BMA Health Policy and Economic Research Unit

The Role of the Doctor

Building on the past, looking to the future
October 2008

BMA Health Policy and Economic Research Unit, British Medical Association, BMA House, Tavistock Square, London, WC1H 9JP www.bma.org.uk British Medical Association, 2008

BMA Health Policy and Economic Research Unit

Contents

Setting the scene Introduction Chapter 1 An ancient profession in an ever-changing world Chapter 2 Ancient values distilled over time Chapter 3 The role of the doctor Chapter 4 Safeguarding and promoting the role of doctors Conclusion Looking to the future References

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The Role of the Doctor Building on the past, looking to the future

BMA Health Policy and Economic Research Unit

BMA Health Policy and Economic Research Unit

The Role of the Doctor Building on the past, looking to the future
The times have changed, conditions of practice altered and are altering rapidly, but the ideals which inspired our earlier physicians are ours today ideals which are ever old, yet always fresh and new. William Osler, 1903
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Setting the scene

At the outset of the 20th century, William Osler, an icon of modern medicine, identified the two forces which together shape the role of the doctor medicines constant evolution and the medical professions commitment to a set of long-lasting ideals. The evolution of medicine requires that doctors are able to adapt and respond, changing their practice in the face of new knowledge toward the betterment of patient care. However, this responsiveness is underpinned by the medical professions commitment to a set of enduring values that enable doctors to competently and compassionately meet the challenges presented to them across the many and varied elements that comprise their role. It is the doctors capacity to manage this symbiosis between the twin forces of change and constancy that best defines their role and ultimately determines the nature of their relationship with patients, fellow professionals and their contribution to the continued advance and application of medicine. An appreciation of these forces and their centrality to the practice of medicine has persisted over time and with it a drive to re-examine, continuously, the role of the doctor in the contemporary context. Donaldson, above, reflects the mood exhibited at the close of the 20th century. An added emphasis on partnership, in particular with patients, and the need for health professionals better to engage with responsibilities concerning the wider organisation of health care, increasingly characterised the modern approach to developing the role of the doctor. Yet, in advocating this new kind of health professional in order to meet changing demands and remain in step with the march of medical progress, there remained an understanding that the values and ideals at the core of a doctors practice would continue to provide the firmest of foundations for the delivery of care. Today, at the outset of the 21st century, the need to appraise the role of the doctor has not diminished and, following the publication of the independent inquiry into Modernising Medical 4 Careers, the continued relevance of this endeavour has been well highlighted. The inquirys findings included a useful summation of the key elements of a doctors role yet, more importantly, the inquiry went further in recommending that a common shared understanding of the role of doctors be developed urgently. In the face of constant change, from medical technology, rising patient expectations and as a result of pressures wrought upon the UK health service by NHS reforms, the inquiry noted a growing lack of clarity in respect of the role of the doctor in the contemporary healthcare team. This lack of clarity, it is suggested, threatens to erode doctors valuable contribution, compromise the future of medical training and undermine the quality of patient care. This paper explores the enduring values that underpin, and the skills that distinguish medical practice and, in so doing, illustrates what it is that might be considered uniquely to define the role of the doctor and the distinctive contribution doctors make to the delivery of care and the advance of medicine.

Health care in the 21st century will require a new kind of health professional: someone who is equipped to transcend the traditional doctor-patient relationship to reach a new level of partnership with patients; someone who can lead, manage and work effectively in a team and organisational environment; someone who can practise safe high quality care but also constantly see and create the opportunities for improvement. Liam Donaldson, 1991
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The doctors role as diagnostician and the handler of clinical uncertainty and ambiguity requires a profound educational base in science and evidence-based practice as well as research awareness. The doctors frequent role as head of the healthcare team and commander of considerable clinical resource requires that greater attention is paid to management and leadership skills regardless of specialism. An acknowledgement of the leadership role of medicine is increasingly evident. John Tooke, 2008
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The Role of the Doctor Building on the past, looking to the future

