The performance of doctors. i: professionalism and self regulation in a changing world
BMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7093.1540 (Published 24 May 1997) Cite this as: BMJ 1997;314:1540
Introduction
The performance of doctors embraces attitudes to practice, knowledge, and skills. It is the outward and visible expression of our professionalism. In general, people think highly of the medical profession in Britain; rising expectations are a mark of our success. Nevertheless, self regulation, on which our professional independence and self respect depend, cannot be taken for granted. Sympathetic critics such as lay people, sociologists, and doctors reflect a wider public perception that we seem reluctant to assure doctors' competence and protect patients from poor practice. There are also criticisms that we are not addressing the widespread dissatisfaction with the attitude of some doctors, including their paternalism and poor communication with both patients and colleagues, and are failing to make self regulation demonstrably effective and responsive.1 2 3 4 5 6 7 8 9 10 11 12
These criticisms, if not dealt with, could seriously damage public trust. They provide ammunition for people who oppose professional self regulation on the grounds that, where doctors' and patients' interests conflict, doctors' interests will invariably come first. Greater external control of the profession is their prescription.
In this article, and another to follow, I propose a modern expression of medical professionalism, founded on sound self regulation, that should bring the public's and the profession's interests together successfully.
The changing world
Our professionalism is shaped by the context in which we work. First and foremost, medical knowledge and skill have expanded at an unprecedented rate. This, together with the revolution in information technology, has huge implications for the profession. Can we, for example, maintain medicine as a distinctive entity in the face of growing subspecialisation? Can we adapt to careers that may not last a lifetime without reorientation and retraining?
People know more about health matters because they have independent access to clinical information and because their interest has been stimulated by media attention. More patients want an open relationship with their doctors: they want to be well informed and involved in decisions about their care.
Doctors are no longer alone in the clinical management of patients. Multiprofessional teamwork, the philosophy behind modern shared care, has to be reconciled with the personal nature of the doctor-patient relationship.
Modern healthcare is complex to manage. A structured managerial framework, more accountability, and overt rationing now exist in the NHS. Many doctors are unhappy at the impact these developments have on their ability to practise in their own way. Yet the public expects doctors to help make the system work well.
Summary points
Professional independence is a privilege, not a right
Professional independence cannot be assured without competent self regulation
A new agreement between medicine and society is needed
Doctors' attitudes are also changing. For example, more doctors attach as much importance to the quality of their lives outside medicine as to their medical work.13 Part time practice has become more common for both men and women. Such developments have major implications for continuity of care and the organisation of medical work.14
The effects of these changes are both exciting and bewildering. We delight in the successes of medicine–and at times oversell it. Many doctors, though, feel alienated and undervalued.14 And the sheer complexity and pace of modern medicine is itself stressful.
To retain our independence, and reasonable control over our affairs, our professionalism must be capable of adapting to change.
The importance of independence
Medical professionalism rests on three pillars which together constitute the basis of our independence–or autonomy: expertise, ethics, and service. Expertise derives from a body of knowledge and skills whose utility is constantly invigorated by the results of research. Ethical behaviour flows from a unique combination of values and standards. Service embodies a vocational commitment to put patients first.
Independence gives individual doctors clinical freedom and the profession collectively the authority to decide about standards of professional practice and education, the organisation of medical work, and discipline. Furthermore, independence gives doctors that self respect which motivates them to perform well.15 Patients rely on an independent medical profession for authoritative advocacy on behalf of individuals and where the state or big business may engage in activities that threaten health (M Stacy, second international conference on medical registration, Melbourne, 1996). Equally, a profession with a strong sense of ethical duty makes an important contribution to a “civic society.”
Our independence rests on three claims: firstly, that there is such an unusual degree of knowledge and skill involved in medical work that non-professionals are not equipped to evaluate or regulate it16; secondly, that doctors are responsible–they may be trusted to work conscientiously, without supervision; and, thirdly, that the profession itself may be trusted to undertake the proper regulatory action when individuals do not perform competently or ethically.
Professional self regulation
Professional self regulation underpins the concept of an “independent profession.” It is a privilege given by the state through parliament. The Medical Act of 1858 established the statutory framework, including the General Medical Council. The Merrison committee said in 1975 that the GMC has to “assure itself that those admitted to the register are competent and to remove those practitioners unfit to practise. The maintenance of a register of the competent is fundamental to the regulation of a profession.”15
The universities are accountable to the GMC for basic medical education, and the royal colleges determine standards of practice and education in their specialties. The Specialist Training Authority and the Joint Committee on Postgraduate Training for General Practice certificate the completion of training for entry to a specialty or general practice. Specialist certification leads to specialist registration with the GMC.
