1. Professional obligations: personal, cultural, national. NZ experience A John Campbell Chair Medical Council of New Zealand

2. © MCNZ 2007 Characteristics of a profession “… the inaccessible nature of the knowledge and the commitment to altruism are the justification for the profession’s autonomy to establish and maintain standards of practice and self-regulation to assure quality.” Cruess, Cruess & Johnston Lancet 2000; 356: 156 - 59 Balance of power and public good

3. © MCNZ 2007 Shifting boundaries: the public and the profession Professional group self determination –“unbridled medical power and paternalism” Self regulation to meet professional standards Public and professional regulation to meet agreed standards Public/political regulation to meet public standards

4. © MCNZ 2007 Trust and self regulation Trust must reside at some level, or with one group in the system Professional accountability is dependent on other members of the profession Cannot move from stupid trust to stupid accountability –Onora O’Neill Clin Med 2004; 4: 269-76

5. © MCNZ 2007 Breadth of professional obligation: individual practitioner

6. © MCNZ 2007 Am I my colleague’s keeper? Unequivocally It is the most difficult responsibility of all It is fundamental to professional self regulation

7. © MCNZ 2007 Responsibilities under the Health Practitioners Competence Assurance Act Health of a professional colleague As a Council appointed supervisor Fitness to practise –CPD including peer review and audit –responsibility for the poorly performing colleague

8. © MCNZ 2007 Fitness to practise Requirement under the HPCAA Patient care Public confidence The shockers Peer awareness of practice deficiencies Evidence of deteriorating performance

9. © MCNZ 2007 Deteriorating performance 32 of 62 decreasing performance 13 of 62 deterioration in some aspects –knowledge (all), –diagnosis and screening (63%), –therapy (74%), –outcome (57%) Possible cohort effect, failure to update Ann Int Med 2005; 142: 260-73

10. © MCNZ 2007 Good Doctors, Safer Patients Sir Liam Donaldson, Chief Medical Officer. London: Dept of Health, 2006

11. © MCNZ 2007 Fitness to practise Recertification and revalidation External body - regulatory authority Explicit standards Regular formal assessment –knowledge –peer assessment –patient assessment

12. © MCNZ 2007 Assurance of fitness to practise American Board of Medical Specialties Recertification 6-10 years Professional standing Commitment to lifelong learning Cognitive expertise ( standardised examination ) Standards based evaluation of performance in clinical practice

13. © MCNZ 2007 Fitness to practise Strengthened peer review and audit Continuous knowledge assessment Norm referenced Regular College assessment of performance Employing body / College becomes unit of assessment Regulatory authority approves accreditation processes Accountability for colleagues

14. © MCNZ 2007 Medical professionalism Nothing can substitute for having a trustworthy doctor “ not laws, not regulations, not a patient’s bill of rights, not watchdog federal agencies… nothing” Jordan Cohen President Assoc American Medical Colleges

15. © MCNZ 2007 Breadth of professional obligation: cultural competence

16. © MCNZ 2007 The HPCAA s.118 Functions of authorities The functions of each authority appointed in respect of a health profession are as follows: … (i) To set standards of clinical competence, cultural competence, and ethical conduct to be observed by health practitioners of the profession:

17. © MCNZ 2007 Other prompters Lack of complaints received from minority groups, leading Council to question its own cultural competence Complaints received about individual IMGs and their interactions with female patients An awareness that cross-cultural interactions are becoming increasingly common

18. © MCNZ 2007 Other prompters Dr Mason Durie’s argument that cultural competence is a necessity in clinical consultations and should be a tool for improving patient outcomes

19. © MCNZ 2007 Developing resources A scoping study A discussion document containing a draft definition, standards and a framework for implementation Consultation Four full-day workshops

20. © MCNZ 2007 Criticisms of the draft Our mention of Māori culture did not go far enough. There was insufficient mention of Treaty obligations There was too much discussion of Treaty obligations which took away from the focus on patient-centred care This was too much a bi-cultural document rather than multi-cultural

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22. Definition Cultural competence requires an awareness of cultural diversity and the ability to function effectively, and respectfully, when working with and treating people of different cultural backgrounds. Cultural competence means a doctor has the attitudes, skills and knowledge needed to achieve this.

23. © MCNZ 2007 Definition Cultural mores identified by the Council are not restricted to ethnicity, but also include (and are not limited to) those related to gender, spiritual beliefs, sexual orientation, lifestyle, beliefs, age, social status or perceived economic worth.

24. © MCNZ 2007 Statement content Attitudes Awareness and knowledge Skills

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26. Resource booklet Information on health disparities. Information on key Māori cultural concepts. Guidance on Māori preferences. Case studies.

27. © MCNZ 2007

28. Framework for implementation Undergraduate: part of MBChB for students. Specialist: part of their College recertification programmes. General: within accredited hospitals or within their vocational training programmes. Part of NZ REX assessment

29. © MCNZ 2007 Breadth of professional obligation: international

30. © MCNZ 2007 Registration options Medical student support Special scope postgraduate training –no entrance exam, English requirement –two year limit with extension –practice restrictions –home sponsor and return to home –no benefit for subsequent registration

31. © MCNZ 2007 Regulatory support PNG 2006 WHO report. Enhance regulation 2007 IAMRA NZAID support for Chairperson’s attendance MCNZ funded site visit - Sue Ineson and Jonathan Coates Draft regulatory bill Next steps –WHO support –materials –visit –twinning

32. © MCNZ 2007 Board members and Jonathan

33. © MCNZ 2007 Project team – Jonathan, Alice (Registrar) and Pedro (Executive Officer for the Medical Society

34. © MCNZ 2007 Characteristics of a profession “… the inaccessible nature of the knowledge and the commitment to altruism are the justification for the profession’s autonomy to establish and maintain standards of practice and self-regulation to assure quality.” Cruess, Cruess & Johnston Lancet 2000; 356: 156 - 59