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THE development of the various clinical specialties presents a fascinating story in medical history.
The evolution of surgery and internal medicine followed long cultural paths from guilds to professions.
The newer specialties are evolving according to different influences — operational, cultural and scientific.
My own specialty — emergency medicine — has travelled far in just 25 years.
From the days of “casualty”, run by retired surgeons and staffed by the most junior doctors, emergency departments are now complex, purpose-built units run by specialist staff and managed according to sophisticated principles.
But, as many will recall, growing up wasn’t always easy.
These days, there are other “new kids” on the specialty block — each having to go through the inevitable life stages before reaching maturity.
In the past couple of decades, focus has fallen on the areas of clinical quality and safety.
Moves began to measure outcomes, look for trends and analyse the root causes of error within healthcare.
Out of this movement has arisen the discipline of clinical governance, which is still in its “adolescence” — experiencing growing pains and not yet certain of its own identity.
The definition of clinical governance is not standard. It does vary across different organisations, different states, and even different countries.
But it’s a term that has been increasingly used in healthcare since incompetent paediatric cardiac surgery led to the deaths of babies at the Bristol Royal Infirmary in the UK from 1984 to 1995.
Like all other specialties, the practice of clinical governance has been driven by a perceived need and led by forward-thinking individuals.
Like most new endeavours, these people are well motivated and doing their best with whatever resources and skills they have.
However, like most specialties in their infancy, clinical governance is largely managed by self-made leaders and staffed by “untrained” practitioners still finding their way.
Many of us in more established specialties may perceive the newcomer as relatively unsophisticated — wielding blunt instruments, treading on uncertain territory, unsure of its appropriate role.
This can manifest as a focus on process over outcome and as an intrusion on clinical autonomy.
Day-to-day, we may see over-reaction to minor risks, and obsession with standardisation and protocols.
However, learning to estimate risk takes time, as does accepting that all risk in health care can never be fully eliminated.
It will take some patience from all of us as we watch clinical governance go through its life cycle.
From the infant taking its first steps to the adolescent who knows everything and respects no-one, a mature specialty must develop that understands risk pragmatically and deals maturely with human nature.
Its practitioners will be purpose-trained. Its results will command respect.
This mature specialty will take its place among its colleagues in a collaborative and productive way, and will be welcomed to the fold.
That’s growing up. And we all need to help it through the process.
Dr Ieraci is a specialist emergency physician with 25 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. She also runs the health system consultancy SI-napse.
Posted 6 December 2010
Tell us about your experiences with clinical governance by posting a comment below
Agree, a “Specialist in Clinical Governance” is an oxymoron – if he’s seeing no patients its not “Clincal Governance” and if he is, he can’t be a specialist in Governance.
Bit like leadership, really. I have been privileged to work with many clinicians who are excellent leaders but all of those I respect see patients. And that includes the ADON at Maryborough who would offer to escort patients to the ward or even roll up her sleeves occasionally. A session a week might do. The DMS can’t do everything every consultant does – but he should be able to do everything an intern is expected to do and offering to do ward cover once a month -ideally unanounced! – would give a matchless insight into how things actually work. And if he’s worried about being out of date with drugs or guidelines – maybe he could substitute a shift with the Emergency Receptionist.
In my time as a physician in Maryborough Queensland, clinical guidelines were poorly followed, cooperation with clinical based stage 3 drug trials was poor. Attitude to innovation was never encouraging and audit was seen as a reflection of policing, indeed of failure.
These attitudes I think are born within the medical training and throughout advanced training. I applude any effort to measure results, but the attitude that such measurement matters must be encouraged from the earliest stages of medical training.
I wonder if Clinical Governance needs to be a specialty in its own right. Although there will need to be specialists to teach and do the research, there is an ethical duty that requires ALL clinicians to review their work, ensure that it is safe and of the highest standard. In this respect we all need to have skills in Clinical Governance. Such skills need to be in the undergraduate and postgraduate curriculae which they currently are not.