Open up medicine's cloistered world

May 31, 1996

Medicine is a profession charged with a duty to serve all members of society, but which is dominated by white, middle-class men. A profession that still learns the bulk of its trade by apprenticeship and in which the teachers represent only one faction of society. A profession whose failure to communicate is infamous and whose conduct sometimes appears more concerned with furthering its own interests rather than those of patients.

But it is society that pays for medical education, pays the salaries of most doctors and provides doctors with the wherewithal to practise. Society deserves better treatment, but for this to occur the community will need to play a much greater role in the way doctors are selected and trained. The public can no longer afford to delegate to the medical profession responsibility for producing the next generation of doctors, rather this should be the product of partnership.

Some key objectives of the partnership are clear - to produce a mix of doctors that reflects the composition of the National Health Service population as a whole in terms at least of gender, race and class; and to select and train doctors so that they can competently serve in an effective NHS (or its equivalent) and have the ability to teach and do research.

It will be difficult to achieve these goals through an equitable partnership, not least because society has little idea of what goes on in medicine and how the profession runs itself. Nor, I imagine, does society know exactly what it wants of the profession. What qualities, for instance, do patients see as constituting competence to practise and how should these be prioritised?

As a first essential step any criteria set for selection and training will need to involve at least the four key players - patients, doctors, educators and government, and there may well be additional special interests that will also need inclusion.

Next, the relationships between the players will have to be based on honesty (people have a right not to be deceived), transparency (policies and their derivation and implementation should be explicit), equality (individuals have the right to equality of opportunity and treatment), and with all these mutual respect.

A critical product of this new partnership, and one that will probably prove the most difficult to achieve, will be the establishment of a sound process for selecting doctors. The partnership must ensure that the criteria for selection are explicit and incorporate agreed, measurable, relevant and realistic specifications. It must ensure that the process is monitored and its immediate and long-term outcomes assessed. And finally it must make certain that the criteria and process are reviewed and modified to ensure goals are met. Currently little of this is done, so that when the Commission for Racial Equality asks that medical schools take positive action to encourage applications from black women, it is difficult to see how such a recommendation could be implemented.

But perhaps the greatest challenge will be to produce a scheme that permits diversity. It is diversity that allows all the many fields of medicine to be staffed (prison doctors to paediatric surgeons to psychiatrists to radiologists to pathologists etc). It is also diversity that sets the stage for debate and change.

Selection does not stop on entry to medical school. What public awareness there has been has centred on the move of students from school to university, but the processes by which young doctors are sifted thereafter needs equal partnership, and with it oversight and overhaul. Institutions involved in these later stages, which cover a period lasting ten to 15 years (most doctors are not fully qualified for their definitive posts till their 30s) remain almost monastically secretive, but it is probably here that the greatest influences are inculcated.

For there to be real change the idea of partnerships must be embraced by the medical schools as they design their courses and set their exams. Moreover, the same must hold true for the various Royal Colleges (for instance the Colleges of General Practitioners, Surgeons and Physicians), all of which hold exams to assess professional competency, but none of which involves the public in designing the syllabus, setting exams or assessing the candidates. One of the key issues that patients complain about is the failure of doctors to communicate with them. Would it not be reasonable for such a skill to be assessed by representatives of the community? Can there be any defence for appointing consultants who are unable to listen, let alone explain?

Such a failure to involve the public and to practise transparency is deeply ingrained in the profession and even ramifies through the General Medical Council (GMC), the public's delegated guardian of the profession. When, in December 1993, it produced its report on Tomorrow's Doctors, which has already caused fundamental changes in undergraduate medical education, no mention was made of the members of the working party who produced the report, nor details given of the consultation process. With probing, it became clear that only one of the permanent members was a woman and none was from an ethnic minority. More probing revealed that in the consultation process, which involved personal visits to most, if not all of the UK's medical schools, very little time was spent seeking the views of patients and consumers. It is likely that there have been some changes to the GMC's working practices since 1993, but evidence of such has yet to filter into the public gaze.

None of the changes proposed is going to be easy to implement, but, if they are adopted, I am sure that the benefits would be enormous. With the realignments in the profession's composition, attitudes and qualities I believe clinical interests will broaden, research interests will be more relevant to the needs of the community, patients interests more readily satisfied, student interests more fully addressed and the medical profession more richly endowed and effective. If all these are on offer what reason can there be to resist change?

Joe Collier is reader and consultant in clinical pharmacology at St George's medical school, London. Ten years ago, in collaboration with Aggrey Burke, he was responsible for discovering that the computer programme used at St George's for processing student admissions forms discriminated against women and members of ethnic minorities.

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