286
COLLEGIALITY IN HISTORY* JANE A. PETRO, M.D. Associate Professor of Surgery New York Medical College Valhalla, New York
CONTEMPORARY HISTORIES OF MEDICINE and education'-6 yield myriad fables, myths, and anecdotes detailing uncollegial behavior but few examples that fit the modem concept of collegiality. Historical memorywhat is recorded and subsequently retained-is selective and depends on the physical survival of evidence and written documents. The paucity of described collegial formations when compared to the colorful nature of conflicts may result from preference for war over peace as a subject. Those collegial formations that can be identified, therefore, must play a distinctive role, a unique value that renders them worth recording and retaining. Durant has observed "most of history is guessing and the rest is prejudice. Mangiardi and Pellegrino8 conceive a "collective commitment to some idea, the pursuit of which entails certain privileges and also certain obligations." Collective is the operative concept in the search for collegiality. What identifies a collegium is the establishment of a group-or collective-accepting a self-definition, common purpose, standards, and through these shared ideas creating an exclusive formation. By setting standards and defining the group in exclusive terms, a collegial formation must be elitist. Elite has come to have negative connotations, but in the context of collegiality, elitism provides the fundamental basis of the collegial formation. Without common purpose and identified standards, the group would not exist. In defense of the elitism implied by the definition of collegiality, Mangiardi and Pellegrino acknowledge that in addition to privileges obtained by membership, obligations are also assumed. The association of privilege and obligation is fundamental to medical codes and the ideals of the medical profession from earliest times, as in the Code of Hammurabi and the Hippocratic Oath. This may distinguish professional organizations from trade associations.9-11 This does not necessarily imply that professional associations are also necessarily collegial. * Presented as part of a Symposium on Academic Collegiality in American Medicine held by the Foundation for Neurosurgical Research at Camp Topridge, New York September 7-9, 1990.
Bull. N.Y. Acad. Med.
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7 V1-R
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THE MODERN CONCEPT OF COLLEGIALITY
Max Weber, a German social scientist and one of the founders of modem sociology, described the conflicts between professionalism, which is considered proethical, and bureaucracy, which he considered promaterialist.'2 Weber viewed collegial structure as the chief mechanism for advancing specialization. The collegial structure provided a forum for communication among individuals with highly specialized roles, and through shared ethical standards regulated against both naked self-interest and the arbitrary exercise of power. Malcolm Waters, in a comprehensive review of Weber's analysis,'3 emphasizes the distinction between authority based on knowledge-the professional collegium-and authority based on power the bureaucracy. The structural difference between collegial vs. bureaucratic formation is based on the distinction between a monocratic organizational structure such as the bureaucracy derived from legal authority and the consensus of equals where power is derived from legal authority and the consensus of equals where power is derived from expertise and is not monocratic. Internal governance of the collegial body is characterized by its theoretical knowledge base, a performance oriented formal egalitarianism, a career progression divided into stages culminating in tenure, internalized organizational standards and scrutiny of the work product, and collective, consensual decision making. The advantage for professionals of the collegial structure includes maintenance of status closure, market regulation, and internal control of standards of professional practice. Despite his view that professionalization derived from collegiality was proethical, Weber did not consider collegial formations successful or effective bases for social regulation. Weber gives the advantage to the bureaucracy where the monocratic power structure, rule making, and enforcement potentials are significantly greater. Waters distinguishes Weber's structural characteristics of the collegial/ professional organization into distinct aspects with broad social and individual consequences. For example, the theoretical knowledge base of the profession makes expertise available but may also exclude by credentialism. This is, of course, the basis for contemporary medical licensure. In another example, internal scrutiny of the work product that is part of the collegium may both monitor adherence to ethical standards and result in the nonobservability of practice. This type of sociological examination of medicine provides a significant way to analyze the strength and weakness that professionalization creates. The advantage Weber attributes to bureaucracy may also provide an Vol. 68, No. 2, March-April 1992
288 288
PETRO A. PETRO J.J. A.
understanding of the success federal and state governments have had in imposing external reviews, regulation, and control over medical practice.
