Spring 2004, Volume 4, Number 2 ajob W3 Open Peer Commentaries Professionalism and the Social Role of Medicine Peter L. Twohig, Saint Mary’s University Chris MacDonald, Saint Mary’s University There is much to commend in Wear and Kuczewski’s “The Professionalism Movement: Can We Pause?” (2004). The reforms they suggest are generally progressive. However, we identify three signiªcant failings in the article. The ªrst is the adoption of a relationship-centered approach to professionalism, which fails to acknowledge that the pro- fession is more than a collection of individual relation- ships. Second, Wear and Kuczewski focus on only the academic medical environment, to the exclusion of non- academic clinical care. Finally, Wear and Kuczewski’s fail- ure to recognize the complexity of the question of the social role of medicine leads them to endorse, too uncriti- cally perhaps, a social-justice perspective for individual physicians. Indeed, all three failures arise from Wear and Kuczewski’s failure to recognize the complexity of the question of the social role of medicine. Professionalism under Seige Medicine regards itself as a profession under siege. The President of the Australian Medical Association declared in 1995 that new “threats” appeared on a weekly basis, from “government, bureaucracy, or allied health groups wanting some of our territory” (Weedon 1995). States are actively shaping delivery models, rationalizing resources, facilitating the introduction of new kinds of providers, or expanding the scope of practice of existing providers. The social organization of healthcare workers is now character- ized by integrated care models, multidisciplinary teams, or other such innovations (Cott 1997; Jenkins, Carr, and Dixon 1998). There is, therefore, some need to understand how various political processes, social contexts, and ªnancial constraints shape professional relationships and health policy. The dramatic changes to the social organization of healthcare have prompted a number of statements on pro- fessionalism to be issued. For example, the Medical Profes- sionalism Project (MPP), launched in 2000 as a joint ini- tiative of the American Board of Internal Medicine Foundation (ABIM) and the European Federation of Inter- nal Medicine (see http://www.abimfoundation.org/mpp 2003/index.html), poses the question “why is raising awareness about the core value of medical professionalism important?” Their response invokes the accelerating pace of change within healthcare and its broad scope and, more speciªcally, issues such as the rise of managed care, union- ization of residents and physicians, and the role of the pharmaceutical industry. The MPP concludes that “medi- cal professionalism is universally endangered” and that a “united front to inºuence and inform the culture and con- text of both clinical practice and medical training are par- ticularly timely, appropriate and needed.” Relationship-Centered Medicine It is clear that the terms of the social contract between pro- fessional medicine and the people it serves are changing in response to changes in knowledge (such as the rise of evi- dence-based medicine), technological innovation, and the organization of health services. Among the most impor- tant transitions in clinical care has been the rise of the “pa- tient-centered” approach. Patient-centered care seeks to create “expert” patients and to develop shared approaches to the management of disease (Stewart et al. 1995). Wear and Kuczewski’s position extends the patient- centered model to a relationship-centered model of profes- sionalism. That is, they claim that medical students and residents will learn more about professionalism through its daily enactment with particular patients than through “abstractions.” The difªculty with this “relationship- centered professionalism,” as McCullough (2004) points out, is that it inevitably leads to individual practitioners starting “their reºections from scratch,” without reference to the prior knowledge, debates, or theory of professional- ism in medicine. This does damage to the notion that the medical profession is grounded in a body of shared knowl- edge. Further, the focus on individuality is at odds with our best understanding of professional ethics: the moral foundation of professionalism is the shared ethical stan- dards of the professional group, decided on collectively and enforced through self-regulation and peer review. This implies an important role for “abstract” notions such as duty. A strategy of relationship-centered professionalism would do little to invigorate professionalism in medicine at a time when “the value and even the validity of medical professionalism have been called into question” (Canadian Medical Association 2001). We concur with Jecker’s ob- servation (2004) that an abstract theory of professionalism serves an important function for the profession as a group. The existence of a theoretical model of professionalism might reveal some of the assumptions that prevail within a subset of medicine or, indeed, individual practitioners. The presence of an abstract idea of professionalism de- centers the assumptions of the individual (and those of their subdiscipline, institution, or local community), causes individuals to reºect on their own assumptions (and those prevailing around them), and in this way enriches and invigorates the very idea of medical professionalism.