On professionalism.

This engineer’s view of professionalism is not far removed from the medical profession’s view, articulated by Sir Donald Irvine in his recent Duncan Memorial Lecture.2 Engineers developed their civic role through the huge engineering projects of canal and iron bridge construction during the nineteenth century, giving Thomas Telford both the technical and the moral experience which led his young assistant Henry Robinson Palmer to found in 1818 the Institution of Civil Engineers, the first professional engineering body in the world. It was through the practice of civil engineering that ‘the competencies of civilised behaviour in the selfdeveloping craftsmen’ emerged. The term ‘civil engineering’ defined ‘the moral sphere’ in which they worked. It is of the greatest concern now to witness the indictment of professionalism in engineering, with the replacement of professional expertise by business managers so vividly presented in David Hare’s recent play, The permanent way. The professions of law, medicine and others are equally concerned about the erosion of trust in professional expertise. The idea of trust, ‘now often seen as obsolete, even dangerous, in public and professional life, and particularly dangerous in medical practice’, is analysed in detail by Baroness O’Neill in the Samuel Gee Lecture, which we are privileged to publish in this issue.3 Yet it was trust in the professions which gave doctors among others their standing in society. In an editorial in this journal in 1967, the late Dr Stuart Mason described the doctor as a good citizen with ‘a stabilising influence in an uneasy society’.4 There is now a notable absence of doctors from civic life, as observed by Professor Eric Thomas, Vice-Chancellor of Bristol University, in his recent Lloyd Roberts Lecture at the College.5 The decline of their civic status as professionals has no doubt been accelerated by the new accountability culture, which, in the words of Baroness O’Neill, ‘explicitly seeks to marginalise professionalism and professional standards’.3 The causes of the erosion of the professional status in medicine have been much discussed. In examining these issues, our President, Professor Carol Black, has given her own specific description of professionalism for doctors: it means, she says ‘mastery of technical knowledge and skills – clinical skills and communication skills – and attitude and behaviour’.6 The assault in the present climate is on attitude and behaviour. But why? Pressures in medical training have led to fragmentation of traditional teams and ‘firms’ and a consequent decline in apprenticeship. It is not possible to learn competencies from books. A professional attitude and behaviour is acquired from mentors and seniors. Indeed, a German trainee working in this country perceptively described the supportive atmosphere in the UK in which doctors ‘strive to be memorable teachers to the next generation’.7 We must hold fast to these traditions even as they are eroded by the demands of reduced working hours and shift working patterns. These have led to a decline in continuity of care for patients which also results in a loss of learning opportunities for trainees just when the importance of direct supervision is increasingly recognised. All of these changes are accompanied by new contractual demands to achieve clinical targets, inconceivable in past generations. Recognition of the problems leads us to seek solutions. Lord Phillips, solicitor and life peer, wrote n EDITORIALS