- Email: [email protected]
New professionalism in the 21st century
Correspondence
After publication of our paper (Jan 7, p 52),1 we were alerted to errors in it by Fabio Levi, of the University of Lausanne. An independent review of the programs and calculations used in the study has now been carried out. Although the key conclusions of the paper remain unchanged, an inadvertent error in the program used to analyse the data has regrettably necessitated non-trivial changes to many of the numerical values quoted in the paper. We regret any confusion caused. The corrected tables and the figure are available online. We describe below the changes required in the Results section. The other sections of the paper stand as originally published. Cirrhosis mortality rates in Britain are increasing sharply, contrary to the declines seen in many other European countries. Between 1987–91 and 1997–2001, cirrhosis mortality in men in Scotland more than doubled (112% increase [vs 104% in original paper]) and in England and Wales rose by over two-thirds (67% [vs 69% in original paper]). Mortality in women increased substantially (63% in Scotland [vs 46% in original paper] and 35% in England and Wales [vs 44% in original paper]). Cirrhosis mortality rates in Scotland are now among the highest in western Europe, in 2002 being 28·9 (vs 45·2 in original paper) per 100 000 in men and 12·8 (vs 19·9 in original paper) in women. The corrections to the figure showing temporal trends in cirrhosis mortality have made almost no difference to the 45–64-year age-group. For the 15–44-year age-group the changes compared with the original are larger but the pattern remains the same. Between 1950–54 and 2000–02, rates in men increased by a factor of four (vs five in original paper) in England and Wales and by a factor of six in Scotland (as in original paper). In www.thelancet.com Vol 367 February 25, 2006
women there were corresponding three-fold and four-fold increases in rates (vs four-fold for both countries in original paper). Since the 1970s, cirrhosis mortality rates for the aggregate European comparison group have declined by 40–50% (vs 25–30% in original paper) in both sexes and agegroups (15–44 years and 45–64 years). Scottish cirrhosis mortality rates are more than double those of the European comparison group. In the period 1997–2001, Scottish women had the highest cirrhosis mortality rates and Scottish men the fourth highest (vs second and third highest, respectively, in original paper). Table 2 shows that in the all ages group, Scottish men and Scottish women had the steepest proportional increases in rates between 1987–91 and 1997–2001, with England and Wales showing the second highest increase for men and third highest for women (vs second in original paper). At all ages, Norway and the Netherlands now show declines in both sexes. Within each of the individual agegroups in table 2, Scottish men have the highest rate of increase in cirrhosis mortality rates. Scottish women also have the highest rate of increase in the 15–44-year and ⭓65-year agegroups, being second to Ireland in the 45–64-year age-group. Men in England and Wales show the second highest rate of increase after Scotland, with the exception of the ⭓65-year age-group where they are in third place after Ireland. Women in England and Wales have the second (⭓65 years), third (15–44 years), or fourth (45–64 years) highest rates of increase. Overall, the proportional increases in liver cirrhosis mortality rates in Britain are the steepest in western Europe, as originally reported. The increases in Scotland are even steeper and warrant particular attention. We thank Tim Collier who independently reviewed the whole set of programs and concluded that the revised figures represent robust and valid results, assuming the validity of the WHO source data. We also thank Fabio Levi and colleagues for alerting us to the problem and for verifying our corrections to table 3.
*David A Leon, Jim McCambridge [email protected] Non-Communicable Disease Epidemiology Unit, Department of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK (DAL); and National Addiction Centre, Institute of Psychiatry (King’s College London), London, UK (JM) 1
Leon DA, McCambridge J. Liver cirrhosis mortality rates in Britain from 1950 to 2002: an analysis of routine data. Lancet 2006; 367: 52–56.
