It is a wonderful honour to be asked to give the R.I. Harris Lecture. R.I Harris is a genuine Canadian hero. He was recognized as being a leader throughout his career, having been the gold medalist in his medical school, decorated twice for overseas service and rapidly rising to be one of the founders of modern orthopaedics, not just in our country, but world wide. He was directly responsible for the first combined meeting, was instrumental in establishing the ABC traveling fellowship, was a key to the creation of the Journal of Bone and Joint Surgery, and participated in almost all of the activities which serve as the foundation of today's orthopaedic surgery. In addition, a part of his legacy was his son, W.R. Harris, who also served as president of the Canadian Orthopaedic Association.

I would like to begin with a quote from an eminent Sociologist. One should note that contemporary sociologists are not always kind to the medical profession but William Sullivan has come to the conclusion that Professionalism is of importance to society. He stated that "neither economic incentives nor technology nor administrative control has proved to be an effective surrogate to the commitment to integrity evoked in the ideal of professionalism." Let us examine this issue, consider the alternatives, and discuss how it might impact on public policy.

By way of introduction, let us refer to a few generalities which we are all experiencing. In the first place, we live in a time of unprecedented change. There have been times of change recorded in history, but the rate of change found during the past few decades has not been seen before and all observers are agreed that this accelerated rate will continue. We live in a questioning society. When my generation entered medicine we had almost unquestioned authority. This is no longer true and that is a good thing. The professions including medicine have lost status as all forms of authority have boon greeted with skepticism. We will never return to what has been called a golden period in the practice of medicine. Nor should we because during that golden period neither Medicare nor Medicaid was present, there were no national health services in most Western countries, and there were serious socioeconomic barriers to care in almost every jurisdiction. Finally, the future will depend in part on how we in medicine respond and Professionalism appears to be the key to public trust.

So what is Professionalism and what is a Profession? We would propose that the physician has two roles - that of the Healer and of the Professional.

The two roles must be served simultaneously but they cannot be fully understood unless you divide them and analyze them separately.

We believe that we can justify this statement because the two roles, that of Healer and Physician, have different roots and have evolved in parallel but independently of each other. The concept of the Healer arose before recorded history. We in the Western world trace our roots to Hellenic Greece with the Hippocratic and Escalation traditions. Indeed, the Hippocratic Oath is fundamental to our self-image throughout the western world. There was not much change for one or two millennia until modern science arrived and the Healer acquired the ability to cure. The Professional on the other hand, arose in the Middle Ages. We all know of the learned professions of the Clergy, Law, and Medicine derived from the Guilds and Universities of Mediaeval England and Europe. These professions had very little impact on society, serving mainly the elite. However, the Industrial Revolution provided sufficient wealth so that many services could now be purchased, including health, and science made health care worth buying. Some form of organization was required and, society turned to the pre-existing concept of the profession as a means of delivering these services. This was accomplished by legislation in the middle of the 19th Century which established licensure, granting a monopoly to many professions including medicine and thereby essentially redefining professionalism. Because science was fundamental to modern medicine, medicine drew closer to the universities. There are two important links between the two roles. Codes of ethics have always governed the conduct of both the Healer and the Professional and science, of course, empowers both.

In order to clarify the separation of the roles, we would point out that one can assign attributes to the Healer or to the Professional, obviously with a very large and very important group that apply to both. There is nothing in the Hippocratic tradition which states that the Healer should sit on an audit committee but the Professional in today's society must. Autonomy, Self-Regulation, Responsibility to Society and Teamwork are not found in the traditions of the Healer but those very important qualities which relate most directly to the patient are - caring and compassion, insight, respect for the healing function and for the patient's dignity as well as the difficult to define idea of presence - that we will be there for our patients - are thousands of years old. Competence, Commitment, Confidentiality, Altruism, Integrity and Honesty, Morality and Ethics, and responsibility to the Profession are shared with the Healer.

However, we must never forget that what society actually requires is the Healer and the only justification for the rights and privileges accorded to the professions relate to the healing function. In addition, we must recognize that the value systems which both society and medicine appear to cherish are derived from both traditions - from that of the Healer and that of the Professional.

