AAMC Reporter: September 2007

Physicians, Patients Aim for Good Medical Practice

A new document created by dozens of physician, health care, and consumer organizations hopes to be a modern update on the Hippocratic oath, contributors said.

"Good Medical Practice—U.S.A." sets forth a variety of guidelines and expectations for the physician community's responsibilities toward their patients, their colleagues, the larger health care system, and themselves. The document was released this month, with stakeholders invited to begin using and providing feedback on its guidelines.

"I think what's unusual and important about this is that the profession is coming forward to articulate the expectations that patients have for doctors, and doctors have for doctors," said Jordan J. Cohen, M.D., former AAMC president and an alliance participant. "The hope is that regulators, accreditors, educators, and others in a position to establish standards of accountability will use this document when setting up those standards."

Contributors said they intend for "Good Medical Practice" to help physicians and patients translate ideas into action.

"It focuses on what doctors actually do in practice," said Carol A. Aschenbrener, M.D., alliance participant and AAMC executive vice president. "This movement toward competency emphasizes continuous physician improvement rather than unproductive blaming. It gets at the heart of the outcome we all want, which is better medical practice…These expectations are not lofty platitudes, but expressions of what doctors should actually know and do day to day."

Patient and consumer advocates offered their basic expectations for the physician-patient relationship, recommending that doctors have up-to-date knowledge and skills, commit to shared decisionmaking and attentiveness, be as accessible as possible, and have clear and respectful patient interactions, among other things.

"The consumer voice in this dialogue is too often overlooked," said Jim Guest, president of the Consumers Union. "But I think that this effort is helping us move from 'doctor knows best' to the notion that consumers should be more heavily involved."

The alliance drew input from scores of physicians in setting forth guidelines by and for doctors. The guidelines cover physicians' assessments of themselves and others, participation in individual and system-wide efforts to improve quality, colleague and patient interaction, personal and professional integrity, information gathering, and continuous training and intellectual curiosity.

The document is modeled after the 2006 "Good Medical Practice" tenets created by Great Britain's General Medical Council. It also builds on six core competencies for physician performance—patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills and communication. The six competencies were established by the Accreditation Council for Graduate Medical Education in 1999.

By fleshing out specific expectations for physicians throughout the continuum of their educations and careers, the alliance hopes to streamline training and practice procedures and inform decisionmaking in all areas of the health care system.

"Those individuals that we educated, trained, and licensed, there are some gaps in there," said Carol Clothier, vice president of examination and post-licensure assessment services of the Federation of State Medical Boards, which oversaw the creation of "Good Medical Practice—U.S.A." "The hope is that this document brings consistency and uniformity to how doctors are trained, so physicians are not burdened by different sets of expectations.

"Unless we can collaborate, the system is not sustainable. The profession will increasingly be challenged to meet expectations, and that is the last thing anyone wants."

According to Aschenbrener, both professionalism training and continuing medical education (CME) could be particularly revitalized by the report. (Currently, 14 states do not require physicians to engage in CME training.)

"In medical education, the GMP will emphasize the importance of work that some faculty members are doing in the area of clinical skills, such as giving bad news to patients and considering the information they bring," she said. "Currently, CME is largely at the discretion of the doctor. In many states, physicians can meet CME requirements by selecting courses that are unrelated to their practice. The GMP will bolster efforts to focus on competency and practice improvement across the continuum of physician education."

As the alliance begins to disseminate the document to stakeholder groups, there is speculation that some guidelines will be viewed as controversial. The report's emphasis on cultural competence, repeated mandates that a physician should subjugate personal values in the interest of optimal patient care, and calls for greater patient interaction that could place more demands on physician schedules, may all be the source of some contention, alliance members said.

"I wouldn't be surprised if the document raised some questions," Cohen said. "The degree to which the profession itself can address all these issues is uncertain."

Overall, document authors said that, as is the case in many areas, change will probably not happen overnight.

"It will be interesting to see the reaction of the academic community," Aschenbrener said. "We anticipate some deep dialogue. This competency focus is a culture shift. Although this shift has already begun, culture change typically takes 10 to 15 years. So like most things, I think some will adopt it early, most will wait and see, and some will fight it to the end."

Alliance members said they welcome the discussion, and will incorporate input into Good Medical Practice as these dialogues progress.

"The intent of this document is that it be embraced by the medical profession, not imposed," Aschenbrener said. "The GMP is a modern explication for the Hippocratic oath."

—By Scott Harris

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