THE SOCIAL CONTRACT, PROFESSIONALISM, AND ITS ASSESSMENT: THE STRATEGY OF THE ABFM GOING FORWARD
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* Warren Newton
* Coleen Conry
* Beth Bortz
* Elizabeth G. Baxley

> Society granted physicians status, respect, autonomy in practice, the privilege of self-regulation, and financial rewards on the expectation that physicians would be competent, altruistic, moral, and would address the health care needs of individual patients and society. This “arrangement” remains the essence of the social contract.1
> 
> Sylvia Cruess and Richard Cruess, 2004

At the foundation of the American Board of Family Medicine’s (ABFM’s) new strategic plan is a commitment to renew the social contract between family medicine and society across all of the Board’s activities. Despite hospital consolidation, despite employment of most family physicians, and despite changes in practice promised by augmented intelligence, genomics, and new technology, family physicians remain bound by an implicit social contract. We benefit from the respect of society, earn more than most Americans, and have substantial autonomy in our work, in return for commitment to improve the health of the public, follow a code of ethics, and self-regulate.

The social contract is fragile. The landmark Bristol case in the United Kingdom serves as a warning for all of us.2 Over many years, despite compelling data and whistleblowers, physician leadership in the Bristol health district chose not to address significant problems in the quality of care in pediatric cardiac surgery. In response, the Parliament took away some of the power of physicians to review quality of care. As important as improving quality of care is, however, the implications for us today are even broader—they reach inside the exam room to how we interact with patients on a daily basis. A current example comes from the opiate crisis. While the epidemic has had many origins, it seems clear that physicians played an important, though well-intentioned, role in contributing to the crisis and allowing the epidemic to spread. We did not self-regulate effectively: since we did not, many state legislatures have stepped in to regulate how we manage pain, even to the extent of monitoring the exact dosing of narcotics. The social contract is informal and implicit, but it is binding. When the contract is not followed, society will respond, and the solutions will be poorer quality and more restrictive of our roles than if we had addressed the issues ourselves.

What should medicine—and family medicine—do to better fulfill its part in meeting our obligations under the social contract? An important first step is to focus explicitly and publicly on professionalism and the social contract. It is for this reason that we were an early supporter of the Professionalism Charter3 and recently established the Center for Professionalism and Value in Health Care,4 with its primary objective of shaping of the clinical work environment to support the professionalism of family physicians and other health professionals. We will continue to champion education about professionalism as we contribute to developing standards for residency education and support evolution in continuing medical education.

The ABFM Certification portfolio itself reflects our commitment to the needs of the public. We require that family physicians engage in lifelong learning and self-assessment, conduct rigorous independent assessments to assure that Diplomates have the cognitive expertise necessary to serve the public, and assure that Diplomates are meaningfully working to improve the quality of care they provide. Most direct is our assessment of professionalism. Like other ABMS Boards, we rely on the Diplomate holding a full active and unrestricted license as a key measure of professionalism. We do not have investigatory powers, so we rely on the state medical board’s adjudication process to establish the facts of individual cases. They then provide that information to the Federation of State Medical Boards. From this, ABFM seeks the detailed information from the medical board’s order regarding the physician and his/her situation.

ABFM has a thorough review process; due process includes appeals with peer review by physicians on our Board of Directors before making a consequential decision regarding certification. Our guidelines for Professionalism, Licensure and Personal conduct5 allow our Professionalism committee to respond more flexibly to the facts of individual cases, even when specific license actions are not determined to be in violation of our Professionalism policy.

How might we improve assessment of the professionalism of Family Physicians? As we think about the new ABFM strategic plan,5,6 we acknowledge that using state medical license information is an insensitive diagnostic test—that there may be some family physicians who do not meet the highest ethical standards but who still have a full, valid, and unlimited license to practice medicine. Keeping in mind the complexity of establishing a robust process for almost 95,000 active Diplomates, one option is to improve our diagnostic sensitivity by exploring additional national databases for regular review. One example might be partnering with the National Practitioner Data Bank, where additional information regarding hospital privileging and other types of reporting is centralized—with the premise that there may be concerns about their professional behavior that have not yet reached the medical board but warrant further evaluation and peer review. Another possible option is to increase transparency. When state medical boards restrict a physician’s medical license, they publish the details. If a decision is made to remove certification, should we link electronically to the original decision of the medical board so that the reasons are public? At least two other specialty boards are already doing this.