SUCCESSFUL COLLEGIAL FORMATIONS In the book, Natural Obsessions, Natalie Angier"4 recounts how Robert Weinberg runs his lab at the Whitehead Institute for Biomedical Research in Cambridge, Massachusetts. Weinberg is the principal investigator in ongoing projects studying oncogenes. Angier seeks to document how one individual can run a laboratory from which many crucial discoveries emerge in a continuing fashion. The formula she describes appears surprisingly simple. A bright, hard-working, motivated, well-funded person has working for him similarly hard-working, motivated, and bright younger people willing to be lesser lights either temporarily as research assistants, students, and postdoctoral assistants or permanently as assistants. When asked how he selects postdoctoral fellows from among hundreds of applications, Weinberg states "one of the most important things to me is that the person be nice. On a number of occasions I've turned away extraordinarily good people because they were pains in the ass. My science may have suffered as a result, but at least my health and well-being have been preserved." The laboratory at the Whitehead Institute provides a contemporary example of a collegial formation structured around a strong individual under whose direction motivated individuals work toward a common goal. Historically identifiable collegial medical institutions first appear with the Code of Hammurabi, circa 2100 B.C. The extant portion of the code establishes a fee schedule and sets standards by creating punishments for failures or complications. The subsequent larger body of Egyptian documentation also identifies a fee schedule, educational practices, and standards. There is a contemporary primitive as well as historically persistent close association between healers and religious figures in society. The image of the physician as omniscient, arrogant, secretive, and unable to recognize limitations may relate to this confusion of roles between the sacred-religious and secular-medical practice. A persistent, dogmatic reliance on texts may also result from this religious/ secular confusion. Physicians emerged in Greece as craftsmen and priests.8 Religious healing tradition embodied in the Asclepian temples extended through the Greek into the Roman world. The Hippocratic tradition arose from the crafts concept of the healer.8 Osler9 attributed to Hippocrates the importance of medical observation and the value of familiarity with the natural history of Bull. N.Y. Acad. Med.
COLLEGIALITY
HISTORY
COLLEGIALITY IN IN HISTORY
289
disease. Hippocrates is credited with laying the foundation of modern medical collegiality. His work set standards for the profession of medicine and created a system of thought based on observation that remains an ideal. He contributed a sense of humanism, the obligation of service to the community, and standards of physician comportment that remain valid after 2,400 years. The library at Alexandria, founded in 331 B.C. by Alexander the Great, represents the best example of an enduring collegial, historical institution. The library lasted until 640 A.D., funded by government and supporting the scholars who worked there.'5 Free intellectual inquiry was encouraged and no similar institution has survived over such an extended period since that time. An example of historical noncollegiality, Galen (129-200 A.D.) has been called the most influential medical writer of all time, and he may also have been the greatest physician of all time. The body of writing left by Galen became a canon of medical knowledge for the following 1,500 years. Galen was dogmatic, pedantic, and encyclopedic, and was absolutely convinced that he was right in everything that he said. He founded no collegial institutions, and accounts of his personality do not indicate that he was a collegial individual. Yet his work outweighed that of any other individual for many centuries. IMPLICATIONS OF COLLEGIALITY
