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MODERN EXPRESSION OF PROFESSIONALISM – A VIEW FROM PRESIDENT OF GMC In two papers in the BMJ in 1997, Dr Donald Irvine, President of General Medical Council proposed a modern expression of medical professionalism, founded on sound self regulation, that should bring the public's and the profession's interests together successfully. A synopsis of these two papers is given below. The performance of doctors is the outward and visible expression of our professionalism. In general, people think highly of the medical profession; rising expectations are a mark of our success. Nevertheless, self regulation, on which our professional independence and self respect depend, cannot be taken for granted. Sympathetic critics such as lay people, sociologists, and doctors reflect a wider public perception that we seem reluctant to assure doctors' competence and protect patients from poor practice. There are also criticisms that we are not addressing the widespread dissatisfaction with the attitude of some doctors, including their paternalism and poor communication with both patients and colleagues, and are failing to make self regulation demonstrably effective and responsive. Greater external control of the profession is their prescription. The changing world Modern healthcare is complex to manage. Doctors' attitudes are also changing. More doctors attach as much importance to the quality of their lives outside medicine as to their medical work. Part time practice has become more common for both men and women. Such developments have major implications for continuity of care and the organisation of medical work. A structured managerial framework, more accountability, and overt rationing now exist in the NHS. Many doctors are unhappy at the impact these developments have on their ability to practise in their own way. Yet the public expects doctors to help make the system work well. Professional independence cannot be assured without competent self regulation. A new agreement between medicine and society is needed. To retain our independence, and reasonable control over our affairs, our professionalism must be capable of adapting to change. Three pillars and three claims of medical professionalism Medical professionalism rests on three pillars which together constitute the basis of our independence or autonomy: expertise, ethics, and service.
Our autonomy rests on three claims:
Professional self regulation as the underpin Professional self regulation underpins the concept of an "independent profession." It is a privilege given by the state through parliament. The Medical Act of 1858 established the statutory framework, including the General Medical Council. The Merrison committee said in 1975 that the GMC has to "assure itself that those admitted to the register are competent and to remove those practitioners unfit to practise. The maintenance of a register of the competent is fundamental to the regulation of a profession." The universities are accountable to the GMC for basic medical education, and the royal colleges determine standards of practice and education in their specialties. The Specialist Training Authority and the Joint Committee on Postgraduate Training for General Practice certificate the completion of training for entry to a specialty or general practice. Specialist certification leads to specialist registration with the GMC. Professional self regulation is one element in the complicated relationship between the medical profession and society. For self regulation, and therefore professional independence, to continue, patients must feel able to trust their doctors and society must feel able to trust the collective medical profession. We must become more transparently accountable for our performance and show, in ways that the public can understand and relate to, that self regulation really works. With this recognition, a wider vision is now emerging. We are beginning to see professional self regulation as a dynamic continuum starting with the individual doctor and extending through the clinical team and local peer networks to the professional standards bodies. It needs to be seen by doctors as positive and helpful, part of continuing education, personal professional development, and quality assurance of practice. Values and standards as the foundation of self-regulation Clearly enunciated values and standards are the foundation of effective self regulation.
Patients' involvement Modern self regulation is incomplete without involving people at all levels, to incorporate the patients' view of quality. To this end the GMC recently decided to increase its proportion of "lay" members to 25% and to appoint lay assessors to the teams that will assess doctors' performance under the new performance procedures. External peer review External peer review is an essential stimulus to effective performance and should become an integral part of self regulation. It applies equally to individuals, clinical teams, and institutions. Diversity with coordination Diversity characterises the British system of medical regulation. It means that each university medical school puts its stamp on basic medical education and each royal college determines standards of practice and education in its field. Each clinical team has its distinctive ethos. Diversity encourages new ideas, the development of different ways of achieving the same ends, and excellence in practice. Without effective coordination, however, it is difficult to see the whole picture, how one part of the system relates to another, and whether the system as a whole works well. The best results will surely be achieved by setting individuality, with its evident strengths, within a framework of agreed goals and well coordinated partnerships, both locally and nationally. Then each partner will maintain a sense of ownership and achievement while contributing to a common purpose. The leadership role of teachers Role modelling is a powerful force in medicine. Marinker used the term "the hidden curriculum" to describe the effect of the professional attitudes and behaviour of clinical teachers on students and doctors in training.21 The everyday behaviour of clinical teachers is the living demonstration of their expertise, ethics, and commitment: their professionalism. What they do and how they do it matters as much as what they say-as in, for example, communicating with patients, students and colleagues; recognising the limits of their own practice; using clinical audit to improve their practice; applying formative peer appraisal for their own professional development; handling personal criticism; tackling poor performance in themselves and others; and caring for colleagues in difficulty. The kind of leadership teachers give is critical to the quality of medical practice and education and to professional self regulation. The assessment of attitudes and interpersonal skills should therefore have a high priority in medical education. The safe doctor and practising safely The public now seeks assurances that doctors remain capable and safe throughout their practising lives. For the profession this means refocusing self regulation on fully established doctors. For the General Medical Council it means that all doctors on the register working in Britain must maintain an appropriate standard of practice. Where doctors do not, the GMC must ensure that action is taken, either locally or by itself.
