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[afro-nets] Do doctors have a future?

  • From: "Jawad Asghar" <jawad@alumni.washington.edu>
  • Date: Mon, 30 Apr 2007 14:31:18 +0500

Do doctors have a future?


The Lancet 2007; 369:1405-1406


Do doctors have a future?

Richard Horton a, Ian Gilmore b, Niall Dickson c, Steve Dewer c and Susan Shepherd b

In 2005, the Royal College of Physicians published results of ayear-long inquiry into the state of medical professionalism.1 That investigation, chaired by former Health Minister Baroness Cumberlege, devised a new definition and description of professionalism (panel). The College's working party also examined six implications of this revitalised conception of professional values—for leadership, teams, education, appraisal, careers, and research. It went on to make 19 recommendations, affecting the General Medical Council, the Royal Colleges and Academy of Medical Royal Colleges, medical schools, the British Medical Association, Department of Health, research funding
bodies—and individual doctors themselves.

Panel: Royal College of Physicians' definition and description of medical professionalism1 Definition

Medical professionalism signifies a set of values, behaviours, and relationships that underpins the trust the public has in doctors.


Medicine is a vocation in which a doctor's knowledge, clinical skills, and judgment are put in the service of protecting and restoring human wellbeing. This purpose is realised through a partnership between patient and doctor, one based on mutual respect, individual responsibility, and appropriate accountability.

In their day-to-day practice, doctors are committed to:
•continuous improvement
•working in partnership with members of the wider health-care team.

These values, which underpin the science and practice of medicine, form the basis for a moral contract between the medical profession and society. Each party has a duty to work to strengthen the system of health care on which our collective human dignity depends.

Despite this detailed critique of UK medicine, medical professionalism, and the conditions in which it operates, the College was upbeat. Research into the views of its fellows and trainees showed that professionalism was greatly valued as the embodiment of what it means to be a doctor in a health service that is undergoing rapid and continuous reform. Professional values meant something important to doctors. The College's report ended with the aspiration that "Our abiding wish is to put medical professionalism back onto the political map of health in the UK".

The Royal College of Physicians has continued to develop these conclusions in its work on setting and monitoring standards of clinical care.2 The College also joined forces with the King's Fund, which had recently published its own report on medical professionalism.3 Together they have run nine roadshows in England and Wales during 2006 and 2007. The aim was to stimulate debate within and beyond the profession at a time when many doctors perceived the notion of professionalism to be under threat. These events comprised introductory scene-setting, consideration of a series of questions about the future of doctors and professionalism, electronic voting, small-group discussions, and a question-and-answer panel debate not only about professionalism but also about the uncertain future of Britain's health system.

Several common themes emerged. On professional values, many participants thought that being a doctor was similar to other roles within the NHS. To be sure, judgment, complexity, and uncertainty are unifying features of modern clinical practice. But trust, an ethical code, and a commitment to care are common to all health professions. A robust debate is needed about the part that each professional group should play in an evolving health service. This debate is not flourishing as it should be at a time of unprecedented change.

Can professionalism be taught? A doctor's education embeds professional values at every stage. But whether values can be taught explicitly or whether they are learnt through exposure and experience is still open to question. One variable in the teaching of professionalism is the maturity of the student. It is expecting a great deal of a 20-year-old to adopt a full range of professional behaviours. Moreover, as the health service has changed, so the kinds of values expected of doctors have changed too. New technologies, the importance of team-based working, a public expectation to be more the equal partner of a doctor—all of these shifts mean that mid-career doctors, who are often role models for their younger colleagues, will need to rethink, sharpen, and update their professionalism.

An even more difficult challenge is the assessment of a doctor's professionalism. Although there was substantial agreement that appraisal was welcome and much needed, there was great uncertainty about how this assessment should be done. Appraisal of professional values would not prevent another Harold Shipman from emerging. Indeed, the Chief Medical Officer of England's proposals on regulation and revalidation received a mixed response. Although some kind of recertification was clearly essential, his plans were regarded by some participants as an over-reaction, a resort to bureaucracy that would erode rather than strengthen professionalism.

