President’s Convocation Address
Charles K. Francis, MD, MACP
April 14, 2005
Rediscovering Our Values
I am pleased to add my welcome to the Convocation ceremony of the American College of Physicians. The opportunity to serve the College this year as President has made me proud to be a member of the College, proud to be a specialist in internal medicine and a member of the medical profession.
At times like this, you reflect on those who contributed in so many ways to whatever success one has been fortunate to enjoy. I must thank my dad who inspired me to become a physician, and fulfill the dream he had of becoming a health professional. He was unable to fulfill his dream because he had to drop out of college during the depression. I must also thank my mother, an educator and administrator, who taught me that dreams could come true with hard work. As all of you know, when someone pursues a professional passion, there is always a price to be paid in time, attention and days spent away from home. I would like to thank my daughter, Betsy, and my son, Paul, for their love and support, they are my proudest accomplishments. Most of all, I want to thank my wife, Irma, for her love and support throughout college, medical school, military service in England, residency, fellowship, and academic positions on both coasts.
Tonight we celebrate the individual achievements of our new
Masters and Awardees.
Congratulations to all of you. We are also here to recognize those of you who are becoming Fellows of the American College of Physicians. My remarks tonight are directed largely to the new Fellows who are now able to use the letters FACP in their title. Unlike some other Colleges, where the primary criterion for fellowship is to pass a certification examination, FACP not only indicates that you have passed an examination but that you also possess certain special characteristics: “personal integrity, superior competence in internal medicine, professional accomplishment and demonstrated scholarship.” In addition, you epitomize and will carry on the highest traditions of our ancient and venerable profession. Fellowship recognizes your professional excellence and is emblematic of your connection to the long line of distinguished specialists in internal medicine that have shared the title of FACP.
Your status as a Fellow of the College will resonate throughout your professional life. It is likely that the College will play a role in your future career, in ways that you may not have imagined. For myself, the College has been linked to several milestones in my career, beginning with my internship at the Philadelphia General Hospital, in which my first attending was Dr. Truman Schnabel, a President Emeritus of the College, to Dr. Gerald Thomson, also a President Emeritus of ACP and my predecessor as Chair of Medicine at Harlem Hospital. Dr. Thompson was the one most responsible for my becoming active in the College, becoming a Fellow, and being elected to the Board of Regents. The President of the New York Academy of Medicine, where I currently direct the Office of Health Disparities, is Dr. Jeremiah Barondess, also a President Emeritus of the College.
Now let me speak of internal medicine, the specialty that you new Fellows and most of the rest of us in this room have chosen. Internal medicine plays an important role in virtually all levels of American medicine. It is one of the fundamental disciplines in undergraduate medical education, providing a foundation for a wide array of medical, as well as surgical, specialties. Over 21% of all residents graduating from ACGME-approved programs are specialists in internal medicine. During the last 10 years, over 30% of the primary specialty certificates granted by the American Board of Medical Specialties were awarded in internal medicine. Over 23% of full time medical school clinical faculties are in internal medicine. As internists, we can all be proud of the accomplishments of our specialty.
However, despite the many accomplishments of American medicine and the College, there is a widespread feeling among the public and health policy makers, as well as physicians and patients, that something is fundamentally wrong with the American health care system. Numerous reports have called attention to the need to improve the quality of health care, decrease medical errors, enhance patient safety, eliminate racial and ethnic health disparities, and provide coverage for the more than 44 million Americans who are either under insured or uninsured. We are expected to accomplish all of this, while reducing the cost of health care.
There is also a pervasive feeling among practitioners of internal medicine that the specialty is in crisis. A severe case of professional malaise has afflicted internists, whether general internists or sub-specialists. Internists are frustrated by the limited time physicians have to deal with patients, by excessive bureaucratic and administrative chores, rising medical liability costs, threatened reductions in reimbursement rates, mounting overhead and declining income. Medical students, observing the dissatisfaction with the practice of internal medicine in their medical school attendings and in practicing internists in the community, have reacted predictably. After a six year decline, applications from US seniors for internal medicine residencies have increased slightly for the last two years. Even though I am encouraged by the recent improvement in the internal medicine match, I remain concerned that many medical students still are not attracted to careers in internal medicine.
Recognizing the need for action, in November 2003 the College convened a “revitalization summit” to address the challenges for internal medicine in today’s health care environment. Four themes emerged from the summit: repair the dysfunctional payment system, redesign the practice of internal medicine, define and articulate the value of internal medicine, and educate and train internists for the future. However, the recommendations that came out of the summit will be resolved, for better or for worse, in the political arena. Resolution will require a dialogue between organized medicine, payers, patients and government. The current situation, in which general internal medicine and the subspecialties each has their own agenda, may lead to even greater chaos in the healthcare system. In the possible ensuing disarray, we are each likely to be less effective in the marketplace, in legislatures and within the medical profession.
However, the combination of the American College of Physicians and key internal medicine sub-specialty organizations could speak collectively with a much more powerful voice. Together we could be even more effective in addressing the critical issues in internal medicine and in the health care system. Achieving our shared goal of ensuring the highest quality care for all Americans will require unification of all branches of internal medicine.
Given the multiple roles played by internists and the growing fragmentation of internal medicine, what common themes can unite the specialty with its sub-specialties? The solution is to rediscover our core values.
Examining the roots of the term “physician” is a good starting point. What does it mean to be a “physician”? The term “physician” dates from antiquity and is derived from the Greek word “physikos, which means “natural” or “according to the laws of nature.” Physikos included physical, biological and medical sciences and its practitioners were called “physicians.”
