Introduction (Doctoring Medical Governance-Medical Self-Regulation In Transition)

‘[Medicine]…must be enthused with a spirit of openness, driven by the conviction that… decisions must be routinely open to inspection and evaluation, like the openness that pervades science and scholarship’.

Freidson (1994: 196)

This topic is concerned with the sociological study of the medical profession and the principle of medical self-regulation. This is the view that medical professionals should be left alone to manage their own affairs in regards to members training, practice and discipline. Like in many other Western nation-states, in the United Kingdom (UK) professions such as medicine, dentistry and law have traditionally possessed monopolistic control over entry onto and exit from a legally underwritten state approved register of qualified practitioners. Furthermore in the UK the principle of professional self-regulation has been embodied by the public institution which for the last one hundred and fifty years has symbolized the principle of professional self-regulation within medicine: the General Medical Council (GMC). However there have been substantial changes in the governance of professional expertise in recent times. Growing concern over the effectiveness of existing self-regulatory arrangements has caused the state to act to ‘open up’ the previously ‘close shop’ field of professional regulation, and in doing so it called for greater inter-professional cooperation and managerial and lay involvement in the regulation of professional expertise. This has directly challenged the traditional viewpoint held by professional elites that they should be left alone to manage their own affairs. A similar trend has been recognised internationally by sociologists in Europe (Kuhlmann and Allsop 2008), Canada (Coburn et al 1997), Australia (Coburn and Willis 2000), New Zealand (Doolin 2002) and USA (Freidson 2001). Consequently, although its empirical case study is grounded in the UK, this topic is of international relevance to social scientists concerned with how medical practitioners are reacting to contemporary shifts in the regulation of expert services (Kuhlmann and Saks 2008).

It may have long been recognised internationally by sociologists that doctors are becoming increasing subject to formal calculative regimes, such as audit and appraisal, which seek to contractualize and formalize their working arrangements and professional judgements to economise health service provision. However two important points need to be recognised here. First, little sociological research has been undertaken on recent challenges to medical autonomy from the perspective of doctors themselves, and furthermore, what has been published is primarily concerned with doctor’s perceptions of a possible decline in their clinical freedom ‘at the bedside’. Second, no published research has focused on exploring the relationship between contemporary challenges to the principle of medical self-regulation and medical practitioners’ educational activities. This is not too much of a surprise given that the sociological study of professional regulation in general was seen to be a ‘backwater topic’ until the late 1990s (Davies 2004). This topic seeks to fill a recognised gap in the current ‘sociological corpus’ that has been recognised as needing to be filled for quite some time (i.e. Elston, 1991). It achieves this by, firstly, reviewing the current ‘state of the art’ of the sociological literature concerned with professional regulation in light of contemporary shifts in the practice of state governance, and secondly, by documenting the findings of empirical work undertaken with doctors in the UK examining the impact of portfolio-based performance appraisal on how they supervise medical trainees and keep themselves up to date and fit to practice in their chosen speciality.

The system of medical training and regulation in the UK has undergone substantial reform in recent times. As they have responded to external pressure for reform, medical elites such as the GMC, medical schools and the Royal Colleges have enforced a move towards a structured competence-focused outcome-based approach to training and career progression by means of formal appraisal. They advocate a ‘new medical professionalism’, sometimes called ‘professionally-led’ medical regulation, as they seek to maintain the principle of self-regulation, albeit in a new more publicly accountable form. For the contemporary political climate requires medical elites themselves adopt a more open, transparent and inclusive governing regime which relies upon a ‘best evidenced’ approach to medical governance (see Irvine 1997 2001 2003, Catto 2006 2007). So it should come as no surprise to learn that this ‘new professionalism’ has also signalled the beginning of a proactive surveillance, inspection and control programme by the GMC and the Royal Colleges of the delivery of medical training at undergraduate, postgraduate and continuing levels. Clear quality assurance standards are used to govern their content and outcomes (Bateman 2000, Searle 2000). As the ex-chairman of the GMC, Donald Irvine, (2001: 1808) notes ‘the essence of the new professionalism is clear professional standards’.

A key tool that medicines elites have used to support their new open and accountable governing regime is the ‘learning portfolio’ or ‘portfolio of achievement’ (Challis 1999, Southgate 2001). Portfolios support the implementation of a ‘best evidenced’ outcome based performance appraisal within the medical club (Snadden 1998, Wilkinson 2002). Indeed, today’s medical students will encounter portfolio based professional development planning and performance appraisal throughout their professional careers (Davis 2001). For paper-based and electronic portfolios are being used throughout medical school and junior doctor training, in later specialist training, as well as to support the implementation of Annual Appraisal of doctors as part of their National Health Service (NHS) contract (BMA 2005).Yet the political utility of portfolio learning as a governing strategy that supports the renewal of principle of professional self-regulation lies in the fact that a completed portfolio acts as a personalised bureaucratic surveillance record of key events and turning points in the career biography of individual workers (Gilbert 2001). Their increased use within medicine is due to their ability to act as a concrete record of an individual doctor’s competence and career development. Furthermore, they are completed in an apparently inclusive manner under the banner of promoting individual and institutional transparency and accountability, as required by medicines ‘new professionalism’. In short, portfolios act as one of medicines new ‘visible markers of trust [which as]…tools of bureaucratic regulation fulfil [a] function as signifiers of quality’ (Kuhlmann 2006b: 617).

By tracking the development of the principle of professional self-regulation it details contemporary challenges to medical autonomy from both within and outside of the NHS. In doing so it highlights how elites within the medical profession have been criticised for possessing a ‘closed shop’ club mentality towards the issue of who should regulate doctors’ activities, as well as for consistently placing their own professional interests above those of the general public. It concludes by discussing the 2008 Medical Act, which has instigated a series of fundamental reforms to medical governance, including the implementation of revalidation nationally in 2010.In doing so, it covers neo-Weberian, neo-Marxist, Feminist and Governmentality perspectives as it seeks to analyse the entwined nature of the development of the modern state and professions. Topic five leads on from this discussion, noting how there is a lack of empirical literature relating to the sociological study of medical training and regulation. This is particularly true from the perspective of doctors themselves and concerning the affect on their actions, if any, of recent reforms within medical education. Based on this gap in the literature, the topic concludes by proposing an investigation into the introduction of portfolio based performance appraisal within medicine.Embedding its discussion within the context of the historically situated policy analysis provided in topics two and three, as well as the theoretical perspectives and empirical literature discussed in topics four and five, it details how the doctors interviewed adopted a stance of ‘paperwork compliance’ toward portfolio based performance appraisal. Topic seven discusses this findings contribution to the sociological literature concerned with the study of professional regulation in general, and the medical profession and the principle of medical self-regulation in particular.

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