Bold Ideas Are Not Only for the Young: Mandatory Reporting of Physician Public Service Hours

You gotta love the fall: school begins, temperatures cool, leaves change color, the harvest wraps up, pumpkins and persimmons appear at the market, people prepare for the holidays, and residency interview season begins!

In my 27 years as a county hospital family medicine faculty member, I have been witness to the reflections of fourth-year medical students. What are they looking for? What are their passions? Today, the topics are diversity, equity, and inclusion, with a focus on underrepresented minorities in medicine; medically administered treatment for opiate use disorder; health care for the LGBTQ+ community; global health concerns, including both access to care and the effects of climate change; and what their role should be in advocacy and leadership addressing the social determinants of health (SDH).

When I was a medical student in the early 1980s, the most explosive issue of the day was nuclear disarmament in the face of possible total global annihilation. Many of us were members of Physicians for Social Responsibility.

Times and issues have changed. The passion of young people to look toward the future and to work and fight for what they believe in has not.

Thankfully.

Admittedly, I do not always get it these days. Despite working with learners daily, I sometimes struggle to see what they see. Other times, I think I see clearly, but my perspectives and words seem out-of-date.

I would like to believe that my career—my actual behavior in working and teaching in the safety-net for many years—demonstrates my commitment to service and my dedication to community. I appreciate, however, that not everybody else sees those efforts. Perhaps I need to be more openly demonstrative of my values. I probably need to develop some new vocabulary. And I definitely need to continue examining both medicine and society from the vantage point of 25-to-35-year olds. As Michelangelo is reported to have said at the end of his career, when asked about the most important thing that he had learned: I am still learning.

One thing I am learning is how to rediscover my own passion and voice on issues that are important to me. Bold ideas are not only for the young. The bold idea I propose in this essay—mandatory reporting of physician public service hours—has been bouncing around in my head for years. I am grateful to my young colleagues for inspiring me to document it.

Another thing I am learning is how to mentor students and residents better on the reality that the best way to effect real change is for all of us to work together. Ideas by themselves, without organized, cooperative, sustainable action, accomplish little over time.

Opportunities for action abound. This fall, in addition to our usual autumn activities, the country will be facing the 2020 election. Health care is a central theme of our national conversation, providing all of us the occasion to think about what kinds of citizens we want to be.

While physicians will undoubtedly not agree on all of today’s social and political issues, we should at least address those for which evidence of the impact on the health of our communities is clear. When we do all work together—when we speak and act with conviction and consensus—we have great moral authority.

It is time once again to be physicians for social responsibility.

We know that what we do as doctors matters. I believe that we should stop debating whether health care is a right or a privilege and start advocating that providing care for all of our neighbors—regardless of health history, legal status, or other demographics—is simply the right thing to do.

We also know that the widely accepted social determinants of health—air and water quality and other environmental concerns, food safety and insecurity, the availability of affordable safe housing, the accessibility of behavioral health and substance abuse treatment resources, public education and health literacy, among others1 are worthy of greater public intervention. We also need to study reasonable gun control in the interest of public health and safety as another SDH.

As physicians, how we address these issues should be based on our history. With the founding of the American Medical Association (AMA) in 1847, doctors became society’s first organized professionals: highly-trained individuals with a social contract to provide high-quality care to their communities, in exchange for the privilege of self-monitoring and maintaining status and income.2

Physician professionalism remains difficult to define, despite being one of the six core competencies of medical education and practice.3-4 Hopefully, it will become a focus of our 2020 reflections, as together we find the courage to make our voices heard. The principles we have traditionally professed provide a structure for us to do this.

One of the AMA Principles of Medical Ethics states, “A physician shall continue to study, apply, and advance scientific knowledge.”5 We honor that principle by documenting continuing education hours, as proof that we take this responsibility seriously.

Two other AMA Principles state, “A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health,” and “A physician shall support access to medical care for all people.”5

I propose that we honor those principles by documenting a minimum standard of public service activities in order to maintain board certification and/or professional society membership.

These standards may be met by minimum hours of service to safety-net patients and the uninsured, by public advocacy work for universal access to medical care, or by other activities addressing the social determinants of health, to be defined and publicly advocated independently by each specialty.

Individually we cannot do everything, but we all must do something. Only together can we meet our historic professional obligation. Only together can we prove to our young colleagues—the future of our profession—that we care and that we remain committed to the principles on which we were founded.

Family medicine should lead the way.