Clinical and Health Affairs
Whose Best Interest?
By Ryan M. Antiel, M.A., Jon C. Tilburt, M.D., M.P.H., Fredric W. Hafferty, Ph.D., Michael D. Brennan, M.D., And Paul S. Mueller, M.D., M.P.H.
■ In the summer of 1910, William James Mayo, M.D., delivered the commencement address at Rush Medical College in Chicago. In his speech, he uttered words that have become the cornerstone of Mayo Clinic’s model of care: “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, a union of forces is necessary.” In this article, we reflect on issues raised by Mayo’s speech that strike at the very heart of our professional identity and ask two questions: Is medicine’s foremost concern the best interest of the patient? And has medicine really united over the last century in the service of patients?
In June of 1910, William James Mayo, M.D., delivered the commencement address at Rush Medical College in Chicago. He urged his audience to consider the need for physicians to work together.
As we grow in learning, we more justly appreciate our dependence upon each other … the very necessities of the case are driving practitioners into cooperation. The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, a union of forces is necessary.1
That same month, Abraham Flexner delivered his now-famous report on the state of medical education and called for a more uniform and scientifically grounded approach to the training of physicians.2 A few years later, in 1915, Flexner delivered an address, “Is Social Work a Profession?,” to the National Conference of Charities and Corrections in Baltimore.3 In this speech, Flexner compared a number of occupations, including pharmacy, nursing, medicine, social work, and business, to identify the qualities and characteristics of a “profession.” Flexner’s report and subsequent address generated considerable discussion and ultimately helped redefine the structure and content of U.S. and Canadian medical education. Although Mayo’s commencement address received less national attention than Flexner’s talk, the philosophy Mayo articulated complemented that of Flexner and became the cornerstone of the model of care practiced at Mayo Clinic.
At a glance, it appears that the medical profession today is struggling with Mayo’s ideas. In the United States, at least, medicine looks more like a loose collection of vendors in a marketplace of products and services than a unified profession.4 Physicians trade in relative value units and formulate business plans and market strategies. Reconciling what some have called the “two opposing orders”—the physician’s covenant to uphold patients’ interests and the necessity of economic survival—appears to be no small task.5 And some have asked whether medicine has become “payout-centric” rather than “patient-centric”?6 In this article, we revisit remarks that William Mayo made more than 100 years ago that strike at the very heart of our professional identity and ask two questions: Is medicine’s foremost concern the best interest of the patient? And has medicine really united over the last century in the service of patients?
100 Years Ago
Between the late 1800s and early 1900s, medicine experienced a series of exponential changes. The educational requirement for becoming a physician shifted from high school and a two-year course to college followed by four years of medical education. At the same time, medical practice was becoming more grounded in science with “hypothesis, supposition, and fancies” being replaced by “demonstrable facts.”1 (Interestingly, Mayo expressed concern about the “dependence upon the laboratory and special investigations” hindering new physicians’ clinical observation skills.) As a result of these changes, the scientifically competent, highly trained, altruistic physician was in great demand compared with what Mayo described as the “ill-prepared men of low ethical standards and often commercial instincts” of an earlier era.
During a time when physicians historically had worked independently of others, Mayo envisioned that teamwork, in a multidisciplinary sense, would transform medicine into a more patient-centered endeavor. Indeed, around the turn of the 20th century, laboratories, radiologists, physicians, and surgeons were being combined in multispecialty group practices. According to Mayo, “a spirit of unity which was unknown to the previous generation” was starting to prevail. He believed a more rigorous, technical, and specialized medical profession would require physicians to coordinate their work and cooperate with one another. He remarked that the “sum-total of medical knowledge is now so great and wide-spreading that it would be futile for one man to attempt to acquire ... even a good working knowledge of any part of the whole.” Serious teamwork was needed for “specialism” to work well.
It should be noted that the prototype that emerged from Mayo’s vision of group practice was not embraced by all. Physicians resisted group practice for a variety of reasons; chief among them was profit.7 Many physicians complained that group practices cut payment rates. Although initially a for-profit entity, Mayo Clinic was placed under the ownership of a nonprofit foundation in 1919; and in 1923, the former Mayo partners, including William Mayo and his brother Charles, became salaried staff. In so doing, Mayo Clinic was criticized for “underselling” its local competition.7
Medicine as a Profession—Then and Now
In his Rush Medical College commencement address, Mayo called for a professional culture that implicitly linked the needs of the patient with the character of physicians. He considered attributes such as excellence, accountability, reflection, and, importantly, altruism as central to medical professionalism. In his 1915 address, Flexner echoed Mayo’s words regarding altruism in medicine.
According to Flexner, a “true” profession possessed six characteristics. It must be intellectual in nature, consist of an ever-expanding learned body of knowledge, be practical in the object of the knowledge, require educational training, create a sort of caste, and finally be altruistic in motivation.3 Altruism, by definition, requires self-sacrifice for the well-being of others. Flexner highlighted altruism in particular in showing how the profession of medicine differed from trades such as plumbing. “It must in fairness be said that the medical profession has shown a genuine regard for the public interest against its own, that it is increasingly responsive to large social needs.”3 In short, for Mayo and Flexner, the core of the physician’s professional identity was an altruistic desire and orientation to serve those in need.