Recertification and the alternative of professional culture The principle that doctors should be able to show that they practise safely is unarguable. Unfortunately, discussion of the means tends to be contentious because of the threat of "recertification," implying the regular testing of all career doctors. Yet there must be considerable doubt about whether, in our current state of knowledge, a formal national programme of periodic recertification would achieve the results that its advocates claim. There is no consensus on method, and the benefits would be small when measured against the cost of assessing large numbers of doctors already considered to be performing well. Given these uncertainties, a different approach may be more constructive. Such a strategy would rest on a strengthening of our culture of professionalism. It would be inclusive, involving all doctors and embracing continuing medical education, personal professional development, clinical audit and quality improvement methods. It would have six core components:
The system and good practice The starting point remains the duty of the individual doctor. However, today most doctors work in medical and multiprofessional clinical teams. Most general practitioners belong to medical partnerships and practice teams, and comparable arrangements exist in hospitals. The idea that doctors in teams should assume some collective responsibility for their standards of practice is now taking root. It makes sense to create a mutually supportive environment which helps to maintain the clinical effectiveness, integrity, and good name of the team as a whole, including its individual members. Everybody benefits. Doctors are most likely to maintain good practice when they work in teams which
Effective teams use
Teams working in this way are able to document and demonstrate the results of their work, including insights on their performance, so that the outside world can see that their members are functioning well. This kind of proactive, team based, self regulation needs proper resources. Handling dysfunctional doctors The GMC has said in Good Medical Practice that doctors have an ethical responsibility to act where they believe that a colleague's conduct, performance, or health is a threat to patients-if necessary by telling someone from the employing authority or from a regulating body. Doctors who ignore this responsibility place themselves at risk of action by the GMC. Some doctors seriously breach accepted standards of professional conduct and practice. Others become ill without recognising the consequences for their patients. Yet others show evidence of a pattern of poor practice, the causes of which include professional isolation, complacency, arrogance, idleness, and simply losing touch. Some are referred to the GMC by patients or are reported by the courts. But if local professional self regulation is working as intended, other dysfunctional doctors will have been identified by their colleagues and local action taken. Some will be beyond local care, necessitating referral to the GMC. Examples of serious clinical dysfunction in doctors:
The Medical (Professional Performance) Act 1995 gives the GMC new powers to investigate a doctor's performance and, where it finds the standard of performance to be seriously deficient, to impose conditions on or to suspend a doctor's registration.11 From September 1997 the GMC will therefore have at its disposal a range of procedures-conduct, performance, health-for dealing with seriously dysfunctional doctors. Protection of the public is the first priority, coupled with the rehabilitation of the doctor wherever possible. Under these performance procedures, a doctor's registration may be questioned by repeated or persistent failure to comply with the professional standards appropriate to the work being done by the doctor, particularly where this places patients or members of the public in jeopardy. This may include repeated or persistent failure to comply with the GMC's guidance in Good Medical Practice (GMC minutes, May 1996). Doctors whose performance is found to be seriously deficient, whether locally or after referral to the GMC, should have every reasonable chance of putting things right through remedial action. Doctors will be able to seek preliminary advice and help through their regional postgraduate dean or regional director of postgraduate general practice education. Looking ahead The public and the medical profession share a common interest in showing that doctors provide a good standard of practice and care, and that patients are protected from doctors who are not safe. The GMC's strategy offers a practical way forward. Good documentation at every stage, and openness with the results, will be essential to see what works and where the gaps are. The strategy can be developed and refined in the light of experience and on the basis of evidence. Success in implementing this strengthened professionalism should secure the public's trust and safeguard the independence of the profession. References Irvine D. The performance of doctors. i: professionalism and self regulation in a changing world. BMJ 1997;314:1540 (24 May) Irvine D. The performance of doctors. II: Maintaining good practice, protecting patients from poor performance. BMJ 1997;314:1613 (31 May)
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