This article appears in the February 2003 edition of the Catholic Medical Quarterly
What is Professionalism?
When I attended a meeting of the Southwark Branch of the Guild in May 2002, I was sufficiently unwise to question the speaker about his use of the term professionalism. Almost inevitably I was asked to give a short talk on this subject at a subsequent meeting. As the Master of the Branch is also editor of the Quarterly I am now constrained to respond to my question in print.
When I retired in 1994,1 could look back on nearly forty years in general practice. When I started in Hertfordshire in 1957, general practice was, as Dame Annis Gillie described it at that time, a Cottage Industry1. By the 1980s, it had developed enormously. There was well regulated vocational training, many doctors were practising from purpose built premises, with teams of nurses and health visitors. There was active research into different methods of delivering primary medical care and into the special knowledge and skills needed to pursue it. It was attracting some of the best graduates from our medical schools and respected through out the world. This had not occurred as a result of government intervention. In fact the famous "Family Doctors� Charter" of 1966 came about from pressure from the profession. In the book," General Practice under the National Health Service, 1948-1997"2. l attributed these changes to the professionalism of the doctors.
Professionalism is not a straightforward concept to define. As a number of commentators have noted, the word "profession" is, today, almost synonymous with occupation: the term professional is now applied to a wide range of such individuals as footballers and cricketers. In tackling this problem, I have turned to the work of a professor of moral philosophy, Robin Downie3 who has written extensively on this subject. Seeking to identify the essential nature of professions by examining what existing professions do, he has developed six characteristics of professionals summarised as follows:
- The professional has skills or expertise proceeding from a broad knowledge base.
- The professional provides a service based on a special relationship with those whom he or she serves. This relationship involves a special attitude of beneficence tempered with integrity. This includes fairness, honesty and a bond based on legal and ethical rights and duties authorised by the professional institution and legalised by public esteem.
- To the extent that the public recognises the authority of the professional, he or she has the social function of speaking out on broad matters of public policy and justice, going beyond duties to specific clients.
- In order to discharge these functions, professionals must be independent of the influence of the State or commerce.
- The professional should be educated rather than trained. This means having a wide cognitive perspective, seeing the place of his or her skills within that perspective and continuing to develop this knowledge and skills within a frame work of values.
- A professional should have legitimised authority. If a profession is to have credibility in the eyes of the general public, it must be widely recognised as independent, disciplined by its professional association, actively expanding its knowledge base and concerned with the education of its members. If it is widely recognised as satisfying these conditions, then it will possess moral as well as legal legitimacy, and its pronouncements will be listened to with respect.
There are other views about what characterises a professional. Although Professor Downie recognised that professionals should be �independent of the state or commerce�, Elliot Freidson4, an American commentator on professionalism in medicine, goes further. He identifies autonomy as the characteristic central to professionalism, in that a profession is given the right to control its own work by determining who can do the work and how the work should be done. From this characteristic flows self-regulation. In the context of the medical profession in the UK, this means the authority delegated by the state to the profession to determine standards of conduct, practice and training, and to regulate entry to the profession and continuing practice within it on the basis of these standards.
Despite the advances in the 1980s, it was recognised that standards in general and hospital practice varied widely, and that professionalism alone did not seem sufficient in all cases to maintain them. Margaret Thatcher was deeply suspicious of professionalism, not only in medicine but also in nursing, education and the law. She was convinced that only market competition and detailed accountability would improve the situation. As a result, a new contract was imposed on doctors directed by management and accountability, devised by a grocer�s daughter and advised by the chief executive of Sainsbury�s.
Many believe that this approach is particularly inappropriate to the provision of primary medical care. Many of the services provided by general practitioners are concerned with caring which can not be easily quantified. How for instance do you quantify the facility to listen to a distressed patient, the provision of continuing care in incurable disability and disease, or measure the outcome of terminal care which is inevitably death? In these situations, I believe that professionalism is essential for the maintenance of high quality care. In my Presidential address to the BMA in 1994, I expressed this view and said that I believed it was incumbent on the BMA and its members to restate their core values and recommit themselves to them.
The BMA responded and in 1994 held a conference to debate Core Values in Medicine. It was attended by the Presidents of all the Medical Royal Colleges and the Conference of Deans
In my "Position Paper" at the conference, I suggested that the starting point from which to consider core values in the professionalism of doctors should be medical practice itself.
James Spence, in 1960, published a book entitled "The purpose and practice of medicine"5. In this he wrote, "The essential unit of medical practice is the occasion when, in the intimacy of the consulting room or the sickroom, a person who is ill or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation: all else in medicine derives from it. The purpose of the consultation is not the diagnosis or technical treatment of disease, it is the explanation and advice, with the diagnosis acting as a means to these ends" 4. That description of the core activity of the medical profession is as true today as when it was written. The professional values required to preserve this may be summed up, I would suggest, in the words: confidence, confidentiality, competence, contract, community responsibility and commitment.
