Working Parties : Medical Professionalism

Medical Professionalism - Friday 6th May 2005

Evidence from:

Mrs Denise Chaffer

Thank you for giving me the opportunity to submit my views on medical professionalism. My views are shaped from working for over twenty years in the health service, being a registered nurse, registered midwife, registered tutor and currently an Executive Director of Nursing in an acute District General Hospital. In my current role I am actively involved in clinical governance, which includes risk management and the management of serious untoward clinical incidents. I have developed a number of clinical leadership programmes more recently for medical consultants who are clinical directors. I believe the quality of clinical leadership to be key to the delivery of high quality care to patients.

Overall I believe we have a medical profession to be very proud of, which serves the public and the NHS to a very high standard. The public still continues to hold the medical profession in high regard, but this has been recently compromised by a number of serious high profile cases that has led to demands to more closely manage the ‘professionals’. I believe that all health professionals should practise within a consistent, and well-publicised clinical governance framework, and that robust mechanisms must exist to ensure early detection of misconduct and malpractice are exposed and rapidly dealt with.

Do you think that professionalism has any meaning today? Say why you think this is so .

Professionalism is important today to ensure that the public and any individual has the confidence that a member of a profession, from whom they seek advice is, as far as possible, governed by an agreed set of rules and standard of conduct, drawn up by the public and the profession in the public interest. It is important that the public and government understand this. However it is also important that the professionals do not interpret professionalism as a license to serve the interests of the profession itself, rather than the population that they are there to serve. It is also important that professionals maintain standards which are independent of politicians but remain accountable to the public they serve.

If you believe that professionalism is a relevant concept, what threats and challenges do you think it faces today? What threats do you foresee in the next 10 to 15 years?

Threats to the concept of professionalism appear to come from a number of sources, firstly that from public confidence which has been seriously undermined by issues such as ‘Shipman’ the ‘Bristol enquiry’, the ‘organ retention scandal’, and the ‘Laming report’. These seriously undermine public confidence and lead to demands and pressure to the government of the day to ensure that the professionals involved are ‘called to account’ and questions of whether the current regulatory bodies are fit for purpose. In addition to this the public question the behavior of some professionals, in particular a perception of ‘arrogance’ or use of ‘position power’ where other professionals can only question the views of the professionals, and the views and opinions of the ‘consumer’ are not seen as relevant or credible.

Medical professionals in particular are seen by the public as gate keepers of services and as such means that they are perceived as very powerful, this has the potential to seriously disempower patients and their relatives. They can also be viewed as commonly ‘closing ranks’ thus the perception is that if mistakes are made, the professionals will cover up for each other.

The other challenges come from government itself, who see professionals (doctors in particular) as spending large amounts of the health resource on areas such as drugs, surgical innovations and using the clinical judgments / professionalism to justify expenditure on the basis of best practice and evidence-based medicine. Hence the action from government to the professionals comes in the form of some controls, e.g. NICE guidelines, consultant contract, GMS contract, patient choice, to apply some consistency and restrictions on expensive practices. The Healthcare Commission and some other bodies such as the CNST, the Patient Safety Agency, Cancer Peer Reviews, and the confidential enquiries into various patient group deaths, use a form of peer review, i.e. other health professionals looking for benchmarking standards to compare and ensure consistency between professional practice.

Other threats and challenges arise where there may be conflict between political targets and clinical priorities, some of which may lead to resources being redirected. Greater dialogue with the health professionals would help address some of these conflicts, as health policy can sometimes be viewed more about winning votes than acting in the best interests of patients. The influence the government has over areas such as future medical training, EWTD etc, again needs greater balance. The establishment of more forums for greater dialogue and less polarization could help to balance the conflicts between best safe clinical practice and effective use of resources.

What can be done to strengthen those aspects of professionalism that you care about? How would you propose to go about doing this ?

I think that all aspects of professionalism should be preserved but an accountability and clinical governance framework should be applied and monitored to all professionals. No health professional should ever be permitted to be solely independent, all must report in some form, and be accountable to someone senior. This could be a manager, supervisor, peer board or mentor, but all should ensure that their professional practice is conducted within a prescribed clinical framework similar to that provided for the recent CHI reviews. These include monitoring of patient outcomes, clinical risk, evidence based practice, patient involvement and response to patient feedback, education, research etc. This does not oppose the concept of the ‘single handed general practioner’, but seeks to ensure that they practice within a recognised supervisory structure. Independent midwifery is one example of where this is already in place. These governance arrangements must be free from political control, and remain consistent and robust, regardless of which political party is in power. These arrangements should be regularly reviewed and not ‘knee jerk reformed’ by government intervention when incidents occur. These governance arrangements must stand up to public scrutiny and thus reassure the public that individual complaints and issues will be dealt with in a fair and transparent manner. This should also protect the medical profession from trivial or malicious complaints, and serve to increase public confidence that professionals can be called to account for their practice and conduct.

