Clinical and Investigative Medicine

 

Professionalism, laws and kings

Richard L. Cruess, MD
Sylvia R. Cruess, MD

Clin Invest Med 1997;20(6):407-13.

Richard L. Cruess and Sylvia R. Cruess are with the Centre for Medical Education, McGill University, Montreal, Que.

This article was presented by Dr. Richard L. Cruess as the Wendell MacLeod Lecture.

Reprint requests to: Dr. Stuart M. MacLeod, St. Joseph's Hospital, 50 Charlton Ave. E, Hamilton ON L8N 4A6

Contents

How small of all that human hearts endure, that part that laws or kings can cause or cure
-- Samuel Johnson

Introduction

We in medicine are in charge of our own destiny. It is not the laws under which we are governed or the rules or regulations that determine our fate, it is how we handle them.

No Canadian in the health care field could help but be honoured by being asked to present the Wendell MacLeod Lecture. Wendell MacLeod is a wonderful man. Born in L'Esprit in the Eastern Townships of Quebec, he was educated at McGill University and is still on staff at the Royal Victoria Hospital in Montreal. He spent time in Spain during the revolution, was dean of medicine at the University of Saskatchewan (where he had a profound influence on the course of medicine in Canada), and founded the Association of Canadian Medical Colleges (ACMC). It is gratifying for me to give this presentation in his name.

When my wife and I left our administrative duties, we had become more worried about the values of medicine than about budgets or the organization of teaching hospitals. We were concerned about 2 major areas. The first is professionalism. The second is the link between universities and their medical schools; however, this is still "work in progress." This presentation deals with professionalism and, in particular, professionalism in relation to medical education. The mandate of this meeting is to attempt to look forward 5 to 10 years and to position our educational system to allow us to better meet our challenges and obligations. In education we have come to believe that there are some things that we probably haven't been doing and that we must do to meet the future. After considerable study we would like to offer the following general perceptions.

There have been times of change in the past, but the rate of change today is generally agreed to be greater than at any time in our recorded history. Physicians now live in a questioning society. Whereas, 20 or 24 years ago, we had great authority and people would accept our statements without question, this is no longer true. All professions, and medicine in particular, have lost status, in part because of the questioning society. We will never return to the "golden age," but will go forward into a different time. Interestingly enough, those people who wish to privatize our health care system seem to believe that, through privatization, they would go back to something resembling the pre-medicare days. This would not occur. They would instead go forward to a system resembling that found in United States. The future will depend on how medicine responds, and public trust is the key. Most of what will be said this morning relates to maintaining that public trust. To influence the course of events, physicians, individually and collectively, must have a clear understanding of professionalism and of the obligations that must be met to maintain public trust. From informal questioning of colleagues, we predict that you, all of whom have some link with medical education, would give us a very imprecise answer if we asked you to define professionalism and its obligations.

The physician in modern society has 2 roles: that of healer and that of professional. We believe that these roles must be looked at separately, while they must be played simultaneously. If one traces these 2 concepts through history, one sees what we mean when we separate them. The concept of the healer goes back before recorded history to antiquity. In fact, we date modern medicine from Hippocrates. Much later, science started to establish a basis for medicine, technology arrived, and all of a sudden we were no longer only healers, but also curers. However, the concept of the healer has remained to the present. The professional is different. The concept of the professional has deep cultural roots in the Middle Ages, in the learned professions of the clergy, law and medicine. Guilds and the early universities of England established our roots. The professional and its role became much clearer as one moved into the 1800s, and in about 1850 was codified under licensing laws. Science arrived, as it did with the healer, and medical education became closely linked with universities.

