According to Wikipedia, up to the beginning of the 19th century there had been only 3 occupations that were considered to be professions, Divinity, Medicine and Law.
A profession is considered a trade or occupation that transforms itself through “the development of formal qualifications based upon education, apprenticeship, and examinations, the emergence of regulatory bodies with powers to admit, discipline members, and enforce adherence to an ethical code of practice.”
Professionals are autonomous, with the “freedom to exercise their independent, professional judgment,” and have “a high degree of control over their own affairs.” All professions have power, used to control the conduct of its own members, as well as “exercise a dominating influence over its entire field which means that professions can act monopolist, rebuffing competition from ancillary trades and occupations.” A profession is characterized by the power and high prestige it has in society as a whole. It is the power, prestige and value that society confers upon a profession that more clearly defines it.
Physicians have historically been considered the cornerstone of medicine, one of the original and oldest professions. As a result, physicians have for many years now enjoyed a high social status, regard and esteem conferred upon them by society. This high esteem arose primarily from societies’ view and appreciation of the “higher social function of their work, which is regarded as vital to society as a whole” and thus of being special and holding valuable.
I do not believe that the majority of physicians today find themselves meeting many of Wikipedia’s defining characteristics of a profession. Neither as individual physicians, nor as a profession as a whole, do we find ourselves with any significant degree of autonomy, control or power over our own affairs.
Have we done as much as we could have to enforce our ethical code? Do we find ourselves dominating and truly in a position to protect our area of expertise? Have we done and are we doing all we can to ‘rebuff’ the competition? Over time we have gradually accepted being told more and more what to do and how to do it. I believe that to whatever degree we once may have met the defining characteristics of a profession, it was granted to us based solely upon our having survived the education, examinations and apprenticeship(s) we went through. At some point we probably had power enough to protect our area(s) of expertise, but I’m not sure we ever really made the most of it, or even realized we had it.
Over the last several years I believe that as physicians we have put up relatively little resistance to being told what our professional judgment will be, at least if we want to get paid, now referred to as reimbursed. This would not necessarily be all bad, if not for the fact that so much of what we’re being told is based upon cost to the payor and not true quality for the patient. Our government who started things off with entitlements has and is finding it necessary to weigh in even more heavily in order to keep our economy from taking a double dip, or prolonging its slow recovery.
Some hospital systems have formed foundation models, or other types of legal entities needed in their particular state, in order to buy, control and employ groups of physicians. Insurance companies are also getting into the act by buying both hospitals and physician groups. I wonder whose best interest is being considered here. Other hospitals, which are fortunate enough to monopolize their service area, are charging just about however much they want per overnight stay, and insurers have to pay, leaving that much less for physicians and the rest of the healthcare systems’ participants.
Upon entering the profession, I believe that many physicians did not realize that along with the privileges granted to them came the responsibility to guard and protect those privileges, the most important of which was the responsibility of making sure that things were always done in the best interest of the patient. Changes to the characteristics of our profession simply snuck up on most physicians. There has been a certain amount of conscious neglect on our part, most probably from being progressively overwhelmed by busy work, as well as not really knowing what to do about it. How best to protect our area(s) of expertise and/or rebuff the forces working to take away and assume our control, were not part of our education or training.
There has been a fair amount of talk for a while now about the needs for and benefits gained by all parties involved, (e.g. patients, physicians and hospitals) by joining forces and establishing better overall business models, like ACOs. Whether or not you agree with this concept is not as important as that you realize the following. If we care enough about the privileges we earned and the responsibilities that go along with them, it is well past the time that physicians unite, reach common ground, stand up for all that is needed to maintain our status as a profession, thereby allowing us to fight for and protect all that is in a patient’s best interest.
If we don’t, then we should simply expect our continuing transformation back from a profession to a trade or occupation, under the ever increasing control of others.
Richard A. Foullon is a family physician.
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