“Physician,” as in the “College of Physicians,” traces its origins back to 1518 and the Royal College of Physicians of London, after which the American College of Physicians was modeled. The Royal College of Physicians, to quote Sir Max Rosenheim, “was a vocational body, charged with the repression of unqualified practitioners, with examining and licensing those who wished to practice, and with some kind of supervision over medicines. It set high ethical and intellectual standards for its members.” King Henry the Eighth designated the Royal College of Physicians as the standard setter for medicine, established the distinction between “physicians” and “surgeons,” which continues to the present in the United Kingdom. This Convocation, with its wonderful pomp and circumstance, connects us to our English progenitors and serves as a reminder of the historical role of “Colleges of Physicians” in assuring the quality of patient care and maintaining the high intellectual and clinical standards of the specialty. These traditions remain at the core of the American College of Physicians and unite us all as “physicians.”
Our modern understanding of the role of medicine and the physician’s responsibility to society harkens back to the mythic traditions of the Greek physician/hero of medicine, Asklepios. Asklepios was the central figure in Greek and Roman medicine and was the archetype for the physician as healer, helper, soother of cruel pain and hero to the common people. The Asklepian principle of equally serving princes, slaves and paupers—without regard to personal risk, self interest or financial gain—provides the foundation for contemporary expectations of the medical profession. One of the followers of Asklepios was Hippocrates, who articulated and disseminated many of the original principles of the medical profession. These included altruism, beneficence, relief of suffering, integrity, honesty, compassion, humility, confidentiality and respect for patients. From these principles, a universal truth of the human condition is revealed. As Dr. Jeremiah Barondess states in his 1998 article in the Annals of Internal Medicine, the predicament of illness and the vulnerability of the sick imposes obligations on anyone who professes to be a healer. The medical ethos that has sustained medicine through the ages, and is now embodied by professionalism, can be the unifying force that helps to revitalize internal medicine today.
Even though the tenets of the medical ethos have endured through the ages, there is a growing consensus that there has been erosion of the importance of medical professionalism. The vagaries of a dysfunctional payment system, the administrative burdens of practice, the economic demands of medical education and research, technological advances and political exigencies have all undermined professionalism in medicine. To address the changing social and economic context of medical practice, the Physician Charter on Medical Professionalism was created in 2002 by the ACP Foundation, the American Board of Internal Medicine and the European Federation of Internal Medicine. The Charter outlined the core values of professionalism: social justice, patient welfare and patient autonomy and identified a set of professional responsibilities relevant to internal medicine.
Professionalism reminds us that patients should remain the main focus of all of internal medicine and encourages us to strengthen the patient-physician relationship. Patients desire clinical skill and scientific knowledge in their internist, but also want a partnership relationship characterized by compassion, communication, understanding and humaneness. Professionalism is the key to fulfilling the social contract included in the medical ethos. A commitment by all segments of the internal medicine community to the tenets of professionalism, such as those detailed in the Charter, will help restore the public trust and respect that has been eroded by the priorities of the medical market place, fragmentation of the specialty and changing health care delivery systems.
Rediscovering our core values can be the catalyst that allows all of internal medicine to build upon our ethical principles, shared history, and commitment to ensuring quality health care.
I have typically viewed internal medicine as having two dimensions, breadth and depth. The breadth refers to the broad and all inclusive scope of knowledge of the specialty, while depth acknowledges the extensive and detailed knowledge typical of the specialty. The general internist epitomizes the internal medicine practitioner with great breadth of knowledge. The sub-specialist is the prime example of the internal medicine practitioner with great depth of knowledge. The length and depth of internal medicine are both products of the comprehensive education in clinical and basic science, ambulatory and in-patient medicine, acute and chronic disease, as well as prevention that distinguish internal medicine from other specialties. However, perhaps there is a third dimension.
In a famous sermon, Dr. Martin Luther King, Jr. discusses the “Three Dimensions of a Complete Life: Length, Breadth and Height.” As Dr. King uses it, “length” refers to the inward concern for one’s own welfare, the concern that causes one to push forward, to achieve one’s own goals and ambitions. But, for Dr. King, it also means accepting yourself and what you are; being proud of a rich and noble heritage. Certainly, internal medicine has ambition and a proud heritage. The “breadth” of life that Dr. King refers to is an outward concern for the welfare of others. Dr. King says, “A man has not begun to live until he can rise above the confines of his own individual concerns to the broader concerns of all humanity.” As internists, does caring for the sick address these broader concerns?
Interestingly, Dr. King’s third dimension is “height” by which he means, “reaching upward toward God.” I had more trouble applying this concept in the context of internal medicine. However, in pondering the problem, I happened across a discussion by Dr. Mike Magee, noted columnist, on the patient-physician relationship. In his discussion, care is defined as “goodness,” the delivery of the highest quality care, and “fairness,” as care that is delivered equitably across a population. To completely unify internal medicine will require not only length and breadth, as Dr. King defined them, but also the third dimension of “height,” reaching for the Supreme Good—whether called “God” or given another name. For internal medicine, this is a quest for goodness and fairness in health care.
Internal medicine can be unified by our core values, values that have their roots in the history of the medical profession, in its medical ethos, in the traditions of the College of Physicians and in the commitment of internal medicine to professionalism. If internal medicine is to be revitalized, it must rediscover and apply these core values. Internal medicine will be truly “complete” when, not only are the dimensions of length and breadth reached, but, when the dimension of height, consisting of “goodness,” and “fairness,” is also realized.
I would like to close with this thought from Sir William Osler in his essay, “Internal Medicine as a Vocation,” in Aequanimitas:
“I have heard the fear expressed that in this country the sphere of the physician proper is becoming more and more restricted, and perhaps this is true;
But I maintain ….that the opportunities are still great, that the harvest is truly plenteous and the labors scarcely sufficient to meet the demand.”
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