Understanding the role of the doctorBMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a3035 (Published 18 December 2008) Cite this as: BMJ 2008;337:a3035
What is the role of the doctor? So asked Sir John Tooke, chair of the Medical Schools Council, in last year’s inquiry into UK doctors’ specialist training.1 As Tooke said, without clarity on the doctor’s role, we can’t know how best we should select, educate, and train doctors, or plan the future medical workforce. We have now received the profession’s answer—a consensus statement endorsed by a consortium of leaders of UK medicine.2
This isn’t the first attempt to define what it means to be a doctor. Nor will it be the last. The International Labour Organisation (ILO) is updating its definition (box), and the World Health Organization and the Organisation for Economic Cooperation and Development are drawing up their own. Many forces have converged to prompt these efforts: sociopolitical changes; scientific and technical progress; the end of deference and the democratisation of knowledge; the rise of chronic disease; and the shift to multidisciplinary working, including role substitution and the extended role of nurses.
These were among the factors that prompted the Royal College of Physicians’ 2005 inquiry into the meaning of professionalism. Its report defined professionalism as “a set of values, behaviours, and relationships that underpins the trust the public has in doctors.”3 It talked of a covenant between the medical profession and society, which went far beyond compliance with contracts or job plans and even technical ability. It required doctors to work in partnership with patients and to exercise honesty, empathy, confidentiality, humanity, and above all judgment in the face of uncertainty. It concluded that the most important aim of professionalism was securing trust.
Building on this and subsequent work,4 5 6 the new consensus statement focuses not on values but on the attributes and abilities that doctors need and the range of tasks they undertake. As well as supporting patients in making decisions about their care, doctors must be active in teaching the next generation of doctors, managing resources, and improving the quality of care. They must also be able to work in teams and must take account of finite resources in their decision making, “notwithstanding the primacy of the individual doctor-patient relationship.”
Any attempt to come up with a generic definition of what it means to be a doctor is fraught with difficulties, not least because so much depends on context—the clinical setting, the patient’s preferences, and the doctor’s experience and seniority.7 The doctor’s role cannot be defined in isolation because, as the Royal College of Physicians’ report made clear, relationships are everything in modern health care.3 There are two particularly thorny issues that tend to be skirted around—the distinction between a doctor and a nurse, and related to this, the question of who should lead the clinical team.
The BMA’s recent report on the role of the doctor talks about the unique contribution of doctors, their exceptional skills and competencies, and the need to understand not only what doctors do but what they do that others don’t.6 The consensus statement concludes that doctors “alone amongst healthcare professionals must be capable of regularly taking ultimate responsibility” for clinical decisions. But neither report tackles directly the distinction between doctors and nurses, nor what is precisely meant by the newly omnipresent and euphemistically vague term “clinical leadership.” Taking such coyness to the extreme, the recent report on the role of the nurse, commissioned by the chief nursing officer, mentions the word doctor only once, in its methods section listing which groups were consulted.8
The nursing report is more soul searching than the recent spate of medically focused reports. It says that nursing has lost its way and calls for nurses to reassert the care of patients at the centre of their role. The new consensus statement on the role of the doctor hints at an important distinction between doctors and nurses by emphasising the doctor as clinical scientist, and noting the depth and breadth of medical training and the importance of intellectual ability in selection for medical school. “Doctors must have the ability to assimilate new knowledge critically, have strong intellectual skills and grasp of scientific principles and be capable of . . . managing uncertainty, ambiguity and complexity.” In the ILO’s definitions of doctor and nurse, only the words “scientific” and “care” draw any real distinction between the two (box).
Draft revised definitions from the ILO (www.ilo.org/public/english/bureau/stat/isco/draftdoc.htm)
Medical doctors diagnose and treat human physical and mental illnesses, disorders and injuries, and recommend preventive action, based on the scientific principles of modern medicine. They may specialise in certain disease categories or methods of treatment, or assume responsibility for the provision of continuing and comprehensive medical care to individuals, families and communities.
Nursing professionals . . . treat and care for the physically or mentally ill, [and] the elderly. They assume responsibility for the planning and management of the care of patients, including the supervision of other health care workers, working in teams with medical doctors and others in the practical application of preventive and curative measures, and dealing with emergencies as appropriate.
Somewhere in the awkwardness of talking about this distinction, both doctors and nurses may have lost their way and risk losing their identity. The trust that society places in doctors may well reside to a greater extent than is currently acknowledged in their ability to go back to first principles and make difficult decisions, under situations of uncertainty, on the basis of a deep understanding of the underlying science. All else can probably be carried out by other members of a team using consensus guidelines and protocols. Of course these intellectual abilities must be overlaid with the accrual over time of skills, experience, and judgment, and they must be indivisibly combined with empathy, compassion, and integrity. Where individual doctors fall short of achieving or maintaining this highly demanding combination, the profession needs to have effective ways of taking action in the interests of patients and society.
This consensus statement is an important document, not least because of the united voice it has achieved from the leaders of the profession across the UK. It is unlikely to be the last word, however. As the statement itself says, “the role of the doctor is changing and will continue to change alongside the needs and expectations of patients.”
Cite this as: BMJ 2008;337:a3035
Competing interest: FG attended the consensus meeting on the role of the doctor as an observer.
Provenance and peer review: Commissioned; externally peer reviewed.