The Role of the Doctor Building on the past, looking to the future

BMA Health Policy and Economic Research Unit

BMA Health Policy and Economic Research Unit

Introduction
The Modernising Medical Careers inquirys recommendation to develop a common shared understanding of the role of doctors formed part of what was a welcome response to the considerable shortcomings of the MMC project evidenced during the course of 2007. However, this simple call for greater clarity around the contribution of doctors in the context of the modern healthcare team disguises a very much more complex set of pressures currently in operation across the health care sector. These pressures, and likewise a number of key trends, necessarily impact upon the medical professions engagement with, and contribution to, medicine in the UK both currently and in the future. Together these provide a convincing imperative to explore the role of the doctor as a concept. This report draws upon previous work by the BMA in this area, and more recent thinking carried 5 out across the Association on the role of particular cadres of doctors. In the first section of this report, the nature of these pressures will be addressed and, in concluding, how these require us to reflect on the two forces, change and constancy, which together shape the role of the doctor. The following sections will explore the enduring values that provide an ever-steady platform upon which the medical profession can reliably respond to the challenges it faces. The importance of these values is reflected in the findings of recent research carried out by the BMA that allows us to shift the debate from one of abstract understanding and instead demonstrate the values relevance to current doctors and the public. Further exploration of these values will seek to illustrate how their combination underlies both an individual doctors practice as well as the distinctive contribution that doctors make to health care more generally. Consequently, in looking at the unique aspects of a doctors role, the discussion will be framed by an examination of not simply what is it that doctors do? but, rather, what is it that doctors do that others dont? By gaining an appreciation of these particular exceptional skills and competencies, and the values that underpin them, the fundamental nature of the doctors role will be clearly illuminated. In the final section, the current challenges facing the medical profession will be revisited and consideration given to the consequences of allowing change to unwittingly, or otherwise, erode the values that are at the core of what a doctor is and does. In confronting this possibility, the paper will offer its own challenge to those charged with the responsibility for safeguarding and harnessing these values to the benefit of patients, the NHS and the profession itself in the context of a complex and changing health care environment.

Chapter 1 An ancient profession in an ever-changing world

The role of the doctor is intimately linked to social attitudes and norms. The professional status of doctors carries with it a recognition that doctors have a contract with society. As such a doctors role is closely allied to a sense of civic duty and a responsibility to shape their practice in response to societal expectations as well as the advance of science. Most recently, this evolving relationship with society has been driven by a number of particular social trends which in combination have determined a significant shift in expectations, behaviour and practice amongst sizeable sections of the population.

The growth of consumerism

The twentieth century saw the growth of consumerism. Emerging as part of a historical process that created mass markets, industrialization, and new attitudes toward demand and consumption, the consumerist ethos has permeated a great many social transactions. As the public has become better educated, more informed, and increasingly time constrained it has grown to be more demanding and more expectant in terms of levels of service and quality. Health, or more specifically healthcare, has not been immune from this with consumerist principles influencing the way in which patients approach their health care and their expectations of the health service. In recognition of, and in attempting to address, these new demands a significant focus of recent NHS reform has been the enabling of patient choice. Whilst questions remain as to the success of this element of reform, developing the potential for patients to exercise choice and assume a more proactive role in the way their care is managed continues to be widely encouraged.

The death of deference

The rise of patient-as-consumer has naturally impacted upon the doctor-patient relationship and the changing nature of this interaction has been compounded further by a society moving into a less deferential age. Shifting societal attitudes have resulted in a public less prepared to defer to expert opinion and to established sources of advice. Patients reflect this changing norm and in so doing have acquired greater empowerment and autonomy in their experience of seeking health care. Necessarily, this has meant that the paternalism regarded, for better of for worse, as characterising medicine has been challenged and eroded. As a result, alongside the aim of patient choice, the doctor-patient relationship is expected increasingly to move toward a two-way interaction with a growing emphasis on a partnership approach to deliver a negotiated outcome in respect of decisions concerning a patients care.

The information age

The production of, and access to, information has been both driven by and has accelerated the trend of consumerism and changing attitudes around deference. The information technology revolution of the last few decades, in particular the internet, offers the public the opportunity to access and share information previously the preserve of the expert. In health care, the monopoly of information that the medical profession previously experienced no longer pertains. This routinely means that patients (and their carers) independently review and use information from a variety of sources in order to assess and monitor health, with a view to empowering them in making decisions regarding their care.

The nature of illness

The advance of medicine combined with better hygiene, greater relative affluence and the birth of the NHS have had a remarkable effect on health in modern Britain. Infant mortality has been significantly reduced, vaccination programmes have virtually eliminated the risk from many infectious illnesses and people are living much longer today on average 10 years more than life expectancy in the middle of the twentieth century. However, these improvements have been accompanied by an important change in the nature the illness. The UK, along with most other industrialised nations, faces a growing burden of

The Role of the Doctor Building on the past, looking to the future

The Role of the Doctor Building on the past, looking to the future

BMA Health Policy and Economic Research Unit

BMA Health Policy and Economic Research Unit

chronic disease resulting from changing diet, lifestyle choices and the very fact that people are living longer. Obesity, diabetes, cardiovascular disease, chronic obstructive pulmonary disease and depression are endemic, whist arthritis, Parkinsons disease and dementia are becoming ever more common in our aging population. This requires the focus of health care to change from one dominated by acute care, to one centred on preventive and therapeutic care with the management of chronic and long-term conditions at the fore. Closely allied to this growing emphasis on wellness not simply illness is the need to reinvigorate the public health agenda in order to address the changing nature of illness and the inequalities which in many instances underlie these trends.

