Nursology is regarded as a discipline and a profession, which means that nursology constitutes distinctive knowledge encompassing nursological philosophies, conceptual models, grand theories, middle-range theories, and situation-specific theories (see all content on https://nursology.net and also https://nursology.net/2018/09/24/our-name-why-nursology-why-net/).Medicine, in contrast, is a trade. This assertion is based on my search of literature for several years and pondering the difference between a discipline or a profession and a trade at least since the publication of Donaldson and Crowley’s now classic 1978 article, The Discipline of Nursing. .
I asserted that medicine is a trade in two 2014 publications (Fawcett, 2014a, 2014b) and in 2017, I wrote, under the heading, Medicine is a Trade:
I have never been able to locate any obvious or explicit knowledge that is distinctly medical. A September 18, 2016 search of the Cumulative Index of Nursing and Allied Health (CINAHL Complete) using the search term “medical model” yielded 816 publications. An admittedly quick review of a random sample of the retrieved publications revealed that the term medical model was not defined but rather used in a way suggesting that any reader would know what the term means. (Fawcett, 2017, p. 77)
I have continued to ponder whether medicine should be considered a trade and have wondered why no one has challenged my assertion, at least in any publications or blogs I have seen. Therefore, on January 4, 2021, I expanded my search to other sources–Taber’s Cyclopedic Dictionary, the Oxford English Dictionary, and Wikepedia.
The 22nd edition of Taber’s (Venes, 2013) includes no entry for medical model. Medicine is defined as “the act of maintenance of health, and prevention and treatment of disease and illness” (Venes, 2013, p. 1474). No reference to the knowledge needed to perform the act of medicine is evident. The Oxford English Dictionary also includes no entry for medical model, with only a mention of the term in quotations pertaining to two words, technologizing and miasmatist.
However, two definitions of medicine imply a knowledge base (although not necessarily distinctive knowledge). One definition is: “The science or practice of the diagnosis, treatment, and prevention of disease (in technical use often taken to exclude surgery).” The other definition is: “The medical establishment or profession; professional medical practitioners collectively.”
A search of Wikipedia yielded this statement: “Medical model is the term coined by psychiatrist R. D. Laing in his The Politics of the Family and Other Essays (1971), for the “set of procedures in which all doctors are trained.” It includes complaint, history, physical examination, ancillary tests if needed, diagnosis, treatment, and prognosis with and without treatment.” (https:// en.wikipedia.org/wiki/Talk:Medical model – Wikipedia). Noteworthy is that Laing did not mention the philosophic, conceptual, or theoretical knowledge that would guide the “set of procedures in which all doctors are trained.”
The content in Wikipedia also included an important negative consequence of adherence to the medical model. This consequence is “In the medical model, the physician was traditionally seen as the expert, and patients were expected to comply with the advice. The physician assumes an authoritarian position in relation to the patient. Because of the specific expertise of the physician, according to the medical model, it is necessary and to be expected. In the medical model, the physician may be viewed as the dominant health care professional, who is the professional trained in diagnosis and treatment.” (https:// en.wikipedia.org/wiki/Talk:Medical model – Wikipedia)
My concern with the very idea of “adherence to the medical model” (or adherence to or compliance with anything put forth by a nursologist or a physician) led me to ask “what [do] we mean when we say that a person (called a patient or a client) does not comply with or adhere to a treatment plan. It seems to me that these words reflect the physician’s or the nursologlist’s prescriptions for the patient, which in turn, reflect the physician’s or the nursologist’s power over and control of the patient.” (Fawcett, 2020)
My concern regarding the physician as a professional person is grounded in my inability to identify any distinctive knowledge of medicine that is necessary for the designation of professional in both the OEDO definition of medicine and in the mention in Wikipedia of the professional being “trained,” a word associated with training for a trade.
Of course, I understand that physicians possess a great deal of scientific knowledge. However, that knowledge is of various disciplines, such as anatomy, physiology, histology, and chemistry, not of medicine per se (as there is no distinctive medical knowledge that I have been able to identify),
I have concluded that the so-called “medical model” is a fiction put forth at least since Laing’s (1971) publication by members of the healthcare team (including nursologists) and the general public to ascribe a particular status to a trade. .
