BMJ No 7093 Volume 314
Education and debate Saturday 24 May 1997
The performance of doctors. I: Professionalism and self regulation in a changing world
Donald IrvineThis is the first of two articles. The second will be published next week.
The performance of doctors embraces attitudes to practice, knowledge, and skills. It is the outward and visible expression of our professionalism. In general, people think highly of the medical profession in Britain; rising expectations are a mark of our success. Nevertheless, self regulation, on which our professional independence and self respect depend, cannot be taken for granted. Sympathetic critics such as lay people, sociologists, and doctors reflect a wider public perception that we seem reluctant to assure doctors' competence and protect patients from poor practice. There are also criticisms that we are not addressing the widespread dissatisfaction with the attitude of some doctors, including their paternalism and poor communication with both patients and colleagues, and are failing to make self regulation demonstrably effective and responsive.(1-12)
These criticisms, if not dealt with, could seriously damage public trust. They provide ammunition for people who oppose professional self regulation on the grounds that, where doctors' and patients' interests conflict, doctors' interests will invariably come first. Greater external control of the profession is their prescription.
In this article, and another to follow, I propose a modern expression
of medical professionalism, founded on sound self regulation, that
should bring the public's and the profession's interests together
s Our professionalism is shaped by the context in which we work.
First and foremost, medical knowledge and skill have expanded at an
unprecedented rate. This, together with the revolution in information
technology, has huge implications for the profession. Can we, for
example, maintain medicine as a distinctive entity in the face of
growing subspecialisation? Can we adapt to careers that may not last a
lifetime without reorientation and retraining?
People know more about health matters because they have independent
access to clinical information and because their interest has been
stimulated by media attention. More patients want an open relationship
with their doctors: they want to be well informed and involved in
decisions about their care.
Doctors are no longer alone in the clinical management of patients.
Multiprofessional teamwork, the philosophy behind modern shared care,
has to be reconciled with the personal nature of the doctor-patient
relationship.
Modern healthcare is complex to manage. A structured managerial
framework, more accountability, and overt rationing now exist in the
NHS. Many doctors are unhappy at the impact these developments have on
their ability to practise in their own way. Yet the public expects
doctors to help make the system work well.
Doctors' attitudes are also changing. For example, more doctors attach
as much importance to the quality of their lives outside medicine as to
their medical The effects of these changes are both exciting and bewildering. We
delight in the successes of medicine - and at times oversell it. Many
doctors, though, feel alienated and undervalued.(14) And the
sheer complexity and pace of modern medicine is itself stressful.
To retain our independence, and reasonable control over our affairs,
our professionalism must be capable of adapting to change.
Independence gives individual doctors clinical freedom and the
profession collectively the authority to decide about standards of
professional practice and education, the organisation of medical work,
and discipline. Furthermore, independence gives doctors that self
respect which motivates them to perform well.(15) Patients
rely on an independent medical profession for authoritative advocacy on
behalf of individuals and where the state or big business may engage in
activities that threaten health (M Stacy, second international
conference on medical registration, Melbourne, 1996). Equally, a
profession with a strong sense of ethical duty makes an important
contribution to a "civic society."
Our independence rests on three claims: firstly, that there is such an
unusual degree of knowledge and skill involved in medical work that
non-professionals are not equipped to evaluate or regulate
it(16); secondly, that doctors are responsible - they may be
trusted to work conscientiously, without supervision; and, thirdly,
that the profession itself may be trusted to undertake the proper
regulatory action when individuals do not perform competently or
ethically.
The universities are accountable to the GMC for basic medical
education, and the royal colleges determine standards of practice and
education in their specialties. The Specialist Training Authority and
the Joint Committee on Postgraduate Training for General Practice
certificate the completion of training for entry to a specialty or
general practice. Specialist certification leads to specialist
registration with the GMC.
Professional self regulation is one element in the complicated
relationship between the medical profession and society. For example,
doctors working for the NHS are also accountable as employees and
contractors. In a web of complex regulatory arrangements some tension
is not only inevitable but healthy.
