Renegotiating medicine’s contract with patients

The social contract between doctors and the public is being renegotiated. The contract says in essence: “In return for guaranteeing that we will be treated by competent doctors who will respect our dignity and offer us services better than those of the local garage we the public will give you doctors status, above average incomes, and the privilege of regulating yourselves.” The contract is renegotiated not by bald men in suits in back rooms but rather by the public expressing its disquiet in a myriad of forms—through, for example, parliament, the media, and patients’ organisations—and by the profession recognising the disquiet and responding. The BMA, the Academy of Medical Royal Colleges, and postgraduate and undergraduate deans last month produced a report on improving self regulation at the local level,¹,² while the Royal College of Physicians of London has before it a document that calls on it to “put in place urgently evidence that robust mechanisms exist for self regulation of its members and fellows.” ³ But it is the General Medical Council that is in the front line of negotiation. If it falls, then self regulation will be lost.

These are momentous times at the GMC. The long running case of the Bristol doctors who are accused of failing to warn patients about poor surgical results will probably have ended by the time you read this. The judgment, whichever way it goes, is likely to be accompanied by a debate on the effectiveness of the GMC. The debate has certainly been building while the case has been underway.⁴ Away from the limelight of the Bristol case the council last week approved (with some minor amendments) the document Good Medical Practice that sets the standards that doctors are expected to meet.⁵ If doctors don’t meet the standards then their registration may be removed.

The most important thing about Good Medical Practice is that it sets standards in a positive way. It says what doctors should do, not what they shouldn’t do. Moses never got so far, and the document is a vital step forward. It is a part of the negotiation that is likely to preserve self regulation.

Ian Kennedy—professor of law, one time scourge of the medical profession, and a former member of the GMC—was arguing 10 years ago that doctors needed specific guidelines on what constituted good practice.⁶ In those days he was a voice in the wilderness. Doctors responded that such guidelines would be impossible because medicine was too inexact. Besides such guidelines would need enormous amounts of time and skill to produce and would lead to a restricted and defensive style of practice. Kennedy, who believed that “the jury is still out on whether self regulation by doctors is adequate” also argued that the GMC would have to insist on reregistration and the establishment of an inspectorate. The council has yet to go so far, but the continuing renegotiation of the social contract might require it. The profession certainly needs to show that its members are keeping up with the latest evidence and maintaining their skills. The abundant evidence that the practice of many doctors is not in line with the best evidence has been the main force leading to clinical governance, the government’s concept of the boards of trusts being as responsible for clinical performance as they are for financial and legal performance.

Although many doctors 10 years ago were sceptical of the practicality of and need for guidelines on good practice, the Royal College of General Practitioners had already made important steps forward with its reports on What Sort of Doctor?⁷,⁸ (Sir Donald Irvine, the current president of the GMC and the driving force behind Good Medical Practice, was one of the leaders of the Royal College of General Practitioners in those days.) The professional examinations set by the colleges are educationally meaningless unless it is possible to define what constitutes a good general practitioner, physician, surgeon, or whomever. Good examinations need such definitions. Otherwise, they are as pointless as diagnostic methods where there is no gold standard. Colleges are increasingly recognising this and producing definitions. The Senate of Surgery of Great Britain and Ireland last October, for instance, published The Surgeon’s Duty of Care.⁹

All of these documents emphasise what might be called the “softer side of medicine′—communication, ethical behaviour, treating patients with dignity, and being a team player. All medical students have met the stereotype of the brilliant diagnostician or the outstanding surgeon who is rude to patients, bullies students, and exploits colleagues. It may still be possible to be such a creature and be a successful conductor, footballer, or poet, but it’s not acceptable in medicine. Patients and the public expect much more, and doctors must deliver.

Just as anybody starting a job will read their contract carefully so every doctor in Britain should read Good Medical Practice. This is your social contract with patients and the public. You might read it to avoid the shame of having to tell the professional conduct committee of the GMC or a court that you haven’t—but much better read it to a feel a thrill of pride in your profession and calling.