore our health care system to its proper social rule.  In essence, my argument is that industry naturally and understandably working for its investors' primary interest constantly wants to increase its income, and those are the costs that are breaking the bank.

So, in essence, what you have now is a contest between the 16 or 16 and a half percent of the American economy that's tied up in health care, much of which now is being driven by income seeking and the interests of investors, and the other 84 percent of the American economy which has to pay the cost.  And that's what the CEO of General Motors is now complaining.  It's breaking the bank.  It can't continue.  We have to control health care costs, and we have to make health care more efficient, more effective, serve the public interest.

So I argue that an essential part of the necessary  reforms must be a rededication of physicians to the ethical professional principles upon which the practice of medicine should rest.  The reforms I envision require not only public and political initiatives, but also the active participation of the medical profession.  In my book, I have a chapter entitled "An Open Letter to my Colleagues in the Medical Profession," and I say this is your last chance.  You either will be part of the solution to make the health care system in the future serve the public interest and preserve professionalism or else you're going to be part of the problem and you're going to be swept aside by the inevitable advance of government and private corporations into the health care system.

Now, what could this Council do to help defend and rekindle the ethical foundations of medical practice and thereby promote the integrity and vitality of medicine as a profession? 

I believe that you have major opportunities for constructive engagement in this effort.  You are an influential body and you stand outside of organized medicine and apart from the practicing physician.  You cannot be accused of protecting the welfare of physicians or arguing for any other special interests.  Your judgment on the issues I have discussed here will carry weight not only with the public, but with the profession.

We physicians, it's a habit of thought that we're taught to adopt; we physicians usually pay careful attention to outside experts whenever those experts talk about matters beyond our experience.  We treat the specialist who knows something that we don't know with great reverence.

You are specialists in ethical and social, cultural behavior.  You can say something very important and influential about what role medicine as a profession should play in American society.  Physicians will respect your qualifications as bioethicists and they will listen.

If you were to decide that medicine has become too commercialized, that commercialism undermines the ethical commitments of physicians, and that this erosion of professionalism is not in the public interest, then it seems to me that you should speak out, particularly at this juncture.  In the rapidly expanding crisis in health care, I believe your opinions would receive wide attention and make an invaluable contribution.

Thank you for your attention.  I'd be happy to take your questions.

(Applause.)

CHAIRMAN PELLEGRINO:  Bud, would you sit down and answer the questions?

DR. RELMAN:  Sure.

CHAIRMAN PELLEGRINO:  We've asked Dr. Paul McHugh to open the discussion.

DR. MCHUGH:  Well, Dr. Relman, that was a splendid, certain trumpet, and I was impressed by your last statement that we, if we have such influence, could alter and shape the future of our country in interesting and important ways that you and I and, I think, all the doctors here absolutely agree about about the importance of professionalism.

But there's something about this Council you have to understand.  Part of the issue of this Council is that we bring people to us because we're ignorant about the matters, and then talk about them amongst ourselves in relationship to developing attitudes and developing things that go beyond our professional commitment.

If you and I were just sitting down together and the other doctors here were at a doctoring convention, we'd all just stand up with you and run to the barricades and blast away and wouldn't have to think anything more about it.  You'd just win us around and we win.

But on the other hand, we're here in a bioethics council of people that are intended to spur public discussion over matters that are considering things from several other points of view than just the doctor's point of view.  And I think that's the issue that I was trembling, trembling before your marvelous passion on which I agree.

I want to raise some issues and wonder about in relationship not to professionalism.  Certainly I agree with that, but in relationship to health systems and things of that sort that come out.

Now, I haven't read your book, but I have read these little articles that were sent with us and I've seen and read editorials of yours before, which I've always loved and admired, and I came to it today.  Since just a couple of days ago I was spotted as the person that should speak up.  I thought about what I might say, and to begin with, the most wonderful thing about your writing is the way you go at this issue of profit and show that the promotion of medication use is an expensive service by for-profit activities and institutions; has generated wants for patient services that may not be needed by patients.  That's one way you do it.

And then you go around and turn it right around the other way marvelously and say the restriction of services by profit managed care companies now employed by health insurance, their profit driven things, may by depriving patients of what they want, may also deprive them of what they need.

DR. RELMAN:  Sounds like a great system, doesn't it?

DR. MCHUGH:  I mean, I thought that was a fantastically delightful way of attacking the profit issues and the like.

And now though I'm going to move off in another way to talk a little bit about what somebody who's not perhaps a doctor might wonder about what's happening, and by the way, you talk about the good old days.  I was there in the good old days, you know.  Those good old days were rescued by the health insurance company.  You and I were paid about twenty-five —

DR. RELMAN:  "Good" was in quotes.

