MEDICINE, PROFESSION OF

Professionalism is what distinguishes the professions. It gives each the character by which it is known. In our time many occupational groups have striven for professional status in a quest for authority, prestige, and income. "Professionalism, professionalization, and the professions are increasingly central to any grasp of modern societies," Nathan Glazer claims, "yet persistently elude proper understanding" (p.34). Many sociologists have written about the characteristics of professions, but most agree that all professions possess the five elements identified by Ernest Greenwood:

systematic body of theory;

authority to define problems and their treatment;

community sanctions to admit and train its members;

ethical codes that stress an ideal of service to others;

a culture that includes the institutions necessary to carry out all of its functions.

Jeffrey Berlant, following German sociologist and economist Max Weber's (1881–1961) theory that professionalization is a form of monopolization, lists the steps in the process:

creation of a commodity—in the case of medicine and law, services for a fee;

separation of performance of the service from the satisfaction of the client, which means that a cure need not be guaranteed;

creation of scarcity by reducing supply and increasing demand;

monopolization of supply and control of privileges by legal means, such as licenses;

restriction of group membership, such as admission to study or to hospital staff;

elimination of internal competition;

development of group solidarity and cooperation.

The attributes used to describe professions include responsibilities and privileges, both derived by social contract. It is important to remember that the terms of the social contract change with changing social and economic conditions, and hence may vary from one region or historical period to another. Thus professionalism cannot provide a permanent set of values or standards. Instead it offers a series of guidelines designed to help specific people in specific places resolve important conflicts that arise from the nature of their duties. Each society has evolved some of its own standards, based on its own structure, values, and technological capabilities. Some standards of professional behavior originating in modern industrial societies may be meaningless in other cultural settings (Hughes).

In medicine, historical changes can be illustrated with the example of specialization. Today, specialization is cited as a hallmark of professions. In nineteenth-century U.S. medicine, however, the doctor who specialized was often looked upon as a quack (Rosen, Stevens). Today the physician who claims to have knowledge and expertise in all of medicine would be looked upon with suspicion.

To pose the question "When did medicine become professional?" is like asking "When did medicine become modern?" There are elements of professionalism and of modernity in ancient Greek medicine, as there are in the medicine of the Middle Ages, the Renaissance, and the eighteenth century. The definitions of a profession that appeared in the literature in the early part of the twentieth century, which stressed urbanization and industrialization as prerequisites for the existence of a medical profession, are no longer held. Although it has been true that an industrializing society is a professionalizing society, so far as medicine is concerned there was professionalization long before industrialization (Goode).

Professionalism in medicine developed in a continuous historical process, beginning in antiquity with institutions like state physicians and fraternities of physicians such as the Asclepiads, continuing with the medieval medical guilds, medical schools, and licensing requirements. The modern period, especially after about 1700, is characterized by the emergence of such institutions as medical societies, medical literature, licensing laws, and codes of ethics. In the twentieth century the professional is the recognized expert with special qualifications, and the professional ideal has become a hallmark of modern society (Bledstein, Perkin).

The medical profession of the mid-nineteenth century was very different from the profession of a century later. Yet in both periods many of the characteristics of professionalism were readily evident. The modern model of professionalism—university-based, peer-controlled, and based on merit rather than birth—is derived from the criteria we now use to study professions. Earlier forms of professionalism may have had quite a different set of characteristics; for this reason, the historical dimension of professions becomes increasingly central to an understanding of the development of medicine. The professional character of medicine has always been derived, in good part, from the institutional participation of the physician. These social and legal institutions provide credibility for medicine as a profession (Hall).

Despite the centrality of the professions in the United States, scholars have only recently begun to trace their history (Brown; Calhoun; Haber; Hatch; Kett; Kimball). With a few exceptions, such as Daniel H. Calhoun, historians have not deemed it necessary to engage in comparative histories of the professions, leaving this to sociologists (Abbott; Berlant; Freidson, 1970; Larson; Mechanic, 1968; Rothstein). Although Eliot Freidson has claimed that the status of scholarship in the professions is in a "state of intellectual shambles" (Freidson, 1984, p. 5), the historian Thomas Haskell has noted that "there is really no longer any excuse for scholars working on the professions to be divided into two shops, one made up of people who try to explain what professions are, without ever grasping how they came into being; the other composed of people who try to understand how they came into existence, without being quite sure what they are" (Haskell). For medical historians, generally, as John Burnham has pointed out, it was not until after World War II that the subject of the professions moved to the center stage of history.

