Demoralisation,deprofessionalisation,denial and detachment in medicine?

Introduction

The past two decades have been significant in terms of advances in medicine as a whole and in many specific specialties, and yet there appears to be a sense of demoralisation among medical professionals at all levels, not only in Australasia and the UK but elsewhere. New discoveries, new technologies and new drugs have brought hope to patients. Knowing the efficacy of these drugs and investigations, but with an increasingly tightening financial strait-jacket, means that sometimes there is a sense of despondency in the medical profession. The profession may feel that they are not being allowed to utilise the full potential of various interventions and to perform at the best of their abilities. The relationship between doctors and society is not stretched to breaking point yet, but tensions between doctors and policymakers are apparent, and a sense of mutual distrust can be identified. How did things get to this level? The perceived and real undermining of the profession due to various social, economic and political changes has to lead to a change in the way professionalism is defined and the responsibilities inherent in these roles.

Changes in regulation, the introduction and insistence on treatment guidelines and excessive control of the profession have produced a climate where doctors feel that they are being turned into technicians (Taylor, 2013). The regular and constant interference by the political masters and real or perceived control have all contributed to a sense of bewilderment. Perceived or real de-professionalisation can also produce a feeling of alienation and abandonment by leaders in the profession. Some of the contributory causes are easy to define, but others are not.

Challenges to the profession

Scandals in the medical profession have led to many inquiries in a number of countries. Each inquiry has produced recommendations, mostly resulting in more centralised control and additional layers of bureaucracy. For example, the Shipman Inquiry in the UK led to the recommendation that all doctors should be revalidated regularly. Initially, there were suggestions that this should be every year, and thereby a strong likelihood emerged that doctors would spend all their time preparing for revalidation. It is highly unlikely that revalidation would have picked Shipman out, as patients were queuing at his door to join his list. A strong regulator rather than more form filling and a tick-box approach might have been better. Annual appraisals have become strict tick-box exercises rather than a developmental tool.

Policy changes

As Taylor (2013) points out, in the UK, between 1948 when the NHS was established and 1974, there was only one re-organisation. In the last two decades, there has been one re-organisation every 2 years. In opposition, politicians promise no more top-down reorganisations, but when they come to power virtually the first thing done is to negate all that has gone on before and carry out a further re-organisation. Very little policy is evidence-based. Sometimes it is driven by pure ideology and at other times it is in response to demand rather than need. These 2-year cycles of reform are tiring for staff, and changing regulations and rules leads to a sense of entrapment and defeat. As soon as one has adjusted to one set of reforms and the system has reached a homeostatic level, further changes are introduced. Sometimes a short-termist timetable dictates changes. Few politicians bring with them a long-term vision or strategy to be put in place. When these changes are introduced, with limited or no consultation with the profession, it is inevitable that the profession will feel a sense of alienation.

Technical advances

Rapid technological advances both in investigation and intervention add to the health care bill. Whereas professionals would like access to the latest investigations and tools for treatment, financial resources may not be available, even when the evidence for efficacy and effectiveness is quite clear. On the other hand, patient demands rather than their needs may drive more expensive but less efficacious treatments. What is required is more detailed discussion with society through its stakeholders and an analysis of the efficacy of different treatments. The practice of defensive medicine can also add to the healthcare bill when unnecessary investigations are carried out. Pushing forward the frontiers of science is of great benefit, but a judicious use of limited resources is critical.

Patient expectations

Patient expectations have changed over the past few decades. Patients are more likely to be better informed about their conditions, treatments and the potential side effects of their treatments. The professional–patient relationship is moving towards a genuine partnership. However, training still focuses on old-fashioned patriarchal perspectives, although this is beginning to change. Patients sometimes may like the doctor to make the decision, but good clinical practice mandates that patients are able to understand the implications and that they themselves can take control of the condition and be at the heart of the therapeutic alliance. There will be cultural differences of course, and clinicians must remain aware of these. However, the most important axiom still remains – first, do no harm. Newer diagnoses also bring additional costs into play. The profession needs to negotiate with patients and policymakers as to what is needed and have an honest conversation to deliver that.

Societal expectations

As patient expectations have changed, so have the expectations of society. From an implicit contract, changes in society and social expectations have started to influence this contract, which is becoming more explicit. The expectations that society has from the medical profession and professional values reflect changes that society has experienced over the past few decades. Increasing divorce rates and single parenthood, growing poverty, the ongoing economic downturn, overcrowding and unemployment all increase not only the likelihood of certain physical and psychiatric illnesses but also of social expectations. This contract between physicians and society needs to be re-evaluated and renegotiated.

Consequences

As a result of socio-demographic changes, it is possible that the professions feel threatened and under detailed scrutiny at all times. The role that medical leadership can take in these circumstances needs to be explored further.