DR. MCHUGH:  Yeah, that's right.

You and I were paid, I was paid $25 a month for the happy opportunity to be a house officer at the Peter Bent Brigham Hospital every other night and every other weekend, and I have to tell you I was happy as a clam at high water at the time, but money and things of that sort were neglected for many of my colleagues, some of whom, by the way, with families were on welfare at the very time they were members of the house staff at the Peter Bent Brigham.

And with the advance of technology, of course, great money flowed into our hospitals rescuing them in the face of the costs of technology and in the process, some of that money has flowed to now that people graduate from medical school and go into internships and have, well, quite nice salaries.  And I don't want to deny them that. Okay?

But when it comes to the health system and how we could come at this bioethically, you have to take another view of what government can do and what we should be doing with a system and want to be sure that how you look at people will determine a little bit about what health care services have provided, preferably by professions.

If you think of people as either all kind of vulnerable or misguided children or simply parts of a community machine that's running for the greatest good of the greatest numbers, and they need service, you'll emphasize a certain health system where experts must determine the needs of people and the health services supply those needs doing the fix for the cogs under expert direction, matters such as how the needs will be met, what the people will have to do to get them, how the social goods meeting these needs will be equitably distributed, and even when experts might think that meeting certain needs becomes futile and useless and should be withdrawn from certain people.  Let these experts do it.

Such an enterprise would, like all needs, be really part of the fabric of society, the tax supported things like police, fire and education.

If you think of the citizenry of America as being full of people with needs, you're going to have one kind of approach.  If, on the other hand, you think of the people as individuals who can and should run their own lives and then decide for themselves how to choose to use their resources in terms of both the prices paid for services and the opportunity costs appreciated by their choices, then you might think to build a system in which what they want can be purchased and their foresight stimulated by teaching them to become better consumers on health matters, making savings and insurance plans accessible to them at reasonable rates, and providing the services to them in attractive packages.  The Brigham no longer has E-main where we used to distribute ourselves in little beds around a huge ward, but in lovely accommodations.

The real problem, of course, is that neither of these pictures of human life is complete.  Some people are helpless, powerless in the face of illness and disease, and destitute, and some situations are so catastrophic, destroying a breadwinner and demanding child care, that the best laid plans of anybody are overwhelmed, and here needs trump everything and a system must be provided and we must support it to save lives and to save households.

The suggestion though that what is appropriate in a system that is need-driven and so guarantees our response to catastrophe should be the general system rather than a component, an emergency backup of a want system, might be not the best.  Not only does such need drive things, perhaps encourage dependency in the whole public, they also tend to grow without limit as the British discovered because the demands for needs, you know, they have no restraint.  They certainly tend to provoke inconveniences and often deprivations and can become tyrannous, as I said, in relationship to what kinds of needs are going to be supplied as experts tell us who and what we must do and what we must put up with.

The opportunity costs from those other systems, that system, burgeoning expenses as more and more techniques are drawn in, are carried by a society rather than by individuals, a society that may lose ability to make other investments and respond to other threats and build other supports for family life, safety and the like.

Thinking this way, for example, I can't see the United States perhaps deciding like Britain with its initial national health service, they have governed both the insurance of health care by paying for it as well as the organizer of health care by organizing the hospitals and owning the hospitals.  We'll probably opt for a two-tier system, and I think it's the two-tier system that is problematic.  I think it's what you know, in which the government will be prepared to be the insurer of need, as in Medicare and Medicaid that did save the hospitals, but private insurance, the management of private insurance, will be negotiated by individuals so that we can have what we want and pay for it as adults with a plan for life that we'll prepare.

Rewards, just to come finally back to the profit thing, rewards will continue to be provided in this system.  I mean, we're rewarding our interns much better than I was rewarded financially.

By the way, they're not much more happy; they're not as happy as I was in those old days, but rewards will be.

Services will improve with better expertise and we'll meet the wants and ultimately share them with others.  So that's what an amateur look at economics, politics, and services thinks, and it derives from watching this system in America that you think has come to a crisis, slowly evolve in a trial and error fashion.  That's what we did, trial and error.  We didn't have a revolution in health care like they did in Britain.  I'm not sure that's not the best way.

So here's my questions to you after all of that preamble.  Do you see your views as supporting and derived from an evolutionary process with the conception of what government can do, what private things can do and cannot do and should not do, rather than a big revolution?  Are we going to have to have a huge revolution here in health care in order to once again restore professionalism?

Do you have some actual plans, government plans, noting them in their particular local successes and failures?  For example, you know, are they doing this better in Canada?  Did the internal markets in the British health system make for a better service there as they abandon their particular views?

