The historic importance of this innocuous looking booklet is easy to miss at first glance, despite the warning in the introduction that it will assist in the appraisal and revalidation of psychiatrists. Comparison with the GMC's Good Medical Practice on opposing pages shows not only the superiority of the GMC prose, but also that good psychiatric practice seldom deviates from that which is to be expected of any doctor. The need for integrity, honesty, respect for colleagues and personal probity is rehearsed in both documents, becoming repetitious and eventually tiresome in the one under discussion. Due attention is paid to the vulnerability of patients, especially those unable to consent and the need to ensure the rights and safety of children. There is occasional overkill: is it really necessary to specify that a psychiatrist must achieve competence in taking a history and conducting an examination of mental state? Will cardiological guidelines specify competence in auscultation of the heart? Specialist sections offer their authors (committees?) golden opportunities to strut their stuff, reminding us that the College is unusual in recognising six or seven different types of psychiatrist. Psychotherapists forbid themselves from using treatments that lack sufficient basis in scientific evidence. If they are anything like the rest of us this should leave them plenty of time for continuing professional development! It is to the psychotherapists' credit that it is in their section alone that one finds reference to improper relationships with patients. Prohibition of sexual relationships with patients is never explicit but therapists should be ‘sensitive to the psychological implications of transgressing boundaries e.g. through touch and/or self revelation’.
Scattered throughout the report is a litany of exhortations that have less to do with clinical competence than with straight delinquency. Thus, the good psychiatrist will, inter alia, cooperate with confidential enquiries, take due note of guidelines from various organisations and avoid making autocratic decisions, falsifying clinical notes or ‘deliberately flouting regulations’. The only reference to the primacy of patient needs is a Delphic statement on p. 13: ‘the psychiatrist will be able to judge the ethical implications of management requirements and take appropriate action’.
The report is a radical departure from the traditional role of the College as the arbiter of standards of education and training, to one of social policeman who peers into every nook and cranny of the lives of psychiatrists. If the spin of this report proves typical of similar documents from other Colleges, some will think that Faustian bargains have been struck with a government determined to put doctors in their proper place.
Questions, the answers to which lie outside the scope of this review, inevitably arise as to how this report will be used, to what purpose and by whom. Wedded as it is to the GMC and clinical governance in the UK, its provisions cannot apply to psychiatrists in Ireland, where separate (and hopefully better) arrangements will be needed in keeping with emergent legislation. Only time will tell if these developments will strengthen psychiatric practice in these islands; possible benefits to patients are even harder to predict.
There are some good things here. In its broad sweep the report goes where none has gone before. At least it calls a patient a patient as distinct from a client or service user. An alluring advertisement to encourage young doctors to take up psychiatry as a career it most definitely is not. Nobody wants to perpetuate the archetypal arrogant consultant, but this report loses the plot. Image matters. The image of the future psychiatrist created here is one of a doctor cum civil servant who must not only be competent, but must be all things to all women and men, provided only that the managerial boat is not rocked. It may be too much to hope that a second edition will remind us that psychiatry is a medical calling of high purpose and that the needs of patients are paramount; that any psychiatrist may on occasion be called on to speak out, even under threat, on behalf of patients or to support colleagues who do so. Blandishments here about good relationships within teams are all very well, but they gloss over the reality of final clinical responsibility and pale in comparison with the sheer punch of an earlier guideline: ‘Life is short, and art long; the crisis fleeting; experience perilous, and decision difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate’ (Hippocrates, 450 BCE). O tempora! O mores!
London: Royal College of Psychiatrists. 2000. 48 pp. £5.00. ISBN: 1-901242-57-9