Part of professionalism should include greater development of team working and the development of learning organisation principles, such as openness, fair blame culture, and mutual trust for team members. One important aspect of health professional teamwork is their collective responsibilities to the public they serve, and they must always be prepared to act in the public interest. For example, if a health professional has concerns about another, there must be a clear ‘whistle-blowing’ or ‘raising serious concerns’ process, perhaps a ‘helpline’ for professionals linked to the GMC could be part of this process.

Are there aspects of professionalism that are currently defended that ought to be abandoned?

No, but the public need to be better informed about the components of professionalism and be reassured by what this means.

The components of professionalism should be preserved, but it needs to be made explicit that professionals have to work within a framework and will be called to account.

The professional bodies should urgently establish what professional behavior should be for all professions, and agree a framework of how it should be challenged when clinician behavior falls short of this.

Denise Chaffer Director of Nursing
Worthing & Southlands Hospitals NHS Trust
 

Sir Kenneth Calman

Introduction

This Statement is based on a book, currently in progress, on the history of medical education. The first part of the book reviews the changes from Chinese medicine in the third millennium BCE through to Britain in the 21 st century CE. The second part draws out the main themes identified and tries to analyse them further. The five major themes are,

  • The roles and boundaries of medicine. This includes a discussion on the aims of medicine, professionalism, boundaries between other knowledge bases and professional groups. It includes a discussion on the role of the doctor in society
  • The quest for competence: the search for the good doctor. This includes how to assess the doctor and links to the aim.
  • Who should become a doctor? Selection for medicine.
  • Handing on learning; the learning environment, the curriculum, methods of assessment, etc
  • Beyond learning; dealing with new knowledge. This covers research, discovery, innovation and the concept of the medical magnet, an individual or group which attracts other doctors to go and study and learn with them. This has been a feature of medical education for 3000 years and is still relevant today.

Each of these themes is relevant to the Inquiry of the College, though this Statement will deal only with the first of these points. Further information can be provided as required.

Defining the aim of medicine and its roles is a fundamental task which needs to be done before considering what kind of education is required to produce a medical practitioner or specialist; it is essential that there is a clear view of the role of medicine and of the doctor. Without such a vision of the aim of medicine it becomes impossible to plan an educational programme and to assess whether or not it has been effective.

Poynter, in a Chapter on “Medical Education since 1600” (O’Malley, 1970) make the interesting point that this has never really been clear.

“Medical education reflects the organisation of the profession and its institutions and just as vestigial features are very prominent in the profession in England, so they may be clearly seen in the system in education. This has never been designed and planned as a whole for its purpose. Indeed, nobody is agreed on its purpose, that is, what type of doctor the system is intended to produce. To take an industrial analogy, it is rather as if a great variety of machine tools were assembled from a number of different car factories and linked together in the belief that the ultimate product would be a motor car of some kind, though nobody was at all sure what it would look like or how it would perform. The product does indeed work and does indeed pass the different kinds of inspectors, each of whom is supplied with a different blue print for his tests.”

The historical review in this volume suggests that it is possible to define the aims and roles of medicine and of the doctor on which most doctors are likely to agree. Crucially, however, it also requires the agreement of patients and the public. In achieving the role and purpose of medicine the doctor is seen as the primary mechanism through which these are realised. Such definitions raise issues around the concept of a professional and what we mean by a professional.

The roles and the aims also begin to define the boundaries of medicine. Where does it begin, and where does it end? How is the knowledge base of medicine related to other disciplines and branches of knowledge? What role do the arts and social sciences play in the education of the doctor? How does the doctor interact with other professional groups? These are important questions, and, like the definition of the aim of medicine, lay the groundwork for the subsequent questions in this section of the book; the quest for competence, selection for medicine and the learning environment. Without such a debate then the comment by Poynter at the start of this Chapter will continue to remain true.

The Aim of Medicine

Following the review of the history of medical education it is possible to set out aims for medicine and the roles of the doctor.

It is suggested that:

The aim of medicine is to assist in the process of healing. This is the primary function of the doctor. Doctors do this by providing care, relieving suffering, promoting health, preventing illness and disease. This aim is grounded in the understanding of health and the mechanisms of illness and disease and from this to provide effective and appropriate treatment. Finally doctors must do this in full co-operation with the patient, public and other providers of health care.

Put another way, the purpose of medicine is to serve the community by continually improving health, health care, and quality of life, for the individual and the population, by health promotion, prevention of illness, treatment and care, and the effective use of resources, all within the context of a team approach

The roles of the doctor

Three roles thus follow from the aim set out above:

  • To be a healer, understand the processes of care and to intervene when appropriate. To wish to help others and see medicine as a vocation.
  • To understand people, and use this to provide better care, with co-operation and involvement of patient and the public. To communicate as effectively as possible. To be an advocate for health.
  • To understand the reasons for illness and disease and to use this knowledge to improve health, health care and improved quality of life and well being.

The kind of doctor required is one whose qualities fit these roles; that of healer, people centred, and curious about health and illness. By defining the qualities required, not the type of doctor, it becomes easier to see a way forward. There is not a single “type” of doctor, there may be several “types”, but they should all have the qualities listed above.

