By Louie Fooks, Humanities and Healthcare Policy Officer, OHVP
The government’s Long Term Plan[i] for the NHS, published earlier this month, sets out its vision for a quality health service able to cope with an ageing and expanding population. But, as many commentators point out, without the workforce it needs to support it, the plan will not meet its objectives.
The health care challenge
“Our work in Oxford on enhancing junior doctors’ working lives has highlighted the issues of low morale and well-being amongst trainees, issues that are also increasingly being recognised nationally.” Michael FitzPatrick, Oxford University Hospitals Research Fellow and Co-chair of the RCP’s Trainees’ Committee
More than 100,000 healthcare posts are currently vacant across the NHS and the number is likely to rise after Brexit. Indeed, the difficulty of recruiting, retaining, and ensuring the well-being of doctors has recently been described as a ‘crisis’ – with health organisations warning it’s a greater threat to the NHS than lack of funding.[ii]
Nationally, a quarter of doctors in training say they feel burnt out by high workloads and many are planning to reduce their hours or leave the profession early.[iii] And doctors report working in a culture of blame and fear which is jeopardising patient safety and discouraging learning and reflection.[iv]
Yet all this is set against a background of an ageing population with complex health needs – increasing the demands we put on doctors and making it even more important that they can operate at their best. Healthy life expectancy at birth is currently 63 years[v] (against overall life expectancy of well over 80), with nearly half the population living much of their older years managing one or more chronic health condition.[vi]
Claire Pulford is the incoming Director of Medical Education for Oxford University Hospitals NHS Foundation Trust and explains the situation within the Trust. She says: “Oxford and Thames Valley is lucky not to have some of the recruitment challenges to our medical training programmes which are faced by other parts of the country, but we still see vacancies and rota gaps in many essential specialities such as acute and emergency medicine. In recent years, there has been a marked drop-off after Foundation-level training, with doctors choosing not to move immediately into more senior or specialist training posts. And morale and engagement are adversely affected, with high levels of burn-out increasingly evident.”
Medical professionalism – part of the solution
“The changing face of medicine, and the changing political context of healthcare delivery, make it essential for us as doctors to revisit the concept of professionalism, and make sure it remains up-to-date and accessible to today’s clinical professionals.” Dame Jane Dacre, Professor of Medical Education, University College London, Co-author of Advancing Medical Professionalism
How then should we prepare and educate students and junior doctors for modern medical practice – and enable doctors to maintain professional satisfaction throughout their careers? Advancing Medical Professionalism (AMP), argues that enabling and supporting doctors to develop their professional identities is an important part of the answer.
AMP took as its starting point the RCP’s 2005 definition of professionalism as the ‘set of values, behaviours and relationships that underpin the trust the public has in doctors’. It built on this with a series of workshops with healthcare staff, patients and other stakeholders to explore what professionalism might mean for doctors in 2018 and beyond.
The RCP’s Dr Jude Tweedie, co-author of AMP, says: “Medical professionalism is extremely hard to define. As doctors, we recognise immediately when its absent and instinctively know that it’s essential to great patient care and physician satisfaction – but it can be very hard to quantify. So, we went out to talk not only to doctors, but to patients, academics, practitioners and others to find out what they thought.
The process was really fruitful and helped us identify seven key aspects of doctor’s working lives essential to professionalism, highlighting the many different roles we expect our modern doctors to fulfil. From this we were then able to develop practical strategies and approaches to promote professional values, skills and attributes in each area.”
Seven key aspects of professionalism. Doctor as:
- Patient partner
- Team worker
- Manager and leader
- Patient advocate
- Learner and teacher
Claire Pulford comments: ‘The General Medical Council’s Generic Professional Capabilities have been adopted into the medical curriculum and give a much-needed basis for embedding professionalism in education and training. Advancing Medical Professionalism provides an excellent resource to support this – to start conversations with students, trainees and other colleagues – and to help individuals, teams and institutions to reflect on, and develop, their practice. In Oxford University Hospitals NHS Foundation Trust we intend to use the AMP report as a toolkit to inform our development programmes for trainees and trainers; and to explicitly reference it in our teaching, training, research, and Quality Improvement initiatives.
Michael Fitzpatrick, junior doctor engagement lead at the Trust, is also keen to take forward the approaches in AMP in Oxford University Hospitals and more generally. He says: ‘The report resonates with the desire we know trainees have to develop their professional skills and become better professionals. Adopting its approaches will help us foster flexible and responsive training, clinical kinship and a collegiate workforce.’
What do the humanities bring to healthcare values?
