12 Medicine as an ideal-type profession

Parsons’ work effectively established a set of traits for an ideal-type profession. Doctors emphasised their detachment from their patients (what Parsons called their ‘affective neutrality’) as a way to emphasise their objectivity and clarity of decision-making. But, at the same time, doctors fostered a ‘community of equals’ ^[1], in promoting the idea of medicine as an elite cadre of like-minded specialists. Dating as far back as the 13th century, the medical profession established a strong code of conduct and a collective ethos, and drew on the specialised, shared language of diagnosis, taxonomy and treatment, to differentiate its training and practice from others ^[2]. It emphasised professional achievement and promoted the idea of heroic medicine, and it increasingly took on broad social interests beyond the narrow confines of internal medicine and surgery. Parsons argued that medicine represented the very model of an advanced profession because it achieved all of these things whilst also reasoning ‘instrumentally’, with logic and reason, rather than ‘expressively’, relying on human emotion and subjectivity. He argued that any profession wanting to be considered elite, needed to mirror the following traits:

• A professional body with a large number of members;
• Affective neutrality — or the degree to which the professional can remove emotion from their work;
• Mastery of a specialised body of knowledge and skills learnt through a lengthy process of higher education, and an ongoing interest in developing one’s professional craft;
• Universalism — focusing on rules to guide decisions rather than the particularism and subjectivity that comes with treating each person as an individual;
• Recognition of the exclusive competence of the profession in the domain to which its body of knowledge refers — or a monopoly over a defined area of social need;
• A service ideal — that is, a commitment or ethical imperative to place the welfare of the public or of the individual client above the self-interest of the practitioner, even though the practitioner is earning a living through the exercise of the profession. Parsons argued that ‘medical professionals rightly deserved the high status and high rewards they received because they act in the interests of the whole society rather than their own self-interest’ ^[3];
• Achievement — Parsons believed that status should derive from the profession’s achievements, rather than being ascribed to the group by some accident of birth or other ‘internal’ attribute;
• A recognised code of ethics emphasising the responsibilities of practitioners and defining a limited scope of practice;
• Specificity, or the degree to which the profession focuses on a specific rather than a diffuse field;
• And professional autonomy, or the definition of what constitutes the work of the profession, controlled by the profession itself, including who can legitimately do that work and how the work should be done ^[4][5][6].

It is perhaps remarkable to think that within just a few decades, medicine had arrived at the point where it could be called an ideal-type profession. It was only as little as a century ago, though, that medicine became the organised, coherent discipline it is today. Much of the responsibility for that consolidation derived from the work of Abraham Flexner (1866-1959) and the Hopkins Circle, and their reform of the American medical education system.