San Francisco, CA, November 10, 2002 - Jordan J. Cohen, M.D., President of the Association of American Medical Colleges (AAMC), issued the following statement, today, at the AAMC's 113th Annual Meeting:

Who Can You Trust?

Who can you trust anymore, what with everything we've been reading in the news of late? Starting with the Enron and Arthur Andersen scandals, the media have been full of commentaries about the erosion of trust in the accounting profession and in corporate America generally. World Com, Global Crossing, AOL, ImClone, the list goes on.

The ramifications of that erosion of trust have been devastating. Investor confidence tanked, and with it the stock market. CEO's are being carted off to the hoosegow in handcuffs. Politicians are everywhere promising to restore trust by imposing tighter rules and tougher penalties.

But the apparent undermining of trust hardly stops with the business sector. Consider how we now regard the supposedly impartial judges at Olympic sporting events. Worse yet, consider what's happened to some of the most trusted of all—the Catholic clergy.

Many social commentators would have us believe that the rising tide of mistrust has become endemic—thematic sign of our times. As more and more icons of respectability are toppled from their pedestals, our natural response is to become more distrustful of just about everyone.

What about doctors? Has the public begun to lose faith in the trustworthiness of doctors? Fortunately, the evidence suggests that patients have not lost trust in their individual physicians. When polled, people still hold their own doctors in high regard, expressing confidence both in their abilities and, as shown here, in their trustworthiness. Given the nature of the doctor-patient relationship, this finding—in addition to being reassuring—is not all that surprising.

Recognizing that people are by nature inherently vulnerable when seeking medical care, their need to trust their doctor's good intentions is virtually instinctive. Indeed, medical ethicists from the time of Hippocrates have understood the overwhelming need for trust in the healing relationship, and have uniformly considered trust to be the very essence of medical professionalism. Doctors must be trusted to act in their patients' best interest. Competence, patient advocacy, maintaining confidentiality—all of these are important aspects of professionalism, of course, but it is trust that lays the foundation for all the rest.

But knowing that people still view their individual physicians as trustworthy does not, ipso facto, mean that the public at large still views the medical profession as a whole in the same light. In fact, as you can see from these data, public opinion surveys conducted over many years have documented a significant erosion of trust in medicine as an institutional enterprise.

Why, if people remain confident that their individual doctors are trustworthy, might they feel otherwise about doctors in general?

I would turn that question around. Given the news stories that have appeared in the popular press in recent years, it would be amazing if people did not evidence some mistrust in the medical profession. Let me cite three issues that I think are particularly relevant in this regard.

The first, and perhaps most significant, is a direct outgrowth of the managed care era. Many of the attempts by managed care organizations to control the costs of health care were focused on providing physicians with financial incentives of one kind or another to limit access to services. As a result, for the first time in the entire history of medicine, physicians were confronted with the temptation to do less than necessary to meet their patients' best interests.

That managed care introduced rewards for physicians to limit services, and that some patients appeared to suffer and even die as a consequence, was not lost on the press. Countless stories appeared in which doctors were portrayed, either as powerless to protect their patients' interests or, worse yet, as willing co-conspirators with managed care bureaucrats in withholding needed services.

To be sure, other stories chronicled heroic doctors who even resorted to subterfuge to ensure access to lifesaving treatment for their patients. But the damage was done. New concerns were raised in many people's minds about whether physicians in general could be trusted to act in their patients' best interest.

Furthermore, medicine is still plagued, as it has always been, by a few bad apples—individuals whose greed, arrogance, abuse of power, misrepresentation, lack of conscientiousness, or undisclosed conflicts of interest undermine our professed values.

So, I would cite, as the second source of growing public mistrust of medicine, the widely publicized examples of physicians who, in pursuit of their own gain, have abused their power and privilege in more traditional ways.

I don't know whether bad apples have become more prevalent in recent years, but the ever-more prominent display of such aberrant behavior in the media has doubtless contributed to today's perception of flagging trust.

And finally, there is the matter of financial conflicts of interest in medical research, about which I've spoken at length before. Allegations of failure to disclose pertinent information in obtaining informed consent have been particularly troublesome. The impression has been broadly circulated that some medical researchers—in many ways the high priests of our profession—are in actuality often driven more by avarice than by beneficence; they are even perceived to have jeopardized patient safety in the pursuit of personal financial gain.

Lawsuits against clinical investigators, unheard of as recently as a decade ago, are, regrettably, part of the contemporary landscape. One doesn't often sue those with whom one has a trusting relationship. And in this case, the erosion of trust affects not just individual investigators but the institutions—our institutions—in which clinical research is done.

