Understanding the role of the doctor
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a3035 (Published 18 December 2008) Cite this as: BMJ 2008;337:a3035
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Fiona Godlee’s[1] discussion about the role of the doctor raises some
important considerations.
It is clear that the doctor’s role is ultimately defined by the general
public, in other words the patients, and it is the patients and their
relationship with their doctors who are the ultimate arbiters of the
doctor’s raison d’etre.[2]
Patients trust their doctors because they presume that doctors have
knowledge about illness which they have acquired through their training
and research.[3]
What appears to distinguish doctors from other professionals, including
nurses is that they can contribute such knowledge to a discussion among
professionals in a depth and breath which is not usual among the other
professions.
The ILO definitions clarify the situation in that it is medical
doctors who ‘diagnose and treat human physical and mental illnesses,
disorders and injuries, and recommend preventive action, based on the
scientific principles of modern medicine.’. Nurses, by these definitions
have a more generic role, thus they ‘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’, in other words, it is only the doctors who
have the ultimate responsibility of diagnosing and treating human
physical and mental illnesses’, while nurses plan to implement the
consequences of such a diagnosis and prescribed treatment.[4]
However, it has been the case in recent years that in the UK, [and
not necessarily in the rest of Europe], some diagnosis and treatment has
been devolved to other professions , particularly nurses, thus for
example, many general practitioners have devolved the management of minor
illnesses to especially trained nurse practitioners. What has not followed
is a change in the public perception of doctors, who continue to be seen
as the key persons in the diagnosis and treatment of illness, and thus the
persons who take responsibility for this activity.
As a consequence, the shift in function between doctors and nurses
described above has gone relatively unnoticed outside of the medical
profession, and hence uncontested.
In certain specialities, including psychiatry, where doctors and other
professionals work in multidisciplinary teams, particularly difficult
problems emerge in terms of the interaction of the different professions
in any one case.
On the one hand, it is clear that a patient has a right to a
diagnosis of a mental health illness, such as depression or schizophrenia
being given by a doctor, and a right to discuss the consequences of such a
diagnosis with the doctor, in exactly the same way as a physical
diagnosis, such as carcinoma of the cervix needs to be given and
discussed.
On the other hand, pressures of the service are empowering other
professionals to do more and more, sometimes including initial assessments
which contribute in great measure to the making of a diagnosis.
Whether this should be supported is at present subject to debate in the
profession, However, a more important issue arises; should a disagreement
between doctors and other professionals occur within a multidisciplinary
team, who is to take ultimate responsibility for the patient’s diagnosis
and treatment?
One important measure which provides an answer to this question is the
suggestion by the new consensus statement that "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." It is because doctors as a body
are able to subscribe to this statement that they should be allowed within
multidisciplinary teams to take the lead on difficult decisions.
[1] Fiona Godlee. Understanding the role of the doctor. BMJ 2008;
337: 1425-1426
[2] Royal College of Physicians. Doctors in society: medical
professionalism in a changing world. London: RCP, 2005.
[3]Jon Ford. Letter;Unholy Trinity. BMJ 2007;335:465
[4] The Role of A Doctor: Defined by the International Labour Organisation
2008. www.ilo.org/public/english/bureau/stat/isco/draftdoc.ht
Competing interests:
None declared
Competing interests: No competing interests
Fiona Godlee's editorial was timely and helpful in outlining the
events and developments currently taking place around the role of the
doctor.
However, identifying specific tasks and duties that define the doctor
will at best provide a definition that is only relevant on the day of its
publication; what is required is a definition that is more 'future proof',
and need not be changed every few years to comply with the vagaries of
technology, social mobility or even political correctness.
I would suggest that key to the role of the doctor is that doctors
are professionals, rather than technicians. Society needs professionals
when the decisions that need to be made are too complex to be consigned to
a fixed pathway, algorithm, or computer programme. It's when the variables
are too many or too subtle for Microsoft Vista (or even Mac OS 10.5) to
reach a definite conclusion that we need professionals, whether they be
doctors, lawyers, senior detectives, business CEOs, or even NHS managers.
Those aspects of 21st century life that can be measured clearly and
simply enough for an algorithm to encompass do not need the input of a
professional, although they may need the presence of technicians to turn
decisions into actions. It’s when the decisions are more complex and
subtle that professional input is required.
The reality of true professional working is that it is impossible to
put into neat boxes; whether its the doctor’s clinical ‘hunch’ , the
policeman’s ‘nose’, or the investor’s intuition (perhaps not the best
metaphor in the current circumstances), professional decision making has
to be based on the evidence, but it’s ‘evidence PLUS’ that makes the
difference.
To develop true professionalism requires some relatively simple (to
define, if not to attain) attributes: true professionals are well trained
in the technical aspects of their trade; they will have built up enormous
experience by dint of many years working at the ‘coal face’; they are able
and keen to reflect on their current state of knowledge and remain ever
curious to further hone their skills; they have the wit and the courage to
apply their experience and knowledge to the subtleties of the true
professional challenge; and they possess the skills to communicate with
their clients in a way that is accessible and appropriate, whatever their
clients’ culture, knowledge or intelligence.
