Pay for performance and medical professionalism.

Health care delivery systems are widely studying and implementing physician pay for performance (P4P) initiatives to improve quality and control costs. However, the increasing focus on quality-driven financial incentives has some troubling implications for medical professionalism. This article examines the P4P concept in light of a notion of medical fiduciary professionalism that dates back to the 18th-century Scottish physician John Gregory. Gregory's principles serve as a framework to assess the appropriateness of P4P initiatives in disseminating the principles of high-quality care without damage to professionalism, the patient-physician relationship, and access to care for all patients.