Brief communication

Professionalism and psychiatry: theprofession speaks

Introduction

Professionalism dates back to over a millenniumago when guilds set the standards for training andapprenticeship in Britain. The guilds controlledentry into a craft, training and standards of qualityuntil their monopoly began to hinder the progressof capitalism (1). Now that the National HealthService in the UK is moving from a strong socialistbase to a partial independent market economy it isan apposite time to revisit the notions of profes-sionalism.

There is little doubt that, certainly in the UK,professionalism in psychiatry in line with othermedical specialities is under attack from a numberof sources, including government and policymakers (2). Doctors and lawyers established theirguilds and control of workforce through theseguilds along with periods of long apprenticeshipand this meant that professions could control thenumbers of individuals coming in for training.Thus, these guilds emerged as elite bodies withlinks to university education and professoriate (3).In the last two decades in the UK, professions such

Bhugra D. Professionalism and psychiatry: the profession speaks.

Objective: Recently in the USA and the UK, the medical profession asa whole and psychiatry in particular have felt �deprofessionalised�. Thisstudy aimed to explore ideas about professionalism and the threat ofdeprofessionalisation from psychiatrists themselves.Method: Attendees at three meetings related to the activities of theRoyal College of Psychiatrists were invited to respond to a shortquestionnaire. These were meetings on different days and differentpeople attended these. The questionnaire had only five simplequestions. In two meetings, all attendees answered and in the thirdmeeting only two of 20 attendees did so.Results: Seventy-three completed questionnaires were received. Ofthese, a vast majority, 89% of 66, believed that professionalism isimportant in modern day clinical practice; key threats toprofessionalism are the government, the media and other specialtiesand disciplines. There was broad agreement that the Royal College ofPsychiatrists should lead and define professionalism.Conclusion: The ownership of professionalism by the professionalsthemselves is the most important factor; ethics, standards, attitudesand skills are seen as significant components of professionalism andshould be taught early to trainees.

D. BhugraHealth Service and Population Research Department,Institute of Psychiatry, King's College London, London,UK

Key words: professionalism; training; clinical services

Dinesh Bhugra, PO Box 25, Health Service and Popu-lation Research Department, Institute of Psychiatry,King's College London, De Crespigny Park, London SE58AF, UK.E-mail: d.bhugra@iop.kcl.ac.uk

Accepted for publication March 28, 2008

Significant outcomes

• Psychiatrists see professionalism as important and under threat.• A professional body like the Royal College of Psychiatrists defines it.• Professionalism implies knowledge, skills and wisdom in practice.

Limitations

• No sociodemographic details gathered.• Not a random sample.• Small sample size.

Acta Psychiatr Scand 2008: 118: 327–329All rights reservedDOI: 10.1111/j.1600-0447.2008.01195.x

Copyright � 2008 The AuthorJournal Compilation � 2008 Blackwell Munksgaard

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as teachers, lawyers and doctors have come undersignificant attack from the state irrespective of thepolitical party in power. Of these professions,lawyers have probably survived relativelyunscathed (4).

Aims of the study

In the 21st century, it becomes appropriate toexplore what it means for a doctor and a psychi-atrist to be a professional. In this short paper, dataon the psychiatric profession�s views of profession-alism are presented.

Material and methods

A short questionnaire was developed following anoverview of the existing literature. At the annualgeneral meeting of the Royal College of Psychia-trists in Edinburgh in 2007, those attending one ofthe sessions were asked to respond, as wereattendees in two other meetings related to Collegeactivities. In the first meeting, all respondents filledin the questionnaire but in the subsequent meetingsthe number of respondents was smaller. These weredifferent attendees who attended on different days.No one attended more than one session and thusno more than one response was obtained from eachrespondent. Overall, approximately 100 partici-pants attended these three meetings. The questionsincluded the respondent�s perception of profession-alism (e.g. their understanding of professionalism;their definition; the ownership of the term; whetherit had any meaning for today�s clinical practice;what were the threats to professionalism; and howand who in the profession should be dealing withthese threats). There was no compulsion on thoseattending the meeting to respond. The individualanswers were analysed using commonality ofthemes to examine for trends across the responses.

Results

Seventy-three completed questionnaires werereturned. The respondents often gave more thanone response; the findings are presented here withthe specific questions.

What do you understand by professionalism?

This question caused some difficulties, as a widerange of components were described. Theseincluded professionalism being a vocation, or agroup identity, having a clear emphasis on skills,training, ethics, autonomy, responsibility, account-ability, competency, expertise, integrity, maintain-

ing standards, self-governance and having anevidence base of practice, among others. Twocommon themes to emerge were knowledge andskills and standards. Training to achieve andmaintain these was considered to be a significantpart of professionalism.