If we are to discuss the dual roles of the physician intelligently, we must define them. The Oxford English Dictionary states that a Healer "makes whole or sound in bodily condition, frees from disease or ailment and restores to health or soundness". That is a part of what it means to be a contemporary physician and it certainly includes surgeons, who, according to the same dictionary "practice the art of healing by a manual operation". We all must be healers and forget it at our peril.

Defining a Profession adds new dimensions. This definition is ours and is drawn from the Oxford English Dictionary and from an extensive review of the literature on the subject, found mostly in Sociology, Philosophy and Bioethics. A Profession is an occupation whose core element is work based upon the mastery of complex body of knowledge and skills. It is a vocation - even the Marxists who write on Professionalism agree that to be a professional must be more than just an occupation. It must be a calling - in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Thus, it includes not just contemporary knowledge but experiential learning or tacit knowledge which can only be gained by doing. We are in the service of individuals and of society. Its members are governed by codes of ethics and profess - there is the word profess. This is the origin of the word profession and is what we do when we recite the Hippocratic Oath or its modern equivalent as we leave medical school - profess a commitment to competence, integrity and morality, altruism and to the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society and in return, society grants the profession a monopoly over the use of its knowledge base, the right to considerable but never absolute autonomy in practice, and the privilege of self-regulation. Professions and their members are accountable to those served and to society.

Another important fact to recognize is that society uses the concept of the Professional as the means of organizing the delivery of the complex services which it requires. Not just medicine, but Law, Accounting, the ministry, and others. This is called the Professional Model by Elliot Freidson, an eminent Sociologist. * There are other models available, and it is important to note that none of these models are pure. The Professional Model, in contemporary society, has a Bureaucratic and Free Market overlay, but one can have a model in which bureaucracy is dominant as was seen in the communist world and of course, the free market has gained enormous prominence in the United States. As we have seen, the Professional Model shares many of the values of the Healer. Neither the Bureaucratic nor the Free Market Models share these values and this is a significant contributor to our present difficulties.

There is general agreement that a social contract exist in health care and that it hinges on Professionalism. It serves as the basis of the expectations of both medicine and society. Essentially, one finds the medical profession on one side, and society on the other and the rules of the game, which outline what is expected of us, depend upon what it means to be a Professional.

Only parts of this social contract are actually written, leaving much which is implicit. Certainly, the laws governing licensure, codes of ethics, the Medicare and Medicaid Act, as well as the Canada Health Act in Canada, represent a part of the written contract. However, much of the value system is passed on informally and is largely undocumented. Secondly, as both society and health care evolve, the contract is constantly changing, or, in other terms, being renegotiated.

The literature on the social contract is sparse and lacks details. The following represents our interpretation. We would suggest that, as is true in any contract, there are deliverables expected of both sides. Society expects medicine to fulfill the role of the Healer, to guarantee competence, to provide altruistic service, to demonstrate morality and integrity in their activities, to be devoted to the promotion of the public good, and to be accountable. We in medicine expect society to maintain our monopoly, and to trust us and treat us with respect. Society gives us status and considerable financial rewards, it grants us autonomy and the privilege of self-regulation and we expect society to provide adequate resources so that we can carry out our assigned tasks. Trust is of paramount importance. If we are not trusted we cannot heal, and a medical profession which does not trust society to meet its commitments will be non-compliant and dysfunctional

If medicine is to preserve its traditional values, it must understand the role of the Healer, the role of the Professional, their interrelationships, and the obligations necessary to maintain our professional status. Our status is granted to us by society, and it certainly may be changed should society become disillusioned with our performance.

However, the definition does not tell the whole story. There are a group of characteristics which have been recognized by the social scientists as together being unique to the professions and we have chosen to link them with the obligations expected of Professionals and the Profession. These obligations impose many duties on us as individuals, but we also have collective responsibilities. The definition, the social contract, and the characteristics and obligations are all reflections of what it means to be a professional.

