The Association of Physicians of Great Britain and Ireland: now what?

This inelegant question was stimulated by two related events. The first was the Association's centenary, celebrated in style at the Guy's Hospital Campus of King's College London in 2006; the second, West's elegant account of ‘one hundred years of an association of physicians’.1 Both made me reflect on the continuing fascination of medicine, its distinguished past and exciting future, and the role of the Association. My purpose is not to analyse the many factors contributing to recent changes in clinical practice—society's expectations, the increasing effectiveness, complexity and cost of modern medicine—but rather to consider how the Association might help meet the needs of physicians in the years ahead. Implicit in that self-imposed remit is a sense that the Association may not have been fulfilling that function as well in recent years as formerly. The picture chosen to illustrate West's history of the Association was of Osler. I have considerable regard for William Osler, bringing as he did Scottish educational values, via Canada and the USA, not just to England but to Oxford.2 He practised at a time when medicine was growing in confidence. The advances of the second half of the 19th century were becoming established practice, the Nightingale reforms had made hospitals safer, and the public both understood the benefits of the new treatments and wanted more; that demand eventually led to the introduction of the National Health Service in 1948 and equivalent health services in other countries. During Osler's time, life expectancy began to increase rapidly, with improvements in public health, obstetrics and the management of infections. Research was blossoming and the many local medical societies ensured that good practice was adopted widely and quite quickly. The advent of the General Medical Council in 1858 ensured that medical education and standards were applied more consistently across the UK. Great Britain and medicine were both flourishing. In that environment, the Association of Physicians was destined to succeed. The benefits of a small society of progressive, like-minded physicians, all motivated by a desire to expand the horizons of medicine and improve patient care, were obvious. And no doubt the elitist nature of the Association was part of its attraction; knowing those in the know was an obvious asset when the medical profession was relatively small. Over the succeeding years, however, the expansion of medicine and its increasing specialization have inevitably changed the role of the Association. Many research studies are now presented at specialist societies. Meeting annually, it seems to me that the Association now has three principal functions: (i) enabling members to keep up to date with developments in medicine, perhaps particularly in specialties other than their own; (ii) promoting critical reasoning and evidence-based medicine; and (iii) encouraging collegiality and mutually supportive friendship. These functions remain important for all of us, but I wonder whether the physicians of the future will find an annual meeting of the Association dealing mainly with these three aspects of their clinical practice sufficiently useful to justify their attendance and active participation. To reverse the argument, are we sure that the Association is making as much use as it might of the undoubted abilities of its members to explore solutions to contemporary problems? Many of these problems are not specialty-specific. What are we doing to address public concerns about patient safety? It is an inconvenient paradox that as other enterprises become safer (travel, energy industry, etc.), medicine has become less so. Of course, as Cyril Chantler noted, ‘medicine used to be simple, ineffective and relatively safe; now it is complex, effective and potentially dangerous.‘3 Nevertheless, perhaps the Association should have a view on how best to minimize the risks for our patients, even if that impinges on present managerial concepts. What of some of the other issues of the day? I believe that the Association could express views on the arrangements for academic medical careers, on the proposed changes to the Research Assessment Exercise and on the future direction of the Medical Research Council, to take just a few issues. What about Modernizing Medical Careers and the way in which we organize our clinical practice—might the Association have opinions on teamwork? We pay lip service to the importance of working in teams, yet provide little practical guidance to patients and colleagues, both medical and non-medical, whose experience of clinical care has changed radically and not always for the better in recent years. In short, has the time come for the Association to decide whether it wishes to continue as it has done for much of the last century, or whether it will focus on some of the current issues of practical concern to the practising physician? I appreciate that there is no shortage of other medical bodies tackling these topics with greater or lesser success; indeed I have argued elsewhere of the need for a single forum to bring the various entities together. On the other hand, I suspect that if the Association concentrated on a single matter of concern, with leadership from the Executive and improved electronic communication and coordination amongst members, much might be achieved—of real benefit to patients and physicians alike. As W.H. Auden observed in Leap before you look: The sense of danger must not disappear The way ahead is short and steep However gradual it looks from here. Look if you like, But you will have to leap. Perhaps we need to make, if not a leap, then a step change in our Association?

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