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BMJ No 7105 Volume 315 Editorial Saturday 16 August 1997
Do professions have a future?Perhaps, if they are not defensive or complacentWithin the medical profession a perception exists of a growing gap between the providers and users of health care and, more generally, between the health professions and society. The commitment to serve society, a key attribute of all professions, has been questioned from within and outside the ranks of medicine, and the medical professions' powers and privileges of self regulation have been challenged.(1-6) A King's Fund seminar last autumn on the future of the professions brought together a range of perspectives, including views from architecture, nursing, medicine, and politics. Central to the implicit bargain between the profession and society is the exchange of privileges (self regulation and the control of training) in return for the trustworthy fulfilment of a role that society recognises as valuable. As with individuals, so with professions, there is an inherent tendency to behave both selfishly (through self interest and preservation) and unselfishly (through disinterested, conscientious service of others). Not surprisingly, the interests of both society and the profession are best served when these tendencies coincide. Perhaps medicine is still viewed as the archetypal profession because in general doctors have been able to serve their patients and enjoy substantial privileges without apparent conflict. That position may no longer be tenable. The consensus at the King's Fund conference was that the medical profession needs to respond to the challenges of increased patient demand in a climate of limited healthcare spending and to greater calls for accountability and transparency in its professional affairs. A complacent, defensive, or nostalgic stance by the profession will not serve. What aspects of the professional bargain need to be reviewed? First is the responsibility to the patient on the one hand and society on the other for managing limited resources. The traditional British compromise of implicit rationing by doctors is becoming increasingly uncomfortable. The profession, the state, and the public need to examine the alternatives. If the NHS cannot provide everything that every patient wants, and which offers benefit, the task of squaring the circle cannot be left to the physician unaided and unseen. Secondly, for self regulation by the medical profession to survive it must be effective, transparent, and demonstrably in the public interest. Initiatives by the General Medical Council are a positive step but they must not stop there. The GMC needs to show its effectiveness in ensuring competence, not merely in policing flagrant lapses in behaviour. The royal colleges and the BMA also have roles - for example, ensuring good standards of care at all hours despite the long overdue reduction in junior doctors' hours and the recent changes in general practice. Thirdly, medicine must be more willing to develop partnerships with the other caring professions and allow greater flexibility in working practices to improve the delivery of patient care. The demarcation lines between medicine and its partners are rapidly changing, and institutions such as the royal colleges have lagged behind in their response. The public's increasing attachment to alternative medicine suggests that more serious attention should be given to its potential contributions. These developments pose no serious threat to medicine's monopoly over its core roles and are being embraced by many doctors. Fourthly, generational differences are emerging between cohorts of doctors in their attitudes toward a host of issues facing the profession, such as the role of doctors in NHS management and approaches to multidisciplinary care.(8,9) Medical leaders need to face up to these changes and the societal trends transforming all occupational groups. Julia Abelson Researcher School of Social Sciences, P H Maxwell
Churchill Hospital, R J Maxwell
Kings Fund, References 1 The Times. "Profession afoul?" 1992;3 Feb: 13a. 2 Armstrong D. "Medicine as a profession: times of change". BMJ 1990;301:691-3. 3 Calman K. The profession of medicine. BMJ 1994;309:1140-3. 4 Morrison I, Smith R. The future of medicine: brighter than you might think. BMJ 1994;309:1099-1100. 5 Shock M. Medicine at the centre of the nation's affairs. BMJ 1994;309:1730-3. 6 Short J. Has nursing lost its way? Dual perspective. BMJ 1995;311:303-4. 7 General Medical Council. The duties of a doctor. London: GMC. 1995. 8 British Medical Association. Core values of the medical profession in the 21st century - survey report. London: BMA, 1995. 9 British Medical Association. BMA cohort study of medical graduates: first report (Part II) - professional values. London: BMA, 1995.
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