Such a definition applied to the clinical field potentially removes
the distinction between experienced nurses and doctors, but as it
currently stands, it is only doctors’ training that includes the
prerequisites that make the emergence of a true professional more likely:
intense training, a long apprenticeship, freedom to take (evidence based)
risks, reflective practice, and communication skills. Some of these are
not ‘givens’ (communication skills and reflective practice are often
notable by their absence, for example), others are under threat (the
reduction in patient contact hours during junior doctors’ post graduate
years is a real threat to the development of clinical intuition),and none
of them are confined only to doctors, but if the medical profession wants
an identity and role that will allow it to carry its badge with pride, we
could do worse than begin our discussions around these parameters.
Competing interests:
None declared
Competing interests: No competing interests
Doctors do have a duty to diagnose, treat and inform but for many of
the public their most important role is as providers of sick certificates
and letters to the Housing Department, supporting you in your divorce
petition, acceding to your decision to refusal to allow a child to visit
your estranged spouse, 'statementing', ie diagnosing Asperger's syndroms
so as to give your child an examination advantage and, of course, to
assist in your claim for compensation.
I am sure all GPs have been confronted by one or more of these
demands , I certainly have in the past but the difference is that in the
past I could politely refuse.Not now in this 'patient led' climate. A few
years ago, when I was doing a long-term locum I refused to refer a woman
to hospital. Her back pain had not changed, there were no neurological
signs and she had two Lloyd George envelopes stuffed with letters and the
result of investigations. All hell broke loose, and I was strongly
criticised by my boss.
As a New Year resolution could the BMJ staff agree to spend, say one
day a month in the market place or, as I did for three years, answering
the phone to callers to The Patients' Association? I loved general
practice, did my best for all who came to the surgery and only rarely
believed what I was told. I was also lucky enough to be able to use my
judgement.
Competing interests:
None declared
Competing interests: No competing interests
The role of a doctor is to put into practice the long training he has
had, with the knowledge gained from his peers and his experience in
seeing a great many patients.
A doctor in any branch of medicine should aim to see in one day as
many patients as he can.
He is not a Scientist; he is an "applied scientist" utilising only
what the purer sciences might provide.
In gaining this experience it would be well to let the recently
qualified doctor go directly out into a good general practice under the
watchful eye of his seniors. There he will learn how to be well-mannered
and how to speak with each of his patients. Thus learning those missing
"communication skills" of the hospital incumbent.
Hence, after a few years, a more experienced doctor may return to
hospital practice and further his career.
Competing interests:
None declared
Competing interests: No competing interests
"Deference is the most complicate, the most indirect, and the most
elegant of all compliments."
William Shenstone. English poet, gardener and collector. 1714 – 1763
The new consensus statement on the role of the doctor [1] says
“the role of the doctor is changing and will continue to change alongside
the needs and expectations of patients.” The editorial comment [2]
asserts that one of the forces that have converged to prompt attempts to
define what it means to be a doctor is `the end of deference`. If, as the
consensus statement concludes, “doctors alone amongst health professionals
must be capable of regularly taking ultimate responsibility”, should not
patients in partnership with doctors respect the person who has that
responsibility? Deference is an attitude of mind that recognizes where
respect is due. But if it is a true and well-functioning partnership, both
respect and deference should ebb and flow between the parties, with doctor
equally able to defer to and respect his patient`s integrity. Doctor and
patient have different attributes and abilities to bring when making
shared decisions. The gentle yielding of opinion between doctor and
patient in partnership, able to respect and defer each to the other,
considerate of values and preferences, because both recognize all the
different skills, experiences and expertises that each person brings, is
the ideal iterative model. Respect and deference are indispensable in
achieving satisfying and satisfactory relationships and decisions.
The egalitarianism implied by asserting that we have seen the end of
deference is dangerous. Professionalism as defined by the Royal College of
Physicians is essential: “a set of values, behaviours, and relationships
that underpins the trust the public has in doctors.” This solid foundation
that should underpin the doctor-patient relationship must be reinforced if
trust is not to slip any further. [3] Trust once lost is difficult to
regain. [4]
Or, to quote the poet and gardener, William Shenstone, again:
“Deference often shrinks and withers as much upon the approach of intimacy
as the sensitive plant does upon the touch of one's finger.”
Professionalism, respect and deference are sensitive plants that must be
nurtured at all costs if trust is to be retained.
[1] Medical Schools Council. Consensus statement on the role of the
doctor. 2008. http://www.medschools.ac.uk/news.htm
[2] Fiona Godlee. Understanding the role of the doctor. BMJ 2008;
337: 1425-1426
[3] Royal College of Physicians` Report. October-November 2007.
