Viewpoint by Noam N. Levey, The Journal of the American Medical Association
May 12, 2015
The medical profession in the United States, by some measures, has much to be pleased about. Public confidence in the honesty and ethical standards of physicians has remained high for decades, even as other professions, including bankers, the clergy, and members of Congress, have endured a steady erosion in public trust. Even though physicians may not enjoy the exalted, even unquestioned, position they did in the middle of the last century, they remain among the most trusted professionals in the United States.
As major changes reverberate through the US health care system, however, the trust that patients have historically placed in clinicians is being challenged. A revolution in transparency in medicine is making an unprecedented amount of information available to the public, potentially undermining confidence in the profession. At the same time, the public is growing increasingly anxious about the broader health care system as increasing costs erode workers’ stagnating wages. Patients also are seeking to be more engaged in their own medical care, including how they confront the end of life, a subject that poses special challenges for the medical profession.
Together, these changes may transform expectations of physicians’ qualifications and affect how the public views organized medicine in general. That raises the stakes in the current debate over the medical profession’s systems of self-governance.
Few developments may be more transformative than the advent in recent years of new data and new federal disclosure requirements. Patients—as well as journalists, politicians and health care purchasers—can now obtain and analyze information about physicians’ billing practices, their ties to other entities in the health care industry, and the outcomes they achieve for patients in their care. This is subjecting the medical profession to a level of scrutiny that was once unimaginable.
For example, the 2014 release of Medicare physician payment data spawned multiple media reports identifying the nation’s top billers and prompted new questions about the kind of care physicians are providing. This has contributed to increased public concern about how much medical professionals and health care organizations of all kinds charge for the delivery of health care services. These data are also fueling demands that the famously opaque US health care system provide consumers with more meaningful information about how to select medical services and practitioners.
The work of investigative news organizations such as ProPublica with data on payments from the pharmaceutical and medical device industries to physicians has also focused attention on potential conflicts of interest in medicine. In the past several years, newspapers around the country have reported often unflattering stories about individual physicians in their communities.
Meanwhile, an increasing number of regional quality organizations, such as Minnesota Community Measurement and Maine Quality Counts, are collecting and posting outcome measures for local medical practices. Augmenting these data, new government and private sector payment systems such as the Medicare Shared Savings Program, although still imperfect, are publicly identifying and rewarding physicians and health care organizations that meet quality targets. These systems will increasingly allow patients to see which clinicians are lagging on key indicators.
How the public uses the new data and what precise effect the information will have remain unclear. To be sure, research suggests that even patients with chronic illnesses have limited awareness about publicly available physician quality information.
However, patients are learning more about their physicians at a time when their faith in the broader health care system and those who lead it is not high. In a recent nationwide poll of 1027 adults, just one-third of respondents expressed confidence in the US medical system, far behind other institutions, including the military, small business, and the police. Moreover, unlike residents of other industrialized nations, those in the United States are highly skeptical of the leaders of the US medical profession, a phenomenon that some researchers attribute to the perception that organized medicine has been more focused on protecting its own interests rather than working to advance broader public health goals.
Layered on top of this is a burgeoning public conversation about a disconnect between patients’ expectations for their medical care and what the health care system is configured to provide. Growing out of a decades-old consumer movement, this discussion in some sense is not new. However, the focus on some of the more complex health-related topics, such as death and dying, has raised new questions about how well the medical profession is prepared to meet patients’ desires and needs.
These may be difficult topics for individual physicians and for organized medicine to address, but the recent proliferation of articles and books on end-of-life care and dying well suggests that the public is eager to delve further into these subjects. Gawande’s moving new book about mortality, which, among other topics, explores medicine’s struggles to confront issues surrounding aging and death, has been on best-seller lists for weeks.
The medical profession has weathered other major shifts in the US health care system. Indeed, the revolution in managed care of the 1990s, which threatened to further undermine public trust in physicians, arguably had the opposite effect. Confidence in physicians, which had been slipping, stabilized as patients focused their dissatisfaction on insurers.
Today, patients may once again look to physicians as a trusted source and harbor amid the turmoil in the broader health care system, including narrowing insurance networks and rising cost-sharing requirements for consumers, as well as the ongoing political and legal battles over the Affordable Care Act. The medical profession could also emerge stronger as a result of many of the current challenges and ongoing changes in health care. Greater transparency, although threatening to some, improves performance, potentially boosting public confidence. More patient engagement should deepen the relationships between physicians and the people they care for, ultimately fortifying public trust in the medical profession.
Physicians ignore the forces shaping public expectations at their peril, however. While Americans may retain confidence in their own physicians, affording the profession some protection from threats to physicians’ credibility and authority, the shield may not be impenetrable. A national survey of 1508 adults about their views on medical care revealed some potentially troubling findings for physicians. Most survey respondents reported that physicians do not spend enough time with patients. Most respondents do not consider physician fees reasonable. Even fewer believe that physicians are trying to hold down the cost of medical care. Perhaps most relevant for the current debate over self-governance is that nearly 1 in 4 survey respondents disagreed with the statement “Doctors are usually up to date on the latest advances in medicine.”
Perhaps a new system for recertifying physicians will restore some patients’ trust, although the effect may be small. Arcane procedures by professional societies that few have heard of seem unlikely to fundamentally move public opinion. Most patients would rightfully assume that organized medicine at a bare minimum had adequate protocols for self-regulation.
More consequential may be the behavior of physicians and their willingness to adapt to the changes under way in the US health care system. Patients across the country are experiencing new models of care that are more coordinated, more transparent, more responsive, and more personal. The best of these systems not only deliver better results, they make patients happier, as anyone who has seen them can attest. If physicians are viewed as standing in the way of these models, they risk the trust the profession has worked so hard to earn.