Some might be tempted to downplay the evident erosion of trust in medicine—to take comfort from knowing, as I mentioned earlier, that many institutions in our society, not just medicine, are being subjected to closer scrutiny. But I submit that diminished trust in medicine is in a special class.

Why? Because of the unique role that trust in medicine plays in a civilized society. Illness, by its very nature, cries out for trust. First of all, nothing short of trust in one's caregivers can serve to quell the fear and anxiety that illness engenders. Nowadays, however, trust has an even more urgent role to play. Given medicine's increasing sophistication and powerful technologies, an individual's interaction with the health care system is not only anxiety-ridden, but risky as well.

The potential for harm when seeking medical care today, if not commensurate with the potential for benefit, is certainly a reality not to be denied—from the unavoidable harm that sometimes occurs even when the right thing is done, to the avoidable harm that always lurks because the right thing may not be done.

Trust in the physician's commitment to professionalism is the only real assurance patients have that their well-being will be protected. There is simply no alternative that comes close to safeguarding an individual's welfare. No laws; no government regulations; no patients' bill of rights; no watchdog federal agency; no fine print in the insurance policy.

Which is not to say that those less desirable alternatives for protecting patients are not in the wings—one might say already on stage in some theaters of our engagement with society. For if society does lose trust in medicine's commitment to serve its interests without oversight, more oversight will surely come. What we do is just too important to leave to chance.

Our bargain with society is crystal-clear: Either we are trustworthy and deserve the privilege of self-regulation, or we are suspect and warrant the close scrutiny of government. We need look no further for an example than to the new regulatory apparatus erected to protect us from self-serving accountants in the aftermath of the scandalous loss of trust in that profession.

But what can be done? More to the point, what can we, in the academic corner of this vast profession do? Can we seize this moment in which people's trust in medicine appears under siege to provoke a counterattack? Can we convert our anxiety at the threat of mounting mistrust into stronger actions to justify our appeal for enduring trust?

My purpose in raising these questions is not to castigate us for inaction. Quite the contrary, academic medicine is already doing a lot to bolster public trust. My hope, rather, is to spur us on, not just to do more, but to be more visible with our efforts—so that, in aggregate, there can be no doubt in anyone's mind that medicine's actions, as well as its moral compass, are directed unerringly toward the public's interest. Here are five suggestions for a targeted action agenda that I think would go a long way toward achieving that goal:

1. Make health care safer. No initiative of ours would be more welcome by the public, nor more indicative of our trustworthiness, than an all-out, concerted attack on the avoidable errors that occur in our complex systems of care. We have a great deal yet to learn about the true nature of medical error and still more to learn about how to effect the fundamental cultural changes needed to eliminate many of their root causes.
   
   Fortunately, a primer for our work is at hand. I refer, of course, to the IOM's two groundbreaking reports, To Err is Human and Crossing the Quality Chasm. These documents are a must read for anyone claiming an interest in maintaining the public's trust in medicine.
   
   Placing the issue of medical errors within the broad context of quality improvement, the IOM reports remind us that patient safety is job one. Given the complexity of what we do, and the inherently uncertain outcomes of many or our interventions, adverse outcomes can never be eliminated. We shouldn't fool ourselves or anyone else about that.
   
   But the opportunities are all around us for reducing avoidable injuries to patients from the care that is intended to help them.
   
   How often do such injuries occur? We may never know the precise number, but we know full well that the number is larger than it has to be. So let's not quibble about numbers, and acknowledge openly to the public that we have a huge problem here to solve. More than acknowledge the problem, let's admit that we need help from others to find appropriate solutions.
   
   Fresh eyes from other industries dealing with safety issues are sure to help us see ways to make our systems less error-prone. Asking others for help in understanding and reducing medical errors would not, as some might fear, be an admission of failure, much less of guilt. Rather, it would signal a genuine eagerness to be accountable. And accountability is, after all, the hallmark of all trustworthy enterprises.
   
   Personal accountability for disclosing errors when they occur and institutional accountability for seeking and eliminating the root causes of error are prerequisites for establishing an authentic "culture of safety," as the IOM admonishes us to do.
   
   
2. Change the culture of GME. Here is yet another way for us to signal our devotion to making health care safer. Our learning environments for residents must be made, once again, truly reflective of their fundamental purpose—education. And the place to start is to put some reasonable upper limits on resident duty hours.
   
   The debate about resident duty hours and on-call schedules has gone on long enough. The debate is over. The public and academic medicine have arrived at a clear consensus.
   
