What’s the price of professional autonomy?
Are we willing to pay it?

We all need people in our lives who are willing to tell us “how it is”. These are special folks, often spouses, relatives or lifelong friends, whose relationship with us is strong enough to allow candid, honest, unvarnished commentary about topics close to the heart.

I found myself in a conversation with one such person recently who had the temerity to point out that Doctors, they have observed, can become somewhat self-absorbed and consumed with their own “specialness”, to the extent that they develop a certain blindness to issues of public concern or, at the very least, impose their own interpretation on such issues. During a time when the profession and government are engaged in rather intense dialogue on many public concerns, it’s certainly not difficult to find examples.

At about the same time, another friend (a physician in this case), dropped an article on my desk with the notation “I thought of you when I read this”. The article was entitled “Ministerial Ethics: A matter of character, conduct or code?” and was written by Joe E. Trull, an Associate Professor of Christian Ethics at the New Orleans Baptist Theological Seminary. Not being at all familiar with either Mr. Trull or the ministerial ethics literature, I was rather intrigued as to why my friend would have identified a connection. In reading the article, it became clear that the issues being engaged by clergy as they undertake their professional roles are remarkably similar to those facing the medical profession and, by extension, many groups that we might characterize as “professions”.

Historically, the term “profession” was initially applied to Clergy, Medicine and Law, groups entrusted respectively with the spiritual welfare, physical health and personal rights of all citizens. Many other groups have emerged with responsibility for other areas of social concern, such as nursing, engineering, architecture, pharmacy, and dentistry, to name a few. All are similarly described as “professions”, a term that has come to identify groups of individuals whose role in society is primarily to provide a needed service or role, with a degree of commitment to that cause which goes beyond their personal, individual interests. People who engage such roles are said to be “professionals”, and the concept of “professionalism” is ingrained in the values and training of such groups. It can also be said that any person who engages an occupation in a manner that puts the interest of those served above personal interests is practicing in a “professional” manner. The person who comes in the middle of a cold winter night to fix your furnace or re-establish your power supply can be said to be doing so, at least in part, because of a recognition of your critical need, and therefore providing a “professional” service.

There are several practical features that characterize a profession:

  • Professions have a defined and broadly acknowledged base of knowledge and skills.
  • Professions control or strongly influence their educational processes.
  • That educational process always entails some period of practical training within the practice setting – a derivation of the traditional apprenticeship.
  • Professions control or strongly influence the selection processes for entry to training, and therefore to the profession itself.
  • Professions have societies or organizations that define and maintain standards of practice, define methods by which those standards can be demonstrated, and publicly identify individuals who have achieved them. Membership in those organizations is accepted by society as evidence of competence.

There are also a number of more personal attributes and values that have been identified with professions. Professions are often characterized as “vocations”. The term implies that those drawn to practice professions are somehow “called” to do so. It suggests that they perceive, for whatever reason, a sense of deep and personal purpose in the engagement of that work. It further implies that those engaging professions view their work as an important service to society, and perceive that service as their main purpose and source of fulfillment in life. People who “profess” to serve within a particular domain commit to do so whenever and however the opportunity to serve may arise. It’s significant that the very word “profession” has dual meanings: not only is it a “special occupation”, but also an “avowal, or promise”.

Professions are afforded a considerable degree of autonomy, which relates to a number of practical considerations. Established members of professions best understand their cognitive and skill based “turf”. They are therefore essential to teaching it to others. Their practice experience makes them best suited to define the standards of practice of the profession, and to identify the personal qualities that characterize those best suited to enter and practice the profession.

But above these practical considerations, the autonomy arises from a societal trust that those “called” to practice a profession are motivated solely by the desire to ensure that the quality of that service is maintained to all who require it. In the words of Eliot Freidson, author of Profession of Medicine: A study of the sociology of applied knowledge (University of Chicago Press, 1970), “the occupation sustains its special status by its persuasive profession of the extraordinary trustworthiness of its members”.

But this “extraordinary trustworthiness” comes with a price. There exists an understandable societal expectation of any autonomous professional group.

Responsible professionals:

  • Do not withhold their service from those in need.
  • Do not withhold their service for the purpose of personal gain.
  • Can be relied upon to provide the highest quality work and recognize when they have fallen short
  • Ensure their knowledge and skills are maintained
  • Commit to their responsibilities regardless of clock or calendar
  • Ensure continuity of their responsibilities when they themselves are no longer in a position to provide.

Of all the recognized professions, perhaps none has undergone greater change over the past century than Medicine. The tremendous expansion of knowledge and potential therapies, emergence of specialties, sub-specialties and increasingly focused practices, and need to navigate an increasingly demanding and complex health care system have increased the physician’s role without a commiserate increase in authority. These considerations result in greatly increased personal demands and make it more difficult to achieve the expectations listed above, particularly when combined with a very understandable desire on the part of physicians to protect their personal time and health.

In addition, many of these challenges have brought the profession into conflict with government, which, in our society, is ultimately responsible for ensuring the safety of its citizens and distribution of resources, and have a clear mandate to do so through our electoral processes. A delicate and mutually respectful balance between those who possess and safeguard the necessary skills, and those entrusted to ensure their safe and effective provision seems increasingly difficult to achieve.

So, it appears that the existence of an autonomous medical profession benefits society for all the reasons noted above. It seems equally clear that autonomy is a privilege that must be earned, and is based in trust. That trust, in turn, is rooted in the selfless provision of care, doled out through careers as a series of individual, thankless acts.

Are we willing?

convocation-s-archer

© Photo by Stephen Archer

This past week I participated in two events that are relevant to this issue. The first was the convocation ceremony for our 2015 graduating class. I’ve had the opportunity

to get to know these hundred new physicians quite well over the past four years and, as I watched them receive their degrees, I felt nothing but optimism for the future of an autonomous and vibrant profession, probably much better suited to meet the mounting challenges than was my generation.

belliveau_smallTwo nights later, I attended the retirement dinner of a Queen’s colleague, Dr. Paul Belliveau, who has been active in medical education both locally and nationally, all while maintaining a very active practice in colorectal surgery. The hall was full of faculty from various departments, nursing colleagues, therapists, residents, hospital and faculty leaders, who participated in a very sincere and touching recognition of Paul’s varied contributions. At one point during the evening, his longstanding administrative assistant read a long list of tributes from patients who Paul had treated over the years. All were grateful for the care he’d provided, but all emphasized the compassion and humanity of the man. It was clear that their trust has indeed been earned.

As I was participating in these two events and contemplating the content of this article, it became clear to me that my students and Paul Belliveau were providing the answer to my question. Yes, the profession has been, and will continue to earn that privilege of autonomy, not through edict or legislation, but one patient at a time.

 

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education

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