The continued viability of professions such as dentistry depends on protecting against threats to the five essential characteristics that define professionalism; based on an article in the Journal of the American College of Dentists. (1 credit hour)
After completing the course, participants will be able to:
- Contrast and evaluate the characteristics traditionally associated with professionalism and those offered by recent scholars
- Form a personal definition of professionalism
- Use the history of medicine’s emergence as a professional to identify the roles of research, social policy, economics, and professional organization to understand the dynamic nature of professionalism
Please Review the Following Material:
The professions have been described in terms of their prestige and income, specialized skills and knowledge, protected markets, control over entry and discipline of members, common identity and values, long careers, managed relationships with nonprofessionals, licensure, ethics, and service to clients and the public. As useful as these characteristics are, they fail to capture the essence of the professions, especially the classic ones such as medicine and dentistry. A five-part definition is proposed, consisting of a community including patient, professional, and peers), treating individuals in a customized private and personal fashion based on diagnosis, in a trusting relationship where the professional acts as an agent rather than engaging in economic exchanges. The evolution of the medical profession is discussed as an illustration of the way professions evolve and to reveal some of the historically “taken-for-granted” aspects of professionalism. The fact professional knowledge is both public and scientific and personal and unsusceptible to objective reduction is a paradox. The continued viability of professions such as dentistry depends on protecting against threats to the five essential characteristics that define professionalism.
The professions have been well studied but remain imperfectly understood. That is pretty much as it should be and as it will remain. The professions are uncomfortable with outsiders looking at them, and part of their identity is to remain shielded from public understanding. As Charles Reich says in The Law and the Planned Society, “Professionals can be counted on to do their job but not necessarily define their job.”
This essay is divided into five sections, beginning with digging around among the traditional characterizations given the professions. The second section will propose an alternative five-part definition. Medical practice has undergone immense transformations in the past three hundred years, knowing this history is necessary to understand the health professions. There is also a paradox regarding professional knowledge, and this will be explored in the fourth section. Finally, some of the threats to professionalism will be considered. The most serious of these are the ones that threaten the essence of professional practice.
The Traditional Characteristics
Professions are described by prestige, high income, direct relationships with clients, specialized skills, protected markets, and control over who is allowed to enter the profession. The professions, the soft professions, and the pseudo-professions can be arranged on a hierarchy, with medicine, dentistry, and law at the top, ranging down through ‘nursing, pharmacy, engineering, and ministry, to college professors, social workers, real estate agents, firefighters, and cosmetologists. The more each group represents the characteristics identified in the first sentence of this paragraph, the higher they are on the hierarchy.
W. J. Goode lists seven characteristics of professions. First, members of a profession share a common identity. They read the same literature, dress in a somewhat similar fashion, vacation together, and see many social issues in the same light. If the public is asked to provide a description of a typical professional, even without the obvious clues as to where a person works or what equipment they use, most people would be able to finger the dentist compared to the lawyer, rabbi, or Tae Kwon Do instructor. Professionals also share values. College professors and social workers overwhelmingly vote democrat. Engineers, accountants, dentists, and airline pilots value predictable performance over creativity. All professionals value autonomy and resist outside interference.
The third characteristic of professions identified by Goode is their ability to retain members. Dentists may have sidelines, particularly at the beginning and end of their careers, or may go into teaching because of a disability, but they are very stable in their careers. The average American is fifteen times more likely to change careers than is a dentist. Career stability is an excellent way of grading professions on the hierarchy from the most elite to the most marginal.
Professionals work hard at defining their relationship with nonprofessionals. The boundaries are distinct and ritualized. A physician and a lawyer may be best of friends in social contexts, but their roles change dramatically—who can initiate which conversations, whose opinion is most respected, and what one wears—depending on whether a lawsuit or a serious illness is at stake. Goode also notes that language changes in the professional context. Each profession develops its own way of talking that is designed, to a certain extent, for clear communication within the profession, but to a very large extent, to signal who belongs to the profession and to prevent those who are not in the profession from understanding what is being discussed. The technical term for a language that signals group membership is argot. The true masters of argot in American culture are our teenagers. They constantly reinvent language that even they may not understand in order to serve as social markers and to keep authority figures at a safe distance.