   Those who argue that 36 hours or more of consecutive call, or 100 hours or more of weekly duty, do not pose a risk to patient safety or to residents' well being have lost the debate.
   
   Those who are waiting for more evidence that sleep deprivation and sleep debt contribute to medical errors have lost the debate. Those who believe that placing reasonable upper limits on duty hours will destroy the doctor-patient relationship have lost the debate.
   
   Unfortunately, in resisting for so long the urgent public calls for reform, academic medicine has also lost much in the way of public trust.
   
   I would cite, as prime evidence for this, the considerable momentum behind legislation pending before Congress to do the job for us.
   
   Time is short, in my opinion, but not too short to recover lost ground in the struggle to maintain trust in this arena. Now that the ACGME has put in place some long- awaited duty hour limitations for all specialties, we must get down to business and restructure those residency programs that are not yet in compliance with the newly-adopted rules.
   
   I can assure you that the public's representatives in Congress are watching closely to see how effective we will be in enforcing our own standards and in achieving real change. They are trusting us, perhaps for the last time, to live up our promise to maintain the highest standards in our learning environments in return for the privilege of using real patients to educate novice doctors.
   
   The AAMC is working aggressively to assist our members in making the necessary adjustments. We hosted an oversubscribed, standing-room-only conference in Chicago a month ago that brought together constituents from training programs all over the country to share best practices and promising strategies. We are planning more such meetings and are working on yet other means by which our members can share useful information.
   
   In addition, we are partnering with Don Berwick's Institute for Healthcare Improvement in an effort to see if we can come up with a new design for the entire GME learning environment.
   
   Our belief is that a comprehensive, zero-based examination of the work that needs to be accomplished in GME settings can, without violating the new time limits, yield innovative models for delivering both high-quality care for patients and optimal education for residents.
   
   
3. Manage conflicts of interest in clinical research. The specter of financial conflicts of interest in human subjects research, as mentioned earlier, has raised troubling questions in many people's minds about the trustworthiness of both clinical investigators and the academic centers in which they work.
   
   Quite obviously, this is an area in which our community has a unique opportunity to bolster public trust. To do so, however, will require visibly implementing effective policies designed to address both individual investigators who have financial interests in the outcomes of their studies, and institutions that have financial interests in sponsors of human subjects research conducted under their auspices.
   
   The AAMC's Taskforce on Financial Conflicts of Interest in Clinical Research, convened expressly to develop guidance for managing both individual and institutional conflicts, has now completed its work.
   
   Its two groundbreaking reports, the first released last year and the second just last month, taken together offer medical schools and teaching hospitals a robust framework for reassuring the public that temptations arising from our legitimate dealings with commercial entities are never allowed to compromise—or even appear to compromise—the safety of those who volunteer to participate in human subjects research.
   
   I urge all of you to study these documents carefully. I know that many will find the Task Force recommendations challenging to implement. And indeed, they will be. But the alternative to their prompt and visible adoption is clear. Here again, more intrusive federal interventions are poised to fill the gap if we falter in our professional obligation to do so voluntarily.
   
   
4. Restructure our health care delivery system. Ralph Snyderman has just given all of us a rousing call to action.
   
   He reminded us that our country's health care delivery system, designed to address acute episodes of illness and injury, is grossly ill equipped to deal with today's growing burden of chronic disease, let alone with the fast-approaching challenges of the genomic revolution.
   
   A clear-cut, unambiguous response to Ralph's call for a Prospective Health Care initiative would send a powerful and persuasive message of trust to the public.
   
   Imagine the public's response if academic medical centers across the country were visibly collaborating to implement models of Prospective Health Care. What better way to inspire trust than for leaders of the medical profession to be seen as taking charge of the future for the benefit of everyone—while our politicians remain mired in special interest, unable to effect meaningful, system-wide reform?
   
   The AAMC is strongly behind this initiative and is moving already to establish the infrastructure Ralph recommended to catalyze and facilitate the effort. But the hard work must be done in the trenches of our institutions and cannot be accomplished without the trusted leadership of our deans, hospital CEOs, department chairs, and faculty.
   
   
5. Prepare tomorrow's doctors to deliver tomorrow's cures. The public is well aware, of course, that academic medicine has the unique responsibility for preparing the next generation of physicians.
   
   Many in the public also have at least an inkling that health care is in the midst of an historic transformation, what with the genomic revolution, the stunning advances in information technology, the prospects for miraculously restorative therapies—and the realization that limited resources may deny them access to the promised benefits.
   
   Given the awesome challenges in store, the public must—at some level—be concerned about our ability as medical educators to see that their doctors are adequately prepared to meet these challenges, while remaining dedicated to the humanistic qualities they continue to prize in their physicians.
   
