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?