The last two of Goode’s characteristics of a profession are related. These are control over current members of the profession and control over potential future members. For thousands of years, both the church and the military have sought to maintain a judicial system distinct from the civil process. These tensions are still headline news today. Every profession, through proactive codes of ethics to peer review panels and internal sanctions, covets first right of refusal to discipline its own members. The irony that the law is among the most revered professions and at the same time has such an objectionable odor comes from the fact that among all professions it is the only one that can be used to pierce the veil of self-discipline enjoyed by its sister professions.
Professions also control who can practice and how with the highest professions exercising the greatest control. Lawyers determine who can join the prestigious firms that have access to prestigious clients and who can argue cases under various jurisdictions such as the U. S. Supreme Court. Hospitals determine who has privileges. To a significant extent, the high professions determine who is eligible to enter the profession in the first place. For example, dental schools admit only about half of the individuals interested in the profession to study. Another 5% are selected out of the profession during the educational process. State boards of examiners deny licenses to approximately 2% of applicants at initial licensure and perhaps another half of 1% of dentists lose their practice privileges.
Professions are also concerned with markets, specialized knowledge, and public service. An essential task for professions is creating a protected market. Professions seek monopolies, almost always through political means rather than through relations with customers. Clever groups go further than protecting their markets; they seek to enlarge their markets by encouraging legislation to require extended services. For example, morticians in many states have succeeded in passing laws that require that the remains of one’s dearly departed be buried whether they are cremated or not. Engineers vigorously lobby for increasingly restrictive regulations that happen to require the use of an engineer.
Market formation among the professions also extends to the elimination of counter-veiling forces among clients. Paul Star, in his Pulitzer Prizewinning study of the medical profession, describes the brutal ostracizing of those physicians during the first half of the twentieth century who were salaried employees of companies or groups of employees. Today, in the province of British Columbia, Canada, veterinarians are in court, seeking to restrict the licenses of their colleagues who do not use the fee schedule established by the profession. Lawyers and real estate agents in some states collect a fee for having their secretaries complete simple forms that customers could as easily complete except for legal prohibitions.
Formation of a monopolistic market may be a characteristic of many professions, but it is not a defining quality. Many labor groups, especially unions, are more vigorous in limiting markets than are professionals. Garbage collectors in New York City and the Mafia would certainly have something to show the American Dental Association about market formation. On the other hand, the oldest profession in the world certainly has entry and exit barriers. More than market protection is involved in professions.
Some have said that professions are built around licenses—state-recognized authority to perform certain actions, typically connected with an examination. The argument that licensure is a foundation for professionalism crumbles quickly. Real estate licenses are plentiful; almost anyone who drives a car has a license to do so Years ago, I wanted a bedroom and bathroom added to my house in San Francisco and arranged for a very talented handyman whom I knew to perform the work. The problem was, he did not have a contractor’s license and I wanted the work done to code. The solution was for me to purchase a book on electrical codes and a book on plumbing codes and to study them. After an hour with each, I passed the county contractor’s license and subcontracted the work to my friend. I had the license but he was the professional.
Some critics of the professions recognize the important role played by licensure, educational qualification, certification, bonding, regulation, and liability to lawsuits as necessary demonstrations of professional competence and countervailing power for consumers. But, as Lieberman notes, “because regulation of some professions is necessary does not imply that the profession itself should do the regulating, nor does it imply that anything beyond mere technical competence of the professional should be judged by the regulators.”
Among the usual definitions of professions, the use of specialized knowledge is frequently cited. When we come to discuss the history of the medical profession, it will be clear that the profession existed in a healthy condition for hundreds of years without the benefit of any effective therapeutic skills. On the other hand, farmers often exhibit a wealth of practical knowledge acquired over generations. What is tested on initial licensure examinations in dentistry is a small fraction of what is required to succeed as a practitioner. From the study of several professions, most notably medicine and law, researchers have concluded that the amount of specialized knowledge acquired, and especially the knowledge demonstrated in education and on licensure examinations, is almost entirely unrelated to success within the profession as measured by either client services, financial rewards, or status within the organized profession.
Professions are often described as enjoying autonomy or the privilege of self-regulation. This comes very close to being the case but entirely misses the point. The high professions of law, medicine, the ministry, and others actually do a very poor job of disciplining their members. Being disbarred or having a license revoked for inappropriate practice is exceedingly rare. On the other hand, courts-marshal and internal investigations in the police force are significant realities. Drug lords probably do a better job of autonomous discipline of members than do the professions.