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Professionalism

In North America, Flexner made that link tighter. As we moved into the 20th century, professions proliferated, as did the social sciences, which looked at the role of the professional in society. Society uses the concept of the professional to organize the delivery of the complex services that it requires, including the services of the healer. But we must never forget that the primary role is that of healer. Something else which is important to understand is that professionalism is an Anglo-American concept. In other cultures, such as those in France or Germany, the state is responsible for setting and maintaining standards. In the Anglo-American world, however, physicians are independent and self-regulating, and the healer must function as a professional, since the roles are so tightly linked. Professional status has certain characteristics. It includes a monopoly, which we should never forget; as we move into the sociology literature we'll come back to that. It is not an inherent right, it is granted by society, which gives prestige, social standing and rewards to members of professions; again, not just to physicians. It gives relative but not absolute individual and collective autonomy, and it depends for its maintenance on public trust. It may be modified or withdrawn by society if professionals do not perform adequately. The definition of a profession is important. Several very knowledgeable people feel that the word "professional" is used so widely that it has lost its meaning; we do not agree. We must have a definition that we and society agree upon because it is against this definition that our performance is judged. In the most recent edition of the Oxford English Dictionary we find: "the occupation which one professes to be skilled in or to follow; (a) A vocation in which a professional body of knowledge of some department of learning or science is used in its application to the affairs of others or in the practice of an art founded upon it. (b) In a wider sense, any calling or occupation by which a person habitually earns his living."1

"Professes" is an important verb. Those of us who recite the Hippocratic Oath or a modern derivation are professing something. The word "art" is also important because we do not profess competence only in science.

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Sociology

The study of professionalism is of great interest. There are 2 large bodies of literature pertaining to it, the first from sociology and the second from ethics. There are many major contributors to our understanding of professionalism and the relation of the professions to society. They include some very interesting figures: Beatrice and Sydney Webb of the Fabian Society,2 Brandeis,3 Flexner4 and many of the early founders of the discipline of sociology. There is only one Canadian, Coburn,5 who has been offering wise comments for quite some time on the place of medicine in Canadian society. When an ethicist talks about professional behaviour, he or she is talking about professionalism; it is this material that we have used in developing our ideas. In general, the social sciences deal with the professions and society, whereas ethics deals with physicians, the healer and individual patients. Ethics deals much more with dilemmas and conflicts. Our observations suggest that sociologists and ethicists may know us better than we know ourselves.

Medicine's self-perception differs from society's view of the profession. We create a mystique around ourselves, which we then come to believe. There is a dearth of literature providing "cross-pollination" between medicine as a profession and its observers in sociology and ethics. The literature that does exist can assist us in understanding certain issues facing us. When we look at the characteristics of professions, most authors, except probably the Marxists, would agree with the following characteristics, which expand on the definition. The definition does not change, but the characteristics do, as society becomes more complex.

As a profession, we possess a discrete body of knowledge and skills, over which our members have exclusive control: that's our monopoly. The work resulting from this knowledge is controlled and organized by associations that are independent of both the state and capital (i.e., money, the market). The mandate of these associations is formalized by a variety of written documents, including laws covering licensure and regulations granting authority. The professional associations serve as the ultimate authorities on the personal, social, economic, cultural and political affairs relating to their domain. They are expected to influence public policy and to inform the public within their areas of expertise. When the Canadian Medical Association and the ACMC give public pronouncements, they are doing the things that they ought to do. Admission to the professions requires a long period of education; the associates are responsible for determining the qualifications and usually, but not always, the numbers of those to be educated for practice, the substance of their training and the requirements for its completion. Within the constraints of the law, the profession controls admission to practice, and the terms, conditions and goals of the practice itself. The profession is responsible for the clinical and technical criteria by which its members are evaluated and has the exclusive right to discipline unprofessional conduct. Individual members remain autonomous in their workplace, within the limits, rules and standards laid down by their associations and the legal structures within which they work. Professionals are expected to gain their livelihood by providing service to the public in the area of their expertise. We are not required to work for nothing. And last, but not least, members are expected to value performance above reward, and are held to higher standards than are nonprofessionals, according to Brandeis.3 Listing the characteristics is interesting, but they are not of equal weight. At the core of a profession is the possession of specialized knowledge. Because we know things that only we can know, we must self-regulate because others are not competent to do so. We must have a commitment to service, which is what justifies our autonomy. This is on the understanding that our behaviour will be governed by codes of ethics.