First, we possess specialized knowledge and skills not easily understood by the general public even in this information age. This imposes obligations upon us as the stewards of this knowledge base. First and foremost, we must maintain our competence throughout an entire practice life, Secondly, it is our duty to teach students and trainees, patients, and the general public. We are expected to protect the integrity of this knowledge base and to ensure its proper use. Finally, we do not all have to be scientists, but we must understand that pushing forward the frontiers of our knowledge base through research is a professional obligation and we therefore must support science, even if we do not go to the bench or the computer. As we are individually and collectively granted a monopoly over the use of this knowledge by licensing laws, our obligations apply to our associations and institutions as well as to us as individual practitioners.

The second great characteristic of the professions is the absolute necessity to be committed to service. Again, this affects us as individuals who are expected to place the welfare of the patients above our own and to medicine' associations and institutions, who have a responsibility to put the welfare of society above that of the profession or of the individual members whom they represent. The obligation thus is to individual and collective altruism.

The pervasive nature of conflicts of interest is a major stress on contemporary society. Conflicts have always been with us but their number and nature have changed and without question they are threatening our primary commitment to the patient. In addition, altruism is being redefined by the present generation. It has to do with lifestyle issues and there is some evidence that our generation is not handling this intergenerational discussion as well as we might. Young people are altruistic but they desire a different lifestyle that that which we enjoyed. They must satisfy contemporary society that they will put the patients' interests first because this is absolutely fundamental to the trust which the medical profession requires in order to function. We are confident that this will occur but they must be mindful of the fact that any diminution in trust interferes with both our ability to heal and our status in society.

Everything written about professionals stresses the need for morality, honesty and integrity. Brandeis wrote that "Professionals are held to higher standards than are those in other occupations". The obligation therefore is to be governed by professional and ethical standards of conduct at all times, not just when we're functioning as a physician. It is important to point out that this applies to us individually and collectively. Our professional associations and institutions must also demonstrate morality, honesty, and integrity in all of their activities. There have been some prominent failures in the past, and they have hurt the reputation of the entire medical profession.

Codes of ethics have been characteristic of every profession since they were recognized by legislation in the 19th Century. The first thing that the National Medical associations did following their founding was to establish a code of ethics. Our obligation obviously is to know and be governed by the appropriate code, an obligation which we believe should apply to our associations as well.

One eminent sociologist, Elliot Freidson, feels that the hallmark of a modern profession is its autonomy. This autonomy is both individual and collective. Individually, we must use our autonomy in order to serve the best interests of our patients and to resist restrictions in our autonomy which will interfere with our ability to do so. The gag laws are a perfect example of an unacceptable intrusion and the response of the medical profession and the public was swift, appropriate, and successful. We are given collective autonomy essentially to self-regulate and to carry out our affairs without excessive intrusion. The obligation, of course, is to use this autonomy wisely in order to best serve society as opposed to the individual practitioner. We also must work to maintain enough autonomy so that we can carry out this task.

The social scientists correctly observe that the formation of a professional association was the first step in the emergence of the modern profession. The American, British, and Canadian medical Associations were all formed before licensing laws were passed and their first task, after establishing codes of ethics, was to lobby for the licensing laws which established the modern professions. It is important to include licensing bodies and other institutions with associations as they remain largely controlled by the medical profession. Their authority is granted to them by the state. They use collegiality as a means of identifying common objectives and in order to ensure compliance with these objectives. As Sullivan implied in the quote which opened this presentation, collegiality is a far more effective means of regulation than are rules and oversight. Thus, licensing bodies and professional associations have a major role in self- regulation. They set and maintain standards and discipline unprofessional, unethical, or incompetent conduct. Finally, they have a role in advising the public in matters within their own domain. Collectively we have a very fundamental obligation to carry out all activities in a moral and virtuous fashion. The unfortunate affair of the contract between the American Medical Association and the Sunbeam Corporation represents an example of the system gone wrong where the profession was regarded as just another corporate player in the market place. It did harm to our reputation. Associations and licensing bodies have an absolute obligation to guarantee the competence of their members. In contemporary terms, that they must carry out their activities in an open and transparent fashion. Finally, we believe that it is increasingly apparent that they must be governed by institutional codes of behaviour which are public documents as recommended by Pellegrino and Relman.

