AAMC Reporter: September 2005
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James N. Thompson, M.D.,
President/CEO, Federation of State Medical Boards
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Viewpoint:
"The Precious Privilege of Self-Regulation"
As someone who has served as a medical school dean and now as leader of the national organization representing state medical boards, I have observed a growing neglect in our profession toward what is one of its greatest privileges: the legal authority to self-regulate.
Many physicians believe self-regulation is synonymous with state medical boards. But in fact, medical boards are just one component—albeit a very visible and important component—of the system of self-regulation that physicians pledge to abide by. The responsibilities that accompany self-regulation go far beyond the work of state medical boards.
As a self-regulating profession, physicians have society's permission to set and maintain standards for entering the profession, for working in the profession, and for setting rules for when and how members may be removed from the profession. A report outlining social accountability for Canadian medical schools provides a particularly apt definition of the contract struck between society and a self-regulating profession: "Professionalism is the moral understanding among professionals that underpins the concept of the social contract between the profession and the public. Under this contract, professional occupations have been granted authority to self-regulate and independence to control key aspects of their working conditions through accreditation, licensing, credentialing, and professional conduct review."
Unfortunately, we are increasingly in danger of losing this precious privilege. Reports of unacceptable levels of medical errors and quality shortfalls have cast doubt on the ability of medicine's collective institutions to live up to our responsibilities. Our profession is struggling to embrace alternative approaches to accountability such as increased transparency and performance measurement—concepts that represent significant changes in how we have historically viewed our self-regulatory responsibilities.
The public is alarmed by what it perceives as a profession willing to put its own interests before those of our patients. Having now spent three years in the world of medical boards, I can assure you the public believes when doctors' and patients' interests collide, doctors' interests will prevail. All of us who contribute to the system of self-regulation—from the academic community to certifying boards to medical boards—should find this unacceptable. There should be no confusion about how doctors should interpret their responsibility for protecting patients when a colleague's conduct, performance, or health is a threat to the patient. Yet, it is clear that is not the case.
The ability to instill—and expect—the core values of professional conduct that are the backbone of our profession lie very much within the control of each and every one of us. Previously as a medical educator and now as a representative of state medical boards, I've observed a chasm between medical boards and medical schools. I believe this gap significantly contributes to the apathy many physicians seem to have toward upholding their self-regulatory responsibilities.
We are all highly cognizant of the powerful force role modeling plays in medical schools. The influence of clinical professors' professional attitudes and behaviors on students and doctors in training is unmistakable. Such role modeling is a daily demonstration of the ethics and values embodied by the profession of medicine. For its part, the academic community must recognize the critical role it plays in instilling a solemn respect for the responsibilities that a physician assumes upon entering the profession. Self-regulation has its benefits—but it comes with costs and responsibilities.
You may recall the study published in the March 2004 issue of Academic Medicine, in which Maxine Papadakis, M.D., associate dean of Student Affairs at the University of California San Francisco School of Medicine, linked unprofessional behavior in medical students with subsequent disciplinary actions taken by a medical board. The research team looked at various possible predictors, including gender, grades and MCAT scores. The most reliable predictor for a subsequent disciplinary action by a state medical board was an indication of problematic behavior in medical school. Dr. Papadakis concluded professionalism is an essential competency that must be demonstrated for a student to graduate from medical school.
The findings in Dr. Papadakis' study should grab the attention of both medical school programs and licensing authorities. Indeed, one might argue that dialogue should be occurring now between licensing boards and the medical school programs within their jurisdiction to explore means for joint initiatives to address this issue.
However, as vital as the medical board-medical school dialogue is, I am convinced a much more vigorous discussion must occur. We must change our view of state medical boards as having sole responsibility for upholding the principles of self-regulation. To retain the privilege of self-regulation, we must be willing to reach out across institutional lines and work together in finding ways to rebuild the public's trust—through communication, collaboration, and cooperation. It is this kind of dedication to ensuring ours is an effective system of self-regulation that will ultimately assure the public it can trust the collective profession of medicine to put patients' interests before its own.
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