Is medicine still a profession?

Dr Dermot J Ward

Most of you who bother to read this will be aware that The Society of Clinical Psychiatrists does not publish an honours list for members of the medical profession it might consider distinguished. That I should touch on this topic soon after Christmas 2009 may suggest to some an over indulgence in Christmas pudding moistened too generously with a liquid preservative. But as I, all to sober, pen this New Year treat for you I must move to a most sobering thought  stimulated  by an editorial in last September (2009) Journal of the Royal Society of Medicine’s Dr Kamran Abbasi, titled exactly as this.

In it he recounts how earlier last year he welcomed a group of medical students to ‘a profession that allows you to pursue many different paths catering for the diverse personalities that  constitute any medical school’s intake’. Now he wonders if he misled them not just in terms of those putative interesting career benefits but more fundamentally in the perception of medicine as a profession. He describes how doctors traditionally augmented their ‘day job’ with involvements in committees , college councils, faculty conferences, training courses as additions to their fulltime role. These he mention as important differentiations between medicine as a profession and medicine as a factory job.

He sees developments such as the European Working Time Directive (EWTD), senior doctors’ job plans and organisations becoming more ‘corporate and less enlightened.’ I find at once comfort in sharing the same hymn sheet and yet that sense of foreboding for our profession’s future: the belief that  it cannot be diminished qua profession without consequential damage to patient care.

Writing in BMA NEWS, (November 21, 2009) Professor of Psychiatry at Memorial University of Newfoundland, Canada Amin Muhammad described his early training some years ago in the NHS. He observed that NHS consultants then enjoyed a highly privileged position: they were in a leadership position and their word held great value for policy makers. He had heard that now doctors are leaving the NHS for countries such as Australia, Canada and New Zealand. He states that colleagues in the current NHS report a loss of authority (since managers have assumed the upper hand in healthcare) cutbacks in hours of work or sessions and a huge mound of paperwork.

His curiosity prompted his doing a locum in the UK and was rewarded with shabby isolated accommodation with a communal bathroom and kitchen which prompted him to stay in hotel accommodation for the duration. He found that bureaucratic generated paperwork took up a disproportionate amount of his time. There is more in his elaboration. He concludes, “it would be safe to say that the status of a consultant has been reduced to that of a ‘medical doctor’ similar to any grade in the NHS system”.

Another BMA NEWS letter (November 19, 2009) was anonymous (name and address supplied ). It was written following completion of a locum physician post ‘in a British district general hospital’ where there were attempts, it was claimed to bully. Early in the locum a ward round was interrupted by a nurse telling him “he had to remove his jacket, ring and tie and roll up my sleeves  because some visiting management  type might see me fully clothed. To continue the round he compromised “by replacing my tie with a bow tie, hung up my coat and adjusted my sleeves to elbow level. Dressed like an artisan I completed my work.” On asking a fellow consultant for a rational explanation for the preferred state of partial undress he was abruptly told “we won’t go down that road”. A number of physicians who held substantive posts  at that hospital subsequently apologised to him for the discourtesy and indicated they had to “kowtow” to trust policy or risk being disciplined. He reverted to his customary form of dress and two months later a letter arrived announcing that “it had been brought to my (the writer’s) notice that you had been seen not clothed according to dress codes”. He was invited to ‘a discussion in his office. The anonymous physician headed his published letter ‘I am too old for disciplinary visits to the headmaster, and filed the invitation in the waste bin’.

Recognition of the sapiential authority of doctors in medical matters, the related concept of clinical freedom are essential components of a confident , necessarily vigorous profession pursuing appropriate individual patient best treatment and leading progressive healthcare policies. I hope to return to different aspects of such considerations as we approach a General Election. A JRSM paper titled ‘Referral into a void’ : opinions of general practitioners and others by Rains et al (2005;98:153-157) examined the effect of DH promoting patient referral by GPs to a MHP  (mental health professional) team member rather than a named consultant psychiatrist concluded ‘...the approach erected boundaries because it impeded the establishment of professional relationships and transfer of knowledge. GPs thought the system reduced their capacity to be accountable to their patients and limited the potential for their own professional development. MHPs (non-medical Mental Health Professionals) did not seem to be aware of GPs’ concerns.’    

Let me finish for now with, not an ‘honour,’ which is something not in my gift, but a salute to Dr Abbasi  for his courage in asking a serious question about the present and future medical profession during his JRSM editorship.