Professionalism Charters for Health Care Organizations: Sorely Needed but Not Ready for Prime Time

In a recent article in Annals of Internal Medicine, physicians from the University of Missouri described their experience helping to create a “professionalism charter” for health care organizations (1). As the authors note, the need for such a charter is heightened by the troubling health climate, with millions of patients at risk of losing insurance coverage, scores of physicians experiencing burnout, and health care organizations grappling with how to preserve mission and margin in the shift toward value-based care. While acknowledging the need for organizations to maintain financial viability, the charter outlines 4 core principles—patient partnerships, organizational culture, community partnerships, and operations and business practices—in an attempt to “[shift] the focus toward employees, patients, and the community.”

This effort is unquestionably worthy. However, I worry that such charters may have limited impact unless they evolve to also directly address inherent tradeoffs and articulate what should not to be done in pursuing professionalism at the organizational level.  

For example, the Charter highlights the worthy organizational commitments to “high-value care” and “innovation.” Although it also touches on the importance of social responsibility, the Charter lacks guidance related to “low-value care,” costly services that provide little to no benefit and could even harm patients. A growing body of literature, including another article in Annals (2), suggests that the de-adoption of low-value care can be even more challenging than promoting high-value care because of the psychology and financial incentives driving these practices. Just as the physician charter on professionalism (3) notes that patient autonomy must be respected as long as it does not “lead to demands for inappropriate care,” organizational charters could provide guidance about the kinds of care that health systems should not support in the name of professionalism.

Similarly, given limited organizational resources, the pursuit of innovation requires fundamental tradeoffs in the types of innovation pursued. This choice between different types of innovation has been described as an “innovation–innovation tradeoff” in the context of drug pricing (4) and can be directly applied to organizational operations. The upshot of innovation–innovation tradeoffs for organizations is that patient subpopulations are likely to benefit differentially based on the kind of innovations that receive organizational investment (e.g., new imaging technologies versus care management platforms for “superusers” or housing support for socioeconomically vulnerable patients). Charters for health care organizations should address the importance of such decisions as it relates to professionalism.

A major reason that this kind of clarity (about tradeoffs and what should not be done) is sorely needed is that physicians working in organizations—whose numbers continue to grow around the United States, particularly among early career physicians—will inevitably feel commitments to both their patients and their organizations. On one hand, physicians are patient agents charged with pursuing their best interest. On the other, physicians are members of their organizational communities, tasked with supporting their initiatives both through formal pay and promotion, as well as informal expectations to be good “organizational citizens.”

These patient and organizational commitments often align behind clinical decisions, but they can also conflict. For example, organizational goals of reducing high-cost utilization may conflict with patient preferences for advanced imaging, antibiotics, or other care that they deem valuable based on their preferences. Ongoing trends in both patient-centeredness (which emphasize the centrality of patient preference) and value-based care transformation (which emphasize accountability over cost and utilization) will likely exacerbate this tension when it arises. Therefore, professionalism charters that take clear stances on the appropriateness of organizational goals, and provide guidance about how to navigate situations in which they do not align with patient preferences, would greatly benefit physicians.

Ultimately, I agree with the authors of the Annals article that charters for health care organizations are needed now, perhaps more than ever. As they also admit, their charter is aspirational as a description of “model organizations” and likely to face headwinds from existing cultures and processes. However, a full view of organizational professionalism involves consensus about what health systems ought to avoid and tradeoff as much as about what they ought to pursue. Addressing these issues in future charter writing efforts is not only achievable, but also important for realizing the goal of “equitably [meeting] the needs of those [organizations] serve.”

References

1. Fleming DA, McDonald WJ. Professionalism charter provides guidance to health care organizations in these troubled times. Ann Intern Med. 2017;166:665-6. [PMID: 28346951] doi:10.7326/M17-0388
2. Roman BR, Asch DA. Faded promises: the challenge of deadopting low-value care. Ann Intern Med. 2014;161:149-50. [PMID: 24781317] doi:10.7326/M14-0212
3. ABIM Foundation; ACP–ASIM Foundation; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136:243-6. [PMID: 11827500]
4. Sachs RE, Frakt AB. Innovation-innovation tradeoffs in drug pricing. Ann Intern Med. 2016;165:871-2. [PMID: 27723887] doi:10.7326/M16-2167