0

The full content of Annals is available to subscribers

Subscribe/Learn More  >
Editorials |

Medical Professionalism and the Parable of the Craft Guilds

Harold C. Sox, MD, Editor
[+] Article and Author Information

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Customer Service, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.


Ann Intern Med. 2007;147(11):809-810. doi:10.7326/0003-4819-147-11-200712040-00015
Text Size: A A A

Professionalism has deep roots in Western society. In his book, Death of the Guilds, E.A. Krause (1) makes a compelling case that the medieval European craft guilds are the antecedents of today's professions. The craft guilds have not survived. As a commentary on the article by Campbell and colleagues in this issue (2), I will argue that, like the guilds, the medical profession exists in a 3-way relationship with government and business. As such, its privileged position in society is subject to changes in the balance of power. I developed some of these ideas in a recent essay (3).

First Page Preview

View Large
First page PDF preview

Figures

Tables

References

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
Response to Medical Professionalism and the Parable of the Craft Guilds
Posted on December 9, 2007
Peter Glusker
Mendocino Coast District Hospital, Adjunct Clinical Assistant Proffesor , Neurosciences, Stanford
Conflict of Interest: None Declared

Dear Editor:

Your editorial is interesting and thought provoking, but it misses the mark because its focus is limited to a purely economic interpretation.

The history of the guilds is much more complex that the economic viewpoint presented. Jacques Le Goff's excellent and thorough discussion in his Time, Work & Culture in the Middle Ages, reviews the complex evolution of the concept of labor and its relation to the church, the aristocracy and society.

Doctors, or their equivalent in indigenous cultures, shamans, have always held positions of respect. This is based on the focus of their work, the healing of their patients' suffering The respect for healers of all sorts derives from the ethos of their work, in whatever cultural context, western, eastern, or indigenous.

It is the development of capitalism itself which has changed and defined value in purely economic terms. Therein lies the heart of the issue. Medicine's ethos became subjugated to an economic bottom line, rather than the social good it had always been before. That subjugation then created the circumstances in which medicine is exploited to create economic profit.

It is ethically wrong to profit economically from human suffering. All cultures' healers' credos have so stated. Western medicine has lost sight of this, and has been subverted to economic profits of insurance and related medical companies An alternative is presented in my essay (Viewpoint: "Universal Health Care That is Not For Profit Can Work"; National Catholic Reporter, Sept. 21, 2007.) We must shift the focus of our dollar-value view, and develop a way to have part of our economy devoted to the social good, without economic profit. One analogy is our social security system. This was developed out of a sense of social obligation to the elderly and the disabled. Similarly, we need to develop a system in which the profit that is built into each horizontal and vertical layer is extracted.(from band-aids to MRI's to physician and hospital care). True actual costs for salaries, research, raw material, equipment, etc would be covered. The economic savings would almost certainly be enough to provide universal coverage I believe physicians and scientists would continue to invent better drugs, devices and methods because the challenge is there. That is the basic motivation of being human: we care for our fellow beings, are intensely curious about our environment (e.g. space exploration), and are great problem solvers.

Peter Glusker, MD-PhD, FACP.

Conflict of Interest:

None declared

Medical Professionalism
Posted on December 17, 2007
Peter Glusker
Mendocino Coast District Hospital, Stanford Department of Neurosciences
Conflict of Interest: None Declared

Re: Medical Professionalism and the Parable of the Craft Guilds by Harold C. Sox, MD, Vol. 147, #11, 4 Dec. 2007.

Dear Editor:

Your editorial is interesting and thought provoking, but it misses the mark because its focus is limited to a purely economic interpretation.

The history of the guilds is much more complex that the economic viewpoint presented. Jacques Le Goff's excellent and thorough discussion , reviews the complex evolution of the concept of labor and its relation to the church, the aristocracy and society.

Doctors, or their equivalent in indigenous cultures, shamans, have always held positions of respect. This is based on the focus of their work, the healing of their patients' suffering The respect for healers of all sorts derives from the ethos of their work, in whatever cultural context, western, eastern, or indigenous.

It is the development of capitalism itself which has changed and defined value in purely economic terms. Therein lies the heart of the issue. Medicine's ethos became subjugated to an economic bottom line, rather than the social good it had always been before. That subjugation then created the circumstances in which medicine is exploited to create economic profit.