Rights were not granted to include this image in electronic media. Please refer to the printed journal
New professionalism in the 21st century Good policy, compelling position statements, and inspiring documents on issues of the moment are worth their weight in gold. Examples proliferate: the Kyoto Protocol to the United Nations Framework Convention on Climate Change and the WHO’s Health for All Declaration of AlmaAta spring to mind. Think in longer historical sweeps and you could throw in the Magna Carta or the US Declaration of Independence for good measure. Each of these established the prospect of meaningful change in society. It is hardly an exaggeration to suggest that, for the first time in the history of medicine, we might have such a document for the profession. Doctors in society: medical professionalism in a changing world (Dec 10, p 1985),1,2 written by a working party convened by the UK’s Royal College of Physicians, could become one of the most important milestones in medical progress, having ramifications beyond Britain and its National Health Service. It has application to a large international audience hungry for real reform rather than meaningless restructuring. It creates a fresh, evocative definition of professionalism in medicine (“a set of values, behaviours and relationships that underpins the trust the public has in doctors”) and asks doctors to live these out in their everyday practices. Some of us have been worried for a while, observing the erosion of professionalism in medicine.3
See Department of Error
e-mail submissions to [email protected]
645
Science Photo Library
Liver cirrhosis mortality rates in Britain, 1950 to 2002
Correspondence
Doctors in society was crafted after widespread consultation. Few who read it will fail to be convinced by this document’s erudite arguments for new professionalism and aspirations for medicine, and almost everyone will want for it to work, and to become deeply rooted in medicine’s collective consciousness. But there’s the rub. Journeys to translate evidence into everyday work, policy into practice, and knowing into doing are littered with false starts, wrong turns, and dead ends. Without advocating procrastination, for the problem is too important and urgent, we need an equally well-crafted case explaining how changes at the levels of health systems, organisations, groups, and individuals would be accomplished in order to embed the era of new professionalism. The working party says that we require improved leadership and multidisciplinary teamwork. It argues for education for new professionalism, better approaches to appraising the values of doctors, an emphasis on fresh career pathways for the profession, and research into the relations between new professionalism and improved heath outcomes. But more than this, we need to think through the models of change we will harness, because there are many, and to understand the context for change, the processes of enacting new professionalism, and the mechanisms to involve sufficient people to create a tipping point.4 In short, we now have the “what” and “why” to renovate medical professionalism, but we will need the “how” and “who”. In the first century BC, Horace said5 “no man ever reached to excellence in any one art or profession without having passed through the slow and painful process of study and preparation”. So the profession itself must study and prepare, and recognise that at times transformation will be painful, and not fast enough for some. To deny this is to deny history. I declare that I have no conflict of interest.
Jeffrey Braithwaite [email protected] 646
Centre for Clinical Governance Research, University of New South Wales, 10 Arthur Street, Randwick, New South Wales 2052, Australia 1 2
3 4
5
Horton R. Medicine: the prosperity of virtue. Lancet 2005; 366: 1985–87. Royal College of Physicians. Doctors in society: medical professionalism in a changing world. Report of a Working Party of the Royal College of Physicians of London. London: RCP, 2005: 66. Southon G, Braithwaite J. The end of professionalism? Soc Sci Med 1998; 46: 23–28. Gladwell M. The tipping point: how little things can make a big difference. New York: Little Brown and Company, 2000. Horace [Quintus Horatius Flaccus]. The works of Horace. Salt Lake City: Gutenberg Press, 2004.
Richard Horton1 rightly emphasises the importance of the report of the Royal College of Physicians (RCP) Working Party on Medical Professionalism.2 However, his criticism of the current redraft of the General Medical Council’s (GMC’s) Good medical practice reflects a disappointing misunderstanding of its contents.3 The term “professional” is indeed used in the text of the document, but in each case it refers to “belonging to or relating to a profession”—ie, to being a doctor as opposed to not being a doctor.4 As far as the use of this term relates to “showing the skill, artistry, demeanour or standard of conduct appropriate to a member of a profession”,4 this is what the text of the document itself describes, and the leadership shown by the GMC in publishing and then updating Good medical practice has been internationally recognised. The purpose of the current revision of Good medical practice is to ensure that it is “up to date, fit for purpose and contains principles that are held to be important by doctors, patients and the public”. The RCP Working Party report was published at an opportune time and will contribute significantly to further consideration of the responses generated during consultation, and to the final document which will continue to form the foundation of all GMC guidance, provide the framework for medical education, underpin doctors’ appraisal and revalidation, and set the standards of competence, care, and conduct expected of doctors.
