Second opinion: The significance of Bristol
Dr Michael Fitzpatrick
Last month the General Medical Council judged that two Bristol surgeons were negligent in continuing to operate on babies, despite warnings from colleagues, when their death rates were far in excess of the national average. The distressing accounts of the Bristol cases led to widespread demands for closer regulation of the medical profession and within days the government announced plans for hospital 'league tables' based on surgical survival rates and other indicators of medical performance. But can such methods work?
The furore over the Bristol case follows a series of revelations in the press and on television about negligent, incompetent and fraudulent doctors. There have also been numerous exposures of the GMC as at best a toothless old bulldog and at worst a conspiracy of doctors out to protect their own against a hostile public.
Like all doctors I have my stock of grisly anecdotes about colleagues of dubious competence and sobriety and have personally (as a witness) experienced the ponderous ineptitude of the GMC. But there is nothing new in any of this, while the upsurge in concerns about the performance and propriety of the medical profession is very recent. It is impossible to separate the flurry of medical horror stories in the past few months from the drive to impose new forms of regulation on doctors.
The proposed hospital league tables follow the proposals in the recent White Paper, 'The new NHS', to establish a new framework of 'clinical governance', involving a National Institute for Clinical Excellence and a Commission for Health Improvement (Nice and Chimp). These plans to extend the methods of Ofsted from education into health have been widely welcomed as marking the decline of deference to medical mystique and the advance of patient empowerment.
I wonder. The real problem here is that it is impossible to resolve the mismatch in knowledge and expertise between doctor and patient at the level of the individual encounter. This is particularly the case when the patient's relative ignorance is compounded by the incapacity resulting from illness and decisions need to be taken promptly. Even when the gulf between doctor and patient can be reduced by recourse to league tables and the internet, a leap of faith is still required.
The leap of faith in the medical consultation assumes a level of trust, not only between doctor and patient, but more broadly between the medical profession and the public, and within society as a whole. Indeed it is the breakdown of relations of trust in society that is at the root of the current predicament of doctors.
One conspicuous manifestation of the breakdown of trust is the loss of faith in doctors that leads to the chorus of demands for regulation following the Bristol case. A less apparent but more fundamental manifestation of the problem is the way that doctors have lost confidence in themselves and in medical science.
The current vogue for medical ethics - in essence a new etiquette governing medical practice and now a 'core subject' in the curriculum prescribed for 'tomorrow's doctors' by the GMC - reveals the insecurity of today's doctors. The discussion about how to reformulate the Hippocratic Oath implies that difficulties in medical practice can be resolved by reference to a statement of absolute principle derived from ancient Greece and redrafted by a committee. The extraordinary credulity extended to diverse forms of quackery (homeopathy, acupuncture, etc) by modern doctors is another illustration of the extent of contemporary demoralisation. In one of the few critical responses to this trend in the sphere of medical education, the distinguished physician and scientist David Weatherall has warned that 'it is essential that, while trying to improve the social, pastoral and communication skills of our future doctors, we do not dilute their scientific education' (see Science and the Quiet Art: Medical Research and Patient Care, 1995, p329).
In his historic 1925 work Medical Education, the American physician Abraham Flexner quoted with approval a review by Naunyn of the early days of scientific medicine in Germany in the 1860s. Emphasising the common approach of investigator and practitioner, he observed that 'our patients obeyed us gladly. Our zeal led them to respect and trust us. It never occurred to them to inquire whether this zeal was in the interest of treatment or in the interest of science' (p8).
At a time when scientific medicine and society moved forward together, patients put their trust in doctors who were themselves inspired by the prospect of using science in the service of humanity. It is worth noting that this trust predated by several decades the emergence of truly effective med- ical treatments in the early twentieth century.
In the 1950s, when the Manchester orthopaedic surgeon John Charnley, pioneer of the hip replacement, discovered that the plastic used in his first 100 artificial hips was liable to perish, he simply invited his former patients back to hospital for a replacement. Whereas today he would be castigated in the press, condemned by the GMC and sued for millions, then his patients, sharing his commitment to experimentation and innovation, obeyed gladly.
It is ironic that popular faith in doctors has declined at a time when their treatments are more effective than ever. The poor performance of the Bristol surgeons reflects the dramatic advances in heart surgery in recent years - even 20 years ago their survival rates would have been considered unremarkable.
How can public confidence in doctors be restored? Not through hospital league tables, surgical batting averages, computerised audits, public inquiries, institutes or commissions, guidelines and protocols, oaths and codes of practice - or through litigation. These mechanisms simply reflect and compound medical insecurities, encourage a cautious and conservative practice and offer illusory protection to the public. The process of restoring trust in doctors can only begin with doctors regaining trust in themselves and in the methods of clinical science that won public confidence in modern medicine in the first place.
Reproduced from LM issue 112, July/August 1998