Do professional medical colleges serve a function in the 21st century?

Medical colleges were first formed over 500 years ago in an environment that was radically different from that existing in the early part of the 21st century. It is not at all unreasonable to question whether the roles of professional colleges are indeed still relevant. In Australia and New Zealand, the colleges were formed less than 100 years ago and the environment in which they were formed and the drivers for their formation are significantly different from that which drove the development of the colleges within Europe. The initial rationale for the development of medical colleges in Great Britain was largely for official recognition of the scope of practice. The surgeons, for example, sought recognition to separate their scope of practice from that of the barbers. In 1926, when the Royal Australasian College of Surgeons (RACS) was formed, the drivers were maintenance of standards, both in terms of surgical practice and surgical facilities and to renounce the unprofessional behaviour of fee-splitting. Initially, the College had no role in surgical education or examination but simply confirmed the adequacy of surgical training, undertaken elsewhere, by a newly defined Australasian standard. Subsequently, the RACS assumed a greater range of roles and while its current constitution1 includes the maintenance of standards for the practice of surgery amongst its top two objectives, it also includes surgical education, training, research and advice to the Government and the public. Each of these objectives could be further defined to include maintenance of competence and the defence of professionalism. What is the evidence that RACS is meeting these challenges and effectively promoting and supporting the standards of surgeons and surgery as well as maintaining professionalism, and could other bodies do this as well or better? Before embarking on this debate, it is impossible in 2016 to have a discussion about the role of the RACS without considering the roles of the specialty surgical societies. With increasing specialisation, surgical societies have been developed, some as long ago as 1940 (Neurosurgery),2 focused on the requirements of their own particular craft groups. While there have been examples where the societies’ directions did not necessarily parallel those of the RACS, with respect to the issues being discussed here, the activities of the specialty societies are synergistic. An example would be surgical training where this is now delivered by the speciality societies under a template approved by the College and accredited by the Australian Medical Council (AMC). In effect any reference to the role of the RACS could also be interpreted as the role of the College and specialty surgical societies. RACS’ initial raison d'etre and prime ongoing activity relates to maintaining the standards of surgery. This can be translated into maintaining the standards of surgeons by educating them well and providing the opportunities for them to maintain their competence. RACS began examining surgeons in the 1930s but only to test their knowledge and experience against an Australasian standard. Providing formal training in accredited posts began in the 1940s and only became widespread in the 1950s. Subsequently surgical education and training has become one of the keystone activities of the College. RACS provides training in nine specialties and the standards for entry, core components and exit examination are common throughout Australia and New Zealand. The training programme is evaluated and accredited by the AMC. The context in which training is provided is one of the key areas in which the question can be asked as to whether the College is the optimal provider of this education and training or should it be educational bodies like the universities. The complexity of this question becomes apparent when one considers that to train in surgery a trainee needs to see surgical patients and participate in and undertake surgical operations. The patients are predominantly public patients, the employer of the surgeons is usually a Government or State funded health authority, and the facilities in which the consultations and operations take place are also funded by the tax payer. While a minority of surgeons are university employees, the majority are part-time employees of the health authorities and undertake the clinical aspects of surgical training as part of their regular work. The governance aspects of surgical training are largely undertaken on a pro-bono basis and governed by the educational Boards of the College and the specialty surgical societies. There is little debate that surgeons should be training surgeons in the hospitals and clinics where they now do so. Any debate centres on whether this is governed, and where appropriate funded, by the Universities or Health jurisdictions. The RACS goes to great lengths to set a single standard for surgical training and maintain that across all Australian States and New Zealand. While the universities are also accredited by the AMC, they are different and provide different products. Indeed, they often go to great lengths to emphasise their differences. Expecting universities to employ surgeons, access publically funded hospitals and provide a single Australasian surgical product is counterintuitive. Providing surgical training in a university setting would also require considerable resourcing either by the State, and/or through student fees, well above the fees for surgical training currently charged by the College. An alternative argument is that the health jurisdictions should train surgeons as they have the patients and already employ the surgeons. Any argument that the universities lacked consistency is magnified many times when it comes to the health bodies that run public hospitals. It was a fact that in Europe, and is a fact in the United States, that institutions train surgeons rather than the relevant college. The end result is widely recognised variability in the surgical product that is produced. Unacceptable variability was one of the concerns that saw the formation of the RACS in 1926 and its current approach to the maintenance of surgical standards in the interests of the community is one of the reasons that the RACS is a relevant professional organisation in the 21st century. Maintenance of professional standards, demanded by the registering bodies in both Australia and New Zealand is another area where the RACS takes a uniform approach. The resources available to Fellows of the RACS as a result of financial membership are important in this regard. Access to