And finally, you certainly hold the whole concept of profit in some disdain.  You've mentioned it a number of times, but any exercise that depends upon human cooperation and behavior depends on rewards.  You've got to reward something.

Do you simply dislike rewards that go to investors rather than to the workers and, therefore, can cheer for nonprofit hospitals, even though you and I are now well aware that over the last decade or two not only have hospital workers and administrators seemed to have huge increases in their compensation.  The higher level people now receive bonus packages and salaries in the millions of dollars, ride in chauffeur-driven vehicles and vie with one another for profit with businessmen on trusteeships, board memberships and the like. 

There's money going into these nonprofit organizations, and I wonder whether you think that's the problem.

So thank you very much.

CHAIRMAN PELLEGRINO:  Thank you, Paul.

Do you want to respond, Bud, or do you want to get more questions?

DR. RELMAN:  Let me just make a general observation.  Dr. McHugh raises a whole panoply of basic philosophical and practical questions pertaining to the comments that I made.  It's impossible to deal with them adequately in the time that we have.  I hate to do this, but I beg you to read my book.

DR. MCHUGH:  I will read your book, of course. 

DR. RELMAN:  It's short.  It's easy to read, and it's surely one of the questions —

DR. MCHUGH:  I only had two —

DR. RELMAN:  I understand.  It deals with every one of the questions that you raise.  But let me make it clear.  It's not profit.  Everybody has to in a general sense have a profit in order to survive.  You have to have income greater than your expenses or else you go bankrupt.  I understand that, and it's not profit per se.

What was a revolution in American health care, it occurred over ten or 20 years.  It started in the mid-1960s and by the mid-1980s it was virtually complete. 

What was a revolution was the entry into the health of the medical care delivery system, not the pharmaceutical industry or the medical products or medical supplies, but the medical care delivery system, the entry of investors.  That was the revolution.  That was a new idea, a revolutionary idea, and that changed everything.

I'm talking here though, Dr. McHugh, about what doctors can do.  I didn't imagine that this Council should engage in the problem of how to change our health care system.  I think it needs to be changed radically, but that's another matter.

I thought that you could speak effectively and consequentially to physicians about the ethics of medicine.  If doctors really followed the basic ethical principles in medicine, they would behave differently, and that different behavior would include a more constructive attitude towards changing the health care system.  That's all I'm saying.

CHAIRMAN PELLEGRINO:  Thank you for the clarification.

I have five people wishing to speak already.  I suspect we may have some more.  May I ask for a little bit of conciseness in the questions.  End with a question that is specific and concrete, if possible.

Thank you.

Dr. Gómez-Lobo.

DR. GÓMEZ-LOBO:  Thank you.

Thank you for your exposition.  I think not being myself in the health profession, I think it articulates something like the popular view that we have of how things are getting out of hand.  I think that there is this view that physicians are making this huge amount of money and that there must be something intrinsically wrong with that.

However, relating to the job of this Council, the first question that arises in my mind is when are those profits really unfair or unjust.  I think that that should be for us the leading question, and I'm asking you perhaps to address that or it will be addressed in the next panel, I think, to a great extent.

But that's something to consider because there is, indeed, the feeling also out there that there are many virtues in American medicine and that they should not be overlooked, and I suspect they may have been driven precisely by the fact that so many smart people saw in this field a place where investments would give a return.  So that's my first question.

The second one is this.  Since the problem is huge, what steps, I mean, could be prompted to even get a handle on it?  What would be, let's say, bioethical or moral starting point to say this and this should be done in the face of this overwhelming wave that is breaking over us?

Thank you.

CHAIRMAN PELLEGRINO:  Thank you very much.

Dr. Relman has expressed an interest in having the questions  and then answer several of them as a group, and I think that might be helpful if you wish.

I have next on my list Dr. Carson and then Dr. Dresser, Dr. Meilaender, and Dr. Hurlbut, in that order, and Dr. Kass.

DR. CARSON:  All right.  Dr. Relman, thank you very much for that.  I've heard so many things about you over the years.  It's a real honor to have you with us today.

I agree that there's no question that physicians really need to take control of the disposition of medicine.  We've withdrawn into our clinics and our operating rooms and our laboratories and really have left it to other people, and I believe that that's why we're in the mess that we're in now, and we really have a big responsibility there.

But you know, in terms of what's happening to the way physicians look at medicine, I wonder if we as a society could be somewhat responsible for that.  I think about the 80-hour work week, for instance.  You know, I've noticed since the imposition of that edict that, you know, physicians in training tend to think more in terms of my shift rather than my patient, and if you're thinking more in terms of my shift, then there is automatically the question of what am I getting for this shift, whereas when it was my patient, you knew what you were getting.  You were getting a healthy patient, and there was a wonderful feeling associated with that.

