AAMC Reporter: February 2009

A Word from the President: "Professional Integrity in an Era of Heightened Expectations"

You may have seen the January 15 article by Dr. Marcia Angell, "Drug Companies and Doctors: A Story of Corruption," published in the New York Review of Books. There, in the stark print headline heralding three new books, were the words none of us want to see together: "doctors" and "corruption." Or, perhaps you saw the recent Institute of Medicine (IOM) report, Resident Duty Hours: Enhancing Sleep, Supervision, and Safety, which raised again the issues of resident fatigue and patient safety.

These examples, together with many other recent articles, show the dissonance between how we believe we are maintaining professional integrity and how others perceive our behavior. While we always have felt that our professional ethics and values inherently assured our integrity in the public eye, questions persist about our ability to manage these issues ourselves. Academic medicine ignores these questions at its own peril, and we would be mistaken to interpret increased attention from policy makers and the media as a temporary shift in public attitudes. And while our deep concern about integrity has been demonstrated by an array of outstanding AAMC activities and reports, matched by dramatic changes at individual institutions, our efforts have not led to increased public trust. Additionally, recent breaches in trust by other professions compel us to more closely examine our own dealings across all our missions, with all our stakeholders, and in all our interactions.

Take the issue of managing industry relationships. In my annual meeting address last November, I noted how one of the tough questions we face is whether maintaining, and in some cases regaining, public trust will take more than aggressively freeing ourselves from perceived conflicts of interest (COI). Our institutions have made remarkable progress in defining and maintaining a culture of institutional integrity in each of our mission areas. Additionally, the AAMC has published many outstanding and well-received task force reports on conflicts of interest and professionalism. At the national level, however, we are only beginning to address other important aspects of this issue, and concern about COI seems to have reached a fever pitch. More, rather than fewer, articles have appeared in the press questioning institutional integrity, with more of them focusing on the ethics of some of our institutional business practices.

In my view, we need to develop and sustain a culture where successfully managing industry relationships is so ingrained in our way of thinking that it becomes second nature to the way we and our students act, and is immediately apparent to anyone observing what we do. Stated another way, integrity is not, per se, the act of turning down the drug company pen or meeting sponsorship, but rather involves internalizing the thinking that leads to these actions.

Moving beyond the realm of COI with industry, how does this thinking apply to our role as educators? Let us turn to the issue of duty hours. For more than two decades, the AAMC has supported duty hour limits, and worked closely with the Accreditation Council for Graduate Medical Education to develop the 2003 standards (i.e., that residents should work no more than 80 hours per week, as averaged over four weeks). Throughout that time, our teaching hospitals and graduate medical education (GME) program leaders have worked hard to ensure optimal learning environments that emphasize appropriate supervision and a proper balance between education and patient care.

The IOM report indicates, however, that questions persist about resident fatigue and patient safety. Just as we would lose sight of the bigger picture of institutional integrity if we thought refusing corporate sponsorship alone addressed the issue, we would miss the critical point about GME and patient care if we focused simply on 80 hours. The real concern is whether our learning environments honor the role of residents as learners first, and whether they promote a culture of patient and resident safety.

If we turn to how we interact with patients, we find that in a world of increasing scrutiny, the old adage "trust me, I'm a doctor" does not suffice anymore. Patients must experience that we are putting their interests first and believe they are getting the best care possible. It is no longer acceptable to presume that, because we are academic, we have an inherent quality advantage. Today, we must rigorously demonstrate that we are better. Many of us measure patient satisfaction, but do we act upon the data we receive or change our behavior in response? And importantly, do we create a culture of quality that nurtures and sustains these needed changes in behavior?

In the end, having regulations, disclosure guidelines, benchmark measures, or data is not the same as having integrity. Today's social environment is a new one to which academic medicine must not only adapt, but continually work to stay one step ahead. Notably, this issue became the centerpiece of discussion at our first Board of Directors meeting and Leadership Forum last December. The Board became particularly interested in developing a broader-scale initiative to assure the public that we focus on how institutions can create a culture of professionalism and integrity, not just on paper, but also in action. I am confident that the AAMC and our members can meet the challenge of identifying and implementing the steps necessary to create that culture.

Darrell G. Kirch, M.D., AAMC President and CEO