Chapter 3: Professionalism - Great Expectations

Today’s doctors are working in a constantly evolving environment, where many of the old expectations regarding the role of doctors, nurses and patients are being replaced by new ones.The roles themselves are changing – doctors are clinicians, leaders, teachers, managers, commissioners and purchasers of services.

Public expectations of medicine have never been higher, and political scrutiny of performance has never been greater. In this chapter, we will look at how these expectations have changed over time.

Where many years ago, poor practice by a minority would have been tolerated, doctors are welcoming patient autonomy and pursuing quality through knowledge, transparency, accountability and collective responsibility for setting and maintaining professional standards.

"Today’s doctors are working in a constantly evolving environment, where many of the old expectations regarding the role of doctors, nurses and patients are being replaced by new ones"

So what led to this change? Through the 1970s, 1980s and early 1990s, the system of medical regulation faced mounting criticism, increasingly from the public and independent commentators, much of it focusing on the failure to identify early, and deal effectively with, doctors who were a potential danger to their patients.¹⁵

In the early 1990s, a series of highly publicised medical scandals, some to do with poor practice by individual doctors, others to do with local service failures in which patients were harmed, gave rise to mounting public concern. The Bristol Inquiry into the poor standard of care offered in the paediatric cardiac surgery service in that city, and the avoidable deaths that resulted, was a major turning point.

Nationally strides were made to move away from the autocratic “doctor say patient do” system to a more patient-centred one where doctors and patients would work together in a partnership.

The medical and nursing professions only started to recognise the extent and seriousness of patient harm from medical errors in the mid 1990s. Before this medical error was seldom acknowledged or written about. In 1990 the editor of the BMJ argued for a study of the incidence of adverse incidents and was criticised by the president of a royal medical college for drawing national attention to medical error.¹⁶

Patients’ expectations

“In society we can see the ‘triumph of the autonomous individual’, but this shift has been difficult to accommodate in the professional mode rooted in 19th century value systems of a clinician as ‘expert’ and ‘authority’. Unmodified, medical paternalism will perish in a global market-led economy where individual choice, autonomy and consumerism reign supreme.” Glyn Elwyn (2005)²⁶

This statement is a manifestation of the shifting power dynamic between doctors and patients, as discussed previously. In response doctors have had to reflect on and improve their communication skills, adopting various consultation methods to facilitate shared-decision making and more patient-centred care.

Immanuel Kant expressed the view that each person has intrinsic worth and possesses certain rights that others are obliged to respect. The right of an individual to follow their own self-directed choices in life is called autonomy. Such behaviour may not always be dignified (eg, choosing to drink to excess and getting drunk). However, the acceptance and understanding exhibited by the healthcare provider who subsequently treats that same individual for an injury sustained whilst they were drunk, demonstrates a respect for autonomous behaviour and also restores some dignity to the situation.

Competence

A doctor has a duty to provide care of an appropriate standard to avoid allegations of negligence. The progressive upward revision of the required standard of treatment to be provided is based on evidence that is constantly evolving, and is also influenced by the local culture and laws, as well as patients’ expectations. As a result, the skills, diagnosis and treatment options for delivering medical care have changed dramatically over the past ten years. In addition, clinicians face greater demands from patients who want more information about the benefits and risks of any treatment they undergo.²⁷

"A doctor has a duty to provide care of an appropriate standard to avoid allegations of negligence"

Respect

By adopting a respectful attitude to your patients and colleagues you will protect their dignity and earn their respect in return. The professional relationship is inevitably enhanced by an approach that recognises each patient as an individual, with feelings and sensitivities of their own, and which may differ from those of the previous patient and, possibly, from your own.

It is not necessary to agree with all that a patient believes or feels but it would be unethical to deny them such freedom. Respect does not necessarily imply deference but it does exclude selfish or prejudiced behaviour on the part of the clinician. The concept of respect predates any legal rights that may have subsequently been introduced in an attempt to protect the rights of the individual.

Most medical boards and medical councils around the world issue guidance on professional conduct, which stresses the need to treat all patients with respect and dignity. In some countries these principles are also enshrined in codes of human rights or similar legislation. Consequently, a failure to recognise and address issues relating to ethnicity, religion, sexual preferences, disabilities etc can have farreaching professional consequences.

A patient’s expectation of their surgeon

“For patients, important characteristics of a surgeon are skill, experience and empathy. We would expect the surgeon to have a good reputation with their colleagues and, if we needed unusual surgery we would expect the surgeon to have that sub-specialist expertise and, if not, that they would refer us onwards to someone who did. We would assume that they would have up-to-date knowledge, and would expect that the profession would make assessments to ensure that was so.

“Finally we would expect a transparency in all dealings, and an ability to independently check any claims made would be key to earning and maintaining trust. We would expect the professional societies responsible for the practice of surgery under consideration to set clear standards of care, monitor those standards, and use the data to drive quality improvement. We would also expect them to have a strategy for getting information to patients about the relevant disease and treatments, as well as providing comparative clinical outcomes, to help us become an informed partner in any decision making process.”

David H Geldard MBE, patient representative and board member of Society for Cardiothoracic Surgery.²⁸

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