Chapter 2 Ancient virtues distilled over time

Doctors are trained to deal with clinical episodes that will typically involve a high degree of complexity, uncertainty, a strong need for flexibility, and the application of scientific, evidence based judgement. Moreover, this judgement must be exercised in the context of changing circumstances and with a patient-oriented approach that is sensitive to wider considerations concerning the allocation of resources. Accordingly, the demands of medical training are exceptional and medical school education provides the first step toward equipping doctors with the unique and diverse range of knowledge, skills and attitudes, that are required to meet the expectations made of them. However, medical education also instils in doctors the high standard of ethics that must always guide them in fulfilling their roles. This ethical foundation that serves doctors so well can be traced back to the Hippocratic Oath and is formalised today in the code of practice established by the General Medical Council which sets out the principles and values on which medical practice should be based. The code of practice states that doctors must, Make the care of your patient your first concern; protect and promote the health of patients and the public; provide a good standard of practice and care; treat patients as individuals and respect their dignity; be honest and open and act with integrity; never abuse your patients 6 trust in you or the publics trust in the profession. Understandably, it is the patients tacit understanding that their interests must always be a doctors overriding concern and the publics knowledge that doctors must adhere to this strong ethical foundation that underpins their trust of doctors. This high standard of ethics is therefore central to both the profession generally and to the daily practice of doctors in their various roles. This being the case, what are the other key values that medical training confers and develops? This question has been the subject of much recent debate. In particular, the issue of medical professionalism has been thoroughly examined, most recently by the Royal College of Physicians in its 7 report, Doctors in society: medical professionalism in a changing world. In exploring the values that underpin the medical profession the report suggests that, Professionalism acts as the continuity and counterweight to changes reinforcing the view, expressed here, that it is the existence of a set of core values and principles informing the conduct of doctors, that enables the profession to deliver a high quality of care and respond so flexibly to altering circumstances. The BMA has explored this issue before. In particular, the BMA led debate in the 1990s on the challenges posed by advances in medical practice and a changing health service to those values that doctors have held consistently over the millennia. In its resulting report, Core values for the medical 8 profession in the 21st century, the BMA reflected on the emerging consensus around the nature of these values and stressed that the medical professions ancient virtues distilled over time remained doctors greatest asset. Moreover, there was strong agreement these ancient virtues would continue to be relevant to the practice of 21st century medicine and would allow doctors to shape health care in the future. Consequently, the report determined a set of nine qualities which were said to characterise the value-set of doctors. These were: commitment caring compassion integrity competence spirit of enquiry confidentiality responsibility advocacy.

The NHS and NHS reform

In the UK the role of the doctor is, of course, inextricably linked to the NHS. Being a social institution the NHS has been required to respond accordingly to the forces for change described above. Yet, whilst evolving in the face of such changing expectations and circumstance, the NHS is itself also a great force for change and no more so than in respect of its relationship with doctors. Over the past few decades in particular, and most acutely since the turn of the century, government-led NHS reforms have introduced new practices and measures in to the NHS that both directly and indirectly impact upon the roles and responsibilities of doctors. A range of centrally imposed targets concerning access and quality, an everincreasing focus on productivity and corporate goals, new financial flows and payment systems, expanding policy on having care delivered in more diversified settings, workforce initiatives involving new ways of working, skill mix and role substitution, and, more recently, a renewed focus on clinical leadership are but a few of the developments that have required doctors to reassess their roles in the context of a changing NHS.

A changing profession
Whilst recent social trends, policy initiatives and organisational change have all played a part in shaping doctors roles, these may be regarded as external forces; equally significant in determining the nature of doctors roles have been a range of drivers internal to the medical profession. Some of these are closely allied to the changing social norms already discussed. The increasing mobility of women within the wider labour market has been reflected in the medical profession and continues to be evidenced such that 60% of medical students today are female. If current trends continue by 2015 there will be more women than men practising medicine. Alongside this, expectations within the medical profession are evolving with doctors seeking a more conventional work-life balance than traditionally has been the case. Some would argue that medicine has become less of a vocation and more of a job, though even if this is true, there would be further arguments about what was cause and what effect. As doctors themselves experience the pressures arising from such change they have begun to discuss what this means for their professional status. In respect of the death of deference and the development of new and extended roles for other health professionals many doctors suggest there is a growing sense of deprofessionalisation. Yet, in the face of these challenges, doctors have continued to be responsible for, and responsive to, major advances in medicine. The rapid pace of scientific discovery and technological innovation over the last few decades has been unprecedented. Medical practice remains dynamic and constantly evolving and is an expression of the key synergy between the application of new technologies and the values that provide the foundations for the role of the doctor. The vast scope for adaptation and improving clinical delivery is what has led to the increasing emphasis on clinical leadership with a view to ensuring that innovation is translated into better care and better health. Given these forces for change and their ongoing impact on the role of the doctor, we might consider that there is a real risk of eroding the medical professions identity but what is it that lies at the heart of a doctors practice?