Andrew Abbott's review of the sociological literature of the professions is a concise summary of how modern societies have institutionalized expertise as professionalism. He describes the professionalizing process in terms of a series of jurisdictional disputes. These disputes over the professional boundaries of medicine in the nineteenth and twentieth centuries do explain much of medicine's history (Abbott). Samuel Bloom's history of the field of medical sociology traces its institutional formation.

During the last few decades of the twentieth century, when social historians began to depict medicine as oppressive and more interested in social control than in social melioration, medicine began to be subjected to much closer analysis of its professional attitudes, values, and styles. Medicine as a twentieth-century profession could not always get what it wanted, but until the mid-1960s and the passage of Medicare and Medicaid legislation, it had great success in resisting what it did not want. As the twentieth century drew to a close, this negative power had begun to diminish with increasing speed.

Medicine as a Profession in Antiquity

Much of what we have come to believe about ancient medicine we have inherited from the views of nineteenth-century scholars, who tended to create a picture of ancient medicine that reflected their own contemporary institutions (Nutton).

In early Greek antiquity, Homer portrayed doctors among the fighting heroes: "A doctor," he wrote, "is worth many men put together …" (Nutton, p. 15). Plato, in his Laws, described doctors and doctors's assistants, who were also called doctors: "These, whether they be free-born or slaves, acquire their art under the direction of their masters, by observation and practice and not by the study of nature—which is the way in which the free-born doctors have learned the art themselves and in which they instruct their own disciples" (Plato, p. 307–309). The Hippocratic physician was a craftsman, and despite the high status of some of the crafts, there were in ancient Greece as yet none of the restrictive practices of the guilds of later centuries (Edelstein; Temkin, 1953). Only in one of the Hippocratic works, the Oath, was there a clear description of a closed, family-like guild that restricted entry to outsiders. But this does not represent Hippocratic medicine as a whole (Edelstein). Since ancient times it has been true that there have been several classes of doctors, and patients have always received care depending upon their own station in life and that of their doctor. Recent new scholarship about the Hippocratic Oath reaffirms its historical importance but also stresses its complexity. It should not simply be ascribed to the followers of Pythagoras, as Temkin, in 2002, and Dale C. Smith have noted.

The Alexandrian Library was one of the earliest institutional influences on medicine. It was here, according to the second-century physician/scholar Galen, that the writings of Hippocrates and the Coan school in which he taught were first assembled (Nutton). The ancient Greek physician did not receive a scholarly or systematic training; such was left to those who became philosophers and rhetoricians. Galen claimed that the best physician is also a philosopher. This implied that medicine could be understood only in terms of natural philosophy—biology, chemistry, and physics. Such a lofty sentiment implied that medicine was for the benefit of the whole community rather than for the private gain of the physician. This was the ideal toward which medicine should strive, according to Galen. It is a professional ideal we still recognize (Horstmanshoff).

The Medieval Medical Profession

In the later Middle Ages, with the development of cities, the rise of commerce, and the creation of universities, doctors found an expanding market for their services. These developments, in turn, led to the development of medical faculties in the universities, the passage of laws that defined the minimum education required for the physician, and a more rigorous definition of medical competence. Thus the trappings of professionalism and professional organizations became more evident after 1050. Debates began about what were the appropriate standards for a license to practice medicine, and who was to define the criteria and to enforce them. In the thirteenth century, the battle over training and licensing was between the new universities and their faculties of medicine, and the trade companies or guilds. Universityeducated physicians formed a professional elite. Guilds became the formal licensing bodies in some of the Italian cities, but generalization is difficult (Park, 1992).

In Florence, the medical profession can be traced to the medieval guilds, such as the Guild of Doctors, Apothecaries, and Grocers, established in 1293. It was a protective association and asserted monopoly privileges. Medicine was considered one of the prestigious occupations, along with law, banking, commerce, and notary practice. What really elevated some of the practitioners of medicine, and hence the whole profession, was that they taught and wrote. These activities, not just medical practice itself, elevated medicine from a mechanical to a liberal occupation and from an art to a science (Park, 1985). Medicine's place in the universities assured it an important and enduring role in the intellectual life of modern society.