Professor Joshua Hordern, of Oxford University Theology Faculty and the Oxford Healthcare Values Partnership, sits on the RCP Committee for Ethical Issues in Medicine and co-authored the AMP report. He believes passionately that the humanities can provide vital insights into the modern health care challenges we face. Hordern says: "Most doctors go into the profession with a strong sense of vocation and commitment. But heavy workloads and the increasingly complex context in which they practice take their toll. We hope the approaches in AMP can support doctors in sustaining values of compassion, respect and integrity, developing their vocation and professional identity, and refreshing their joy and confidence in the work they do."
Professor Karen O'Brien, Head of the Humanities Division at Oxford University, has championed the collaboration between the humanities and external healthcare organisations and believes the work on advancing medical professionalism is an excellent example of what this can achieve. She says: "The Humanities and Healthcare project embodies our commitment to supporting partnerships between academic departments and healthcare organisations. Humanities researchers bring insights and skills to fields of research and practice that require emotional intelligence, inter-professional understanding, and a deep appreciation of human complexity. The AMP report is an exemplary instance of this multi-disciplinary approach."
Advancing medical professionalism in practice
“The AMP report brings renewed clarity to the challenges that face doctors from the perspective of the different facets of the vocation that is 'being a doctor'. I am really excited that the Oxford region is developing these ideas and agenda in a relevant and practical way.” Professor Andrew Goddard, President, Royal College of Physicians
Doctors increasingly face ethical dilemmas and clashes in professional values, such as the desire to advocate for the best care of a single patient while needing to husband finite resources, or the obligation to voice concerns about patient care, knowing this may result in reprisals for themselves or others. Professionalism cannot provide a model answer for every situation but developing professional values, skills and attributes can empower doctors to navigate the challenges they face.
Doctor as healer: The concept of the doctor first and foremost as a healer is at the core of medical professionalism and the sense of vocation which brings most people into the profession. The report explores how reconnecting with the idea of healer – through a focus on the little things such as how patients are treated or the willingness to have difficult conversations about issues such as end-of-life care – can help boost physician morale and satisfaction. The values of compassion, respect and integrity are central to the role of healer.
Doctor as advocate (on patient safety): The case of Dr Hadiza Bawa-Garba, a paediatrician found guilty of manslaughter by gross negligence, whose own reflective practice was used as evidence against her, sent shock waves through the medical profession. A patient safety culture informed by professional values will be genuinely transparent and non-judgemental. It will hold staff accountable for unprofessional conduct yet not punish them for human mistakes.
Doctor as team worker: The growing complexity of healthcare makes good teamwork increasingly important. A professional approach to teamwork will foster communication and the ability to reflect on and learn from events, and build a positive working culture even in short-lived or quickly changing teams. Team building should be recognised as an important process and time should be allowed for it by leaders and managers.
Doctor as innovator: Artificial Intelligence, machine learning and digital technologies have perhaps the greatest potential to impact on how doctors work. They also raise many questions about the doctor’s role, values, ethics and medical professionalism. Smartphones are already enabling consultation at a distance; wearable technology can automatically collect physiological and health data from patients; and machine learning is expected to allow more efficient use of data.
AMP argues that technology will not displace but rather adjust the role of doctors. Experienced doctors can build on the combination of machine-generated data, their own previous experience, patient contact, and professional insight to form a diagnosis and keep the human encounter at the heart of healthcare. As technologies continue to change healthcare, doctors can innovate by exploring aspects of other disciplines - including philosophy, theology, and history – which can shed light on these changes, so that they achieve the best blend of innovation and patient care.
About the report
Advancing Medical Professionalism was authored by Dr Jude Tweedie, research fellow to the president, RCP; Professor Dame Jane Dacre, immediate past president of the RCP; and Professor Joshua Hordern, Associate Professor of Christian Ethics, University of Oxford. Professor Hordern leads the Oxford Healthcare Values Partnership and is a member of the RCP’s Committee for Ethical Issues in Medicine. Dr Richard Smith added to, and extensively edited, the report.
Find out more
With fully referenced sources for further information and a practical exercise at the end of each chapter, Advancing Medical Professionalism is available HERE and its short, accessible summary HERE.
Oxford Healthcare Values Partnership is a partnership of University of Oxford researchers and healthcare staff seeking to understand and improve the ethos of healthcare services. Advancing Medical Professionalism was developed as part of the healthcare and humanities programme, generously supported by the Arts and Humanities Research Council.
[ii] The health care workforce in England make or break? The Nuffield Trust, Kings Fund, The Health Foundation, November 2018
[iii] General Medical Council National Training Survey 2018, published Dec 2018. https://www.gmc-uk.org/education/how-we-quality-assure/national-training...
[iv] Caring, supportive, collaborative? British Medical Association, September 2018
[v] Health state life expectancies, UK: 2015 to 2017, Office for National Statistics, December 2018
[vi] Projections of multi-morbidity in the older population in England to 2035: Kingston, A, Robinson, L, Booth, H, Knapp, M, Jagger, C, & MODEM project. (2018). Age and Ageing, 47(3), 374-380