The GMC makes a unique and important contribution to maintaining and developing the professionalism of medicine and ensuring it remains “medicine’s most precious commodity”. However, as emphasised in the RCP Working Party’s recommendations, this will require an integrated response from all involved—national bodies and the four UK Departments of Health, and from each individual doctor. I am Chairman of the GMC Standards and Ethics Committee.
John Jenkins [email protected] General Medical Council, London NW1 3JN, UK 1 2
3
4
Horton R. Medicine: the prosperity of virtue. Lancet 2005; 366: 1985–87. Royal College of Physicians. Doctors in society: medical professionalism in a changing world. London: RCP, 2005. General Medical Council. Good medical practice—a draft for consultation. London: GMC, 2005. Anon. Chambers dictionary, 9th edn. Edinburgh: Chambers Harrap Publishers, 2003.
Richard Horton is right in every respect.1 Professionalism is at the heart of the medical enterprise and is being subtly eroded by many current developments. But the Royal College of Physicians bullet points he promotes are too anodyne. They may well define the aspirational base of the profession, but they say nothing about the tough facts of its application and maintenance. They need to be complimented by a more fully worked out theory of medical knowledge and defence of the professional conditions necessary to maintain this knowledge. The student doctor may begin from an altruistic impulse, but in training has to acquire a coherent knowledge base and, crucially, learn how to apply this in a live setting. Confidence comes from the repeated experience of mediating such knowledge with unique patients, each experience representing a different synthesis of predicament and the relevant knowledge required. Horton points rightly to the self-confidence, the sense of authenticity, independence, and flexibility of mind essential to apply the knowledge base www.thelancet.com Vol 367 February 25, 2006
After publication of our paper (Jan 7, p 52),1 we were alerted to errors in it by Fabio Levi, of the University of Lausanne. An independent review of the programs and calculations used in the study has now been carried out. Although the key conclusions of the paper remain unchanged, an inadvertent error in the program used to analyse the data has regrettably necessitated non-trivial changes to many of the numerical values quoted in the paper. We regret any confusion caused. The corrected tables and the figure are available online. We describe below the changes required in the Results section. The other sections of the paper stand as originally published. Cirrhosis mortality rates in Britain are increasing sharply, contrary to the declines seen in many other European countries. Between 1987–91 and 1997–2001, cirrhosis mortality in men in Scotland more than doubled (112% increase [vs 104% in original paper]) and in England and Wales rose by over two-thirds (67% [vs 69% in original paper]). Mortality in women increased substantially (63% in Scotland [vs 46% in original paper] and 35% in England and Wales [vs 44% in original paper]). Cirrhosis mortality rates in Scotland are now among the highest in western Europe, in 2002 being 28·9 (vs 45·2 in original paper) per 100 000 in men and 12·8 (vs 19·9 in original paper) in women. The corrections to the figure showing temporal trends in cirrhosis mortality have made almost no difference to the 45–64-year age-group. For the 15–44-year age-group the changes compared with the original are larger but the pattern remains the same. Between 1950–54 and 2000–02, rates in men increased by a factor of four (vs five in original paper) in England and Wales and by a factor of six in Scotland (as in original paper). In www.thelancet.com Vol 367 February 25, 2006
women there were corresponding three-fold and four-fold increases in rates (vs four-fold for both countries in original paper). Since the 1970s, cirrhosis mortality rates for the aggregate European comparison group have declined by 40–50% (vs 25–30% in original paper) in both sexes and agegroups (15–44 years and 45–64 years). Scottish cirrhosis mortality rates are more than double those of the European comparison group. In the period 1997–2001, Scottish women had the highest cirrhosis mortality rates and Scottish men the fourth highest (vs second and third highest, respectively, in original paper). Table 2 shows that in the all ages group, Scottish men and Scottish women had the steepest proportional increases in rates between 1987–91 and 1997–2001, with England and Wales showing the second highest increase for men and third highest for women (vs second in original paper). At all ages, Norway and the Netherlands now show declines in both sexes. Within each of the individual agegroups in table 2, Scottish men have the highest rate of increase in cirrhosis mortality rates. Scottish women also have the highest rate