courses, an annual scientific congress and access to an immense and relevant list of journals and texts through the on-line library are all resources where the College is ideally placed to support this goal. Educational events are of course provided by a range of other bodies but the College provides not only the educational resources but also a way to confirm their use and indicate that to the registering bodies. The College also supports surgical audit both directly, through the Australian and NZ Audit of Surgical Mortality, and indirectly though audits run by the specialty surgical societies such as that run by the ANZ Society for Vascular Surgery. Audit is a potentially threatening process for surgeons and wherever it is run it does so under the banner of qualified legal privilege. This arrangement would be impossible in a State-run organisation and to run a standardised process across Australia and New Zealand through either the universities or health jurisdictions is unlikely. While one of the founding principles of the College was to ensure suitable standards of surgical facilities, this is one area where the College has devolved a substantial amount of this activity to the State. In large part, the health jurisdictions ensure the standards of surgical facilities and there is a wide range of legislation which covers these activities. The College does take an active interest in the standards of surgical facilities as they apply to surgical training and the College's Trauma Committee oversees a verification process for facilities wishing to demonstrate appropriate levels of trauma care. Another of the principles outlined in the College's constitution is to support surgical research. Perhaps in an ideal world, one body could be responsible for funding surgical research but this is not the world we live in. As many funding sources and research opportunities as possible need to be available and the College, which has never set itself up to be the only research funder, is nonetheless an important contributor. In 2015, RACS provided 40 surgical scholarships and the Foundation for Surgery contributed a total of $1.7 million towards research activity At a recent tripartite meeting of the RACS, the Royal Australasian College of Physicians and the Royal College of Physicians and Surgeons of Canada, professionalism was accepted as an occupation requiring mastery of a complex body of knowledge and skills, used in the service of others, where its members are governed by a code of ethics and are committed to the promotion of public good.3 The underlying requirements of professionals under this code are honesty and integrity, altruism, confidentiality, respect and compassion. While there have been some spectacular lapses in adherence to this expectation, RACS has remained determined and committed to this public contract.4 Recently, examples of bullying and sexual harassment came to the College's attention. These events, and there were multiple examples, were a result of surgeons not behaving professionally. While the College was deeply disappointed by these activities and set in place a thoughtful and comprehensive programme to address these shortcomings,5 it should also be noted that these surgeons were public employees and the events occurred during their regular work as employees of the State. The evidence that the employer instituted any programme aimed at maintaining the professionalism of its employees is limited and it was evident from the public response that the expectation was on the College to address this issue, rather than the State. The RACS has also been active in the ‘Choosing Wisely’ campaign,6 addressing the overuse of tests and treatments and bringing this issue into focus for its Fellows and trainees. It should be evident from the content above that the RACS is neither anachronistic nor self-serving. It has regularly examined its structure and function over the years refreshing these to match the expectations of contemporary society. As an organisation comprising professionals, it is committed to the service of others and the promotion of the public good. Evidence to the contrary is lacking. As opposed to similar organisations in Canada and some of the Asian countries, the medical colleges in Australia and New Zealand remained independent rather than combining under the umbrella of a wider pan-medical professional body. The colleges do work together actively at a structural level through the Committee of the Presidents of Medical Colleges and with significant collaboration between individual colleges for activities, such as education and professional development. While a case could be made for even greater collaboration, the needs of individual members in the numerous craft groups would still need to be met. There is no doubt that the colleges face some challenges as they attempt to comply with the expectations of their constitutions but in large part they are the best bodies to do this, with support in some areas. As the colleges are not the employers of their Fellows and trainees, it gives them the opportunity to select, place and examine the trainees impartially and consistently, ensuring a single standard for surgical qualification in Australasia. As the RACS is not the registering body, it is able to advise impartially the registering body whether it believes the surgeon is qualified to be registered and in what scope of practice. It is an anomaly that in Australia and New Zealand each country's registering body places different emphasis on this advice but it is appropriate that the body responsible for setting a standard is not also the registering body. The college's role in supporting research is entirely appropriate and its minor supporting role in accrediting the quality of facilities in which certain activities (surgical training and trauma care) are provided is also appropriate. With regard to maintenance of professionalism, for professionalism to actually exist it must be governed and maintained by the body to which the professionals belong. For any other body to undertake a similar role would mean that it was acting under the format of an industrial contract as an employer and on that basis professionalism could not be displayed. Medical colleges are not passive bystanders but active contributors to the development of the medical workforce and the maintenance of their professionalism. While there are alternatives for some aspects of their functions, none provide opportunities which preclude the colleges’ ongoing contributions to the quality of health service provision in Australasia in the 21st century.

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