Perhaps the most cherished traditional criteria for professions are ethical integrity and placing the public’s interest first. Ethics are essential to healthy human relations. But they are no less important at Enron or in the research laboratory than they are in the professions. In a very literal sense, lawyers do not put my interests above their own, or they wouldn’t charge me as much as they do. In an ironic sort of way, discount justice is unprofessional but double-price justice is not.
Ethical codes in the professions are a mixture of rules about relations with clients and rules about relations with other professionals. Although there has been movement over the years in the right direction, no profession that I know of has made the customer the standard for the profession’s success. Arlene Kaplan Daniel’s analysis of the professions concludes that there are no differences in the ethical standards of professions with high-standing and those that are marginal. She concludes, “What professions say about themselves in justification of their privileged status above ordinary occupations might better be studied as a political ideology than as an indication of intrinsic difference between professions and other types of occupations.” Elliot Freedman calls professionals codes useful ideologies that cannot be proven.
The shibboleth that professions are groups with special knowledge that have been given the privilege of self-regulation in exchange for their promise of placing the public’s interests first is probably much better known within the professions than it is by those whom they serve.
The potential defining characteristics of market monopoly, licensure, specialized knowledge, self-regulation and placing the public’s interests first are individually characteristic of professions, especially the high professions, but they are not unique to them. If all five criteria were combined as a potential way of identifying true professionals, police officers, firemen, and the marines would emerge near the top.
A profession is a community of individuals who advance the personal interests of individual clients in a trusting relationship. There are five components in this definition, as identified in Table 1.
Professionals form a community of individual practitioners who must simultaneously meet standards set by their customers, themselves, and their professional peers. It is obvious that dentists work to advance their patients’ and their own interests at the same time. Sometimes, they are altruistic and sometimes they do pro bono work to enhance their reputation or the image of the profession. The public expects professionals to charge sufficiently high fees in general so that no single interaction with a patient or client is dominated by financial interests.
Professionals work for each other in the sense that the good that each does individually shines on behalf of the profession as a whole and vice versa. Professionals tend not to work for companies, organizations, bureaucracies, and others who offer employment for a salary. Although there are employed professionals, there are no examples where professional employees enjoy a higher status than self-employed professionals performing the same work.
Professionals have individual clients. They do custom work. True, a lawyer may represent a Fortune 500 company that employs thousands, but he or she must represent that company in a unique fashion. This makes the high emphasis on diagnosis a seminal feature of the professions and is part of the reason it is under-compensated. In any profession, those who treat a generalized or group clientele have lowered status and professions that deal with mass interactions—such as teachers or journalists—tend to rank lower on the hierarchy of professions.
Professionals also deal in private and personal matters. We go to the lawyer when our finances or legal status are threatened. We go to the physician when our health is compromised. When our soul is hurting we seek the advice of clergy. In all cases, we are trying to recover a full sense of who we are. We expect to be treated with dignity and confidentiality, because we are not acquiring something, we are being changed. The same is true to a lesser extent with accountants, teachers, or other advisors. It is certainly not the case with police officers or beauticians.
Professionals work as agents to advance the interests of their patients and clients. They do not offer a menu of transactions; the whole patient or client is the professional’s concern. This is a different kind of economic transaction from buying a cell phone or having one’s toilet repaired. The professional is paid for doing the best he or she can according to the conventions of the profession. Professionals are not paid for results (some lawyers at the very lowest end of that professional scale to the contrary); they are paid for prudent advice and action.
Although it is true that professions create monopolies, they are not restricted by market transactions in the same sense that the sewer company has a monopoly. They are monopolies on who can serve as an agent for various actions on behalf of their clients. There is no product that is exchanged and the rules of supply and demand are inappropriate in the sense that the demand for health, justice, spiritual well-being, and other benefits provided by professionals is essentially open-ended. It is wrong to assume that the economics of goods and services apply to the relationship between professionals and their clients. The assumed antithesis between commercialism and professionalism is bogus.