The published characteristics of professions rarely include explicitly but always take as a given that a profession must be moral (must serve the public good) and that professionals should aspire to the ideal of professionalism. The goals are set higher than can be achieved. However, in the literature, unrealistic objectives are not set for professionals. It is understood that we are human beings and that there are some days when we approach the ideal and others when we fall short.

Until 1970 the professions were documented and defined in the literature, and the service commitment was stressed. It was felt that professionals were desirable because of the service commitment. While there was some criticism, the concept of the professional as being a benefit to society was not questioned. In the 1960s and 1970s, the emphasis shifted. The benefits of professionalism to society were questioned, and very effectively. Many believed that the concept itself was flawed. The self-serving power of an elite, and its impact on social policy was stressed, again very effectively. There is no question that these criticisms influenced public opinion.

Elliott Friedson, a sociologist, started the questioning of professionalism in 2 massive books published in 1970.6,7 Medicine found his views disturbing. Friedson was a dominant person in the field of sociology, and his work was so powerful that everyone who wrote on professionalism had to contend with what he had written.8­10 The closest he has come to writing in a format that physicians might read was 1 article in the Journal of Dental Education.11 He stressed the control over an exclusive body of knowledge and coined "the professional dominance theory," which states that medicine uses control to preserve its monopoly and to remain dominant both in society and in the health field.

Friedson suggested that medicine had convinced the public that it was trustworthy because of its ethical behaviour and because of the integrity of its body of knowledge. He identified the inherent conflict between altruism and self-interest, and this remains a major criticism of medicine. He stated that self-regulation was weak, and that the rules and their application were imperfect. He outlined the key role of autonomy: if one is not autonomous and able to make independent decisions, one is not a professional. And he stated that medicine had created a mystique, which it had then come to believe.

Although Friedson was not a Marxist, Johnson12 and Larsen13 were; they were much more critical of our profession and actually rejected Friedson's premise. They felt that professionalism was a method of gaining occupational control over work in the Marxist sense. The profession then organized itself to gain a monopoly over service, and to create a demand for the service that it controlled. Further, professions use social closure to limit entry to people deemed to be acceptable, and they use power in a self-serving way. Haug,14 another interesting commentator, felt that the number of professions and the strength of professionalism would decline in the future. She dealt specifically with medicine, stating that it was being deprofessionalized, that increased specialization had caused fragmentation of the body of knowledge, and then fragmentation of the profession itself, as different organizations commanded the allegiance of groups of physicians. She stated that information technology and the education of the public have increased the accessibility of knowledge, therefore decreasing the power of medicine over its knowledge base. The development of other health care professions with comparable skills is also diminishing medicine's dominance. Writing 10 years after this original publication, Haug looked at the world again, and found that these concepts were still valid, but that deprofessionalization had not taken place to the degree she expected.15

McKinley,16 a very eloquent Marxist, felt that medicine was being "proletarianized." Physicians are workers in a capitalist society and must sell their services. The competitive environment leads to a decrease in remuneration and professional autonomy. Corporate sector involvement accelerates this trend. Looking at the United States, McKinley identified the projected surplus of physicians and felt that this would allow the corporate sector to play off groups of physicians against each other to decrease their remuneration. In fact, this describes the present situation in the United States beautifully. Paul Starr, in his Pulitzer-Prize-winning book, The Social Transformation of American Medicine,17 stressed the corporatization of medicine. In a very interesting and effective way, he outlined how both liberal and conservative policies have led to increased corporate control. He also stated something that we in Canada know is true: when the state becomes a purchaser it acts like a corporation, trying to decrease unit costs, although it is immune from the profit incentive. Many authors have talked about bureaucratization, which goes back to Weber,18 who first described it. (We actually live in a Weberian society.) He felt that professionalization would be a means of organizing society, and that skilled professionals would provide stability to society as older organizations such as guilds and religion diminished in importance. The process of bureaucratization involves the subordination of practitioners, patients or institutions to a hierarchical structure outside the profession. We know something about that in this country. Many of the bureaucracies to which we are subject are external, either in the state or the corporate sector. Their aim is to implement cost control. What we tend to forget is that many of the bureaucracies to which we are legitimately subject are internal, in universities, hospitals, licensing bodies and professional associations. These internal bureaucracies are essential parts of our self-regulatory process. We do not recognize that, when we resent the bureaucracies to which we are subject, we are, in fact, denying self-regulation. All of these bureaucracies intrude upon autonomy, many appropriately.