Since the medieval period, universities have been the key to the professionalization of medicine, although in some countries, such as Great Britain and the United States, there were periods when medical schools were quite separate from the university. In antiquity the institutions that we associate with professionalization of medicine did not yet exist, though there were certainly groups of healers who were united by rudimentary professional bonds. In the Middle Ages, medicine became a more distinct, high-status, and terminal occupation (Bullough).

In the Middle Ages, then, medicine as a healing activity became distinguishable from medicine as a branch of higher learning. In the twelfth century, King Roger II of Sicily and his grandson, Frederick II, instituted licensing examinations by the masters of the School of Salerno. The objectives were to ensure competence and honesty to protect both society's and the profession's interests. There was as yet, however, neither uniform licensing nor a uniform medical profession in medieval and early Renaissance Europe (Siraisi).

Guild controls and restrictions were justified in the fifteenth century, as they would be in the twentieth, by members who claimed they needed to maintain high standards of competence and proper professional behavior. With an increasing service sector of the economy and an increase of prestige once it became a university faculty, medicine gained in stature (Cipolla).

The Medical Professions in Early Modern Europe

In late-fifteenth- and early-sixteenth-century England, there was little order in the practice or regulation of medicine. In 1511 Henry VIII introduced some governmental control. Although the parliamentary legislation he secured created no organized group of physicians, it brought a measure of state control over medical practice and made way for the conferral of substantial powers on medical groups. It stipulated that no one could practice physic or surgery in London or seven miles around without a license from the Bishop of London or the Dean of Saint Paul's Cathedral, and it required an examination of all candidates for licensure before a panel of experts selected by those officials.

The three main corporations or guilds of medical practitioners in early modern England were the Physicians, the Surgeons, and the Apothecaries. While they did represent a fairly distinct division of labor, their separation, particularly in the countryside, was not as rigid as often portrayed; in the early-sixteenth century there was as yet little order and no real regulation of practitioners. Margaret Pelling has argued cogently for the importance of the guild tradition in the history of medicine's professionalization in sixteenth- and seventeenth-century Great Britain. Earlier historiography of medicine often depicted professionalization as a continuous process, ultimately ending in the triumphal terms of the profession as we know it today. The strength of the social history of medicine, as that history is understood in the early-twenty-first century is to reveal the many complexities of and byways to what was earlier assumed to be a much straighter path to modernity (Pelling, 1987, 1998; Pelling and Webster).

In 1518, the humanist-physician Thomas Linacre (1460–1524) and five other physicians with university educations prevailed upon Henry VIII to grant them a charter for a Royal College of Physicians. Their resultant monopoly, however, extended only to London and its environs. The United Company of Barber Surgeons (made up of apprentice-trained barber-surgeons who carried out simple operations such as bleeding) received its charter in 1540, and the Guild of Apothecaries was granted a separation from the Company of Grocers (a rival guild) in 1617. Not until 1745 did George II grant the surgeons separate status from the barbers (Cook).

This tripartite division of British medicine is well known, but it should not be viewed as a simple or a unified system. In the rural areas, the surgeon-apothecary came to act as a general practitioner, and by 1809 was so acknowledged by name (Loudon). The physicians, who were at the top of the social scale of the medical practitioners, considered themselves gentlemen, had taken a classical university degree, received honoraria rather than fees, and made diagnoses, prescribed appropriate remedies, and made prognostic declarations for their patients. It was up to the apothecaries to give the remedies at the direction of the physicians. To the surgeons were left the tasks of bleeding, pulling teeth, setting fractures, and performing the few operations, such as amputations, that were carried out in this pre-anesthesia and pre-antiseptic age. For most of the population the medical tasks were often combined, as noted, or they were carried out by other healers such as midwives or a variety of traditional practitioners, some of whom were outright quacks (Christianson, Parry and Parry).

