Humanism and Social Responsibility: The Role of Certification and Recertification JULIUS R. KREVANS, MD* l h e r e is n o t h i n g m o r e di~]icult to t a k e in hand, m o r e p e r i l o u s to conduct, or m o r e uncertain in its success, t h a n to t a k e the lead in the introduction o f a n e w order o f things, because the i n n o v a t i o n has f o r enemies a l l those w ~ o b a r e d o n e w e l l u n d e r the o l d conditions a n d l u k e w a r m defenders in those w h o m a y do w e l l u n d e r the new. THIS WAS THE ADVICEMachiavelli gave in The P r i n c e . It was q u o t e d in a s p e e c h entitled " H o w Vigorous an Acc o m m o d a t i o n to Societal Needs?" given b y the late Ivan Bennett to the Council of Deans of the Association of American Medical Colleges inApril 1972. ~This address has provided m e with a n u m b e r of useful quotations for this paper. The American Board of Internal Medicine has certain essential features against w h i c h its initiatives should be examined. First, the Board has given itself the mandate of determining the r e q u i r e m e n t s for quality in the practice of internal medicine. The Board has no formal constituency; its authority is vague and is derived from an autocratic, not a democratic, process. Finally, the Board is accountable to i t s e l f - - i n summary, an exquisite and useful instrument to a c c o m p l i s h goals. The late H. L. Mencken w o u l d have approved, just as he c o m m e n t e d that w h e n the monarchs of England lost the authority to c h o p o f f p e o p l e s ' heads arbitrarily, " s o m e t h i n g beautiful w e n t out of the w o r l d . " One w a y to look at Board actions is to over-simplify the process into two steps: 1) d e t e r m i n e the attributes n e e d e d b y an e x c e l l e n t internist; and 2) provide a valid and equitable instrument to ascertain the status of those attributes in individuals. In 1983 the Board addressed the issue of humanistic qualities and made the determination that these qualities w e r e needed. A Board subcommitteeJ; was charged to d e v e l o p the valid and equitable instrument. The s u b c o m m i t t e e first defined humanistic qualities, using the a p p r o p r i a t e confidence of a Supreme Court that knows p o r n o g r a p h y w h e n it sees it. We w e r e comforted by the fact that these w e r e abstract terms and, as

"Chancellor, University of California, San Francisco, 513 Parnassus, Room S- 126, San Francisco, California 94143-0402. Presented at the Symposium to Honor John Benson, Philadelphia, Pennsylvania, June 12, 1991. Address correspondence and reprint requests to Dr. Krevans. :]:Members of the subcommittee were: Julius R. Krevans, Chairman; John A. Benson, Jr., Linda L. Blank, Eugene P. Frenkel, Edward W. Hook, Albert R. Jonsen, Lynn O. Langdon, Laurence Scherr, and Nell J. Smelser.