Also recognize that there are certain pressures that have come to bear upon physicians which I think have changed a lot of the way they think.  For instance, when I first started practicing medicine, we didn't have the horrible reimbursement issues that have been imposed by insurance companies.

You know, in the  State of Maryland, for instance, Blue Cross/Blue Shield reimburses at 28 cents on a dollar, very arbitrary; Alabama, 80 cents on a dollar.  Why do they have the ability to do these arbitrary things which impact so significantly upon the way people are able to take care of patients?

In my profession of neurosurgery, the average age of retirement now is 55.  Why has it moved down to that level?  Because it used to be when people reached about 50 years of age or so they wanted to slow down a little bit, but now they don't have the ability to slow down because the malpractice premiums are so high.

You know, in Philadelphia it's $300,000 a year for a neurosurgeon if you've never had a malpractice suit.  You know, these are ridiculous economic pressures which change the way that people look at their profession, and you know, I'm sure that there is some problem associated with physicians, but I think we need to begin to look at some of these outward pressures that have created this situation and maybe address those.  I'd like to know what you think about that.

CHAIRMAN PELLEGRINO:  Thank you, Dr. Carson.

Professor Dresser.

PROF. DRESSER:  Thank you.

I was interested in your views on what professional associations might do to instill, you  know, ethical judgments, normative judgments, standards about relationships with commercial entities as well as other professional issues that relate to the fiduciary role.

It seems to me that, I mean, many of the organizations such as American Academy of Pediatrics and American College of Obstetrics and Gynecology have ethics committees and they issue positions and so forth, but there isn't much effort to educate the members about them or to make them a part of a sort  of notion that this is how we want to practice.  This is what a good physician is, and I would be embarrassed not to behave in that way.

So I wonder about your thoughts on that.

CHAIRMAN PELLEGRINO:  Thank you.

Dr. Meilaender.

PROF. MEILAENDER:I'd just like to get you to think with us a little more about the nature of the crisis that you say you see because there's something about it I haven't got my finger on.

You don't think that seeking or getting a profit is incompatible with altruism just in principle.  You don't think that increased technology is itself incompatible with professional altruism.  You don't think that increased specialization is itself incompatible with professional altruism.  So, you know, exactly why is it that these factors are undercutting professional altruism in the medical profession?

And there are other professions, after all.  Educators make far less profit.  It's not clear to me that professional altruism is stronger there than it is among physicians.  Clergy make far less profit and have far less specialization, and to tell you the truth, it's not clear to me that professional altruism is more common there and that's a profession I know something about.

So you know, if we once grant that these various factors are not incompatible with altruism, then it seems to me, especially when you think about what we as a Council might do, you know, we need somehow to figure out a little deeper about what's going on here.  I at least haven't quite gotten to it and I'd like your help.

CHAIRMAN PELLEGRINO:  Thank you, Gil.

Dr. Hurlbut.

DR. HURLBUT:  My question relates very much to what Gil just said.  You say that M.D.s are at the center of the health care industry and that what's needed is a change of our professional ethos, our restoration.

I teach a lot of pre-med students.  They're very idealistic individuals.  Ioften tell them to read Lewis Thomas' book, The Youngest Science, as they're heading off to medical school just to get a sense of how things have, indeed, changed.

But it isn't clear to me, short of a kind of larger cultural change, what exactly you're saying is the problem.  An M.D. by the time he's out and actually making a salary has spent an enormous amount of money getting educated, usually has heavy debts, is part of a culture where an equivalently intelligent, educated person would have already been making a lot of money.  I'd like to ask you for some basic facts.

How much does the average physician actually make?  What percentage of the cost of health care is represented by that overall payment to physicians?  And also is this so-called industry actually a profitable industry?  And if so, is that bad?  Does it reinvest itself and therefore improve the industry?

Who then also makes the profit in this industry?

The point I'm getting at is obviously if you're going to have esprit de corps and sustained engagement, the physician needs at least the convenience of having a car that doesn't break down and a comfortable place and safe place to leave his family for long hours when he's not home, and maybe the basic social prestige that comes with some of these things.

I just wonder if the character of medicine may have changed partly because of a general social attitude toward physicians, as well as from within the profession itself.

There was a lot of criticism of the medical profession in the years after I graduated from medical school and a lot of price pressure on physicians.  What are the realities here?  What exactly is going on?