It should be obvious, for example, that not all doctors will spend an equal amount of time nor will they have specific expertise in each of these roles, but all will have some part in them, and all will ensure that their work is directed towards the aim as set out above. For example pathologists will spend much of their time examining the process of disease, but will have an interest in how this is applied to the process of care. The research scientist will operate in the same way. The psychiatrist may have a greater emphasis in understanding people, as may the doctor interested in changing the public health. The general practitioner will have a more even spread, while some specialist clinical colleagues will spend more time on care processes such as treatment. Trying to find the “ideal” doctor may be an illusion. What we may need is a range of doctors with a series of qualities which are expressed in different degrees in different individuals.

Defining a Profession: A Summary

One way of defining a profession is to set out the characteristics which seem to be most appropriate. Using the work cited in the review, and the paper by Calman (1996) these might include

  • Medicine is a vocation or calling and implies service to others. This remains an important part of being a doctor. The wish to be a doctor and to help others may seem old fashioned in a time of increasing commercialisation of medicine but it remains central. When we consider how best to select medical students and young doctors for particular specialties this will be an important factor to consider.
  • Trust and respect are two key aspects of a profession. The patient and the public must trust the doctor, and there should be mutual respect. These two factors (trust and respect) can be difficult to establish and require considerable care and hard work. They can be easily lost, and in the words of the proverb “Trust come on foot and goes on horseback.”
  • Respecting the value of human life. This is an important value. Doctors are in such a privileged position which could allow then to take advantage of those who are vulnerable.
  • Maintaining privacy and confidentiality. Those who consult a doctor expect to have their privacy protected and that their health information will remain confidential.
  • Acting as an advocate for the patient and the public in health related matters. It recognises that the doctor has a role as advocate, supporter, agent for change and educator.
  • Medicine has a distinctive knowledge base which is kept up to date. The knowledge base comes from the sciences, arts and social sciences. It is broad and constantly changing. This requires that the doctor must continue to learn and keep up to date.
  • Medicine has a special relationship with those it serves, patients or clients, including the importance of trust. This is not just a client or customer relationship. It is deeper and grounded in values and based on trust.
  • It has particular ethical principles-the ethical base. This is of fundamental importance, and has been central to clinical practice for generations. These are set out in various ways through codes, oaths and sets of principles.
  • Setting standards and examinations. This has been a part of professional practice for centuries, set by the profession, assessed by the profession. Slowly this will change as the public have a hand in the standards set.
  • Self regulating and accountable to patients, clients and the profession itself. This is perhaps the most contentious at the present time. How far can the profession continue to be accountable to itself, and how much can it relinquish this to those not part of the profession? The view of this author is that involvement of patients and the public in a tangible way will only strengthen the profession. There is nothing to hide or be afraid of.
  • Is open and available for evaluation. This is the corollary to the discussion on self regulation. The need to be open and transparent in relation to outcomes of care and public health practice.
  • Works closely with other professional groups. The important of teamwork and of recognising the skills and expertise of others is very much part of being a profession
  • Ability to lead and determine direction of the clinical team. This must be earned by the demonstration of many of the qualities listed above.

These then are some of the characteristics of a profession though there are some who would argue that in the 21 st century medicine is no more than a trade, a series of skills which can be easily mastered and bought at a price. This is not what a profession should be. It has at its core the commitment to people and has a strong vocational aspect without which it would just be another job. It follows from this that respect for the value of human life is a given, as is privacy and confidentiality. Acting as an advocate may seem again to be out of place, but, as will be discussed in another section it is increasingly important. Perhaps the most contentious is that the profession should sets its own standards and be self regulating. In the 21 st century the public should expect be part of this and that self regulation could be seen to perpetuate an inward looking club, with no responsibility to the public. But these views are not incompatible, and there is no need for contention. The public involvement in such bodies as the General Medical Council and increasingly in the Royal Colleges provides a way in which such an input can occur. The profession of medicine should not be afraid of such ventures as it can only strengthen the profession when those outside see the effort involved. As Freidson noted, Medicine should not be “Free of lay evaluation”

This list above attempts to define some characteristics and qualities of the profession, but what about professionals? Clearly they should subscribe to the list of characteristics above but this then needs to be translated into personal values. These might include the ability to demonstrate

  • The wish to be a doctor and to see it as a vocation; to be committed.
  • respect for human life and an interest in people
  • care, compassion and concern for patients and the public, empathy
  • ethical consideration of all issues
  • Interested in health as well as illness.
  • Communication and advocacy skills
  • act as an educator and advocate of change
  • demonstrate the courage to take difficult decisions
  • equanimity in the face of difficult issues and stressful circumstances
  • a wish to continue to learn and undertake continuing professional development
  • confidentiality and privacy in their work
  • An understanding of teams and the value of colleagues in other disciplines.
  • ability to analyse and solve complex problems
  • teaching ability-for patients and the public
  • accountability to patients, the public and the profession
  • curiosity and an interest in research and development
  • humility and to recognise when things could have been done better
  • An advocate for health
  • Be a leader in promoting health.

Such a list can of course be debated, discussed and refined. Its potential value lies in the selection of those who wish to study medicine or who wish to proceed up the career ladder. Such a set of characteristics might be useful in this process.

Kenneth Calman

This page last updated on May 18, 2005