Too many rules could stifle a doctor's wisdom

MEDICAL MATTERS: As the Department of Health and the Health Service Executive (HSE) begin to negotiate new contracts for both hospital consultants and general practitioners, the accountability of the medical profession will be high on the employers' agenda.

This was clearly signalled by Tánaiste Mary Harney when she said she wanted to see a new form of hospital contract under which consultants in public hospitals would do public work only. And somewhat provocatively, she said such a contract would mean that consultants would never "show favouritism towards someone who has ability to pay".

Adverse clinical events are another driver of reform. Many adverse events are the result of systems failures within hospitals. The death of Pat Joe Walsh in Monaghan hospital last October, while waiting for emergency surgery, is an example of such a failure. In Our Lady Of Lourdes hospital in Drogheda, Dr Michael Neary was found by the Medical Council to have unnecessarily performed caesarean hysterectomies on a number of women.

Undoubtedly, there is a need for regular practice audit, multidisciplinary team meetings and critical event analysis. Clinical guidelines and risk management processes must be implemented if high-quality patient care is to be delivered.

Such an era of professional accountability must be welcomed. But there is a caveat. New processes and new contracts must not harm a precious commodity: medical professionalism.

Following the crimes of Harold Shipman and the inquiry into excessive deaths from paediatric cardiac surgery in Bristol, the National Health Service in Britain began a process of ever tightening regulation of doctors. Overall, the attitude of the state towards doctors hardened.

Doctors in Britain now complain they are obliged to practise "tick-box" medicine. General practitioners are paid according to how well they meet more than 100 quality markers. The more ticks you can enter on this menu of services, the better a doctor you are considered to be. Dr Raymond Tallis, doctor and philosopher, has likened the process to "accountability transformed into accountant-ability".

How does this threaten medical professionalism? At the heart of professionalism lies the notion of uncertainty. A doctor makes many decisions each day based on intense unpredictability. Experience and knowledge form the basis of such judgments. But you cannot measure wisdom, and so such decisions appear to lack transparency and accountability to an outside observer.

However, this wisdom, the ability to live with uncertainty, is central to good patient care. An experienced doctor knows when to go against guidelines in the interest of a particular patient.

It may be the memory of successfully treated cases in the past, or even an acutely developed sixth sense; whatever the stimulus, it is at the very core of professionalism to follow a finely tuned clinical instinct.

If medical professionalism is sacrificed on the altar of absolute accountability, then doctors will become pawns of a consumerist society. We will simply present patients with a range of treatment options from a menu set by administrators. The days of being an advocate for patients, fighting on their behalf, will be gone.

The more ill a patient is, the less satisfactory such a passive doctor-patient relationship will be. The less ill are, however, more numerous and more vocal.

We are in danger of creating a culture where patients are emboldened rather than empowered. Those with the most aggressive demands will have the most influence on changing the character of medicine into a set of shallow transactions.

Recognising the dangers, the Royal College of Physicians (RCP) in the UK recently redefined medical professionalism as: "a set of values, [ in which]. . . 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.

The Medical Council is planning to issue a document on medical professionalism in the near future. It would be helpful if the royal colleges here, along with the Irish Medical Organisation, The Irish Hospital Consultants Association and the Irish College of General Practitioners, took this document and developed it into a joint position paper.

Doctors, and other health professionals, must become more accountable. But it would be a grave mistake if, in the headlong rush to reform, we devalued the therapeutic role of the doctor.

Far better to initiate a public debate about the nature of medical professionalism and the role of the doctor in creating a healthier society.

Dr Muiris Houston is pleased to hear from readers but regrets he cannot answer individual queries.