Everyone is entitled to a good doctor

When patients and their relatives say they have a “good doctor”, they mean a doctor whom they feel they can trust without having to think about it. They equate “goodness” with integrity, safety, up-to-date medical knowledge and diagnostic skill, and the ability to form a good relationship with them. For them, good doctors are clinically expert and at the same time are interested in them, kind, courteous, empathetic and caring. All these attributes matter to them because they know that their doctors’ decisions can affect the outcome of their illness — even make the difference between life and death, or between enjoying a speedy recovery and suffering serious disability.

In his lifetime, William Osler epitomised the good doctor. He was at the leading edge of medicine — his classic textbook of medicine, his skill as a clinical diagnostician and his charismatic bedside teaching all stand testimony to that.1,2 But, to an exceptional degree, he matched his scientific and clinical prowess with a love of people, a powerful sense of ethical conviction and a passion for his profession which set him apart from his contemporaries.3

Today, we would call Osler an outlier, one who stood at the very top of his profession. Beneath him and a few others like him were — and still are today — the vast majority of good doctors who are competent, conscientious and trustworthy. The large size of this group constitutes a critical mass of what Avedis Donabedian called “goodness”, of which the profession can be justly proud.4 It has been fundamental to sustaining considerable public confidence in doctors.

Beneath this group is another layer of doctors whose practice is in some way not good enough. Some are clinically inadequate, others cannot communicate, or relate appropriately to patients. Some cannot do any of these things well. Currently, this group is impossible to quantify, but we all know that these are doctors we try to avoid if possible. We know about them from our friends, from local gossip — “the word on the street” — and from our own experience. Doctors themselves, with their insider knowledge, are careful to steer clear of them when their own families are ill.

Beyond this band of substandard practice there is another group of outliers: potentially dangerous doctors who are unfit to practise unsupervised. An indication of the size of this group may be gained from the United Kingdom’s National Clinical Assessment Service (NCAS), which has shown recently that the 1-year rate of referral to NCAS is 0.5% for all doctors, rising to 1% if doctors in training are excluded.5 These doctors were tolerated until very recently — the past 10 years or so — by what the public would say was an excessively self-protective profession.

This bell-curve pattern of practice has been with us since the modern medical profession emerged in the middle of the 19th century. The profession has long accepted it as normal. For over a century, the public thought the same. However, recently that mutual understanding between profession and public has been under increasing strain as respective expectations started to diverge. While doctors’ attitudes have remained substantially unchanged, the health care expectations of an increasingly well educated and informed consumer society have been changing quickly.

The result is that many more people today have their own ideas about what they want from the doctor–patient relationship.6,7 For them, it is the patient who defines the basis of the relationship, not the doctor. Equally, now that they have become more aware, this section of society is making it clear that they are no longer prepared to put up with a profession and a system of professional regulation that continues to tolerate what they consider to be inadequate or bad practice. Their appreciation of good doctoring is as strong as ever: they are not anti-doctor. However, they think that, in a modern health service with effective professional regulation, quality assurance and risk management, all doctors should be good doctors. There should be no element of chance about it. Some doctors find this expectation threatening, others perfectly reasonable.

The modern medical profession began to take shape in the second half of the 19th century — Osler’s time. This was the age of small, single-handed general practice, with the emerging specialties largely confined to the newly developing university teaching hospitals. The leading physicians of the day concentrated on achieving a better understanding of the body, and on describing and diagnosing disease. Despite these advances, medicine was essentially harmless because, at that time, treatments were largely ineffective. Good relationships with patients were important because doctors’ incomes depended on it, and they had little else to offer.

All this changed rapidly after the Second World War, when specialisation in high-tech medicine really took off.8,9 Armed with new science and technology, specialists were able to do more and more wonderful things. They were nearly all men, and they were glamorous, powerful role models. Paternalism dominated relationships with patients, who were expected to do as they were told — “doctor knows best”, as the saying goes. Communication was a one-way street. And things like consent to treatment were mere formalities, if sought at all.

The downside of this medical success story was the tolerance of poor practice.10 In English-speaking countries, the process of self-regulation was supposed to ensure that doctors were properly trained and that their practice was safe. However, history shows that this was never as effective as its promise because of the intrinsically self-protective nature of the medical culture. Turning a Nelsonian blind eye was the easiest thing to do. Elsewhere, regulation run directly by the state was no more effective, for the same reason.

This self-protective, “take-it-on-our-terms” attitude persisted through the century right up to the 1980s. The public was content because the heady successes of medicine seemed so reassuring. People trusted the profession to do all that was necessary to protect them.

This trust was misplaced. British general practice is a good example of a prolonged struggle to deal with a substantial tail of poor practice.11-13 Doctors like my father formed the College of General Practitioners in 1952 to try to establish some basic standards, but professional resistance was strong. Furthermore, successive governments colluded over the years with the powerfully protective medical trade union — the British Medical Association (BMA) — when it suited them to do so. “There is no such thing as a bad general practitioner”, said a BMA general practitioner leader in the 1970s.14 Poor practice was less prevalent in the hospital specialties because the specialties had more robust entry standards, and working in a team offered some informal oversight of practice by peers — but it was there just the same.