A major issue facing virtually every association is the presence of a conflict of roles which has always been present. Our obligation to be altruistic conflicts with our collective self-interest. Associations are meant to represent their members - the British Medical Association is a legal union under the British Labour code as are the provincial medical associations in Canada. However, we also require that our associations put the public good before that of the membership. These stresses are difficult to resolve, particularly when it is clear that medicine must be represented in these difficult times and be represented well. However, each association has the potential to either promote or subvert the image of medicine by how it conducts its affairs and the public good must therefore always take precedence.

There is also an individual obligation related to the privilege of self-regulation. First and foremost individuals are responsible for maintaining their own competence. To an increasing degree, this requires some form of recertification or re-licensure as society no longer accepts the fact that a certification of competence at age 30 is good for life. Individuals also have an obligation to participate in and to submit to the process of self-regulation, They must support the professional associations and regulatory bodies in their activities as they are carrying out our collective responsibilities. Finally, as members of these associations, they must ensure their integrity.

Listing the characteristics seems to make them equal. They're not. Being a member of a profession involves using a specialized knowledge, both science and art, in service to others in a moral fashion. That is what it means to be a professional.

Let's briefly look at what the social scientists have thought about the professions and their performance during the past one and one half centuries. In retrospect, what they were actually doing was interpreting the state of the social contract of the time. From the end of the 19th Century until the 1960's and 1970's this extensive literature was largely supportive of the concept of the professions. The early social scientists examined the professions, described them, and recorded the characteristics outlined today. They identified the inherent tension between altruism and self-interest which is found in every individual. They were very supportive of the professions because they could not believe we would not be altruistic. In fact, in a somewhat cynical piece, Parsons stated that it was in our best interest to be altruistic and therefore we would be.

When we entered the time of the questioning society, things changed dramatically. The sociologists became extremely critical of the professions, documenting many of our failures. They stated that, rather than being devoted to the public good, abused our monopoly while pursuing our own self-interest and they were highly critical of our regulatory procedures. They stated that we had weak standards which were irregularly employed. They seriously questioned the Professional Model and its relevance to society, with many of them advocating doing away with the status and privileges of the profession.

The more recent literature of the 80's and 90's is of great interest as it now reflects the new reality. Sociologists look upon our sector as made up of three countervailing forces: the state, the market place, and the professions. We were clearly dominant until 20 or 30 years ago but now either the state or the market place have taken over and medicine's influence is greatly diminished. The second thing which they have concluded is that "accounting logic" is now being applied to the practice of medicine and as this occurs, the so-called bottom line is all-important. The value systems of the state and the corporate sector have become more influential in the health care sector than have the values of Professionalism.

The social scientists are no longer as critical. They conclude that the Healer will continue to have status and to be reasonably well compensated, whether as an independent practitioner or employee. They believe that this is in large part because the state and the market place do not wish to be directly responsible for life and death issues and hence reasonable autonomy and income will be preserved. Of some importance, their most influential members now support a renewed professional model. Sullivan has talked of "civic professionalism", Elliot Freidson, the dominant sociologist of the last 50 years, talks about "a reborn professionalism" and Rosemary Stevens a "reinvented professionalism". They do so because they believe that the present state where the values of the state of the market place are ascendant is not beneficial to society at large. Some, but not all, are pessimistic as to whether Professionalism will maintain its influence.

Essentially, they have come to believe that their colleague Marshall was right when he wrote 60 years ago that "in spite of its failings, Professionalism is based on the real character of certain services. It's not the clever invention of selfish minds".

So the social scientists have returned to faith in the value of the professions, but segments of society remain skeptical and must be convinced. It is critically important that this occur.

There are, however, valid reasons for optimism. The public is dissatisfied. The State and the corporate sector now control the market place and they are blamed for defects in the system. This was not true three decades ago when we were deemed responsible. We retain more trust than the State or the corporate sector and health is a political issue. Health is regarded as a necessary public good, if not a right. The political process is leading to change in every country and here we must return to the role of the Healer. Society absolutely requires Healers and this need will buffer us from undue change if -and it is a big if- we can meet our obligations.