Please note that I acknowledge the importance of trades in society. I certainly cannot survive without many tradespersons in my life. However, I maintain that it is important to be very clear about the words we bestow on the members of healthcare teams, words that clearly reflect whether those members belong to a discipline/profession or trade. If members of a discipline/profession, it is necessary to identify the distinctive knowledge that guides practice, and research and education, too..
What do you, a reader of this blog, think? Have you been able to identify distinctive philosophic, conceptual, and theoretical knowledge that would constitute the discipline of medicine? Please add your thoughts to the comments section of this blog. Thank you very much.
References
Donaldson, S. K., & Crowley, D. M. (1978). The discipline of nursing. Nursing Outlook, 26, 113-120.
Fawcett, J. (2014a). Thoughts about collaboration—or is it capitulation? Nursing Science Quarterly, 27, 260-261.
Fawcett, J. (2014b). Thoughts about interprofessional education.Nursing Science Quarterly, 27, 178-179.
Fawcett, J. (2017). Thoughts about nursing conceptual models and the “medical model.” Nursing Science Quarterly, 30, 77-80. (Permission to provide a link to the PDF of this article was granted by the journal editor)
Fawcett, J. (2020, March 17). What is Reflected in a Label about Health? Non-Nursology and Nursology Perspectives. Blog.
Laing, R. D. (1971). The politics of the family and other essays. Routledge
Venes, D. (Ed.). (2013). Taber’s cyclopedic medical dictionary (22nd ed.). F. A. Davis.
No doubt in my mind – medicine is a profession and not a trade. Yes, medicine incorporates manual psychomotor skills, as does nursing, but the level of education and scientific knowledge required to become a medical doctor is professional. However, medicine is an applied field with a more nascent, less developed, disciplinary science than nursology. Nursologists who hold PhD degrees in various fields are akin to MD-PhD physician scientists educated in cell biology, anthropology, or history of medicine (https://students-residents.aamc.org/choosing-medical-career/article/why-pursue-md-phd/ ) . Medicine as a discipline has developed to the point of debating concepts of health and illness, embracing philosophy, and co-creating the field of bioethics https://plato.stanford.edu/entries/medicine/ As theorists, medical scientists lack the disciplinary depth and breadth of nursologists.
Nevertheless, there are many physicians who engage in explorations of health-related, caring-oriented phenomena, such as loneliness (Vivek Murthy), well-being at end of life (Atul Gawande), and patient safety (Don Berwick). These are shared phenomena of interest to both medicine and nursology. Indeed, definitions such as Newman’s “the study of caring in the human health experience” cannot belong to nursology alone. “In much the same way that nursing draws on the knowledge of physical and social sciences, other professions can draw on nursing’s knowledge of caring” (Cook & Peden, 2017).
Accordingly, the doors to nursology PhD programs should be wide open to physicians and allied health professionals — indeed all those with bachelor’s degrees who have the ability and passion to further the science of caring in the human health experience. Nursology benefits from the breadth of scientific knowledge gained from other disciplines. Medicine will gain from examining, testing, and applying nursing theories to the practice profession.
Dorothy Kent, MSN
PhD Student
University of Wisconsin-Milwaukee
Cook LB, Peden A. Finding a Focus for Nursing: The Caring Concept. ANS Adv Nurs Sci. 2017 Jan/Mar;40(1):12-23. doi: 10.1097/ANS.0000000000000137. PMID: 27608144.
What amazing timing you have. I’m in the midst of teaching an epidemiology course in our MSN program. One of the things the students struggle with in analyzing the studies is the fact that so few epidemiological studies devote any time at all to discussing the researchers’ theoretical framework. They end up throwing their hands in the air and saying, “It must be the medical model, whatever that means to them.” Considering many of these studies are looking at health behaviors as “adherence” or “compliance,” that is likely a fair assessment, and a concerning one.
How would we feel if a physician wrote a piece saying that nursing is a “trade”? Does nursing have the right to define “medicine” any more than medicine has the right to define “nursing”?
The hypothesis being presented here seems to be that medicine, unlike nursing, does not have an epistemology. Prior to the Flexner Report in 1910, which was funded by the fledgling pharmaceutical and device industry, 80% of the medical schools in the US followed the “vitalist doctrine” which asserted that “man assists but nature heals”.
