Most professions have discourse about the "professional." Merriam Webster's dictionary defines professions as "a: a calling requiring specialized knowledge and often long and intensive academic preparation b: a principal calling, vocation, or employment c: the whole body of persons engaged in a calling." Professions define themselves in part by excluding others.
Professionalism can be described in terms of power relations. Setting the bounds of knowledge, professionals take the position of agents who know better, and to whom decisions about appropriate action should fall. The ways in which professionals impose these "realities" on "lowers" are sustained as "regimes of truth" through discourses, institutions and practices.1,2
Paul U. Unschuld is a medical sociologist, sinologist and historian. He has made important contributions to the knowledge of traditional Chinese medicine (TCM) and is currently Professor and Director of the Horst-Goertz Institute for the Theory, History, and Ethics of Chinese Life Sciences, Charite Medical University-Berlin. Here is a paraphrase of his ideas about professionalism: There are responsibilities of a profession that include the protection of access to the resources, tools and materials; protection of the right to make decisions over fees for services (autonomy); efforts that protect rights to professional judgment and the decision about when to provide services; and efforts to develop the body of knowledge that composes the discipline.3 To which should be added, an ethics statement.
Confucian social values presented a complex scenario that was averse to the professional practice of medicine. They attempted to avert the rise of special occupational groups so as to create a literate class who could perform as required by the government. Individuals who identified with the professional practice of medicine were discouraged. During the Yuan dynasty (1271-1368CE), many Confucian intellectuals were jobless and turned to the practice of medicine for a living; they promoted the idea that ethical practice required expertise. Their opponents published anecdotes of physicians killing and cheating patients. The Confucians eventually began to publish cases that advertised their approach to medicine.3,4
Sun Simiao (540–682CE) influenced the practice of Chinese medicine. He is likely the first to have published the Chinese equivalent to the Hippocratic oath. The origins of ethical codes were located in two areas: first, as an offering or benediction, and secondly, in the attempt to influence public opinion. Traditional Chinese Medical physicians have powers to harm and heal; they are allowed into a patient's private life in ways that others may not. They are also asking deeply personal questions that require high levels of propriety. It is through these propositions that physicians began to professionalize.3
In the West, law, medicine and theology were the only available professions as late as the opening of the 19th century.5 With increasing economic power came an interest in education. At the close of the 19th century, a booming middle class heralded the rise of multiple professions.5 These trends also culminated during the 1970s, when a degree virtually guaranteed employment for those who desired to work. Compare this to 2011, 40 years later, where we see a large part of the unemployed population with degrees. Degrees remain useful, however, since there are twice as many unemployed workers who have no college education.6
Acculturation to a profession and its values are important features of preparing a practitioner at the entry level. Society clearly benefits from an individual with sufficient focus to gain the skills for trades and professions. Licensing is created in order to demarcate those who are prepared to provide service and prevent those who are not prepared from participating in the social and economic gains thereof.
One of the primary purposes of a professional education is to provide the student with the core knowledge and skills sufficient to perform professional obligations. These include core competencies of practice as well as an awareness of the professional's contract with society. There are limits to what is possible. Famous medical educator, William Osler circa 1900 at Johns Hopkins University makes the point; "We cannot hope to teach them everything necessary to enter practice. The best we can hope for is to inspire them to lifelong learning."7
But, herein lies the risk. As technical expertise narrows, it becomes a greater source of wealth and power. Thus, professionals become engulfed in ever more specialized groups and each specialist's feeling of responsibility for the whole become diminished. Ethical judgments can be construed in overly technical terms, thus imperiling their broadly human significance.5
Legal code defines the license and scope of practice. Such distinctions create a monopoly upon opportunities, privileges and resources, excluding outsiders, who are defined as inferior and ineligible. Similarly, members of a profession may define sub-specialties with exclusive privileges.
Some professions seek to include others scope of practice. Note in particular, chiropractors and physical therapists, wishing to practice acupuncture. This strategy of inclusion might be dismissed as an attempt to usurp powers maintained by the elite and privileged class that holds monopoly.8,9 Further, there is risk these practices related to turf protection can contribute to sociopolitical and socioeconomic conditions that are isolated and disconnected.
Positive expressions of professionalism serve as the basis of Chinese medicine's contract with society. Such a contract involves: placing the interests of patients above those of the physician, defining standards of competence, and providing expert advice to society on matters of health. Public trust in the practitioner is essential to this contract because it depends on the integrity of the individual physician and the profession as a whole.
This article is designed to raise consideration for some of the complexities that take place in the development of a profession. A historical framework was provided and more importantly a concern for how a profession demarcates itself, defining a specific set of knowledge, skills and abilities that are used to define those who may participate and those who may not. Such ideas are important in the dialogs about who can provide acupuncture and who may not.
References
- Reason P, Bradbury H. Handbook of action research. Thousand Oaks: Sage Publications; 2006.
- Elden S. Discipline, health and madness: Foucault's Le pouvoir psychiatrique. History of the Human Sciences. 2006 February 1, 2006;19(1):39-66.
- Unschuld P. What is Medicine?: Western and Eastern Approaches to Healing. Berkeley, CA: University of Calfornia Press; 2009.
- Morris W. Case Study: An Approach to Knowledge. 2011.
- Wilshire B. The Moral Collapse of the University: Professionalism, Purity, and Alienation. Albany: State University of New York Press; 1990.
- Jones R, Scanland K, Gunderson S. The Jobs Revolution; Changing How America Works. Chicago: Copywriters Inc.; 2004.
- Osler W. The Evolution of Modern Medicine; a series of lectures delivered at Yale University on the Silliman Foundation in April, 1913. New Haven: Yale University Press; 1913.
- Parkin F. Strategies of social closure in class structure. London: Tavistock; 1974.
- Hollenberg D. Uncharted ground: Patterns of professional interaction among complementary/alternative and biomedical practitioners in integrative health care settings. Social Science & Medicine. 2006;62(3):731-44.
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