We also want to be more proactive—to support family physicians who seek help for a personal need, such as burnout, mental health condition, or substance abuse, before something happens that causes them to be forced into a Physician Health Plan as a condition of maintaining their license. The ABFM Board recently voted to change our Guidelines for Professionalism, Licensure and Personal Conduct in order to provide protection from loss of certification in cases where help is sought before an ethical breach. Are there other ways, working alone or with partner organizations, that we might explore to enhance early identification of Diplomates at risk, with a goal of supporting them through their career?

But improving the sensitivity and transparency of our assessment can only go so far. In the broader societal dialogue about the role of physicians, we believe that there has been too much emphasis on “bad apples”—the physicians who have significant breaches of the social contract. Indeed, most physicians equate “professionalism” with “unprofessionalism.” In reality, the latter group is rare. In a five-year audit of our process, we found that only 0.9% of ABFM Diplomates come before our Board of Directors’ Professionalism Committee for review in any given year. Of these, only 1/10 lose their board certification; one-half of these regain ABFM certification in time. The ABFM Board is keen to identify ways to recognize the vast majority of family physicians who are serving their patients and communities well. We believe that family physicians care deeply about the quality of care they provide, put patient needs ahead of their own personal needs, and go to great effort every day to improve the health and lives of their patients and communities—and that these efforts need to be honored.

So how will ABFM promote “positive professionalism”? We will begin by changing our language so that it is clear that nearly all family physicians are honoring the social contract and acting professionally in their daily lives and practice. We will emphasize that those who fall outside our expectations are uncommon. We will also explore more formal recognition of the many ways that family physicians are making a positive difference in the lives of their patients and communities, from daily improvement of care for individual patients, to developing new systems of care or working to reverse disparities of health.

We call upon our specialty colleagues and community of practice to join us in this effort. Practicing family physicians and their representative organizations can help renew our common standards of professionalism. Researchers can help us to learn more about the attributes of settings which challenge our Diplomates’ ability to be professional so that we can test strategies that support professionalism of family physicians in practice. Most importantly, all of us need to engage in this critical discussion: we must focus on improving health and health care for our patients and communities. We must regulate ourselves. Otherwise, as the Bristol and opiate examples teach us, we will lose our privilege to self-regulate, and our relevance.

*   © 2020 Annals of Family Medicine, Inc.

## References

1.  Cruess S, Cruess R. “Professionalism and medicine’s social contract with society.” Virtual Mentor. 2004;6(4):185–188. doi:10.1001/virtualmentor.2004.6.4.msoc1-0404. Accessed Dec 3, 2019.
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1001/virtualmentor.2004.6.4.msoc1-0404&link_type=DOI) 

2.  Fox R. Bristol scandal. Circulation. 2001;104(7):e9014. [https://www.ahajournals.org/doi/full/10.1161/hc3201.097067](https://www.ahajournals.org/doi/full/10.1161/hc3201.097067). Accessed Dec 3, 2019.
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MTQ6ImNpcmN1bGF0aW9uYWhhIjtzOjU6InJlc2lkIjtzOjExOiIxMDQvNy9lOTAxNCI7czo0OiJhdG9tIjtzOjIyOiIvYW5uYWxzZm0vMTgvMS84NS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

3.  American Board of Family Medicine. The Physician Charter. [https://abimfoundation.org/what-we-do/physician-charter](https://abimfoundation.org/what-we-do/physician-charter). Accessed Dec 3, 2019.
    
    

4.  Phillips RL Jr., Bazemore AW, Newton WP. Pursuing practical professionalism: form follows function. Ann Fam Med. 2019;17(5):472–475.
    
    [FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTcvNS80NzIiO3M6NDoiYXRvbSI7czoyMjoiL2FubmFsc2ZtLzE4LzEvODUuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

5.  American Board of Family Medicine. ABFM Strategic Plan. [https://online.flippingbook.com/view/489900/](https://online.flippingbook.com/view/489900/). Accessed Dec 3, 2019.
    
    

6.  Newton WP. The American Board of Family Medicine: what’s next? JABFM. 2019;32(2):282–284. [https://doi.org/10.3122/jabfm.2019.02.190015](https://doi.org/10.3122/jabfm.2019.02.190015).