Professionalism Is Redemption

What is likely to be most at risk for the professions is their freedom to set their own agenda for the development of their discipline and to assume responsibility for its use. Thus, the most important problem for the future of professionalism is neither economic nor structural but cultural and ideological. The most important problem is its soul.(1) --Eliot Freidson

Medicine and the other traditional professions developed in a world in which access to specialized knowledge was not readily available to most people. The special skills required to treat disease are developed through a prolonged medical education and presume that such work is “so specialized as to be inaccessible to those lacking the required training and experience, and . . . cannot be standardized, rationalized, or commodified.”(2)

Such professions have unique control over their own work and thus are afforded a considerable degree of power and privilege. Consequently, holders of such specialized knowledge have specific obligations to those whom they serve due to the unequal relationship in power.

Much of the medical literature prior to the late 20th century that addressed the conceptual requirements of professionalism, therefore, emphasized the “right” behaviors by physicians in their interactions with their patients. In his essays on the physician-patient relationship in 1888, for example, S. Weir Mitchell, MD, LLD, stated that:

The physician cannot be a mere intellectual machine. None know that better than we. Through all ages, we have insisted that he shall feel himself bound by a code of moral law, to which, on the whole, he has held without questions, while creeds of more serious nature were shifting and changing.(3)

Weir focused on privacy (“He must guard the secrets wrung from you on the rack of disease.”), empathy (“The capacity to enter into, to realize, and hence to feel with and for you.”), objectivity (“I once saw a very young physician who burst into tears at the sight of a burnt child, a charming young girl. He was practically useless for a time.”), and truthfulness (“One is troubled to do what is right and to say in answer to their questions what is true.”) as qualities of the physician’s professionalism.(4) He believed that the physician must be one who is “competent, clear-headed, honest, scrupulously careful” but not “plain, ill-dressed, and uninteresting.”(5)

By the late 20th century, the emphasis on specific types of professional behavior was codified in standards of professional ethics that focused on the responsibilities of the physician:

. . . diagnosing the patient’s condition, informing and educating the patient about his condition, including its prognosis if treated or untreated and about the various possible treatment alternatives, recommending the course of action that the physician considers the best medical approach for that individual’s problems, and, carrying out those procedures, for example, monitoring, prescribing-that are required by the approach chosen for the patient.(6)

These specific behavioral responsibilities are integrated into the basic precepts of moral theory embedded in the values of autonomy, nonmaleficence, beneficence, and justice such that veracity, privacy, confidentiality, and fidelity are used as standards for defining appropriate clinical behavior.(7)

Beauchamp and Childress’s work in biomedical ethics in the 1980s and 1990s sought to “move beyond principles, rules, obligations, and rights” and into a framework based on “virtues, ideals, and aspirations for moral excellence”(8) based on compassion, discernment, integrity, and conscientiousness “such that an Aristotelian framework in which innate human virtues are developed by appropriate training and exercise.”(9)

They specifically discussed virtues and ideals in professional life within the metaphors of saints and heroes and cite four conditions(10) of moral excellence that must be met to achieve this heroic professional status:

• “Faithfulness to a worthy moral ideal.”

• “A motivational structure conforming to patterns of virtuous persons.”

• “An exceptional moral character.”

• “Deep personal integrity.”

These constructs of medical professionalism, defined within the context of moral behaviors obligated by the power invested in the authority of specialized knowledge, are in direct conflict with the rise of managerialism in the 20th century, which is based on “the authority to command, organize, guide, and supervise both the choices of consumers and the productive work of specialists.”(11) Managers have power by virtue of their authority to allocate resources necessary for work.(12)

The rise of complex organizational infrastructure in the 20th century is the result of the invention of management in which claims of general knowledge that is “superior to specialization because it can organize it rationally and efficiently and falls back on its own special kind of preparation for positions of leadership — an advanced but general formal education that equips them to direct or lead specialists, consumers, and citizens.”(13) Thus the “ideology of professionalism, which is generally rooted in specialization, contends with the challenge of populist generalism advanced by consumerism and elite generalism advanced by managerialism.”(14)