The Role of the Doctor Building on the past, looking to the future

The Role of the Doctor Building on the past, looking to the future

BMA Health Policy and Economic Research Unit

BMA Health Policy and Economic Research Unit

The outcome of this work has subsequently been used to frame further attempts by the BMA to refine the concept of professionalism and what it means to be a modern doctor. Arguably, much of the recent debate around medical professionalism has been based on the views of key stakeholders, organisations and influential individuals. An obvious omission from this endeavour is empirical evidence of grassroots doctors views on professional values and, perhaps to a lesser extent, the view of the public. In an attempt to correct this and progress understanding around the role of the doctor the BMA has 9 used its cohort studies of 1995 and 2006 medical graduates to examine the views and perceptions of junior doctors regarding professional values. This has provided an opportunity to explore the legitimacy of the above value-set in defining the foundation upon which medicine is practised. In addition, the BMA has more recently surveyed the public to capture its views on the importance of these core values and how these qualities relate to the role of the doctor today. With regard to doctors, in both studies (1995 and 2006 UK graduates) participants were asked to rank the core values described above in order of importance. The findings clearly demonstrated that competence (to practise medicine) was regarded as the most important for both cohorts of doctors. Perhaps understandably given the growing emphasis on competency based training the perceived importance of this core value has increased: 49 per cent of the 2006 cohort rated competence as the most important core value at graduation from medical school, compared with 39 per cent of the 1995 cohort at graduation. Indeed, the centrality of technical competence in medical professionalism has international credence with a recent review of professional codes and standards of doctors across the 10 UK, USA and Canada emphasising this point. Perhaps more interestingly, the values rated most highly after competence showed greater variance between cohorts and over time. Caring, compassion and commitment were the core values rated as next most important by the 2006 cohort of doctors. This is in contrast with the results of the 1995 cohort study, whereby doctors were more likely to rate caring, responsibility and integrity as most important. Furthermore, nine years after graduation, 1995 cohort doctors ranked integrity as the second most important core value, followed by caring and compassion. This variance suggests that doctors relationship to the value-set can and will evolve over time yet their recognition of the values in combination as central to their practice and roles remains constant. The findings from our work with the public suggest that these qualities have a wider resonance also with the majority of the respondents rating them as very important to the role of a doctor. The top four rated qualities were competence (97%), followed by integrity and spirit of enquiry (each with 77%) and confidentiality with (76%). In addition, the public, as with the doctors in our cohort study, were asked to prioritise the qualities and the results revealed striking similarities. Competence was again considered to be the top priority required in a doctor with 71% of the respondents rating this as number one. Moreover, this figure rose to 87% when scores for the second and third quality priorities were included. Excluding competence, the next three highest qualities prioritised by respondents were integrity, spirit of enquiry and caring and commitment (which were rated as equally important). This brief examination of an evident consensus amongst the profession, and between doctors and the public, in respect of the ancient virtues perceived as central to a doctors role is helpful in shaping an approach to medical professionalism and in developing an understanding of the values that underpin medical practice. Nevertheless, these values do not in themselves define the role of a doctor. Rather, they provide a foundation upon which doctors can develop the skills and expertise necessary to enable them to deliver the wide and varied elements that comprise their roles and to make their unique contribution. It is therefore to the question, What is it that doctors do? that we now turn.
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Chapter 3 The role of the doctor

In exploring the range of activities that doctors perform and the many duties which doctors fulfil there are two further considerations which must be borne in mind. First, doctors support, and are supported by, teams. The health professionals with whom doctors work so closely share many of the same values and are expected to exercise a variety of clinical skills alongside doctors in delivering care to patients. The traditional monopoly that doctors once had in many areas of clinical practice therefore no longer pertains with the contribution made by other heath professionals in caring for patients, investigating, prescribing and treating ever expanding. The new ways of working, skill mix initiatives and increasingly multidisciplinary approach which enable this bring welcome benefits: skills and expertise are complemented and team-working delivers seamless, integrated care (though this blurring of boundaries presents challenges too which will be raised later). Secondly, when attempting to define the role of the doctor one must quickly recognise that each doctor will shape their own roles according to the requirements made of them, their particular strengths and the interests they wish to pursue. In respect of competencies these must be equal to the doctors responsibilities and will vary dependent on the doctors role(s) e.g. trainee, general practitioner, intensivist, surgeon, academic, teacher and so on. Moreover, continuous learning through practice and the desire to maintain and improve the quality of the patient experience will inevitably lead doctors to define themselves in these roles as clinical leaders, mentors, trainers, researchers and managers. Therefore, in defining the role of the doctor, one size does not fit all. However, this diversity is crucial to delivering the range of necessary patient care, to training the doctors of the future, to advancing medicine and to furthering development and innovation. Consequently, to define usefully what it is that doctors do it is imperative to distinguish those roles in which doctors can be thought of as offering something over and above that of other health professionals and to recognise that it is the manner in which doctors combine these different characteristics in their practice that makes their contribution unique. A number of these roles and characteristics will, like the values explored earlier, be core to all doctors practice, transcending specialty divides. Others will reflect roles where choice has been exercised to develop particular expertise and push boundaries of practice and knowledge.

