By SUSAN ADELMAN, MD
What is a profession? The on-line Oxford Dictionary defines a profession as “a paid occupation, especially one that involves prolonged training and a formal qualification.” What is a guild? The same dictionary defines a guild as “a medieval association of craftsmen or merchants, often having considerable power…[or] an association of people for mutual aid or the pursuit of a common goal.” What are proletariat? This dictionary defines proletariat as “workers or working-class people, regarded collectively. (often used with reference to Marxism)” also, “the lowest class of citizens in ancient Rome.”
What attributes characterize a profession? According to the Association of Accredited Public Policy Advocates to the European Union, these are “great responsibility, accountability, based on specialized, theoretical knowledge, institutional preparation, autonomy, clients rather than customers, direct working relationships, ethical constraints, merit-based, and morality.” Further, “A profession makes deliberate choices where others have choices made for them or they simply react to what comes their way.”
Remember, Karl Marx defined the proletariat as “the social class having no significant ownership of the means of production (factories, machines, land, mines, buildings, vehicles) and whose only means of subsistence is to sell their labor power for a wage or salary.”
Which one sounds more like medicine today? When I entered the medical profession over 50 years ago, almost all doctors were in private practice, a large proportion in solo practice, and they were joined in fellowship through multiple memberships in professional societies and associations. Southeast Michigan had regional pediatric societies, two surgical societies, two medical honor societies, strong county medical associations, and an affiliated state medical society. There also were active ethnic medical societies, and hospital medical staff physicians held meetings four times a year. Hospitals had doctors’ lounges, where doctors met and socialized over coffee. If a threat to the profession arose, real or perceived, members of the profession shared their reactions, after which they complained to their professional societies, which represented them before the appropriate authorities.
Now most physicians are employed, with few remaining active societies, virtually no hospital staff meetings, no cozy doctors’ lounges, and little in-person contact with colleagues in other specialties. Professional contacts now are within employment groups, and deeply disgruntled or oppositional doctors must be careful how loudly they complain, lest they lose their jobs. Few doctors take their grievances to their country or state medical associations anymore because they are too busy or have little enthusiasm for collective action. Many of them are hostile to unions too, the modern way of trying to effect change.
Today, doctors who are employed – that means most doctors – have their hours and appointment times determined by a hospital or clinic, their office notes restricted to computer program spread sheets, their billing controlled by hospital billing departments, and their payments meted out by insurers. They have no ownership of their clinics or offices, and their wages are determined by their employers. Karl Marx’s ideal?
So, is medicine today still a profession? Or are we proletariat, punching in, and punching out? Not that there is anything wrong with that, Seinfeld would say, but I am just asking.
If we are in danger of no longer being a profession, is there anything we can do? Or do we not care? Should we form or join unions? Many argue that would mean we no longer are professionals. If that is not what we wish, we must reinvigorate our medical societies, come back, pay our dues, demand meetings, instruct our lobbyists to work on issues we care about, send meaningful resolutions up to the AMA, volunteer for committees, and show up.
Yes, medical schools can accept or refuse applicants, and state boards of medicine still are authorized to take away licenses when deemed appropriate. Granted, specialty societies have control over our board exams and recertification. At least those aspects of professionalism remain. But hospitals and clinics dismiss doctors today for promulgating or prescribing treatments that are in political disfavor, even for publishing contrary opinions on social media. And I do not mean proposing swallowing bleach. I mean prescribing an approved drug that has been used safely in the past for one condition and later is tried for another.
All this said, we have not even touched the subject of AI. Will AI be so much better that it displaces real doctors for increasing numbers of medical purposes? Will it be even more formidable competition than nurse practitioners and physician assistants are? Can doctors successfully rise to all these competitive challenges? Can they do it alone? Or do they need to be part of a profession or a guild to help them remain professionals? Will they recognize this need in time to save their profession?