Medical professionalism: out with the old and in with the new

`Professionalism is medicine's most precious commodity.'<sup>1</sup> So writes Richard Horton, editor of the Lancet and the prime author of a report on medical professionalism from a working party of the Royal College of Physicians.<sup>2</sup> `Medical professionalism... underpins the trust the public has in its doctors', and yet it `is under broad attack'.² It is essential that medical professionalism is restored to the heart of medical practice, although this must be a new professionalism that includes patients rather than the old, elitist, exclusive professionalism. Otherwise, calamity awaits—not only for patients but also for doctors. These few sentences summarize the thesis of the working party, and the thesis seems to be supported by a poll of medical trainees and by evidence from the good and the great of British healthcare. One flaw in this outbreak of consensus may be that the rank and file of the profession likes the old concept rather than the new.

There is undoubtedly a great increase in interest in professionalism. A collection of European and American bodies of physicians and internists has produced a charter on medical professionalism, which sets out three principles—on patients' welfare and autonomy and on social justice.³ The King's Fund has recommended a redefinition of medical professionalism;⁴ the Picker Institute Europe has launched an initiative on patient-centred professionalism under the chairmanship of Donald Irvine, former president of the General Medical Council who had a more rigorous concept of revalidation than the profession was able to accept. All of these bodies have argued—as does the British government⁵—that being more responsive to patients is central to the new medical professionalism and to modern healthcare. They are surely right: a professionalism built around patients is modern, whereas an exclusive professionalism is anachronistic.

Adherents of the `old' medical professionalism resent the implication that doctors have ever been anything but patient centred. Yet four fifths of the medical trainees answering the poll thought that `increases in the public's expectations of access to and outcomes of medical care' are some of `the main challenges to medical professionalism'.<sup>6</sup> The context suggests that trainees were interpreting the business school word `challenge' more as a threat than an opportunity. It is hard to imagine Tesco's staff seeing rising customer expectations as a threat rather than an opportunity; maybe that is one of the reasons why the government (which, like it or not, was democratically elected and has a mandate to reform the health service) is strong on business methods and sceptical about the old professionalism. (The working party regularly quotes the trainee poll but omits to mention in the main report that the response rate was only 9%. The plebeians may be less interested in professionalism than the patricians.)

Doctors' revived interest in professionalism clearly comes from feeling threatened. Some of the trainees put it very strongly: `Doctors are increasingly becoming glorified clerks and robots following protocols to satisfy centrally created Stalinist targets within the NHS. Furthermore, their professionalism is becoming increasingly undermined by nurse specialists assuming titles that lead patients to believe they are medically qualified... '. Or `As medicine becomes feminised, it is undermined by managers, government and the increasingly professionalised and masculinised allied professions'. Or, a statement that is quoted with some humility by the working party in the main body of the report: `I feel that our profession has been sold up the road by our superiors over the years for a few pieces of silver, for their own selfish interests. That has eventually placed us, both present and future doctors, in very difficult positions, undermined our morale, confidence and standing in society. We lack leadership and foresight in our present day peers/seniors'.

Box 1 Definition of medical professionalism

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

In their day-to-day practice, doctors are committed to:

• integrity

• compassion

• altruism

• continuous improvement

• excellence

• working in partnership with members of the wider healthcare 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 healthcare on which our collective human dignity depends.

Sadly perhaps, `professionalism' is a loaded and poorly defined word. The connection that comes first to the mind of many in 2006 was coined by George Bernard Shaw exactly a century ago: `All professions are conspiracies against the laity'. The onslaught that Shaw made on doctors in his preface to The Doctor's Dilemma repays regular reading. He argues, for instance, that the profession having exploited the public `tries to reassure it with lies of breath-bereaving brazenness'. Perhaps too he foresaw the internet when he wrote: `All that can be said for medical popularity is that until there is a practicable alternative to blind trust in the doctor, the truth about the doctor is so terrible that we dare not face it'. The working party can be grateful that Shaw is not alive to critique its report, but cynics would see doctors' interest in medical professionalism as primarily an attempt to fend off other health workers, particularly managers and nurses, and justify why they should be paid more than anybody else.