Medical education and training/scientific evidence-base of medicine

The exceptional demands of medical school education and medical training have already been allluded to. The rigorous programmes are defined by the scientific basis of medicine and the subtleties of clinical practice. The breadth, depth and complexity of required knowledge in respect of the clinical and basic sciences, as well as elements of the behavioural and social sciences, establish doctors as experts in their understanding and application. Doctors capacity to interrogate, marshal and employ the scientific evidence base places them in a privileged position amongst fellow health professionals, distinguishing them as sources of authoritative insight.

Diagnosis and prognosis

It is the application of a doctors expertise which provides for what is commonly recognised as the hallmark of medical practice: diagnosis. Responsibility for this key act responding to the initial presentation of illness, prioritising and synthesising information and making a clinical assessment largely differentiates doctors from other health professionals. Making a diagnosis, differential or otherwise, through a process of history taking, physical examination, and appropriate investigations is central to a doctors role and is the cornerstone to ensuring a patient receives effective care.

The Role of the Doctor Building on the past, looking to the future

The Role of the Doctor Building on the past, looking to the future

BMA Health Policy and Economic Research Unit

BMA Health Policy and Economic Research Unit

Moreover, the capacity of doctors to make a diagnosis is called upon in a diverse range of settings a patients home, a GPs practice, an outpatient clinic, an emergency department, a laboratory, a psychiatrists office with each context requiring doctors to employ their expertise accordingly. This act inevitably informs the course of a patients treatment, frames the prognosis and determines how their health is managed. It is the patients faith in a doctors ability to make a diagnosis, and through careful, compassionate communication to explain its implications and set out a plan of action in response, that rests at the core of the doctor-patient relationship.

Of particular importance is the role of those doctors undertaking academic medicine who work to combine service delivery with research, teaching and/or administration. Clinical academics are uniquely placed to use their expertise to make interconnections between clinical research and clinical practice, and pose new research questions, arising from clinical observations and experience. Improvements in the quality of healthcare that stem these roles bring about not only innovation in the delivery of care but also long term efficiencies for healthcare systems.

Training the next, and current, generation of doctors Dealing with uncertainty and managing complexity
Closely allied to this capacity to make a diagnosis and determine an effective intervention is doctors ability to operate in circumstances characterised more often than not by uncertainty. In their everyday roles doctors must manage complexity and risk. The assimilation of scientific knowledge, the manipulation of data, the understanding of co-morbidities, the recognition of changing circumstances, each require doctors to exercise good judgement in situations beyond the scope of protocols and guidelines. It is doctors willingness and ability to assume this responsibility, and the expectations made of them in this regard, that underline their real and unique value in contributing to, and leading, patient care. Doctors distinctive relationship with scientific knowledge and clinical experience, and to develop each other as fellow professionals, is further evidenced in respect of the commitment to medical 12 training and education which informs their careers. The GMCs, The Doctor as Teacher , states that all doctors have a professional obligation to contribute to the education and training of others, and that every doctor should be prepared to oversee the work of less experienced colleagues. We again see that whilst all doctors are expected to recognise this imperative, it is the case that certain of their number will focus in particular on acquiring the knowledge, skills and behaviors needed to ensure the effective teaching and training of medical students and doctors. These medical educators and clinical teachers develop, deliver and manage teaching programs and engage in scholarship and research into all aspects of teaching, learning, and assessment in 13 medicine. Medical students, junior doctors and those more senior doctors undertaking CPD all benefit from this shared understanding of the fundamental importance of education to their professional endeavor and their role as doctors. These unique relationships between experienced consultant and the less experienced colleague, between the specialty doctor and the junior doctor, or the GP trainer and the GP registrar, serve to extend the capabilities of the profession and further improve the standard of patient care.

