Correspondence
Medical Professionalism in Society
N Engl J Med 2000; 342:1288-1290April 27, 2000
- Article
To the Editor:
The article by Wynia et al. (Nov. 18 issue)1 is a praiseworthy attempt to describe comprehensively the emergence of medical professionalism, but it omits the important role of the government in defining and licensing the profession in a democratic society.
Historically, society has attempted to assure its citizens of safe and effective medical care through the licensure of the profession. Beyond licensure, it has relied on the ethical values of the profession and its social contract with society to provide an adequate supply of physicians through medical education and training. Despite problems, this social contract has worked quite well. Even more can be said for the spectacular growth in the biomedical-research enterprise.
The failures in the social contract are largely in health services. For decades, the organized medical profession, as represented largely by the American Medical Association (AMA), regarded government as an enemy and strongly resisted the political will of the people to extend services. Its bitter opposition to the passage of Medicare was one of the fiercest attacks on legislation during the past century. Small wonder that the public — and political leaders in particular — came to regard the AMA as a proprietary interest group.
The failure of the organized medical profession to deal with rising health expenditures is also important. Without proactive policies to define “how much is enough” and to deal with the concerns of public officials, employers, and the public, it was inevitable that entrepreneurs would emerge and, especially through managed care, become dominant in determining how medicine is practiced and how health policies are formulated. The recent congressional legislation to regulate managed care is a public reaction against corporate entities directing the practice of medicine.
Although the authors of the article suggest an archetypal model of medical professionalism entailing three elements, “devotion, profession, and negotiation,” the context must be emphasized. Individual physicians can subscribe to these principles, but unless there is organized support, little will change. The medical profession needs to reestablish its social contract with society. It must stop viewing public officials as the enemy and develop better ways of responding more broadly to the interests of the public.
1 ReferencesJulius B. Richmond, M.D.
Leon Eisenberg, M.D.
Harvard Medical School, Boston, MA 02115-60191
Wynia MK ,Latham SR ,Kao AC ,Berg JW ,Emanuel LL . Medical professionalism in society. N Engl J Med 1999;341:1612-1616
Full Text | Web of Science | Medline
To the Editor:
Many authors, including ourselves,1 have chosen to define professionalism more precisely than by characterizing it as a collection of attributes or behavior patterns. We believe, however, that the approach taken by Wynia et al. is valid. It has been translated into recommendations offering guidance to the practicing physician. Wynia et al. imply that the inherent morality of professionalism has always been questioned. Virtually all early observers believed that the expected commitment to service was the basis of the morality of professionalism, and this idea was not questioned until the middle of the 20th century. Thus, the authors are actually recommending a return to the foundations of professionalism.
The authors elevate the importance of the professions to a level equal to that of the state and the corporate sector, a view not supported by the literature or current reality. According to the literature, it is the complex and sensitive nature of the services required that justifies professionalism, and morality is a prerequisite for the trust required for its maintenance. Krause2 authoritatively documents the loss of power among the professions in recent years, making the equality suggested by Wynia et al. unachievable.
The relationship of physicians to professional associations is mentioned only obliquely. Wilensky3 documented the fundamental role of associations in establishing professions, and all other observers have commented on their importance. If every professional were guided by the principles outlined by Wynia et al., the public's belief in the moral basis of professionalism could still be threatened by the actions of associations mandated to serve as a source of expert advice and to act on behalf of the professions. Obviously, individual members must feel responsibility for the activities of their professional associations, given the consequences of these activities. Guidelines for the conduct of associations have been proposed.4 Some guidance for physicians would have been appropriate.
4 ReferencesRichard L. Cruess, M.D.
Sylvia R. Cruess, M.D.
McGill University, Montreal, QC H3A 1A3, Canada1
Cruess RL ,Cruess SR . Teaching medicine as a profession in the service of healing. Acad Med 1997;72:941-952
CrossRef | Web of Science | Medline2
Krause EA. Death of the guilds: professions, states, and the advance of capitalism, 1930 to the present. New Haven, Conn.: Yale University Press, 1996.
3
Wilensky HL . The professionalization of everybody? Am J Sociol 1964;70:137-158
CrossRef | Web of Science4
Pellegrino ED ,Relman AS . Professional medical associations: ethical and practical guidelines. JAMA 1999;282:984-986
CrossRef | Web of Science | Medline
To the Editor:
Doctors today have less ability to promote noble virtues because their everyday realities involve maintaining a minimally acceptable level of satisfaction, security, and control in their jobs. As an academic sociologist who studies the changing work lives of individual doctors,1-3 I am disappointed at the continuing inability of those who ponder the nature of professionalism to incorporate these realities into their models. When talked about at an abstract level, professionalism sounds perfectly reasonable. But reasonable is not the same as achievable. These days, the less rhetorical and more important discussion should revolve around how the profession can integrate physicians' larger moral imperative with their specific (and increasingly diverse) job demands. Without this discussion, we run the risk of being left with a word, “professionalism,” whose bark remains more powerful than its bite.