I do not see it that way—although (following perhaps professional values) I started sceptically. I think that the working party was right to emphasize the importance of professionalism and right to redefine it. Its challenge is to spread its vision of professionalism throughout the profession.

The working party discards the old notions of professionalism of `mastery, autonomy, privilege, and self regulation', but I wonder if the broader profession will follow. Mastery, says the working party, `can suggest control, authority, power, and superiority—ideals that are not compatible with our view of the patient-doctor partnership'. Well, `control, authority, power, and superiority' might seem outdated to the working party (and I believe them to be right), but they are very attractive to many doctors. Similarly, autonomy, privilege, and self-regulation are felt to many doctors to be the deserts of their dozen years of medical training.

Having discarded some of the traditional characteristics of a profession, the working party goes for a short and a long definition. The short definition states: `Medical professionalism signifies a set of values, behaviours, and relationships that underpins the trust the public has in doctors'. The long definition is in Box 1, and the working party spends several pages unpicking its meaning. The relationship with patients is central (leaving hanging what professionalism means for the many doctors who do not see patients), and the working party emphasizes wellbeing, dignity, partnership, and mutual respect. Also important is the relationship with other professionals, and doctors cannot escape responsibilities for management, resource allocation, and the workings of the whole healthcare system. Many doctors hanker after a simpler age when there were doctors and patients and few if any other players of any importance. But those days are long since gone for all but a very few doctors. Most now work in highly complex (and, it has to be said, defective) systems⁷ and must accept broader responsibilities to be true professionals.

The working party draws out six major themes that will be important in promoting the new professionalism: leadership, teams, education, appraisal, careers and research. It devotes most space to leadership, which, as I have argued elsewhere, has always proved difficult for doctors (and, indeed, most professionals).⁸ Leadership involves vision, strategic thinking, emotion, empowerment, motivation, trust, teamworking, and mess, whereas many doctors prefer practicalities and `getting on with the job'. Leadership also implies followership, which is not a strength of doctors. Hence, doctors are inclined to create unleadable institutions and then elect compromise candidates to lead them (look around you). The working party is right to emphasize the importance of leadership, but it needs to explore the barriers more deeply. It is also right to recommend `a common forum' so that medicine can speak with `a unified force'. George Godber, one of Britain's most distinguished chief medical officers, recommended the same 40 years ago, but the profession has gone in the opposite direction with new bodies appearing regularly. Unfortunately, as John Green, once chief executive of The Royal Society of Medicine, acutely observed to me: `There is no kingdom too small for a doctor to be king of'.

When it comes to research, the working party seems confused. On p S20 of the report it refers to `a large body of published evidence about professionalism', while on p S11 we read: `Research into professionalism is in its infancy and needs to grow'. It also charges ahead of the evidence (in an unprofessional way?) by describing medical professionalism as `an important lever for improving the quality of services to patients', but then concedes that it has `been struck by how weak the research base is on the effects of medical professionalism'. We do need more research, and let us hope that it shows that professionalism is good for patients not just for doctors.

Even though I quibble I am a critical friend, and I support the working party's recommendations. The tough job is to instil this new professionalism when role models are sparse. When Jordan Cohen, president of the Association of American Medical Colleges, spoke at a GMC meeting last year he argued strongly for professionalism but said: `Finally, and perhaps most importantly, what we do not want to include in the curriculum is the modelling of unprofessional behaviour... Speaking from my own experience in the States, probably the most fundamental issue in terms of professionalism is that we have learning environments that are not emblematic of the highest professional standards because of the way in which the system is currently operating'. Or, as another American, the author James Baldwin put it: `The price one pays for pursuing any profession, or calling, is an intimate knowledge of its ugly side'.

There is, however, one powerful lever that the profession has to pull—revalidation. The working party steered clear of revalidation (not, I hope, because it was too controversial), but a great battle is being fought over what form it will take. Mike Pringle, professor of general practice in Nottingham, argued in the John Fry lecture that revalidation offered a once in a lifetime opportunity to take a leap forward with patient-centred professionalism.⁹ The GMC and the BMA watered down the original proposals—to a point where Dame Janet Smith pronounced them worthless.^10,11 Now Liam Donaldson, England's chief medical officer, is having to decide on what will be introduced. Here is a great opportunity for promoting medical professionalism not just talking about it.