Spirit of inquiry
From the outset as medical students to the final days of practice as experienced and expert practitioners, doctors recognise the value of continuing professional development. Doctors commitment to this endeavour ensures that developing their abilities is a constant, ongoing process and an essential part of their role and professional identity. Doctors have a responsibility for the integrity of their knowledge base, for its proper application, for its expansion and for its transmission to future practitioners and the public and consequently they place a high value on peer review and appraisal. A doctors practice is therefore intimately linked to the evidence base, guided by experience and compassion; or, where the evidence is not to hand, doctors are responsible for searching it out, evaluating it for scientific validity and assessing its practical application in the development of new treatments and the evolution of medicine. These three imperatives evaluating, discovering and extending are what require a doctor to be educated to a higher and broader level, and for a longer period, than most other healthcare workers. This characteristic reflects the spirit of inquiry which was identified by doctors and the public alike in our surveys as a key element of a doctors role. While not every doctor operates a scientific inquiry as a formalised research programme, all doctors must at all times work in accordance with this spirit of enquiry. As a result it can also be found as the driving force behind a number of other important facets of a doctors role.

Role models and mentorship

Similarly, doctors value the apprenticeship tradition of medical learning wherein senior and/or more experienced colleagues look to pass on knowledge and skills that reflect wider aspects of a doctors responsibilities with training in teaching, clinical leadership and management, rather than just clinical expertise. Established general practitioners, consultants and other experienced doctors see it as a professional duty and central to their professional roles to mentor their newly appointed and less experienced colleagues, and to be available informally as sources of advice, tutorship and support. These relationships - based on mutual respect and confidentiality promote confidence and trust within the profession and are a vital element of the roles of both the mentor and mentee.

Leadership, management and service innovation

The qualities described above ideally position doctors to assume leadership roles. Leadership is central to many of the roles already discussed concerning education and training, research and innovation, and mentorship. However, doctors are uniquely placed to take on further responsibilities and play a vital part in the management and leadership of health services. In this way doctors can make a valuable contribution in respect of the running of practices or departments, in managerial decisions, in improving and developing new local services, in the wider management and leadership of the organisations they work in, and the NHS generally. Doctors concern with clinical standards, outcomes, effectiveness and audit mean they can be relied upon to lead the drive to improve quality and are central to its assurance.

Research and academic medicine

This spirit of inquiry leads doctors to question and critically appraise established knowledge. Without this questioning approach, healthcare delivery would stagnate. The products of this method are new ideas, best evidence and advanced technologies which bring about improved patient care and reductions in the cost of healthcare. Medical research, including clinical trials, experimental medicine, translational research, epidemiological studies and public health, as well as basic scientific laboratory research aimed at understanding the underlying mechanisms of disease, depends on the dedication of doctors to this spirit of inquiry.

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The Role of the Doctor Building on the past, looking to the future

The Role of the Doctor Building on the past, looking to the future

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BMA Health Policy and Economic Research Unit

BMA Health Policy and Economic Research Unit

Such leadership is evident across the spectrum of practice: GPs lead improvements in the delivery of primary care, increasing access and shaping local services; public health doctors lead programmes focused on the health of communities; junior doctors and their senior colleagues lead developments in training both locally and at a national level through involvement in the Royal Colleges, deaneries, PMETB and other relevant bodies; and consultants, in their everyday posts, as well as in a range of more specific roles, including medical managers and medical directors, take the lead in developing policies and making management decisions within their own departments and hospitals, promoting innovation and excellence. In many of these cases it is by virtue of their longevity in post and their subsequent deep understanding of the needs of the local community, their hospital and their patients, that these doctors offer the necessary knowledge and continuity required to improve services and the care of patients.

complexities and supporting decision-making about health choices. Importantly, though we have explored the death of deference and the empowering effect of the information age above, it is apparent that most patients still rely on doctors to offer confident and competent reassurance and guidance based on mutual trust and understanding built up over time. However, this trusting relationship and the position of patients advocate must be balanced with a further role wherein doctors must exercise their judgement in order to manage resources effectively. This is particularly true for the vast majority of doctors in the UK who inevitably find themselves practising in the NHS where skills, time, facilities, and finance are all finite. As such the doctor is trusted to balance the needs and interests of one patient with those of current and future patients. Doctors face this complex dilemma daily and employ their knowledge and skills compassionately to address these questions of delivering the best possible care whilst ever mindful of resource allocation issues at a higher level. The necessary management of these pressures highlights the role that doctors have in serving both the patient and the public and further underlines the nature of the social contract doctors have with society. The individual doctor is trusted to serve the individual patient, but doctors also have a duty to whole families, and whole communities, treating illness and promoting health. It is commitment to this cause which defines their professional role.