I have interviewed and surveyed hundreds of physicians in my research. Although probably not one of them, in an “ideal” situation, would not advocate the professional tenets Wynia et al. describe in their article, probably not one at present also has the ideal blend of enthusiasm, time, focus, and energy to be the strong professional activist the authors envision. Moreover, some of the ways in which Wynia et al. expect individual doctors to promote their brand of professionalism do not jibe with the realities of physicians' everyday lives. For example, these research subjects would most likely venture that it is problematic to express “dissent” against organizations (an example of “professional activism” Wynia et al. advocate) when those organizations increasingly hire and fire them, provide them with salary and patients, and allow them balanced lifestyles that include family and other non–work-related interests. Maybe we need to add a fourth element to the model proposed by Wynia et al. — the element of stewardship, which recognizes a physician's professional ethic at the same time as it recognizes his or her need to survive as a worker. Blending physicians' workplace realities into any ideal of professionalism makes the latter that much more pragmatic.
3 ReferencesTimothy J. Hoff, Ph.D.
State University of New York at Albany, Rensselaer, NY 121441
Hoff TJ ,McCaffrey DM . Resisting, adapting, and negotiating: how physicians cope with organizational and economic change. Work Occup 1996;23:165-189
CrossRef | Web of Science2
Hoff TJ . Same profession, different people: stratification, structure, and physicians' employment choices. Sociol Forum 1998;13:133-156
CrossRef | Web of Science3
Hoff TJ . The social organization of physician-managers in a changing HMO. Work Occup 1999;26:324-351
CrossRef | Web of Science
Author/Editor Response
The authors reply:
To the Editor: Richmond and Eisenberg raise important points. The complex interplay of professional associations and the government deserves more attention. They note that more than individual attention to professionalism is necessary to support social change; organized medicine must support health values and advocate for them in discourse with the government. We agree.
In the spirit of engaging professional associations, the emphasis placed by Cruess and Cruess on the responsibility of physicians with respect to professional associations is similarly appropriate. Many professional associations have enough democratic representation in their proceedings that individual physicians must recognize their responsibility for shaping — or failing to shape — the association.1 Pious dissent and private opposition to the policies of a professional association without activism for improvement from within are no more admirable or useful than failing to vote in government elections and then grumbling about the nation's leadership. In addition, although it may seem currently unachievable for the profession to regain the moral credibility needed to become the equal pillar of society that it should be, this should not be an excuse for lassitude. Some trends must be fought even if victory is not in sight. But it is also not so clear that a return to true professionalism is unachievable. A full understanding of the values that we serve, especially if reinforced through well-functioning professional associations, should help to reunite us within our collective calling in society.2 We hope in future work to address more fully how both individuals and associations can reestablish trustworthiness under the auspices of the values and people we serve.
We also concur with Hoff that the nature of the work environment needs rigorous assessment and prompt change to allow the values of the public and of patient health care to thrive. Toward that end, we have founded Ethical FORCE (Fundamental Obligations Report Card Evaluations), a multidisciplinary research program, to create valid performance measures of ethical conduct by institutions so that accountability is achievable in a helpful fashion.3,4 We have also engaged in research to determine what structures drive intolerable conflicts between health care needs and other values.5 Much more work of this nature is needed.
5 ReferencesLinda Emanuel, M.D., Ph.D.
Matthew Wynia, M.D., M.P.H.
American Medical Association, Chicago, IL 60610Stephen Latham, J.D., Ph.D.
Quinnipiac School of Law, New Haven, CT 065181
Emanuel LL. Professionalism and accountability in managed care. In: report of the 1996 ABIM Summer Conference. Philadelphia: American Board of Internal Medicine, 1996:67-72.
2
Emanuel LL . Systems ethics in health care. Camb Q Healthc Ethics 2000;9:151-168
CrossRef | Web of Science | Medline3
Emanuel LL . Professional standards in health care: calling all parties to account. Health Aff (Millwood) 1997;16:52-54
CrossRef | Web of Science | Medline4
Wynia MK . Performance measures for ethics quality. Eff Clin Pract 1999;2:294-298
Medline5
Kao AC ,Green DC ,Zaslavsky AM ,Koplan JP ,Cleary PD . The relationship between method of physician payment and patient trust. JAMA 1998;280:1708-1714
CrossRef | Web of Science | Medline
- Citing Articles (2)
Citing Articles
1
Kirk L. Smith, Rebecca Saavedra, Jennifer L. Raeke, Alice Anne O’Donell. (2007) The Journey to Creating a Campus-Wide Culture of Professionalism. Academic Medicine 82:11, 1015-1021
CrossRef2
Edward Lowenstein. (2004) Cardiac Anesthesiology, Professionalism and Ethics: A Microcosm of Anesthesiology and Medicine. Anesthesia & Analgesia927-934
CrossRef