Our beliefs, in looking at the sociology literature, are as follows. The dominance of medicine is decreasing for a variety of factors; dominance of all professions is also decreasing. Within the health care field, medicine remains the dominant profession. We believe this decreased dominance is inevitable but we also believe that we must remain the dominant profession, simply because our body of knowledge is so large and is the knowledge all other health care professions must cope with. That doesn't mean that we shouldn't abandon some areas legitimately, for the welfare of society. Proletarianization is an important factor in the decrease in status and autonomy, particularly in the United States and in the private sector in the United Kingdom. Although it is less of a factor here, it will become one if we privatize, because we will certainly go to some type of health maintenance organization or insurance arrangement. Deprofessionalization certainly has occurred, but it is not yet a very significant factor. Corporatization and bureaucratization are major trends throughout the world. They are probably the principal threat to our autonomy, and they are with us for the foreseeable future. You cannot run complex, science-based capitalist or socialist societies without bureaucracies, and we are, like it or not, going to have to live with this fact.

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Ethics

Ethics deals primarily with the healer, who is a professional in our society and must be considered a professional in the Anglo-American world. The literature must deal with the professional, but it rarely does so explicitly. There is a confusion of roles. That is why we believe it's important to separate the healer and the professional for analytical and pedagogical purposes. Ethics is concerned primarily with conflicts in society and their resolution. The contribution of the ethics literature to our understanding of professionalism is, however, important.19,20 Codes of ethics regulate the behaviour of the healer and the professional; they are clearly within the domain of ethicists. The physician­patient relationship is at the heart of medicine, as we all recognize, and ethicists have defined it and have consequently analyzed a part of the life of the professional. The relationship is fiduciary: we have an obligation to act in the best interests of those who come under our care. It is also based on trust, and there is a large literature indicating that mistrust is inimical to healing and that trust promotes healing. The relationship is characterized as inherently moral and as demonstrating virtue. The sociologists also believe that.

The concept of beneficence, doing good, versus its opposite, maleficence, is clearly important to society. It is understood that beneficence necessitates autonomy, and there is extensive literature on the autonomy of both the physician and the patient. Beneficence requires that the professional use his or her power for the good of the patient; this echoes criticisms found in the sociology literature. We are criticized repeatedly, often with justification, for putting the welfare of the professional and the profession above that of the patient, for failing to adequately self-regulate, for lacking accountability, and for failing to address societal problems.

Virtually all authors in both the sociology and ethics literature have commented on the changing role of the physician in society. The independent solo practitioner is becoming less common, yet the image of the practitioner as an independent professional is an important part of our self-image. It is also clear that, when we were independent solo practitioners working for fees paid by patients, we had a much greater ability to demonstrate altruism. It is very difficult to demonstrate altruism in a society in which everybody's fee is paid by a third party. This has caused us difficulties, and will continue to do so. However, the employment status of physicians in society is more important. We are members of groups, we are entrepreneurs in a competitive environment, we are employees, and we are also managers. All of this is difficult for us to fit into our codes of ethics. The objectives of the state and the marketplace are often in conflict with the ideals and obligations of both the healer and the professional. Much of the current controversy in medicine springs from this conflict of roles, and the resolution must include compromise, which requires an understanding of the roles and the areas of conflict, if we are to preserve what is important.

