Professionalism as a Social Construct: The Evolution of a Concept.

Abstract

I n this issue of the Journal of Graduate Medical Education, the article entitled ‘‘Creating a framework for medical professionalism: an initial consensus statement from an Arab nation’’ by Abdel-Razig and colleagues provides another enlightening contribution to our understanding of professionalism in global terms and adds to the literature on professionalism in the Muslim world. Our comments will be directed to 2 areas of interest: (1) the evolution of our understanding of professionalism, and (2) a brief analysis of the consensus definition developed for the United Arab Emirates as compared to definitions in contemporary use within Western cultures. The independent and self-regulating professions, as we in Western society understand them, have their origins in Hellenic Greece, are derived from the guilds and universities of medieval Europe and England, and emerged in approximately their present form in the middle of the 19th century. Their moral foundations are deeply rooted in Judeo-Christian traditions of morality. The Anglo-American world has exerted significant influence on the concept of the medical professional, although the role of individual physicians and the medical profession is very similar throughout Western culture. It is significant that if one consults dictionaries in non-English speaking countries, the references to professions and professionalism almost uniformly relate to differentiating amateurs from professionals. The autonomous and self-regulating professions are largely absent. Definitions of professionalism from dictionaries of the English language stress service and the fact that the professions are granted monopolies over the use of specialized knowledge, with the understanding that they will deliver certain services and behave in prescribed ways. We, and others, have termed this a social contract. There is little question that, until recently, there was an assumption within the English-speaking world that this concept of professionalism was truly universal and applicable to all nations and all cultures. Indeed, the intent of the committee that created the International Charter on Medical Professionalism, to which the authors refer in their article, was to provide a document that would be universally relevant. We can attest to this, as we participated in the creation of the charter. It is difficult to know when social scientists arrived at the conclusion that there were major differences in the interpretation of professionalism in different contexts. Most sociologists believe that society uses the professions as a means of organizing work—in the case of the professions, work of a specialized and essential nature. Thus it is logical to believe that even early sociologists would find it natural for different countries and cultures to choose different means of organizing this work. What is certain is that, for at least the last 2 decades, social scientists have recorded that each country expresses professionalism in a slightly different fashion. In 1993, contributors to a volume edited by Hafferty and McKinley compared professionalism in 15 Western countries and China, and in 1996 Krause studied 5 professions in 5 Western nations. Both seminal works noted, along with many commonalities, significant differences in the nature of professionalism across national boundaries. The contributors to this literature stressed the differences imposed in patterns of medical practice by different health care systems, but did not probe into the impact of culture. The consensus was that professionalism was used to organize the services of the healer, and that there were differences in national organizational approaches imposed by different health care systems. Many assumptions long held by the medical profession in the Western world have been questioned in the course of an ongoing critical appraisal of professionalism in society that has taken place over the past half-century. These include the motivation of the medical profession to pursue its own selfinterest, the profession’s failure to self-regulate with rigor, its neglect of some issues of importance to society, and, of course, the relevance of the concept of the professions to countries with their own histories, cultures, and concepts of morality. Ho and colleagues systematically studied the differences between Western concepts of professionDOI: http://dx.doi.org/10.4300/JGME-D-16-00102.1