Is the business of health care hurting the profession? (Big Business/Noble Profession).

I NEARLY MISSED MY exit on Interstate 95.

The spirited conversation on the radio about concierge care was fascinating, even though I firmly believe that health care, its delivery to patients and its management, are something rather special.

Health care is something apart from the profit driven entrepreneurial goals of other market segments. Health care is a profession.

I was listening to National Public Radio's All Things Considered whose guests were arguing the significance of a new trend in health care delivery, a franchise that promises personalized, timely and responsive care to selected patients.

For an annual fee of $600 to $5,000 per patient, physicians agree to limit the size of their practice to something like 1,000 patients, ensuring their availability and uninterrupted time with patients.

This fee is in addition to any compensation from insurance plans the patient may hold. And by "greatly curtailing the size of their practices, the physicians can get to know their patients better," according to a January 24, 2002, article in USA Today.

The potential benefits to this group of patients seem obvious. The benefits to physicians' income is equally clear. The service imperative is realized. Market law prevails.

But is there something wrong here?

In the news

Consider the other types of health care stories making headlines today:

* The American Medical Association's union group recently achieved a large legal victory involving doctor's unions, the February 11, 2002, issue of Modern Healthcare reports. It seems the National Labor Relations regional office ruled that 21 New Jersey doctors are eligible for union status because they are employees -- not supervisors. The potential impact of this decision on future unionization efforts is discussed in the article.

* Another article in the same issue reports on the creation of a new nursing group, the American Association of Registered Nurses (AARN). The group would, among other things "serve as a union representing its members' interests in labor negotiations."

* In the February 28, 2002, USA Today, an op-ed piece suggested that boutique hospitals that specialize in selected branches of medicine may "imperil care." In pursuit of high tech, name talent and solid profit, the author states that boutique hospitals may exclude the "uninsured and the millions more whose health care is rationed."

* The op-ed was in response to an February 20, front page story in the paper headlined "Hospitals fight for turf in medical arms race; Medical centers become more specialized to increase profits."

Meanwhile, the February 11, 2002, Modern Healthcare reports that hospitals are finally getting serious about customer relations.

They're spending big dollars to compete on service and getting advice on how to do that from the Magic Kingdom, Ritz-Canton and a few leading customer service hospitals.

No doubt that hospital service-- a veritable oxymoron in some settings--can be improved greatly. But simply replacing the magazines in the doctor's office with some from the current year isn't the answer.

For many institutions, real help is needed to meet the expectations of an informed, Internet savvy public who buys from L.L. Bean, where "your shirt is your receipt" and you may simply return any item that doesn't yield complete satisfaction.

There's no doubt that focus on the customer in health care is long overdue, even as we wince at the word. "Customer" does not fit easily into the lexicons of the physician community.

* But isn't there something different about health care from other businesses?

* Are patients simply customers in this country's largest service industry?

* What makes this a profession rather than a job, a vocation or a trade?

Defining profession

Guests on NPR's The Connection were discussing uniforms, those visible statements of values, position and authority. Uniforms offer recognition and tradition, while implying a common language.

Is there such symbolism within the professions?

The nurse's white uniform and the physician's long, white coat signaled many of health care's cherished values: empathy, safety, caring. Many of these symbols of communication went the way of the lighthouse, replaced by the golf shirt, the suit coat and multicolored scrubs.

The profession's values need declaration in some other idiom.

The Oxford English Dictionary cites common usage of the word "profession" from about the 12th century. Its source is a "public declaration," a "business" that professes a certain set of values, one that promises that its members' conduct will be within certain guidelines and that those guidelines will serve an important societal goal.

The Internet is replete with additional definitions and examples. In my distillation of them, the four core values of a profession are:

1. Competence in a specialized body of knowledge and skill

2. An acknowledged set of specific duties and responsibilities toward the individuals it services

3. Self-responsibility for training, disciplining, advancing or dismissing its members

4. Public declaration, a contract, to service beyond personal gain (1,2)

Albert Jonsen, PhD, professor and chair of medical history and ethics at the University of Washington asks, "What is the difference between a profession and a business?"

