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

In his deliberately provocative but nevertheless thought-provoking lead editorial,1 Professor Gorman could be perceived as blaming all the misdemeanours undertaken and tolerated by the medical profession, and all the ills of modern healthcare provision, on the inabilities of medical colleges to address these issues adequately. He even goes so far as to demonstrate Godwin's Law2: ironically, originally formulated to reduce the incidence of inappropriate hyperbolic comparisons. While Gorman does quite correctly allocate a level of obligation to other groups, he does not ascribe to them the same level of responsibility as he does to medical colleges. This is despite the fact that these other groups may have the legislative powers, political influence and other ‘levers’ to address these issues, while colleges often do not. Perhaps colleges should be flattered that they are considered so influential, carry such moral authority and have the wherewithal to address these issues of gargantuan proportions. Ah, that this was indeed the case. In reality the colleges are but one, and at times a small part, in the complex behemoth that is modern healthcare. Many of the technologic, social, economic and political changes which are taking place in health and society are outside the current sphere of influence of the college. Even in post-graduate medical education, the training environment is complex and other cultures may exert as much if not more influence on the trainee than the college. The challenge for modern colleges is to define and assert clearly and unambiguously their roles and then deliver on these in a way that benefits patients and the community. In defining this role, I would encourage the colleges to be aspirational; to seek and secure roles well beyond those that they currently assume. George Bernard Shaw said: ‘the reasonable man adapts himself to the world: the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man’. Gorman is exhorting members of colleges to be more ‘unreasonable’ – on this point I wholeheartedly agree with him. This is very similar to the concept of ‘disruptive innovation’ outlined by Derek Bell in the closing plenary address on quality, safety and value in healthcare at the recent Royal Australasian College of Physicians (RACP) Annual Scientific Congress. It is not my intention that this article descend into a point-scoring exercise and semantic arguments, as to do so would trivialise the important question raised by Gorman: ‘Medical colleges – whose purpose, if any, do they serve?’ In addressing this question, I do not wish to be perceived as a ‘denier’ of the fact colleges have not always done all they could have, or been as proactive as they could and should have, in relation to certain issues; the ‘passive bystander’ argument of Gorman does have credence. The question is whether lessons have been learned and whether colleges are performing better. In the case of the RACP, I believe we are and hope to provide evidence for this contention. I will respond to some of the specific issues raised by Gorman, leaving my colleagues to address other aspects of the question posed. Gorman provided a brief synopsis of the history of the UK colleges. While it is important to understand the origins of colleges, to suggest that our origins as guilds means that colleges are simply self-serving organisations ignores a great deal of evidence to the contrary. Being of the same generation as Gorman, I too was an avid reader of the works of Ivan Illich, including ‘Medical Nemesis’. However, to suggest that colleges used ‘community service-type platforms’ merely to advance their own causes, is an unreasonably cynical and a somewhat disingenuous interpretation of the writings of ‘the Prophet of Cuernavaca’. In the remainder of this article, I will focus on the present and the future, although by doing so run the risk of diminishing the enormous significance of previous actions by medical colleges that have profoundly affected the health of millions. For example, based on research conducted by Professor (Sir) Richard Doll and colleagues, the Royal College of Physicians’ statement on cigarette smoking as a risk for development of lung cancer changed the smoking habits of society, brought about legislative changes and undoubtedly saved the life of millions.3 Sadly, it is necessary that the RACP advocacy on tobacco control continues to this day. As repeatedly demonstrated within and outside the profession, colleges are a ‘soft target’ for critics. Detractors take perverse delight in referring to colleges as “old boys’ clubs”. The reality is quite different; the RACP membership is neither old nor dominantly ‘boys’. The RACP has 24 291 members; 16 507 fellows and 7784 trainees. Of the fellows, 45% are <50 years and 34% female. Of trainees, 57% are female. All colleges, including our own, need to reflect on whether their deeds and actions and the resultant public perception make them vulnerable to such accusations and portrayals. The Earl of Chesterfield said: ‘Advice is seldom welcome; and those who want it most always like it the least’. Our college needs to be able to take advice and accept criticism. However, there are also obligations on the critics; their criticism should be informed, well-intentioned, constructive, given in the best interest of the college and always provided in a collegial fashion. ‘Hominum servire saluti – to serve the health of our people’ is the motto of the RACP. In the cases of the RACP (and the Royal Australasian College of Surgeons (RACS)), it is the college of rather than the college for; a very important distinction I believe. In relation to the particular characteristics of a profession by Brandeis referred to by Gorman, the RACP (and the RACS) would seem to meet all three requirements. First, the major role of the RACP is education; specifically vocational training and continuing professional development. Second, the college's engagement in advocacy and other activities (which will be discussed