Proliferations and Vulnerabilities: Hybridization of Professionalism in the Field of Cancer Medicine

Hybridization and professionalism as discourse

Approaches from the sociology of professions, which take up the previously described developments in a constructive manner, emphasize the relationality of professionalism and societal development. Professionalism is thereby less defined as a distinct form of controlling labour and rather described by its embeddedness within bureaucratic structures, organizational rationalities and interdisciplinary communities of practice. Overall, between professional work and the changing contextual conditions, direct interactions can be stated. Out of the attempts at theoretical conclusions, Evetts’ (2011) analysis of the discursive turn of the concept of professionalism, as well as the diagnosis of hybridization, has gained special attention (see also Gourdin & Schepers, 2011; Noordegraaf, 2007).

Evetts (2011) suggests that classic professionalism, as referring to an occupational group in the Durkheimian (Durkheim, 1993) sense of an epistemic or a moral community (“occupational professionalism”), still exists. Moreover, a cultural and symbolic extension of the idea of professionalism is assumed. The “discourse of professionalism,” also described by Fournier (1999), can be interpreted as a reaction of the contemporary transformation of capitalism, which is characterized by tertiarization and facets of the emergence of knowledge societies. The “appeal of professionalism” would, therefore, serve as an ideological tool in the service sector, which indeed relies on self-governance in the Foucaultian sense but is still more or less distant from enabling an autonomous professional practice. Here, Evetts (2009) introduces the term “organizational professionalism” to characterize a type of professional practice that demands specialist knowledge and self-dependent action but decisively stays obligated to the interests of an employing company or organization.

Hybridization describes the entanglement between professionalism, on the one hand, and requirements and constraints, which traditionally lie outside the professional area of responsibility, on the other hand (Noordegraaf, 2007). This concept does not refer to the inflationary rhetorical use of the term professionalism in contexts that are only seemingly liable to professional standards; rather, hybridization refers to classic professional work that now turns out as increasingly dependent on external interests and evaluation. The emphasis of the analysis thereby lies in overcoming the classic model of professionalism, which equates the latter with an all-encompassing structural autonomy. Besides, the influence of the criticism of professionalism might have affected this interpretation. The conflict-oriented and power-sensitive debate had its starting point in the late 1970s, in reaction to the earlier relatively schematizing and rather affirmative interpretations of professions. Instead, a critical glance was cast on the monopolization of responsibilities and the ideology of professional altruism, partly by highly detailed historical studies (Johnson, 1972; Larson, 1977). The professionalization of the established occupational groups has been reconstructed as a strategy of social exclusion and collective upward mobilization, which could only be achieved at the price of depreciating, subordinating, and discriminating against other occupations (e.g., care work versus medicine). Following the interpretation that professional autocracy under the guise of autonomy did not prove itself historically, new findings take up the structural transformation as a logical consequence of social transformation and potential advancement.

The hybridization concept does not solve the contradiction between professionalism and market constraints or organizational interests, but these contradictions are considered within contemporary professional work. Hybridized professionalism not only has to incorporate professional knowledge and the corresponding moral and ethical responsibilities, but it also has to justify its effort in an adequate and balanced manner (Brint, 2006). Instead of the “third logic” of controlling work (Freidson, 2001) that comprises closure and autonomy, professionals are integrated into organizations that require verifiable professional performance and therefore operate with more or less elaborated forms of evaluation. In contrast to the discussion in the 1990s on the crisis of professions, hybridization is not interpreted as de-professionalization but as a realistic and contemporary form of professionalism. However, professionals are trusted to cope with the modified demands. Instead of a polarized interpretation implying either “pure professionalism” or ideologically disguised subsumption, tackling ambiguities and negotiating compromises characterize hybridized professionalism in particular.

The key to dealing with the structural transformation here is perceived in an active self-contextualization, which has to be integrated into the professional self-conception. Thus, it is in the nature of professional work to handle complex, paradoxical and partly unsolvable demands. Professional per se is characterized by a high amount of reflexivity because theoretical knowledge can never be transferred directly in the concrete individual case but presumes a systematic setting in relation to different forms of judgement. It refers to societal or rather collective problems occurring in a most complex, individual (by situational and contextual influences) and overdetermined manner that should be processed accordingly. This attribute of professionalism is now conferred on the modified framework conditions and needs to be extended correspondingly to these newer interpretations. Therefore, professional and ethical standards not only have to be followed but often have to be explained, vindicated and made transparent. Nonetheless, it is assumed that professionals with the intellectual and the methodical resources to reflect on the manifold manifestations of societal problems in individual cases should also be able to deal with altered and possibly conflicting requirements to a certain degree.

