Abstract
For at least the past several decades, medicine has been embroiled in a crisis concerning the nature of its professionalism. The fundamental questions that drive this ongoing crisis are primarily three. First, what is the nature of medical professionalism? Second, who are medical professionals? Third, what does medicine or these professionals profess or promise? In this paper, the professionalism crisis vis-à-vis these questions is examined and analyzed chiefly in terms of both Francis Peabody’s and Edmund Pellegrino’s writings. Based on their writings, I introduce a conceptual framework for professionalism to address the crisis. In addition, I contend that to address the professionalism crisis adequately, medicine’s position within an evolving health care network must also be considered. To that end, I first discuss the genesis of the crisis in terms of the Flexner Report and especially Peabody’s response to it. Next, I explore how the crisis intensified during the twentieth century, particularly in terms of medicine’s ultimate scientification and eventual commercialization, and how Pellegrino reacted to this. I then propose a health care professionalism cycle and a care-competence cycle to provide a conceptual framework for addressing the crisis. I conclude that medicine’s position is no longer as the center of health care but rather as another node within a wider evolving health care network. And the resolution of medicine’s professionalism crisis depends on medicine’s positioning and defining itself in terms of the professionalism for each of the other professions within the health care network.
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Notes
It is interesting to note that, as Daniel Sulmasy argues, Peabody’s article on the care of the patient [3] and Pellegrino’s scholarly work on professionalism in clinical medicine [4] would most likely not pass contemporary peer review. But this probably says more about problems with the peer review system than with the quality of either Peabody’s or Pellegrino’s works.
In prefatory remarks to the report, Roosevelt writes:
New frontiers of the mind are before us, and if they are pioneered with the same vision, boldness, and drive with which we have waged this war we can create a fuller and more fruitful employment and a fuller and more fruitful life. [11, p. 4]
Medicine was certainly part of that new frontier of scientific progress.
Although Fig. 1 captures many of the components of the health care network, other components, such as family members, health care administrators, and politicians, are missing. In addition, connections between particular nodes are missing, such as between doctors and nurses or medicine and hospitals. Part of the reason for the lack of comprehensive representation and interconnection is that the figure is more patient-centered than it is health care-centered.
Indeed, medicine cures few diseases, especially chronic diseases. It mainly manages diseases, particularly their symptoms. As Eric Cassell [19] argues, the aim of medicine should be to reduce suffering, which translates to Peabody’s caring for and Pellegrino’s helping the patient in returning toward some semblance of wholeness, which constitutes healing.
To generalize Pellegrino’s tripartite structure in terms of health care, the act of medicine should be christened the act of health care and then each health care profession can define that act in terms of its specific professional responsibilities. So the nursing profession, for example, would certainly exhibit the first two acts, with its act of health care being branded the act of nursing.
The notions of pathos, logos, and ethos, according to Aristotle, can function rhetorically [42]. To that end, pathos refers to emotional appeal, logos to rational appeal, and ethos to ethical or moral appeal.
The similarity with other professionalism models provides a kind of justification for the proposed health care professionalism cycle, especially in terms of embedding medical professionalism in an evolving health care network.
Peabody’s locution, “For the secret of the care of the patient is in caring for the patient” [10], has been criticized as being “circular” [4]. However, it is not circular in terms of begging the question, since care has two meanings for Peabody. The first is the care of the patient that involves taking care of the patient technically, and the second is the care for the patient that involves being motivated emotionally to care for the patient.
Although the process of unification may not be clear initially, the union of health care professionals must be realized to resolve potential conflicts between health care professionals and business administrators.
Medical commercialization and its impact on medical professionalism are more than simply about money; rather, they are about power. Commercialization has empowered to participate in health care those who have been marginalized traditionally by medicine’s hegemony. The patient in particular has been empowered to seek others within the health care network, especially within complementary and alternative health care, such as acupuncturists, chiropractors, herbalists, and homeopaths, as well as nurse practitioners, among others.
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Marcum, J.A. Professing clinical medicine in an evolving health care network. Theor Med Bioeth 40, 197–215 (2019). https://doi.org/10.1007/s11017-019-09492-x
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DOI: https://doi.org/10.1007/s11017-019-09492-x