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LEARNING OBJECTIVES

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  1. To understand the history and evolution of medical professionalism.

  2. To review key efforts to institutionalize professionalism within the arenas of medical education and clinical practice.

  3. To frame some of the modern issues of conflict-of-interest, duty hours, and social media in the light of professionalism.

  4. To link the concepts of professionalism with that of the hidden curriculum.

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INTRODUCTION

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This chapter examines the history and evolution of medicine's modern-day professionalism movement. The brief discussion in this chapter is partial and not comprehensive, and is intended to provide readers with some historical context. In particular, we think it is useful to realize that medical professionalism, while it has roots back into the 1600s, has only recently received a good deal of attention in medical literature and medical education. Furthermore, understanding this history may allow readers to reflect on the present day challenges facing medicine and consider how professionalism will continue to evolve.

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ROOTS

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For the last several hundred years, medicine has been considered, and considered itself to be, a profession. Historical documents reflect this view. During the Great Plague of London in 1666, an apothecary William Boghurst argued:

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Every man that undertakes to be of a profession, or takes upon himself an office must take all parts of it, the good and the evil, the pleasure and the pain, the profit and the inconveniences all together and not pick and choose; for Ministers must preach, Captains must fight and Physicians attend upon the sick (Huber & Wynia, 2004).

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In 1803, Thomas Percival published his pivotal book entitled Medical Ethics (Percival, 1803). Percival labeled medicine as a “profession,” and he characterized the practice of medicine as a “public trust.” Percival recast medical ethics as a collective rather than an individual physician responsibility “essentially creating the notion of medical professionalism” (Wynia & Kurlander, 2007). Although the term “profession” would not be a common descriptor for most of the second millennium, the historical connections of medicine to the guild structure of medieval Europe and to the notions of skilled labor and apprenticeship training, is well documented (Sox, 2007).

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Occupational claims of expertise were not always supported by the public. By the 1700s and 1800s, there were widespread signs that the public held a deep distrust of trade and professional groups over the tendency of such groups toward self-interest. Writers as disparate as Adam Smith and George Bernard Shaw framed professions as “conspiracies against the public” (Smith, 1991) or against the “laity” (Shaw, 1946), with Shaw adding an occupationally specific dagger in characterizing medicine as “a conspiracy to hide its own shortcomings.” Over time, and as documented in Paul Starr's book The Social Transformation of American Medicine (Starr, 1984), organized medicine became strategic and proactive in its attempts to reclaim its image and to solidify its claims to professional powers and privileges—a process Starr characterized ...

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