How can professionalism be defined? (additional factors)

This question did pose some problems in thatrespondents found it difficult to describe, althoughmost respondents said that it had been definedabove. As one respondent pointed out: �Godknows. It�s like defining what is humorous, whenwe don�t really understand what the point of thelaughter is�.

Defined by whom and owned by whom?

An overwhelming majority (53, 71%) acknowl-edged that professional bodies define, whereas theremaining responses were split between the societyand the individual. Interestingly, nine (12%) indi-cated that �we� (assuming professionals) define it.

Is professionalism important?

Two respondents said it was probably important,whereas one was negative. One respondent thoughtit was more important than before and two felt itto be less so. The rest (68 of 73 who had respondedto this, 94%) gave an unequivocal yes.

What are the threats to professionalism?

Among over 20 threats identified, three majorthemes were the government, the media and otherdisciplines and specialties. Both external andinternal threats were noted. Loss of autonomyand self-regulation was reported to be an impor-tant threat. Among other factors, pharmaceuticalcompanies, scientology, New Ways of Working(changing practice of service delivery according topolicy changes) and changes related to traininginitiatives in the UK in the last year along with asense of learned helplessness were identified.

What should be done?

The Royal College was seen as a significant factorin challenging the threat through training, educa-tion, unity, working with others to raise standardsand increased awareness through expertise, guid-ance and peer support.As one respondent put it succinctly, �profession-

alism is an individual response to the highest

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demands of the chosen profession�. Anotherrespondent suggested, �professionalism involvesconducting one�s self in the practice of one�sknowledge, skills and training with integrity,respect for others and expert competence. Profes-sionalism involves putting others� needs and goodbefore one�s own needs and it involves keeping upto date in one�s knowledge, skills and practice.Professionalism implies wisdom in practice!�

Discussion

The sample is not random and no sociodemo-graphic details were collected. However, from thissmall sample, it would appear that the psychiatricprofession in the UK does feel under siege,especially from the government and the media.There is no doubt that, unless the profession takescharge, professionalism will continue to be eroded.Medical professionalism is linked to an occupationthat regulates itself through systematic mandatorytraining and collegial disciplines. It has a base intechnical specialised knowledge that has a servicerather than profit orientation established in itscode of ethics (5). As many respondents noted,keeping the good of the patient paramount whilemaximising patient care was an important compo-nent of professionalism. The commitment to thepatient by improving competence, access to careand scientific knowledge are some of the keyfactors that the profession must take on board.An overwhelming majority of the respondents

said that professionalism still remains very impor-tant, even today. As Irvine (6) notes, modernprofessionalism is both the encouragement andcelebration of good practice and the protection ofpatients and the public from suboptimal practice.Public trust is dependent on both.The �old� professionalism relied on mastery,

autonomy, privilege and self-regulation withinwhich mastery suggested control, authority,power and superiority. The changes in socialexpectations, set against the National HealthService flexing its muscles as a monopoly employer

that is able to dictate what kind of doctors it wouldrequire, mean that privilege and mastery asconcepts become outmoded. Self-regulation, acore principle of professionalism, has been affectedby various medical scandals in the UK. The �new�professionalism sees itself as a set of values,behaviours and relationships that underpin thetrust the public has in doctors. In this therelationship with the patients is the crux, evenwhen doctors (such as some pathologists) do notsee any patients. It seems that the respondentssampled in this study see the threats as real and arelooking at the professional bodies to help defineand deliver professionalism in the 21st century.As a result, we need a very clear understanding

of what we can and perhaps even more impor-tantly, what we cannot do. The focus on improvingclinical services is and should remain our firstpriority – the core of our professional activity andat the heart of our professionalism. Forgingalliances with patients and families, public andvoluntary agencies can only strengthen our cause.

Acknowledgements

The authors acknowledge financial support from the Depart-ment of Health via the National Institute for Health Research(NIHR) Specialist Biomedical Research Centre for MentalHealth award to South London and Maudsley NHS Founda-tion Trust (SLaM) and the Institute of Psychiatry at King�sCollege London.

References

1. Krause EA. Death of the guilds: professions, states, and theadvance of capitalism, 1930 to the present. New Haven:Yale University Press, 1996.

2. Brown N, Bhugra D. New professionalism or profession-alism derailed? Psychiatr Bull 2007;31:281–283.

3. Sox HC. The ethical foundations of professionalism: asociologic history. Chest 2007;131:1532–1540.

4. Bhugra D, Brown N. Psychiatry: deprofessionalisation. IntJ Soc Psych 2007;53:291–292.

5. Starr P. The social transformation of American medicine.NY: Basic Books, 1982.

6. Irvine D. New ideas about medical professionalism. Med JAust 2006;184:204–205.

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