And just one final comment that ties in with my previous comment to the previous speaker.  It seems to me that the society as a whole has become more preoccupied with money than it was when I was a child.  Now, maybe that's just the age I'm seeing the world through, but it seems to me there's an awful lot of emphasis.  Some of our cultural heroes seem to be people who have made a lot of money.  There's a lot of entertainment related to money making.  We seem to want to win the lottery more than anything else in our society now.  There's almost you might call it a kind of drug dealer mentality, that the way to operate in the world is to make a lot of money fast for relatively little in the way of actual service or contribution to the society.

Am I misperceiving this or is this a general cultural emphasis?  In which case, to the degree that physicians are guilty of this, they're just part of a larger ethos.

CHAIRMAN PELLEGRINO:  Thank you, Bill.

Dr. Kass.

DR. KASS:  Thank you, and thanks very much, Bud, for a stirring presentation and for continuing to agitate this question.

I wouldn't deny that the financial incentives and the introduction of investment into medicine produces certain kinds of deformations, though I would comment that other forms of organizing medicine will produce their own deformations, and we'll probably get into some of that this afternoon.

The Wall Street Journal this morning has an article about the so-called better systems where the physicians, in fact, are pushing for a kind of privatization in order to improve the actual care for their patients who wind up spending huge amounts of time on waiting lists.

But I want to come back to the view of the profession internal to the profession as those of you, those of us who educate rising physicians see it and have taught it.  And it does seem to me that 25, 30 years ago when bioethics took up the question of the medical profession, not Dr. Pellegrino who has held the fort on this subject valiantly, but the bioethicists were interested in autonomy, and they attacked professional authority, called it paternalism, and we began to move from a view of a doctor-patient relation as you point out to a provider and consumer-client relation, and that became a kind of orthodoxy.

Granted there were certain excesses that might have invited this kind of correction, but that begins to undermine the internal sense of the profession as a profession, and the profession in many respects caved in and adopted that criticism.

Second, in the definition of what the professional ethic is, you emphasized Freidson's category of ideology doing useful work and ethical commitment to the patient and society.  That's in a way novel for the medical profession, and yet that, too, became part of the ethos and it produces certain kinds of tensions when the duties to patients and the duties to the society might be at odds.

And I guess when Gil spoke he talked about professional altruism.  That seems to me too woolly a notion for what we're talking as the ethic of the profession of medicine.  Aren't there certain profession specific ways to describe what it is the physician swears an oath to, which used to be sworn?

In other words, what are the particular profession specific norms that ought to guide and govern?  It can't simply be this loose thing called altruism rather than self-serving, but one has to talk about I will use my knowledge for the benefit of the sick.  I will not give a deadly drug if asked, and so on.

In other words, it seems to me the profession has abandoned the attempt to articulate its own profession specific aspirations, and I doubt that you could get the physicians under 40 and the physicians over 60 to sit down and give a comparable account of what the guiding internal norms of the professions would be and what the boundaries are that they ought to have.

So I wouldn't lay this all at the blame of external pressures and profit motive, but I think there has been a kind of failure of the profession to understand itself and to pass down that self-understanding and training, and I wondered if you'd comment.

CHAIRMAN PELLEGRINO:  Thank you.

Dr. George, and then I will ask Dr. Relman to respond, and then there may be more questions after that, but I think you've got plenty to respond to at the moment.

Robby.

PROF. GEORGE:  Thank you, Dr. Pellegrino.

And thank you, Dr. Relman.

In listening to your remarks, I was struck by the similarity of your concerns and warnings to those I've heard expressed by senior and distinguished people in the legal profession about the situation in that profession.  I myself was trained in the first instance as a lawyer and was briefly in full time practice, and I've kept a hand in ever since, although my own vocation has been as an academic.

One of the — certainly the finest lawyer and one of the finest men I've ever know is a man 87 years old now named Wiley Vaughan, Herbert Vaughan.  He was with the firm of Hale & Dorr in Boston for many, many years, very distinguished, very successful, made a lot of money.

But as he was wrapping up his career and going into retirement, he said to me something that struck me at the time reflecting on the situation with law as a vocation in the early part of his career and moving more in the direction of being a business in the later part.  He said that he was glad that he was at the end of his career in the law rather than at the beginning because he was able to practice at a time when law truly was a client oriented and helping profession, and it just wasn't that as far as he was concerned anymore.

So I am struck by the thought that what you say about medicine can be said not only about law, although of course with interesting differences, but probably about other professions within our society as well.

I wanted to ask some questions that were specific to your remarks though.  One, I wondered about the phenomenon that you described and even gave us a sense of the historical timing of, of the marketization of the delivery of health care by the movement into the process of investors.

I'm wondering what do you see, if any, as the pros of that that are to be weighed against the cons that are pretty clear from what you've said and from what some of our colleagues here who are doctors have said.

