Medical colleges: whose purpose, if any, do they serve?

The purpose, if any, that medical colleges could or do serve in 2017 is uncertain. The future college role might be constrained to professional and technical evaluation of doctor competence and up-skilling. The sentinel question is whether or not the medical guilds can become effective socially beyond intrinsic guild-need and play a role in preventing and mitigating, and in responding to, health system failures. Medical colleges have long been a part of the ‘health system architecture’. The Royal College of Surgeons (RCS) arose first as the Guild of Surgeons within the City of London in 1368. An agreement in 1493 resolved a consequential long-standing dispute between the surgeons and the barber-surgeons (from whose unqualified ranks the quaint habit of the titular Mr, and now similar feminine forms, arose instead of Dr). In 1540, Henry VIII formed the Company of Barber Surgeons as a union of the Worshipful Company of Barbers and the Guild of Surgeons. The surgeons broke away from the barbers to form the Company of Surgeons in 1745, and the RCS in London was created by way of a royal charter in 1800. The RCS in London is nevertheless well predated by the Barber Surgeons of Dublin, who were incorporated in 1446 by a royal decree from Henry VI, and just preceded in 1505 by the Barber Surgeons of Edinburgh, who were formerly incorporated as a Craft Guild of Edinburgh. In response to considerable lobbying from physicians and apothecaries, and sometime after similar regulatory interventions elsewhere in Europe, Henry VIII also formed the Royal College of Physicians by a royal charter in 1518, followed by an Act of parliament in 1523. There is no doubt about the craft-guild origins of the medical colleges and/or their longevity. The question to be debated is do the colleges still have any utility or are they anachronisms? To balance this historical introduction, it needs to be acknowledged that increasing patient safety by way of practitioner regulation was a strong element of the foundation debates. Critics of the medical profession, such as Roy Porter,1 argue that the sociological construct of the medical colleges has proven resilient and that they remain craft guilds. It is tautological then to argue that colleges are self-serving, as this is a central purpose and function of any guild. Both Porter, and other critics, such as Ivan Illich,2 would also suggest an alternative market-control (i.e. patch-protection and/or constraint-of-trade) rationale for practitioner regulation that is masked by patient-safety rhetoric. They would accept the various colleges’ public health affirming mottos but counter that craft guilds have always used community-service-type ‘platforms’ to advance their own causes, and in the case of health, sometimes at the expense of societal best interests. The history of medicine is littered with atrocities perpetuated by and/or tolerated by the medical profession,1, 3 and by doctor-led health system failures;4, 5 notwithstanding the considerable good for which the medical profession has been responsible, the unanswerable question in this context is why have the medical guilds repeatedly failed in their core and founding ‘patient-safety’ mission? Recent British examples of such systemic failures, which resulted in considerable patient-harm, such as in Bristol, and about a decade later in Mid-Staffordshire,4, 5 suggest that little is learnt and that medical colleges are, at best, somewhat passive bystanders. Similarly, contemporary treatment injury data do not illustrate contextual college efficacy. Extrapolating from the most recent annual report of New Zealand's comprehensive and no-fault Accident Compensation Corporation,6 treatment injury costs will soon exceed those of any other source of injury (i.e. either road traffic accidents, or industrial and domestic accidents). In the USA, medical error is now reported as the third most common cause of death, exceeded only by heart disease and cancer.7 First, a profession is an occupation in which the necessary preliminary training is intellectual in character, involving knowledge and to some extent learning, as distinguished from mere skill. Second, it is an occupation, which is pursued largely for others and not merely for oneself. Third, it is an occupation in which the amount of financial return is not the accepted measure of success. The question we posed at the time, and would do so again, is to what extent has the medical profession, both directly and through the organs of the profession, such as the colleges, abandoned one or more of these professional characteristics? Ray Moynihan's investigative journalism is now almost 20 years old,10 but his core hypothesis, that Australia is subject to ‘too much medicine’, remains as poignant today. Is there a purpose that medical colleges could or do serve in modern health systems? This lead editorial will identify issues that are germane to answering this question; two former presidents of Australasian medical colleges have written follow-up editorials. Although, in general, form should follow function, as a preface to considering the roles of medical colleges, how well constructed are the Australasian medical colleges to serve any role beyond guild-husbandry? The contrast is with the singular Hong Kong Academy of Medicine, albeit an umbrella organisation, and