In Doctors in Society,1 the working party reported that "leadership in medicine today is seriously failing. The profession is underselling itself". This view was repeated by many who attended the roadshows. Medical leadership was too fragmented. Too often we heard that no one is leading doctors. The public is confused and even doctors are confused about who speaks for medicine. Yet there was a desperate need for leadership on a range of clinical and professional issues central to the health of the nation. Doctors are frequently silent on the most important matters of the day.

The final theme that emerged concerned the National Health Service (NHS) itself and the responsibilities of the profession to influence public policy and to deliver health-service reform. Here, there was also great uncertainty. Managing the health service responsibly is key to the fair, effective, and efficient allocation of resources. The College's report1 concluded that "Doctors currently have a neglected role in health-service management and leadership". The King's Fund had emphasised the part the profession should play in public debate and health-service improvement: "The medical profession should aim high. It should seek to define a modern professionalism that focuses on the interests and experiences of patients and requires doctors to take part in improving health services."3 The consultation was less confident than either report. Doctors and managers have different priorities. Doctors may not have the time, skill, or desire to be effective managers. And adopting a management role—adhering to a target culture, for example—may actually damage professionalism.

The consultation phase of the Royal College of Physicians' inquiry came to a close with a final meeting in London on April 25, 2007. What conclusions can be drawn? First, doctors are less optimistic about their future than non-doctors. Doctors want to debate their prospects openly and energetically. Professional values are not redundant. They reflect the purpose and identity of doctors, and they translate directly to the quality and continuous improvement of patient care.

But second, many doctors feel dangerously disengaged and alienated. Roadshow participants discussed the fiasco of the implementation of Modernising Medical Careers, the paralysis of Connecting for Health, the rhetoric of patient choice—they felt these initiatives, launched with large and loud claims, have demoralised health workers. Add to these, payment by results, independent-sector treatment centres, Healthcare Commission ratings, contestability, and financial failure, and one has drawn the contours of a health system passing through a phase of extraordinary instability. The evidence we have gathered from the roadshows indicates that the re-engagement of the health professions in policy and strategy is critical for the restoration of order in the NHS.

And here lies the third lesson. This joint initiative showed the power of working in a different way—not as discrete professional groups, but as cross-disciplinary teams, including managers, students, patients, and the public. This spirit must be amplified across the health service.

The process this latest alliance has sustained has created a hope and expectation that more will follow. More engagement, more consultation, more leadership, more thinking, and more advocacy from the professions to secure the public interest. "Will anything change?", asked several of those who took part. Part of the answer lies with the profession itself and the willingness of doctors and managers, together with other professions and patients, to work effectively on shaping and running their services at local level. Partly, it is also about leadership at the top of the profession and how government behaves.

The government is now seeking to involve the profession more in its work. Doctors are mobilising to act on important issues of the moment. Although it is too early to tell whether measurable systemic change has taken place, medical professionalism is now back on the political map of UK health. It is up to the professions to make something of that success, for the benefit of patient care and the long-term future of the NHS.

We thank Ros Levenson for analysing the transcripts of small-group discussions.

1. Royal College of Physicians. Doctors in society: medical professionalism in a changing world. London: Royal College of Physicians, 2005:.
2. Gilmore I. The future for specialists and the Medical Royal Colleges?. Lancet 2006; 368: 1559-1560. Full Text | Full-Text PDF (56 KB) | CrossRef
3. Rosen R, Dewar S. On being a doctor: redefining medical professionalism for better patient care. London: King's Fund, 2004:.

a. The Lancet, London NW1 7BY, UK
b. Royal College of Physicians, London, UK
c. The King's Fund, London, UK

Rana Jawad Asghar MD. MPH.

Coordinator South Asian Public Health Forum
Typhoid Net http://www.typhoid.net