For most of the 20th century, Australia's Medical Colleges have played an important role in our healthcare system. The Colleges were founded to maintain and enhance professional standards in medicine's various disciplines. This was achieved through providing opportunities for the continuing medical education of College Fellows, by certifying that aspiring specialists could practise independently, and by encouraging research. The training role of Colleges was progressively developed, with evolution of training curricula, and through involvement in selection of trainees, appointment of supervisors and accreditation of hospitals and other healthcare providers as suitable sites for specialist training.

Over the years, the Colleges have attained considerable professional and community respect. This respect has underpinned the freedom that Colleges enjoy and allowed for their participation in the medical profession's regime of self-regulation. However, this respect and standing could rapidly diminish if the Colleges do not jealously guard their independence, while acknowledging their accountability to society. In this, they should be concerned primarily with the knowledge, competence and performance of their Fellows and with ways to assist in the maintenance of these attributes.

More recently, Colleges have sought to have the expertise of their Fellows contribute to community debates on the safety and quality of healthcare and broader health policy issues. This has been facilitated, in a number of instances, by the establishment of health policy units such as that of the Royal Australasian College of Physicians, which provides an evidence base for College views. For this expertise to be widely accepted, the Colleges must not be subject to external influences, nor have a major role in protecting their Fellows' financial and narrow professional interests.

Our Colleges increasingly recognise that they must be actively involved with the community and other key organisations in the healthcare and educational systems and that their activities should be open to external scrutiny. The acceptance of this move to external scrutiny is demonstrated by the strong support of the Colleges for the Australian Medical Council (AMC) to become the accrediting body for specialist education and professional development programs. Already, trial accreditation of two Colleges (the Royal Australian and New Zealand College of Radiologists and the Royal Australasian College of Surgeons) has demonstrated the rigour and value of the process.1,2 Areas requiring improvement have been identified and the Colleges taking part have to report to the AMC on a regular basis on how these shortcomings are being addressed. Accreditation is helping the Colleges to ensure that they are meeting the expectations of their Fellows, trainees, providers of healthcare and consumers, and that they are publicly accountable. Hopefully, it will ensure that College trainees are not only skilled clinicians but also appreciate the issues associated with the delivery of safe, high-quality care in the Australian healthcare system. AMC accreditation is also providing a transparent pathway for other organisations to seek accreditation for training and professional development programs in competition with those of existing Colleges. No other country has developed such a robust external system of accreditation of specialist education and training, and the process is attracting considerable international interest.

Our Colleges are also working closely with the AMC and Medical Boards to establish specialist medical registers in all States and Territories. Among other benefits, these registers will allow the community to more readily identify medical practitioners as recognised specialists. As part of this process, Colleges are contributing to the development of the criteria for regular re-registration and examining how these can reflect the maintenance of professional standards.

Rightly, the community expects that all medical practitioners will maintain their competence and behave in a professionally appropriate way. While it may seem appropriate for Colleges to consider complaints that one of their Fellows has failed to meet these standards, Colleges in Australia do not have this role. Medical Boards, but not Colleges, have the statutory authority to investigate complaints against doctors and can give protection to the complainant. The legal position of Colleges in undertaking such investigations is far from certain. The appropriate role of the Colleges in such difficult matters should be to provide independent advice on standards to Medical Boards and other statutory bodies, and to provide assistance to the Board in the re-education and retraining of underperforming Fellows.

The traditional discipline base of the Colleges may impede innovative developments in healthcare delivery. Increasingly, there is overlap and close collaboration in clinical activities (such as in radiation oncology and medical oncology) and there is a trend to bring together, in one service unit, physicians and surgeons dealing with the same body system.

Strengthening the intercollegiate body (the Committee of Presidents of Medical Colleges), while maintaining individual College autonomy, may well assist this process by promoting multiple College training and professional development programs. This would seem preferable to formation of new Colleges, although the AMC now has a more robust and transparent process for these to be recognised.

If Colleges are to continue to command the respect and confidence of the medical profession and society, they must not become financially or otherwise dependent on government or other organisations with a vested interest in their opinions and contributions to public debate. While it is understandable that Colleges, because of their unique expertise, may undertake some contractual work for governments or other organisations to assist in improvements to healthcare, this must be done with great caution. Colleges should ensure they are not influenced by the provider of the funds; furthermore, it would be extremely unwise to build up a significant College bureaucracy or facilities that are dependent on such external funding.

Equally, Colleges should be extremely reluctant to become fundholders for government-sponsored training programs or to build up organisations dependent on such funding. Political decisions, as has recently happened with the training program for general practitioners, can place a College in a very difficult position. The threat of removal of such funding and the resulting impact on the financial viability of a College could temper criticism of the policies of government or other organisations.

These issues have received considerable attention in North America and Europe. Pellegrino and Relman3 recently argued strongly that a professional organisation such as a Medical College can not become involved in protecting its members' financial welfare or other narrow professional interests: "It would be far better . . . for physicians to promote patients' interests on ethical and medical grounds as members of medical associations than to seek confrontation as union members. In our view, unions and truly professional associations are simply incompatible." These sentiments obviously have parallels in Australia.

As the eminent ethicist Sullivan4 points out, true professionalism depends on the moral contract between the professional and society. It is only when the responsibility to patients and to the public interest is held to be paramount that members of the medical profession can expect society to accept self-regulation of the profession and to listen carefully to proffered opinions and advice. Colleges must continue to promote these principles to their Fellows and trainees, and Colleges and their Fellows must demonstrate to society their commitment to them.