By the end of the seventeenth century, the apothecaries were intruding into the domain of the physicians so often that the College of Physicians brought suit against an apothecary by the name of James Rose, charging him with the practice of medicine for which he was not licensed. In 1703, hearing the case on appeal, the House of Lords ruled that the apothecaries could charge for medical advice as well as for the drugs supplied to the patient. This landmark case legalized the function of the apothecaries as ordinary practitioners of medicine in London. They were already enjoying these rights by custom in the countryside. Adam Smith, in his The Wealth of Nations (1776), recognized the apothecaries as the physicians of the poor (Hamilton; Holloway, 1966a, 1966b).

In France, a medical profession also existed prior to the period of industrialization. The profession that appeared abruptly at the time of the revolution in France at the end of the eighteenth century replaced one that had existed in somewhat different form (Gelfand, 1981, 1984; Ramsey). It was especially the professional character of the surgeons that changed abruptly in the 1790s. Earlier in the century, the surgeons already had a legal status, received their initial training as apprentices, and had a versatile medical practice including medicine and pharmacy as well as surgery, but still had a relatively equal social relationship with their patients. Thus the French surgeons—the ordinary practitioners, as Toby Gelfand described them—were more socially inclusive than would be the case in the twentieth century. With the breakdown of elitist distinctions, the post-revolutionary profession in which surgery and medicine were now united was generally even less elitist and exclusive than the earlier French physicians had been. However, in the course of the nineteenth century, elitism appeared in French medicine as it did in the professions in other countries. The new elitism was increasingly based on merit rather than on status, on accomplishment rather than on birth. Much of the history of medical professionalism is included in the history of medical education, but until recently we had had little comparative work. In 1995, Bonner filled this gap for Western Europe and North America for the two centuries after 1750.

The Medical Professions in Early U.S. History

American professionalism originated in the traditions and practices of seventeenth- and eighteenth-century England. Although any occupation might be termed a profession, the recognized learned or liberal professions continued to be law, medicine, and divinity. These required a collegiate education; exposure to the classics and the liberal arts curriculum provided the breadth of mind and personal character necessary for a gentleman. As a gentleman, the physician had a professional duty to play a role in all community affairs.

The North American colonies did not offer an attractive field for professional physicians until well into the eighteenth century. Unlike England, the North American colonies provided few examples of organizational development in medicine. The colonial environment required that practitioners assume all functions of the healing art and eliminated a form of rivalry that had brought about organization in England, where some medical groups had united to prevent the encroachments of others. Frontier conditions usually isolated physicians and discouraged organizational growth. The shortage of the ideal gentleman-physician in the colonies broke the traditional distinctions and divisions of medical labor. Thus, prior to the early 1700s, in the first century of colonial history, there were few doctors, no medical institutions, and little focus on medicine as a profession. Some healers were mainly working as midwives; others were ministers, whose professional identity was with religion, not medicine (Benes and Benes, Watson).

After 1700, as some historians have noted, there was a deterioration of the public's health as measured by a variety of vital statistics. This produced some increased demand for higher levels of medical skills. Besides the needs presented by the changing diseases and diminishing life expectancy, there were also great strains in the occupational structure. Fathers had typically passed to their sons their pulpits and their land. When population increased and there were neither enough pulpits nor sufficient land, the sons began to seek alternatives. Since many ministers also practiced medicine, it was natural that some of their sons turned to medicine as a career (Hall).

After 1750, some of the professional aspects of medicine became more visible, especially in the northern colonies. Young physicians with English and Scottish educations and degrees now began to want the institutional trappings for their profession. With the aid of Benjamin Franklin, the Pennsylvania Hospital was founded in Philadelphia in 1751. Modeled on the British voluntary hospitals, it was intended mainly to care for the sick poor and to provide medical teaching for young men who wished to become doctors. In the 1760s, the first medical schools appeared in Philadelphia and New York. The first colonial medical society was founded in New Jersey in 1766, and an early licensing law was passed in New York City in 1760. By the turn of the nineteenth century, a rudimentary medical profession existed, though it was responsive to local forces and conditions and had no national unity as yet. In many areas midwives continued to supply medical services to families and still routinely assisted at most births (Ulrich).

Although some medical leaders, such as John Morgan of Philadelphia, hoped to establish the British distinctions of physician, surgeon, and apothecary on the American side of the Atlantic, neither the social climate nor the political realities allowed it. As Richard H. Shryock has noted, it was not that the British distinctions were simply rejected in the more egalitarian ethos of the colonies. In fact, very few physicians had emigrated and there was no way to educate sufficient numbers in the colonies. The surgeon-apothecary or general physician simply assumed the title of doctor in the colonial setting. Like the merchants in North America, physicians, in the absence of a nobility, became part of the upper class (Shryock, 1960).

