Friday, May 15, 2015

Internal Medicine and ACP: The “Conscience of the Medical Profession”

Three weeks ago, ACP celebrated its 100th anniversary during our annual scientific meeting in Boston, Massachusetts.  I was glad to be there for the festivities, which included the release of a book, Serving Our Patients and Our Profession: A Centennial History of the American College of Physicians, 1915-2015, now available for sale through the ACP book store.

I was especially honored to co-write, with ACP President-emeriti Dr. Lynne Kirk, the book’s chapter on public policy and advocacy.  With a particular focus on the College’s support for universal coverage, which many current and former leaders told us they were most proud of, our chapter covers the first 60 plus years when the College tread lightly, if at all, into public policy issues (including its silence in the debate over Medicare); its awakening in the 1970s to the importance of advocacy, to the opening of its Washington office in 1983, to its first foray into advocating for universal coverage in 1990, to its support for—and great disappointment over the defeat of—the Clinton healthcare plan; the merger with ASIM in 1998, to the College proposing  in 2002 its own “7 year” plan for universal coverage, through enactment of the Affordable Care Act in 2010, to the present day.  Dr. Kirk and I summarized the College’s public policy journey this way:

"Although it wasn’t until the 1980s that the College made public policy and advocacy a principal concern, and not until the 1990s that it called for universal coverage, the history recorded in this chapter shows that once ACP became engaged in the cause, it did so courageously and diligently . . . In doing so, it demonstrated that it is possible for a physician membership organization to 'put the interests of patients first' by advocating for policies supported by the evidence and developed through consensus-the 'ACP way' of public policy and advocacy.”   

In writing the chapter, we were asked to produce a scholarly account, supported not only by internal documents, but by outside independent sources—which we tried, and I think, succeeded in doing, supporting our account with 118 citations.

What one thinks of one’s own history, of course, matters less than what others think of it.  I was heartened, then, to read an article in The Lancet, the highly respected and independent UK medical journal, called "Osler redux: the American College of Physicians at 100," written by Dr. Charles S. Bryan and published just days after our own centennial celebration.  Describing internal medicine and (quoting directly from Dr. Kirk’s and my chapter), Dr. Bryan describes our role in advocacy thusly:

“. . . perhaps most importantly, internal medicine has in many ways served as a conscience for the medical profession at large. The early decision by the ACP to abstain from political controversy led to the formation in 1956 of a closely-allied American Society of Internal Medicine to represent internists' concerns in the halls of US Government. In 1998, the two organisations formally merged. In the meantime, in 1978, the ACP decided to engage more directly in public policy 'as a fresh, scholarly, non-self-serving, medical voice that would become known as a valuable resource to legislators and regulators'. Since then, the organisation has—in addition to its leadership in continuing medical education, medical ethics, and quality assurance—endeavoured to promote the public interest even when its recommendations might run counter to the financial best interests of its membership.”

The conscience of the medical profession—has a nice ring to it, doesn’t it?

I think Dr. Bryan captures what makes the internists, and ACP, so different from other specialties and their professional associations:

We are not like other professional or trade association, or labor unions, formed to promote the self-interests of members.  Rather, we have a philosophy of “put the patient first” as Dr. John Ball, the first head of the ACP Washington office and later the College’s CEO, characterized it when he was interviewed by us for the centennial book chapter.

It is this commitment to “put the patient first” that just this week, led us to take on the issue of lesbian, gay, bisexual, and transgender(LGBT)  health care disparities.  In a position paper published on Monday in the Annals of Internal Medicine (web-first version), we recommended that gender identify, independent and fundamentally different than sexual orientation, be included in nondiscrimination and antiharassment policies, that medical schools, hospitals, physicians' offices, and other medical facilities adopt gender identity as part of their nondiscrimination and anti-harassment policies,that public and private health benefit plans include comprehensive transgender health care services and provide all covered services to transgender persons as they would to all other beneficiaries, all hospitals and medical facilities to allow all patients to determine who may visit and who may act on their behalf during their stay, regardless of their sexual orientation, gender identity, or marital status.  We also came out in support of civil marriage rights for same-sex couples, recognizing that the denial of such rights can have a negative impact on the physical and mental health of these persons and contribute to ongoing stigma and discrimination for LGBT persons and their families.  We oppose the use of “conversion,” “reorientation,” or “reparative” therapy for the treatment of LGBT persons.

