Renewing psychiatry’s contract with society

The practice of medicine does not occur in a vacuum. We work within a culture and a society, and we owe it to the society that our services are of a standard that will ensure their use by patients and one in which carers will have confidence in our abilities to look after their loved ones. Society

The practice of medicine does not occur in a vacuum. We work within a culture and a society, and we owe it to the society that our services are of a standard that will ensure their use by patients and one in which carers will have confidence in our abilities to look after their loved ones. Society expects certain standards of care and skills from its clinicians and as in any contract we, in turn, expect things from society. However, as such a contract is not specifically written down but is instead a virtual and an implicit one, some factors become crucial in understanding the relationship between society and the psychiatrist. Here, I propose to highlight some of the components of such a contract and how we renew this in the 21st century.
In order to deliver healthcare, first and foremost we, as psychiatrists, have to be professional. Often professionalism is confused with occupation where anyone belonging to an occupational body can classify themselves as professionals. However, a profession is an occupation that regulates itself through systematic required training and collegial discipline, one that has a base in technical specialised knowledge and has a service rather than project orientation enshrined in its code of ethics (Starr, 1982). A commitment to thoroughness and the use of rational methods; attitudes of objectivity and rigour; the reporting of and ongoing reviews of clinical decisions; a demand for first-hand information; and the requirement to keep abreast of recent research, combined with the use of scientific knowledge and technology are all aspects of clinical medicine (Montgomery, 2006). Medicine is a science with an easily described and defended ethical discipline but being a science by itself is a frail defence against uncertainty, death and human emotion (Montgomery, 2006). The codes of professional conduct are the tangible expressions of professionalism (Sox, 2007). The certainty of uncertainty has become the watchword in the brave new National Health Service (NHS). Present day codes of professional conduct have evolved from a need to balance the relationship between the medical profession, government and business. These also need to be revisited.
The professional guilds emerging between the 12th and 16th centuries controlled the number of apprentices being admitted and also the tools needed for training and production. They also maintained high standards of production and controlled the rates of output. When their monopoly started to impact with the forces of capitalism, guilds in France and England started to lose their power to strong central governments (Krause, 1996). In the modern NHS a similar pattern is beginning to emerge. A move to capitalist principles means that the medical profession and medical Royal Colleges are seen as 'stickin-the-mud' institutions impeding the march of the free market and implies that politicians have to enable these changes by actions directed to the medical profession.

Professionalism
The responsibilities of the professional are many and include, among others, professional competence, maintaining appropriate relations, honesty and confidentiality with respect to their patients, and commitment to improving access and quality of care. In addition, the professional must deal with the just distribution of finite resources and avoiding any conflicts of interest. The professional's responsibilities mean that we should be respectful of each other, maximise patient care and have self-regulation including remediation and disciplinary action (American College of Physicians, 2002). Modern professionalism is both the encouragement and celebration of good practice, and the protection of patients and the public from suboptimal practice (Irvine, 2006). Stern (2004) focuses on caring, compassion, communication, respect towards the patient along with altruism, excellence (excellence, scholarship and leadership), accountability and responsibility. Rohrich (2006) also aligns professionalism with the core attributes of specialised knowledge, relative autonomy in practice with the privilege of self-regulation, altruistic service to the individual and society, and responsibility for maintaining and expanding professional knowledge and skills. Thus, there appears to be a broad agreement between scholars about what constitutes professionalism.
Professionalism, medical humanism and clinical bioethics were taken for granted up to the early part of the 20th century but started to change due to increased malpractice claims, media influences and complaints by patients (Zuger, 2004;Talbott & Mallott, 2006). There have been many challenges to professionalism in the UK in recent times from both internal and external factors. The external factors include increased consumerism (increased rights with perhaps reduced responsibilities), a generally increased knowledge base and increased ease of access to such a base. Relevant internal factors identified in a recent study among 73 psychiatrists included internalised hopelessness and a perceived loss of autonomy (Bhugra, 2008).
Values which are or should be unacceptable to professionals include greed, misrepresentations, abuse of position, abuse of power, breaches of confidentiality, cheating, and sexual harassment (Page, 2006) and these must be eliminated. Sadly, scandals in the UK in past decades have demonstrated all of these across various medical specialties. Racy (1990) identifies the profession as a socially sanctioned activity whose primary objective is the wellbeing of others above the professional's personal gain. An approach of 'reflection-in-action' is central to the act by which practitioners sometimes deal with situations of uncertainty, instability, uniqueness and value conflict (Sch˛n, 1988). Psychiatrists are, arguably, best placed to deal with ambiguity and uncertainty and we need to enhance these skills. Reflective practice and emotional intelligence are important parts of self-awareness and growth which we need to encourage.
Our relationships with other disciplines, team members and stakeholders are crucial to our survival as a profession. The Royal College of Psychiatrists, therefore, is in a unique position to do this and take it forward without guilt and shame. We must be proud of what our skills and competencies are and we must take pride in our achievements and learn when we founder. For any leadership to be successful it must have vision, strategic thinking, motivation and trust, all of which are now being challenged.