Licensing (and thus a rudimentary form of professional control) began to appear in the late eighteenth century, however these laws were not yet a means to restrict the practice of medicine as distinctly as they later would be. Licensing in the early nineteenth century merely gave those who were deemed legal physicians the right to sue for their fees. It did not as yet give the doctors any control over the medical marketplace. As a form of public recognition, licenses were uncontroversial; but as an attempt to be restrictive, they quickly became a source of sharply divided opinions. Some physicians, such as John Bard (1716–1799) and his son Samuel (1742–1821) in New York, favored restricting the practice of medicine. Others, such as Benjamin Rush (1745–1813) in Philadelphia, believed in "every man his own physician." Rush claimed medicine was sufficiently simple that anyone could learn to practice it.

Medical Practice in the Mid-Nineteenth-Century United States

During the mid-1800s in the United States, medicine was by no means a unitary profession. Its increasing professionalization was accomplished and stimulated by a similar process in science generally (Daniels). In both fields, compensation slowly increased. A wide variety of healers gave their allegiance to one or another medical philosophy, such as the Homeopaths and Eclectics, or followed the therapeutic doctrines of quite rigid systems, such as the Thomsonians or the water-cure doctors. Even among the so-called regular physicians, there was a wide diversity of education, medical belief, and medical practice (Kett, Rothstein).

In the three decades prior to the Civil War, the Jacksonian period, popular democracy had profound effects on the professions. Most states and localities repealed licensing laws for medicine, and what determination of professional competence there had been was transferred from the profession to the people. Contrary to the course of regulation in England, where the Apothecaries Act of 1815 and the Medical Registration Act of 1858 brought some order and governmental control to medicine, the North American states were abandoning regulatory efforts (Holloway, 1966a, 1966b; Shryock, 1967).

Between 1830 and 1850, the number of medical schools in the United States nearly doubled, from twenty-two to forty-two. The rising number of regular graduates produced by these largely profit-seeking, faculty-owned institutions competed with established practitioners, while the new schools lowered requirements to compete for students.

The physicians who established the American Medical Association (AMA) in 1847 had as their avowed goal the improvement of medical education (Davis). In drafting unrealistic requirements for admission to medical schools, however, they became vulnerable to charges that they sought merely to preserve the apprenticeship system and destroy most medical schools. By 1860, however, graduates of the many new medical schools founded in the nineteenth century outnumbered the so-called irregular doctors by a ratio of ten to one (Kett). Since the regular physicians as yet had no real claim to controlling medical activities, their professional strategy in these middle decades may be seen in the attempts to raise the standards of medical education by raising entrance and graduation requirements. Such strategy, while only partially successful before the ideology of science was added to the banner of reform at the end of the century, was aimed at reducing or at least controlling the number of doctors being produced.

The AMA, facing apathy among many regular physicians and hostility from sectarian groups, could do little to reduce physician supply or improve the quality of medical practice (Rothstein). Nor could the association move effectively to enforce its own version of professional ethics. It adopted substantially the principles of Thomas Percival's Medical Ethics (1803), which deals with topics such as the duties of physicians and surgeons and their "moral rules of conduct." Robert Baker and his colleagues have told the story of the origins, evolution, and fate of the 1847 AMA code, and have included the code itself and supporting documents in their useful book.

At the time of the Centennial celebrations in 1876, John Shaw Billings characterized three classes of physicians among the predominant or regular members of the medical profession. There were a few among them, he noted, who loved "science for its own sake, whose chief pleasure is in original investigations, and to whom the practice of their profession is mainly, or only, of interest as furnishing material for observation and comparisons. Such men are to be found for the most part only in large cities where libraries, hospitals, and laboratories are available for their needs.…" A much larger group of physicians, Billings claimed, was mainly interested in "money, or rather the social position, pleasures, and power, which money only can bestow." These doctors are well-educated because "it pays," according to Billings. But the great majority of physicians, Billings concluded, were not well-educated, having memorized only enough of the medical textbooks as was needed to gain a diploma (Billings, p. 479).

