Author + information
- Patrick T. O’Gara, MD, FACC, ACC President∗ (, )
- Debra L. Ness, MS, Trustee, American College of Cardiology, Trustee, American Board of Internal Medicine and
- John Gordon Harold, MD, MACC, MACP, ACC Immediate Past President, Trustee, American College of Cardiology, Trustee, American Board of Internal Medicine Foundation
- ↵∗Address correspondence to:
Dr. Patrick T. O’Gara, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
More than a decade ago, on February 5, 2002, precisely, a document was published that was the result of a project undertaken by the American Board of Internal Medicine Foundation, the American College of Physicians–American Society of Internal Medicine Foundation, and the European Federation of Internal Medicine. The joint effort was the Medical Professionalism Project, and the document was titled “Medical Professionalism in the New Millennium: A Physician Charter” (1). Known as the “Charter on Professionalism,” or more simply the “Charter,” and published simultaneously in The Lancet and Annals of Internal Medicine, the Charter quickly became the standard for a document expressing the tenets of medical professionalism, and it was subsequently adopted by more than 100 medical societies and medical specialty societies around the world. The American College of Cardiology (ACC) was not one of those societies.
Memories dim over time and details fade, but there is general agreement among current senior members of the College that there was never any opposition to the Charter. No one took issue with it in any way; no one contested any of its principles. Formal adoption was simply not considered at the time. This oversight, however, was corrected on November 6, 2014, when the ACC Board of Trustees unanimously ratified the adoption of the Charter, which was initially approved by the Executive Committee of the Board of Trustees on September 23, 2014.
One may ask, “Why now?” This is a fair question, and there are at least 2 reasons.
First, statements such as the Charter are essential in formally defining the most basic characteristics of organizations and institutions. They provide a grounding point, a documentation of the fundamental ethos, which can be referenced not only when times are easy but also when times are hard.
The practice of medicine and the specialty of cardiology are highly challenged. Threats are present on multiple fronts: financial, legal, regulatory, and societal. We are facing several challenges: rapidly changing health care delivery and payment systems; calls for new levels of accountability; migration from volume to value; new requirements for maintaining certification; new parameters for relationships with industry and conflicts of interest; and new norms defining patient- and family-centered practice.
What better time than the present to pause and review the fundamental principles by which we all aspire to conduct ourselves?
Second, the publication Understanding Medical Professionalism, by Wendy Levinson, Shiphra Ginsburg, Frederic W. Hafferty, and Catherine R. Lucey (2), offers novel scholarship and fresh insight into the concept of professionalism. It is a primer on medical professionalism fit for all levels of the profession, from medical student to senior clinician. It points out that professionalism in the past was considered a static character trait that one either had or did not have, and that a single breach would suffice to label one “unprofessional.”
Levinson et al. (2) reject this outdated view and suggest that professionalism is rather a series of behaviors and skills that can and should be taught and practiced over the course of one’s career as a true competency. Lapses in professionalism become opportunities for teaching for which everyone in the profession is responsible, and learning and improvement are a continual community effort. Health care systems can promote a culture to support the ability of team members to manage professionalism challenges in daily practice.
It is with these thoughts that we ask our readers to take the time to read or reread the Physician Charter on Medical Professionalism, fully reproduced with permission below, to study its tenets and to reweave them into their professional lives. The benefits of this effort will accrue to us individually, to our profession, and, most importantly, to our patients who depend on us for their welfare and their lives.
The Physician Charter on Medical Professionalism
ABIM Foundation, ACP-ASIM Foundation, and European Federation of Internal Medicine.
Professionalism is the basis of medicine’s contract with society
It demands 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. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession.
At present, the medical profession is confronted by an explosion of technology, changing market forces, problems in health care delivery, bioterrorism, and globalization. As a result, physicians find it increasingly difficult to meet their responsibilities to patients and society. In these circumstances, reaffirming the fundamental and universal principles and values of medical professionalism, which remain ideals to be pursued by all physicians, becomes all the more important.