   As a consequence, we have a unique opportunity—indeed an obligation—to bolster public trust by highlighting the efforts we are making not only to realign our educational programs in accordance with medicine's new and emerging responsibilities, but also to reinforce the timeless skills of good doctoring.
   
   In an effort to seize this opportunity, the AAMC has just launched the Institute for the Improvement of Medical Education, which, in conjunction with our ongoing public education effort, known as "Tomorrow's Doctors, Tomorrow's Cures," is designed to underscore the impressive changes that have been made—and are being made—to fulfill our educational mission.
   
   We still have a lot more to do across the continuum of medical education to respond adequately to contemporary challenges, but we should not be shy about ballyhooing our current efforts.

The public deserves to know that we are dedicated to preparing their doctors to be proficient knowledge seekers in an IT-empowered age, to be culturally competent as population diversity escalates, and to be collaborative in era of patient-centered care delivered by integrated teams.

But there is, I believe, an undercurrent of anxiety that people have about their future doctors that has less to do with worry about their competence and much more to do with qualms about their integrity. As I mentioned earlier, most people still express a high level of trust in their individual doctors, no doubt in part because the alternative, when one is sick and vulnerable, is simply too scary to entertain. Notwithstanding its innate source, however, trust in one's physician is not unshakable.

And what is threatening to shake it loose is the growing concern about physicians' conflicts of interest in the everyday practice of medicine. Those conflicts are not going away; indeed, they are likely to escalate as the temptations for personal gain intensify in our market-driven system.

We could do a lot, it seems to me, to enhance trust in medicine by reassuring the public that medical educators are vigorously addressing their legitimate concerns in this regard.

We know that physicians' willingness to place their patients' interests above their conflicting personal interests has always been—and will always be—rooted most firmly in the precepts of medical professionalism.

We've always understood that our solemn obligation as medical educators is to ensure that those precepts are planted so deeply in the next generation of practitioners that nothing can uproot them.

We know that intellectually well-endowed and well-motivated students can readily learn how to be technically competent doctors. But it's not so easy, as we also know, to learn how to withstand temptation, how to joyfully serve the interests of others, how to keep focused on doing the right thing when some of those around us are pursuing expediency.

We know all these things, but I doubt that the general public has a full appreciation of how hard we work to see that our students are steeped in the professional values that sustain medicine as a moral enterprise.

Our new Institute for the Improvement of Medical Education will trumpet this critical goal of medical education, but it ultimately rests with all of us, not only to reassure the public that tomorrow's doctors are prepared to be trustworthy, but to redouble our efforts to ensure that that promise is never broken.

Let me conclude now with one of my favorite maxims:

Trust is earned, not owed. And the only way to earn it is to be trustworthy.

Medicine has attained such a privileged place in American society that many of us have been lulled into the false belief that we are entitled to be trusted, that society somehow owes us their trust because of all the wonderful things we do.

Such a false belief can only breed complacency. And for me, the stakes are simply too high to risk complacency. I may have come across as a bit of an alarmist today, but if we allow suspicion, wariness, and outright mistrust of medicine to take root, we will be consigning our successors to an era of external oversight and government regulation from which our profession may never emerge. And from which the public will undoubtedly suffer.

I know for sure that none of us wants to leave such a legacy behind.

And there's another thing I know for sure. Once lost, trust is exceedingly difficult to regain.

So, I urge you all: be trustworthy. See to it that your students learn the importance—and the fragility—of trust. To cherish the virtues that warrant public trust.

And to insist that those virtues—service, self-sacrifice, devotion to the common good—continue to guide everything we do in the name of medicine as an enduring profession.

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The Association of American Medical Colleges represents the 125 accredited U.S. medical schools; the 16 accredited Canadian medical schools; some 400 major teaching hospitals, including Veterans Administration medical centers; more than 105,000 faculty in 98 academic and scientific societies; and the nation's 66,000 medical students and 97,000 residents. Additional information about the AAMC and U.S. medical schools and teaching hospitals is available at www.aamc.org/newsroom.

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The Association of American Medical Colleges is a not-for-profit association representing all 129 accredited U.S. and 17 accredited Canadian medical schools; nearly 400 major teaching hospitals and health systems, including 68 Department of Veterans Affairs medical centers; and 94 academic and scientific societies. Through these institutions and organizations, the AAMC represents 109,000 faculty members, 67,000 medical students, and 104,000 resident physicians. Additional information about the AAMC and U.S. medical schools and teaching hospitals is available at www.aamc.org/newsroom.

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