In both approaches, the struggle for control is moved from the structural to the symbolic-cultural level. It is referred to as the rhetoric of normative control, which does not remain entirely without effect but leads to the enforcement of selected, soft and subtle standards in particular.

This “fuzziness” also affects the relation between individual professionals and the professional community. Hybrid professionalism is characterized by “patterns of fragmented association” instead of stable and homogeneous groups (Noordegraaf, 2007, p. 781). While Evetts critically examines the use of the discourse of professionalism for strengthening corporate identities to effectively control professionals, Noordegraaf emphasizes the structuralizing potential of professional identity.

Professionalism today can therefore also be understood as “a search for … appropriate work identities … that can be used for coping with trade-offs between individual demands, professional claims, and organizational action” (Noordegraaf, 2007, p. 780).

Overall, these new interpretations react to the structural transformation without abandoning the concept of professionalism. Nevertheless, the thesis of hybridization also demonstrates that professionalism has slipped into a defensive position. In the following section, I further discuss the interpretation of hybridization with regard to a field, which on the one hand is dominated by the ideal-typical profession of medicine but on the other hand, does not provide a refuge for pure professionalism by any means. Hybridization shapes the entire field and therefore enables a reconstruction of different forms of professionalism under these conditions.

Contrasting constellations of hybrid professionalism

The development cycle of a new active substance takes at least 12 years from the first laboratory attempts to approval. According to the pharmaceutical industry, the expense for every new drug is estimated at several billion euros. Hence, high drug prices in the field of cancer medicine are justified with investment costs (not with their material production costs, for instance). Although companies do profit from each successful approval, the biomedical turn in oncology entails economically ambivalent preconditions. In accordance with molecular biological diagnostics, treatments have become more target oriented, aiming at a smaller number of patients in the sense of “stratified medicine.” Therefore, diseases within the oncological complex, which have a high prevalence, are of considerably higher economic interest. Since better opportunities for financing and sophisticated research proposals are provided, the chances of securing a solid reputation in the medical profession are better in a field of high prevalence compared to research on rare or more specified health risks. Regardless of how it is objectified, successfully developing a new substance or treatment is essential for success in both professional and commercial spheres. Thus, in the arena of oncology, different constellations arise. This can be exemplified by comparing the colon cancer and the brain tumour research fields.

The indication area of colon cancer is rated as an epidemic disease (according to the German Cancer Research Center at the Helmholtz Association (DKFZ, 2016), every seventh case of cancer is related to the intestines, with about 60,000 new diseases nationwide in 2014). Nonetheless, considerable progress has been made in colon cancer therapy over the last 10-15 years. The survival rates have risen, and the quality of life has also generally improved under treatment. Medication functions more effectively, there are fewer side effects, and the intensity of medical surgery has been reduced accordingly. At the same time, diagnostics have been refined, and the population has been sensitized towards participating in prevention programmes promoted by healthcare policies. That is why colon cancer therapy offers very high chances of success for both medicine and industry. Despite the overall increased life expectancy, the demand for oncological therapies will not decline due to the disproportionate cancer incidence in the population. Thus, it can be assumed that in the field of colon cancer, the contradiction between medical and commercial interests is evened out (at least on the surface). Medical researchers are coerced to design their research projects in accordance with commercial purposes, but professional interests meet the interests of the pharmaceutical industry to a relatively far extent. ¹

In contrast, brain tumour research represents a rather marginalized field in cancer research. In 2012, only 7000 people who were newly taken ill with malignant tumours had been reported in Germany. The disease is medically challenging and rapidly leads to massive impairment of health and the quality of life. It is particularly drastic for the patients because a brain tumour affects not only the body but the whole personality. At the same time, medical interventions on the brain are risky; surgeries particularly require extraordinary precision and are inevitably life threatening. There had been therapeutic achievements in some subcategories of the indication area of brain cancer in the past; nevertheless, it is still rated as incurable in most cases.

Therefore, this field turns out to be academically and economically much less promising than that of colon cancer. The medical challenges are nonetheless extensive. Apart from the technical challenges of working on the sensitive and delicately structured brain, the psychological burden for physicians is exceptionally high due to the severe consequences of even the smallest mistakes or sloppy work. Moreover, successful interventions will probably not effectively prevent patients’ suffering and death. Experimental drug therapies offer hope for therapeutic progress but still require comprehensive research. Due to the small size of the target group, the industries’ commercial interest in this therapeutic area is limited. Research and development are promoted by new health policies to a certain extent, allowing simplified licensing procedures for new drugs targeting the so-called orphan diseases. However, mostly, the only reason for investing in drug development in such a small market is the application of already existing substances on diseases that have so far not been included in the drug approval.