Two, is there any realistic chance if a judgment about the pros and cons in the end comes down in favor of abandoning that or getting rid of it or going back on it if possible; is there any realistic chance of changing it in a way that won't cause more harm than good?

And third, I was wondering about what you perceive as the effect of the new system with investors playing such an important role on who is attracted into the medical profession and on whether it makes a difference as to how many people are attracted into the medical profession. 

Is the weight of people or the numbers of people who are aspiring to careers in medicine different now than they were in an earlier period of time when medicine was different or not? 

And either way, what would account for either there being a change or there not being a change in view of the dramatic difference in the profession that you've described as a result of this marketization?

Thank you.

CHAIRMAN PELLEGRINO:  I'm going to ask Dr. Relman to respond.  Up to this point, Carl, I saw your request.

PROF. SCHNEIDER:  I have a brief follow-up.

CHAIRMAN PELLEGRINO:  Is it brief?  Okay.  I believe you.

PROF. SCHNEIDER:  Yes, it is brief.  I just wanted to pick up on the point that this was a phenomenon in law as well.  Let me read to you what the Chief Justice of the United States said on June 15th.

"More and more the lawyer must look for his reward into the material satisfactions derived from profits as from a successfully conducted business rather than to the intangible and more durable satisfactions to be found in the professional service more consciously directed toward the advancement of the public interest.  The commercialization of law has made the learned profession of an earlier day the obsequious servant of business and tainted it with the morals and manners of the marketplace in its most anti-social manifestations."

This was said by the Chief Justice of the United States on June 15th, 1934.

All of us people over 50 here are looking back at an edenic past and saying how much worse things are now.  There is a study of lawyers between 1925 and 1960, which marks five different crisis periods in which exactly these words are used to describe what is happening in law, and the author of the study says that in the 1890s much of the same rhetoric can be found. I suspect it can be found by lawyers working under the Code of Hammurabi.

So I just raise a cautionary note about whether or not we are accurately describing real changes.

CHAIRMAN PELLEGRINO:  Thank you very much, Carl.

There will be time for further discussion after Dr. Relman responds to that large number of very important and interesting questions.

Bud.

DR. RELMAN:  Well, I want to thank the Council very much for the really probing and challenging questions.  They're all important, and I'll do my best to be brief.  And forgive me if I don't deal with every aspect of the questions that you raised.

When are profits unfair?  What's the value of profits?  I want to make it clear again that it's not profit that I'm concerned about.  I recognize I use the word "profit."  I should have used the word "investor owned." Profit really means monetary gain from one's work, and everybody has to have that or else you're working as a slave or in the Army or for the government.

I'm not opposed to profit.  It's not profit.  It's investor interest, and the reason that investor interest is bad is somebody said what are the pros.  There are no pros as far as I'm concerned.  It's bad because investors, as defined by the gurus of economic theory, by the Milton Friedmans of this world, investors expect a gain from putting their money into something, and the people who are in charge of that money, that is to say the managers, the administrators of the investor owned organizations in health care have an obligation to see that the investor's money gains something.

The purpose of investment is not to produce a particular product.  It's not to take care of people's health care needs or to make American society healthier.  It's to make more money, and I don't think that that has any role in health care.  I'm all for investment in many other parts of the American economy.  I invest myself.  I'm not a hypocrite.  I hold stocks.  I believe in capitalism.

But I do believe that as some very smart people have argued before me that there are parts of the American economy or American society in which investment is not a good idea.  It doesn't work.

Now, probably the first and the smartest person to talk about the inappropriateness of the market principle and the investment principle in health care was Kenneth Arrow in 1963.  For those of you who want to argue with me about the value or the usefulness of profits and what's wrong with investment, read Kenneth Arrow, 1963, American Economic Review, a very thoughtful, penetrating, not the first time, but a devastating analysis of market failure in health care.

He came to this fresh.  He never thought about health care before.  He was developing some theoretical analysis of welfare economics as applied to health insurance, and he thought about should there be a medical market.

And you should read..  There are about — I don't know — five or ten pages in that lengthy and very difficult economic analysis in which he devastatingly takes apart the concept that market principles apply to health care.  They do not; they cannot; and they should not.

That's my position.  That's the position of many people now, including some smart economists like Thomas Rice at the University of California.  I believe that investor ownership should have no place in American health care.

Can we get rid of it?  Would it be devastating?  Would it be unrealistic?  It would be difficult, but it can be done, considering the amount of money we spend on health care and considering the cost to the health care system of investor ownership.  We can afford to buy out investors, make them whole.  Give them the current market value of their money and say, "We suggest you take your money and you invest it in timber, in oil, in solar energy or whatever you want to invest it in, but not health care."

