Fear, Regulations, and the Fragile Exoskeleton of Medical Professionalism.

We live in a world riddled with rules. Standards of group behavior innervate virtually every aspect of our social and work lives. Some are formal (laws); others are informal and tacit. Some appear well intentioned; others, draconian. Most arise from—and reflect— power dynamics. This can be the power of groups (how ‘‘people like us’’ see and do things), or the power of those among us able to impose their will on others. As a form of social structure, rules can precipitate unanticipated consequences 1 and subcultures of purposeful circumvention. Some circumvention is public and transparent: ‘‘the rules say do it this way, but everybody knows it is best to do it the other way.’’ Others are sub rosa—even subversive. At the group level, acts of opposition rarely are clandestine, sometimes rising to the level of insurrection. Medicine’s current insurrection against the principles of maintenance of certification is a case in point. 2,3 Whatever the unintended or oppositional particulars, reactions to rules often spawn still more rules as those in power attempt to mute the havoc wrought by countervailing action. Examples abound. Americans face a regulatory environment strewn with more than 4000 types of federal crimes (a 50% increase since 1980) and a Code of Federal Regulations that exceeds 175 000 pages. The National Collegiate Athletic Association rulebook, covering college sports, is infamous for having morphed into a mountainous tangle of qualifications and addenda. This April, Churchill Downs issued a bevy of new rules that outlaw the use of drones and selfie sticks during the Kentucky Derby. And so it goes. In an ideal sense, professionals (unlike denizens of ‘‘normal’’ occupations) are expected to stand somewhat outside this tangle of ferment and fugue. Professions, by definition, are allowed to regulate themselves, and do so on behalf of the others—the patients and society—they serve. In turn, this