Can we assess professional behaviour in anaesthetists?

The title of this editorial, in questioning whether we can measure professional behaviour reliably and apply appropriate assessment techniques, makes a debatable presumption. It presumes that anaesthetists do indeed behave professionally, or at least acquire and exhibit professional traits. But can we take this for granted? That anaesthetists require professional training and assessment, in the same way as other professionals such as lawyers, accountants and architects, is not in doubt. As Robert Louis Stevenson said: ‘Politics is perhaps the only profession for which no preparation is thought necessary.’ In fact, anaesthesia shares more with other professions — such as law, accountancy or architecture — than we often care to admit, especially when one considers that many of the current threats to the role of the ‘professional’ are common to a range of professions. The purpose of this editorial is to suggest that our professionalism as anaesthetists is not something we can take for granted; it is not something that is static and unchanging. It is constantly in need of development, of nurturing, if our speciality is to survive. The way to ensure that this happens is to instil professional habits in our trainees, using assessment techniques that not only measure professional behaviour but help to encourage and build it too. Professionalism should not be regarded as a ‘second-level’ activity to be mastered after basic skills, but should be integrated from the beginning of training. First base in this process is to define the question: what is a professional? It is an important question. According to Della Fish and Sheila Twinn [1], professional behaviour encompasses a repertoire of characteristics: skills, abilities, capacities, professional knowledge, personal attributes, personality, ability to work with other professionals, flexibility, educational understanding, moral awareness and professional judgement. A vital component of professionalism is reflective behaviour. This entails the ability to look critically at one's own practice and, in doing so, refine that practice and the knowledge associated with it. Professional behaviour also involves the ability to investigate that practice. Together with reflective behaviour, we also need to demonstrate professional artistry. This involves the wisdom to ‘read’ a situation, the flexibility to react to it and the ability to improvise in order to meet its specific demands. Professionals can only practice effectively and justly if they learn from individual cases. This is because their expertise, as a body of knowledge, is always inadequate and incomplete with respect to its objects and purposes. That is to say, as professionals, we never know everything. And as professionals we increasingly face difficult challenges to our authority and status. Doctors are not alone in this, of course. The threat to all the professions can be traced directly to one of the godfathers of our modern industrial society, Henry Ford, who effectively re-engineered the process of work. As a pioneer car maker, Ford inherited groups of expensive professionals, each possessing its own particular set of skills. There were wheelwrights and blacksmiths, coachbuilders and engineers, upholsterers and coachpainters. But Fordism, as it became known, broke down the process of building a motor car into a series of smaller tasks, each simple and repetitive. Such tasks could easily be performed by low-cost semi- or unskilled workers. The end was now in sight for the expensive skilled tradesmen. How did Ford achieve this? By borrowing the techniques of standardisation and interchangeability. Does this approach ring any alarm bells? Are there echoes here of Audit Commission approaches to the question of who should give anaesthetics? If still in any doubt, for standardisation and interchangeability, read ‘protocol’ and ‘delegation’. Today, almost a century later, all the professions are under siege from new directions, from politicians anxious to undermine alternative knowledge and authority bases and from a consumerist and media-led public which has a growing tendency to apply shopper's rights to professional services. These pressures, over a period of time, take their toll and result in a collective ‘loss of nerve’. As Peter Hennessy, Professor of Contemporary History at University of London, puts it: ‘The crumbling of our confidence as a professional society has led to breaches appearing in our institutional walls, through which has marched an expensive and assertive array of management consultants, accountants and self-proclaimed reformers who evangelically recite the latest acronymic babble from the business schools’ [2]. This can be observed in the context of the National Health Service. Other professions face similar encroachments. Lawyers face low-cost conveyancing shops which cherrypick much of their core business. Accountants face cut-price tax shops and alternative sources of tax advice, such as banks and insurance companies. Architects, meanwhile, face construction managers, quantity surveyors and design-and-build contractors which undermine their historical role at the head of the building team. Architects make an interesting case study for comparison with medicine. So immense has been the threat to architects that, in