The Purpose and Limits to Professional Self-regulation

Trust me, I’m a doctor.” In the United States and United Kingdom, a recent survey reports, more than 80% of the public does.¹ According to the Cambridge moral philosopher O’Neill, “Each of us and every profession and every institution needs to be trusted.”² She questioned whether the new climate of accountability and regulation in society was improving trust in physicians. She suggested that new systems of accountability cannot only change but also distort the proper aims of professional practice; if society wants a culture of public service then professionals and public servants must in the end be free to serve the public rather than their paymasters.² However, if physicians are to be trusted by the public they serve, they have to deserve to be trusted, and that is why medical professionalism matters.

A report on Doctors in Society prepared by the Royal College of Physicians of London in 2005 suggested that professionalism lies at the heart of being a good doctor.³ This report defined medical professionalism as a set of values, behaviors, and relationships that underpins the trust the public has in physicians.

Following this report a series of consultation events across England and Wales took place to debate the issue of medical professionalism with physicians and medical students, nurses, allied health professionals, and managers as well as patients and families. At all these events there was support for regular and robust testing of fitness to practice.⁴ This is also the subject of the article by Shaw and colleagues from the United States, United Kingdom, and Canada in this issue of JAMA.⁵ While comparing recertification in these countries, the authors ask whether physician self-regulation can survive under the increasing pressure for accountability and transparency in the regulation of the medical profession.

Others have suggested a need to redefine medical professionalism given the changing roles of physicians and the increasing expectations of the public, and this in turn will have an effect on regulation. New ways of practice have developed including more team and multidisciplinary work and diversification of medical roles to include academic, managerial, strategic, and advisory functions that raise questions for the profession.⁶ Can or should professional self-regulation cover all roles of a physician in the delivery of health care⁷ or should it be restricted to clinical practice and principally to the patient-physician encounter? If so restricted, what should be covered by professional self-regulation and what by contractual accountability to an employer within a health care system, or to the patient or insurer that pays for care?

There are many aspects of the problem to be considered in addressing these questions. The notion of value in health care encompasses the quality and safety of the care provided but also whether it is effective and efficiently delivered.⁸ Profligacy in the care of one patient within a cost-contained publicly funded health care system can lead to denial of adequate care for another patient. Do physicians have responsibilities to act as advocates for the sick and to encourage justice in health provision? Given that most health care expenditure now is for preventable chronic illness, should physicians, while providing clinical care, also function as public health professionals to reduce the burden of chronic illness?⁹ What are the responsibilities of physicians to ensure that they adapt their clinical practice to facilitate the introduction of new systems designed to improve clinical practice, such as electronic medical records,¹⁰ and that they share information appropriately with patients and colleagues?

The importance of measuring outcomes and concentrating resources on effective and necessary treatments is at the heart of the current debate regarding the reform of health care systems, and not just in the United States.¹¹ The General Medical Council (GMC), which regulates the profession in the United Kingdom, has made clear that the duties of a physician include the protection and promotion of the health of patients and the public.¹² The GMC standards also set out clearly the requirement to contribute to team work, to cooperate with research, and where appropriate to provide education. The GMC also offers guidance to physicians involved in management. Should professional self-regulation and recertification cover all these activities and responsibilities?

On the other hand, there is concern that recertification processes could impair a physician's ability or desire to take on wider responsibilities. During consultation events with UK physicians on professionalism it became clear that those in the early or middle part of their careers thought it might not always be easy to change their roles and responsibilities if revalidation and recertification were not sufficiently flexible to allow for this. There was also anxiety that physicians who took on other activities might not be able to maintain their clinical skills, thus putting their recertification at risk.⁴ Adequate systems of training and retraining for both clinical and other responsibilities, together with recertification systems that measure competency in all aspects of a physician's role, will be necessary to address these issues.

As Shaw et al⁵ point out, all physicians will be required to recertify for medical practice in the future. The question is what should be the scope and how can it be ensured that recertification is fit for purpose and not too onerous. There is a risk that if the medical profession does not accept the need for self-regulation to cover the totality of a physician's work rather than just the clinical encounter that others will, either by contract or by an alternative form of regulation. The loss to professional esteem will be real and the effect on patients and society will be damaging. It is perhaps better for physicians as well as for society that physicians should work for love as well as for money and that they should protect their own professionalism. Physicians need trust more than regulation, but it is up to them to introduce systems that are comprehensive and fit for most purposes but not too bureaucratic or burdensome.