A plea for professional behavior: North American Spine Society Presidential Address, Montreal, Canada, 2002

Stanley A. Herring, MD

Such a glowing introduction by my dear friend, Joel Press, MD, seems best put into perspective by a quote from Isaiah Berlin, the recently departed Latvian-born English philosopher, who upon being honored noted that, “While I fear that my accomplishments may have been overestimated, I will not pretend that this causes me great despair.” This year, I have had the privilege of serving as your president of the North American Spine Society (NASS), a position I never imagined assuming. I was surprised and flattered to be nominated, and now I have the perspective to realize the honor of holding this leadership position. It has been educational, exhilarating, occasionally exasperating and humbling all at the same time.

This year has forged a friendship between myself and our chief executive officer, Eric Muehlbauer, a wonderful navigator and advisor who deplores public adulation, not that this brief thank you could ever express my gratitude. My thanks also to the always hardworking NASS staff, dedicated individuals who translate policy into practice. I know that my enthusiasm this year created extra toil for you. I have been fortunate to be surrounded by a board of directors composed of knowledgeable leaders involved with NASS for all the right reasons and demonstrating the same commitment to service as our other members who volunteer their time. Thank you all.

My most important acknowledgments, of course, are also the most personal. To my wife, Betsy, patiently married to someone who frequently confuses working with living, and to our children, Tracy and Nathan, who still embrace an often-distracted father, thank you for indulging me this opportunity with NASS. This one was really worth it. I would like to also recognize my sister, Joyce Herring, and brother, Ralph Herring, who have traveled to Montreal for the meeting and festivities. Finally, I would like to take a moment to honor the memories of my father, Earl Herring, who would have been proud of all the kind things that Joel has said about me, and to my mother, Mary Ann Herring, who would have actually believed them.

NASS has come of age. What began in 1985 as a loosely organized group of 50 physicians interested in the management of patients with spinal disorders has now blossomed into a multidisciplinary organization of 3,395 members and is growing rapidly. At this annual meeting, outstanding original research in the form of 108 papers and 73 posters is being presented (there were a remarkable 790 abstracts submitted), eight major symposia are being held, and there are precourses, and special interest groups. The NASS Research Fund now tops 1.6 million dollars, supporting many projects designed to help our patients. Like other premier professional organizations, we have official publications. The Spine Journal and SpineLine are excellent academic and pragmatic resources, two of the many ways NASS strives to continually improve our members' knowledge. We are also proactive leaders in patient safety, advocacy and education.

Ironically, NASS's rise to prominence has occurred at the same time that our beloved profession of medicine is at a crossroads. Patients seek rights to health care and rights in health care while government, insurance companies and employers understandably strive to limit costs. Speaking about health care, former Colorado governor Richard Lamm has noted that, “We are inventing the unaffordable and spending the unsustainable” [1]. One symptom of this health-care crisis is the push for population-based medicine, the idea of making care for an entire group of patients a higher priority than caring for each individual patient. Physicians are expected to adopt what has been called an ethic of distributive justice, the principle being to provide the greatest good for the greatest number of patients within the allotted budget 2, 3, 4. However, how can physicians provide the best care for each of their patients and for the entire group simultaneously when patients want access to the very best care available and, incidentally, once they have access to it, they want all of it. Physicians find themselves as agents of fiscal policy for patient care [5] while struggling for their own economic survival as reimbursements are repeatedly slashed. Yet, if physicians are vocal only about the injustices of payment and the capriciousness of health-care delivery, we can appear callous and uncaring about the individual patient. Our detractors, of course, revel in our behavior as they demonize us to the very public we are trying to serve. We have been made villains in a system that we had little part in creating.

What is our solution for this conundrum, indeed for the entire current health-care crisis? There is only one solution for us that is enduring; only one solution that will outlast the current dilemmas of access, reimbursement and technology applications, and one solution that will outlast future dilemmas that are sure to follow. This solution is seemingly simple and may appear even to be naı̈ve, yet it is eloquent and unassailable in its depth and sophistication. Professional behavior is the answer to this dilemma. These are the words of John Benson, Jr., MD, Dean and Professor Emeritus of Medicine at Oregon Health Sciences University, who introduced this solution to my thinking in his timely article on the burdens of professionalism published in 2000 [4]. Dr. Benson implored us as physicians to rely on the very core values of our noble undertaking to keep us above the bickering and finger pointing of today's and tomorrow's health-care delivery issues. Otherwise, he warns, we will be defined by these very issues. Indeed, without professionalism, we risk becoming simply tradesmen, skilled laborers without a philosophy. Dr. Benson reminds the reader of the message from Samuel Thier, MD, previous president of the Institute of Medicine, who called on us to “behave as a learned profession” or jeopardize our traditional social contract with the public 4, 6. Dr. Thier goes on to remind us that our profession as physicians requires of us first to be the keeper of a body of knowledge, both intellectual and experiential, and that we are responsible for advancing that knowledge and teaching the next generation of practitioners. He notes that secondly, our profession must maintain its integrity by setting and maintaining standards of competence in education, licensure, residency training and clinical care. The essence of professionalism is self-governance. Physicians must guard their own standards of education and practice or risk losing this responsibility to other agencies, governmental or corporate. Finally, and most critically, our profession must value performance and service to others over personal reward of any type. This is an ethical code of conduct that must never be compromised. Our disquieting and uncertain times as physicians are not unique and offer no excuse for violating this principle. For indeed as Plato noted over 2000 years ago, “No physician, insofar as he is a physician, considers his own good in what he prescribes, but the good of his patient; for the true physician is also a ruler having the human body as a subject, and not a mere moneymaker.”