The literature has changed in the last 10 to 12 years, and it has become less critical of us. Not surprisingly, Marxist views have lost ground. State and corporate control over the organization of health care has increased, and the public understands this. The state and corporations are receiving more blame for defects in the health care system, and we are receiving less. It is understood that we are no longer in charge. There are some hints in the literature, in particular from a wonderful sociologist at the King's Fund named Rudolph Klein,21 that states are going to give us enough autonomy so that we can share the blame. They don't really wish to be perceived as directing things. Professionalism and the concept of service are again regarded as beneficial. The literature is suggesting making changes to improve our performance, rather than taking the system apart and putting it back together. Of great symbolic importance is that Friedson's last book, published in 1994, was entitled Professionalism Reborn.22 When he came to the end of his career he looked at professionalism, and at the various methods of organizing complex services in society, and concluded that professionalism, as modified to work under a bureaucracy, was of greatest benefit to society. Pessimism is not appropriate. Change isn't all bad. It's just different. The core values of the healer remain our greatest asset, and this has been emphasized in the literature in recent times. The public is actually our ally. Patients do not wish decisions to be made by either a corporation or the state; they prefer decisions to be made by their doctor. Those of us from Quebec remember former health minister Marc-Yvon Côté's health care law, which was very effectively countered by a coalition of the medical profession in a series of advertisements showing physicians in traditional, familiar roles. The caption read, "Do you wish decisions about your health care to be made by a bureaucrat or by this doctor?" The premier of Quebec at the time, Robert Bourassa, forced Côté to change the law. Thus, the public is our ally. In 1939, Marshall said, "In spite of its failings, professionalism is based on the real character of certain services. It is not a clever invention of selfish minds."23 I think this is probably something that most people believe.

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Conclusions

What are the implications for the educational establishment? We believe that educational institutions, in the broadest sense, must teach professionalism as a concept. They must teach it specifically and in a structured way. Professionalism must also be part of the socialization of physicians. In the past, one was supposed to understand what professionalism was, and what professional obligations were, by copying role models. We believe that professionalism should be present in undergraduate and postgraduate programs and is important enough to be reinforced in continuing medical education. The curriculum should emphasize specific ideas. We beleve that the interdependent concepts of the physician as healer and as professional must be taught separately because they have separate origins. Further, the definition, characteristics and origins of professionalism must be outlined. We think that professionalism must be taught as an ideal to be pursued, and that the nature of individual and collective autonomy must be discussed, together with the limitations to that autonomy. We believe that a general knowledge of codes of ethics for both the healer and the professional must be taught, including their historical and philosophical origins. Teaching materials should include relevant literature from social scientists and ethicists. Students of medicine should not be allowed to avoid critical literature; such avoidance would allow them to maintain the mystique referred to earlier.

The professional's obligations to society, and the reasons for their existence, should be taught explicitly. These include the following. One must know the appropriate codes of professional behaviour and be guided by them. One must know the relevant national and regional laws and regulations. One must maintain competence throughout a career, and there is a obligation to the profession as well as to society and to individual patients to do so. One must be prepared to be accountable for all decisions, which requires that these decisions be based on data. We have specifically avoided referring to evidence-based medicine because we think that this is a "buzzword," but the responsibility remains to be able to justify everything that one does. One must promote the expansion and integrity of the knowledge base of medicine. That's what empowered us. Without science, we're faith healers. One must understand the obligation to participate in effective and transparent self-regulation, both by serving on regulatory bodies and by being regulated as a professional. Lay involvement in but not control of regulating bodies should be encouraged. Lay involvement opens up the process and promotes trust. Physicians must involve themselves in health care issues that society believes are important. There is an obligation to place the welfare of the individual patient above one's own, and this should be done as publicly and noisily as possible. One has an obligation to ensure the maintenance of sufficient autonomy to serve the patient. That, in fact, is a very important obligation at the present time. We have a role as patient's advocate, and intrusions into our autonomy are increasingly interfering with this role. Finally, all physicians should be governed by the same standards, regardless of what position they occupy, whether they are self-employed, employees, managers or employees of the ministry of health. We remain physicians, and we are governed by the same codes of ethics. Guidance is only starting to appear for physicians placed in these roles, but it is of great importance.