For self regulation, and therefore professional independence, to
continue, patients must feel able to trust their doctors and society
must feel able to trust the collective medical profession. We must
become more transparently accountable for our performance and show, in
ways that the public can understand and relate to, that self regulation
really works.
Tomorrow's Doctors (1993) signalled the GMC's new
approach to undergraduate medical education.(19) The medical
schools have gone to work on this with a real will. The New
Doctor, published this year, reflects the GMC's determination
to transform the preregistration year into an enjoyable and worthwhile
experience.(20)
A quality assured system Performance - Evidence of competent management,
good leadership, operational criteria and standards, good systems and
data, effective performance monitoring, and feedback
Consistency - Evidence of thoroughness, fairness,
and a systematic approach
Effectiveness or efficiency - Evaluation of the
impact of procedures; evidence that the organisation is efficient and
achieves good value for money
Accountability - Responsibilities and lines of
accountability well defined and understood; wherever possible the
process of regulation made visible and results published; evidence of
external audit
Overall acceptability - Evidence that the overall
performance and results of self regulation inspire the trust and
confidence of the public, the medical profession, and doctors'
employers
Patients' involvement
External peer review
Diversity with coordination Without effective coordination, however, it is difficult to see the
whole picture, how one part of the system relates to another, and
whether the system as a whole works well. The best results will surely
be achieved by setting individuality, with its evident strengths,
within a framework of agreed goals and well coordinated partnerships,
both locally and nationally. Then each partner will maintain a sense of
ownership and achievement while contributing to a common
p
The leadership role of teachers The kind of leadership teachers give is critical to the quality of
medical practice and education and to professional self regulation. The
assessment of attitudes and interpersonal skills should therefore have
a high priority in medical education.
The time is ripe for a new agreement between medicine, the state,
and society generally. It is our responsibility to see that
professional practice is at one with people's expectations and to show
that self regulation is effective. For its part, the state must give
doctors the time needed to do a professional job for patients and to
maintain standards of practice using modern methods. The proper
resourcing of good medical practice - including medical education - must
become an agreed given of good quality health care. With such an
approach, we can be confident that our strengthened professionalism
will keep the public's respect and trust.
This paper is based on the George Haliburton Hume, Cohen, and
Telford lectures given in Newcastle upon Tyne, Edinburgh, and
Manchester, respectively.
References
1 Kennedy I. The unmasking of medicine.
London: Granada, 1983.
2 The doctor's dilemma. The Times 1992 March
2:15.
3 Klein R. The state and the profession: the politics of the
double bed. BMJ 1990;301:700-2.
4 Select Committee on the Parliamentary Commission for
Administration. Report of the Health Service Ombudsman for
1995-96. London: Stationery Office, 1997.
5 Rosenthal M M. Promise and reality: professional
self-regulation and problem colleagues. In: Lens P, van der Wal G, eds.
Problem doctors: a conspiracy of silence. Amsterdam: JOS
Press, 1997.
6 Stacey M. The GMC and professional accountability.
Public Policy and Administration 1989;4:12-27.
7 Stacey M. Regulating British medicine: the General
Medical Council. Chichester: Wiley, 1992.
8 Rosenthal M M. The incompetent doctor: behind closed
doors. Buckingham: Open University Press, 1995.
9 Allsop J, Mulcahey L. Regulating medical work: formal
and informal controls. Buckingham: Open University Press, 1996.
10 Smith R. Profile of the GMC: the day of judgment comes closer.
BMJ 1989;298:1241-4.
11 Lock S. Regulating doctors. BMJ 1989;299:137-8.
12 Armstrong D. Medicine as a profession: times of change.
BMJ 1990;301:691-3.
13 British Medical Association. Core values for the medical
profession in the 21st century: survey report. London: BMA,
1995.
14 Allen I. Committed but critical: an examination of young
doctors' views of their core values. London: BMA, 1997.
15 Committee of Inquiry into the Regulation of the Medical
Profession. Report. London: HMSO, 1975. (Cmnd 6018;
Merrison Committee report.)