Table 1. The Five Characteristics of a Professional
- Community of practitioners who simultaneously work for themselves, customers, and peers
- Help patients and clients who are individuals making their own personal choices
- Serve private and personal needs of customers seeking wholeness
- Work as agents on behalf of customers, instead of transacting services
- Function in a relationship of trust
The fundamental relationship between professionals and their clients is one of trust. This one factor may well serve as the most useful index for identifying professionals and for ranking professions in a hierarchy. (See Table 2 for the results of the most recent Gallup survey on trust in professions.) Because the nature of professional services is both personal, individual, and beyond the client’s ability to evaluate, the relationship between professional and client is inherently asymmetric. A patient, for example, is not an individual who has medical or dental needs. (There are many people who have such needs that do not seek professional care.) A patient is one who has agreed to follow the lead of a professional with regard to their personal health.
This final characteristic, the relationship between professionals and everyone else being based on trust, is the one that ties the other characteristics together and separates professionals from all others. The client trusts the professional to advance his or her own personal individual interests and to leave the qualifications of a professional, the determination of what ultimately is in one’s best interest, and the evaluation of the results to the individual professional and the professional community. Autonomy and putting the patient’s interests first come close to capturing this quality, but they miss the full nature of the professional being a trusted agent. Trusting the profession to decide what is right and to do it in the case of personal and individual needs is the mark of a professional.
Evolution of Medicine as a Profession
The higher professions are not guilds from the middle ages that have raised themselves by their bootstraps. The pedigree of the professions is the aristocratic and gentlemanly classes. Until well into the eighteenth century, the oldest son in the English aristocracy prepared himself to inherit land and title and perhaps dabble in politics. Additional sons were dedicated to the clergy, law, or the military. Occasionally, one became caught up in medicine. It was, however, clearly understood that the gentlemanly practice of medicine should not be mistaken for the pragmatic healing skills. This was to be left to a lower status of individuals trained as surgeons or apothecaries.
Table 2. Public Perceptions of Honesty and Ethics, 2003-04 Gallup Poll
The Royal College of Physicians in London existed for many years as a club for the minor aristocracy. Admittance to the college was strictly by invitation, with a requirement that fellows and members be graduates of Oxford or Cambridge Universities. Remarkably, neither university offered medical training.
The job of the physician was to serve as a confidant to members of the aristocracy and to oversee palliative care and to explain illnesses to prestigious clients. Fees were haphazard because it was assumed that physicians enjoyed some degree of financial independence. The job of the physician was to lend dignity to poor health.
In the Wealth of Nations, the capitalist manifesto by Scottish economist Adam Smith, it is noted, “We trust our health to the physician; our fortune and sometimes our life and our reputation to the lawyer and attorney. Such confidence could not safely be reposed in people of a very low or mean condition. The reward must be set, therefore, as may give them that rank in the society which such important a trust requires.”
In democratic America, the aristocratic version of the physician was rejected like a bad organ transplant. We probably pulled down or held back the development of professions in this country, especially in the years before the American Civil War. During the Jacksonian years of rugged individualism, states actually revoked legislation that gave exclusive practice privileges to attorneys and physicians.
In the last half of the nineteenth-century medicine was a vicious battle among allopaths, osteopaths, practitioners of chiropractic, homeopaths, and even Christian Scientists, who to this day continue to charge for their healing services. There was no united voice in medicine to protect the public from the army of charlatans and self-credentialed practitioners. The regrettable truth was that no brand of medicine taught in formal training could be demonstrated to be superior to another or even better than the self-educated practitioners in terms of predictable improvements in patients’ health. By the turn of the century, the United States government acknowledged this fact and encouraged patient self-medication through allowing patent protection to elixirs on the sole criteria that they contained ingredients that were unique without requiring that they be effective. The medical and dental schools of that era were for-profit organizations that had the commercial advantages over previous apprenticeship training of grouping the apprentices in a single situation, removing them from high tone patients, and requiring a smaller faculty-to-student ratio.
What changed all this at the beginning of the twentieth century was the rise of a new kind of university. Johns Hopkins was the first American university to completely organize itself along the German model centered on research. Major universities across the country changed from a mission of educating gentlemen (there were separate schools for educating gentlewomen) to show how knowledge could improve society, especially through the professions. For the first time, we had medicine that worked reliably and the promise of continuous improvements. For the first time, it really made sense to close down the quacks and the proprietary schools. The Flexner Report in medicine. documented this change more than it caused the change. It was followed by the Reed Report in law and a decade later by the Gies Report in dentistry.