Therefore, these two constellations within cancer medicine differ fundamentally from each other. The colon cancer constellation reflects a kind of virtuous circle, wherein the dependency on commercial interests does not seem to imply a hindrance to professionalism. A more profound empirical insight reveals that thereby, professionals have to accept compromises as well, but this does not impair their professional reputation. In comparison, brain tumour research is structurally shaped like a vicious circle. The disease is rarer yet particularly frightening since it is accompanied by much pain and an impairment of personality and is still claimed to be incurable and lethal. Although some public funding is allocated for this disease, the research relies on industry support because of the expensive patented substances in use. Compared to the colon cancer constellation, it seems less promising to build a professional career on specializing in this therapeutic area. It is also much more difficult to acquire industry sponsorship for research in this field. ²

Both fields are structurally characterized by hybridization and the mutual interdependence of professionalism and pharmaceutical companies. Regarding the type of professionalism arising from this constellation, contrast is revealed as well. In analogy with the depicted structural requirements, this contrast can be described in two phenomena—as the renewal of the knowledge–power nexus and as vulnerable professionalism.

A new knowledge–power nexus?

To capture the hybridization phenomenon more precisely, I explain it with an ideal–typical contrast, exemplified and fathomed by the colon cancer and the brain tumour research fields. First, I reconstruct colon cancer research as a (re-)institutionalization of hybridized professionalism.

Within the German scientific community of oncological research, the so-called working groups have been established, bringing together medical professionals and industry representatives for periodic symposia, workshops and conferences. Colon cancer research herein forms a major group, uniting reputable scientists and large companies involved in cancer research. Apparently, hybridization has reached a level of institutionalization and closure in this field; even potential internal conflicts and competitions among members will be resolved within the working group.

An empirical example involved the case of a dispute about a national study investigating a new therapy strategy. The debate focused on the treatment of patients with metastasized colon cancer by administering medication which includes different antibodies. The study had been designed as a comparative type and should have proven a new active substance’s superiority over the established combination of drugs. The study effectively failed to reach its self-imposed goals, and only a subgroup of the patients participating in the study had gained advantages from the new therapy. Some of the patients even died earlier than would have been expected from the standard therapy. Nevertheless, the findings were presented as medical progress and ascertained as a new therapeutic standard. ^{3 , 4}

The conflict culminated when the findings were supposed to be presented at an annual conference of the working group. The company that had developed the standard medication until then (thus a competitor of the particular study’s sponsor) prevented the presentation of the results by an interim injunction. At that point, the working group had a controversial discussion on the proper conduct, the evaluation of the results and the adjustment of the treatment guidelines. ⁵ The dispute resulted in an appeal to the ethics commission, and briefly, the pragmatic consensus among the clinical doctors involved in this study, other medical professionals and the pharmaceutical corporations became questionable. At issue was nothing less than a euphemistic portrayal of the research results and a default of scientific standards, a prestigious professor who probably made promises for obtaining sponsorship and last but not least, a competition between two major companies. Nonetheless, just a little later, the study’s results were published in a positive manner, stressing the medical progress against the threat of cancer, even touted as one of the most important achievements of the year in cancer research, whereas the disputes behind the scenes remained invisible outside of the working group. ⁶

The important point in interpreting this phenomenon lay with the structural fastening of the connection between medical professionalism and company interests. A marketing slogan by the pharmaceutical industry—“The best medicine is research” (Forschung ist die beste Medizin) (Verband forschender Arzneimittelhersteller, 2011)—symbolized the legitimation of this alliance. As long as the promise to society that cancer would be fought by any means could be demonstrated by successful research, the contradictions in the relationship between profession and commerce in this field of research could be concealed.

Regarding the professional self-conception, structural hybridization seemed to come along with a discourse of pure professionalism in this field. Despite this contradictory setting, the actors tended to adhere explicitly to the ideology of traditional professionalism. The medical leader of the mentioned study, who had been criticized for withholding the negative treatment results, justified his decision by reiterating his unquestionable responsibility as a medical doctor for the well-being of his patients. ⁷ Complementary to the retaining of traditional role sets, the medical managers working alongside the industry in this field also insisted on the different roles of doctors and managers. They referred to their motivation to carry medical progress forward as well but viewed themselves in the positions of communicators, leaders and organizers. ⁸ Career opportunities on both sides of the cooperation between the pharmaceutical industry and the medical profession appeared very promising. The corporate careers of three of the interviewed medical managers advanced within two years. Overall, the subfield of colon cancer was characterized by hybridization but already developed a new framework that stabilized and sheltered the group from internal and external criticisms. At the same time, traditional roles were defended, at least at a discursive level.

