Saturday, March 13, 2010

Narrative Medicine, the Charter and the battle to preserve professionalism

Last week I became engaged in one of the most educational programs I've ever been before - it is a project sponsored by the ABIM (American Board of Internal Medicine) Foundation to promote the use of Narrative in Medicine (reflective writing) as a vehicle to increase self-awareness, with the intention of improving empathy among physicians. Multiple institutions are participating in this project and have different goals.

We started by reviewing a classic document that I read many years ago, the Physician Charter, published in Annals of Internal Medicine as well as The Lancet. This document was created by internists worldwide with the intention of rescue professionalism in medicine which is being threatened by the new "values" in industrialized world which has prompted to changes in healthcare delivery. This document supports physicians' committment to patient welfare and social justice, which by itself is just a confirmation of the principles by which we as a profession have always abided to for ages.

I liked the document, and I think that most of my colleagues by reading it just confirm what they are already practicing, however, I do agree that in the current world - especially non-academic medical centers and practices - physicians need to reconsider whether the circumstances of practice are interfering with these principles of care.

It is interesting as I participated last week in the session of the Healthcare and Public Policy committee of my local ACP chapter and I heard interesting stories from colleagues working in non-academic practices, where the medical insurance companies essentially block them from practicing medicine, and decide in an arbitrary manner whether "the customer" (that is how insurance companies see patients) needs a study or not - for example they deny a stress test to a patient "because he can walk, so doesn't need a stress test", or a CT scan "because they should do a pelvic US first"....of course, my colleagues cry their inmense frustration as can't practice Medicine anymore without hurdles put in place by unscrupulous non-physicians. So, their internal battle arises from their frustration as they try to practice Medicine with the highest regards and respect for patient's welfare, but totally external influences - the "industry"-really threatens professionalism.

My dilemma surges from the fact that I am privileged to work in an institution that promotes an academic and humanistic environment that promotes the patient's welfare as its principle - our motto is "Patient's First" - for instance, we get the opportunity to participate in this ABIM Foundation activity - however, I feel terrified for my colleagues in non-academic environments, where they need to fight for every space they deserve in order to preserve their principles as physicians.

So, moving along the way, the Charter starts by defining Professionalism, which is "placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health." They then discuss how the role of the physician as a "healer" is being threatened by the current changes in healthcare, advancement in technology, etc.
Then they state the three Fundamental Principles of the Charter - which should not be put under pressure from the industry needs- are:

1. Principle of primacy of patient welfare:  Altruism and the best interest of the patient is the driving force in medical practice.

2. Principle of patient autonomy:  The patients should receive honest and clear information about their health, and should be empowered to make their very own informed decisions about their treatment. Of course, these decisions should be honored only if they are supportive of ethical practice and permits appropriate care. Essentially, respect the patient's medical decision making if they are able to acquaint and express an understanding the risks and benefits they are getting involved into.

3. Principle of social justice:  All individuals belonging to society, regardless of their religious or political beliefs, gender, ethnic backroung, socioeconomic status, etc. have the same rights to healthcare.
Then they discuss the Professional Responsibilities, to which all physicians are commited to:

1. Professional competence. Physicians should be knowledgeable up-to-date. This basically supports the use of mainteinance of certification process, CME, etc. This is why physicians who don't keep their CME can be expelled from the State Medical Boards.

2. Honesty with patients. The truth is fundamental. We need to let patients know all risks and benefits of the medical care. But if we commit a mistake, we should be open about it. Is all about transparence.

3. Patient confidentiality.  This is why HIPPA exists. However, if welfare of others is compromised, then this can be overruled.

4. Maintaining appropriate relations with patients. Relationship with patients are exclusively professional.
5. Improving quality of care. Will sound redundant - this is what supports all measures of quality improvement; these protocols in the medical system are designed to minimize human error with increase in patient safety, and promoting an optimal utilization of resources. All this leads to improved outcomes.

6. Improving access to care. This basically entails that we should identify and minimize all barriers to adequate health care. These barriers can be based on patient educational level, laws, economic status, geographic location, as well as social discrimination.

7. Fair distribution of finite resources. Cost-effective care should be sought at all times as this will render in enough resources for everybody.
8. Adequate scientific knowledge. Essentially - we are commited to lifelong learning and up-to-date knowledge.

9. Maintaining trust by managing conflicts of interest. Physicians should disclose their relationships with industry and pharmaceutical companies.
10. Professional responsibilities. We need to ensure that our colleagues practice within the medical and ethical standards of care as well as that they are updated in their medical knowledge. This supports the sanctioning by State Medical Boards to unethical physicians.

In summary, this Charter is a document that reinstates and brings back the principles that rules an ethical medical practice with the intention of respecting the patient's welfare to the most.

On that day, we reviewed the principles in the charter, as well as some terminologies that we need to be aware such as the difference between patient vs. customer, physician vs. provider, the hospital as a healthcare site vs. corporation, etc, etc, etc. We reviewed as well some bibliographic basis for narrative writing such as this small article by Dr. Charon, as well as other articles that discuss the conflict that physicians suffer when adapting to the new changes in healthcare after introduction of technology, cost-saving industry behaviors, etc.

Then afterwards we sit down in several groups to write down a specific time when our empathy was challenged. We all spent a good 30 minutes of writing and then heard out stories. The beauty of reflective writing, is that the patient's identity can be very well concealed and some components could be fictional. In reflective writing it is encouraged to do so freely without caring for grammatical details or vocabulary changes, as it will permit more freedom to express the physician's feelings. The fictional components won't take away the substance and power from the document; the beauty of it is that we open up to our colleagues some of the hardest and most challenging times we've had as human beings and as physicians, and we all learn from these stories. We all become better, we get to understand our colleagues in a better way. I truly admire my colleagues by the way the see life and medicine and really feel honored of being able to share my experience with them.

In my travel along the discovery of Narrative Medicine I found several excellent reources:
Literature, Arts and Medicine Blog.
Medical Humanities Blog.
Medical Humanities.
Narrative Medicine Program at Columbia University.
Master of Science in Narrative Medicine.

I have always been interested in writing besides scientific writing; essentially writing essays and my own thoughts and feelings. Did it all the time in medical school, but never thought it was so useful and so powerful. Now I have rediscovered this great resource and will encourage my young colleagues, medical students and residents to pursue it. We may add a session on reflective writing in future meetings (such as our local chapter meeting) to provide more resources to promote empathy and professionalism.

I think that this is one of the best ways of pursuing the principle of primum non nocere...

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