Our commitment to “put patients first” is also why we continue to take on the controversial issue of regulating firearms.  At ACP’s meeting in Boston, we announced that more than two dozen organizations, endorsed a paper published earlier this year by ACP, seven other national health professional organizations, and the American Bar Association, calling for policies to help mitigate the rate of firearm injuries and deaths in the United States, including universal background checks and bans on large-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity. As of today, 31 organizations have signed on in addition to the original eight.

And it is our philosophy of “put patients first” that has led us to champion, since 1990, the cause of universal health insurance coverage, including our ongoing efforts to preserve and protect the  Affordable Care Act from judicial and legislative efforts to undo the gains in coverage that have resulted from it.

To be sure, there are risks to ACP taking on these, and many other, controversial issues that may not result in a direct economic benefit to its membership.   There is a thin line between being perceived as the “conscience of the medical profession” and being self-righteous: on most of these issues, there are people of conscience who disagree with ACP’s views, and such differences should be respected, not dismissed.

There is a risk of ACP being viewed as “too political” and “too ideological”, as one unhappy member has written about our stance in support of civil marriage for same-sex couples.   The College, though, doesn’t approach issues from the stance of what is politically correct, or where it fits on the ideological spectrum, but based on what we think is best for patients—while recognizing that engaging in the political process is the means to achieve many of the policies we favor.

There is a risk that ACP members may feel that we aren’t doing enough to support their own interests, even though the College’s advocacy for the public  interest does not conflict with, nor take away from, our parallel efforts to advocate for better reimbursement for internists and for eliminating unnecessary regulations on them.

Yet I think most ACP members, and certainly the ones we interviewed for our centennial history chapter, are proud that the College “endeavor[s] to promote the public interest even when its recommendations might run counter to the financial best interests of its membership.”  Someone, after all, needs to be the conscience of the medical profession, and I’m glad that it’s internists, and ACP, that have chosen to fill that role.

Today’s questions: What do you think of ACP’s reputation as the “conscience of the medical profession”? And about our new policies on LGBT health care disparities?


Jay Larson MD said...

Compared to other medical societies, the ACP does place more emphasis on patients and not as much on its members like the AMA. But what if patients benefit from advocacy for their physicians? Does a patient benefit when they no longer have access to a general internist? There is an alarming decline in the number of internal medicine residents choosing to be an outpatient general internist. There is also a trend for internists choosing not to go into private practice, even though studies have shown that solo practitioners can better keep their patients out of the hospital at a lower cost compared to large multispecialty clinics and physicians employed by hospitals.
Over the years, burnout has become more apparent and medical professionalism has been challenged. I encourage you to read “Medical professionalism in a commercialized healthcare market” by Arnold Relman. JAMA Dec 12, 2007. Vol 298 #22 pg 2668-2670.
For patients truly to benefit from advocacy, there needs to be strong advocacy for primary care. A 10% Medicare primary care bonus and adding a few billing codes has not overcome the stagnancy of Medicare reimbursement. As primary care has struggled, proceduralists have profited well. Only 5-7% of the healthcare dollar is spent on primary care. Yet primary care is tasked to lower the other 93-95% of healthcare spending.
How about advocating for lower hospitalization costs, lower diagnostic imaging costs, lower procedural costs and lower pharmaceutical costs. Over $80,000 to treat one case for Hepatitis C. Over $90,000 to extend the life of a patient with metastatic prostate cancer 3 months. The percent of the healthcare pie consumed by Big Pharma is increasing. This just squeezes the rest of the healthcare pie and increases the burden of primary care because insurance companies are demanding prior authorization forms filled out for the higher costing drugs. One day my medical assistant had to fill out 23 prior authorization forms for medications, which included several generic medications. This requires a call to the insurance company to get the form, filling out the form, faxing the form back to the insurance company, get the reply back from the insurance company, then contacting the pharmacy that the prior authorization was approved so that the patient can finally get their medications.
Yes there are many things wrong with our healthcare system. How much longer we can go on this dysfunctional path is yet to be determined.

Walter Bond said...

Leavig aside political positions that are at best tangentially related to the field of medicine, there is a current internal medicine issue on which the ACP has remained curiously silent: the financial scandal at the ABIM. Here you have serious allegations of greed, poor financial management, and worse. Five months have passed since Dr. Cutler’s presentation in Philadelphia and yet I have read nothing on this blog regarding this subject.
When I ask this question on social media, the cynical reply from many is something like: “ACP won’t comment because they make so much from test prep materials and courses, etc.” I hope this is not the case, but if true then far from being “the conscience of the medical profession” it would mean that ACP is selling its soul for the basest of motives. How do you respond?

Gil Ross said...