It was difficult enough for male physicians to achieve professional status in the United States during the nineteenth century, but for women it was even harder. Elizabeth Blackwell (1821–1910), the first woman to receive a medical degree from a regular American school, in 1849, thereafter wrote frequently on the important role women could play in bringing to medicine greater professional status (Blackwell). The admission of women to medical schools varied from region to region, but with only occasional exceptions it was less than 10 percent of the total. Not until the late-twentieth century did the proportion increase mark-edly, reaching 30 to 40 percent by 1990.

Like their male counterparts, women physicians also founded their own medical institutions, including hospitals, medical schools, and societies (Morantz-Sanchez). After 1876 there was token representation of women in the AMA; full membership was not granted until the early-twentieth century. The American Medical Women's Association was founded in 1915, but by then most of the women's medical colleges had closed or merged with predominantly male schools. In 1910, at the time of Abraham Flexner's report on U.S. and Canadian schools of medicine, only three of the seventeen women's medical schools still existed, and only half of all the 155 North American schools admitted women for the study of medicine. While virtually all accepted women by the middle of the twentieth century, as late as 1959, twenty-eight schools still explicitly said they preferred men (Walsh, 1992; Bonner, 1992; More).

Blacks who wished to study medicine had an even harder time. Todd Savitt has described ten black medical schools existing in 1900 (Savitt). A decade later only three survived. The AMA refused to accept black physicians for membership until the 1940s, so the National Medical Association, founded in 1895, served to promote the professional concerns of black physicians (Cobb, Morais).

Professionalization of Medicine in the Early Twentieth Century

Robert Wiebe and other historians have seen the increasing professionalization of medicine around the turn of the twentieth century as a key element in the emergence of a growing and more influential middle class in American society (Wiebe). The expanding middle class both increased the demand for professional services and also provided recruits for the professional ranks (Johnson). It also provided students for the growing universities and readily embraced science as the key to future progress of medicine. Science came to be the cornerstone of the reforms in medical education (Ludmerer, Rosenkrantz).

The reforms in medical education that occurred in the early years of the twentieth century were funded and spurred on by philanthropic foundations such as those established by industrialist and philanthropist Andrew Carnegie (1835–1919) and the Rockefeller family, but also came from within the profession itself. In 1900 only 8,000 of the country's 120,000 physicians belonged to the AMA. With reorganization based on a federation of the state and local medical societies, membership grew to over 70,000 by 1910, about 60 percent of all physicians.

The new medicine of the 1890s included a physiology heavily influenced by chemistry and physics. This new physiology in turn stimulated departures in experimental pharmacology as well as scientific hygiene. More medical schools, following the lead of a few such as Harvard and the University of Pennsylvania, became integral parts of universities—not merely in name, but in financing, administration, and educational philosophy as well. Schools of medicine began to assume what they called a university point of view, according to which research was an opportunity and a natural activity for all instructors (Weed).

In contrast to the medical professionalism of the early nineteenth century, which Thomas Bender has called a civic professionalism, the professionalism associated with the new medicine was based firmly on disciplinary loyalties. The values of late-nineteenth- and early-twentieth-century medicine were drawn increasingly from science and, by the middle of the twentieth century, from the medical specialties and their societies and journals rather than from localities or universities.

Science and research provided the main rationale for a firmer link between medicine and the university. For the would-be reformers of early-twentieth-century medical education, such as Henry Pritchett of the Carnegie Foundation, William H. Welch of Johns Hopkins, and Abraham Flexner, the future of medicine depended upon such a relationship. Flexner's 1910 survey, sponsored by the Carnegie Foundation and assisted by the AMA's Council on Medical Education, included visits to all 155 North American schools of medicine and osteopathy. The resulting report, a classic of the muckraking tradition of the Progressive period, is a landmark in the history of medical education. Now best viewed as a catalyst for continuing change rather than as a source for new or revolutionary ideas, the Flexner Report was a clear statement of the importance of science for medicine (Hudson). For Flexner, the data derived from the patient in the clinic or at the bedside was as scientific as that discovered in the laboratory.