As complex organizations rose in the 20th-century medical industry, the necessity of managerialism created a direct challenge to the traditional power and authority implicit in the old definitions of professionalism. The authority of the medical profession became relegated to the limited arena of their field of specialized knowledge. Rather than serving as an autonomous institution granting professional control over their work, the specialized knowledge was to “serve rather than command in the market and polity.”(15)

As Freidson’s “ideology of professionalism” indicated, a concern that the traditional professions were undergoing a process of “deprofessionalization” manifested by the late 20th century. The democratization of information by the Internet further challenged traditional views of professional authority. The tension between the authority granted professionals due to their expertise with the populist denial of any authority to specialized knowledge “literally deprofessionalized the labor force, the labor markets, and the organization of work.”(16)

Many have claimed the professional status of medicine is weakening due to the access to medical information now available to the public through the Internet. Claims of authority based on specialized expertise alone do not permit adequate rationalization for authority if expertise is not seen as a quality separate from information.

The ideology of managerialism that denies authority to expertise by claiming its form of general knowledge is superior to specialized knowledge for allocation and organization of resources cannot in and of itself challenge professionalism without excluding the additional claim on the part of professionals that expertise must be coupled with specific forms of expected behavior. Thus, many of the recent approaches to medical professionalism have rediscovered the traditional focus on moral virtues and behaviors and sought to redefine professionalism within new social roles.

The American Medical Association (AMA) code of ethics from 1957 to 1980 urged physicians to be “upright” and “pure in character and diligent and conscientious in caring for the sick.”(17) From 1980 to 2000, the AMA’s code of ethics deemphasized virtues except for the admonition to “expose those physicians deficient in character or competence.”(18) However, by 2001, the AMA refocused on moral virtue within the context of social responsibility.

In December 2001, the American Medical Association (AMA) issued its Declaration of Professional Responsibility.(19) In this declaration, physicians’ duties are aligned with their global commitment as:

• Healers of the sick.

• Protectors of patient privacy and confidentiality.

• Drivers to work toward advances in medicine.

• Supporters of initiatives for the education and advocacy of change that improves the health and wellbeing of humanity.

In 2015, the Journal of the American Medical Association (JAMA) took a deep dive into professionalism, in one article emphasizing the responsibility and accountability of medicine to self-govern and self-regulate(20) and the ability to enhance professionalism through management skills in another.(21) Both points of view focused on how medical professionalism requires an updated approach to professionalism that keeps pace with the changing environment in which physicians practice:

The leveling effect of social media and the Internet have changed the way citizens relate to each other and to their institutions, demanding a much more participatory and engaged style of leadership and more shared models of authority . . . physicians are continuously connected, embedded in teams, and reliant on technology and many other individuals to meet the needs of patients. Physicians confront previously unrecognized issues, like safety, shared decision making, and the expectation that physicians need to be involved-continuously-in making care better.(22)

How should medical education be changed to enhance professionalism? One possible way is to incorporate systematic business and management education in medical school. . . . For physicians to improve their organizations’ ability to reduce errors, improve patient safety, recognize and improve quality of care, incorporate new knowledge, ensure equitable care, reduce waste, and facilitate provision of services based on patients’ values and interests, physicians need better management skills.(23)

The ideology of management, with its historical grounding in the development of complex organizations in the business community, is focused on planning, organizing, directing, controlling, monitoring, and decisional roles within companies.

Although social responsibility and ethics are discussed within management theory, the ethical emphasis tends to be on effectiveness and efficiency that make up much of the value system of capitalistic business models rather than personal and ethical responsibilities traditionally embodied in relationships between physicians and patients. So while the healthcare delivery system is most frequently organized into institutions with specific missions, visions, and values pertinent to the care of patients, the utilitarian approach to ethics that pervades business and organizational culture is substantially and qualitatively different from the individual relationship-based traditional and ethical approaches in medical professionalism.

However, the juxtaposition of the contrasting ideologies of managerialism and professionalism in the contemporary healthcare delivery system creates the opportunity for medical professionalism to be redefined not simply by areas of specialized medical expertise but also by unique, expected forms of behavioral and personal responsibility focused on service to patients.

The self-regulation of behavior that is intrinsic in the traditional autonomy granted to professions is as critical to maintaining status as a profession for physicians in the 21st century as it has historically been, and it must be focused on keeping patients safe, practicing high-quality care, and promoting health policies that are in the public interest.