If professionalism is the solution to our health-care dilemma, then what are its elements? The American Board of Internal Medicine has defined them as altruism, accountability, excellence, duty, honor and integrity and respect for others. The Board has now made it policy that accredited training programs require the demonstration of professionalism by residents 4, 7. Unequivocally, these elements of professionalism are not just options to be added to an academic education and board certification, for once again recall that without these qualities, a practitioner is forever sentenced to be at most a technician, providing treatment to patients, not for patients. Recently, the Council on Ethical and Judicial Affairs of the American Medical Association House of Delegates felt it was necessary today to revisit this issue, and they composed and recommended the adoption of the Declaration of Professional Responsibility: Medicine's Social Contract With Humanity [8]. The preamble to this contract notes in part that, “Never in the history of human civilization has the well-being of each individual been so inextricably linked to that of every other… As physicians, we are bound in our response by common heritage of caring for the sick and the suffering… Today, our profession must reaffirm its historical commitment to combat natural and man-made assaults on the health and well-being of humankind.” The declaration itself reads as follows:

We, the members of the world community of physicians, solemnly commit ourselves to:

We make these promises solemnly, freely, and upon our personal and professional honor.

One of my most meaningful and satisfying privileges as the president of NASS was to offer our endorsement of this declaration.

Now, have I made my case that maintaining professional behavior is the solution to the current dilemma of the health care provider? Maybe not. Professional behavior certainly elevates us ethically and, as Dr. Thier stated, it demonstrates our commitment as keepers of a body of knowledge and guardians of standards for our peers. Yet, it is Dr. Thier's point about the final component of professionalism—performance and service to the patient—that not only was the genesis of the AMA Declaration, but also is the nonnegotiable tenet that provides the ultimate answer to our health-care dilemma. Because no matter what, at the end of the day, “medicine is, at its center, a moral enterprise grounded in a covenant of trust” [5]. This covenant should not be confused with the swearing of an oath of service to mankind in general, a personal pledge based on the Hippocratic tradition. No, a covenant is a solemn agreement that binds the physician with the individual patient [4]. It is a contract that obligates us to be competent and to use that competency in the patient's best interest. This must be a sacred obligation, a trust that is not violated from within by physicians' materialistic self-interest nor from without by for-profit forces or misguided governmental policy [5]. In short, spine care must be the best patient care, not unnecessary epidural steroid injections masquerading as appropriate nonoperative care, or the overutilization of minimally invasive technologies—too often a procedure looking for an indication, and not indiscriminate discectomies and fusions disguised as reasonable operative care. Nor can patient care be depersonalized, viewed simply as a business by insurance companies or as a numbers game by our legislators.

If we honor our moral duty and uphold this covenant, we earn our patients' unending loyalty. The patients hold the ultimate power to enact change in health-care delivery. Their wholesale rejection of a health-management organization system foisted upon them is a clear example. We have been given the privilege of caring for them. The maintenance of our professional behavior ensures that by being the tireless advocates for these patients, we will in turn receive the benefit of their power. They will trust us and take direction from us regarding health-care reform and delivery. They will raise their voices in support, and the multitude of those voices will be heard.

If our solution to the current health-care dilemma is professional behavior, what does NASS offer to help us along the path? Recall that Dr. Thier, past president of the Institute of Medicine, noted that one duty of professionalism is to keep and advance a body of knowledge and mentor the next generation of practitioners. The breadth, depth, multidisciplinary nature and scientific quality of this very annual meeting serve as testimony to the commitment of NASS to this tenet of professionalism. So, too, does the addition of four more stand-alone hands-on courses next year, our online educational opportunities, our involvement in World Spine II and our continued collaboration on joint meetings with the Japanese Spine Research Society and the South American and Brazilian Spine Societies. Additionally, our Guidelines for Resident and Fellow Education provide the academic blueprint for the next generation of spine practitioners.

NASS is fundamentally committed to the advancement of knowledge through our research efforts as well. We fund at least three research projects annually, having provided over 1 million research dollars in the last 10 years. We are encouraging our members to get more involved in research through the helpful resources of the NASS Research and Funding Guide and the Compendium of Outcomes Instruments. Thank you, Dr. Gatchel, for providing these texts. Our Research Council has broken new ground by not only supporting quality scientific study, but performing it as well. The first two NASS-member research efforts are underway: a complication data registry and a spine-care research study.