Professional self regulation is one element in the complicated relationship between the medical profession and society. For example, doctors working for the NHS are also accountable as employees and contractors. In a web of complex regulatory arrangements some tension is not only inevitable but healthy.
For self regulation, and therefore professional independence, to continue, patients must feel able to trust their doctors and society must feel able to trust the collective medical profession. We must become more transparently accountable for our performance and show, in ways that the public can understand and relate to, that self regulation really works.
With this recognition, a wider vision is now emerging. We are beginning to see professional self regulation as a dynamic continuum starting with the individual doctor and extending through the clinical team and local peer networks to the professional standards bodies (fig 1). It needs to be seen by doctors as positive and helpful, part of continuing education, personal professional development, and quality assurance of practice.
Maintaining good practice; the continuum of self regulation
Important principles
Values and standards
Clearly enunciated values and standards are the foundation of effective self regulation. In 1995 a national conference considered the profession's core values, such as commitment, caring, competence, and integrity17; the BMA is taking this initiative further. In the same year the GMC published Duties of a Doctor, in which, for the first time, the principles of good medical practice were described.18 Doctors and the public have reacted positively, showing how important it is that the profession indicates what individual doctors should do and what the public can expect of them.
Tomorrow's Doctors (1993) signalled the GMC's new approach to undergraduate medical education.19 The medical schools have gone to work on this with a real will. The New Doctor, published this year, reflects the GMC's determination to transform the preregistration year into an enjoyable and worthwhile experience.20
A quality assured system
To show that self regulation is effective and efficient we need to test the system against explicit criteria and standards, requiring hard evidence of compliance. The box shows some illustrative attributes and criteria. The GMC, for its part, will use such an approach to assure and improve the quality of its own performance.
Assuring quality in self regulated medical practice
Purpose and values–Well defined values, functions, responsibilities, and strategic direction
Performance–Evidence of competent management, good leadership, operational criteria and standards, good systems and data, effective performance monitoring, and feedback
Consistency–Evidence of thoroughness, fairness, and a systematic approach
Effectiveness or efficiency–Evaluation of the impact of procedures; evidence that the organisation is efficient and achieves good value for money
Accountability–Responsibilities and lines of accountability well defined and understood; wherever possible the process of regulation made visible and results published; evidence of external audit
Overall acceptability–Evidence that the overall performance and results of self regulation inspire the trust and confidence of the public, the medical profession, and doctors' employers
Patients' involvement
Modern self regulation is incomplete without involving people at all levels, to incorporate the patients' view of quality. To this end the GMC recently decided to increase its proportion of “lay” members to 25% and to appoint lay assessors to the teams that will assess doctors' performance under the new performance procedures.
External peer review
External peer review is an essential stimulus to effective performance and should become an integral part of self regulation. It applies equally to individuals, clinical teams, and institutions.
Diversity with coordination
Diversity characterises the British system of medical regulation. It means that each university medical school puts its stamp on basic medical education and each royal college determines standards of practice and education in its field. Each clinical team has its distinctive ethos. Diversity encourages new ideas, the development of different ways of achieving the same ends, and excellence in practice.
Without effective coordination, however, it is difficult to see the whole picture, how one part of the system relates to another, and whether the system as a whole works well. The best results will surely be achieved by setting individuality, with its evident strengths, within a framework of agreed goals and well coordinated partnerships, both locally and nationally. Then each partner will maintain a sense of ownership and achievement while contributing to a common purpose.
The leadership role of teachers
Role modelling is a powerful force in medicine. Marinker used the term “the hidden curriculum” to describe the effect of the professional attitudes and behaviour of clinical teachers on students and doctors in training.21 The everyday behaviour of clinical teachers is the living demonstration of their expertise, ethics, and commitment: their professionalism. What they do and how they do it matters as much as what they say–as in, for example, communicating with patients, students and colleagues; recognising the limits of their own practice; using clinical audit to improve their practice; applying formative peer appraisal for their own professional development; handling personal criticism; tackling poor performance in themselves and others; and caring for colleagues in difficulty.
The kind of leadership teachers give is critical to the quality of medical practice and education and to professional self regulation. The assessment of attitudes and interpersonal skills should therefore have a high priority in medical education.
Towards a new agreement
The time is ripe for a new agreement between medicine, the state, and society generally. It is our responsibility to see that professional practice is at one with people's expectations and to show that self regulation is effective. For its part, the state must give doctors the time needed to do a professional job for patients and to maintain standards of practice using modern methods. The proper resourcing of good medical practice–including medical education–must become an agreed given of good quality health care. With such an approach, we can be confident that our strengthened professionalism will keep the public's respect and trust.
Acknowledgments
This paper is based on the George Haliburton Hume, Cohen, and Telford lectures given in Newcastle upon Tyne, Edinburgh, and Manchester, respectively.