below) and reflected in the motto, indicates that the college is striving to act ‘largely for (the benefit of) others and not merely for (itself)’. Third, the RACP made the decision some time ago that it would not engage in discussions or negotiations regarding the remuneration or working conditions of specialists. These philosophies are contained in the Tripartite (RACP, RACS and Royal College of Physicians and Surgeons of Canada (RCPSC)) statement on professionalism4 and is reflected in the Professional Qualities Curriculum and Supporting Physicians Professionalism and Performance framework.5 The major role of the college is education: this is reflected in budget allocation, the staffing in the college and in levels of fellow engagement. While our college has provided trainees and fellows with excellent clinical knowledge and technical skills, the major change in the past 10–15 years has been the additional emphasis on the non-medical expert domains of the Professional Qualities Curriculum and Supporting Physicians Professionalism and Performance. The college will discharge a substantial proportion of its social contract by ensuring that all physicians have, and maintain throughout their professional career, the requisite knowledge, skills and behaviours required of a modern physician. These now include a focus on continuous quality improvement, patient safety and provision of quality health care with the elimination of waste. Furthermore, these physicians are willing to be appraised to ensure they possess these qualities and are committed to improving their performance continuously – the concept of ‘demonstrable professionalism’. In doing so, they, in partnership with the college, are providing reassurance to the community (and regulators) that all physicians are ‘good enough’.6 Form should indeed follow function. While this is certainly not how the college structure came about, there has been major progress in the last decade to address a governance structure that had grown incrementally and was not fit for contemporary purpose. The major activities of the college are now reflected in college-wide committees for education, fellowship, finance, policy and advocacy and research. The various specialties within the broad church of the RACP are now more equitably represented on the College Board: the concept of ‘Specialists. Together’. At the most recent Annual General Meeting, a motion was passed that will allow a smaller (read less cumbersome) board, which will be less overtly representational and more skills based. It will continue to include non-fellows who bring additional but very valuable skills. This should allow the board to focus better on strategic issues. However, one could also argue that we still have a long way to go in the efficient and effective functioning of the college. Does the RACP really need almost 300 committees to allow it to function? Are all of these committees fulfilling their roles? In an ideal world, all college committees would be effective and efficient decision-making bodies that could reflect on their annual performance with a degree of satisfaction in the knowledge that they had ‘made a real difference’. Surely this is not unreasonable when one considers that it costs on average $1000 for each member of a committee to attend each and every face-to-face meeting. The relationship between the college and the specialty societies is an ongoing issue but one that is important for the long-term viability of both parties. Somewhat ironically, this issue was the reason for my involvement in the college. As President of the Thoracic Society of Australia and New Zealand, and thus as a member and subsequently Chair of the (then) Specialties Board, I recognised the critical importance of this, at times fraught, relationship. This is a maturing and mutually dependent relationship. The college cannot and does not wish to compete with the specialty societies in areas such as specialty-specific medical education to fellows. However, the college does have an important role in relation to the broader domains of professionalism, a role that it has been developing and expanding over the last few years. While it is the college education programme that has been accredited, cooperation and collaboration have existed for some time in the area of vocational education. However, there are much greater opportunities for joint activity, as exemplified by recent advocacy activities. Another example of the more collaborative nature of the relationship between the college and the specialty societies, and one that extends beyond training, is the contribution of specialty societies to EVOLVE. Gorman challenges the need for individual medical colleges and suggests alternative structures based on international models. Any discussion of this needs to bear in mind that RACP is already a very ‘broad church’, much broader than other Australasian colleges; only RACS comes close. This has tremendous advantages but also presents challenges. There is no doubt that the RCPSC is a highly functional and effective organisation. It is undoubtedly the leader in vocational/post-graduate medical education. While this may relate to some extent to ‘scale’, I believe it is less due to college structure than due to the employment by the college of fellows with educational expertise on substantive contracts and who are then able to devote considerable time and effort to the Royal College. The Academy of Medicine in Hong Kong is an umbrella organisation. We already have such organisations: the Committee of Presidents of Medical Colleges in Australia and the Committee of Medical Colleges in New Zealand. These committees do provide the opportunity for interaction and dialogue between colleges. However, this interaction sometimes demonstrates the very different philosophical approaches taken by colleges. While these committees also provide a conduit to other important stakeholders, they remain in the category of ‘unrealised potential’. The medical colleges of Australasia have not been successful in developing