An analysis of the discourse of professionalism

Abstract

The field of medicine as a clinical profession is widely perceived to be under siege these days, though the perceived assaults come from a confusing combination of directions. Managed care organizations, government regulators, competing professional groups, "alternative and complementary" practitioners, vengeful lawyers, crusading political activists, unhappy consumers (formerly known as patients, and now unhappy for all sorts of reasons), and others attack from the outside. Meanwhile from within, the explosion of new medical information, the inability to clarify the roles of generalists and specialists, the growing concern about health disparities and the social determinants of health, the persistent inattention to prevention, the catastrophe of tens of millions who remain uninsured or underinsuredall of these crises (and any of us could name yet more) have made the clinical practice of medicine an uncertain and troubled occupation. This, in turn, has made basic medical educationthe preparation of new practitioners enormously challenging. One response to the crises in medical practice and medical education has been a call for a "renewed professionalism." The American Board of Internal Medicine (ABIM, 1995), the Association of American Medical Colleges (AAMC, 1998), and other professional organizations and individual educators (e.g. Pellegrino, 2002) have issued calls for a return to the ideals at the moral core of the profession of medicine. The discussion, as it is most commonly framed, focuses primarily on inculcating in physicians a set of (not particularly controversial) virtues, such as altruism, duty, and integrity. These virtues have been widely criticized as too vague, and not surprisingly, some commentators have called for more precise, concrete, and measurable definitions (Connelly, 2003; Wear & Nixon, 2002). The issues that underlie the recent calls for a renewed professionalism within medicine deserve focused attention, such as the concern for excellence in patient care, the appropriate regulation of practitioners, and the need to adequately serve community needs. However, we believe that the proposed approach is not an effective or useful response to the multiple crises in medical education. The problem is not just a matter of the ambiguity of the invoked virtues, but rather that efforts toward definitional precision and measurement rely on a mistaken view of language and of the relationship between language, social institutions, and practice. An even more fundamental problem is the effort to locate the solution to systemic problems of medical education and practice in the virtues of individual physicians. We will argue that the "renewed professionalism" movement reflects deeply held (though confused) beliefs about the role and status of professionswhat we will call "the discourse of professionalism." This discourse of the professionalism is powerful in part because of its ideological confusion; that is, its ambiguity works to unify and solidify social networks and interests, and to make that unity seem natural and inevitable. However, the organizing work of professionalism discourse has become increasingly untenable, and the tensions within this discourse especially as it is used within medicineare becoming more difficult to avoid. The discourse of medical professionalism is not likely to be salvageable through the "new professionalism" project. What is instead required is the more difficult (and politically charged) project of renegotiating the social contract between physicians, communities, and other occupational groups. This paper will begin with a discussion of two broad models of language, the conventional one of language as a symbolic or representational system, and an alternate one, in which language is seen as a social practice. We will then examine the social context within which the discourse of professionalism is enacted and the multiple purposes it serves. In particular, we will focus on the recent changes in social and cultural institutions and practices upon which medical professionalism depends and through which it occurs. Recent calls for a "new professionalism" tend to ignore those institutions and social changes (as well as the problematic aspects of the profession's claims to authority and power). As a result, the movement is limited in its ability to help physicians and educators cope with those changes and transform those institutions, or to help contemporary communities negotiate more effectively with the medical system to meet their own needs. Finally, we will address how the confluence of discourse theory and the rhetoric of virtue ethics offers the potential to see a more useful direction for the reform of medical education and medical professionalism. © 2006 Springer Science+Business Media, LLC.