An evolution of professionalism

I would agree with the components of the current preferred model of new professionalism¹ outlined by Dr Stanton et al., but I believe there is something missing when they talk about accountability. They cover the dynamic between patients and professionals and the benefit of assuming a stronger sense of responsibility for the ways in which the wider health system works, but they seem to miss a fundamental plank of professionalism which is accountability to and for your peers.

For my part, I feel it is vital that the profession is seen to tackle issues apparent in its own back yard. Revalidation, rightly in my view, is going to depend absolutely on annual appraisal, hopefully whole practice appraisal to cover all aspects of a doctor's practice (NHS and/or private). If appraisal is really going to work to protect patients and encourage continuous quality improvement, then it must be a rigorous and fair peer review. As soon as a doctor with doubtful data or unanswered issues is ‘let off the hook’, the appraiser has failed in that accountability, both to peers and public. It is a big responsibility, but surely crucial to be carried out consistently and effectively if we are to maintain our independence as a profession.

An area which might be tackled via appraisal, but which professionals need to be aware of between appraisals, is significant unwarranted variation (particularly outliers, say outside three standard deviations from the mean). I was talking to an orthopaedic audience recently and used the example of knee arthroscopy for osteoarthritis, for which there is almost no evidence of effectiveness in the absence of mechanical locking. To be fair, they were astounded when I told them about the thousands of knee arthroscopies that health insurers pay for per annum; that the rate in private practice was substantially more than the rate in the NHS and that we knew of one orthopaedic surgeon who was probably doing around 2000 a year overall in his private practice. The point I was making was that in this, and multiple other situations in both public and private sectors, professional colleagues often sense where there are elements of poor practice and, as clinical data feedback improves, outliers in local clinical practice will now be increasingly exposed; so, it must surely be up to the profession to tackle these issues because, if they don't, others (e.g. health insurers) will which, while it may protect patients, will undermine professionalism, old or new … but, sadly, the professionals will only have themselves to blame.

Competing interests

None declared