Everything said here about the ACP is true and praiseworthy indeed. As an ABIM-certified internist (1975), I've always been proud of this designation and the ACP.
Until recently (4/21/15), when the org. announced their position statement on tobacco harm reduction/e-cigarettes
When did the ACP become hyper-precautionary, when confronted with almost half-million cigarette-related deaths each year in America? Warning smokers not to even try e-cigs is antithetical to public health, as the FDA-approved patches gums and drugs work maybe 15% of the time. WORSE, perhaps, is that the ACP is heavily funded by pharm. companies in whose interest restricting effective competition from e-cigs this policy statement happens to coincide--WITHOUT DISCLOSURE.
For a more thorough expression of the rationale for my disgust with this destructive opinion, see ACSH's Dispatch on it: Gil Ross MD/ACSH

neutral said...

They may have advocated for universal coverage but what they got was still unequal with the middle class paying even more, and with less overall quality. Maybe universal but definitely not equal, especially if you work for a living!
Government meddling in the practice of medicine has been a curse.

Wendy Ring said...

I hope ACP will lead by example on climate change and divest from fossil fuels.

Robert P. N. Shearin said...

It's difficult to reconcile ACP's self-proclaimed role as "conscience" and its "avoidance" of PC issues with its support of the LGBT agenda.
To this reader it seems like a typical liberal "disclaimer" i.e. claiming that one will not do something and then doing precisely what was disclaimed.

james gaulte said...

The web site states that in 2014 ACP spent 1.075,542 in lobbying efforts.This is considerably lower that the 2,120,00 spent in the year 2000.Based on your comments I can assume that this money was spent to further enhance efforts to "put the patient " first and not to improve the position of internists in anyway.With the typical reputation that lobbyists have earned over the years your claims in that regard may be a hard sell.

B Doherty said...

Interesting comments. A few observations from me:

Dr. Larson suggests that ACP advocate more for primary care, pointing out that continuing the 10% Medicare bonus payment isn't enough. We agree. The College has been advocating for Patient-Centered Medical Homes and other primary care based models that under the new Medicare SGR repeal legislation, could potentially qualify them for very substantial increases in payments. He also asks: How about advocating for lower hospitalization costs, lower diagnostic imaging costs, lower procedural costs and lower pharmaceutical costs? We are: ACP has joined the Campaign for Sustainable Drug Pricing, see

We have also joined a coalition to eliminate the additional "site of service" (facility fee)charge that hospitals impose on patients when they go to a physician office that is owned by a hospital.

Walter Bond asks about ABIM. I haven't commented in this blog or my @bobdohertyACP twitter account about ABIM for a simple reason: it is not within my area of expertise or responsibilities for at ACP. I am responsible for the ACP's governmental affairs efforts (federal and state legislation, regulations by CMS and other regulatory agencies, payment policies by third party payers, the Affordable Care Act, etc), and while I am generally aware of the controversies relating to ABIM, I as a matter of sound practice and policy do not express my opinion, or purport to speak for ACP, on other issues that fall outside my direct governmental affairs responsibilities. There is plenty of information on the ACP website on the College's efforts to improve the certification process, however.

Dr. Ross implies that ACP's policies on electronic nicotine delivery systems are affected by ACP being "heavily funded" by drug companies. This is incorrect. I don't even know how much grant money ACP gets from drug companies although I expect it is much less than Dr. Ross imagines it to be. More to the point, though, when public policy positions are developed by ACP, something I do have direct knowledge of, there is absolutely no discussion of any pharmaceutical grant support for educational or other programs in ACP. To the contrary, there is an absolute firewall between drug company support for other programs and services in ACP, which are the form of unrestricted educational grants, and our public policy development process, which is entirely separate from drug industry funding. Specifically, as we developed the ENDs paper,the views that the drug companies may have about ENDs, and the smoking cessation policies they sell, never came up. The paper drew its conclusions about the potential risks and benefits of ENDs based on a comprehensive review of the evidence, which can be found if one reviews the full paper published in Annals. There was nothing to disclose because the authors, our Health and Public Policy Committee, and ACP staff writers and researchers, do not take any money from drug companies. We fully complied with Annals' disclosure policies. And our evidence-based review met Annals' publication standards.

(To be continued)

B Doherty said...