Public Awareness of Physicians and Trust in Professionals. www.ipsos-
mori.com/_assets/polls/2007/pdf/trust-in-professions-2007.pdf
[4] McCartney M. Reality check. FT Weekend, September 27/28 2008,
p26-29.
Competing interests:
None declared
Competing interests: No competing interests
I, and many others, now see the medical profession as agents of the
state: in the USA, perhaps, as agents of insurance companies. In either
event, it is a third party that determines what we can have and expect.
Our health tax money, or insurance contributions, are pooled for what is
perceived as the general good, not used to meet our own needs. When these
fail to correspond to a significant extent, political discontent will
reach a critical level. Medical NHS salaries are now regarded as obscenely
high, whatever the alleged justification. "Trust" will not thrive in this
atmosphere of envy and perceived exploitation.
Doctors would not need to ponder about their role if they had to satisfy
their patients and depend directly on them for their income. Charity to
those in need existed long before the NHS. The lack of any real
consideration for the expense and efficacy of consultations, examinations,
investigations and treatment (below the much maligned NICE) will continue
so long as neither the agents or the patients have themselves to foot the
bill. A bit less navel gazing and a bit more economic realism would help
solve these issues.
Competing interests:
None declared
Competing interests: No competing interests
It is heartening to see that the new consensus statement tries to
define a doctor as being something other than just another of the
government's army of allied health professionals. It is a sad sign of the
times that we need to redefine the role of a doctor.
We define ourselves by our personal histories, training and our
actions; hence no matter how good a statement on the role of a doctor
actually is, it is unlikely that this kind of gesture will have much of an
effect on the reality of what the role of the doctor is becoming in the
21st century.
The further privatisation and marketisation of the health system in
the UK, which has been catalysed by various reforms including Modernising
Medical Careers (MMC) and Choose and Book (C&B), is changing the role of
doctor for the worse. The prioritisation of economic needs ahead of the
clinical results in the service being stripped of quality to feed the
profits of various opportunistic companies and individuals (2). The
doctor becomes less of a clinical decision maker and more a protocol
performing agent of the state.
The role of the doctor can only be properly defined in the context of
today's mismanaged healthcare system and as heartening as detached
statements on the role of the doctor appear superficially, they are but a
token cry for help.
1. AM Pollock. NHS Plc. 2006.
2. W Jeffcoate. Mismanagement as a prelude to privatisation of the UK NHS.
The Lancet,Volume 368,Issue 9530,Pages 98-100.
Competing interests:
None declared
Competing interests: No competing interests
It seems relevant to consider the influence of a sixty-year monopoly
NHS on the recent definitions of professionalism and role of doctors in
the UK. The syntax of the RCP definition of professionalism rather
obscured the fact that the statement could be read backwards as well as
forwards. It then becomes ‘Those characteristics which underpin the trust
the public has in doctors is (what we call) Professionalism’. This seems
then rather narrowly dependent on ‘the public trust’, which is a poorly
defined entity rather clearly dependent on what the Media and Government
wish to make of it, and seems to exclude any non-contingent, enduring
elements. It seems unlikely to generate much proud identification with
role and begs the importance of the NHS experience and the factors that
profession and public have come to see as relevant to that context. Does
this colour the perception of medical activity in the UK compared with the
rest of the world?
The consensus statement endorsed by the leaders of UK medicine contained
sections asserting medical responsibility for resources and public health,
adopting contingencies as major factors in decision making and
concatenating individual patient and population interests on a utilitarian
basis. While these elisions seem plausibly consistent with the UK Health
Care model to date, the increasing fragmentation of the Service, and
developing independence of both Commissioners and Providers of health
care, may challenge the desirable medical responsibilities within the
individual-agency-government spectrum. While ‘The doctor’s role must be
defined by what is in the best interest of patients…..’ how far should it
reflect the health care system as surrogate for ‘… the population served’?
This is already a source of concern at organisational level, for example
in the collaboration of the professional bodies with the privately owned
‘Map of Medicine’. The consensus statement asserts prominently the
approval of the four chief medical officers, and well it might, since
political influence has played a large part in characterising whatever
anyone may consider ‘public trust’. How far that abstraction actually
corresponds to ‘…the needs and expectations of patients’ remains to be
seen. The ‘ever evolving’ idealisations of the medical role are imposed as
‘Duties’ through the GMC, although just which agency is being rehearsed
may come to be a source of disquiet if the cultural history of the NHS is
not taken into account.
Competing interests:
None declared
Competing interests: No competing interests
The Doctor Patient
The most important role of the doctor is as a patient, because then, and only
then, can the doctor truly understand how frustrating and frightening it is to be
sick and seek help. This understanding enables the doctor to identify with
patients and relate to them in a more effective, compassionate, and humble
manner. And this, in turn, improves the doctor-patient relationship, patient
compliance, and treatment outcome. In short, having been on both sides of the
stethoscope, scalpel, and gurney, the doctor-patient is uniquely motivated to
practice and advance the art and science of healthcare.
Competing interests:
None declared
Competing interests: No competing interests