The sciences basic to medicine—chemistry, physics, and biology—provided the foundation students needed to study and to understand the preclinical sciences such as anatomy, physiology, microbiology, pharmacology, and biochemistry. And from the advancing knowledge about health and disease derived from these preclinical sciences, the practice of medicine was to be placed on a firm scientific basis. Science—and therefore science-based medicine—was best taught and learned in the university setting.

In the decades after 1910, the Rockefeller philanthropies and other foundations provided millions of dollars to build up academic medicine in many universities. Teaching and research became full-time professional duties for an increasing number of faculty.

Flexner's report documented the inadequacies of many schools and accelerated the closing or merging of some of them. The number of schools fell from a high of 166 in 1904 to a low of 76 in 1929; it began only slowly to rise again in the following decades, reaching 127 in the early 1980s.

By the 1930s, with several newly discovered specific remedies available for diseases such as diabetes, pernicious anemia, and after 1937, for pneumonia, medicine was once again viewed by the public as a true profession, a special calling. But despite continuing discoveries of new therapies and spectacular new technologies for viewing the body and how it works, by the mid-1980s observers of the American medical scene were saying that "the profession is increasingly being seen as more nearly a commercial enterprise with vested economic interests than a calling of professionals whose foremost concern is the well-being of the patient" (Iglehart, p. 324). This profound shift in the public perception of medicine was accompanied by the increasing number of liability suits and the corporatization of medical care (Starr). The coming of the corporation doubtless has been both a positive as well as negative organizational force. A business view has become dominant in hospitals and medical schools, as well as in the private practice of medicine.

Medicine has never been a homogeneous profession. It is perhaps even more disparate at the beginning of the twenty-first century than it has ever been. Until the 1960s, most doctors in the United States ran their practices like independent small businesses. In the corporate world of the late-twentieth century, by contrast, bureaucracy came to define medical practice better than autonomy. Legal challenges to the status of the profession have also questioned whether medicine and the law have acted to restrain trade, as in the 1975 U.S. Supreme Court decision Goldfarb v. Virginia State Bar (Rodwin, Sheehan). In that case a young lawyer brought suit against his own profession because he found that no lawyer would perform a title search for a house he was negotiating to buy for anything less than one percent of the purchase price. This commonly fixed price, he argued, violated the Sherman Antitrust Act. The case became a landmark for application of the antitrust laws to all the professions.

Medical professionalism in the context of American culture has always been faced with two apparently conflicting ideals that have shaped its history. Professions, by their very nature exclusionary, have been forced to grow and to prosper in a society that has prized egalitarianism. Equal opportunity has been a basis for American society since colonial days, yet increasingly the medical profession has drawn its recruits from the more privileged strata of U.S. society.

Also, still characteristic of late-twentieth-century medical practice, the patient is often not in a position to judge the quality, the necessity, or the extent of the services provided by the physician. This has remained true despite much more consumer (patient) involvement in medical decision making since the 1960s. As is true for the notion of egalitarianism in society, this continuing separation of esoteric medical knowledge from that which is commonly held provides potential ethical dilemmas for doctors.

A continuing paradox has prevailed in medicine of the late-twentieth century. The more effective medical services have become, the greater has been the demand for them. At the same time they have become increasingly expensive and so more difficult to obtain by many, and nearly inaccessible to those with no insurance coverage. Thus two conflicting concepts of medical care that have always existed in American medicine continue: medicine as a public service and as a private enterprise (Brieger).

Organized medicine in current usage usually refers to the dominant professional societies that have worked in both the professional and the political realms to help doctors achieve or preserve desired ends such as social status, economic rewards, or professional authority. Since one of the hallmarks of a profession is its organizations, the term organized medicine is redundant, albeit commonly used. We have come to assume considerable political power on the part of organizations such as the AMA, the Association of American Medical Colleges, the American College of Physicians, and the American College of Surgeons. While their positive power may have waned somewhat in recent decades as consumer interests have become much stronger, medical organizations until the 1960s were very effective in preventing measures they did not believe were in their best interest from becoming public policy or law (Burrow, 1963, 1977).

gert h. brieger (1995)

revised by author

SEE ALSO: Medical Codes and Oaths; Medicine, Anthropology of; Medicine, Philosophy of; Medicine, Sociology of; Nursing as a Profession; Professional-Patient Relationship

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