Quality in Primary Care Open Access

Raymond Tallis is Professor of Geriatric Medicine at the University of Manchester, but in addition to his medical interests has contributed to philosophy. In this book, professor Tallis reviews the current state of medicine, and observes a dissociation between what medicine has achieved and the way in which it is perceived. He argues that we need to rethink the relationship of medicine to society.

The book is set out in three distinct sections. In the first, the rise of medicine from the experiences of prehistoric peoples through the renaissance into the scientific age is outlined, the focus being the way in which scientific medicine has made the human body more human. Self-criticism has made an important contribution to the success of scientific medicine; doc-tors have adopted a sceptical stance towards received ideas and sought to question authority, thereby pro-moting gradual advance in the effectiveness of medical interventions.

In the second section, the contemporary discon-tents are introduced. They include what Tallis regards as poorly informed expectations of doctors in relation to communication, time and waiting. The argument that doctors are unreasonably powerful when compared to their patients is erroneous, and the culture of sus-picion and distrust fostered by politicians and others is leading to increasingly stringent controls on doctors and the practice of defensive medicine. In the world outside medicine, misunderstanding of scientific method and prejudice serve as enemies of progress, and fail to acknowledge that scientific medicine ‘for all its faults, is the bravest and most honest attempt to mediate between the needs of suffering humans and the ‘‘un-human’’ body’. To add to the problems, some journal-ists and lawyers misrepresent doctors’ intentions.

The third section looks into the future. Tallis anticipates that if the relationship between society and medicine does not change, medicine will cease to be a profession – it is in danger of losing its values, of medicine as a ‘calling’, and becoming a service industry staffed by technicians skilled in customer care, who may be too shallow to cope with the depths of serious illness. Tallis then effectively demolishes the argument that increasing life expectancy must lead to more years of dependency in old age. Good medical care de-medicalises old age. There is much still to gain, therefore, from the future of scientific medicine.

Most doctors will find something to agree with in Hippocratic Oaths. The accumulating pressures on doctors from policymakers, managers, media and patients are undeniable. More control and more bureaucracy are features of every doctor’s life. But Tallis’ thesis – that the threat to medicine of being irreversibly corrupted comes not from the profession but from society at large – is more difficult to swallow. Of course society has made life more complicated for doctors, but doctors and their leaders have played their part. Tallis fails to adequately question the role of doctors’ professional organisations as they have sought to defend doctors over the last 30 years. For this reason, although many doctors will feel their cause is well served in this book, most readers outside medi-cine are likely to see it as another attempt to defend doctors rather than an invitation to a dialogue or guidance to doctors on what they must do to preserve professionalism into the future. I found the debate on power was the point at which Tallis’ argument lost its way. He argues that the power of doctors and the powerlessness of patients are both exaggerated, and that the policies followed in the NHS and the attitudes of society based on this exaggeration are misguided and damaging. This view does not reflect my personal experience nor the findings of relevant research. On this issue, scientific medicine is apparently, not so scientific. If Tallis’ thesis about the source of the threat to medicine is rejected, an obvious question arises – why have doctors failed to preserve their profession in the social environment of the late 20th and early 21st centuries? I suspect the answer is that doctors have failed to understand society and not that society has failed to understand doctors. However, you will enjoy reading this book and coming to your own con-clusions in this vital issue.

Richard Baker

Department of Health Sciences University of Leicester

There is a growing interest among medical teachers and leaders in the idea of professionalism. While there is no clear agreement about what constitutes pro-fessionalism, there is a discernible consensus that it is important, it is not as healthy as it should be, and something must be done to assist doctors, particularly the doctors of the future. Pattison and Pill’s timely book presents an opportunity to step back from the debate about professionalism in medicine and reflect on what professionalism is, and the values that might be part of a strong medical professionalism.

There are 14 chapters by authors from a mix of professions including engineering, nursing, theology, law, town planning, and health services management as well as philosophers and academics. They begin by trying to define what we mean by values; this is no easy task and the reader at the beginning of the book may wonder whether the concept of values is useful, but by the final chapter is likely to agree that they are fundamental to our understanding of the role and responsibilities of professionals. Having tried to ex-plain what values are, the book examines professional values from different perspectives and in different con-texts. The conflicts between values and professional identity are explored, the way in which values are embodied in professional codes discussed, and the place of values in education and teaching outlined. We learn that values can be challenged by developments in society, national policy or the management of daily work. They can cause a profession to become trapped in a narrow and dysfunctional pattern of behaviour, as in the case of law; they can raise questions about whether a group is a profession at all, as in the case of health service managers; or they can be used to assist a profession in developing independence and coher-ence, as in the case of nursing. They can also serve as a bulwark against unreasonable attempts at control and dominance when the professional’s key task is to be the advocate of the disadvantaged (the social worker) or to challenge orthodoxy and promote freedom of thought (the researcher).

The editors conclude that a static view of pro-fessions and their values is untenable – both are subject to change and reflect the relationships between the professions, the people they serve, and the society in which they live. If we desire effective professions, we need to understand their values and how they develop as the social milieu changes. They argue that several things need to be done. The first in their list is to encourage professional bodies to think more critically and self-consciously about their values and how they instil them in their members. The public should be involved by professional bodies in a dialogue about the values of the profession. I fully agree with the editors’ analysis on this point. Perhaps the new dis-cussion of professionalism in medicine is the first stage in such a process. The editors also argue for more research into professional values, and again I agree.

Values in Professional Practice will be of interest to those who are interested in the issue of medical professionalism, and others concerned about values. It does not provide a manual on the development of values nor does it offer a set of values for medical practice, but its broad perspective will generate ideas that would be missing from a book with a narrow focus on medicine. It is a refreshing journey beyond the boundaries of a single profession.

Richard Baker

Department of Health Sciences University of Leicester