F ORUM

ISSUES IN MEDICINE

Revitalising professionalism

Janet Seggie

‘Medical professionalism is not optional. It is an essential part of being a doctor, no matter how many challenges face us.’ (trainee doctor 1 )

Against the background of current social criticism of the medical profession, well captured by Benatar 2 in this journal in 1997, the medical profession has been intensely introspective over the past 5 years in seeking to respond to society’s disquiet.

A working party of the Royal College of Physicians, whose mandate was to re-consider medical professionalism in a changing world, set the ball rolling in 2005 but were soon joined by other august medical bodies, including the Health Professions Council of SA. The result has been a series of reports 1,3-7 that have sought to modernise the definition and explore the elements of what might be termed a new professionalism for the 21st century.

If it is accepted that professionalism is ‘a set of values, behaviours, and relationships that underpin the trust the public has in doctors’, 1 we are surely all comfortable with the admonition that doctors should be committed in their day-to-day practice to keeping the good of the patient as the highest priority and serving him/her with:

• integrity

• compassion and empathy

• altruism.

We understand and accept also that there should be a striving for excellence, which implies a dedication to continuous improvement and evidence-based decision-making.

But what of an injunction to:

• develop good communication skills

• establish a partnership between patient and doctor and a willingness to provide information to enable the patient to fully participate in decisions relating to his or her own treatment

• utilise judgment … being astute about what we choose to do for the individual patient (in an age when technology and pharmaceuticals are available for seemingly every eventuality)

• accept individual responsibility … being prepared to justify the decisions and actions we take

• accept appropriate personal accountability (‘appropriate’ meaning fit for the purposes of enabling doctors to work in the best interests of patients without fear of penalty if an error is made unintentionally and in good faith 8 )

• be comfortable with uncertainty while patients expect certainty

• accept the requirement for revalidation, encompassing relicensing and recertification, to ensure fitness to practise and appraisal of performance to track career development (not yet asked of doctors in South Africa)

• attend to self-care and one’s own well-being (willingness to seek medical and occupational health advice and avoid alcohol and substance abuse) in the interests of public safety

• work only within the limits of one’s own competence

• work with confidence and composure

• commit to teaching, training and mentorship

• develop the skills of leadership and role modelling and, when appropriate, followership because one is so often required to agree to …

• work in partnership with members of the wider health care team , which includes health-care managers

• be computer literate.

and acknowledging that there should exist a moral contract between the medical profession and society, with doctors accepting responsibility for:

• reporting a deficient (impaired or incompetent) colleague if believing that s/he may be unfit to practice and be putting patients at risk

• improving access to medical care

• protecting and promoting individual and public health

• playing an active role in improving health services

• commitment to a just distribution of finite resources?

It transpires that the general public seek in their doctors what the authors of a recent survey categorised into ‘clinicianship’, ‘workmanship’ and ‘citizenship’, that together exactly encompass the new elements of professionalism explored above. 9

Exactly a century after publishing the Flexner Report, the Carnegie Foundation has issued a fresh call for reform in educating physicians, 10 emphasising that professional identity formation — the development of professional values, actions, and aspirations — should be the backbone of medical education. The final report of a Global Independent Commission on the Education of Health Professionals for the 21st Century 11 endorses this call, and arrives at the conclusion that medical schools, and the universities that support them, have a moral obligation to ‘transform education to strengthen health systems in an interdependent world and deliver doctors whose practice will be patient-centred and team based’.

For our medical schools, there exist several challenges to the achievement of such educational transformation.

Because the learning of professional behaviour and absorption of professional values depends on strong, engaged relationships with positive role models in the course of authentic work experience, under- and postgraduate students benefit from watchful senior guidance while being held personally responsible for the care of cohorts of patients as integrated members of a clinical family or ‘firm’. This facilitatory structure has, however, been steadily weakening for several reasons: the firm of today is made up of a passing parade of personnel; the length of hospital stay is typically very short, militating against a student forming a close bond with patients assigned to her/him; and clerkships within a firm may be only a few weeks in length, lessening the opportunity for teaching staff to form a secure opinion of an individual student’s professional behaviour.

The continuing focus of clinical education on the care of seriously ill inpatients limits students’ ability to learn the skills and professionalism linked to the long-term provision of care to patients with chronic illnesses in outpatient settings, 12 this latter trend characterising modern medical practice.

