Why doctors and plumbers are different

MEDICAL MATTERS:WHEN I wrote about medical professionalism recently, it was in the context of a Prime Time report on symphysiotomies. Many of you responded positively and asked me to expand on the theme in a future column.

Traditionally, medical professionalism is seen as a topic for discussion among medical students and doctors. But I was reminded of the wider public context following a recent interaction with a relatively senior healthcare administrator. We were discussing decision-making when I referred to the expectation that doctors communicate respectfully and expeditiously with one another – just one of the many aspects of professionalism.

“Don’t give me that,” was the rather animated and unexpected response. “Doctors are no different from plumbers, and the sooner they realise it the better.”

Cue stunned silence. Later, as I reflected on the raw nerve I had obviously touched, it struck me that if this represents the view of people working in the health service, how does the public see its stake in medical professionalism? Or to put it bluntly: what role must the public play to ensure it continues to experience the benefits of professionalism?

A useful definition of medical professionalism, from the Royal College of Physicians (RCP), is 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, altruism, compassion, 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.

Maintaining health and combating disease are among our most fundamental needs. Society invests much of the responsibility for addressing these needs to “healers”. In return, it needs to ensure that these healers (in this case, physicians) use their expertise for the benefit of patients and the public, and not in pursuit of self-interest. As a result, three interlocking control mechanisms have emerged: a regulatory model, achieved by government supervision; a commercial model, driven by market forces; and a professionalism strand, which relies on a social contract.

However, no regulatory scheme or market force can guarantee high quality and ethically robust healthcare: only professionalism can hope to deliver assurance on this area, a compelling reason why the public must be involved in medical professionalism.

Writing in the Annals of Internal Medicine, Dr Harold Sox has linked medical professionalism to the rise and fall of medieval, European craft guilds. Ultimately, the guilds, which for centuries guaranteed high quality products, declined slowly because of their insensitivity to the interests of the public and their failure to adapt to new circumstances. But business and government played a part too. "Seen in the light of the history of the medical guilds, a root cause of the decline of the medical profession is the rising cost of healthcare, which has become a very serious problem for both government and business," he says.

Sox maintains the medical professional is currently under the thumb of powerful societal forces, because government and business cannot cope with the high costs triggered by doctors’ decisions. He favours enlarging the definition of professionalism to include a commitment by doctors to provide healthcare based on the use and cost-effective management of limited clinical resources.

Therein lies the challenge for modern doctors. But it is a challenge that coincides with straitened economic circumstances, which may represent an opportunity to underline the importance to the public of professionalism. The medical profession must step up to the plate and adopt a lean, evidence-based style of practice to help reduce the effect of plunging heath budgets.

mhouston@irishtimes.com