Collegial practices of necessity include a form of discrimination. A group of individuals with differing ethnic, racial, sex, and sex preference, religious, and socioeconomic class backgrounds would have a difficult time identifying a set of shared values, a common purpose, a self definition, or even a set of internally determined standards. yet we find in the early European medical schools at Padua, Bologna, Montpellier, a diverse student body of men and women with differing backgrounds who both elected a faculty and determined the curriculum resulting in universities that still survive.' By acknowledging the existence of racism, sexism, classism, and all the other isms of a struggling egalitarian society, it would be necessary to struggle even harder to find, much less to create, collegial associations. The existence of distinct separatist institutions and professional associations, all women's or all men's colleges, Negro colleges, the American Medical Women's Association or the National Medical Association, make more sense and become justifiable in the context of collegiality. The elitism required by a collegial formation seems to exclude such groups unless they form their own associations. The severe reduction in the number of women entering Vol. 68, No. 2, March-April 1992
290
J. A. PETRO
medicine as physicians by 1910 resulted in part from the disappearance of the women's medical colleges existing prior to 1900 and the failure of women applicants to gain admission to the medical schools providing the professionalization of medicine and medical education occurring by the time of the Flexner report.'7 Discrimination based on suitability, meeting standards, and the need to preserve the institution/collegium may or may not be tolerable depending on the historic setting of place and time. The survival of the collegial formation depends on the persistence of the ideals upon which it is based. These may be preserved in the originally intended form, as in the Hippocratic tradition, or transformed through successive leaders. Boulding, in his essay on education, notes the risk of unmodified collegiality that may easily turn "into the slothful excusing of one another's inactivity and a total absence of progress or development." If the collegium seeks to become too uniform, progress ceases. The dilemma of collegiality revolves around a need for the protection of the collegial environment without inhibiting the development of ideas8 and the need to maintain the stimulation of diversity. Weinberg's concepts of the "6nice" person may provide a peaceful atmosphere. In the absence of strong leadership, however, one wonders whether the "nice" people would continue to function and to produce. The enduring collegial formations, the professional associations of medicine, or the university depend not on the strong leader but on the preservation of power, prestige, and expertise. The question is whether the goal of collegiality as set forth here can be sustained. REFERENCES 1. Johnson, P.C.: Guy de Chauliac and the grand surgery. Surg. Gynecol. Obstet. 169: 172-76, 1989. 2. Newman, J.H.: The Idea ofa University. Notre Dame, IN, Notre Dame Press, 1982. 3. Osler, W.: Evolution ofModern Medicine. Birmingham, 1982 (original Yale Press 1922). 4. Maulitz, R. and Long, D.: Grand Rounds: One Hundred Years of Internal Medicine. Philadelphia, University of Pennsylvania Press, 1988. 5. Walsh, M. R.: Doctors Wanted: No Women Need Apply. New Haven, Yale University Press, 1972. 6. Haeger, K.: History of Surgery. New York, Bell, 1988. 7. Durant, W. and A.: The Lessons ofHistory. New York, Simon and Schuster, 1968. 8. Mangiardi, J. and Pellegrino, E.: Collegiality, what is it? Bull. N. Y. Acad. Med. 68: 292-96, 1992. 9. Horstmanshoff, H.F.S.: The ancient physician. Craftsman or scientist? J. Hist. Med. Allied Sci. 45: 176-77, 1990. 10. Pellegrino, E.: The medical profession as a moral community. Bull. N.Y. Acad. Med. 66: 221-32, 1990. 11. Pellegrino, E.: Medicine and Philosophy. Some Notes on the Flirtation of Minerva and Asclepia. Philadelphia, Society for Health & Human Values, 1973. 12. Weber, M., Ross, G., and Wittick, C.: Economy and Society. Berkeley, CA, Univ. of California Press, 1928. Bull. N.Y. Acad. Med.
COLLEGIALITY IN HISTORY
291
13. Waters, M.: Collegiality, bureaucratization and professionalization: a Weberiana analysis. Am. J. Sociol. 94:945-72, 1989. 14. Angier, N.: Natural Obsessions. Boston, Houghton Mifflin, 1988. 15. Lyons, A.S. and Petrucelli, R.J.: Medicine: an Illustrated History. New York, Abrams, 1978. 16. Boulding, K.: Quality vs. equality: the dilemma of the university. Daedalus: 298-303, 1975. 17. Walsh, M.R.: Women in medicine since Flexner. N.Y. State J. Med. 302-08, 1990.
