Physicians' dual roles — as healer and professional — are linked by codes of ethics governing behaviour and are empowered by science.
Being part of a profession entails a societal contract. The profession is granted a monopoly over the use of a body of knowledge and the privilege of self-regulation and, in return, guarantees society professional competence, integrity and the provision of altruistic service.
Societal attitudes to professionalism have changed from supportive to increasingly critical — with physicians being criticised for pursuing their own financial interests, and failing to self-regulate in a way that guarantees competence.
Professional values are also threatened by many other factors. The most important are the changes in healthcare delivery in the developed world, with control shifting from the profession to the State and/or the corporate sector.
For the ideal of professionalism to survive, physicians must understand it and its role in the social contract. They must meet the obligations necessary to sustain professionalism and ensure that healthcare systems support, rather than subvert, behaviour that is compatible with professionalism's values.
A distinguished journalist has stated that with globalisation has come "a sense that your job, community, or work place can be changed at any moment by anonymous economic and technological forces that are anything but stable".1 Medicine has not escaped this phenomenon. In developed countries it has changed in one or two generations from a cottage industry to one consuming a significant portion of each country's gross domestic product. Solo practice has become rare, new payment methods have appeared, primary care and specialised medicine have become more complex, and public expectations have altered dramatically. In all parts of the developed world physicians have had to adapt to a new and sometimes unfamiliar world work environment. Most have three concerns:
their ability to provide quality care;
the threats to their clinical autonomy; and
Among the many responses of the medical profession to the present situation has been an effort to rearticulate and re-emphasise the values that have traditionally characterised medicine.
In society, the physician fills two roles — that of a healer and a professional.4 In the Western world, the healing tradition goes back to Hellenic Greece, and the Hippocratic Oath (or its modern derivative) has long been an important part of the self-image of the physician.5 The professions have their origins in the guilds and universities of medieval Europe and England. During these times physicians served only the élite, until the Industrial Revolution provided sufficient wealth for healthcare to be purchased, and science made it worth purchasing.4-9 The two roles of physicians are linked by codes of ethics governing their behaviour in both roles, and by science which empowers both roles.
A working definition of "profession" from the Oxford English Dictionary,10 with elements drawn from the literature, is:
An occupation whose core element is work, based on the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning, or the practice of an art founded on it, is used in the service of others. Its members profess a commitment to competence, integrity, morality, altruism, and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.
The contract between professions and society is relatively simple. The professions are granted a monopoly over the use of a body of knowledge, as well as considerable autonomy, prestige, and financial rewards — on the understanding that they will guarantee competence, provide altruistic service, and conduct their affairs with morality and integrity. In outlining the characteristics of a profession, the obligations which the profession acquires will be linked with each characteristic.
There is general agreement that the raison d'être for professions is the complexity of the specialised knowledge which each profession controls.6-8 In spite of modern information technology, this knowledge is not easily understood by the public, and consequently the professions are given substantial control over its use. In this, they acquire responsibility for its integrity, for its proper application, and for its expansion, which, for medicine, means the support of science. Finally, professions have an obligation to transmit their knowledge by teaching it to future practitioners, the general public, and their patients.
The knowledge is used in the service of others. For almost two millennia, physicians used their knowledge primarily to benefit individual patients. The complexity and cost of healthcare during the past quarter-century have resulted in medicine acquiring an obligation to serve the wider society as well, involving such issues as access to healthcare and a just distribution of finite resources.11
There is agreement that the trust placed in the professions12 and their privileged status are only justified by the expectation that they will be altruistic. For physicians this means consistently placing the interests of individual patients and society above their own.7,13,14 Professions must be devoted to the public good.
Another important characteristic of a profession is autonomy. Individually, physicians are granted sufficient autonomy to act in the best interests of their patients.7,8 Until late in the 20th century, autonomy was expressed in a paternalistic fashion, but modern society, recognising patient autonomy, now views the physician–patient relationship as a partnership.15
The profession is also granted collective autonomy through self-regulation.4,6-8 It has the privilege and obligation to set and maintain standards for education and training, entry into practice, and the standards of practice. It must guarantee the competence of its practitioners, and has an absolute obligation to discipline unprofessional, incompetent, or unethical conduct.
