As Reform Begins, the National Physicians Alliance Answers the Question: “Are Physicians Knights, Knaves or Pawns”?

Summary: The National Physicians Alliance (NPA) is the American Medical Association (AMA) of the future. The AMA began as a guild, designed to protect the interests of its members. The NPA, by contrast, looks outward, and understands that it can save the profession only by focusing on the legitimate needs of patients.  Founded in 2005 by former leaders of the American Medical Student Association, the NPA represents a broad spectrum of some 20,000 forward-looking doctors committed to “service, integrity and advocacy.”  Its members take no money from the pharmaceutical industry.

Below, excerpts from a letter written Dr. Valerie Arkoosh, president of the NPA, to her membership, on the six-month Anniversary of the Patient Protection and Affordable Care Act. (ACA)

I am posting Dr. Arkoosh’s letter because I think it is essential for patients to realize that a large, broad-based and well-organized national group of doctors supports reform—not for political reasons–but because these doctors believe that the ACA supports a much needed overhaul of our health care system.

In the past, Arkoosh suggests, physicians have been cast in the role of knaves or pawns.  It is time to for them to take their place as knights, fighting to make sure that as we implement reform, we “get it right.” She points to “the Mammogram Wars” as an example of a battle which calls on physicians to acknowledge the gray areas of medicine, putting patients’ interests ahead of vested interests.

Arkoosh begins her letter by listing the reforms that are already beginning to take effect.

“Today, thanks to you, we are one decisive step closer to Secure Health Care for All:”

  • Young adults under age 26 will no longer be automatically dropped from their parents' policies at graduation.
  • Coverage of a preexisting condition can no longer be denied to children under 19.
  • Adults who have been denied coverage because of a pre-existing condition can now enroll in new pre-existing condition insurance pools.
  • Thanks to tax credits, fewer small businesses will find the cost of insuring their employees unaffordable.
  • Seniors will no longer have to skip pills as the Medicare Part D prescription drug "donut hole" begins to close.
  • Patients with a costly illness will no longer face lifetime limits on their insurance benefits.
  • Women will no longer pay higher premiums just because of their gender and will be able to see their ob-gyn without prior authorization from their insurance company.
  • Patients will no longer have to pay a co-pay for proven preventive health screenings and treatments like immunizations, mammograms, and colonoscopies.

Arkoosh adds: “We also have much to look forward to as numerous additional provisions await implementation.  The tasks ahead won't be easy.  In order to get implementation right, NPA physicians, together with our friends and communities, must ensure that our patient-centered values lead the way. 

“As I think about what physician leadership looks like during the next phases of implementation, I would like to share with you two thought-provoking commentaries.  Both describe the fundamental need for a certain kind of physician leadership during the next few years: 

“In the first, ‘Societal Perspectives on Physicians: Knights, Knaves or Pawns?’  NPA Foundation Board Member, Christine Cassel and her colleague Sachin Jain, urge policy makers and health care leaders to think about how the choices we make in payment, policy and coverage characterize physicians and their roles in health care.”

Too often systems and policies impose requirements on physicians that recast them as pawns – to be controlled, or as knaves – not to be trusted,” Arkoosh writes. “But, most physicians are knights – guided by their sense of professionalism and their desire to be healers above all else.  This commentary points out how important it is that the policy and regulatory environment  . . . reinforce professionalism.” 

I couldn’t agree more.  It is essential that reform and regulation support the expectation that physicians put patients’ interests first. This is part of what I was trying to get at in a recent post, “The Hospital of the Future, Brought to You by GE.” Anything that undermines professionalism by treating physicians as “knaves” will only weaken reform. Doctors, like most other people, live up to our expectations.

Arkoosh then points to a second lodestar for reformers:  “Lessons from the Mammogray Wars,” by doctors Kerianne Quanstrum and Rodney Hayward.  The editorial, which was published in the New England Journal of Medicine earlier this month, discusses the controversy in the physician community that erupted after the release of new mammography guidelines.

The authors of “Lessons” begin with an epigraph from Adam Smith’s The Wealth of Nations: “People of the same trade seldom meet together . . . [without] the conversation end[ing] in a conspiracy against the public.” (Here, one glimpses the cynicism that leads to “caveat emptor”, or “buyer beware.”  Smith believed that in the free market, each individual, whether he is a buyer or a seller,  strives to become wealthy "intending only his own gain." Thus, the seller tries to get the highest price possible, while the buyer does his best to pay the lowest price. Quanstrum and Hayward will go on to argue that, as a professional, a physician is not a merchant who is peddling product; his goal is to make sure that his patient gains from the encounter.  Medicine cannot be “a conspiracy against the public.”)

The political firestorm over mammograms  erupted, Quanstrum and Hayward explain,  when an independent panel, the Preventive Services Task Force, recommended that routine screening mammography begin at the age of 50 years. The Task Force indicated that women between the ages of 40 and 49 years should make individual decisions with their doctors as to whether their preferences and risk factors indicate screening at an earlier age. “The panel also recommended that screening mammograms be performed every other year, which they suggested would reduce the harms of mammography by nearly half while maintaining most of the benefits provided by annual imaging” they observe . “In short, the panel concluded that we had previously overestimated the value of mammography: that mammography is good, but not that good; that it is necessary for many women, but not all; and that it should be performed at some frequency, but perhaps not every year, for every woman.”

Arkoosh comments on what this means for reform:  “As a profession, we have the potential to play a very real role in improving our health care system. We can choose to acknowledge the gray areas of medicine and insist that they be reflected in clinical-practice guidelines and in performance measures. And we can work to prevent vested interests from being granted the loudest voices in health care – even when those voices blazon from our own specialty – by granting credence to groups such as the Preventive Services Task Force that seek to formulate evidence-based guidelines in an objective way. Or we can, instead, conduct our own version of the mammography wars when a prudent application of the evidence threatens the profitability and stature of our own specialty.’

“The NPA was founded in 2005 to restore the covenant between doctors and patients,” she concludes.  “We are a community of physicians who place the best interests of our patients above all others and who avoid conflicts of interest and financial entanglements with the pharmaceutical and medical device industries.  The NPA empowers physicians to stand up with their patients to advocate for health.  . . .

Knaves and pawns need not apply.

Warmest regards,


Valerie Arkoosh, MD, MPH
National Physicians Alliance

2 thoughts on “As Reform Begins, the National Physicians Alliance Answers the Question: “Are Physicians Knights, Knaves or Pawns”?

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