The medical profession everywhere is embedded in diverse cultures and national traditions, but its members share the role of healer, which has roots extending back to Hippocrates. Indeed, the medical profession must contend with complicated political, legal, and market forces. Moreover, there are wide variations in medical delivery and practice through which any general principles may be expressed in both complex and subtle ways. Despite these differences, common themes emerge and form the basis of this charter in the form of three fundamental principles and as a set of definitive professional responsibilities.
Principle of primacy of patient welfare
This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician–patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.
Principle of patient autonomy
Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.
Principle of social justice
The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.
A set of professional responsibilities
Commitment to professional competence
Physicians must be committed to lifelong learning and be responsible for maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care. More broadly, the profession as a whole must strive to see that all of its members are competent and must ensure that appropriate mechanisms are available for physicians to accomplish this goal.
Commitment to honesty with patients
Physicians must ensure that patients are completely and honestly informed before the patient has consented to treatment and after treatment has occurred. This expectation does not mean that patients should be involved in every minute decision about medical care; rather, they must be empowered to decide on the course of therapy. Physicians should also acknowledge that in health care, medical errors that injure patients do sometimes occur. Whenever patients are injured as a consequence of medical care, patients should be informed promptly because failure to do so seriously compromises patient and societal trust. Reporting and analyzing medical mistakes provide the basis for appropriate prevention and improvement strategies and for appropriate compensation to injured parties.
Commitment to patient confidentiality
Earning the trust and confidence of patients requires that appropriate confidentiality safeguards be applied to disclosure of patient information. This commitment extends to discussions with persons acting on a patient’s behalf when obtaining the patient’s own consent is not feasible. Fulfilling the commitment to confidentiality is more pressing now than ever before, given the widespread use of electronic information systems for compiling patient data and an increasing availability of genetic information. Physicians recognize, however, that their commitment to patient confidentiality must occasionally yield to overriding considerations in the public interest (for example, when patients endanger others).
Commitment to maintaining appropriate relations with patients
Given the inherent vulnerability and dependency of patients, certain relationships between physicians and patients must be avoided. In particular, physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose.
Commitment to improving quality of care
Physicians must be dedicated to continuous improvement in the quality of health care. This commitment entails not only maintaining clinical competence but also working collaboratively with other professionals to reduce medical error, increase patient safety, minimize overuse of health care resources, and optimize the outcomes of care. Physicians must actively participate in the development of better measures of quality of care and the application of quality measures to assess routinely the performance of all individuals, institutions, and systems responsible for health care delivery. Physicians, both individually and through their professional associations, must take responsibility for assisting in the creation and implementation of mechanisms designed to encourage continuous improvement in the quality of care.
Commitment to improving access to care
Medical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.
Commitment to a just distribution of finite resources
While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one’s patients to avoidable harm and expense but also diminishes the resources available for others.
Commitment to scientific knowledge
Much of medicine’s contract with society is based on the integrity and appropriate use of scientific knowledge and technology. Physicians have a duty to uphold scientific standards, to promote research, and to create new knowledge and ensure its appropriate use. The profession is responsible for the integrity of this knowledge, which is based on scientific evidence and physician experience.
Commitment to maintaining trust by managing conflicts of interest
Medical professionals and their organizations have many opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage. Such compromises are especially threatening in the pursuit of personal or organizational interactions with for-profit industries, including medical equipment manufacturers, insurance companies, and pharmaceutical firms. Physicians have an obligation to recognize, disclose to the general public, and deal with conflicts of interest that arise in the course of their professional duties and activities. Relationships between industry and opinion leaders should be disclosed, especially when the latter determine the criteria for conducting and reporting clinical trials, writing editorials or therapeutic guidelines, or serving as editors of scientific journals.
Commitment to professional responsibilities
As members of a profession, physicians are expected to work collaboratively to maximize patient care, be respectful of one another, and participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards. The profession should also define and organize the educational and standard-setting process for current and future members. Physicians have both individual and collective obligations to participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all aspects of their professional performance.
The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges center on increasing disparities among the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform health care systems, and the temptation for physicians to forsake their traditional commitment to the primacy of patients’ interests. To maintain the fidelity of medicine’s social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society. This Charter on Medical Professionalism is intended to encourage such dedication and to promote an action agenda for the profession of medicine that is universal in scope and purpose.
- American College of Cardiology Foundation