The time has come to reduce the dominance of the teaching hospital(s) and to offer students clinical experience in different kinds of hospitals and community (including rural) settings. 11,18 Within the latter, students are best placed to bond longitudinally with patients and be afforded the opportunity to demonstrate their patient-centred care. With the exception of the Walter Sisulu University’s medical school, South African medical schools are based in urban areas but are seeking opportunities (and the necessary funding) to establish long-term clinical clerkships within rural family practice and primary care settings. Exposing medical students to practice in rural environments among underprivileged and underserved communities would ‘represent the best of socially responsible professionalism’. 11

The students themselves pose further challenges. As the custodians of professionalism, they must achieve transformation from ‘lay person’ to physician during the course of their medical studies and early years of practice. 12 Born after 1990, they belong to a generation that values free time and life balance and is skeptical of total commitment. Women are in the majority and generally intend to work fewer hours while expecting flexible employment opportunities. 12 This generation also, it must be noted, rejects mechanistic approaches to teaching (and assessing) professionalism. 6 These realities demand an authentic work environment that nevertheless will permit flexible work hours and practice conducive to a healthy life balance. It is reassuring that medical students support and endorse the reforms laid out by the Global Commission on Education for the 21st century. 14

If professionalism is to be revitalised, students must be offered opportunities to perform as doctors under stable senior supervision with real patients ‘from the very first day’ 15 and in settings that properly reflect our country’s delivery of health.

1. Royal College of Physicians. Doctors in society. Medical professionalism in a changing world. 2005. http://www.rcplondon.ac.uk/wp/medprof/ (accessed 8 November 2010).

2. Benatar SR. Medicine and social responsibility – a role for South African doctors. S Afr Med J 1997;87:281-283.

3. Health Professions Council of South Africa. Guidelines for Good Practice in the Health Professions. General Ethical Guidelines for the Health Care Professions. Pretoria: HPCSA, May 2008. http://www.hpcsa.co.za/downloads/conduct_ethics/rules/generic_ethical_rules/booklet_1_guidelines_good_prac (accessed 8 November 2010).

4. General Medical Council. Good Medical Practice, revised 2006. London: General Medical Council, 2006. http://www.gmc-uk.org/publications/index.asp (accessed 8 November 2010).

5. General Medical Council. Tomorrow’s Doctors. London: General Medical Council, 2009. http://www.gmc-uk.org/publications/index.asp (accessed 23 July 2009).

6. Levenson R, Dewar S, Shepherd S. Understanding Doctors: Harnessing Professionalism. London: King’s Fund and Royal College of Physicians, 2008. http://www.kingsfund.org.uk/publications/ (accessed 8 November 2010).

7. ABIM Foundation, ACP-ASIM Foundation, European Federation of Internal Medicine. Medical Professionalism in the New Millennium: A Physician Charter. Ann Intern Med 2002;136:243-246.

8. Emanuel EJ, Emanuel LL. What is accountability in health care? Ann Intern Med 1996;124:229-239.

9. Chandratilake M, McAleer S, Gibson J, Roff S. Medical professionalism: what does the public think? Clin Med 2010; 10: 364-369.

10. Summary of: Educating Physicians: A Call for Reform of Medical School and Residency. The Carnegie Foundation for the Advancement of Teaching. 2010. http://www.carnegiefoundation.org/elibrary/summary-educating-physicians (accessed 15 November).

11. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-1958.

12. Smith LG. Medical professionalism and the generation gap. Am J Med 2005;118:439-442.

13. Ludmerer KM. In: The Education of Medical Students: Ten Stories of Curriculum Change. Washington DC: AAMC and Milbank Memorial Fund, 2000.

14. Stigler FL, Duvivier RJ, Weggemans M, Salzer HJF. Health professionals for the 21st century: a students’ view. Lancet 2010;376:1877-1878.

15. Kanter SL. An open letter to new medical students. Acad Med 2010;85:1395-1396.

Accepted 27 December 2010.

Janet Seggie is a consultant physician and Professor of Medicine at the University of Cape Town. Her special fields of interest are nephrology, general internal medicine and medical education. She played a leading role in the design and implementation of the revised MB ChB curriculum introduced at UCT in 2002. She maintains that modelling professionalism for medical students in authentic practice settings constitutes an essential component of contemporary undergraduate medical training, and hence her particular interest in writing this paper.

Corresponding author: J Seggie (Janet.Seggie@uct.ac.za)