That's my position.  Now, Dr. Carson talked about external factors, changing doctor's views.  Of course; of course, the doctor's professional commitment has been battered by all of these external forces that are impinging on it.  That's why doctors should be in the vanguard of advocating change.

I devote a chapter in my book to talking to doctors and saying here's why it's in your professional interest and in the interest of your patients and in the interest of American society to change the system so that you won't be forced by all of these external factors to behave in ways that are not consistent with your professional commitment.

Professional associations, what can they do?  Dr. Dresser asked me that.  I think they can do a lot.  I do not imagine that the medical profession's involvement in health care reform will sort of spring spontaneously from grassroots.  It will have to be led by professional associations that have some commitment.

Now, there are some professional associations that are concerned about changing the health care system like the American College of Physicians, the American Academy of Family Practice, the American Academy of Pediatrics, and there are some professional societies which have taken traditionally a much more conservative view, like the AMA.

But I think that professional associations do have an obligation to lead the way, to lead discussion.  I say this to doctors.  You are trained to look at data.  You are trained to look at evidence, good or bad, pleasant or unpleasant, and make reasonable decisions to maximize the utility — I'm talking like an economist now — of your patients and American society.  Look at the facts.  Look at the facts.  Look what's happening to the American health care system.

Somebody said — I think, sir, you said — we've had crises for 100 years.  Everybody thinks it's a crisis.  Never in the history of American health care were we at a situation where we are now.  What's different?  What makes this situation unique?

Never has the American health care system taken 16 and a half percent of our economy and unless something drastically happens is predicted by everybody who's qualified to make such predictions to reach 20 percent in ten years and maybe 30 percent after that.

Now, it can't go on.  That's not ho-hum, more of the same.  That's a dramatic change in the amount of the American health care economy committed to health care, and at the same time never, never has the health care system been so wasteful.

I mean, it's true.  For many, many years the American health care system wasn't very effective.  We couldn't do very much, but along about, you know, as Henderson said, along the early part of the 20th century the American health care system got good enough so that it was a better than 50-50 chance that a doctor-patient encounter would benefit the patient.

Throughout the 20th century, we were benefitting patients reasonably efficiently.  There's a lot we were dumb about.  We didn't understand.  We did things that didn't work, but gradually we've done a lot to help patients.

Now, for the first time, I conservatively estimate — and I'm not the only one to make this estimate — that maybe as much as 40 percent of the $2.2 trillion we spend on health care is wasted, is not buying us anything useful or productive.  The evidence is overwhelming that we're wasting huge amounts of money.

Well, that's a crisis.  I trained in all my life not to cry "fire" in a crowded theater.  I'm a very conservative, evidence-based person.  We are now facing a crisis, and if doctors don't recognize it, who will?

Maybe Rick Wagoner, the president of General Motors, will recognize it.

Dr. Meilaender, you said that I mentioned all these factors that were not incompatible with professionalism.  So why is there a problem?

Well, yeah, they're not incompatible with professionalism if the profession behaved consistently with its values.  It could deal with all of these problems, but it is being lured away by money, by economic pressures and by a general change in attitude.

But money is the main problem, and somebody said everything is driven by money in this country.  Health care unfortunately now follows the money, and doctors come out heavily indebted.  They see there are enormous differences, far greater than ever before between the kind of life and the kind of income that specialists can command versus primary care doctors, and people are fleeing primary care by the thousands, and there's a crisis, yes, a crisis in primary care.  Nobody is going into primary care anymore.

If you don't think there's a crisis, I suggest that you go to any number of American cities as a newcomer.  You've just moved there and you want to get an internist or a family physician for your family, for you, to look after your general health and advise you about what specialty services you need.

Good luck to you.  All over America now you can't find internists anymore.  They're disappearing.  Why?  They're all becoming specialists.  Why are they becoming specialists?  Because per hour that they work they make far more money as a procedurally oriented specialist than in primary care.

The system is broken, and it needs to be changed.

What percentage of health care costs go to doctors?  Dr. Hurlbut at Stanford asked that.  I can give you an exact number.  Gross, before all expenses are paid, before malpractice insurance, retirement pay, office expenses, between 20 and 21 percent, and that's fairly steady over the years, increasing just a tiny bit.

Net, after you pay all your expenses or practice, including retirement benefits and your staff and blah, blah, blah, around 11 percent.  That's the number.

Is the health care industry profitable?  You bet.  Why would there be this great rush to put investment; why are there health care investment funds?  Everywhere you look in health care new businesses are springing up because of the opportunities to make money.  That money that the health care for-profit industry takes out of the system is for the most part not contributing to health care.  The private, for-profit, investor-owned health insurance companies, they are the majority of private health care insurance companies in this country.  Before they pay the providers, before they pass their money along to doctors or hospitals, they have taken out of the premium that they've collected anywhere from a minimum of ten percent — that's the lowest amount I've ever seen — to a maximum of around 25 percent.

