Professionalism Charters for Health Care Organizations: Sorely Needed but Not Ready for Prime Time - Annals of Internal Medicine: Fresh Look Blog


Wednesday, December 6, 2017

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.”

  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


  1. Dr. Liao has deep insights and writes elegant English.

  2. In his December 6, 2017 blog post, Dr. Joshua Liao describes the effort of the Charter on Professionalism for Healthcare Organizations (the Charter) 2 as worthy but raises “concerns that such charters may have limited impact unless they evolve to also directly address inherent tradeoffs and articulate what should not be done in pursuing professionalism at the organizational level. “ In particular, Dr. Liao states that physicians working in healthcare organizations may or will face potential conflicts between patient and organizational commitments and cites the need for greater clarity about how to make these trade-offs.

    In addition, although the Charter discusses the importance of Healthcare Organizations emphasizing high-value care, Dr. Liao feels that it also should have addressed how to discontinue and avoid low-value care.

    The ethics of individual healthcare professionals has been grounded by the philosophy of medicine and four basic ethical principles: autonomy, beneficence, nonmaleficence, and justice. -3 Clinicians have traditionally used all four of these principles to evaluate individual clinical decisions from an ethical perspective. As practice has evolved, new ethical dilemmas have occurred, resulting in new decisions. However, the philosophy of medicine as discovered in the healing relationship and principles have remained the same.

    We agree that patient and organizational commitments inevitably conflict and appreciate Dr. Lao recognizing the need for a professionalism charter for healthcare organizations to help guide resolution. The Charter states the core principles that should guide ethical decision making for healthcare organizations. It also offers examples of specific behaviors or activities that would demonstrate or embody these principles. However, just as the application and balancing of core ethical principles to the care of individual patients can result in different decisions for different patients with ostensibly the same clinical condition, application of the principles advocated in the Charter could result in different actions for different healthcare organizations. The Charter is aspirational and our hope is that it will be widely adopted and implemented. This implementation will be challenging, during which healthcare organizations will have to balance a variety of competing interests and goods, including tradeoffs as to what should be pursued and avoided in the pursuit of high value care, while striving to avoid low value care. Healthcare organizations will also have to consider local factors, such as available community and financial resources, in deciding how to implement the charter.

    The Charter steering committee looks forward to working with others to obtain endorsements of the Charter, widely disseminate it and promote a research agenda that further evaluates and delineates the optimum strategy for promoting professionalism at the organizational level.

    David J. Gullen MD, David A. Fleming MD and Walter J. McDonald MD.

  3. Drs. Gullen, Fleming, and McDonald, thank you for the additional perspective on the Charter. As both a clinician and a health system administrator, I appreciate your emphasizing the challenge that organizations will face as they work to "balance a variety of competing interests and goods, including tradeoffs" and "consider local factors", while also recognizing the importance of this effort. To the extent that the Charter serves as one of the catalysts for this kind of work, I'm excited to see it become part of the discourse going forward.


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