Intended for healthcare professionals

Opinion Acute Perspective

David Oliver: Why shouldn’t doctors defend our distinct professional identity?

BMJ 2023; 382 doi: (Published 19 July 2023) Cite this as: BMJ 2023;382:p1630
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter @mancunianmedic

Last month’s publication of NHS England’s Long Term Workforce Plan1 amplified some robust debate about newer NHS clinical roles,23 professional titles, distinct identities, and roles across the NHS clinical workforce—some of it tribal, even hostile. Modern healthcare is a multidisciplinary and team based venture, with each clinical group bringing its own distinct contribution and added value. This requires mutual respect and close collaboration—not blame, disparaging language, or interprofessional culture wars. But that compact doesn’t always hold, especially with the current high pressure and low morale.4

The kinds of contentious issues I refer to include the plan’s proposals to increase the number of physician associates (PAs) and advanced care practitioners (ACPs), while aiming to shorten the duration of undergraduate medical training and create an “apprentice doctor” route. Then there’s nomenclature—such as the title “consultant practitioner” for people working at senior levels in nursing, in pharmacy, or as allied health professionals. Although these job descriptions have existed for several years, the term “consultant” is still generally used for senior doctors with a certificate of completed medical training. The term “consultant practitioner” could confuse.

Anecdotes (perhaps apocryphal?) abound on medical social media about PAs describing their role in a way that’s less than clear to the public—and about the additional work involved in doctors still having to prescribe or be accountable for the practice of the non-registered PAs they work with.56 I’ve also seen several social media fights about the potential for the rising number of PAs and ACPs in long term substantive posts, sometimes reducing training opportunities for transient rotational junior doctors; about PAs or ACPs out-earning them; or about ACPs, PAs, or training courses describing role equivalence to grades of doctor.78

In the face of protests from doctors, other professional groups seem keen to argue that the erosion of doctors’ status, power, and pay differentials is overdue—an end to some self-serving patriarchal hegemony. But those other professions often seem happy to take pride in their own unique professional identity, skills, and qualifications, such as when nurses routinely and proudly use their postnominals on social media profiles.

I think it’s high time that doctors reasserted our own professional identity in the way that nurses or physiotherapists or paramedics or pharmacists do. UK medical schools reject over five in six applicants—many with very high grades.9 The traditional courses are considerably longer and more examined than those for the other clinical professions. Even graduate entry medicine is four years. Medical graduates in turn incur high levels of debt.10

Medicine is unique in the clinical professions in having (as standard) a postgraduate multisite, multispecialty training programme of five to nine years (longer if less than full time or not “run-through”), with multistage professional exams, competitive selection at each grade, annual review of competency and progression, and a final certificate of completed training for GPs or consultants to be licensed to work that level. There’s no equivalent mandatory requirement for any of those other professions, including the most senior NHS managers. And the designation and formal requirements for the title of ACP, clinical nurse specialist, or consultant practitioner are not standardised.11

Doctors are prescribers and requesters of a full range of investigations from day one, unlike any other group. And even very early in our career we’ll often carry responsibility at nights and weekends for patients spread across multiple ward areas. The degree of responsibility taken and the risk carried by a medical registrar on a busy acute take, or by a GP with 1800 patients on their list and 60 daily contacts (often only a few years after qualification), is beyond what other groups would take on at that stage.

When it comes to complaints, coroners’ inquests, or carrying the can for key decisions over starting or stopping or prioritising treatment, admission and discharge, or difficult conversations with patients and families, we generally take responsibility. And we’re unique among UK clinical professions in that even among the most senior and best paid practitioners continue in hands-on clinical practice, even alongside academic, educational, management, professional leadership, or government roles. Why shouldn’t we be proud of the ways in which we’re different and unique (not better)? And why shouldn’t it be made very clear to patients about the degree and rigour of training and the professional background of the people treating them, so that they’re in no doubt?

The difficulty of becoming a doctor, with the distinct nature of our roles and responsibilities, is a major factor drawing us into medicine and gives us a point of difference from others. Naturally, the erosion of terms and conditions—along with attempts to shorten and narrow medical training or to replace our work with less highly trained or qualified roles and lessen our status from that of autonomous, assertive professionals to managed and biddable employees—has upset many of us.

Interprofessional resentments, even if they’re seen as “punching up,” and demoralising doctors won’t solve the workforce problems in the NHS.