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Should GPs have to teach? -a view from the Oath

John Spicer is a GP and teacher in Croydon, South London. He is on Twitter: @johnspicer3

Carwyn Hooper is a Reader in Global Health Ethics and Law, St George’s University of London. He is on Twitter: @hoopercarwyn

The Hippocratic Oath puts it fairly strongly: physicians ought to pass on their knowledge, and by implication, skills, to the next generation of doctors.1 A number of august medical organizations echo this thought. Thus, the General Medical Council (GMC) in the UK claims that medical doctors should be willing to contribute to teaching, training and mentoring2 and the New Zealand Medical Association’s (NZMA) Code of Ethics states that it is “the duty of doctors to share information and promote education within the profession”.3 Interestingly, whilst most attention is inevitably given in the literature to the acquisition of episteme [knowledge] and techne [practical skills], less is given to that of teaching and learning phronesis [wisdom]. The oath does not distinguish the 3 elements.

Teaching medicine and practising medicine require different skills because they are inherently different activities.

Teaching medicine and practising medicine require different skills because they are inherently different activities. Furthermore, the possession of a medical credential does not automatically imply teaching capabilities any more than a teaching credential necessarily implies expertise in the art of practising medicine. Thus, we suggest that progress from doctor to doctor-teacher requires more preparation than has hitherto been imagined, though in recent years this has been addressed both at undergraduate and postgraduate level. It may also require specific credentialing and some mechanism of audit and quality control.

This is not to deny that many of the skills needed to be a good doctor are needed to be a good teacher. Indeed, a number of the requisite talents are transferable and generic. For example, both the practice of teaching and the practice of medicine both mandate good communication skills. Nonetheless, some of the skills are disparate and it is important to acknowledge and address this rather than blithely assume that the differences do not exist.

We also suggest that there is something appealing about the moral requirement alluded to by the Oath, and many modern medical organisations imply that the profession should bring on its own successors. Admittedly, student progress might dictate that doctors disinclined or unsuitable to teach ought not to be involved in the education of students or trainees.4,5 Likewise, patient welfare almost certainly dictates the same terms, for a doctor who teaches students badly today may endanger the lives of patients tomorrow. However, none of this detracts from the underlying claim that doctors conceived as a professional community have pedagogical duties.

The underlying rationales for these duties are manifold.  Regulators such as those mentioned above ground a putative duty to teach in the eventual benefit to patients. This claim has something of a utilitarian hue, though it also could be grounded in deontological terms. For example, the  NZMA, simply states that the “education of colleagues and medical students should be regarded as an ethical responsi­bility for all doctors” without clearly explaining why.3 Followers of Hippocrates, meanwhile, probably conceived the duty as stemming from the requirements of a virtuous doctor. The oath did not specify this either.

Thinking on the matter in more depth, we might argue that a moral duty to teach could  be attendant on membership of a profession itself or based on the value of fostering experiential learning at an early stage. It could also be based on the claim that senior doctors are role models and a commitment to teaching from seniors will help to instil in juniors the importance of lifelong learning and lifelong teaching and the duty to impart accumulated wisdom, knowledge and experience to the next generation.

Taking a broader approach, we might ground the duty to teach within the context of a wider duty to encourage the flourishing of other human beings. In contrast  if we take a narrower approach we might  argue that the duty is legally positivist and is thus “merely” contractual in nature. Historically it is worth noting that, in the UK, there has traditionally been a distinction between primary care, where to be a credentialed teacher is a matter of privilege, earned by formally learning about teaching; and secondary care where it is a matter of right, in virtue of the position of being a specialist senior. This is less clear than it used to be and most specialists now have some form of preparation for teaching built into their roles.

One of the justifications for this putative duty to teach is essentially practical. Primary care teams in the UK are currently  at a watershed. We are a time of profound change in the nature of those teams, who are becoming more multiprofessional and interdependent. This is in the context of a current and worsening workforce shortage overall, reckoned to be between 8,000 and 19,000 whole time GPs short over the next 10 years, with similar numbers for GP Nurses and other disciplines.6 As such these facts impel a powerful moral argument to mandate NHS leaders and politicians to address the problem, but also for the educational activity that will inevitably follow. Whilst part of the solution is to prevent attrition in our teams, another is to take responsibility for training our colleagues. If this is correct, it says nothing of the arrangements and financial flows that must be part of the solution, but simply adds to a conception of duty to teach with the ultimate aim of providing universal health care efficiently. You might call it a pragmatic justification.

Given the changing nature of primary care provision in recent years, this emergent duty could and should be extended to our colleagues in other professions, where we each teach [not excluding assessment] one another. Whilst it’s impossible to describe Hippocrates as a member or even head of a team of health care professionals, it seems reasonable to extend the duty to all those involved in the care of patients.

…does the existence of a duty to teach imply a right to be taught and if so how much teaching must be provided before the duty is discharged?

However, there are clearly some theoretical counter arguments and considerations. Where the duty is normative in nature, a number of questions arise: is the duty perfect or imperfect; is it superogatory; where does it belong in the hierarchy of duties; is it grounded in a consequentialist or deontological approach or is it best conceived in terms of virtue? Wherever claims of duty are made it is also incumbent to ask where the right lies and what scope it has: does the existence of a duty to teach imply a right to be taught and if so how much teaching must be provided before the duty is discharged?

These questions are pressing and complex, and answers are needed if we are to seriously argue that doctors have a duty to teach. This is especially true because although, as  noted above, there something appealing about the moral requirement for doctors to train the doctors of tomorrow the complexity of the role of modern medical teacher, held parallel with the role of modern physician, implies a doubled professionalism that Hippocrates could not have anticipated and which may make the duty to teach fall away.

We suggest that much more work needs to be done to understand what the duty to teach is and what it implies from a theoretical point of view, as the scholarship in the field is rather undeveloped. Nonetheless that should not prevent expanding the educational effort we outline above on the assumption that a moral argument can be made which at least  approximates to Hippocrates claim. We also suggest that serious consideration needs to be given to the claim that all doctors who wish to teach (or who must teach) be trained to do so. This might involve a credentialing process. Perhaps this will be too onerous, but if we are to take Hippocrates’ claim seriously, perhaps this must be done.

References

  1. Hippocratic Oath  [circa 4th century BCE]    National Library of Medicine  2012  http://www.nlm.nih.gov/hmd/greek/greek_oath.html  Accessed 29.7.22
  2. http://www.gmc-uk.org/guidance/good_medical_practice/teaching_training.asp Para 39 & 42  Accessed  29.7.22
  3. Code of Ethics Redesign 2020_updated.indd (website-files.com) para 63 Accessed 29.7.22
  4. How important are role models in making good doctors   Paice E, Heard S and Moss F   Brit Med J  2002  [325] 707
  5. Early practical experience and the social responsiveness of clinical education  Littlewood S, Ypinazar V et al  Brit Med J  2005 [331]  387-391
  6. Health Foundation 2022: NHS workforce projections  REALCentreWorkforceProjections_2022_v2.pdf Accessed 29.7.22

Featured image: Bust of Hippocrates against stone, taken by Andrew Papanikitas, 2022

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Thanks to John and Carwyn for this very important issue. There are many arguments for expecting clinicians to be involved in education. One essential item I would flag is the association between being involved in education and improvements in patient care. There is a significant body of evidence that clearly links both – involvement in postgraduate GP education and patient outcomes.

Surely, this is as much (if not more so) an imperative for all involved in clinical care to also be involved in education for better patient outcomes, experience, and effective practice.

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