The Changing Roles of Doctors

Penny Cavenagh, Sam Leinster, Veena Rodrigues, Mick Collins, Susanne Lindqvist, Ann Barrett, Andrea Stockl, Amanda Howe, Alistair Leinster

• Publisher: CRC Press
• Year: 2022
• Print ISBN:
  9781138443440
• eBook ISBN:
  9781000605297
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This fascinating new book describes the evolution of the medical profession and how the role of the doctor and expectations of that role have changed over time. It critically examines developments in the light of both external influences such as the ageing population, patient attitudes and knowledge and government regulation, and internal changes such as the increasing knowledge base, advances in technology and changes in recruitment. Challenges in management, working environment, education and training are considered and practical recommendations for both practising and student doctors are offered. The holistic approach is supported with contributions from both primary and secondary care practitioners together with academics and educationalists. It is highly recommended for doctors and medical students seeking new strategies for understanding and managing change. Sociologists and policy makers, too, will find the wide-ranging perspectives enlightening.

List of contributors

Professor Ann Barrett, OBE, MD, FRCR, FRCP, is Emeritus Professor of Oncology at the University of East Anglia (UEA) and was formerly Deputy Dean of the Norwich Medical School, UEA, and lead clinician for oncology at the Norfolk and Norwich University Hospital NHS Trust.

Email: [e-mail]

Dr Ian LP Beales, BSc (Hons), MB BS (Hons), MD, FRCP (London), FHEA, FEBG, MAcadMEd, is Clinical Senior Lecturer in Cell Biology and Gastroenterology at the University of East Anglia and Honorary Consultant Gastroenterologist at the Norfolk and Norwich University Hospital. He is also the Training Programme Director and Head of Specialty Training for the East of England Gastroenterology Training scheme, and Co-Director of the Norwich Endoscopy Training Centre.

Email: [email protected]

Dr Laura Bowater, BSc (Hons), MSc, MAHEP, PhD, is a Senior Lecturer in Medical Education at the Norwich Medical School, University of East Anglia.

Email: [email protected]

Dr Bernard Thomas Brett, BSc, MB BS, FRCP (Lon), AMM (BAMM), is currently the Deputy Medical Director and Responsible Officer at the James Paget University Hospitals NHS Foundation Trust (JPUH) and was formerly the Medical Director from 2009 to 2012. He is also a Consultant Gastroenterologist and a Consultant Physician at the JPUH.

Email: [email protected]

Dr Mick Collins, PhD, BSc (Hons), Dip HSc, Cert Ed, is a Lecturer in Occupational Therapy in the Faculty of Medicine and Health Sciences at the University of East Anglia.

Email: [email protected]

Dr Sandra Gibson, BSc (Hons), PhD, PGCE, FHEA, is a Senior Lecturer in Medical Education and Head of Assessment and Information at the Norwich Medical School, University of East Anglia.

Email: [email protected]

Professor Christopher H Hand, MA, MSc, MB BChir, FRCP, FRCGP, is a retired general practitioner in Bungay, Suffolk. Until his recent retirement he was a Deputy Course Director of the Bachelor of Medicine and Bachelor of Surgery programme at the Norwich Medical School, University of East Anglia.

Email: [email protected]

Professor Amanda Howe, MA, MD, FRCGP, FAcadMEd, is a Clinical Professor of Primary Care at the Norwich Medical School, University of East Anglia. She is also an academic general practitioner at Bowthorpe Surgery in Norwich.

Email: [email protected]

Joanne Kellett, BA Hons, is a Research Associate at the Norfolk and Norwich University Hospitals NHS Foundation Trust.

Email: [email protected]

Alistair Leinster, BSc, PG Cert, MBA, is a General Manager working within the Alder Hey Children's NHS Foundation Trust.

Email: [e-mail]

Dr Susanne Lindqvist, BSc, MSc, PhD, QTS, is a Lecturer in Interprofessional Practice in the Centre for Interprofessional Practice, Faculty of Medicine and Health Sciences at the University of East Anglia.

Email: [email protected]

Dr Veena Rodrigues, MBBS, MD, MPhil, MClinEd, FFPH, is a Clinical Senior Lecturer in Public Health at the Norwich Medical School, University of East Anglia, and an honorary Consultant in Public Health Medicine, NHS Norfolk and Waveney.

Email: [email protected]

Professor Krishna Sethia, DM, FRCS, is a Consultant Urologist and Medical Director of the Norfolk and Norwich University Hospitals NHS Foundation Trust.

Email: [email protected]

Dr Andrea Stöckl, MA, MSc, PhD, is a Medical Anthropologist and Lecturer in Medical Sociology at the Norwich Medical School, University of East Anglia.

Email: [email protected]

Dr Richard Young, MA, MB BChir, FRCGP, DRCOG, FHEA, is an honorary Senior Lecturer and Lead Practice Development Tutor at the Norwich Medical School, University of East Anglia.

Email: [email protected]

CHAPTER 1 Drivers for change in the medical profession

DOI: 10.1201/9781846199202-1

Sam J Leinster

INTRODUCTION

The medical profession is an ancient and increasingly diverse institution. Both its status and its role in society have varied with time and place, but the pace of change has accelerated in the past 100 years. This chapter will attempt to survey these changes with particular reference to the United Kingdom. The effects of legislation and the structure of healthcare delivery will differ from country to country. The effects of developments in medical science and changes in professional attitudes will be more widely applicable.