Vol. 68, No. 2, March-April 1992
COLLEGIALITY IN HISTORY* JANE A. PETRO, M.D. Associate Professor of Surgery New York Medical College Valhalla, New York
CONTEMPORARY HISTORIES OF MEDICINE and education'-6 yield myriad fables, myths, and anecdotes detailing uncollegial behavior but few examples that fit the modem concept of collegiality. Historical memorywhat is recorded and subsequently retained-is selective and depends on the physical survival of evidence and written documents. The paucity of described collegial formations when compared to the colorful nature of conflicts may result from preference for war over peace as a subject. Those collegial formations that can be identified, therefore, must play a distinctive role, a unique value that renders them worth recording and retaining. Durant has observed "most of history is guessing and the rest is prejudice. Mangiardi and Pellegrino8 conceive a "collective commitment to some idea, the pursuit of which entails certain privileges and also certain obligations." Collective is the operative concept in the search for collegiality. What identifies a collegium is the establishment of a group-or collective-accepting a self-definition, common purpose, standards, and through these shared ideas creating an exclusive formation. By setting standards and defining the group in exclusive terms, a collegial formation must be elitist. Elite has come to have negative connotations, but in the context of collegiality, elitism provides the fundamental basis of the collegial formation. Without common purpose and identified standards, the group would not exist. In defense of the elitism implied by the definition of collegiality, Mangiardi and Pellegrino acknowledge that in addition to privileges obtained by membership, obligations are also assumed. The association of privilege and obligation is fundamental to medical codes and the ideals of the medical profession from earliest times, as in the Code of Hammurabi and the Hippocratic Oath. This may distinguish professional organizations from trade associations.9-11 This does not necessarily imply that professional associations are also necessarily collegial. * Presented as part of a Symposium on Academic Collegiality in American Medicine held by the Foundation for Neurosurgical Research at Camp Topridge, New York September 7-9, 1990.
Bull. N.Y. Acad. Med.
rC~TT TNT1 HTTl fCOT-T.FC.I AAI TITY TN HNTOR Y 111 1~lT
7 V1-R
287
THE MODERN CONCEPT OF COLLEGIALITY
Max Weber, a German social scientist and one of the founders of modem sociology, described the conflicts between professionalism, which is considered proethical, and bureaucracy, which he considered promaterialist.'2 Weber viewed collegial structure as the chief mechanism for advancing specialization. The collegial structure provided a forum for communication among individuals with highly specialized roles, and through shared ethical standards regulated against both naked self-interest and the arbitrary exercise of power. Malcolm Waters, in a comprehensive review of Weber's analysis,'3 emphasizes the distinction between authority based on knowledge-the professional collegium-and authority based on power the bureaucracy. The structural difference between collegial vs. bureaucratic formation is based on the distinction between a monocratic organizational structure such as the bureaucracy derived from legal authority and the consensus of equals where power is derived from legal authority and the consensus of equals where power is derived from expertise and is not monocratic. Internal governance of the collegial body is characterized by its theoretical knowledge base, a performance oriented formal egalitarianism, a career progression divided into stages culminating in tenure, internalized organizational standards and scrutiny of the work product, and collective, consensual decision making. The advantage for professionals of the collegial structure includes maintenance of status closure, market regulation, and internal control of standards of professional practice. Despite his view that professionalization derived from collegiality was proethical, Weber did not consider collegial formations successful or effective bases for social regulation. Weber gives the advantage to the bureaucracy where the monocratic power structure, rule making, and enforcement potentials are significantly greater. Waters distinguishes Weber's structural characteristics of the collegial/ professional organization into distinct aspects with broad social and individual consequences. For example, the theoretical knowledge base of the profession makes expertise available but may also exclude by credentialism. This is, of course, the basis for contemporary medical licensure. In another example, internal scrutiny of the work product that is part of the collegium may both monitor adherence to ethical standards and result in the nonobservability of practice. This type of sociological examination of medicine provides a significant way to analyze the strength and weakness that professionalization creates. The advantage Weber attributes to bureaucracy may also provide an Vol. 68, No. 2, March-April 1992
288 288
PETRO A. PETRO J.J. A.
understanding of the success federal and state governments have had in imposing external reviews, regulation, and control over medical practice.