An overemphasis by specialty societies and organized medicine in the financial and social wellbeing of physicians will lead to the public seeing physicians as one more special interest group looking out for itself and will lead to deprofessionalization of medicine as the public reacts with regulatory and market-based responses to perceived grievances. Thus, physicians must frame their claims to professional status not only in technical expertise but also codes of behaviors based on stewardship, servant leadership, and patient-centered approaches to policy advocacy.

Physician professional status is threatened when the caregiver aspects of the healer role are not incorporated into the overall cultural role. Sociologically, underemphasizing care-giving permits others to fill that important responsibility:

Thus, American medicine, which has increasingly relied on the culture’s male values of heroism and efficacy to legitimate its interventionalist healthcare, has faced serious challenges from competitors justifying their own presence in the healthcare field with the female values of nurturance and forethought.(24)

Leicht and Fennell argue that the work that managers and professionals do is starting to look more similar due to changes in professional work brought on by the exponential growth in concerns about the accountability and prerogatives exercised by professionals resulting in external regulatory controls disrupting traditional professional routines.(25)

The perception of managers that they are entitled to control certain areas by virtue of their own judgments as managers led to a crisis of accountability on the part of medical professionals that is creating a convergence in the roles of professional and manager as physicians reacquaint themselves with the need for accountability within their professional role.

However, as physicians are increasingly employed by organizations where traditional sources of professional power are constrained, there is also a tendency for the development of stratification within the profession.(26)

In such complex organizational environments, the need to understand the general constructs that unify medicine as a profession must be understood within the diverse roles in which physicians practice.

Expertise and organizational role will deprofessionalize medicine without a commonly accepted understanding of expected behaviors, virtues, and values that are self-regulated, universal, and socially relevant regardless of institutional context.

This existentialist approach to medical professionalism provides a basis for leadership and differentiates the professional role of the physician from those aspects that are increasingly convergent with management or technical content experts, such as can be found in vocational fields such as engineering or airline piloting.

REFERENCES

1. Freidson E. Professionalism: The Third Logic, Chicago, IL: The University of Chicago Press; 2007, p. 213.

2. Freidson, p. 17.

3. Mitchell SW. Doctor and Patient. Philadelphia, PA: J.P. Lippincott Company. 1988. Reprinted special edition, Classics of Medicine Library. Bethesda, MD: Gryphon Editions;1994, p. 43.

4. Mitchell, pp. 43-48.

5. Mitchell, p. 53.

6. Jonsen AR, Mark Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 2nd Ed. New York, NY: Macmillan Publishing; 1986, p. 12.

7. Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 4th ed. New York, NY: Oxford University Press; 1994, pp. 395-461.

8. Beauchamp, p. 502.

9. Beauchamp, p. 48.

10. Beauchamp, pp. 494-5.

11. Freidson, pp. 116-17.

12. Freidson, p. 149.

13. Freidson, p. 149.

14. Freidson, p. 117.

15. Freidson, p. 121.

16. Freidson, p. 116.

17. Freidson, p. 139.

18. Beauchamp, p. 464.

19. American Medical Association. Declaration of Professional Responsibility. Medicine’s Social Contract With Humanity. Adopted by House of Delegates of the American Medical Association on December 4, 2001.

20. Baron RJ. Professional Self-regulation in a Changing World: Old Problems Need New Approaches. JAMA.2015;313(18):1807-8. doi:10.1001/jama.2015.4060.

21. Emanuel EJ. Enhancing Professionalism Through Management. JAMA. 2015:313(18): 1799-1800.doi.10.1001/jama.2015.4336.

22. Baron, p. 1807.

23. Emanuel, p. 1799.

24. Abbott A. The System of Professions: An Essay on the Division of Expert Labor. Chicago, IL: University of Chicago Press; 1988, p. 188.

25. Leicht KT, Fennell ML. Change in the Organizational Context of Managerial and Professional Work. In: Professional Work: A Sociological Approach. Oxford, UK: Blackwell Publishers; 2001, pp. 96-132.

26. Leicht, p. 174.

Excerpted from Reframing Contemporary Physician Leadership: We Started as Heroes by Grace E. Terrell, MD, MMM, CPE, FACP, FACPE.