Facilitating a multidisciplinary approach: taking ultimate responsibility

Whilst leadership, in its many guises, informs many of the varied roles doctors fill, it is accompanied by another key attribute the ability to apply skills and expertise in the context of an increasingly multidisciplinary, team-based approach to health care. New roles for nurses and other health professionals, the application of protocol based care, and a growing complexity in respect of technology and the management of care, means teamwork has become essential to patient safety and patient care. This has been compounded by changes to doctors working hours and a belief implicit in a range of NHS reforms that greater efficiencies might be secured through role substitution. Doctors recognise the limits of their own scope of practice and therefore appreciate the benefits of working and learning in teams. As doctors roles have developed accordingly there has necessarily been reflection on what this means in terms of the devolution of responsibility. Traditionally ultimate responsibility for the patient and for decisions taken with regard to their care rested with the doctor charged with their care. Today, doctors largely remain at the head of the clinical team, but responsibility for the actions of those comprising the team is often found to be diffused further with nurses and other health care professionals now accountable to their own hierarchies and, more significantly, in certain circumstances recognised as assuming the majority of the responsibility for a particular patients care. Nevertheless, it remains the case that, fundamental to the role of a doctor, is their capacity to assume ultimate responsibility for a patients care. A doctors training, the breadth and depth of their expertise, their ability to deal with uncertainty and manage risk, and the bond of trust so central to the patient-doctor relationship, identifies them as best equipped to take on this obligation. It is at the heart of what it is to be a doctor.

Trust and the patient-doctor relationship

Gaining a patients trust, maintaining it and acting in the patients best interests forms the bedrock of the doctor-patient relationship. It is central to doctors code of practice which states, Make the care of your patient your first concern be honest and open and act with integrity; never abuse 14 your patients trust in you or the publics trust in the profession. This primary concern is evidenced in all the qualities, attributes and roles herein described trust in the doctor to make a diagnosis, trust in the doctor that they are up-to-date and ready to seek out the most appropriate treatment, trust in the doctor that they are capable of responding to the patients needs, and trust in the doctor that they are ready to take responsibility for the patients care. This trust is nurtured in partnership with the patient, through meaningful communication, patience and empathy. This role and the importance of partnership is increasingly central to the patient-doctor relationship with doctors acting as interpreters of information, navigating for the patient, translating

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The Role of the Doctor Building on the past, looking to the future

The Role of the Doctor Building on the past, looking to the future

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BMA Health Policy and Economic Research Unit

BMA Health Policy and Economic Research Unit

Chapter 4 Safeguarding and promoting the role of doctors

To explore the wide and varied contribution of doctors is to confront the twin elements of change and constancy that were earlier identified as defining forces in the evolving roles of doctors. Both doctors and the public recognise that a doctors role has at its heart a set of enduring values, which inform doctors professionalism and underpin patients trust. These ancient virtues cannot be discounted as merely a nostalgic pledge but rather must be championed as the guiding principles that sit at the heart of the patient-doctor relationship and secure the commitment of doctors to improving health. Moreover, in examining the qualities that doctors bring to their practice and the roles they fulfil it is apparent that this sense of constancy, the firm foundation that shapes doctors conduct, does not breed complacency. Rather, it provides the necessary tools to adapt to change and respond to shifts in expectations. The core values which comprise it compel doctors to widen their roles, refine their skills and lead innovation. However, these values and the unique contribution that doctors make in delivering care are not immune from threat. It is essential that they are appropriately recognised, encouraged and promoted if they are to be safeguarded and harnessed for the benefit of patients and the health service. This is particularly true of a number of key areas:

Furthermore, the growth in new practitioner roles inevitably means doctors in training are suffering reduced exposure to a range of procedures that would have traditionally offered a valuable source of learning. It is a concern that the impact of changing roles on doctors access to training opportunities and the gaining of necessary clinical experience has yet to be fully assessed. There is something of a dichotomy here wherein we are seeing the rise of increasingly protocolised basic medicine with which there is a risk that doctors will be deskilled in parallel with a corresponding increase in the complexity of advanced treatment which will require doctors to acquire ever more developed expertise. Finding an acceptable balance in this will be fundamental to the future role of doctors.

Leadership and clinical engagement

Doctors capacity for leadership and their ability to add real value across many spheres in health care is evident in both their every day clinical practice as well as in their wider contribution to training, research, service improvement and management tasks. Consequently, it has been a growing concern that in recent years the profession especially in England has often felt marginalised in discussions with government and the health service in respect of NHS reforms and service redesign. The sense of alienation, felt by the majority of doctors, arising from many recent decisions that have had far-reaching consequences for their practice has led to significant disaffection. This situation has been damaging with reform both lacking clinical insight and support in its implementation, despite contemporary evidence demonstrating that the most effective and efficient NHS organisations are those with the highest levels of clinical engagement 15 16 and leadership.