No dictionary can cleave a constant distinction. Their worlds overlap. The professions are, after all, entitled to make a living at their art. Hospitals need margins to survive for long.

Jonsen suggests that one crucial difference does exist: "professionals have a fiduciary responsibility toward those they serve. This means that professionals have a particular duty to assure that their decisions and actions serve the welfare of their patients or clients, even at some cost to themselves." (1)

A professional's performance to uphold their social contract--whether in the field of the clergy, law, medicine or education--can best be judged in light of this measure.

It is "a moral enterprise grounded in a covenant of trust." (3) It implies a set of values, attitudes and behaviors that enhance the trust of the patient and of the society.

Professionals, be they physicians, nurses, clerics or physician executives behave in ways that reinforce the basis of the social contract and enhance the public trust. Decisions and actions they make are in the best interests of the patients and clients.

Inspiring confidence

Less explicit from the definitions and parameters is the expectation of confidentiality.

As any observer of recent affairs knows, internet security can be breached, computer files are assailable, hard drives can be forced to give up their secrets and identities can be stolen.

The compact between the professionals and their clients, the contract between the health care enterprise and its customers requires confidentiality--confidentiality of language, discussion, information and confidentiality of touch.

Society's contract with the medical profession, which allows the healing professionals to touch patients in the performance of their arts and in pursuit of their fiduciary responsibilities, is perhaps unique among the professions.

There are many threats to the promises of these professions.

* Entrepreneurs gone bad

* Profit incentives too alluring

* Commercialism

* Health care as a commodity

* Regulation

* Misinformation 

* Competition

* Conflicts of interest

* Major money

Mix in numerous business cultures and different values, and fiduciary accountability can become blurred. At a time of shaken trust in historically safe institutions, offices and officers, it is perhaps most timely that physician executives and the health care professionals renew our public promise.

* Can business and the professions occupy the same podium at the same time, embracing Adam Smith and Patch Adams?

* Can we move responsibly between customer, client and patient?

* Can we fulfill what we have professed?

* Is it a business you run or a profession you practice?

Yes.

When patients in a health plan negotiate for better terms and conditions or clients lobby for better coverage from the Medicaid program, health care is a business and patients are customers.

But when the same person is seated on the physician's exam table wondering about that funny mole on her arm or when the half-clad man in your CT department is frightened about the results of his scan, clients and customers are patients.

We as physician executives must bring to medicine and market, the skills, ethics and behaviors needed to manage both well.

References

(1.) Jonsen, AR, PhD with Braddock, CH and Edwards, KA. "Ethics in Medicine." University of Washington School of Medicine, Professionalism, http://eduserv.hscer.washingtn.edu/bioethics/topics/profes.html

(2.) Cohen, J, MD. "Word from the President." Reporter of the Association of American Medical Colleges. http://www.aamc.org/newsroom/reporter.htm October, 1998.

(3.) Crawshaw, R and others. "Patient-Physician Covenant." JAMA. 1995, 273:1553.

ACPE Resources

A new ACPE book is now available that addresses similar topics. It's called: Independence Day: Revolutionizing the Physician's Role in Health Care

by Richard G. Wendel, MD, MBA 

$37 members, $47 nonmembers 144 pages, 2002

The book proposes a paradigm shift in values for a medical practice. It outlines a group of strategies for a medical practice to "be all it can be" for all patients who enter the office. "Owning" the patient's entire experience in health care is key to "owning" the marketplace. See if your practice can institutionalize same of the new value chain.

Visit the online ACPE Bookstore at www.acpe.org/Publications/index.htm or call 800/562-8088.

Robert B. Klint, MD, MHA, FACPE, is chairman of the board of SwedishAmerican Health System in Rockford, Ill. He previously sewed as president and CEO. SwedishAmerican is com prised of a ma]or acute care hospital, a network of primary care and multi-specialty clinics, home health care branches and an ambulatory surgery facility. He can be reached by phone at 815/226-9688 or by e-mail at [e-mail]