The obvious question is why a profession with so many conscientious people could act so defensively. How does this behaviour fit with a profession committed to putting patients’ interests first? One explanation lies in the 19th century cultural mindset of unfettered professional autonomy that, deep down in the profession’s collective psyche, lingers on even today. This assumes that, once doctors are fully trained, for the rest of their professional lives they are then entitled to exercise wide discretion as to how they practise medicine, how thoroughly they keep themselves up-to-date, how they relate to patients and colleagues, and what standard of practice they personally consider acceptable. It’s all their call. Patients’ views don’t come into it. Think, for example, of the difficulty there is even today in getting new knowledge adopted quickly into practice through evidence-based medicine.15

Another reason stems from that strong sense of brotherhood and pride in belonging to an honourable profession, which is instilled in doctors through medical education. It is one of the great strengths of the medical culture. However, until very recently the culture was strongly self-protective, which made doctors reluctant to report poor practice. In his day, Osler, an enthusiastic advocate of professional solidarity, publicly urged doctors not to criticise colleagues: “Never let your tongue say a slighting word of your colleague”.16 Britain’s General Medical Council (GMC) reinforced this attitude until the late 1980s by advising doctors not to “disparage” a colleague.17 To do so was considered unprofessional, and could precipitate disciplinary action, not against the doctor who gave cause for concern but against the doctor who was sounding the alert!

This inward-looking view of professional responsibility could not last. In the 1980s, the public mood in the Western world was changing as the consumer revolution took hold. People became more questioning about services in all walks of life. In Britain, consumer organisations became far more critical of too many doctors’ poor communication skills and the continuing tolerance of poor clinical practice: poor practice was the public’s main concern.18-20 So, the gap between the public and the profession was growing wider.

In 1995, the GMC sought to unify the profession around new, explicit, patient-centred professional duties and standards that reflected public understanding as well as doctors’ understanding of what constitutes good medical practice.24 In 1998, in the aftermath of Bristol, it decided that compliance with these standards would be best achieved by embedding them in medical education, licensure, specialist certification, revalidation and contracts of employment.25,26 These fundamental changes were intended to signal a decisive break with the doctor-centric professionalism of the past, to put patients’ interests unequivocally first.

There has been real progress towards redefining the relationship between the public and the profession around the twin principles of patient autonomy and transparent physician accountability. Nevertheless, opinion in the profession is still divided. Some doctors are fulsome and enthusiastic about renewing their professionalism and profession regulation around patient-centred principles. Others, deeply conservative, want to make the least change consistent with keeping up good appearances. Revalidation gives focus to these different views.

The divisions were fully exposed in 2004 during the Shipman Inquiry into the case of Dr Harold Shipman. The Inquiry was conducted by Dame Janet Smith, a High Court judge.27 She was strongly critical of the GMC for having just emasculated its own originally coherent proposals for revalidation and fitness to practise that it had launched soon after Bristol. It seemed that the GMC, when faced with continuing resistance from some in the profession to a form of revalidation robust enough to give the public proper protection, altered course to accommodate these doctors’ interests, to the detriment of patient safety. Dame Janet exposed this policy reversal with devastating precision. Consequently, as a result of her criticisms, the government asked the Chief Medical Officer for England, Sir Liam Donaldson, to make proposals that would get the reform program, particularly revalidation, back on track.

In an outstanding report, Good doctors, safer patients, Sir Liam builds on the standards-based model.28 He places the regulation of doctors within the wider set of institutional systems for improving and quality-assuring medical practice. He recommends a common standard of entry to the profession that would be assured through a new standardised national examination. He restores rigour to the process of revalidation. In the management of concerns about a doctor’s practice, he emphasises the importance of a supportive rather than an adversarial approach, with proper retraining and rehabilitation for doctors, where appropriate.

Obviously, we are most likely to achieve a good doctor for all if the medical profession can see patient-centred practice in a positive light, as the right thing to do for the public and individual patients, and the hallmark of their modern professionalism. The good news is that more and more doctors are not only thinking this way, but also giving practical leadership in their own practices.

In making this difficult cultural transition, I cannot overstate how important it is that, for optimum results, professional standards of practice have to be internalised across the profession. This can only be done by having medical leaders and teachers who are prepared to lead by example, as Osler did, by putting their own clinical practice publicly on the line. They also need to know how to engage hearts and minds, and to be prepared to make the effort to win the argument with as many individual colleagues as possible. It means leaders among the regulators and within the colleges and specialist societies and medical schools, who know how to change institutional cultures. And it means leaders who will not sacrifice the best interests of patients or the longer-term interests of their profession on the altar of short-term political expediency.

It helps enormously if people can see the direction of travel clearly and also the good things that can flow from it. For individual doctors, there should be the greater peace of mind and self-confidence that comes from knowing, and being able to show others, that they are really on top of the job, and therefore known to be absolutely reliable and trustworthy. Doctors who are self-confident and self-aware are more able to take control of their own professional lives, and not to feel that they are being driven by the system as so many do today. Self-confidence, self-respect and self-control beget high morale.

For the profession, there would be gains in being seen to be firmly patient-oriented, and in being able to demonstrate to the public with conviction that the house of medicine is indeed in good order. The result could be a measure of trust and respect in wider society that the collective profession today can only dream of. That trustworthiness would be an immense strength for the profession and a civic force for good. It could provide the basis for the profession to join with the public, together to play a much more assertive role in helping to shape public policy on the science, ethics and delivery of health and health care as economic pressures make this more and more difficult.

I have no doubt that this cultural revolution in medicine will result in much stronger patient-centred professionalism and professional self-regulation. It will be immensely reassuring to the public and patients, and appeal to the huge majority of conscientious doctors who take pride in the standing of their profession. It makes me wish that I were starting all over again!

William Osler, who epitomised everything that patients want in a doctor, might have wondered what on earth all the fuss was about. He thought that: “In a well-arranged community, a citizen should feel that he can at any time command the services of a man who has received a fair training in the science and art of medicine, into whose hands he may commit with safety the lives of those near and dear to him.”43 For him it was obvious — everyone is entitled to a good doctor.

3 Patients’ experiences of five measures of doctor’s professionalism in five countries41