Professional associations and licensing bodies are characteristic of all professions.4,7 They operate with State-sanctioned authority, which may be altered if society becomes dissatisfied with their performance. Collegiality helps to establish common goals and encourage compliance with them.16 Their role in self-regulation is major, as is the expectation that they will advise the public as experts in their domain. The associations and licensing bodies have a primary role in guaranteeing the quality of healthcare services.
Medical associations also have an obligation to protect the interests of their individual members. The two roles can conflict and professional associations have not always managed this conflict wisely, being seen to ignore the public's interests in favour of their own.3,17 This has contributed to a loss of trust in all professions, including medicine.12 Because the function of professional associations is so important, they require the support of their members. Individual physicians are responsible for the actions of their associations.
For centuries, physicians were accountable to their patients and to their profession.2,7,15,18 The importance of modern healthcare to society's well-being, coupled with its cost, has engendered a new accountability at economic and political levels.19 Thus, physicians continue to be accountable for patient care and self-regulation, while acquiring accountability for the financial impact of their decisions and for the health and the well-being of populations.19,20
The professions are expected to be moral, ethical, and carry out their activities with integrity.13,14,18 Indeed, professionalism has been defined as "an ideal to be pursued",18 recognising that physicians will not always meet all of the conditions required, but must continually strive to do so.
Not only are individual physicians expected to demonstrate morality and virtue, but so are the institutions which represent them.21 Thus, professional associations and licensing bodies must not engage in activities which detract from the morality and integrity of the profession. Finally, morality and virtue must be integral to the rules, processes and procedures by which medicine governs and regulates itself.22
The literature on the professions is extensive, but, until recently, was found almost exclusively in the social sciences and philosophy, and thus was difficult for physicians to access. This is unfortunate, because there were times when the literature was highly critical of the medical profession. It both reflected and helped to shape public opinion and public policy, and physicians were unaware of its impact on the perception of the profession. In the past decade, analyses have appeared in publications readily accessible to physicians.4,23-28
From the early 1900s until the 1950s, the literature was supportive of the concept of professionalism.29-34 It described the professions, the rationale for their being, and stressed the service commitment of individual professionals. It recognised the conflict between altruism and self-interest, but believed that commitment to service would result in altruistic behaviour.
In the questioning society of the 1960s,7,8,35-39 the literature changed. It asserted that physicians exploited their monopoly to create a demand for services which they then satisfied.37,39 It identified serious failures in self-regulation,7,35,39 and abuse of collegiality to protect incompetent or unethical physicians. It criticised physicians for pursuing their own financial interests at the expense of both individual patients and society. Finally, it questioned the benefits of professionalism to society.35-37,39
With the growing importance of governments and the corporate sector in healthcare, the literature of the past two decades has shown a significant shift.6,13,18,22 It documents the fact that medicine has lost control over the medical marketplace, no longer dictating its structure, methods of payment, or levels of remuneration.20 Depending on the country, control shifted from the profession to the State and/or the corporate sector. Social scientists recognised that organising healthcare around models based on either State or corporate control imposes different goals and values from models which are structured around professionalism. They have returned to support the "professional model"22 as being more value laden, but remain unanimous that professionalism must be devoted to the public good — one observer calls it "civic professionalism".13
The changes in healthcare systems throughout the developed world have been dramatic, resulting in medicine having diminished input into major policy decisions by the State and corporate sector.8,20 The increased complexity and cost of modern medicine undoubtedly made this inevitable, but the consequences for the profession have been substantial. The application of "accounting logic"20 to the practice of medicine has intruded into the autonomy of individual practitioners.6,11,17 As the profession participated in the process of renegotiating its social contract with society, it has been at a disadvantage and has not done so effectively. The negotiations appear to primarily concern methods and amounts of remuneration, as well as patterns of practice, but there is evidence that physicians are as worried about the values of their profession as about financial issues.40 Thus far, values do not seem to have been a distinct issue at the negotiating table.