Confidence. The confidence of patients in their general practitioners, revealed by repeated surveys of patient satisfaction, derives from the continuity of care provided by doctors in the National Health
Service. It is built up over a period of time at a series of contacts for a variety of problems. The relationship which develops is described as the doctor/ patient relationship. It is dependent on the professional integrity of the doctor which allows the patient to share intimate details of their life and lifestyle with the doctor and to permit, if required, intimate physical examinations with total confidence in the doctor s propriety. Implicit in this is the moral rectitude of the doctor in respecting the autonomy of the patient. It promotes a unique relationship, quite different from any commercial transaction.
In referral for a specialist opinion, this confidence is transferred to the specialist who has been selected as the right person to provide for this patient�s needs at this time This aspect of professionalism assumes an important relationship between general practitioners and specialists unencumbered by commercial interests.
Confidentiality. The intimacy described by Spence explains the importance of confidentiality. This is not just to do with diagnosis but with the intimate nature of the consultation between patient and doctor. The development of team work in medicine raises issues of confidentiality between team members and the development of corporate confidentiality as part of the team s ethos. It may be threatened by accountability to management and by audit and evaluation of clinical care, and the development of electronically recorded and transmitted data. Information may at times be stored in the doctor s mind rather than on records when, for confidentiality, this is in the interest of the individual patient.
Competence. The consultation may be the core unit of medical practice, but it will not fulfil its function if the doctor is incompetent. Methods of continuing education, which may include audit, peer review and reaccreditation, may be necessary to ensure high quality care and maintain the respect and confidence of the general public. Adherence to protocols of care should not be regarded as reflecting competence when clinical judgement of the needs of individuals is at variance with such protocols. Clinical judgement is a core function of the medical professional and must be inculcated from the earliest years in medical education. It should be informed by research in both medical and behavioural sciences and be cognisant of moral and philosophical values.
Contract. Doctors, as professionals, have an unwritten contract with their patients to provide optimal care within the resources available. They also have contracts with Health Authorities and Trusts or such other bodies as may evolve over the next decades. Problems may occur if these Authorities demand services, the benefits of which have not been demonstrated by research or which are motivated by economic rather than clinical considerations. In such circumstances professionals have a responsibility to challenge such demands and, if necessary, refuse to cooperate in such activities.
Community Care. Doctors have a professional responsibility to the communities for whom they have contracted to provide care. They must ensure as far as possible an equitable distribution of resources, restraining where necessary abuses of demand for care, and avoiding overinvestment in certain areas of care simply to satisfy their own personal interests. Public health physicians have a unique role to play in identifying the needs of populations, determining a proper distribution of resources in meeting these needs and ensuring that the care provided is informed by properly conducted research. They must be free and unbiased in providing advice to the profession and management on the costs and benefits of services available. If they are to fulfil their role, they must be protected from situations in which they are asked to function as both judge and jury in determining the services to be provided.
Commitment. Those entering the medical profession are privileged to commit their working lives to the service of individuals disadvantaged by disability and disease. It is not a job which can be constrained by strict working hours or subject to demarcation disputes. It has been described as a vocation and is certainly a commitment to service and to the constant need to study and keep up to date. It is a commitment which has an inevitable impact on family life, friends and social activities. Individuals who are not prepared to make this commitment should be deterred at a very early stage from entering this profession. The commitment of so many members of the profession in the past, is perhaps the strongest argument for the preservation of professionalism in medicine.
These core values were accepted by the BMA conference. They were reported on television and radio. The proceedings of the conference were distributed to all members of the BMA.
But it seemed that it was now too late for the profession to put its own house in order. The new Labour government, of which there had been great hopes, continued the policy of centralised bureaucratic control of the Health Service. In so doing it used inappropriate and sometimes fraudulent statistics to set targets for medical care and league tables for performance. The professionals have voted with their feet. Recruitment and retention of nurses and general practitioners is in crisis.
Can professionalism as I have defined it, and the core values of the profession which I have described, survive in a secular culture characterised by commercialism, confrontation and self interest? In this culture, will medicine continue to be seen as a vocation meriting the term, profession, in which doctors accept that their commitments will sometimes interfere with their social and family life and will demand sacrifices? Alternatively, is medicine simply a job controlled by management, targets, audit, clinical guidelines and accountability?
- Central Health Services Council, Standing Medical Advisory Committee. The Field of Work of the Family Doctor. (The Gillie Report;) London; HMSO, (1963).
- Loudon, I. Horder, J. Webster, C. General Practice under the National Health Service 1948-1997. Clarendon Press, Oxford. (1998).
- Downie, R.S. Professions and Professionalism. Journal of Philosophy of Education. 24.2. (1990)
- Freidson, E. A Study of the Sociology of Applied Knowledge. (1988). Dodd, Mead and Company.
- Spence, J. The Purpose and Practice of Medicine. p276, Oxford University Press, Oxford. (1960).
Professor D.C. Morrell OBE is Emeritus Professor of General Practice in The University of London.