Reinventing doctorsBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7174.1670 (Published 19 December 1998) Cite this as: BMJ 1998;317:1670
Will move doctors from this winter of discontent to a position of leadership
- Cyril Chantler, Dean
This is not a happy Christmas for our profession or indeed for many doctors. Doctors work extremely long hours under difficult conditions and many are demoralised by lack of resources and constant criticism. We feel proud of the advances in medical science and find it difficult to understand when patients complain because our efforts are not always effective. Much of the recent poor publicity has originated from the reporting of cases before the General Medical Council. It is ironic that these demonstrations of self regulation should lead to criticism of the system of self regulation by both the public and politicians. Now the government is introducing legislation to ensure the quality of clinical services and to make the profession more accountable.
Last year Professor Roy Porter published a history of medicine entitled The Greatest Benefit to Mankind, which was Samuel Johnson's accolade to the medical profession.1 Porter points out that we are healthier than ever before yet more distrustful of doctors and the “medical system.” As he writes, such ambiguity is not new, but we need to attempt to understand it.
Much of medicine and medical practice has changed during the past generation. Modern medicine is complicated and often uncertain. For example, babies born at less than 28 weeks' gestation are now routinely ventilated and, though more survive, around a quarter of those who do have disabilities and 10% are severely handicapped.2 Given that about 1% of pregnancies result in premature delivery are we sure that parents are fully informed of the risks and benefits of modern treatment and can we be surprised that faced with the problem of caring for a child with severe handicap they should seek to apportion blame? The advances in medical science and technology are set to continue, probably at an increasing pace.3 The only thing that is certain is that the financial and personnel resources available to the National Health Service will not keep pace with these changes.
The cardinal principles of medical ethics are to protect life and health, to respect autonomy, and to strive for equity and justice. A new emphasis exists on autonomy and individual rights. This may be in part because totalitarian dictatorships have used mass movements in this century to gain power and have then terrorised individuals in the name of society. Emphasising the rights of individuals may be seen as a defence against such abuses of power.4 Alternatively, it may be linked to increasing prosperity, leaving people with more marginal income with which to exercise choice.5 In the NHS this rise in consumerism is represented by the various patient charters introduced over the past decade. Though these may well change, patients now wish and need to be informed and consulted about their medical care as never before. 6 7
The circumstances of doctoring have changed, and we doctors need to change too. We need to be open and to work in partnership with our colleagues in health care and with our patients.8 Like us, most patients wish to be in control of their own lives and often of their own deaths also. As Sikora points out, 70% of the cancer budget is spent in the last six months of life, and positive involvement in self help programmes will make it easier for patients and doctors to say no to last ditch medical interventions.9 For doctors to work as advisers and partners rather than as controllers, however, they need good communication skills. Options need to be discussed with regard to the patient's own circumstances and wishes. Hospital doctors and general practitioners need to consult each other and other health workers, especially nurses, before framing their advice. Information needs to be shared and available when a crisis occurs. Too often patients are seen by doctors who do not know them when an acute event occurs against a background of chronic disability. Simple measures such as providing copies of all letters and summaries to patients would help.
Sharing responsibility with colleagues, not just doctors, is also necessary if the workload is to be managed satisfactorily. But good teamwork also requires special skills and training. We will need to learn how to audit processes of care and how managers, doctors, and nurses can best work together to provide good quality care which is appropriate rather than just being possible because of modern technology.
Both undergraduate and postgraduate medical education is changing and will need to change further to ensure adequate skills in learning and problem solving, communication, teamwork, information technology, ethics, and the behavioural and social sciences. We need to cooperate with the new systems of clinical governance to ensure the quality of clinical services, so long as they are not overly bureaucratic and are themselves audited to make sure they are fit for purpose. These new systems should not be seen as a threat or indeed as a substitute to self regulation, but rather as an adjunct.10 Self regulation itself is a matter for all doctors and for their associations and colleges, not just for the General Medical Council. As such it should be supportive rather than simply punitive. The task at a local level is to help each of us to maintain and improve our practice, so that few cases reach the General Medical Council and result in publicity that damages the whole profession.11
It is possible that not only the way we practise but also the way the medical profession is organised will need to change to meet the challenges of modern medicine. A theme of Marinker and Peckham's book Clinical Futures is the role of doctors as diagnosticians and the distinction between generalists and specialists.12–14Perhaps the traditional distinction between the general practitioner and the consultant will disappear, to be replaced by the generalist physician based in the community but working in hospital and other settings, while the specialist, with high technical skills, will also operate in both community and hospital. But while healthcare teams become the norm, each of us still needs a personal doctor who can offer advice and support.15 Perhaps the new generalist physicians will fulfil this role, but in any case we all need to remember that one day we too will be patients and want our doctors to care about, as well as for, us.
Even in this winter of discontent there are reasons for optimism. The profession has already indicated its willingness and ability to listen and to change; young people with intelligence, energy, and strong social consciousnesses still apply in large numbers to our medical schools; many doctors still gain deep personal satisfaction from their work. But if this is to continue there are other needs. Those of us who teach must be careful that we do not allow our frustrations to turn to cynicism and destroy the idealism of the young. The public needs a deeper understanding of the complexities of modern medical practice. And there needs to be wider understanding of the shortage of resources and the need to make choices. While doctors can play their part in determining clinical priorities, the public must help set the framework for resource allocation and politicians must accept their responsibilities. The advances in medical technology and the new systems of governance will cost significant sums, and even at Christmas “you don't get owt for nowt.” Above all we need to accept our new role as advisers and partners to our patients. Our authority will come, not as an automatic accompaniment to the practice of medicine, but from the quality of our leadership.