the mid-1990s, the Royal Institute of British Architects commissioned a three-year strategic study into the future of the architectural profession [3]. One of the chief recommendations of a very comprehensive report was that architecture needed to change its philosophy from being ‘a learned profession to a learning profession’. I believe that anaesthesia, like all branches of the medical profession, could benefit from adopting this philosophy. We too need to change from being a learned profession to becoming a learning one. Architecture as a profession is characterised by two components: knowledge and skill. In fact it could be said to sit on the faultline between knowledge and skill; the know-what and the know-how. Anaesthesia also combines the know-what with the know-how. Clearly, to balance knowledge and skill, we must never stop learning as a profession. But do anaesthetists actually behave professionally? A recent paper by Klemola and Norros looked at the behaviour of anaesthetists to determine whether they could identify different approaches, or ‘orientations’, to their everyday practice [4]. The study used semistructured interviews which were performed by an anaesthetist and a psychologist. They questioned 16 experienced specialist anaesthetists in considerable detail over a wide range of aspects of anaesthetic practice. From these extensive interviews, the authors concluded that anaesthetists could be categorised as displaying one or other of two distinct patterns of behaviour: ‘objectivistic’ in which the patient is regarded as a ‘natural object’, whose behaviour can be predicted by general knowledge. There is strong confidence in pre-operative plans and rigorous application of general principles to concrete problems; and ‘realistic’ behaviour in which there is an interpretative and interactive approach, recognising the uncertainty inherent in the practice of anaesthesia. This study was not performed in a clinical setting, nor was it related in any way to outcome measures. However, it raises some important questions. Only five out of 16 anaesthetists studied demonstrated an interpretative, or realistic, approach. That is to say, only five out of 16 anaesthetists used a ‘reflective’ approach to their practice of anaesthesia. In this study, a minority of anaesthetists demonstrated a core aspect of professional behaviour. One might care to ask which pattern of behaviour, described in this paper, most easily lends itself to the possibility of being performed by technicians rather than professionals? Clearly it is the ‘objectivistic’ approach, which leads me directly to the problems of assessing anaesthetists in training. There is a spectrum of approaches to assessment. These approaches fall between two extremes. At one end of the spectrum is the ‘NVQ approach’ which looks at how trainees perform a series of ‘competencies’. In anaesthesia, these might include certain practical skills, such as cannulation or intubation. However, the NVQ method of assessment was not designed for professions, but for occupations. It is inadequate for all but the most basic tasks. It can lead to the development of short-term learning only and not long-term learning and in-depth understanding. It does not look at the learner as a human being with personality, emotions, interests, strengths and weaknesses, the so called inner qualities. It is designed to be used for bureaucratic and political purposes, rather than real educational needs [1]. At the other end of the spectrum, we have the ‘Formative approach’ to assessment which is informal and is part of a day-to-day educational approach. It looks at long-term educational needs and provides continuous informal feedback. There is emphasis on the whole individual. This method is self-referenced. Between these two extremes, the NVQ and the Formative approaches, there are divergent and conflicting views. Which should we choose? I would argue that we should avoid a system based on competencies. Such an approach trivialises professional behaviour with its complex reasoning and makes no attempt to assess these deeper aspects [5]. Focusing on skills alone is easy. One can certainly be objective. A system of assessment based on skills is easier to organise, too. But the danger of focusing only on skills is that assessors will misvalue judgements and the complexities of how and when to use such skills, which are part and parcel of professionalism. That is the conundrum of assessment. Those finer aspects of professional behaviour we would wish to examine are difficult to assess objectively. And conversely, those aspects which are most easily and objectively measured are not those which are the most important ones. Any system of assessment used must be based on what trainees actually do during the course of their day-to-day practice in hospital. But perhaps most important of all, whatever system of assessment we do use must encourage in our trainees the lifelong habit of self-assessment. The current climate of attacks on medical professionalism reflects more than ever the importance of using assessment techniques that encourage a more reflective approach. ‘Can we assess professional behaviour in anaesthetists?’ Clearly we can. But it is vital that we do so using assessment techniques that not only measure professional behaviour but encourage and sustain it too.