Vulnerable professionalism

For the field of brain tumour research, no comparable establishment could be stated. Notwithstanding the German working group and regular expert meetings at the national level, international networks were more important. The case of a surgeon, who was hired by a pharmaceutical company after performing several roles in research and medical practice, illustrated how far this subfield within the arena of oncological research was also representative of the hybridization of professionalism. He was contracted to support the process of the indication extension of an antibody for a specific type of brain cancer up to the legal approval. Deeply affected by the experience that patients could not be healed from their torturous illness and confronted with the limits of standard therapies, the surgeon adopted the role of medical manager. His designated goal for accepting this position in a pharmaceutical corporation was the regular provision of this antibody for patients. He had observed improvements for patients when this drug was used in experimental therapy approaches. His new position in the pharmaceutical industry seemed to him an opportunity to apply his professional knowledge more successfully and even in a more satisfying manner. ⁹

The characteristics of hybridized professionalism, as described by Noordegraaf (2007), were thereby met in an ideal manner. He engaged in the project management of the company, explained the medical backgrounds to the different decision-making bodies, worked with an interdisciplinary team, acknowledged the company’s commercial interests and reflected on his work situation as a reasonable compromise. His professional self-conception was stabilized by the subjective envisioning of limited alternatives in the fight against brain cancer and especially through a network of colleagues from industrial research and from medical practice, which encouraged him to follow that direction and to try to improve the situation of the disease-ridden patients.

According to his own interpretation, the interviewee did not attain his goal. The main reason was that the company’s marketing department insisted on a broader definition of the indication field. It was stated that the costs of the approval procedure would be too high for the very small scope of application planned for the drug. Not even the warnings about the risks of a further extension of the indication would bring the company’s strategy on track again. The approval procedure failed. Although the company offered him a new position in another project, the surgeon returned to medical practice. ¹⁰

This case reflected the hybridization of professionalism in cancer medicine, as well as in the example from the field of colon cancer. However, it showed a different pattern of hybridized professionalism. Research on active ingredients in the field of brain cancer would depend on industry sponsorship, not only for funding large studies but also in the case of experimental research because the producers should at least provide the active substances. The hiring of a brain surgeon for the project on indication extension by the pharmaceutical company and his subsequent resumption of medical practice also showed a historically new permeability of the boundaries between industry and profession.

Differing from the colon cancer research field, in which profession and industry potently merged, the constellation of brain tumour research was defined by a vulnerability of professionalism, reinforced rather than qualified by hybridization. Thus, both examples resembled each other in that the medical development tended toward the direction of minimizing the target collectives of patients, while the industry constantly bore in mind the enlargement of the sales market. Nonetheless, in the case of the actual colon cancer study, this conflict was solved behind closed doors, while the results were presented to the public as an utter success in the fight against cancer. In the other case, the indication extension of the antibody for treating brain tumours, medical expertise conflicted with the mechanisms of business management and led to the project’s failure.

This case of the brain surgeon took up the core argument of classic professionalism theories in as much as the problem (the severe disease of brain cancer) guided action. In the issue at hand, it even substantiated his willingness to abandon his professional role as a medical practitioner and to adopt another, the functional role of a medical manager. Instead of the powerful aspects of professionalism, its vulnerability was revealed. The interviewee described difficult surgical interventions on the brain and mentioned that he had “screwed up people” when he was unable to remove a tumour without injuring the healthy tissue despite his extreme efforts. ¹¹ The confrontation with the limits of existing therapies explained his openness to the requirements of industrial project management. On the other hand, he neither understood nor accepted technocratic thinking, particularly of his colleagues in the corporation. Thus, he came into conflict with the company’s marketing division, which was not susceptible to medical arguments.

According to these observations, an ideological discourse of professionalism paradoxically appeared to apply to the prestigious professor in the field of colon cancer rather than to the brain surgeon in the role of a medical manager. While the professor rejected fallibility by referring to his undeniable professional obligation for patients’ well-being, the brain surgeon turned out to be resistant to the company’s internal and external ideological appeals.