MEDICAL MATTERS:It's time for doctors to get their act together, writes MUIRIS HOUSTON
LAST WEEK’S Prime Time report on symphysiotomies made for uncomfortable viewing. Apart from the unethical procedures revealed, it was also a reminder of Michael Neary’s warped Caesarean hysterectomy practices. Indeed, the disgraced gynaecologist made a cameo appearance, suggesting the symphysiotomy victims were motivated by compensation rather than suffering.
Such behaviours cause despair for the vast majority of medical professionals. But they also help drive the effort to redefine medical professionalism. In 2005, the Royal College of Physicians (RCP) came up with a useful definition, when it said that medical professionalism “signifies a set of values, behaviours and relationships that underpins the trust the public (and patients) have in doctors. Medical professionalism is a set of values, . . . doctors are committed to integrity, compassion, altruism, continuous improvement and a working partnership with members of the wider healthcare team”.
The RCP said these values should form the basis for a moral contract between the medical profession and society. And it called for the partnership between patient and doctor to be based on mutual respect, individual responsibility and appropriate accountability.
Last week was also the occasion of the 85th Abraham Colles lecture at the Royal College of Surgeons in Ireland. Dr Michael Brennan, a RCSI graduate and president of the staff of the famous Mayo Clinic, spoke passionately about professionalism. He suggested that certain episodes involving the inappropriate behaviour of doctors had undermined the “compact” between society and medicine.
As an educator, he emphasised the development of “the professional self” in students; the internalisation of the values and virtues of medicine as a calling. In the past, this supposedly occurred by osmosis, part of a student’s informal curriculum. Now, it is formally taught, but there is also recognition that a “hidden” curriculum, based on how students interpret what they see, also exists.
The performance of medical students, and increasingly qualified doctors, in areas such as interpersonal skills, communication skills and professionalism is now formally assessed. And professionalism is actively taught: at NUI Galway medical professionalism is given a substantial 20 per cent of curricular time in each of the five undergraduate years.
The 12 learning outcomes of the new curriculum include five that relate directly to the development of a new health professional; graduates must be able to demonstrate a full range of communication skills and professional behaviours in all areas. (Declaration of interest: I teach medical professionalism at NUIG.)
What are the challenges in maintaining professionalism? Autonomy, protected by generations of doctors, may suggest protectionism rather than excellence to society. There is a need for selflessness and discipline in working with others and following procedures. But a good doctor needs to get used to uncertainty. Experience and knowledge form the basis of such judgments. But you cannot measure wisdom, and so such decisions may appear to lack transparency to an outside observer.
One of the most important aims of professionalism is securing trust. The only way to achieve this is in partnership with patients, supporting them in making decisions about their care. Teamwork, too, is crucial – Dr Brennan referred to it as “the nexus of quality and professionalism”.
But he also reflected on the US healthcare crisis. Financial gain for individual doctors and physician self-interest were contributing to the blocking reforms. But at least they are negotiating, unlike here in the Republic where reform is being carried out by decree, not discussion.
Rather than shrink away under the harsh light of investigation into inappropriate behaviour by a few, it is time for doctors to renegotiate a contract with society based on trust. It’s time for partnership, not conspiracy.