It is ethically wrong to profit economically from human suffering. All cultures' healers' credos have so stated. Western medicine has lost sight of this, and has been subverted to economic profits of insurance and related medical companies An alternative is presented in my essay A Universal Health Care That is Not For Profit Can Work. We must shift the focus of our dollar-value view, and develop a way to have part of our economy devoted to the social good, without economic profit. One analogy is our social security system. This was developed out of a sense of social obligation to the elderly and the disabled. Similarly, we need to develop a system in which the profit that is built into each horizontal and vertical layer is extracted.(from band-aids to MRIs to physician and hospital care). True actual costs for salaries, research, raw material, equipment, etc would be covered. The economic savings would almost certainly be enough to provide universal coverage I believe physicians and scientists would continue to invent better drugs, devices and methods because the challenge is there. That is the basic motivation of being human: we care for our fellow beings, are intensely curious about our environment (e.g. space exploration), and are great problem solvers.

Peter Glusker, MD-PhD, FACP.

1 Jacques Le Goff, Time, Work, & Culture in the Middle Ages, transl Arthur Goldhammer, Univ. Chicago Press, 1980 2."Viewpoint",National Catholic Reporter, Sept. 21, 2007

Conflict of Interest:

None declared

Question
Posted on December 25, 2007
Michael K. Rees
harvard medical school
Conflict of Interest: None Declared

To the Editor:

In his timely editorial, Dr. Sox writes: "Will we respond grudgingly to these carrots and sticks, or will we meet our partners halfway." This seems to imply that a partnership currently exists between government and business and the medical profession and that somehow we are not doing our fair share. If there is such a partnership, somehow in my forty plus years of general medical practice, I have been left out. Nothing in my long experience suggests that the practicing physicians enjoys even a smidgen of partnership with either government or industry (i.e.,insurance). Rather my experience suggests that the payer dictates and that we either obey or suffer the consequences. How else to explain the ever increasing burden of inefficient and costly administrative responsibilities that especially industry forces us to endure? I challenge Dr. Sox to provide evidence of this partnership.

Conflict of Interest:

None declared

More than local leadership
Posted on January 18, 2008
Jeffrey Sneider
SUNY Upstate University
Conflict of Interest: None Declared

January 18, 2008

Dr. Harold Sox Editor Annals of Internal Medicine 190 N. Independence Mall West Philadelphia, PA 19106-1572

re: Medical Professionalism and the Parable of the Craft Guilds

Dear Dr. Sox,

In your editorial(1) you point out the danger which the medical profession faces if we continue to ignore the outcries of payers (government and business) about the cost of our product. Yours is the first voice I have heard making the connection between our failure to "listen to the customer" and the recent decline of the US medical profession.

In spite of the Charter for Professionalism which you quote(2), most physicians seem to think that it is unethical to consider the cost of services when making decisions about an individual patient's health care. The profession has shied away from direct alliances with business (HMOs) to reduce cost in favor of "quality improvement" and "Pay for Performance" initiatives which seek to finesse financial considerations while making treatment decisions based on scientific and medical factors - evidence. There are significant ethical considerations here(3), also, and this course of action is likely to be too indirect to have any promise of actually reducing the cost of care any time soon.

There are many factors which account for the high cost of medical care in the United States(4) not all of which are under the control of physicians. As decision makers, however, physicians can have a very important impact on the future of health care costs.

We can make a difference, but I believe that it will take much more than local leadership to reverse the course that the profession has chosen thus far. What I propose is a campaign to reduce the cost of health care analogous to the CDC campaign to reduce the unnecessary use of antibiotics(5). The CDC campaign should be a model for a campaign to reduce unnecessary expenses in the provision of high quality medical care.

It will take a combined effort which starts with a recognition of the problem and acceptance of responsibility for its solution. As you stated, there is sufficient evidence that we can reduce unnecessary cost without negatively affecting the quality of care while leaving more resources to provide care for everyone. We just have to do it.

Sincerely,

Jeffrey S. Sneider, MD, FACP Syracuse, NY

1.) Sox Harold C. Medical Professionalism and the Parable of the Craft Guilds. Ann Intern Med. 2007;147:811-812.

2.) ABIM Foundation, ACP-ASIM Foundation, European Foundation of Internal Medicine. Medial Professionalism in the new millennium: a physician charter. Ann Intern Med. 2002; 136:243-6.

3.) Nelson Alan R. Pay for performance programs: Ethical questions and unintended consequences. Current Clinical Practice. 2007; 1:16-18.

4.) Bodenheimer T. High and Rising Health Care Costs. Part 1: seeking an explanation. Ann Intern Med. 2005;142:847-54.

5.) Department of Health and Human Services Centers for Disease Control. Get Smart: Know When Antibiotics Work. http://www.cdc.gov/drugresistance/community/

Conflict of Interest:

None declared

Submit a Comment

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Topic Collections
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)