When I was in college I signed up for a course in the department of Sociology called, "The Professions." It quickly became clear how difficult it is to actually define what is meant by that word, "profession."
Many people use the word only in a pejorative sense: "Oh, that was so unprofessional," by which they mean they are unhappy with someone.
My father laughed when a barber told him, "That guy tells me how to cut his hair. Who does he think he is? I'm a professional!" To my father no barber was a "professional." Doctors are professionals. Some lawyers were professionals. Some engineers. But not auto mechanics. Auto mechanics, tailors, electricians, plumbers were "in the trades" or craftsmen.
It's hard to know what he would make of IT people today. The nature of work has changed so greatly, so transformed by computer technology.
One of the characteristics of professions, my professor suggested, is they are given the power to regulate the quality of their practitioners--so the government does not design tests for physicians but cedes that task and privilege to organizations of professionals. On the other hand, government does devise licensing exams for physicians in some states and government decides to make board exams, created by professionals, to be requirements for medical licenses in some states, despite objections by some doctors the government has no business endorsing or ceding its own judgments to boards of examiners who often seem to care more about restricting competition or generating profit than insuring quality of practice.
Today, a pulmonary specialist asked me about a diabetic patient who he was thinking of starting on a drug which stimulates the pancreas to make more insulin but he had read this would certainly cause the demise of whatever insulin making cells the patient had left. I pointed out there is no clear agreement these drugs actually push islet (insulin making) cells over the cliff. He was surprised by this. It struck me the difference between what he knows and what I know is important and constitutes the difference between my specialty and his. I would know the studies on sulfonylureas and apoptosis (the process by which cells destruct) because that is my specialty.
But the guys who create the specialty board exams certifying me as a specialist would never ask that question, and in fact would never ask any of the questions I get daily which I answer more accurately because I go to the national conferences and keep up with the literature in the area of endocrinology. Every day, I see other doctors make mistakes in the management of endocrine problems because their knowledge has not been refined by the process of education I cleave to in my own specialty. (I'm just as clueless when faced with questions in their specialties.) But the design of the exams which are supposed to distinguish who has the special knowledge is so flawed there is no way these exams can make the very distinction they claim to make.
I don't know who makes up these exams. It used to be academic types. Might still be in some specialties. But I do know I could make up an exam very few full time faculty members at the university hospitals could pass, in my own specialty. The answers would elude them because they simply do not know the things you need to know to take care of patients:
1. Are thyroid nodules homogeneous enough that a fine needle sampling of them is representative of the whole nodule--like dipping a spoon into soup or is it more like a salad, where a fork in one part of the nodule would bring out a different result than the fork in another part of the salad?
2. If a man is on testosterone injections and his doctor finds he has coronary artery disease should he stop the testosterone?
3. An overweight patient with dismal blood sugars has been brought into control using insulin but he's gained weight. Is the trade off of weight gain for blood sugar control a good one?
4. A patient is found to have five, 7 mm thyroid carcinomas in her gland. If she had one 35 mm thyroid cancer she would require not just surgery to remove her thyroid but follow up radioactive iodine, but does she need it with 5 small cancers?
These are the questions which separate the men from the boys, and to know the answers to these, you have to skulk around the national meetings, grilling the experts when you can pull them aside. But you'd never see these questions or their ilk on a board exam.
Once, I served on a committee at Georgetown University School of Medicine and someone suggested Georgetown deny hospital admitting privileges to anyone who had not passed his board exams, as a "quality measure."
Wait, I said, can you name a single question from the last board exam in internal medicine? Just one?
Nobody in the room could.
All these doctors were ready to cut off from their livelihoods physicians who needed hospital privileges but they had no clue what was asked on the exam.
"Well," the leader of the pack said. "I just figure if you can't pass that exam, there's something wrong with you."
"Would you be willing to take that exam today?"
"Well," he said, smiling, "Actually I've been grandfathered in."
"And doesn't that just say it all?" I said. "The exam is so important we only make the new guys take it. Not only that, we make the young docs keep taking the exams over and over, just to be sure they're not getting out of touch. But none of us have to demonstrate that we're up to date, just the guys a decade behind us have to do that.
It's a way for you to control competition, plain and simple."
That's professionalism for you.
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