Future Medical Workforce Project: phase 1 report

What is the role of a doctor?

We asked doctors working in Scotland, what they think the role of the doctor is and what is unique about that role.

Participants attending the focus groups and responding to the national survey, provided a wide variety of answers, reflective of the broad range of roles and responsibilities doctors undertake as well as their career stage, training, experience and personal development. Their views are summarised below beneath themed headings.

"Being a doctor, it’s a science and an art." - GP, focus group attendee Patient Care

In relation to patients, participants discussed the role of diagnosis, treatment, specialised care, advocacy, continuity, and communication. Senior doctors tended to comment on the role in relation to managing complexity and problem solving. Participants typically referenced these elements when considering what isunique to the role of doctors describing working beyond guidelines or flowcharts (which typically other health professionals are required to work within) and the key role of clinical intuition. Some participants also discussed more holistic elements to the role in relation to preventative or lifestyle advice and practicing realistic medicine^[15]. Some doctors also felt that they had a role in relation to public health and ensuring the health of a population or their communities. There was however a split view on whether this is the role of a doctor, or just particular kinds of doctors. This is confirmed through the survey responses where there was the greatest diversity of views on whether ‘Doctors act as guardians for population health’. Responses indicated that 80% agreed, 10 % disagreed and 10% were neutral in their responses.

Medical students typically focused on the relationship between patients and doctors and talked about this in a way which was less paternalistic than other categories of doctors, placing emphasis on supporting self-management and bringing the human elements to that relationship.

Defined by training

Participants consistently referenced the breadth and depth of training, again as a unique element to being a doctor. It was reported that this training was felt to prepare doctors (and senior doctors in particular) to fulfil their responsibilities of risk management and decision making. Training was also referenced in preparing doctors for their roles in thinking holistically and managing complexity.

However, it was felt that training was coming under threat. Senior doctors spoke of concerns regarding the rise in Less Than Full-Time (LTFT) training noting that this could decrease the ability of trainees to gain the required experience and honing of intuition and pattern recognition that are required to become a senior doctor. Resident doctors typically commented that the quality of training is at risk due to service pressures.

Leadership

All doctors (and particularly Foundation Year doctors) commented that from day one all other health care professionals look to them to take decisions and provide ultimate accountability. Senior doctors also spoke to their role as leaders, managers and supervisors of multi-disciplinary teams (MDT). Those in remote and rural areas felt that their leadership role left them more exposed to risk and had greater clinical accountability.

Guardians of NHS

Senior doctors all spoke to their role as gatekeepers to the NHS – particularly GPs – and their role in rationing NHS resources such as diagnostic testing, referrals and treatments.

• Some commented on how this relates to the practice of realistic medicine, but more felt this to be a reactionary position due to service pressures and doctors ultimately holding risk on behalf of services and the NHS. Consultants view part of their role as picking up the failure demand from a lack of investment in primary care or a change in referral patterns from GPs (who they feel are becoming more risk averse).
• GPs typically felt that they were left holding the risk associated with patients waiting for long periods for specialist services.

Survey responses suggest that while this may describe the role that senior doctors play, other grade doctors do not necessarily view that as part of the role.

When asked whether ‘A doctor’s primary responsibility is to their immediate patient as opposed to the population health need’

• 61.5% of respondents agreed,
• 16.6% were neutral and
• 21.9% disagreed

Using themes identified from the focus groups, survey respondents were asked to rank their agreement with a number of roles of the senior doctor. Amongst these Gatekeeper of services ’ had the highest number of neutral/disagree responses.

"The NHS doctor role of ‘gatekeeper’ to investigations, i.e. ‘realistic medicine’ or ‘reducing over-investigation’ is at odds with a societal desire for greater investigation and less risk. Individual patients and doctors are being asked to assume risk (to their health and career respectively) because our health system cannot support the increased levels of investigation which have become the norm in modern medicine in other developed countries." - Specialty trainee, survey response

Public expectations

All doctors reflected on how the role is perceived by the public. Positive elements included being a recognised regulated profession, trusted and with the traditional role of being able to help people or make people better. Negative comments focused on the influence of social media and tabloids creating a more antagonistic relationship with the public/patients (particularly for GPs).

Professional Standards

Some participants referenced the professional standards set by the GMC as defining the role of the doctor but more commonly referenced their interpretation of these standards. This interpretation included being held to a higher standard than other members of the public in terms of morality, that being a doctor gives them an elevated status in society and ultimately being required to be ‘more than human’.

Working with others

In addition to leadership and management of teams, participants also referenced working with other specialists, other professionals, participating in clinical networks and working in local and national contexts.

Variety/Portfolio careers

A wide range of other responsibilities were shared from doctors taking forward portfolio careers. This included roles as educators, mentors, undertaking research and supporting innovation, medical management, politics, service design and improvement. For clinical academics, it was recognised that a key role is translating biomedical research into improvements in care.