Our educational efforts also extend to our patients. NASS already provides 20 patient-education brochures, five more are near completion and plans for future production are in place. Our website continues to expand and acts as an excellent learning resource for patients. Our most recent Back-to-Health Month video on osteoporosis has reached an estimated 25 million people.

NASS provides education in another fashion as well: education to the public and to policy makers. We do this through our advocacy efforts. If you attended the Symposium on Current Issues in Spine 2002 earlier today, you heard David Springer and former Congressman Dan Lundgren of the Venable Law Firm, our well-spoken, insightful, broad-thinking advisors. They clearly understand the complexity of the health-care system and our position in it and eloquently speak to the absolute requirement for us to be significantly involved in advocacy, for the patient's benefit and for our very own survival. For how can we be professionals, how can we serve our patients, if our ability to practice medicine disappears? We owe a debt of gratitude to our past president, Neil Kahanovitz, MD, who has been an early and tireless champion of political action and advocacy. The commitment of NASS to advocacy, education of our members and patient education remains strong and will continue to grow.

Along with its education efforts, NASS also stands tall regarding Dr. Thier's second principle of professionalism: acting as a guardian of standards of behavior for our members. A clear example is the NASS Code of Ethics [9], adopted by our board of directors and now approved by our membership. This document, quoting from its introduction, establishes “A Code of Ethics for its members intended to serve as guidelines in medical, social, and professional relationships which occur in spine care practice. This code is a statement of ideals, commitments, and responsibilities of NASS members to patients, other healthcare professionals, society and themselves, and thus may be considered as one of the measures used to evaluate a member's maintenance of good professional standing, and to evaluate qualifications for membership by applicants.” This Code specifically covers ethics as they relate to the spine-care provider, ethics of relationships between health-care providers, ethics related to the patient and patients' families, ethics related to the legal profession, responsibilities of NASS members to government, ethics related to the physician and insurance, compensation and reimbursement agencies, and ethics related to community and world affairs. As of today, the NASS Code of Ethics is available on our website.

Our neurosurgical members may recognize a very similar code of ethics as a component of the American Association of Neurological Surgeons' (AANS) Professional Conduct Program. This admirable program of professional self-regulation provides an equitable and impartial system for upholding the AANS Code of Ethics and resolving complaints of unprofessional behavior [10]. A focal point of this program is expert witness testimony. Guidelines have been established to ensure a standard of quality and impartiality in expert witness testimony by AANS members. The consequences of unprofessional behavior, including inappropriate expert witness testimony, range from censure, membership suspension or even expulsion from the AANS. There are protocols in place to guarantee due process, and the system has held up to legal challenges, even at the United States Supreme Court level. Accolades have come from other medical societies, the American Medical Association and even the Department of Health and Human Services, which has opined that this is exactly a role that medical societies should be expected to play.

Those members who read the suggested bylaws changes and additions proposed in September, and those of you who attended Wednesday's business meeting, now know that not only has NASS installed a new Code of Ethics, but I am proud to announce that this Code of Ethics will serve as one component of our own comprehensive professional conduct program modeled on the AANS program. While we all clamor for others to be held to reasonable standards, through tort reform, insurance industry accountability and appropriate government policy regarding health care, NASS is acting now in regard to behavior of our own members. Adoption of this ethical conduct program demonstrates our professionalism through our commitment to self-governance and self-regulation.

That NASS has chosen to enact educational programs and to institute a professional conduct program is laudable and engenders pride in our organization. These efforts of our Society, however, only supplement that primary force that must drive our professional behavior, our personal unfettered commitment to each patient. Remember that covenant that obligates us to be competent and to use that competency in each patient's best interest. I have had the good fortune to be an National Football League (NFL) team physician, which has given me the opportunity to peek inside a world few people see. In professional football, every play of every practice and of every game is recorded. Each of those plays is reviewed and broken down by coaches. Each player is then assigned a grade for every one of those plays. A player's livelihood hangs in the balance of this critical examination that occurs with every snap of the ball. In the NFL, no one takes any plays off. This has given me cause to reflect on how I would fare if my job performance was subjected to such scrutiny. How would I be graded for my performance and service to each of my patients? In the day-to-day unhistoric practice of seeing patients, we must not make excuses for offering less than our best professional behavior, perhaps hoping to do better the next time. For without question, what we have chosen to become stands in judgment of what we might hope to be in the future. The twelfth-century scholar, physician and philosopher, Maimonides, prayed for the spirit and fortitude to faithfully execute his work. He requested, “Let not desire for wealth or benefit blind me from seeing the truth. Deem me worthy of seeing the sufferer who seeks my advice—a person—neither rich nor poor, friend or foe, good man or bad, or man in need, show me only the man.”

The words of Plato and Maimonides confirm that the plea for professional behavior is certainly not new, and it has surely been requested much more eloquently, but never has the need been more timely than now.

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