Renewing the contract with society
In the 21st century, it is only appropriate that psychiatry as a profession revisits what society expects from the profession and in turn what we expect from society. Complacency, paternalism, arrogance, inability to selfregulate and poor leadership have no place in our profession. We need to decide what our contract with society should be and we must negotiate that directly with society but also with society's representatives, for example, politicians. Creuss (2006a), in an admirable paper, lists society's expectations of medicine and medicine's expectation of society in return. The ideas of social contract, Creuss argues, emerged 300 years ago when society granted medicine monopoly over its knowledge base, autonomy in practice, status and the privilege of self-regulation. This was based on the assurances that the profession will ensure the competence of its members who would be devoted to altruistic services, morality and integrity, and would address issues of social concern.
Society's expectations from medicine include altruistic services of the healer, assured competence, morality and integrity, accountability, transparency, objective advice and promotion of public good. In return, medicine expects from society a degree of implicit and explicit trust, autonomy, self-regulation, properly funded and value-driven healthcare system, participation in public policy, shared responsibility for health, financial and nonfinancial rewards, and monopoly. These are by no means exhaustive lists but in order to start a dialogue with the stakeholders we need to remember these.
There is no doubt that changes in funding and values both in the USA and the UK have led to a marginalisation of the medical profession and especially of psychiatrists.
A key challenge for the profession is to begin this dialogue and yet be able to provide comfort and hope.

Challenges and ways forward
The profession of psychiatry must move from old nostalgic professionalism to 'new' professionalism and we must ascertain our civic and fiduciary responsibilities using a number of strategies such as identifying and agreeing standards of quality of care, altruism, and values of the profession identified by us and worked at with other stakeholders.
Discussions between stakeholders (patients, carers, politicians and voluntary agencies) need to look at mutual expectations. Expectations of society towards psychiatrists and those of psychiatrists towards society should be negotiable. Creuss (2006b) argues that if an implicit contract exists then negotiating the details of the contract itself becomes a legitimate professional activity. The characteristics of a psychiatrist as a professional have to be those of a caring, compassionate and altruistic healer who holds hope for patients. In addition, not only should such an individual be open-minded but respectful of others and of patient autonomy. Of course they must be competent in their skills and knowledge, although being competent in itself is not enough. Absolute commitment, autonomy, integrity and honesty, morality and ethics, and promotion of public good and ability to deal with ambiguity are qualities that need to be encouraged. In addition, such an individual shows 'knowledge-in-action', 'reflection-in-action' and 'reflection-in-learning' (Sch˛n, 1988). How these are learnt and taught needs further debate.
Instilling professionalism in medical students and psychiatric trainees is crucial. As Creuss (2006b) recommends, using educational theory to teach professionalism requires institutional support and a cognitive base that draws on experiential learning and role modelling of communication skills. Character formation of the psychiatrist -through mentoring, practice and an educational process that encourages personal, professional and civic development underpinned by a strong ethical and moral framework -is necessary. Senior colleagues need to discern how these requirements can be developed during training. Courses in ethics, humanities and human values (medical history, social sciences, literature and films) can sensitise the clinician by raising awareness and by developing critical reflection. In addition, a clear association between theory and practice is essential.
Bhugra Renewing psychiatry's contract with society editorial Conclusions 'Let Wisdom Guide' is our College's motto. How do we attain wisdom, and perhaps equally importantly, how do we share it? Practical wisdom comes from a change in thinking, a change in character and a change in knowledge in order to ensure that our patients are cared for in the best possible way. The primacy of patient welfare and advocacy for our patients is critical. In order to develop medical, moral interdependence, we need to be honest with ourselves as to what our strengths and weaknesses are but equally we need to be honest with society to declare what we can deliver in reality and what our aspirations are. In order to achieve those aspirations we must work with patients and carers. Since we are their advocates they should be our advocates too.
Professionalism is a dynamic attribute and responds to change; hence, a long-term developmental approach is required. At different stages of one's career, different strategies should be used to allow these attributes to evolve. Role models are crucially importance at all levels. If our trainees see us as tired, fed up and demoralised, they are likely to question not only our commitment but also their own professional attributes. The responsibilities and challenges faced by clinicians are crucially important in aiding us to learn the skills of dealing with the changing expectations of society.