Measuring Medical Professionalism; Understanding Doctors' Performance
Authors: Donald Irvine
Journal: BMJ (2006)

The past 20 years have seen a resurgence of interest among doctors in the concept and practice of “professionalism.” The Royal College of Physicians of London recently defined medical professionalism as “a set of values, behaviours, and relationships that underpins the public trust in doctors.” In his elegant introduction to Measuring Medical Professionalism, Jordan Cohen, president of the Association of American Medical Colleges, said that a physician imbued with professionalism offers patients by far the best chance of a good outcome in our increasingly sophisticated and risky healthcare system. For patients nothing can substitute for having a trustworthy doctor, “not laws, not regulations, not a patients' bill of rights, not watchdog federal agencies... nothing.”​




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Ed David Thomas Stern

Oxford University Press, £29.99/$49.50, pp 311 ISBN 0 19 517226 4

Rating: ★★★★







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Eds Jim Cox, Jennifer King, Allen Hutchinson, Pauline McAvoy

Radcliffe, £27.95/$52, pp 184

ISBN 1 85775 766 1

Rating: ★★★⋆




So where did this new interest come from? After all, professionalism in medicine has deep historical roots. Until the 1980s it was the undisputed keystone of the regulatory bargain between the state and doctors in which doctors promised to put the interests of the public and patients first, ensuring a good standard of competent, ethical practice, in exchange for the freedoms and social status inherent in self regulation. What actually happened is that a culture of professionalism that was originally appropriate for the relatively uncomplicated practice characteristic of medicine in first half of the 20th century failed to evolve. This failure occurred because the international medical profession did not adjust for the effect that burgeoning scientific discoveries were having on the organisation and delivery of medical and health care. Nor did it respond quickly enough to the rapidly changing expectations of an emergent educated middle class society in the information age. The result, unnoticed by many doctors, was that the “old style” professionalism passed its sell-by date. Thus the hole that doctors left in the regulation of medical work began to be filled from outside by the new managerialism and market forces.


“Organised medicine is going to have to say, `There's a new sheriff in town,'—and mean it”


Then came the renaissance. It began with thoughtful doctors, sociologists, and lay people seeing that unrestrained consumerism, commercialism, and managerialism could easily strip the profession of medicine of its ethical core: of its conscience, its identity, its very being, of what the medical sociologist Eliot Freidson calls its soul. That could have disastrous results for patients, the public, and doctors alike, for despite modern science medicine is still a judgment based profession in which trust is fundamental to effective clinical practice.

Three early initiatives to address the problem stand out. In the late 1980s the American Board of Internal Medicine launched an ambitious programme to develop a physicians' charter that sought to align professional core values with public expectations. In Canada the medical school at McGill University was giving new meaning to its Oslerian legacy of professionalism. And in the United Kingdom in the early 1990s the General Medical Council began a fresh, patient centred approach to professionalism, embodied in the 1995 “Good medical practice” statement. Today this consensus statement between public and profession is being embedded into all aspects of UK medical practice, education, regulation, and doctors' contracts of employment.

Which takes us to Measuring Medical Professionalism. The book focuses on the difficult territory of assessing professionalism in the various stages of the medical curriculum. By common consent the development of assessment methods is still at an early stage, so this well produced critical review is timely. The excellent introduction by the editor, David Stern, provides a working framework. The main body of the book comprises chapters, all by US authors, which together represent an authoritative overview of the current state of the art and, incidentally, show just how seriously the Americans are taking the conceptual and methodological challenges. If the book has a weakness it is that the direct assessment of patients' experiences gets too little attention. The book ends with a well argued commentary by Fred Hafferty from Minnesota. Hafferty leads the reader through difficult terrain with engaging frankness and clarity—socialisation, authenticity, altruism, professional standards, and the hidden curriculum are examples. All good stuff.

A lack of professionalism leads ineluctably to poor performance. Understanding Doctors' Performance is edited by a UK group who are experienced assessors of poorly performing doctors. In their multi-author presentation they have brought together existing knowledge about the factors influencing a doctor's performance. They succeed well in their aim of providing practical, evidence based guidance to help individuals, employers, and regulatory, educational, and professional agencies charged with the task of managing concerns about doctors' performance. The essays cover all aspects of impaired performance and are nicely written and of good quality. They provide a sound, basic guide for those having to handle performance problems for the first time.

However, one must sound a cautionary note about such positive movement. Today the public expects that everyone must have a good doctor—that there should no longer be any element of chance about it. Public trust in the medical profession will therefore be sustained only if doctors are serious about being re-energised by the new professionalism. To achieve this, the institutions of medicine must act together decisively, putting the public interest first. Principled, courageous professional leadership will be at a premium. In Hafferty's colourful words, “Organised medicine is going to have to say, `There's a new sheriff in town,'—and mean it.”