The vitalist doctrine was clearly not going to be a money maker for the pharmaceutical or device industry, so the 20% of schools that followed the idea of Cartesian dualism were the only medical schools that remained open. In addition to Cartesian dualism, the Doctrine of Single Cause, since Pasteur’s discovery of microbes, has been the epistemological basis of Western biomedicine. The bio-psycho-social model, that nursing claims to have developed, comes from biomedicine, the work of the psychiatrist and pathologist George Engel (Engel, 1977).
Standardization is the basis of Western biomedical scientific thought. Lock and Nguyen (2010) note that, what counts as “normal” is actually a statistical average. They note that, “Biomedicine is not a result of inevitable development nor the result of an orderly uncovering of the “true” causes of illness” (Lock & Nguyen, 2010, p. 23). Biomedicine, and one could argue nursing as well, is a product of particular historical circumstances, systematic efforts made to understand nature, and making use of techniques designed to produce an objective description of the material world- e.g. statistics (Lock & Nguyen, 2010).
I have heard repeatedly, during the completion of four nursing degrees, that nursing is “holistic” and does not subscribe to the “medical model”. What is the structure of the average BSN program? Students take courses in medical-surgical nursing, mental health nursing, public health nursing, geriatric/palliative care nursing, critical care nursing, pediatric nursing, and obstetric nursing. That sure seems to align with the organ-based, “medical model” that I was taught to abhor.
We have had many problems with our biomedical colleagues in the past and this continues into the present but I see progress and reasons for hope. I have taught critical analysis of racism in healthcare to students at Harvard Medical School; am part of a multidisciplinary team teaching social medicine and anti-racism with Haitian and international French-speaking medical and nursing students in rural Haiti; doing social justice work with a national group founded by medical students that have worked collectively to successfully abandon, in numerous medical centers in the US, the practice of racial correction of eGFR that is killing hundreds of our black patients every year; working with physician and other healthcare colleagues across the globe to dismantle racism in healthcare through the Global Campaign Against Racism; and this week I was invited to facilitate a journal club for first year residents ( at a different university than where I normally teach) around the issue of racism.
Is that the work of “tradesmen”?
References:
Engel, G. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196, 129-136. DOI: http://dx.doi.org/10.3109/13561828909043606.
Lock, M. & Nguyen, V. (2010). The Anthropology of Biomedicine. Wiley-Blackwell, New York.
Jacqueline, Interesting article. I was always surprised how little advanced degree nursing students knew about their discipline. I always found Edwardson, S. 2004 and 2010 articles in Journal of Professional Nursing helpful in the discussions about the differences in medical and nursing advanced degrees. Clarifying that the PhD is the advanced degree for physicians. Best, Martha Raile Alligood
So interesting, Jacqueline. Medicine, law and theology have been deemed professions dating back to the Middle Ages. Professions are characterized by specialized knowledge, formation / training, self-regulation, autonomy. While Medicine may not meet the criteria for a discipline, I think it fulfills the criteria for profession. But I absolutely agree with your point that we need to think about the meaning of these words and their connotations carefully. Thank you.
Thought-provoking! While I don’t generally deal with the term, healer, thinking about some of the ramifications of this article, particularly informed by a growing awareness of the need to decolonize nursing (AND medicine!), I am thinking it is the person in community from whence evolving wholeness comes. Nurses are companions in that process, physicians are outside consultants. These musings will no doubt continue to bubble up, so thanks for the interesting stimulus!
No doubt in my mind – medicine is a profession and not a trade. Yes, medicine incorporates manual psychomotor skills, as does nursing, but the level of education and scientific knowledge required to become a medical doctor is professional. However, medicine is an applied field with a more nascent, less developed, disciplinary science than nursology. Nursologists who hold PhD degrees in various fields are akin to MD-PhD physician scientists educated in cell biology, anthropology, or history of medicine (https://students-residents.aamc.org/choosing-medical-career/article/why-pursue-md-phd/ ) . Medicine as a discipline has developed to the point of debating concepts of health and illness, embracing philosophy, and co-creating the field of bioethics https://plato.stanford.edu/entries/medicine/ As theorists, medical scientists lack the disciplinary depth and breadth of nursologists.