de Toqueville wrote, " A n abstract t e r m is like a b o x w i t h a false b o t t o m - - y o u can p u t in ideas and take t h e m out w i t h o u t being d e t e c t e d . " t The s u b c o m m i t t e e ' s r e c o m m e n d a t i o n s w e r e a d o p t e d by the Board and the results have b e e n reported.2 The core of this assessment of humanistic qualities in the certification process is repeated observation of actual behavior over a period of time. The p r o g r a m was well received b y chiefs of medicine and their residents. Last year the p r o g r a m was r e v i e w e d and imp r o v e d by a n e w set of guidelines. In the original guidelines the Board's tone was tentative. The process was p r o b a b l y accurately described b y that n o t e d philosop h e r Jim Lonborg, the Boston pitching ace, in 1967 w h i l e discussing the use of the " b r u s h - b a c k " pitch against o p p o s i n g batters: " I t is m y intention to place an affirmation of d o u b t in their minds." ~ In the r e n e w e d guidelines the Board was less tentative, less vague, m o r e confident, and m o r e specific. Thus, the Board has a p p r o p r i a t e l y and, I believe, effectively incorporated an assessment of humanistic qualities into the certification process. What a b o u t recertification? This will be m u c h m o r e difficult. The process used for certification reveals p e r f o r m a n c e rather than a c o n c e p t u a l a g r e e m e n t as to a p p r o p r i a t e and inappropriate behavior. Thoughtless, arrogant, disrespectful, and cruel actions are unlikely to be demonstrated and certainly will not be endorsed in any simulation exercise. It will b e hard to find a meaningful instrument for the assessment of humanistic qualities in the recertification process. We m a y have to fall back on Baum's solution for the Tin Man w h o lacked a heart. You will recall that the Wizard of Oz solved that p r o b l e m with a p p r o p r i a t e testimonials. H o w about the Board's role in the b r o a d e r ,social responsibilities?" What do w e do about moral and ethical behavior? These initiatives will be m u c h m o r e difficult to accomplish. The narrow issue of k n o w l e d g e of ethics is n o w well addressed in the certification process through questions on the examinations and should b e equally well dealt with in recertification. The issues of morality, honesty (including financial), bigotry, and respect for the law will be m o r e difficult to deal with. In the universities w e are faced with issues that present similar difficulties, but I d o u b t that the solutions can b e the same. For e x a m p l e , in dealing w i t h fraud in research, the universities have a d o p t e d p r o c e d u r e s that impose an " u n f a i r " b u r d e n on the faculty: an accusation that has s o m e evidence of validity initiates a process (notifi233

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cation, publicity, etc.) that is harmful to the faculty member, even if the accusation is eventually not proved. The rationale for this process stems from the c o n c e p t that there is a price to pay for the privilege of university appointment. I s o m e h o w d o u b t w h e t h e r this c o n c e p t will be acceptable to Board processes. H o w will the Board deal with these issues? The situation resembles that described by Joseph Kraft in a c o l u m n in The Washington Post in the late 60s: "Everybody knows that unstable p e o p l e react to the complexities of m o d e m life by aligning themselves with extremes of right and left. But h o w about us undoctrinaire p r o b l e m solvers o f the center [the ABIM]? H o w do w e cope with difficulties super h u m a n in scale, remote in cause, and with many facets only obscurely connected? The answer I think is that w e trivialize. We focus on matters symbolically related to what really bothers us, but m u c h simpler to understand." 1Thus w e w o u l d like to require honesty, but we will require conviction of a felony to prove dishonesty. We w o u l d like to require moral behavior, but we will search for some "legal" guideline to define and defend any Board actions. Given the Board's origins and attributes, there may be no other choices. The Board should not, however, cringe at addressing these issues. Even if no acceptable process emerges,

the fact that the Board discusses the issues has genuine value. When the Board first undertook a discussion o f humanistic qualities there were many w h o felt we c o u l d not incorporate an assessment of these qualities into the certification process. They were wrong. There were disagreements on our subcommittee. There were many reservations among the program directors. Yet the incorporation of the assessment of humanistic behavior into the certification process has been accomplished. The lack of a formal constituency does not mean the Board has no constituency. Indeed our constituency is the greater society to w h o m certification should predict excellence in the practice of internal medicine. This is the Board's license to operate and its charge to explore even the difficult and controversial issues necessary to fulfill its contract with society.

REFERENCES 1. Bennett ILJr. How vigorous an accommodationto societal needs? Personal communication,presented at the meeting of the Council of Deans, Association of American Medical Colleges, Phoenix, Arizona, April 19, 1972. 2. AmericanBoard of Internal Medicine, Subcommittee on Evaluation of Humanistic Qualities in the Internist. Evaluation of humanistic qualities of the internist. Ann Intern Med. 1993;99:No. 5 (November).

Humanism and social responsibility: the role of certification and recertification.

Humanism and Social Responsibility: The Role of Certification and Recertification JULIUS R. KREVANS, MD* l h e r e is n o t h i n g m o r e di~]icult...
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