Doctors and commitmentBMJ 1995; 311 doi: http://dx.doi.org/10.1136/bmj.311.7021.1654 (Published 23 December 1995) Cite this as: BMJ 1995;311:1654
- Clare Vaughan,
- Roger Higgs
- Chair of South London Organisation of Vocational Training Schemes Professor of general practice VTS Coordinator's Office, St Thomas's Hospital, London SE1 7EH
Nice work—shame about the job
Doctors' working lives are changing radically. Out of hours cover by general practitioners, the new deal on hours of work for junior hospital doctors, and the changing roles and responsibilities of hospital specialists all raise important questions about commitment. How should we, as people with careers to follow and home lives to lead, balance patients' expectations and the demands of reorganised health care with the need for a satisfying and creative job? The patient, the service, the profession, or some higher ideal—to whom or what should doctors be committed, and to what extent?
The doctor-patient relationship is still central to our work. The recent document from the General Medical Council in Britain underlines that doctors must make the care of their patients their first concern.1 This encapsulates a principle of practice that has remained unchanged for over 2000 years and underpins the idea of what a doctor is. However, the context in which this relationship exists is changing so fast that a gap seems to have opened between the ideals of medicine and the realities of doctors' work experience. The “good enough” doctor can somehow never be good enough. Heath highlights the dilemma: “Time and trust are fundamental to our endeavours and both are being undermined in the current crisis.”2
Superficially, the answer may seem to lie in the contracts that clarify what a doctor should give or a patient may expect to receive. According to one registrar in general practice, the origin of our current difficulties is that “doctors offered everything on the basis that patients wouldn't ask too much” (J Thallon, personal communication). Contractual agreements may suit people who have a clear idea of what they need, or institutions with defined workloads and measurable outcomes, but they fit poorly with relationships in which needs change dramatically and continuity is important. The type of commitment required here is much more like a covenant, a promise made which has the fuzzy boundaries necessary for doctors' multitudinous roles.3 Contracts risk remaining locked into the negative aspects of obligation and of minimal expectation; an explicit but broader two way commitment can develop the positive aspects of care and re-empowerment of everyone involved.
How can this fit with the expressed commitment of health service managers to deliver high quality service? Performance indicators may be of limited use.4 In particular, they do not value the richness or variety of responses that professionals can offer. The tasks in health care are demanding, and healthcare workers need support on an individual or group basis. It is unclear where this support is coming from in today's NHS. It may be that re-evaluating roles and responsibilities within the new healthcare team will result in perceived loss. This must be balanced by potential gain, which an environment of “coercive healthism”—where the government's role of health protection is confused with the profession's role of health promotion—has not yet shown.5
When loyalty and commitment are challenged or broken, people feel betrayed. The reaction of many doctors to the uncomfortable process of setting new boundaries has been enormous hurt. This feeling has been expressed by resisting further change, low morale, endless moaning, a rise in the prevalance of stress, and evidence of burnout.
Understandably younger doctors have become increasingly reluctant to sign up for some career paths. This reassessment of what sort of job is worth doing is not confined to medicine: decline in trust and loyalty has been recognised in a variety of work environments.6 Doctors should be able to see medical work in transactional terms without losing their sense of vocation, and young doctors have something to teach their elders about keeping the patients central to their work while creating healthy boundaries between personal and professional life.
The NHS has received enormous loyalty from staff and patients. Whereas loyalty is based in the past, commitment looks to the future and is a conscious choice. Commitment must express what sort of people we want to be as well as what things it seems worth while to do. Although as doctors we are taught to take a good history from patients, our own histories often remain hidden from us. Hitherto we have not needed to be clear about our personal and professional needs and aims, but now we must recognise and explain what lies deeper than current economic or political fashion, and to make our goals explicit. As in Hirschmann's influential challenge to current market orthodoxy, in place of the prevailing culture of “exit” (leaving, closing down, or merging) we need to find our own loyal “voice” to criticise and improve the system while remaining within it.7
Yet a newly skilled and articulate generation will not eliminate the inevitable conflict between different spheres and types of commitment—home or work, patients or paperwork. A promise to give more to one implies a decision to give less to the other. A new task requires new time. The balance of competing commitments requires constant attention and adjustment to ensure the best use of scarce personal resources, including professional enthusiasm, constructive attention, and appropriate compassion. Such resources can be properly understood only in the context of a clear tradition,8 and doctors need the confidence to respect and defend their tradition to set the proper boundaries for a “do-able” job. Only if we value the diversity, energy, and creativity inherent in medical work are we likely to be able to ensure that our commitment flourishes and is transmitted to future generations.