of increase in the 15–44-year and ⭓65-year agegroups, being second to Ireland in the 45–64-year age-group. Men in England and Wales show the second highest rate of increase after Scotland, with the exception of the ⭓65-year age-group where they are in third place after Ireland. Women in England and Wales have the second (⭓65 years), third (15–44 years), or fourth (45–64 years) highest rates of increase. Overall, the proportional increases in liver cirrhosis mortality rates in Britain are the steepest in western Europe, as originally reported. The increases in Scotland are even steeper and warrant particular attention. We thank Tim Collier who independently reviewed the whole set of programs and concluded that the revised figures represent robust and valid results, assuming the validity of the WHO source data. We also thank Fabio Levi and colleagues for alerting us to the problem and for verifying our corrections to table 3.
*David A Leon, Jim McCambridge [email protected] Non-Communicable Disease Epidemiology Unit, Department of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK (DAL); and National Addiction Centre, Institute of Psychiatry (King’s College London), London, UK (JM) 1
Leon DA, McCambridge J. Liver cirrhosis mortality rates in Britain from 1950 to 2002: an analysis of routine data. Lancet 2006; 367: 52–56.
Rights were not granted to include this image in electronic media. Please refer to the printed journal
New professionalism in the 21st century Good policy, compelling position statements, and inspiring documents on issues of the moment are worth their weight in gold. Examples proliferate: the Kyoto Protocol to the United Nations Framework Convention on Climate Change and the WHO’s Health for All Declaration of AlmaAta spring to mind. Think in longer historical sweeps and you could throw in the Magna Carta or the US Declaration of Independence for good measure. Each of these established the prospect of meaningful change in society. It is hardly an exaggeration to suggest that, for the first time in the history of medicine, we might have such a document for the profession. Doctors in society: medical professionalism in a changing world (Dec 10, p 1985),1,2 written by a working party convened by the UK’s Royal College of Physicians, could become one of the most important milestones in medical progress, having ramifications beyond Britain and its National Health Service. It has application to a large international audience hungry for real reform rather than meaningless restructuring. It creates a fresh, evocative definition of professionalism in medicine (“a set of values, behaviours and relationships that underpins the trust the public has in doctors”) and asks doctors to live these out in their everyday practices. Some of us have been worried for a while, observing the erosion of professionalism in medicine.3
See Department of Error
e-mail submissions to [email protected]
645
Science Photo Library
Liver cirrhosis mortality rates in Britain, 1950 to 2002
Correspondence
Doctors in society was crafted after widespread consultation. Few who read it will fail to be convinced by this document’s erudite arguments for new professionalism and aspirations for medicine, and almost everyone will want for it to work, and to become deeply rooted in medicine’s collective consciousness. But there’s the rub. Journeys to translate evidence into everyday work, policy into practice, and knowing into doing are littered with false starts, wrong turns, and dead ends. Without advocating procrastination, for the problem is too important and urgent, we need an equally well-crafted case explaining how changes at the levels of health systems, organisations, groups, and individuals would be accomplished in order to embed the era of new professionalism. The working party says that we require improved leadership and multidisciplinary teamwork. It argues for education for new professionalism, better approaches to appraising the values of doctors, an emphasis on fresh career pathways for the profession, and research into the relations between new professionalism and improved heath outcomes. But more than this, we need to think through the models of change we will harness, because there are many, and to understand the context for change, the processes of enacting new professionalism, and the mechanisms to involve sufficient people to create a tipping point.4 In short, we now have the “what” and “why” to renovate medical professionalism, but we will need the “how” and “who”. In the first century BC, Horace said5 “no man ever reached to excellence in any one art or profession without having passed through the slow and painful process of study and preparation”. So the profession itself must study and prepare, and recognise that at times transformation will be painful, and not fast enough for some. To deny this is to deny history. I declare that I have no conflict of interest.
