An evolution of professionalism

The model of financing and service delivery for the Royal Automobile Club (RAC, England) has not changed substantially for the last 50 years. Yet this belies a seismic change in how those working for the RAC are treated, what they do and how they are incentivized. The most important change has been in the complexity of the machines that they are working with. Twenty years ago, professional patrolmen could take pride in fixing most automobile emergencies, at least temporarily, by the roadside. This is no longer the case. The move towards computer-controlled cars with intrinsically complex electronic software means that increasingly patrolmen are diagnosticians who tow cars to specialized garages. This has impacted hugely on the motivation of patrolmen. Whereas previous satisfaction came from fixing the problem and required great technical skill, satisfaction now comes from guiding the problem to the right place for fixing.¹

Analogies can be taken too far but the pace of change witnessed in healthcare, with the requirement for autonomous health professionals to adapt their clinical practice accordingly, bears similarities to the experience of the RAC patrolmen. Five years ago, the Royal College of Physicians undertook an inquiry into the meaning of medical professionalism. Following extensive consultation, this report defined professionalism as ‘a set of values, behaviors and relationships that underpins the trust the public has in doctors’. It concluded that building and maintaining trust was the most important aim of professionalism.²

The ensuing consensus statement, supported by the four Chief Medical Officers of the United Kingdom, on the role of the doctor begins:

‘Doctors alone amongst healthcare professionals must be capable of regularly taking ultimate responsibility for difficult decisions in situations of clinical complexity and uncertainty, drawing on their scientific knowledge and well developed clinical judgment. The doctor’s role must be defined by what is in the best interest of patients and of the population served’.³

At the time of publishing the above statements, it was recognized that the role of the doctor, alongside concepts of professionalism, would continue to evolve. In part this evolution is driven by internal changes to the practice of medicine such as technology; in part due to a more multidisciplinary approach to healthcare delivery; and in part as a response to the public consensus on what is expected from a clinician. Our current preferred model of new professionalism has a number of components. It places a stronger emphasis on accountability, recognizing the benefits of creating a different dynamic between patients and professionals, and assuming a stronger sense of responsibility for the ways in which the wider health system works and for all dimensions of quality. It promotes a desire constantly to improve what clinicians do, accepting change as an asset rather than a threat. It commits to using a range of different approaches to developing and mobilizing knowledge about how to improve care and to building the formal evidence base underpinning improvement. Finally, it emphasizes the importance of clinicians working in multidisciplinary teams across organizational boundaries. Most fundamentally, no longer is a commitment to improving the quality of patient care an ‘add-on’. It is a central part of the role of a clinician and a core value of the new model of professionalism.

This push towards a new model of professionalism is more than a social construct. It is underpinned by a new science which is complementary to the established ways of knowing which have dominated the delivery of healthcare for over 150 years. Over the last five years, the science of quality improvement (QI) has grown in both clinical popularity and academic recognition. In the last 12 months, PubMed records 360 English published articles containing the key words ‘quality improvement’. Within the UK, there is now an Improvement Faculty for Patient Safety and Quality of Care.⁴ The Health Foundation, an independent charity devoted to continuously improving the quality of healthcare throughout the UK, supports hundreds of projects as part of its improvement programmes. Yet more enthusiasm and commitment for QI is found within Deaneries and the Royal Colleges. These organizations are undertaking pilot studies of trainees in quality improvement projects, replacing the traditional obligatory and unpopular ‘clinical audits’. On an international stage, the Institute for Healthcare Improvement (IHI) has pioneered improvement initiatives such as the 5 Million Lives Campaign in the US.⁵ IHI is now collaborating with tens of thousands of healthcare organizations in countries including England, Scotland, Ghana, Malawi and South Africa. This global push for quality improvement creates momentum for the transition to the new model of professionalism presented here.

Further reinforcement for this model lies in the urgent need, due to the stringent financial conditions, for improved efficiency and productivity. It is widely acknowledged that to achieve this will need clinical leadership by those who understand quality improvement.^6,7 This renewed focus on the clinician developing and actively altering the service they work in to ensure better patient care leads to a new facet of the compact between the public and clinicians around the nature of professionalism.⁸ This does not detract from the primacy of the individual doctor–patient relationship, rather there is an additional caveat – helping the patient is achieved not just by the one to one interaction but the ‘backstage’ changes that are enacted. This understanding of the importance of influencing the environment within which care is provided has long been recognized by the public health community but now needs to become a core body of knowledge and skill for all clinicians.

The importance of training in quality improvement and making quality improvement part of the everyday delivery of healthcare requires training from an undergraduate level. However, the work of Friedson⁹ identifies that professional norms are adopted via modeling from role models in the workplace. The challenge for the NHS, therefore, is that many senior clinicians are unfamiliar with the science of quality improvement and ultimately ill-equipped to teach it. Rather than relying on the traditional gradient of senior to junior transmission of knowledge, we propose that the diffusion of knowledge about quality improvement as core to new professionalism may be best disseminated across networks, formal and informal, online and offline. Furthermore, the locus of knowledge may be required to extend beyond the traditional bastions of professionalism such as the Royal Colleges to include organizations such as IHI and The Health Foundation.

For many industries, including automobile and healthcare, the changing world is complex and often intimidating to professional norms. We encourage clinicians to integrate active involvement in service improvement as part of their professional identity. Because a commitment to improving quality in healthcare is no longer a choice. It is a core value of new professionalism.

Footnotes

DECLARATIONS —

Competing interests None declared

Funding None

Ethical approval Not applicable

Guarantor ES

Contributorship All authors contributed equally