opinion

Ethical principles answer the question: What drives us?

A message to all physicians from AMA President J. James Rohack, MD.

By J. James Rohack, MD is senior staff cardiologist at the Scott & White Clinic in Temple, Texas. He was AMA president during 2009-10 and served as chair of the AMA Board of Trustees during 2004-05. Posted April 5, 2010.

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As I write this column, it is the Ides of March. Reading the multiple e-mails and letters I have received on health system reform both from those opposed and those supporting, it is clear that passions are high. So unlike Julius Caesar, I am careful these days about walking into crowds of folks wearing togas. Or scrubs, for that matter.

But as I have traveled the nation as AMA president speaking to physicians, medical students and the public, I have noticed a common theme.

Individuals want the best medical and technical care that is available in America but want someone else to pay for it. Can we resolve as a nation the quality, cost and access triad when 50% of one's health status is determined by what one chooses to do with -- or to -- it?

For the record, the remaining 50% is composed of genetics (20%), environment (20%) and access (10%).

A recent headline suggest that billons of dollars can be saved by eliminating unnecessary procedures that kill tens of thousands of people a year. It didn't mention the billions that could be saved by eliminating the need for overly defensive medicine designed to avert lawsuits.

And health plans have spent millions of dollars on ads suggesting that the problem is with physicians and hospitals. But the data do not support that claim -- when adjusted for inflation, physician payment is 25% less than it was a decade ago.

So what drives us? Daniel H. Pink writes in his book Drive: The Surprising Truth About What Motivates Us that there are three essential elements that push people forward.

The first is autonomy -- the desire to direct our own lives. For physicians, this is ingrained into our medical education system starting as medical students, through residency and then clinical practice. Our AMA Code of Medical Ethics also speaks to that autonomy in the Principles of Medical Ethics:

"A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate and the environment in which to provide care."

The second element that drives us is mastery -- the urge to get better and better at something that matters. Again, our ethics code weighs in:

"A physician shall continue to study, apply and advance scientific knowledge; maintain a commitment to medical education; make relevant information available to patients, colleagues and the public; obtain consultation and use the talents of other health professionals when indicated."

The final element is purpose -- the yearning to do what we do in the service of something larger than ourselves. Three AMA ethical principles speak to this:

"A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interest of the patient.

"A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

"A physician shall support access to medical care for all people."

Author Pink also identifies two general types of behavior.

Type X is reflected by external desires and the external rewards produced by a given activity.

Type I behavior is driven more by the inherit satisfaction of the activity itself and leads to stronger performance, greater health and higher overall well-being.

This human drive to learn, to create and to better the world is the reason mankind creates organizations to leverage others with a common goal and purpose.

But rewards that are "if-then" -- for example, if you support my opinions on health system reform, then I will pay my dues to this organization -- do more harm than good.

So what drives the AMA? To promote the art and science of medicine and the betterment of public health by helping doctors help patients. Our ethics bind us as individual AMA members to that greater goal. And it is a challenge for many to adhere to those ethics when one is driven by external motivators.

Congress has passed health system reform, and the president has signed it. Its future impact remains unclear. But beyond any action in Washington, the ethics of our medical profession will endure. And for those willing to follow them, the drive will be sustained.

J. James Rohack, MD is senior staff cardiologist at the Scott & White Clinic in Temple, Texas. He was AMA president during 2009-10 and served as chair of the AMA Board of Trustees during 2004-05.

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