Although professionalism recently has been endorsed as a core competency of medical education,8 what the term means and requires continues to be questioned and debated.9 Several formal statements on medical professionalism call forth the idea of altruism;10,11 however, in recent years, altruism has become suspect.12 Medical students question its relevance to contemporary medical practice.13 Furthermore, tools that assess professionalism often lack a measure of altruism.14,12 In contrast to Mayo and Flexner, who both saw altruism as fundamental to medical professionalism, contemporary interpreters of professionalism tend to stress “entrepreneurial professionalism” or “lifestyle professionalism.”15 Entrepreneurial professionalism emphasizes commercialization, technical competence, and professional dominance. Lifestyle professionalism emphasizes autonomy, flexibility, and personal morality. Both interpretations could be construed to imply the opposite of altruism.
Professionalism so conceived poses a serious challenge to Mayo’s and Flexner’s ideas. Indeed, the absence of altruism from physicians’ self-identity has led some to conclude that altruism is professionalism’s “missing hero.”12 What prompted the recent shift away from altruism as a tenet of professionalism?
The Love of Money
The ethos of medicine has changed since Mayo’s and Flexner’s day. Today, multiple interests compete for the attention of both physicians and their patients.16 The demands (financial and time) of physician training, the reimbursement structures, the complex relationships between physicians and industry, and other factors complicate physicians’ thinking about their professional identity. Medicine has become commodified, and physicians are now referred to as “providers” and patients assume the role of “consumers” who shop for goods and services.17 This recent emphasis on health-care-as-market and doctor-as-vendor is viewed by many as necessary for increasing physician effectiveness and improving the quality of care.18 Yet it may prove to be a prelude to the erosion of medicine’s identity as a true profession. It is at least worth asking if Mayo’s words of 100 years ago condemn or exonerate modern medicine, especially with regard to its emphasis on money.
Recent reports suggest that a persistent focus on money has major ramifications for human motivation, a phenomenon from which medicine is not immune. An article in the journal Science explores the research on the effect of money on human psychology.19 It describes nine different experiments that showed that when money is involved, people are significantly less likely to offer help to others. And with money as an incentive, people demonstrate a preference to work alone. This dynamic can have insidious effects in medicine and even undermine cooperation among physicians for which Mayo called.
In their article “Money and the Changing Culture of Medicine,” Hartzband and Groopman make a distinction between “market exchanges” and “communal interactions” and discuss the implications of the former on medicine.20 They note that a market exchange simply requires payment equal to the value of the goods or services provided. In a communal interaction, however, the members of a profession understand that one will offer a service regardless of payment. Medical practice involves both market exchanges and communal interactions. But Hartzband and Groopman conclude medicine has tipped too far toward the market exchange model, making the “collegiality, cooperation, and the teamwork” that Mayo envisioned appear ever more unattainable.20
Our generation is not the first to struggle with the economics and financing of medicine. Mayo Clinic itself was not immune to the economic pressures caused by the devastation of the Great Depression. Yet, at the August 11, 1930, faculty meeting, William Mayo reminded his colleagues that money was not their chief concern: “We must not permit the material side to encroach upon our ideals .... I believe the heart of the Clinic has been more responsible for its extraordinary usefulness to the people and the confidence that the people have in it than any other factor.” In Mayo’s view, at the heart of Mayo Clinic, and by extension all of medicine, was the radical idea that patients come first, even in hard economic times.21
Does Altruism Still Have a Place?
In light of the current economic climate and efforts to reform the health care system, physicians understandably are concerned about the financial viability of the organizations they work for. No health care organization is immune from the fear and panic that economic hardship creates. Perhaps it is not surprising that in the debate about health care costs and reform, physicians have largely avoided discussion of altruism in the practice of medicine. A rare exception is Howard Brody, M.D., Ph.D., who expressed concern in a 2010 New England Journal of Medicine article that physicians were placing their own interests, and especially their financial interests, above the needs of their patients.22 One recent survey showed that one in three practicing U.S. physicians objects to limiting reimbursement for expensive treatments and procedures in order to expand access to basic health care for those lacking insurance coverage.23 Furthermore, physicians in the most lucrative specialties, including procedural and surgical specialties, are the most likely to object to making the sacrifices necessary for reform. In the face of such apparent self-interest, Brody’s criticism seems all the more poignant. If physicians are to maintain their professional identity, serious sacrifices, including revisions to how and how much they are paid, must be part of the equation.
The enduring legacy of Mayo’s vision—nonprofit, multidisciplinary, salaried group practice—frequently has been held up as a model to be emulated in contemporary debates about health care reform.24 Although such a model does not eliminate physician self-interest as a concern, it may at least buffer the physician from the issue of compensation so that he or she can better focus on the best interest of the patient.
Physicians should be well-compensated, but the profession as a whole also must consider the subtle-but-significant difference between making a living and exploiting professional power for personal gain. In the words of William Mayo, our professional success will “not [be] judged by commercial standards, but by the ideals which have ever been held by the long line of worthy men of medicine who have preceded you.”1 In the end, we should not let how medicine is practiced become a business question to be answered by financial analysts and managers. Nor should our own entrepreneurial or lifestyle desires drive how the business of health care is run. Rather, physicians collectively should claim their professional identity rooted in history and endeavor, even at personal expense, to uphold the best interests of every patient. We may no longer be able to say that the best interest of the patient is the only interest to be considered. However, the best interest of the individual patient must, at the very least, be the foremost and primary interest of the practicing physician. Without that, medicine will cease to be a profession. MM
Ryan Antiel is with Mayo Medical School and the Program in Professionalism and Ethics at Mayo Clinic; Jon Tilburt is with the Program in Professionalism and Ethics and the Division of General Internal Medicine; Fredric Hafferty is with the Program in Professionalism and Ethics; Michael Brennan is with the Program in Professionalism and Ethics and Division of Endocrinology; and Paul Mueller is with the Program in Professionalism and Ethics and the Division of General Internal Medicine. All are at Mayo Clinic in Rochester.
References
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