SUCCESSFUL COLLEGIAL FORMATIONS In the book, Natural Obsessions, Natalie Angier"4 recounts how Robert Weinberg runs his lab at the Whitehead Institute for Biomedical Research in Cambridge, Massachusetts. Weinberg is the principal investigator in ongoing projects studying oncogenes. Angier seeks to document how one individual can run a laboratory from which many crucial discoveries emerge in a continuing fashion. The formula she describes appears surprisingly simple. A bright, hard-working, motivated, well-funded person has working for him similarly hard-working, motivated, and bright younger people willing to be lesser lights either temporarily as research assistants, students, and postdoctoral assistants or permanently as assistants. When asked how he selects postdoctoral fellows from among hundreds of applications, Weinberg states "one of the most important things to me is that the person be nice. On a number of occasions I've turned away extraordinarily good people because they were pains in the ass. My science may have suffered as a result, but at least my health and well-being have been preserved." The laboratory at the Whitehead Institute provides a contemporary example of a collegial formation structured around a strong individual under whose direction motivated individuals work toward a common goal. Historically identifiable collegial medical institutions first appear with the Code of Hammurabi, circa 2100 B.C. The extant portion of the code establishes a fee schedule and sets standards by creating punishments for failures or complications. The subsequent larger body of Egyptian documentation also identifies a fee schedule, educational practices, and standards. There is a contemporary primitive as well as historically persistent close association between healers and religious figures in society. The image of the physician as omniscient, arrogant, secretive, and unable to recognize limitations may relate to this confusion of roles between the sacred-religious and secular-medical practice. A persistent, dogmatic reliance on texts may also result from this religious/ secular confusion. Physicians emerged in Greece as craftsmen and priests.8 Religious healing tradition embodied in the Asclepian temples extended through the Greek into the Roman world. The Hippocratic tradition arose from the crafts concept of the healer.8 Osler9 attributed to Hippocrates the importance of medical observation and the value of familiarity with the natural history of Bull. N.Y. Acad. Med.
COLLEGIALITY
HISTORY
COLLEGIALITY IN IN HISTORY
289
disease. Hippocrates is credited with laying the foundation of modern medical collegiality. His work set standards for the profession of medicine and created a system of thought based on observation that remains an ideal. He contributed a sense of humanism, the obligation of service to the community, and standards of physician comportment that remain valid after 2,400 years. The library at Alexandria, founded in 331 B.C. by Alexander the Great, represents the best example of an enduring collegial, historical institution. The library lasted until 640 A.D., funded by government and supporting the scholars who worked there.'5 Free intellectual inquiry was encouraged and no similar institution has survived over such an extended period since that time. An example of historical noncollegiality, Galen (129-200 A.D.) has been called the most influential medical writer of all time, and he may also have been the greatest physician of all time. The body of writing left by Galen became a canon of medical knowledge for the following 1,500 years. Galen was dogmatic, pedantic, and encyclopedic, and was absolutely convinced that he was right in everything that he said. He founded no collegial institutions, and accounts of his personality do not indicate that he was a collegial individual. Yet his work outweighed that of any other individual for many centuries. IMPLICATIONS OF COLLEGIALITY
