A Tale of Two Surgeons
How does the GMC decide what makes a “good enough doctor”? The guidance on what constitutes “Good Medical Practice” gets longer and longer and wider and wider, so that, like the Bible, it is pretty well impossible to get up in the morning and brush your teeth without contravening some part of it. The proposals on revalidation go through endless revisions as the pilot sites angrily report that the whole thing is completely unworkable and has to go back to the drawing-board. Trust managements nervously introduce the prospect of multi-source feedback to the consultant body with all the aplomb of a Thomson’s gazelle approaching a pride of lions at a watering-hole. In a desperate attempt to appear Down With Da Kids, the GMC is now running on its website a cartoon strip featuring a GP called Julia and the daily ethical dilemmas she faces, inviting readers to comment. This has occasioned a mixture of rage and mirth within the profession and the threat of GP’s going to work wearing T-shirts and baseball caps printed with the slogan “What Would Julia Do?” Have a look if you don’t believe me………………….presumably this is part of the GMC’s attempts to appear less like the Spanish Inquisition and more cuddly, so that doctors will no longer have a panic attack every time a letter comes through the door with the GMC logo on the front. It’s usually because they’re asking for money, but lately they have taken to writing chummy little missives telling us how the proposals for revalidation are coming along, reassuring us that it will all be fair and transparent etc etc, or delivering yet more guidance on how not to get tangled up in their distressing and long-drawn-out disciplinary processes. Unfortunately the upshot of all this cuddly accessibility is a rising tide of complaints – on the “if you build it, they will come” principle, if you make it easier for people to complain about doctors, they will, and they do. I also have a worrying suspicion that the Julia cartoon asking for responses to ethical dilemmas is because they really, actually don’t know what Julia should do and are desperately hoping that someone might tell them……………especially because in most of her dilemmas, the answer is, “Well, it depends………………….” A quick glance at the Fitness to Practice hearings calendar might suggest to the casual observer that the main requirement for facing an FTP hearing is having a non-British-sounding name – until referrals are “blinded” before reaching the investigation panels we will never know whether this really represents competence problems among overseas graduates or the institutionalised racism that it might appear to be.
As a very new doctor, I worked with two surgeons, and it is interesting to reflect on what might be happening to them had we been working in the brave new world of today’s obsessive over-regulation. Mr A was what people might think of as a typical “surgical personality” – aggressive, impatient, exacting and very, very shouty. I was too low a lifeform for him to bother with, but he took out his aggression on the two male junior surgeons, regularly screaming at them on ward rounds, shouting and bawling in theatre and generally creating an atmosphere of terror and panic as soon as he hove in sight. In consequence I took care to have all his results and X-rays available and scurried around like a fieldmouse on speed, trying to avoid the rough edge of his tongue. However I noted that not everyone responded like that: one of the most satisfying moments of the year was watching the diminutive Nursing Officer steam into the ward and tear a strip off him in front of the whole ward round because he had shouted at a student nurse. “Don’t you DARE talk to one of My Nurses like that again!” she yelled, and he shrivelled like a deflated balloon. He even apologised to the student nurse. So it was possible for someone with enough clout to stand up to him, but it still didn’t change the kind of man he was. In later years as a GP I still referred my patients to him, but at least one came back and said “Don’t ever send me to see That Man again”, so clearly the years had not mellowed him…………..
Mr B, on the other hand, was a lovely man, and his patients adored him. He was kind and polite, and would sit on the beds and chat for ages – his rounds were long, but the atmosphere was relaxed and comfortable, with plenty of time for a cup of tea afterwards and a paternal concern for how the juniors were getting on. The only problem was, he was the most utterly hopeless surgeon I had ever seen. Despite my very limited experience, one trip to theatre told me that…………………….when I arrived the patient had already been on the table for hours for what should have been a fairly straightforward operation, and I wondered why Mr B was slowly and deliberately oversewing a hole in the small bowel. It was because he had made the hole. I watched with increasing horror as he stuck a scalpel into a swelling on the kidney to see what it was – it being a cyst, a load of infected fluid poured into the peritoneum, the anaesthetist went white and started fiddling with the machines, and I realised that the reason I had been called to theatre was that the op had already been going on for so long that my senior assisting needed to leave to do the afternoon out-patient clinic. Mr B was slow, clumsy and incompetent, and his patients took multiple trips to theatre in attempts to reverse the damage caused by minor procedures that went horribly wrong. Why did nobody stop him operating? Mr A may have been a complete swine to work with, but his technical competence was not in question, his stitches held together and his patients went home rather than languishing on the ward for months or dying.
