The evolution of medicine as a profession. A 75-year perspective.

The profession of medicine has changed dramatically in 75 years. Despite the commitment of individual practitioners to the highest ideals of professionalism, the profession itself has lost privilege, power, and public reputation. It has been toppled from the high moral ground of professionalism. This has happened not so much because individual clinicians have abandoned that ground, but largely because others have occupied it--primarily complex organizations that have developed public mandates to regulate and oversee health care. The issue is not one of unfeeling physicians--it is one of a health care system that has evolved so as to limit medicine's autonomy. This changing system places new constraints and pressures on the physician-patient relationship. The question we are left with is whether medicine can regain its professionalism. How do we reform a system that, by its complexity, has become amoral? The only way is for physicians to re-assume a stout position of advocacy--advocacy for individual patients in a complex and frightening system of care, advocacy for patients as a class of people in a political system that seeks to restrict care, advocacy for patients in a world of environmental and epidemic threats. Such advocacy requires an equally strong moral commitment to the principles of service. Acting in the patient's best interest is not enough. It requires that the profession avoid the appearance of blatant self-interest at every turn. It requires a revised commitment to political activism in the interest of service to patients as a community. The costs are extremely high--but the alternative, physicians-as-technicians and medicine as a slave to corporate and government interests, is hardly acceptable.