Collegial practices of necessity include a form of discrimination. A group of individuals with differing ethnic, racial, sex, and sex preference, religious, and socioeconomic class backgrounds would have a difficult time identifying a set of shared values, a common purpose, a self definition, or even a set of internally determined standards. yet we find in the early European medical schools at Padua, Bologna, Montpellier, a diverse student body of men and women with differing backgrounds who both elected a faculty and determined the curriculum resulting in universities that still survive.' By acknowledging the existence of racism, sexism, classism, and all the other isms of a struggling egalitarian society, it would be necessary to struggle even harder to find, much less to create, collegial associations. The existence of distinct separatist institutions and professional associations, all women's or all men's colleges, Negro colleges, the American Medical Women's Association or the National Medical Association, make more sense and become justifiable in the context of collegiality. The elitism required by a collegial formation seems to exclude such groups unless they form their own associations. The severe reduction in the number of women entering Vol. 68, No. 2, March-April 1992
290
J. A. PETRO
medicine as physicians by 1910 resulted in part from the disappearance of the women's medical colleges existing prior to 1900 and the failure of women applicants to gain admission to the medical schools providing the professionalization of medicine and medical education occurring by the time of the Flexner report.'7 Discrimination based on suitability, meeting standards, and the need to preserve the institution/collegium may or may not be tolerable depending on the historic setting of place and time. The survival of the collegial formation depends on the persistence of the ideals upon which it is based. These may be preserved in the originally intended form, as in the Hippocratic tradition, or transformed through successive leaders. Boulding, in his essay on education, notes the risk of unmodified collegiality that may easily turn "into the slothful excusing of one another's inactivity and a total absence of progress or development." If the collegium seeks to become too uniform, progress ceases. The dilemma of collegiality revolves around a need for the protection of the collegial environment without inhibiting the development of ideas8 and the need to maintain the stimulation of diversity. Weinberg's concepts of the "6nice" person may provide a peaceful atmosphere. In the absence of strong leadership, however, one wonders whether the "nice" people would continue to function and to produce. The enduring collegial formations, the professional associations of medicine, or the university depend not on the strong leader but on the preservation of power, prestige, and expertise. The question is whether the goal of collegiality as set forth here can be sustained. REFERENCES 1. Johnson, P.C.: Guy de Chauliac and the grand surgery. Surg. Gynecol. Obstet. 169: 172-76, 1989. 2. Newman, J.H.: The Idea ofa University. Notre Dame, IN, Notre Dame Press, 1982. 3. Osler, W.: Evolution ofModern Medicine. Birmingham, 1982 (original Yale Press 1922). 4. Maulitz, R. and Long, D.: Grand Rounds: One Hundred Years of Internal Medicine. Philadelphia, University of Pennsylvania Press, 1988. 5. Walsh, M. R.: Doctors Wanted: No Women Need Apply. New Haven, Yale University Press, 1972. 6. Haeger, K.: History of Surgery. New York, Bell, 1988. 7. Durant, W. and A.: The Lessons ofHistory. New York, Simon and Schuster, 1968. 8. Mangiardi, J. and Pellegrino, E.: Collegiality, what is it? Bull. N. Y. Acad. Med. 68: 292-96, 1992. 9. Horstmanshoff, H.F.S.: The ancient physician. Craftsman or scientist? J. Hist. Med. Allied Sci. 45: 176-77, 1990. 10. Pellegrino, E.: The medical profession as a moral community. Bull. N.Y. Acad. Med. 66: 221-32, 1990. 11. Pellegrino, E.: Medicine and Philosophy. Some Notes on the Flirtation of Minerva and Asclepia. Philadelphia, Society for Health & Human Values, 1973. 12. Weber, M., Ross, G., and Wittick, C.: Economy and Society. Berkeley, CA, Univ. of California Press, 1928. Bull. N.Y. Acad. Med.
COLLEGIALITY IN HISTORY
291
13. Waters, M.: Collegiality, bureaucratization and professionalization: a Weberiana analysis. Am. J. Sociol. 94:945-72, 1989. 14. Angier, N.: Natural Obsessions. Boston, Houghton Mifflin, 1988. 15. Lyons, A.S. and Petrucelli, R.J.: Medicine: an Illustrated History. New York, Abrams, 1978. 16. Boulding, K.: Quality vs. equality: the dilemma of the university. Daedalus: 298-303, 1975. 17. Walsh, M.R.: Women in medicine since Flexner. N.Y. State J. Med. 302-08, 1990.
Vol. 68, No. 2, March-April 1992