Mr A, however, would be unlikely to survive today’s emphasis on “team working” and “communication”; of the two, he would probably be by far the more likely to come to the attention of the GMC because he was so unlikeable. I would have loved to read his “multi-source feedback” – although whether knowing that everyone hated him would have improved his “performance” is debatable. Mr B’s mortality rate would have been picked up as an “outlier” much earlier, but rather than being struck off he would have been gently eased into “management” in the erroneous belief that an incompetent doctor could do no harm there, when it actually confers the ability to trash entire populations rather than single individuals. Bad managers kill people too, they just do it a different way. Perhaps rolling the two of them together would have produced one decent surgeon who was nice to work with – such creatures do exist, and the belief that surgeons have to shout is as erroneous as all the other medical stereotypes. Surgeons have to have good hands, first and foremost – despite his obvious character flaws, if it came to an operation for me or my loved ones, Mr A would have been the choice for anyone who valued their lives. The question would be whether he was capable of modifying his behaviour – or whether he was a sort of surgical equivalent of John McEnroe, needing to scream and bawl to psych himself up for the very frightening prospect of holding a patient’s life at the end of the scalpel and knowing that if you get it wrong they might die. Perhaps he was anxious, realising the heavy responsibility he carried, shouting because he wanted things to be perfect in an imperfect system. Perhaps Mr B’s amiability lay in a selfish denial that his patients were suffering, that he was not the best person to treat them no matter how much he still enjoyed gowning up and being a “Mr”, that being a nice chap was not enough.
The GMC’s obsession with “fitness to practise” concentrates on “fitness” as in “worthiness” and is heavily punitive towards “immoral” behaviours, while getting itself all in a mess over what to do with doctors who underperform because their physical fitness has declined through age or illness. Mr B was most likely simply too old – loss of dexterity, poor vision, slowed reaction times, normal effects of ageing that nobody had had the heart to tell him meant he couldn’t operate any more. The revalidation proposals contain no requirement for doctors to have regular medical examinations. Disability discrimination within the profession is the norm rather than the exception, leading doctors who are struggling with health issues to conceal them for fear of being labelled a liability or a burden on their colleagues. The Royal College of General Practitioners’ training on “Health for Health Professionals” is promulgating the ridiculous notion that the main health issues in doctors are the “three D’s – Drink, Drugs, Depression” – as if we didn’t get arthritis and hypertension and cancer and diabetes like everyone else. Training is now so rigid that it is much more difficult for a young doctor who realises that they are not physically or mentally suited to their chosen speciality to move to another. Retraining and remediation is always expressed in shaming terms of “difficulty” or “failing”, and how on earth did we end up calling flexible training “less than full-time”, as if doctors with family, health or caring commitments were some kind of “less than” species of doctor?
I suspect that the unwieldy bureaucracy of revalidation will be killed by the cost. Imagine the chaos if all drivers were told that they would have to “revalidate” by completing tons of paperwork every year and resitting their driving-test every five. Imagine the army of people required to read through piles and piles of “reflective learning” without dying of boredom, administer the testing, the courses, the re-testing, the court cases. Of course, picking up drivers early who were drugged or blind or too arthritic to change gear would save a lot more lives, the most dangerous part of any car being the nut behind the wheel, but it would be too costly and too political so it won’t happen.
Revalidation Lite: one question to all the doctor’s colleagues, as follows. “Would you let this doctor treat you or your family?”
Three possible answers: “Yes, certainly” “Absolutely not” or “Weeeeeeeeellllllllll…………..”
First group: immediate relicensing
Second group: licence on hold pending further inquiry
Third group: approved revalidation course as per speciality, and ask again
That would sort the Mr A’s from the Mr B’s……………….