The reason we retain more trust is partly based on our performance but partly on societal need - thus as we have lost influence, we have actually an opportunity to rebuilt trust.

So let us look at society's needs and what we need before examining public policy.

Essentially, the social contract is being renegotiated and there are legitimate worries and concerns on both sides. These negotiations are complex. It is not like an ordinary contract where everything is clear. Multiple stakeholders are present and can have input - patients, healthcare professionals, the public, editorial writers, large corporations, unions, advocacy groups, and many more. The negotiations occur in a wide variety of settings and situations and the influence on negotiations can be either direct or indirect leading to a minor change in a fee schedule, or a major change in a health care system. We are no longer the dominant player, but because of society's need for the Healer, we certainly are still at the table.

Society's legitimate needs and expectations are not complex. They require Healers who work as professionals using knowledge to heal and/or cure, guaranteeing competence, demonstrating morality and virtue, and being accountable. All things we have talked about.

Accountability in contemporary society requires special attention as there have been major changes in our relationships. Traditionally, we have always been accountable to both patients and colleagues, we have been accountable for the advice we give on public policy and we have been accountable for self-regulation and discipline.

In almost every country in the Western world, there have been very high profile failures in the area of self-regulation and these failures have lead directly to a decrease in trust. One has only to think of the report on medical errors in the United States, on the geographic discrepancies in the rates of medical and surgical procedures without adequate explanation, to the well-publicized failures to guarantee the competence of pediatric cardiac surgeons in Winnipeg and Bristol, and too many others. All point out our inadequacies and cause a loss of trust. The message is that we must self-regulate well in order to assure competence.

We have acquired, during the past few decades, new levels of accountability as pointed out by Ezekiel and Linda Emanuel. Every one of us is now accountable in economic terms, not just to our patients, but to either the corporate sector or the state, depending upon who is paying the bills. Our care must be cost effective and efficient. We are also accountable in political terms for the status of the health care system, for its impact on resources as it is an activity which utilizes so much of the national wealth, and for population health. A part of the reason why we have been unable to influence the means by which we are held accountable in these new areas is because we did not carry out our obligations to self-regulate and lost trust.

However, if there is a contract, we can justifiably expect something of society. In the first place, we all believe that the majority of our colleagues are competent, caring, compassionate, and altruistic, often in difficult circumstances, even though there may be failings in some individuals or some institutions. We therefore believe that both because of the nature of what we do and how we do it, we deserve respect. Much of the disillusionment of the modern physician and surgeon relates to what is perceived as an unjustifiable lack of respect. Secondly, we believe that we have expertise and that this expertise should be recognized and used in health policy matters. Without exception in almost every country we believe that this is not presently true. Thirdly, we absolutely must maintain sufficient autonomy to act in the best interests of our patients and of society. This is another major area of concern. We require autonomy not so that we can do what we wish, but so that we can do what is best. Fourthly, we require regulatory procedures that are reasonable and validated. We have come to believe that regulatory procedures should undergo the equivalent of clinical trials before they are instituted and that these trials should not look merely at the economic impact but their impact on the value system of medicine and on the doctor-patient relationship. Fifth, we require adequate resources to carry out our tasks. This is not as major an issue in your country as it is in mine. Without question, Canadian society, acting through its elected officials, has breached the social contract with health care professionals by underfunding a previously well-performing system. Our response has been to form a partnership with the public and to demand more resources. These resources are beginning to come, but at a painfully slow rate. Sixth and very importantly, we believe that society should provide a health care system which promotes and does not subvert those values which it wishes in its healers - caring, compassion, altruism, courtesy and competence.

So what must we do? In the first place, we must fulfill the role of the Healer. That is the justification for professional status.