Nevertheless, there are many physicians who engage in explorations of health-related, caring-oriented phenomena, such as loneliness (Vivek Murthy), well-being at end of life (Atul Gawande), and patient safety (Don Berwick). These are shared phenomena of interest to both medicine and nursology. Indeed, definitions such as Newman’s “the study of caring in the human health experience” cannot belong to nursology alone. “In much the same way that nursing draws on the knowledge of physical and social sciences, other professions can draw on nursing’s knowledge of caring” (Cook & Peden, 2017).
Accordingly, the doors to nursology PhD programs should be wide open to physicians and allied health professionals — indeed all those with bachelor’s degrees who have the ability and passion to further the science of caring in the human health experience. Nursology benefits from the breadth of scientific knowledge gained from other disciplines. Medicine will gain from examining, testing, and applying nursing theories to the practice profession.
Cook LB, Peden A. Finding a Focus for Nursing: The Caring Concept. ANS Adv Nurs Sci. 2017 Jan/Mar;40(1):12-23. doi: 10.1097/ANS.0000000000000137. PMID: 27608144.
In drug/addiction/substance use theory the “medical model” is contrasted with the “moral model” or “biopsychological model” amongst others. The medical model in this instance is understood as the biological explanation for addiction- in other words a substance use disorder, a health issue, an illness and not for e.g. a moral failing or religious issue (the moral model). This model then leads to medical or psychiatric treatment based on evidence-based principles and not unproven theory/treatment. It also lends itself to research based more on functional MRIs looking for neurological disorders and less on multi-factoral explanations like poverty, trauma, structural violence etc It looks only at the user, generally, or at the substance and tries to locate the disorder in the object. This is an explicit philosophical stance, that may largely be invisible to medical persons. Other approaches and models therefore lead to other explanations and therefore other interventions like drug policy reform
The medical model tends to exclude the biopsychosocial from explanations of illness and does not usually allow for body-mind influences beyond stress response or somatization of feelings.
I would say that the medical model also includes foundational influences from rationality, white, male dominator styles of thought and is analogous to western thought.
What the medical model would look like in eastern or Indian or Hindu, Chinese contexts which have other explicit systems for understanding health, illness etc would be pertinent to reveal what the western medical model is by contrast.
Thanks for this important discussion!
Great, that nursing researchers, scholars and educators appreciate the routs of our profession (e.g. nursings’ distinctive knowledge encompassing nursological philosophies, conceptual models, grand theories, middle-range theories, and situation-specific theories).
Nursing as a profession has its body of knowledge and Professional Nursing Language, which is described in Nursing Classifications (Butcher et al, 2018; Jones et al, 2010; Moorhead et al, 2018).
These classifications provide a framework with related concepts of the Advanced Nursing Process. They ought to be taught at all levels of nursing education, be put into practice and into Electronic Health Records.
The language of the profession, the use of nursing concepts (diagnoses, interventions and outcomes) can make nursing visible.
Sincerely, Maria Müller Staub
Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing Interventions Classification (NIC)(Vol. 7).
Jones, D., Lunney, M., Keenan, G., & Moorhead, S. (2010). Standardized nursing languages: essential for the nursing workforce. Annual review of nursing research, 28, 253-294. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21639030
Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (2018). Nursing outcomes classification (NOC) (6 ed.). St. Louis: Elsevier.
Thank you to everyone for the thoughtful comments. I am delighted that we now have a robust dialogue about medicine and nursology as (or as not) trades, professions, and/or disciplines. WE may now want to thnk about a next step–perhaps engaging physicinas in this dialogue to determine their undersanding of the medical model and hhe source of knowledge used to practice medicine. Again, thank you.
Also, thinking about the classism in these concepts. Or the classism in our RESPONSES to these concepts.
Why is being a professional more desirable than being a tradesperson… What if the word changed to artisan?
In South Africa, the words Healthcare Worker are used in various contexts; its seems doctors have it both ways- experts and professionals in earnings and social power but also health care workers when pushing government for access to covid vaccines. It is unlikely you’ll find doctors as Healthcare Workers on the line of a trade union strike, in solidarity with abused technicians or home based carers..
Multiple layers of power in all these words.
Profession
Trade.
Discipline.
They will always exist in context and in relationship.