The principal threats to medicine's professional status come from public mistrust of the profession as a whole. Two major factors contribute to this mistrust — public perception that medicine failed to self-regulate in a way that can guarantee competence, and that it put its own interest above that of patients and the public.13,17,22 The well-publicised Bristol affair,41 and the reports on medical errors in Australia42 and the United States,43 have contributed to the belief that medicine has protected incompetent or unethical colleagues in the name of collegiality. This belief persists in spite of regulatory procedures becoming more rigorous and more open.
Medicine's reputation for altruism was easier to maintain before the advent of national health services. The tradition of caring for those who could not afford medical care was strong. The virtual disappearance of the truly medically indigent patient in most developed countries, and the necessity to negotiate for both levels of remuneration and details of practice, have accentuated this problem. In addition, the dual role of medical associations8,17,44 — acting as expert advisors on matters of health as well as representing their members — has created a difficult conflict of roles. The literature on professionalism is surprisingly kind to the motivation and performance of individual doctors, but is highly critical of the performance of medical associations.6,8,22
Can the ideal represented by professionalism be preserved in a way that will give continued meaning to the practice of medicine? There are reasons for hope.13,17,22,45 As control of healthcare has passed from medicine to the State and the corporate sector, so has the blame for defects in the healthcare system. Patients remain attached to their physicians and do not wish either the State or corporate sector to make decisions about their care. The public and physicians share a view of the changes needed in healthcare systems.6 Thus, there is an opportunity for medicine to rebuild trust.
Medicine has several opportunities for action.
Because professionalism is at the core of medicine's social contract, physicians must understand the origins and nature of professional status, and the obligations necessary to sustain it. Professionalism must be taught explicitly, and those serving as role models require detailed knowledge of professionalism.4,23 The growing medical literature on how to teach and evaluate professionalism,4,23-28 the initiatives taken by educational and certifying bodies26,46,47 and the important recent elaboration of an "International Charter on Professionalism"48 aid in this venture.
Medicine's professional associations must be extremely wise in how they negotiate for their members.17 Any hint that the public good is being ignored during these negotiations can be damaging to the credibility of the profession and result in loss of the trust, which is so essential to the healing process.3
The privilege of self-regulation entails an absolute obligation to guarantee the competence of members. The setting and maintenance of standards is of overriding importance, and issues such as recertification and revalidation are, without question, now regarded as professional obligations. The disciplining of unethical or incompetent practitioners must be rigorous, open, and have the support of every practising physician. A heavy price has already been paid for failures in this domain.
Individual physicians must consider the consequences of being seen to put self-interest above that of their patient. Altruism and ethical conduct must serve as the backdrop against which medicine is practised.
Even if the medical profession itself carries out the above actions, it is unlikely that the values cherished by physicians for centuries can be preserved unless their preservation is encouraged and supported by society through the structure of the healthcare system. Healthcare systems can actively promote desirable behaviour or they can encourage physicians to place their own interest first. If undue competition among physicians is promoted by the system, one should not be surprised if competitive physician-entrepreneurs emerge. If medical manpower policies coupled with payment methods actively encourage physicians to see large numbers of patients to maintain an adequate income, they will do so. Physicians will maintain professional values, but not at any price.49 Thus, the support of policy makers in preserving a value-based healthcare system becomes critical.50 For this to occur, the issue must be considered to be important by those negotiating on behalf of the profession.
In closing, it is worthwhile to quote William Sullivan, a prominent medical sociologist: "Neither economic incentives nor technology nor administrative control has proved an effective surrogate for the commitment to integrity evoked in the ideal of professionalism."13 Without question, the medical profession itself wishes to function within a system dominated by a healthy and flourishing professionalism. As Sullivan22 and Freidson50 point out, there should also be substantial advantages to society in preserving professionalism as an effective value-based system. The original reason for the use of the profession as a means of organising healthcare was because of the complexity of the knowledge base, the difficulty in regulating it, and the presumption that the profession would be altruistic and devoted to the public good. We believe that nothing in the past 150 years has altered that fact. Thus, both society and the profession should wish for the same type of physician — competent, moral, idealistic, and altruistic. This is best guaranteed by a healer functioning as a respected professional.
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