the two-college Canadian system; the Academy and the Canadian colleges are capable of coordinated, integrated and timely action and reaction. The same probably cannot be said for Australia and New Zealand's fragmented and binational college system. It could be argued that the Royal Australasian College of Physicians (RACP) is analogous to the Hong Kong situation as it is an aggregate of special interest societies and faculties. However, is there a unifying college fellowship and social agency or, as suggested by college conference attendances, do loyalties and social interaction lie with the societies and faculties (that are really only linked by a logistical economy of scale that arises from sharing back office and some trainee assessment functions)? The separation of public health physicians from the RACP to form a standalone New Zealand college and the earlier separate development of the Royal New Zealand College of General Practitioners support an argument that the Australasian colleges are in effect Australian colleges with New Zealand members, and hence that only lip-service is paid to the New Zealand health system needs. A counter-argument would be to cite the number of New Zealand-based current and recent presidents of some of the Australasian colleges. It is unreasonable to claim that the medical colleges do not ‘add value’ in regard to the assessment of candidates for vocational medical registration, or for that matter in collegial evaluative processes that underpin continuing professional development programmes. However, the medical advocacy, training and regulatory milieu is very crowded. Given the existence of such strong unions as the Australian Medical Association and the Association of Salaried Medical Specialists in New Zealand, is there a need for other doctor advocacy (and industrial and employment relations support) groups? Similarly, why are medical colleges necessary when there are so many university medical schools that could assume postgraduate medical educational roles, and when the regulatory authorities and patient quality and safety commissions have such a strong and legislatively mandated role to play in ensuring patient safety? There are three core tasks in ‘rendering’ modern health systems fit-for-purpose, sustainable and affordable to which a medical college might contribute, beyond the obvious roles of the medical administration and public health guilds. The first of these relates to the refractory nature of the core-operating model in healthcare (i.e. a doctor-led, hospital-based, transactional and passive-consumer system that was well suited to meet the disease burden in the 19th century).11 This contrasts with the natural history of almost any other industry, which is for innovative internal and external disruption.12 The only other obvious ‘industrial’ examples of such recidivism are the legal and education systems; it is interesting to note that all the recidivists cited here are dominated by a professional power-elite. The situation is admittedly more complex than implied, as healthcare is somewhat paradoxical in this regard given the concurrence of this refractory core-operating model and the often-unpredictable flux in models of care for specific illnesses and injuries.11 The second is the observation that there is probably a general oversupply of doctors in most OECD countries,13 and that these doctors are not well distributed against health need (i.e. from resident versus senior medical officer, disciplinary, ethnic and demographic perspectives).14 Identifying a role for medical colleges in either of these first two issues would conform to Einstein's definition of insanity; that is, doing the same thing over and again, and expecting a different outcome. There is a strong argument that medical colleges themselves are in part responsible for the persistence of the core-operating healthcare model cited above and for creating and maintaining many workforce mal-distributions. The relevant historical observation is that guilds have always struggled to endorse other guilds unless there is a common gain or shared risk. The third issue is the increasing unaffordability of healthcare and noting that the quality and cost of healthcare are highly influenced by behaviour at the provider–patient interface,15, 16 and that surveys suggest the major contributors to any unmet health need in the European nations are non-health system factors.17 It is interesting that the American College of Physicians require, by way of their ethics manual, that physicians be parsimonious in regard to using healthcare resources.18 The question then is whether or not medical colleges should be involved in, and if they can add value in, broader healthcare issues such as reducing waste and in subsequent healthcare rationing, and in even contributing positively to wider societal problems for which global warming is a good example. So, what purpose, if any, do or could medical colleges serve in 2017? Is the future college role to be constrained to professional and technical evaluation of doctor competence and up-skilling? Can the medical guilds become effective socially beyond intrinsic guild-need and play a role in preventing and mitigating, and in responding to, health system failures? To paraphrase, what is the college value-add for modern healthcare?

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