Jeffrey Braithwaite [email protected] 646
Centre for Clinical Governance Research, University of New South Wales, 10 Arthur Street, Randwick, New South Wales 2052, Australia 1 2
3 4
5
Horton R. Medicine: the prosperity of virtue. Lancet 2005; 366: 1985–87. Royal College of Physicians. Doctors in society: medical professionalism in a changing world. Report of a Working Party of the Royal College of Physicians of London. London: RCP, 2005: 66. Southon G, Braithwaite J. The end of professionalism? Soc Sci Med 1998; 46: 23–28. Gladwell M. The tipping point: how little things can make a big difference. New York: Little Brown and Company, 2000. Horace [Quintus Horatius Flaccus]. The works of Horace. Salt Lake City: Gutenberg Press, 2004.
Richard Horton1 rightly emphasises the importance of the report of the Royal College of Physicians (RCP) Working Party on Medical Professionalism.2 However, his criticism of the current redraft of the General Medical Council’s (GMC’s) Good medical practice reflects a disappointing misunderstanding of its contents.3 The term “professional” is indeed used in the text of the document, but in each case it refers to “belonging to or relating to a profession”—ie, to being a doctor as opposed to not being a doctor.4 As far as the use of this term relates to “showing the skill, artistry, demeanour or standard of conduct appropriate to a member of a profession”,4 this is what the text of the document itself describes, and the leadership shown by the GMC in publishing and then updating Good medical practice has been internationally recognised. The purpose of the current revision of Good medical practice is to ensure that it is “up to date, fit for purpose and contains principles that are held to be important by doctors, patients and the public”. The RCP Working Party report was published at an opportune time and will contribute significantly to further consideration of the responses generated during consultation, and to the final document which will continue to form the foundation of all GMC guidance, provide the framework for medical education, underpin doctors’ appraisal and revalidation, and set the standards of competence, care, and conduct expected of doctors.
The GMC makes a unique and important contribution to maintaining and developing the professionalism of medicine and ensuring it remains “medicine’s most precious commodity”. However, as emphasised in the RCP Working Party’s recommendations, this will require an integrated response from all involved—national bodies and the four UK Departments of Health, and from each individual doctor. I am Chairman of the GMC Standards and Ethics Committee.
John Jenkins [email protected] General Medical Council, London NW1 3JN, UK 1 2
3
4
Horton R. Medicine: the prosperity of virtue. Lancet 2005; 366: 1985–87. Royal College of Physicians. Doctors in society: medical professionalism in a changing world. London: RCP, 2005. General Medical Council. Good medical practice—a draft for consultation. London: GMC, 2005. Anon. Chambers dictionary, 9th edn. Edinburgh: Chambers Harrap Publishers, 2003.
Richard Horton is right in every respect.1 Professionalism is at the heart of the medical enterprise and is being subtly eroded by many current developments. But the Royal College of Physicians bullet points he promotes are too anodyne. They may well define the aspirational base of the profession, but they say nothing about the tough facts of its application and maintenance. They need to be complimented by a more fully worked out theory of medical knowledge and defence of the professional conditions necessary to maintain this knowledge. The student doctor may begin from an altruistic impulse, but in training has to acquire a coherent knowledge base and, crucially, learn how to apply this in a live setting. Confidence comes from the repeated experience of mediating such knowledge with unique patients, each experience representing a different synthesis of predicament and the relevant knowledge required. Horton points rightly to the self-confidence, the sense of authenticity, independence, and flexibility of mind essential to apply the knowledge base www.thelancet.com Vol 367 February 25, 2006