The Professional Knowledge Base
The professions are dependent on the knowledge base created in universities and taught in professional schools in three ways. First, science and scholarship have opened the doors to innovative and effective results. Secondly, they have created a sense of legitimacy and independent verification for the professionals’ knowledge base. They give professionals recognized powerful tools. The third benefit of the large and growing knowledge base in research and professional schools is the barrier it presents to entry into the professions. Calculus is required as an admissions requirement into MBA programs by those schools’ accreditation standards, but calculus is almost never used in any courses in graduate business schools. The sheer amount of material that must be mastered in medical schools, for example, limits applications to the profession to students of high general academic ability and a willingness to spend years of very hard work getting ready for a professional career.
It would be misleading, however, to equate the knowledge base taught in professional schools with the knowledge base used by practitioners. It would also be wrong to confuse research with innovation. Practicing dentists do not read the Journal of Dental Research, nor do they take continuing education courses in the subjects they studied while students. Faculty members in dental schools do teach continuing education courses, but they are not among the most popular of presenters and often faculty presenters at continuing education programs are part-time dental school instructors.
This seeming paradox can be unraveled by observing the distinction between an explicit body of knowledge and a tacit one. Explicit knowledge can be conveyed in journals, PowerPoint slides, and other formal media. Tacit knowledge cannot be converted to words, it is passed on by experience and observation, and it is often performed semiconsciously. Entry into a profession is based on mastery of explicit knowledge through education and formal licensure examination. Status and success within the profession normally come through mastery of tacit knowledge.
Understanding the difference between the scientific face that professions show to the public and the utilitarian face they show to their individual patients helps explain why professionals tend to be conservative. Knowledge is highly portable and can be leveraged. A new computer chip or a new mystery novel can be mass-produced, and the profit margin on a single item can be converted into substantial wealth if the market is sufficiently large. By contrast, professional services cannot be leveraged. Lawyers and accountants bill for their time: physicians and dentists bill by the procedure actually performed by them. The individual and personal nature of professional services means that great ideas, while appreciated, are never as valuable as practical routines that can be effectively and reliably used. Whereas young mavericks can become the heroes of manufacturing and service industries, the elites among professionals almost always have gray hair.
Because value added among professionals is grounded in applications to specific individual patients, it cannot be easily multiplied by the accumulation of equipment, auxiliaries, or capital. Dentists can purchase most of what they need to operate their practices on their personal credit card. Law firms and hospitals have fewer layers of administrative structure than most industries do.
There is paradox about professional knowledge. Publicly professional knowledge is an immense body of material that must be mastered to enter a profession, to drive predictable effective care, and to create an effective barrier to lay intrusion. Professionally, knowledge is the internalized routines and shared standards of excellence that never leave the practitioners’ hands and prevent care from becoming a commodity. Regardless of its validity, there is a limited market for evidence-based anything in the professions, because it challenges the concept of professional knowledge being inherently personal.
The Continued Viability of the Professions
The story about the history of the medical profession suggests that substantial changes can occur in practice and in the relationship between a profession and the public. Nowhere is it written that the professions will remain unchanged. The context in which professions function continuously evolves. The only way for professions to remain viable in such a context in flux is for them to remain faithful to their essence. Attempting to preserve the superficial structure of practice will expose a brittle exterior to erosion and breaking off of parts by the forces of social change.
Professions’ strength flows from their unique character, properly understood and vigorously practiced. This character has already been defined as involving the three-part economic structure (client, professional, and professional organization), personal and private care, customized work, agency rather than market economy, and trust. Looking at differences between established and soft professions may reveal some of the pressures currently threatening the foundation of dentistry as a profession.
Employees are almost never professionals, except in the sense of a professional manner of providing courteous service. Teachers (the largest group of soft professionals), social workers, and engineers tend to be identified with unions as much as professions. Because they are salaried, they must balance their allegiance to a profession with their allegiance to bureaucratic organizations that have different goals and different sets of procedures for how clients are to be treated. Introducing an outside party with economic or political motives always disrupts the professional relationship. The overwhelming majority of dentists continue to work only for their patients, themselves, and the profession at large.