Medical education, training and research

Too often the crucial role that the NHS plays in medical education, training, and research is forgotten. This is particularly true with regard to health service reform. Notwithstanding the impact of the failed MTAS process in 2007 and the uncertainty surrounding the future of postgraduate training following the introduction of MMC, doctors remain concerned that medical education, training, and research is being progressively undermined. Trainees must have their faith restored in the process of training and feel assured that educational curricula and training programmes are sufficiently structured such that doctors are developed into professionals of the highest calibre with the necessary knowledge and expertise to deliver excellence and to take on the responsibilities expected of a doctor in the context of a rewarding career. Similarly, trainers must be given the requisite resources to respond to these demands. The declining size of the medical academic workforce, the growing pressure on those involved in teaching to reduce teaching activities in favour of carrying out clinical duties and the consequences of new tariff-based financial flows for the funding of education and training suggest that more must be done to safeguard quality and provision in this area if doctors are to continue to meet the high standards required to fulfil their role.

Conclusion Looking to the future

It is therefore absolutely vital that, as the current debate on doctors roles moves forward, the value to be gained from investing in doctors leadership qualities must be a central focus. Not all doctors will wish to assume formal leadership roles, but all doctors, by the nature of their practice, offer a means to lead others in securing beneficial change. Doctors command of their evidence base, their trusted relationship with patients, and their intimate knowledge of their local services or complex understanding of wider systems must be championed in an effort to sustain truly clinically-led change. In this respect we welcome the sentiments, expressed in the recently published High 17 Quality Care for All, which stress the importance of clinical leadership. The reports pledge to strengthen the involvement of clinicians in decision making at every level of the NHS must be supported with the necessary action to ensure the lasting engagement of doctors in the leadership of health services. To fail in this would be to ignore the proven value and unique contribution doctors have to offer.

Skill mix
New ways of working, skill mix initiatives and an increasingly multidisciplinary approach point to the essential role teams are now expected to play in health care. The growing contribution made by other heath professionals in caring for patients brings welcome benefits for doctors as well as patients and, as a result, doctors traditional role as team-leader is evolving. It is a challenge for the medical profession to focus on its strengths, while ceding leadership to other professionals, when and where this is clinically appropriate. However, this blurring of boundaries also presents challenges. Without clear lines of responsibility and accountability these new relationships may work to the detriment of patient care. These concerns are particularly acute in areas of medical practice which lend themselves to management by non-medical healthcare professionals using protocols. Where such role substitution is employed, there is a risk that patients do not have access to the range of knowledge and skills that characterise a doctors holistic approach to care.

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The Role of the Doctor Building on the past, looking to the future

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BMA Health Policy and Economic Research Unit

BMA Health Policy and Economic Research Unit

References

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Osler W (1932) On the educational value of the medical society. In: Aequanimitas with other addresses to Medical Students, Nurses & Practitioners of Medicine. 3rd ed. Philadelphia. PA: Blakiston. Donaldson L (2001) Safe high quality health care: investing in tomorrows leaders. Quality in Health Care BMJ 10: ii8-ii12 Tooke J (2008) Aspiring to Excellence: Final Report of the Independent Inquiry into Modernising Medical Careers Ibid. The BMAs consultants committee has recently published its own report on the role of the consultant: BMA (2008) Role of the consultant http://www.bma.org.uk/ap.nsf/Content/roleofconsultant0708 The junior doctors have considered the role of the junior doctors: BMA (2008) The role of the junior doctor http://www.bma.org.uk/ap.nsf/Content/Roleofthejuniordoctor General Medical Council (2006) Good medical practice. London: GMC. Royal College of Physicians (2005) Doctors in society: medical professionalism in a changing world RCP: London. British Medical Association (1995) Core values for the medical profession in the 21st century. London: British Medical Association. BMA (2008) Professional values Findings from BMA cohort studies http://www.bma.org.uk/ap.nsf/Content/cohortprofvalues Chisholm A and Askham J (2006) A review of professional code and standards for doctors in the UK, USA and Canada. Picker institute Europe. This research was carried out by an independent research agency, Hamilton Lock, commissioned by the BMA conducting 1011 quantitative in-street interviews in two geographic areas in England London/the Home Counties and Bristol and in Edinburgh. The interviews were completed between the 26 May and 13 June 2008. General Medical Council (GMC) (1999) The doctor as teacher. London: GMC. Academy of Medical Educators (2008) Frequently asked questions. Web address accessed on 20 June 2008. http://www.medicaleducators.org/faqs.asp General Medical Council (GMC) (2006) Good medical practice. London: GMC. Audit Commission (2007) A prescription for partnership: Engaging clinicians in financial management Commission for Health Improvement (2004) Lessons from CHI Investigations 2000 2003. Department of Health (2008) High Quality Care For All: NHS Next Stage Review Final Report HMSO.

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The Role of the Doctor Building on the past, looking to the future