and presenting a common approach to important health issues. As regards the issue of cooperation between colleges, the RACP has taken the view that a ‘coalition of the willing’ is preferable to ‘forced marriages’. The Tripartite Alliance (RACP, RACS and RCPSC) formally established in 2011 has been a tremendous success with progress on medical education and broad professional issues, that would have not been possible by any of the individual colleges. This limited alliance allowed the development of clear short and medium term goals with consequent tangible outcomes. This success is reflected in the fact that two other Australasian colleges have joined what is now called the Tri-Nations Alliance. Although we both possess Australian ancestry, Des Gorman and I reside in New Zealand. How does New Zealand fare in this organisation? Is it overwhelmed by the bigger partner? Would New Zealand be better served, as Gorman suggests, by having stand-alone New Zealand colleges? Personally, I am in no doubt that New Zealand and New Zealand members benefit enormously by being part of an Australasian organisation. The depth and breadth of talent, the economies of scale and the ability to learn from each other have produced educational, advocacy and other outcomes that would have been impossible for a stand-alone New Zealand college. New Zealand's nationality has been ‘recognised’ within the college governance structure. This does not mean that New Zealanders are not at times frustrated by what they perceive as undue focus on Australian issues, but I think they accept this state of affairs with grudging good grace (most of the time at least). The evidence indicates the New Zealanders ‘punch above their weight’ in the functioning of the college. It is somewhat ironic that the responses to Gorman's article are by a New Zealand-based recent RACS President and a New Zealand based recent RACP President – and that the current RACP President-Elect is a New Zealand-based physician. It is perhaps the ultimate cliché to say that ‘trainees are the future of our College’. As a result of a motion passed at the 2012 Annual General Meeting, trainees became members of the college with voting rights, this representing the greatest change in the membership of the college in its (then) almost 75-year history. Considering the tremendous contributions that trainees make and have made to the college, it is hard to believe that at the time the decision to give trainees voting rights generated so much debate. Trainees are now represented on virtually all college committees (including the board), yet, it was only a decade ago that serious concerns were expressed about how trainees might cope with issues of confidentiality and conflict of interest. My experience is that they deal with these issues at least as well as their more senior colleagues. This is future-proofing for the college – we have a large number of trainees who have engaged with the college in a significant way, served on college committees and hopefully will remain engaged or re-engage in the future. It is just over 4 years since I stepped down as President. Although I have followed the actions of my successors with great interest and admiration, I now know personally fewer and fewer of the senior office-bearers in the college. Rather than bemoaning this fact, I see this as something very positive. The college is engaging new cohorts of members into leadership positions; broadening, refreshing and re-invigorating the college and its activities. Although it has been the RACP policy for some time that fellows should undertake tasks that only fellows can do, and notwithstanding the enormous contribution by highly skilled, dedicated and diligent college staff, the RACP is still highly dependent on the pro-bono activities of fellows who have numerous competing demands on their time. There are also the issues of the reasonableness of expectations on these ‘volunteers’ and the extent to which this dependency has contributed to the lack of responsiveness of the college (in terms of a news cycle) to emerging issues and what sometimes appears to be an in-built stolidity of the college. The challenge is how best to harness the wisdom, experience, professionalism and goodwill of the fellows and trainees that constitute the membership of the RACP. Like the Immediate Past-President, I prefer the term ‘power of unity’ to that of economy of scale. However, is this situation sustainable? Should we not learn from the RCPSC experience and our own success in the appointment of fellows to the substantive roles of Director of Education and Dean, by appointing more fellows to paid positions for certain critical roles within the college? Should we be doing in policy and advocacy what has been so successful in education? The college continues to progress from being reactive to more proactive on contemporary medical and social issues, establishing its credibility through thoughts, words and deeds. It has shown professional leadership particularly in relation to professional standards (partly through Supporting Physicians Performance and Professionalism) and on the issue of revalidation. It has engaged in debates on important, challenging and sometimes controversial, contemporary issues; producing carefully considered, evidence-based statements on the health benefits of work, the harms of alcohol, refugee health and well-being, the medical use of cannabis, to name but a few. The college is engaging much more in the debates regarding healthcare and healthcare delivery; the EVOLVE project is aimed at abolishing low-value treatments and interventions. The point is that the college is evermore outward looking and increasing assuming its right and proper role in societal debates and using its authority and influence for benefit of patients, the community and the profession. Our college has a important role now, but it is in the process of establishing the bases for even more important, relevant and expansive roles in the future.

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