But there are troublesome trends. For the past twenty years there has been a small but steady increase in the proportion of dentists who work for other dentists. The Indian Health Service, prisons, and the military do provide stipends and salaries, but this is to meet a national service need and does not use the professional for commercial services. By contrast, there are new economic schemes that treat dentists as salable commodities. Such practices inevitably erode professionalism.
Like golf pros, piano teachers, and hair stylists, professionals provide personal services. Unlike those just mentioned, the services of professionals are not just desirable enhancements but are regarded as necessary for maintaining personal integrity. Justice, salvation, and health, for example, are in a different category from economic gain, personal self-help, and good looks. It is a core part of the professions to restore individuals to effective functioning, and to do so on a personal basis with dignity.
Tooth whitening doesn’t count as part of the profession. It is probably an aberration that the Baby Boomers have enough money and ego to define appearance as part of their essential identity. For purely demographic reasons, dentistry should not lean too far in that direction. For professional reasons, health must always be the foundation of the profession, and dentists take a great risk if they make the ultimate judge of their professional contributions to be what the patient sees in the mirror. The literature on professionalism accepts as commonplace that quacks are those who trust their reputations to their patients.
Professionals treat individuals. They do not develop products or services whose value can be increased by wide distribution. This means that technology functions differently in the professions than in other segments of commercial or public life. Innovation in dentistry will be continuous and small. There is no capital formation in the profession that allows for the development of expensive and mass technology or for its deployment in large systems.
There have been attempts to bend this rule of professions as custom work. In all cases, moving away from treating one patient at a time has raised concerns. Large clinics compromise diagnosis and follow through, which are low-paying but essential aspects of professional care. Industry has attempted to create an impression that the quality of patient care is directly proportional to selecting and purchasing the right technology. Commercialism accepted on this article of faith will weaken the profession. Arguably, practitioners who have the best-dressed 1040s are those whose clients are other dentists. This is a blurring of the lines delineating what it means to be a professional.
Professionals are outside the supply and demand economy. They function as agents, acting, for an agreed amount of compensation, on the best interests of their clients as they, the professional, and the client agree to define it. Patients do not purchase results or even services that they are well qualified to evaluate. The usual laws of economics are out of the question in the professions, because the demand for what they do always substantially exceeds supply.
Dental practices have inescapable commercial aspects, some of which are appropriate and some of which are demeaning. It is offensive, for example, that veterinarians sell dog food and flea powders in their offices. Any move in the direction of making oral health a commodity, either in the relationship between the provider and the patient or among providers, is a move away from professionalism.
The final element is trust. But this is the most essential and most delicate of the characteristics of professionalism. Informed consent is essential, but it can never be complete. The professions have asked for and society has largely granted the privilege of the professions deciding who can hold themselves out to the public as a professional, whether the work done by professionals is appropriate, and even what services clients need. This is an incredible relationship that does not exist in the insurance industry, our schools, or the home appliance market. The work of professionals is complex and can never be fully explained to the public. It is also inherently based on professional judgment. This follows from the individual, custom nature of the work that professionals do. The project of reducing the work of professionals to a set of written standards that the public could understand is both impossible and unwise.
At the same time, vice d’estime—an attitude that those who don’t understand should be excluded from consideration or that the professional alone is the judge of the value of what professionals do—is a dangerous attitude. The Internet and the media have put a spotlight on professionals. The public is generally aware that the professions “go light” on their own stinkers, and the growing helplessness of consumers generally in the face of complex transactions makes confidence harder to win. I used to feel good about getting an oil change. Now I have to fight my way through the cross-selling of air filters, fan belts, and even some things that I don’t understand but that the service technician implies are necessary to prevent me from being derelict as a responsible car owner. The greatest challenge professionals have today may well be to maintain a distinction between this kind of treatment and professional care that is meaningful to the patient.
Professionalism is not a code, nor is it a contract between the public and some individuals. It certainly cannot be conferred through education or licensure. It is a moment. It is the point in time when an individual patient trusts a professional to provide customized healing skills to the best of his or her ability with no one else watching or saying what it right or wrong. Professions endure to the extent that this moment is continuously repeated.
Chambers DW. The professions. Journal of the American College of Dentists, 2004, 71, 57-64.