And in determining our future actions, we simply must address the principle causes of loss of trust. First, the public perception is that we are less altruistic than we once were. In part, we're a victim of our success. We used to demonstrate altruism by taking care of the poor. This is no longer necessary for large segments of the population and the hospital sector won't allow us to do it for the uninsured. However, it remains an issue. Secondly, we have to address our regulatory failures because consequences can be immediate and dramatic. The Bristol cases in the United Kingdom have led to a radical change in the regulation of the medical profession. As an example, postgraduate education is no longer controlled by the Royal Colleges. A government agency has taken over this task and the medical profession is not in a majority on the governing board. Without question, some of our institutions have embarrassed us and this must not occur. Finally, one must note that the growth of specialization and sub-specialization has not just led to a fragmentation of our knowledge base, it has changed the allegiance of many physicians from their national organizations to their specialty bodies. The end result has been a difficulty in establishing a single voice to represent medicine.

Let's be more precise. We must understand Professionalism, its definitions, evolution, and present state. We therefore must teach it and evaluate it at all levels. We must understand and meet the obligations needed to sustain the professional model. Altruism and Integrity are not just attractive words. They are qualities that we and our institutions must demonstrate in our daily activities. We have to self-regulate and we must be accountable.

Medicine must have a single voice speaking on its behalf as the non-financial aspects of the social contract are being renegotiated. Lessons can be learned from examining the condition of the American, Canadian, and British associations. Essentially, Canada and the United Kingdom split the functions of representing membership and speaking to the public good. The British Medical Association is a legal union and the General Medical Council, the national licensing body, has been given the mandate of setting and maintaining standards and of protecting the public while the British Medical Association represents its members. This separation is not absolute but the duties of the organizations are clear. In Canada, health is a provincial matter and the provincial medical associations have also become unions, allowing the Canadian Medical Association to speak to the public good which it is doing quite effectively. Press coverage during the past decade has indicated that this association enjoys public trust. In the United States, the union function appears to be intertwined with speaking to the public good, and the American Medical Association has lost membership and can no longer be said to represent medicine. Something must be done to establish a single voice, either by restructuring the AMA, a move which has recently failed, or delegating authority from national specialty associations to a new consortium or national forum. The profession at the present time speaks with many voices and we believe that this must be corrected.

Those negotiating on our behalf must recognize and deal with their conflicts of roles. Recognition is the first step. The union function is nothing to be ashamed of, but in performing the union function, societal needs must take priority. This has not always occurred.

As we attempt to maintain the professional model in contemporary society we must look for assistance from those who share in our aspirations. It is striking that the social scientists in their recent publications have advised the medical profession to look for partners and all have come to believe that there is a confluence between what the profession wishes and what patients and their advocacy groups desire. They should represent our strongest allies, as should other health professionals, most of whom are equally unhappy with the status quo. There will also be times when the government and the corporate sector will disagree and as this occurs, we may be able to forge temporary alliances with one or the other. Finally, a media which is mistrustful of the motives of the medical profession can do us enormous harm. It is possible to achieve a reputation for altruism. In Canada we have learned that we can expect editorial support if we are felt to be speaking for the public good. The important point is that partners are actually required.

Those representing us must attempt to negotiate a social contract which supports the values of Professionalism. We do not believe that this has ever been on the agenda as a discrete item and it should be. All studies of which we are aware have demonstrated that physicians' major sources of unhappiness in contemporary society do not relate to financial matters - they relate to respect, and intrusions into their autonomy. Without question no easy way of accomplishing this comes to mind. However, a few things can be suggested. A system which rewards professional behaviour and penalizes unprofessional behaviour would be desirable. It is probably not wise to use competition for cost control if one is interested in professional behaviour as it deemphasizes the values we cherish. The fee-for-service principle can be modified into some form of mixed remuneration that does not reward high volumes. Institutional funding can also promote a value laden system. More rigorous examination of conflicts of interest would help. Regulating the marketing of the health care industry would ease some of our conflicts. These are just a few ideas and there must be others.

One of the roles of those speaking for medicine is to convince society of the advantages of the Professional Model. The International Charter on Professionalism promoted by the American Board of Internal Medicine and the European Federation of Internal Medicine and the American College of Surgeons Code of Professional Conduct represent important steps in making public commitments to society. Public policy must support the Professional Model (53) because as Elliot Freidson has pointed out that "the most important problem for the future of Professionalism is neither economic nor structural, but cultural and ideological. The most important problem is its soul."