16 Freidson E. Profession of medicine: a study of the
sociology of applied knowledge. London: University of Chicago
Press, 1988.
17 Core Values Conference. Core values for the medical
profession in the 21st century. London: BMA, 1995.
18 General Medical Council. Duties of a doctor: good
medical practice. London: GMC, 1995.
19 General Medical Council. Tomorrow's doctors:
recommendations on undergraduate medical education. London:
GMC, 1993.
20 General Medical Council. The new doctor: recommendations
on general clinical training. London: GMC, 1997.
21 Marinker M. Medical education and human values. J R Coll
Gen Pract 1974;24:83-94.
General Medical
Council,
The changing world
Summary points
The importance of independence
Medical professionalism rests on three pillars which together
constitute the basis of our independence - or autonomy: expertise,
ethics, and service. Expertise derives from a body of knowledge and
skills whose utility is constantly invigorated by the results of
research. Ethical behaviour flows from a unique combination of values
and standards. Service embodies a vocational commitment to put patients
first.
Professional self regulation
Professional self regulation underpins the concept of an
"independent profession." It is a privilege given by the state
through parliament. The Medical Act of 1858 established the statutory
framework, including the General Medical Council. The Merrison
committee said in 1975 that the GMC has to "assure itself that those
admitted to the register are competent and to remove those
practitioners unfit to practise. The maintenance of a register of the
competent is fundamental to the regulation of a
profession."(15)
With this recognition, a wider vision is now emerging. We are beginning
to see professional self regulation as a dynamic continuum starting
with the individual doctor and extending through the clinical team and
local peer networks to the professional standards bodies (fig 1). It
needs to be seen by doctors as positive and helpful, part of continuing
education, personal professional development, and quality assurance of
practice.
Important principles
Values and standards
Clearly enunciated values and standards are the foundation of
effective self regulation. In 1995 a national conference
considered the profession's core values, such as commitment, caring,
competence, and integrity(17); the BMA is taking this
initiative further. In the same year the GMC published Duties of
a Doctor, in which, for the first time, the principles of good
medical practice were described.(18) Doctors and the public
have reacted positively, showing how important it is that the
profession indicates what individual doctors should do and what the
public can expect of them.
To show that self regulation is effective and efficient we need to
test the system against explicit criteria and standards, requiring hard
evidence of compliance. The box shows some illustrative attributes and
criteria. The GMC, for its part, will use such an approach to assure
and improve the quality of its own
performance.
Assuring quality in self regulated medical practice
Purpose and values - Well defined values,
functions, responsibilities, and strategic direction
Modern self regulation is incomplete without involving people at
all levels, to incorporate the patients' view of quality. To this end
the GMC recently decided to increase its proportion of "lay"
members to 25% and to appoint lay assessors to the teams that will
assess doctors' performance under the new performance
procedures.
External peer review is an essential stimulus to effective
performance and should become an integral part of self regulation. It
applies equally to individuals, clinical teams, and
institutions.
Diversity characterises the British system of medical regulation.
It means that each university medical school puts its stamp on basic
medical education and each royal college determines standards of
practice and education in its field. Each clinical team has its
distinctive ethos. Diversity encourages new ideas, the development of
different ways of achieving the same ends, and excellence in practice.
Role modelling is a powerful force in medicine. Marinker used the
term "the hidden curriculum" to describe the effect of the
professional attitudes and behaviour of clinical teachers on students
and doctors in training.(21) The everyday behaviour of
clinical teachers is the living demonstration of their expertise,
ethics, and commitment: their professionalism. What they do and how
they do it matters as much as what they say - as in, for example,
communicating with patients, students and colleagues; recognising the
limits of their own practice; using clinical audit to improve their
practice; applying formative peer appraisal for their own professional
development; handling personal criticism; tackling poor performance in
themselves and others; and caring for colleagues in difficulty.
Towards a new agreement
London W1N 6JE
Donald Irvine,
president
Home | Current issue | Past issues |
Classified ads | Career Focus | Feedback
Collections |
About this site | About the BMJ | BMA | Medline