New guidance for medical schools has recently been issued by the General Medical Council. Polly Toynbee thinks the document has been written to refute the old complaints about arrogant, god-like consultants. She says that if new doctors come out of medical school imbued with the ethos of the guidance then we might expect a new generation of hypersensitive and thoughtful doctors, but she warns that human nature is bound to intervene
What makes the perfect modern doctor? The General Medical Council has drawn up new guidance for medical schools as a framework on which to base their curriculums and assessments. Tomorrow's Doctors (see www.gmc-uk.org/) is an idealistic compendium of the best qualities every new doctor should acquire. If medical schools could indeed turn out doctors moulded to this template, then we should expect a new generation of scholar saints and gentle scientists—wise, knowledgeable, sensitive, collegiate, humble, and good beyond imagining.
It is in the nature of every profession to set itself an ideal character and attempt to impose it as best it can on new entrants. It is also in the nature of humanity to fail that ideal most of the time. Visit any training establishment—of barristers, solicitors, police, nurses, or even journalists (a low trade, hardly a profession)—and you will find the most exalted sentiments imparted to the fresh faced young trainees who dutifully note it all down and deliver it back at examination time in well rounded essays on the ethics and best practice of their future calling. Article one of the Press Code as taught to every fledgling reporter is guaranteed to draw ribald laughter from any audience: “Newspapers and periodicals should take care not to publish inaccurate, misleading or distorted material.” Sincere young journalists, police cadets, trainee nurses, or indeed medical students may believe every word of their codes as written up on the blackboard, but no sooner do they step out into the real world of their chosen profession than they tumble into the chasm between the ideal and the real. At police stations it is almost a requirement for old hands to knock the idealism out of the inexperienced new recruits. Young doctors and nurses, too, often receive short sharp shocks to their ethics and values. Short cuts, time constraints, and all the exigencies of true life on the hard pressed wards can put these ideals under severe strain. So it is always well to cast a slightly jaundiced eye over the high flown phrases of professions' protestations of their own virtue, as exhibited in their training manuals.
None the less, all professions need to start out with the best of intentions, and there are plenty of those in the GMC's framework. The priorities for the “curricular outcomes” look sensible. (Is a doctor a curricular outcome?) The principles of professional practice are listed in this order: good clinical care (have good standards and practise within your limits of competence), maintaining good medical practice (keep up to date), relationships with patients (get on well with them), working with colleagues (work well together), teaching and training (be a competent teacher), probity (be honest), and health (make sure your own health does not jeopardise patients' health).
There has plainly been much agonising over the exact order in which the various virtues should be listed. So, for example, “The duties of a doctor registered with the General Medical Council” listed on the front page are in a very perverse order, where six “touchy feely” rather modish qualities are listed before the most important clinical one, “keep your professional knowledge and skills up to date.” So, bizarrely, we get doctors ordered to be polite and considerate, respecting their patients' dignity and privacy, listening to patients' views, giving patients information, and respecting their rights before we know if the doctor is any good at all at medicine. If asked to choose qualities, most patients would probably rather be cured by a brusque doctor with up to date skills than be listened to and respected by one who had hardly looked at new treatments in the past 20 years.
Between the lines, this whole document reveals the history of the changed expectations that we all have of how doctors should work. It reads as if it were written to refute all the old complaints about arrogant, out of touch, unfeeling, god-like consultants who wafted through the wards trailing flotillas of terrified students, when medicine was like the old public school system (“suffer the indignities of being a new boy, and one day, my son, all this grandeur will be yours and you too can bully the life out of your juniors while making them do all the work; you too will be able to terrorise your patients, talk over their heads, and tell them what's good for them while they smile up at you in admiring gratitude”).
Mercifully, those days are more or less gone, and this document is proof of it. With reduced working hours for junior doctors, and consultants coming increasingly under hospital management regimes, and with patients less deferential and more conscious of their rights (even litigious), the old world of the emperor consultant is fading fast. Tomorrow's Doctors warns the modern trainee doctor that the patient is the master now—a trend that can only grow. What is missing is any sense of the ever murkier political shark pool in which doctors must practise. The document doesn't mention the growing interference, demands, and often perverse priorities set by politicians in the affairs of medicine. It doesn't warn or advise about how to cope with these, for surely as election after election is fought over the minute details of medical care, young doctors need to think about how to navigate these choppy waters, when to resist, and what to avoid. It doesn't instruct about private practice and its tricky interface with the NHS. Some trainees will have entered medicine intent on earning sizeable sums, though many will never touch a private penny. The document omits to mention the many ethical questions surrounding money and treatment—relating to NHS rationing priorities or private payment.
But if young doctors come out of medical school imbued with the ethos of this new framework for their education, then we might expect a new generation of hypersensitive, continually learning, thoughtfully cooperative doctors working together in a happy collective of medical harmony. If somewhere between aspiration and reality human nature intervenes, at least doctors can be sure that they will still be practising closer to their own codes of practice than most journalists do to theirs.
Figure.
Polly Toynbee