FROM CARE TO CURE

The image of the ideal doctor is constantly changing. One of the most evocative pictures of the nineteenth-century image of the doctor is the painting by Sir Luke Fildes entitled simply The Doctor, first exhibited in 1891 but drawing on the experience of the death of his first son at the age of 1 year in 1877.¹ The doctor in this painting is clearly caring, concerned and thoughtful, but there is a strong impression that he has little to offer in the way of effective intervention. Interestingly, although the artist is drawing on his own experience, he has chosen to make the setting of the painting the home of a poor family, implying an expectation that the doctor would provide this care for patients based on need rather than their ability to pay.

As the twentieth century progressed, the effective interventions available to the doctor increased exponentially. The discovery of antibiotic agents in the 1930s and 1940s gave doctors the ability to treat life-threatening infections. By the 1960s there was a widespread belief that infective illnesses were no longer a major threat, provided medical treatment was available. The issue became a sociopolitical one of how the benefits of modern medicine could be accessed by the whole world population. The advent of anaesthesia, asepsis and biomedical engineering led to rapid developments in surgery including neurosurgery, cardiac surgery and organ transplantation. New imaging modalities and new laboratory techniques led to major improvements in diagnosis. The image of the ideal doctor shifted from that of caregiver to that of deliverer of cure. The measure of effective healthcare is not how the patient felt about the experience but, rather, what clinical outcomes were achieved.² The implicit model was that the body is a machine and the doctor is a technician with the knowledge and skills needed to maintain the machine and repair it if it goes wrong. Within this model, the depth and extent of the doctor's knowledge is more important than his or her ability to relate to the patient.

The increase in breadth and depth of knowledge has resulted in increasing specialisation and sub-specialisation as medical science developed. In the nineteenth century it was still possible for the well-educated physician to have a sound knowledge of the whole of medical practice and its underpinning scientific foundations. By the end of the twentieth century knowledge was expanding so rapidly that one could only keep up to date by focusing on a relatively narrow spectrum of practice. In the author's own specialty of breast cancer, the Web of Knowledge research platform lists more than 48 428 papers in 2011 alone. Information that is important for improving the management of patients can get lost in the sheer volume of material.

The downside of sub-specialisation is that no one is in a position to take an overview of the patient's condition. The success of modem medicine in prolonging life expectancy has meant that chronic conditions have replaced acute illness as the main focus of medical care. Patients rarely present with a single pathology and are often under the care of several different specialists, each one of who has only a limited understanding of the conditions for which he or she is not directly responsible. Treatments that are effective for one condition may be detrimental for another from which the patient suffers. Added to this, many modern therapies are associated with side effects so that improvement in one condition may result in an overall deterioration in the health status of the patient. Fragmentation of care is often associated with neglect of the patient's psychosocial well-being.³ This in turn may lead to poorer clinical outcomes.

An increasing awareness of the problems associated with a focus on the condition rather than the person has led to a swing back to a more holistic approach to medicine and a resurgence in the status of the general practitioner (GP), often known now as the primary care physician or the family physician. Paradoxically, general practice has become a specialty in its own right, with a growing emphasis on the management of patients with chronic conditions within a community setting.⁴ Care has returned to the agenda.

FROM INDEPENDENT GUILD TO REGULATED PROFESSION

The accepted roles of the medical profession and its relationship to the rest of society have been defined in the past in a variety of codes, the best known of which, in the Western world, is the Hippocratic oath. The earliest code is, probably, the Oath of the Hindu Physicians, dating from the fifteenth century BC, while the most recent to gain widespread acceptance is the Declaration of Geneva, which was first produced by the World Medical Association in 1948 and was most recently revised in 2006. There is remarkable agreement between the codes on the roles and responsibilities of a physician, but there is no common mechanism for ensuring that practitioners adhere to the requirements of the codes.⁵

Medical practice in the United Kingdom in the first half of the nineteenth century was in the hands of a range of different professions of varying status within the community. The most highly regarded were the physicians, who were usually university trained and who were regulated by the College of Physicians in London if they practised in England, or by the College of Physicians of Edinburgh, Glasgow or Dublin if they practised in one of those cities. Their services were expensive and were, therefore, largely limited to the wealthy. Apothecaries, who acted as a cross between a GP and a pharmacist, served the general population. They compounded and dispensed drugs from neighbourhood shops but they also made diagnoses and prescribed treatment. Their training was apprenticeship based and they were regulated by the Society of Apothecaries. A third regulated profession was the surgeons. In addition to carrying out the limited range of surgery that was possible before the development of anaesthesia and antisepsis, they provided general medical care alongside the apothecaries. There was friction between the two professions, with complaints being made that the surgeons were working beyond their training and competence,⁶ but it was not uncommon for individual practitioners to have dual training. In addition to the regulated practitioners, there were a large number of other people offering cures of varying description. Some of these were traditional healers making use of remedies and techniques handed down in families; others were charlatans deliberately exploiting the need and gullibility of the ill.

In response to growing public concern about the standards of medical practice, the UK government in 1858 established the General Council for Medical Education and Registration, later to be called the General Medical Council (GMC), whose functions were to define the minimum standards for training as a doctor and to maintain a register of those practitioners who had satisfied those standards.⁷ Th...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Foreword
• About the editors
• List of contributors
• Index