Add to that the added cost that they lay on the providers.  The Massachusetts General Hospital 30 or 40 years ago used to have a relatively small office for billing and collecting.  Now to deal with the hundreds of insurance plans and all of the rules and regulations, they have several hundred people employed by the Mass. General at huge cost to the hospital because of the insurance system.

So that everywhere you look private business — I'm not opposed to private business, but in health care it doesn't belong.  Why?  Because health care is a social need.  It's not part of the regular market, as Arrow said.  It cannot be controlled by consumers once.  It does depend on needs.  It is need driven for the most part, and the ordinary controls between supply and demand that determine how much money we choose to spend on computers or automobiles or clothing or food don't apply to health care.  For the most part, when you're sick you're sick.  You've got to take care of it or it has got to be taken care of, and you're in no position to — I never met a smart consumer in an intensive care unit or the operating room.  I never saw anybody shopping around for a cut rate brain surgeon.  It doesn't happen in health care.

So it's different, and all of that money is taken out of the health care system.

Dr. Kass, you said we caved in to the consumer.  We certainly did.  Of course we did, and doctors did and the whole country has.  We've bought into the idea.  From the White House down to ordinary citizens, we've bought into the idea that consumers of health care have some wisdom which will enable them to decide what health care they need, when they need it, and what price they should pay.

It ain't so.  It's just not so.  And so, yes, we have given in.  Of course there are M.D. specific norms beyond altruism and we've abandoned them.  The problem is not all due to commercialization, but a lot.  Of course, there are other things, too.  Medical technology drives you to behave in a certain way.  But commercialization is a large part of the problem.

Mr. George, the law also suffering a decline?  Of course, and you know, true, many of the things that were said about law were also said about medicine in the 1930s and the 1940s, but it's different now.  It's different now for the reasons that I've given.

And I say if you don't believe that we have a crisis, you haven't been involved in health.   You've been lucky.  You've not been sick and nobody in your family has been sick.

I can't see how anybody in America can say we don't have a health care crisis who ha had to deal with the health care system.  Of course it's in crisis, and we have to look, I think, honestly at what causes it.

Part of that crisis is that the change in the health care system has changed the behavior of doctors.  Yes, doctors have caved in.  They're only human, and they're not smarter or better than the average educated person in this country, and yes, they've caved in.  They've made terrible mistakes, but I think it's time for us to change.

I really hope that you members of this Council will think about what you can do not to change the health care system.  That's not your job, but you could start a dialogue.  You could issue statements which would stimulate discussion in the medical profession and in the public about what doctors ought to be doing, what ought to motivate doctors.  What are the ethical principles?

Now, it's not very complicated.  The AMA had it right.  Up until 1980 go read the ethical guidelines of the AMA.  I often criticize the AMA for being too conservative and too highbrow in many ways, but they had it absolutely right about what doctors ought to do. 

Until 1980 they said doctors ought to make their living by taking care of patients, not by investing in the facilities that they work in, not by making deals with drug companies or device manufacturers, and they said doctors are not like business people.

It isn't that business people are worse.  It's just that they're different.  Business operates by different rules and different expectations.  When you go to see your doctor and you're sick, expect and you need to be able to expect that that doctor puts your interest, your medical needs ahead of his or her own financial.

When you go to buy a used car or you go to buy a computer, you don't expect that the computer salesman or the used car salesman is going to think first about what's really best for you, what you need.  He or she is going to sell and sell and sell and sell.  The law says they have to be honest.  They can't lie to you or they're not supposed to.  They're supposed to give you an honest product, but they have no obligation at all, and they're not supposed to have any obligation to consider your welfare out of their own economic situation of their companies.

It's different in medicine, and I say that anyone who doesn't recognize that difference is missing the boat and is contributing to the crisis, and I have no doubt.  I have no doubt that the crisis, if unattended, if doctors don't change, if the public doesn't change, and ultimately if government doesn't change, the crisis is going to result in implosion of the American health care system.

Thank you.

(Applause.)

CHAIRMAN PELLEGRINO:  Thank you very much, Dr. Relman.

I think we can get back on track now with the change in our schedule.  We'll break for lunch now and return at 1:30 for Dr. Sullivan who has overcome at least in part the weather blockade that he was involved in and kept him from getting here this morning.

So thank you very much, Bud, and thank the Council for your participation.  One, thirty back here.  This time we're back on the strict schedule.

(Whereupon, at 11:51 a.m., the meeting was recessed for lunch, to reconvene at 1:30 p.m., the same day.)