Learning professionalism: a personal view

Professor John Malins (1915–92), distinguished Birmingham physician and my mentor during my training years, used to observe that the consultants' key role is in outpatients. Why?

The Royal College of Physicians (RCP), the King's Fund and the General Medical Council (GMC) are all commendably emphasising the importance of teaching professional behaviour.^1–3 But can it be taught? It can certainly be learnt, but not really taught² - a view to which many would subscribe. Skills in a profession where a doctor needs to be ‘a shaman, a detective, a priest and a friend’,⁴ might only be acquired after extensive studies of humanities, ethics, theology, sociology and anthropology,⁵ but can in reality probably only be gained by experiencing and observing the behaviour (good or bad) of more senior teachers and mentors.

‘The only real teacher is experience’, Tony Benn suggested at the Hay-on-Wye Literary Festival. The professional skills needed in a consultation must be acquired by clinical experience, argued Sir Douglas Black (1913–2002, professor of medicine in Manchester and former president of the RCP), because, as he said, the balance of risks needed in making decisions in the majority of clinical situations ‘is not easily expressed in guidelines’.⁶ Indeed, Raymond Tallis has argued that doctors are in danger of becoming ‘deprofessionalised, sessional functionaries, robotically following guidelines’.⁷

The role model must be the key to moulding our professional behaviour. The courteousness and gentleness of Sir Max Rosenheim (1908–72, University College Hospital professor of medicine and former president of the RCP) clearly influenced an erstwhile student who observed that he was ‘never annoyed or impatient’.⁸ Professor John Malins, with his profound understanding and knowledge of his patients, excelled at clinical skills, and endeared himself to them not least when he located their origins by identifying their dialect almost to the nearest street! Watching Sir Ronald Bodley Scott (1906–82, physician, St Bartholomew's Hospital) at the bedside gave his juniors a superb example of clinical examination, while his role as the Queen's physician was marked by an exemplary demonstration of confidentiality. My friend and colleague Dr David Pyke (1921–2001, physician, King's College Hospital) passed on fine advice on writing and speaking, as well as those needed for managing managers. Earlier in my career, as a very young senior house officer at the Birmingham General Hospital, I recall an episode when I telephoned a senior physician (Dr Clifford Parsons, 1909–92) for help at 0300 - his immediate response was ‘don't tell me any more, I'm coming in’ - this left a lasting mark on me. And then there was the neurosurgeon in Ian McEwan's fine novel Saturday who dutifully undertook to operate on a thief who had broken into his home and threatened his family with violence.

Personal accounts of the influence of role models on behaviour are very convincing. The supportive influence of senior doctors in the UK, compared to the formerly hierarchical organisation in Germany, was perhaps one of the reasons why many Germans have come to work in Britain. One of them has written of the ‘supportive atmosphere’ in the UK where doctors ‘strive to be memorable teachers to the next generation’. He was surprised that he could even communicate with, and receive advice from, ‘very distinguished doctors’ with whom he worked.⁹

Teaching by example has no equal. A physician friend recently showed me an appreciation from one of his students after he himself was appointed as consultant physician, and he has allowed me to quote from it: ‘I remember sitting in a dingy outpatient room with other students as my consultant conducted the consultation. He did the lot! He welcomed her in, made her at ease with this group of students, took a full thorough history in a matter of minutes, using words that patients understood, and understanding the meaning of all the words she said. All the time he was somehow managing to teach us about medicine. I was deeply impressed, and decided I wanted to be like him.’ So, young doctors in training need guidance towards learning from the practice of their mentors, and how to recognise both the good and the bad. Do I make my case for the role model, and for Professor John Malins' emphasis on the key importance of the outpatient consultation? It is in the stress of the outpatient milieu that professional skills are tested and demonstrated to the limit - courtesy, kindness, technical skill, communication and rapid decision making, all under pressure. It is of concern that some doctors have expressed the view that learning from role models might be undermined by the way in which shiftwork and rotations mean that junior doctors are ‘no longer attached to one group of doctors to learn in training; it is all being dissipated’.² This is a serious and real threat indeed, which underlies the reason for writing this short article.

I end this personal view with a reflection from Yehudi Menuhin: ‘The ability to teach is a gift: a gift of experience, an amalgam of mistakes and discoveries, successes and failures; a gift as unpredictable as the seed the farmer sows, not knowing whether or not it would germinate, which becomes a plant in its own right and produces a new seed, thus completing the great cycle of nature and creation.’¹⁰

• © 2011 Royal College of Physicians