My comments continued:

Neutral suggestions that our advocacy for universal health coverage has resulted in a more unequal system where the middle class pays more. I disagree. Under the Affordable Care Act, millions of Americans who previously had no access to health insurance now have coverage, making the entire system far more equitable than the days when we turned a blind eye to the plight of the uninsured. The ACA has many protections for middle class Americans as well, including prohibiting insurers from turning down coverage or charging more to people with pre-existing conditions. And Americans with incomes up to $94,000 (400% of the Federal Poverty level) may be eligible for premium subsidies to help them buy affordable coverage. Although it is true that some people are paying more for their health insurance, this has little to do with the ACA itself. Higher income persons are required to pay higher Medicare taxes to help pay for the ACA, but at income levels that are well above any reasonable standard of "middle class."

Wendy Ring asks that we take up climate change. Our Board of Governors passed a resolution asking ACP to develop a paper that looks at the impact of climate change and individual and population health. This is in process--stay tuned for our recommendations to come out later this year.

Robert P. N Shearin suggests that our support for the "LGBT agenda" is in conflict with our "self-proclaimed role as 'conscience" of the medical profession. First, ACP did not say we were the conscience of the medical profession, The Lancet did, although we take pride in taking evidence-based positions that put the patient first. Second, we view our advocacy for policies to change policies that have marginalized, excluded, and discriminated against LGBT persons, with documented adverse impacts on their health (as well documented in our paper), as being fully in accord with our goal to put patients first in all of our policy statements. This is not an "LGBT agenda" (whatever that is supposed to be) but a pro-patient agenda.

Again, thank you to everyone for your particularly provocative comments on this post!

B Doherty said...

Dr. Gaulte asks about our expenditures on lobbying. I have not looked into what opensecrets reports about our lobbying in 2000 compared to 2015 but I know for a fact that we have not reduced our expenditures on advocating on behalf of internists and their patients, quite the contrary. My guess is that some of these expenses are reported under ACP Services Inc, which is a separate membership organization, to which all ACP members belong, that was formed to advocate on behalf of the College's public policy recommendations. (ACP itself is a 501-C3 charitable organization, which is restricted in how much it can spend on lobbying and is prohibited from having a Political Action Committee, no such restrictions apply to 501-C6 organizations like ACP Services). So, for instance, the salaries of the legislative affairs staff (lobbyists) are reported under the ACP Services financial statements. (None of this is unusual, by the way, and it all perfectly appropriate, ethical and legal). Though ACP Services and ACP, we advocate for policies that directly help our members, like better reimbursement, while also advocating for public policies to improve individual and population health. Fortunately, we have the resources to do both, it's not one or the other.

Jerry M said...

I appreciate your review of ACPs adventure into public policy. I recall when Hillary Clinton's efforts were initiated, ACP was advocating a universal healthcare budget. This was about as far left as you can go. Her plan was soundly rejected by both sides of congress and rightly so because it would place everyone in a non staff model HMO that was universally hated. You may remember in the movie "As good as it gets" when the Helen Hunt character complained about the HMOs refusing treatment. It was the only time I have heard an ovation from the audience in a movie. Now ACP is advocating for ACOs which in their second iteration causes the physician to take on more risk. It is essentially making the Physician the insurance company. I certainly don't want my physician to be the insurer. Tremendous conflict of interest. This is only one of the acts of mischief ACP have participated in in the name of advocating for the patient.
The support of mandatory EMRs is another fiasco which has caused physicians to increase overhead and spend more time on paperwork. It also has resulted in the use of more paper. When I see a patient who has seen another doctor he brings 5or6 sheets of paper rather then getting a succinct one page letter.
You are being way, way, way too self congratulatory about the end of SGR because it will be replaced by a much more onerous pay for performance system that, of course, you advocate. The way it has been implemented so far means reducing payment for various reasons like readmission which is often needed. You can bet it is not to pay more. You realize that the "ACA" was passed on the basis of reducing Medicare spending by 30%.
I would like to see ACP advocate for what is good for the practicing physician because that is the only way to advocate for the patient. Without the physician the patient will get no care. I was shocked to see the article in The Washington Post May 29 2015 by C Krauthammer "Why doctors quit". He has been out of practice 40 years and appreciates the plight of the physician better than ACP. These positions that ACP takes are also not selfless because it allows the leadership to be at the table. What good is being at the table if you give away any advantage. As Pogo said in 1971 "We have met the enemy and he is us (ACP and Bob Doherty)".

Walter Bond said...

I appreciate your reply. I also appreciate that you primarily comment here on legal/regulatory/policy matters. However, ABIM is not exactly outside of that realm, either explicitly or implicitly. I can only find ACP statements on ABIM and improving MOC. I find nothing on the financial scandal: luxury condos, assets to presidents making $700k/yr, a payroll of $30,000,000/yr, etc. Can you direct me to where I can find ACP's statement on this paramount issue? Thanks kindly.