Medical professionalism: a key to a better health system and more satisfied doctors

richard_smith_2014I wonder how many medical students and doctors could confidently define “medical professionalism.” Few, I suspect. Indeed, I don’t think that I could have done until I spent two months earlier this year editing the Royal College of Physician’s latest report on professionalism. But I’m now convinced that working to improve medical professionalism can both keep the NHS sustainable and help doctors feel better in their work.

There have been many reports on professionalism, including one in 2005 by the College itself. New reports are needed because of the changing context (the rise in multimorbidity, personalised medicine, increasing use of information technology and artificial intelligence, the evolving role of women in society and medicine, and the severe stress on the health system) and because ideas of professionalism evolve. There was also a need to reconsider professionalism in the light of the strike by junior doctors and the case of Hadiza Bawa-Garba, a paediatric registrar who made a serious mistake but whom many doctors thought was scapegoated, not least by the General Medical Council, for systemic failures in the NHS. Some doctors thought it unprofessional for doctors to strike, while others thought it a professional duty to take action when the safety of patients was threatened by failures in the NHS.

Advancing professionalism is, the report argues, important for sustaining the NHS and for the improving how doctors feel about working in the NHS. Research quoted in the report, most of it from the United States, shows that promoting professionalism benefits patients, increases the job satisfaction of doctors, makes for superior organisations, and improves the productivity of health systems. Increasing productivity is essential for sustaining the NHS, and promoting professionalism is, the report argues, better than wellbeing programmes for increasing the job satisfaction of doctors because it involves patients, teams, and the whole system not just doctors themselves.

The old idea of professionalism based on “mastery, autonomy, privilege, and self-regulation” is, the 2005 College report made clear, obsolete, but many doctors who responded to a survey undertaken to provide input to the report seemed to hanker after the old idea. The report defined medical professionalism as “A set of values, behaviours, and relationships that underpins the trust the public has in doctors.” It identified six themes—leadership, teams, education, appraisal, careers and research, which unsurprisingly overlap with the characteristics identified in the new report: doctor as healer, patient partner, team worker, manager and leader, teacher and learner, advocate, and innovator.

The new report tries to be practical, being specific about what is needed by doctors to be successful in each of the seven roles and providing exercises that doctors can do to advance their competence in each role. Medical schools tend to concentrate on the knowledge and skills that are necessary but not sufficient for being healer, and it is a lifetime’s work to increase competence in each of the seven roles. No doctor is likely to be supreme in all of the roles, but the report is clear that to be a master diagnostician or highly skilled operator will not on their own be enough to be a first class doctor in the 21st century.

Doctors to be healers must be up to date with their knowledge and possess technical skills, but standard medical treatments will often not be enough to relieve the suffering of patients. Doctors also need to be compassionate, active listeners, share authority with patients, and be committed and trustworthy. “Little things,” like how patients are greeted, seem to be important for healing, and doctors must be willing—particularly with patients are the end of life—to have “difficult conversations” rather than simply prescribe new treatments. Caring for yourself is also an important part of being an effective healer.

One of the biggest changes in how medicine is practised in the past 30 years is the move from patients being supplicants who are expected to follow the doctor’s advice to being active partners. Many doctors have not found this an easy transition to make, but in an age when most patients have multiple, long term conditions it is patients rather than doctors who have more power than their doctors to achieve their highest potential. The report identifies integrity, respect, and compassion as the values that underpin doctors succeeding as partners with patients.

Most of healthcare is now delivered by teams, and effective team working is essential for high quality health care. Doctors find themselves as members of many different teams. The importance of team working has long been recognised yet continues, the report argues, to be deficient. The report recognises that learning is essential for effective team working. Such learning should be built into the training of doctors and other health workers, often training together, but teams must also have the opportunity to learn as a team. Teams may learn most by reflecting on events, particularly events that have not gone well.

The College report of 2005 placed great emphasis on leadership, and all doctors are leaders, whether they recognise it or not. Some have formal leadership positions, but most lead by the way they practise and act every day. They lead colleagues, particularly junior ones and medical students, but also patients and other members of the health team. The evidence of the power of clinical leadership grows steadily, but leadership also implies followership, and professionalism requires that doctors develop their skills as both leaders and followers; both roles do, however, present challenges to doctors, who were once heroic individuals and still tend to see themselves that way.

If doctors have problems thinking of themselves as leaders they have even more trouble thinking of themselves as managers. Management is a dirty word to many doctors, but the reality is that doctors work in increasingly complex systems that often ask more of managers, doctors included, than profit making companies, which have simpler objectives. Doctors also make most of the decisions that determine the flow of resources within health systems, and, even though it might feel uncomfortable, medical professionals must pay attention to resources.

A more comfortable role for doctors is that of teacher and learner. Every doctor recognises how rapidly medical knowledge changes, and the arrival of personalised medicine and the necessity of using new technology mean that doctors must learn every day. They must also learn new ways of behaving: treating patients as equals, working in teams, and learning to manage resources. And just as doctors are leaders they are also teachers, teaching juniors, colleagues, other health workers, and patients. Teaching requires different skills from traditional doctoring, and here is more for doctors to learn.

Professionalism, says the report, requires that doctors advocate on behalf of their own patients, patients in general, and future patients. The report places great emphasis on doctors advocating for patient safety, and as somebody with a long interest in patient safety I have to observe that doctors were slow to recognise the ubiquity of medical error and the need to make safety a priority. Doctors should also be advocating on the social determinants of heath, particularly poverty and inequality; and doctors, with their scientific training, should be heard speaking up on climate change, the globe’s major threat to health.

The final characteristic the report identifies is doctor as innovator. Improving public health and the care of patients and keeping the NHS sustainable all require innovation, not just in technology but in behaviours and systems. Doctors should be both driving innovation and learning to work with innovations devised by others. The report discusses as an example the way that doctors learn to work with artificial intelligence and machine learning. It’s likely that machines will do many things that doctors do better than doctors, and doctors will need to adapt, learning to do what they can do best but allowing patients to benefit from the capabilities of machines.

What now? Will this, a cynical doctor might think, be just another report or can it make a difference? The College commits itself to developing professionalism and it is also asking the Academy of Medical Royal Colleges to “develop and implement a plan for improving professionalism.” The plan and implementation should include not just doctors but also other health workers, including managers, and those who lead the NHS. We should look to see what the Academy does and whether the forthcoming plan for the NHS has proposals for promoting professionalism.

But the report with its practical orientation should be useful to all doctors and medical students. People, including my medical student daughter, might read all that is required to be a medical professional and feel intimidated, but I hope that they will see it as an exciting challenge, a lifelong task with rich returns.

See also: Preserving professionalism in the current healthcare environment

Richard Smith was the editor of The BMJ until 2004.

Competing interest: RS spent most of two months editing the report. He was not paid, but he has been promised a case of good wine, which has yet to materialise.