One might legitimately ask, Last fall, the King's Fund sponsored a conference on this very question. Participants concluded that it should. Before the conference, we had come to our own conclusions. We continue to believe that professionalism is of benefit to society. It is very hard to provide solid evidence to back that opinion because, when one looks at countries that do not have independent self-regulating professionals, their health care statistics are often as good as or better than ours. However, theoretically, professionalism is a superior form of organizing complex services. It is superior because, if one gives autonomy, one increases motivation. If professionalism is considered an ideal, higher standards will be achieved. But we must remember that professionalism isn't the only way. We could have medical curricula decreed by a ministry, as happens in many countries. We could have entrance requirements decreed by ministries. If we don't do our job, professionalism and the independence that goes with it will not survive.

In summary, the physician must be both healer and professional. The roles are different, but one must fill them at the same time. Professional status requires that trust be maintained, and trust depends upon medicine meeting its obligations. We believe that physicians will meet these obligations if they understand both their nature and their origin, but it concerns us that many professionals do not understand these. Our schools of medicine must make professionalism an integral part of the teaching of medicine. In this way we will both serve society and protect the integrity of medicine. I would like to close by saying that Wendell MacLeod would not need to be taught these things. He would understand them intuitively, and his life has been governed by all of the things I have discussed here today.

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References
  1. Oxford English Dictionary. Oxford: Clarendon Press; 1989.
  2. Webb S, Webb B. Professional associations. New Statesman 1917;9(suppl):17-9.
  3. Brandeis L. Business: a profession. Boston: Small, Olaguard, 1914.
  4. Flexner A. Is social work a profession? School Soc 1915;26:901-11.
  5. Coburn D. Professional powers in decline: medicine in a changing Canada. In: Hafferty FW, McKinlay JB, editors. The changing medical profession: an international perspective. New York: Oxford University Press; 1993. pp 92-104.
  6. Friedson E. Professional dominance: the social structure of medical care. Chicago: Aldine; 1970.
  7. Friedson E. Profession of medicine: a study of the sociology of applied knowledge. New York: Dodd and Mead; 1970.
  8. Friedson E. Doctoring together: a study of professional control. Chicago: University of Chicago Press; 1980.
  9. Friedson E. The changing nature of professional control. Annu Rev Sociol 1984;10:1-20.
  10. Friedson E. How dominant are the professions? In Hafferty FW, McKinlay JB, editors. The changing medical profession: an international perspective. New York: Oxford University Press; 1993. pp 54-9.
  11. Friedson E. The future of the professions. J Dent Educ 1987;53:140-4.
  12. Johnson T. Professions and power. London: MacMillan; 1972.
  13. Larsen MS. The rise of professionalism: a sociological analysis. Berkeley (CA): University of California Press; 1977.
  14. Haug MR. Deprofessionalization: an alternate hypothesis for the future. Soc Rev Monog 1973;20:195-211.
  15. Haug MR. A re-examination of the hypothesis of physician deprofessionalization. Millbank Q 1983;66(suppl 2):48-56.
  16. McKinlay JB. Toward proletarianization of physicians. In: Derber E, editor. Professionals as workers: mental labor in advanced capitalism. Boston: G.K. Hall; 1982. pp 37-62.
  17. Starr P. The social transformation of American medicine. New York: Basic Books, 1984.
  18. Weber M. The theory of social and economic organization. New York: Oxford University Press; 1947.
  19. Bayles MD. Medical ethics. Belmont (CA): Wadsworth; 1989.
  20. Beauchamp TL, Childress JF. Principles of biomedical ethics, 4th edition. New York: Oxford University Press; 1994.
  21. Klein R. National variations in international trends. In Hafferty FW, McKinlay JB, editors. The changing medical profession: an international perspective. New York: Oxford University Press; 1993. pp 202-9.
  22. Friedson E. Professionalism reborn. Chicago: University of Chicago Press; 1994.
  23. Marshall TH. The recent history of professionalism in relation to social structure and social policy. Can J Econ Polit Sci 1939;15:325-40.
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