In antiquity, the role of the priest and that of the physician were not distinct. The healing arts, intercessory petitions to the gods and attempts to alter the forces of nature employed a host of rituals and symbols derived from arcane knowledge and superstitions.

During the Middle Ages in Europe, the small comforts that medicine was able to offer to the ill and injured were generally provided in monasteries and involved herbs, hospice care and spiritual support. Medical education, such as it was, was taught in cathedral schools and monasteries and consisted of training in Hippocratic medicine and empirical therapies. Medical practitioners in villages were by and large ordinary people who had developed some particular skill in such problems as setting bones, incising boils, pulling teeth or helping in childbirth. By the 12th century, the monasteries were drifting away from secular activities; urban centers were forming, and universities were established in many of the larger cities. Physicians attached themselves to these new universities and became increasingly secular, prosperous and professional. University physicians modeled their education after existing learned professions such as law. Greco-Arabic medical texts were translated into Latin and entered the university curriculum.

Over the next few centuries, university medical schools proliferated, yet the number of graduates was small. More than 90 percent of those entering as medical students left without a degree. The association of physicians with the intellectual elites of the university was the defining element in the development of medicine as a learned profession. The continuity and progress of medical education made possible by the institutionalization of a professional faculty assured both the tradition and the conservation of medical knowledge. Physicians held themselves forth to the public and to other professionals at this time as people committed to mastering a body of knowledge in order to serve the health and well-being of patients. The amazing advances in medical science over the last two centuries have driven physicians into defining their areas of expertise in increasingly narrower terms of specialization.

So what is the status of the physician today? There is little doubt that a high degree of training and education are required to produce a physician. The complexity of the knowledge base upon which the practice of medicine relies and the demands that it be mastered by the practitioner are undisputed. There is likewise consensus that service to society generally and to the individual patient in particular are integral to medical practice and that a commitment to service is a signifier of professionalism. Another requirement of professionalism is that there exist a degree of autonomy in thought and activity that is above the standards of the tradesperson or technician. The professional must be capable of being an advocate and protector of the patient and his or her interests in the complex environment of health care. And in the real world in which people eat and buy things, the professional must be compensated for services. There is, and always has been, a dynamic tension between the interests of the physician as patient advocate and the physician as a self-interested provider of marketable services. When self-interest prevails over patient interests, however, professionalism dwindles or vanishes.

I recently attended a lecture given by an attorney/public relations person who made a number of disturbing suggestions to the doctors in attendance that strike at the very heart of professionalism. He described medicine as a “service industry” and claimed that physicians were wise to pursue their own financial interests under the flag of patient advocacy. That is, proclaim a worthy cause but remember that the objective is one’s own economic gain. He recommended a recipe for success that was composed of political action, public relations and the threat of withholding services. He at least deserves points for directness if not for calling forth the best charitable impulses of physicians. In his view, medicine is a market commodity and should be controlled by monopolies and rationed by walkouts.

There is no doubt that medicine as a profession currently faces many challenges. Governmental regulation and reimbursement schedules strain the financial ability of those who care for patients and limit the choices a physician can make in patient care. Contractual relationships with insurance programs and health care institutions tend to make one perhaps too aware of the quantitative relationship between patient services and reimbursable units of compensation. The scientific and technological aspects of our knowledge base are so attractive that they can almost become an end in themselves rather than a tool with which to serve patients.

Professionalism will endure if the medical profession, beset by the above problems, continues to subscribe to the principles that first led its members into medicine. We will continue to be respected because we have dedicated ourselves to excellence in the service of our fellow people. We will retain the privilege of caring for those who turn to us in need, entrusting to our care their most precious possession — their very self. To the extent that we remain the most qualified defenders of our patients’ interests, we will preserve our greatest strength and our most valuable entitlement.

Let the world hear an ancient promise re-sworn: We are here to give the best of the science and art of medicine to those in need.

Peter L. McDermott, M.D., Ph.D., retired from anesthesiology, is Professor of History, California Lutheran University, Thousand Oaks, California. He was ASA President in 1993.