Deprofessionalisation

Professional values are to do with technical competencies, setting standards for self, self-regulation and unique responsibilities embedded in the profession itself. As technical advances are happening at a fast rate, the debate between the role as a generalist or a specialist becomes louder (see Royal College of General Practitioners, 2012). Structures and governance also contribute to the definition of professionalism. Professionalism is about mastery of a complex body of knowledge, competence, integrity, altruism, self-regulation, keeping up to date with knowledge and promotion of public good (see Irvine et al., 2010). In the past, changes in organised medicine led to changes in professionalism and professional values. At the present time, the morale among doctors in many developed countries appears to be low. However, as Weissman and Busch (2010) emphasise, healthcare in the United States is in crisis and varied groups are asking for change, although the reasons may be different. Similar changes can be observed in the UK, where the impact of the recent Francis Report on the number of patient deaths and their care in the Mid Staffordshire NHS Foundation Trust reported that the culture of the organisation was a major problem (Francis, 2013). Its impact on medical professionalism will probably last for a long time to come, even though there was no direct criticism of doctors. As the culture of the organisation was blamed within which medical professionals work, it is likely that the response to these enquiries will lead to further bureaucratisation of services. Anecdotally, in many areas, new patient appointments are given for 2 hours – 1 hour to see the patient and another hour to fill in all the forms. Whether filling in forms can actually stop further tragedies is anyone’s guess. In a similar vein, academic freedom is being controlled and corralled in the same burgeoning of administrative bureaucratic measures. There is no doubt that some of these steps are indeed essential but these have often been imposed illogically and thus gone to the other extreme. It is indeed surprising to see that, as numbers of managers have mushroomed, there is still no regulatory body for this group to define, maintain and promote their ‘professional’ standards. That is, not to recommend that further bureaucratisation is necessary but simply to highlight the question: who holds managerial actions responsible? The use of words such as ‘users’ or ‘consumers’ indicates that, in psychiatry at least, and perhaps in medicine as a whole, the profession itself is becoming a business and a commodity, which will bring a different set of values and standards to the therapeutic interaction.

Demoralisation

When the medical profession feels neglected and rejected – the sense that not only is no one interested in their opinion but no one appears to be listening to professional views and concerns – it leads to a feeling of entrapment and a sense of learned helplessness. A sense of bewilderment and the constant bombardment of changes contribute further to this sense of entrapment. Learned helplessness leads to a depressive state of withdrawal. This withdrawal also reflects a further sense of isolation, where doctors may feel that they ought to focus on things they do best, which is direct patient care. A lack of investment by doctors in the change is thus inevitable, leading to a vicious circle of alienation and further withdrawal and cocooning. This demoralisation has produced further alienation from society. The sense of entrapment needs to be addressed by leaders in the profession. Entrapment and alienation lead to a sense of isolation, withdrawal and suicidal behaviour and one seriously starts to wonder whether that is what is happening to the profession.

Denial and detachment

The sense of denial follows on from focusing on patient care without recognising that the delivery of patient health care depends upon a number of factors and is strongly influenced by society through its stakeholders, such as politicians and policymakers. Most doctors feel that they would rather spend time with patients instead of fighting endless battles for resources. This denial of the broader picture and resulting detachment further allows things to be done to the profession. The desolation and difficulties in recruiting trainees to art specialties (such as general practice and psychiatry) can complicate the status quo, when often the instinctive response is to duck and withdraw into perceived ‘comfortable’ settings of patient care. The desolation experienced by senior doctors may be attributed to cynicism and response to change, but it reflects an underlying malaise where individuals feel trapped and helpless. They do not see themselves as part of the drive to change, but face endless circles of change.

The way forward

There are clear challenges for the regulators, the Royal Colleges or equivalent bodies, policymakers and other stakeholders. The professional bodies need to build alliances, reconstitute the contract with society and define concepts of professionalism in the changing contexts and values. Although there have been some steps in this direction, by and large these have been single-specialty developments (American College of Physicians, 2006; Royal College of Physicians, 2005). The profession must agree with broad definitions of professional values and the roles and responsibilities of the profession. The ‘new professionalism’ with its focus on integrated care with the patient at the heart of assessment and management must also include integrity, compassion, altruism, and striving for continuing improvement and excellence within teams where appropriate. Almost all medical specialties work in teams, even those specialties where direct patient contact may be limited. The challenge for the profession as a whole is to amend the definition of professionalism and to ensure that the next generation of doctors form a key part of this discussion and development. Medical professionalism is not a simple set of values, attitudes and behaviours, but also about relationships with patients, their families and carers and with society at large. Society at large may be represented by the media, policymakers, employers and funders. This contract with society needs to be renegotiated as a matter of urgency.

Society expects doctors to have certain values and responsibilities and, in return, doctors expect recognition and trust. There is no doubt that trust needs to be earned. Cruess and Cruess (2010) argue cogently and impressively that, as this contract is not explicit but implicit, such negotiation is with the policymakers who act on behalf of society. If that does not work, as has been the case sometimes, surely the medical profession needs to go directly to society – first to explain what is possible and what is not and, second, to negotiate the terms and the expectations embedded in this social contract.

Doctors need to take on leadership roles – whether these are small (for the team) or large (for the organisation or professional body). Professionalism as a characteristic is dynamic and if it does not change with the social norms it will die out (Johnston, 2006). Bad behaviour, whether clinical or otherwise, cannot be accepted under any circumstances (Page, 2006) and the profession itself has to take the lead in ensuring that standards are set right and then maintained accordingly.

Conclusions

In a number of countries, it would appear that the medical profession is under siege for a number of reasons. The medical scandals of the past three decades have laid bare the notion that the profession could regulate itself. It was thought that doctors protect each other, but recent experience has shown that this is not always the case and poor doctors do get caught and dealt with. In addition, the profession needs to redefine its values and expectations with suitable training and acknowledgement.