The power and prestige of the medical profession ebbed away. This loss was both self-inflicted and the result of various unforeseen events and societal changes. These events include the scandals listed above, the Internet, and the increasing politicization and monetization of health care. The medical profession sleepwalked through all of this, ceding leadership to managers and Big Science academics. Drastic and catastrophic changes to working practices, and the protocolization of care were accepted with barely a whimper. In the NHS, the scandals from Bristol onwards made it easy for the politicians and the managers, ably assisted by the judiciary and the media, to strip away this power. I do not mean to glamorize the world of my youth. It would be disingenuous of me to argue that doctors were better in 1983. They weren’t. I worked for men (they were mainly men) who were greedy, lazy, arrogant and incompetent. I also worked for men who were selfless, devoted to their patients and kind to their juniors and students. I am unconcerned by status for its own sake, but status should at least be commensurate with responsibility. We handed over our power but not our accountability to our patients. Stanley Baldwin famously dismissed the press as exercising ‘power without responsibility – the prerogative of the harlot throughout the ages’. Doctors have become anti-harlots: we carry responsibility without exercising power.
The philosopher Ronald Dworkin wrote of the professional autonomy once enjoyed by doctors: ‘They did not have to be backslappers or joke-tellers or handshakers; they did not have to get along with their boss or be shrewdly political. Their healing skill was enough to attract patients and earn a comfortable living. Their job in life was largely to supervise themselves. They answered to no one but their patients.’ But that changed too: we’re all in sales now. Perhaps doctors no longer command respect because they have ceased to respect themselves. This manifests in little things, such as how they dress. Most hospitals now operate a ‘bare below the elbows’ policy, which is justified on the basis that it prevents doctors spreading hospital-acquired infections such as methicillin-resistant staphylococcus aureus (MRSA) to their patients. There is little or no evidence to support this. The NHS banned the wearing of white coats by doctors in 2008; this was essentially a political gesture, following rising public concern about hospital-acquired infection. This cheap gimmick was meant to deflect public attention from the real causes of hospital-acquired infection, such as overcrowding, shortage of single rooms and isolation facilities, the outsourcing of cleaning to the private sector, and inadequate staffing. The removal of the white coat was a political act, taking away what some saw as an outdated symbol of doctors’ power. The white coat was a vestige of the golden age, associated with professional competence, scientific progress and (paradoxically) cleanliness. Patients are more likely to trust doctors who look like doctors. The white coat was a uniform, which doctors wore with pride and honour, and which made them immediately identifiable to their patients.
Medicine’s degeneration and corruption has been as much aesthetic and intellectual as professional and scientific. The clinician-aristocrats may have been plutocrats at the top of a feudal medical career pyramid, but they were leaders and carried the memory of their institutions. Many had style and ‘bottom’ – a mysterious quality, a combination of personal substance and integrity. The profession appears to be going through a crisis of bottom; doctors still publicly proclaim their love of the job, but the statistics tell a different story with a rush to retirement. Bullied by managers and frightened of their patients, overseen and regulated by an ever-increasing number of statutory bodies, we let this happen. Over my professional lifetime, we saw the disintegration of medical teams; we saw nursing evolve into a rival, rather than a complementary, profession; we saw specialist training fracture and shorten, producing new consultants who simply weren’t able; we saw administrators evolve into managers, who took over the hospitals. As doctors have lost – given away would be more accurate – their power, they must pay homage to the contemporary orthodoxy that they are simply one member of a multidisciplinary team that provides care for the patient. This orthodoxy holds that no single member of this team should be dominant, or domineering, and that all decisions are reached by happy consensus. The multidisciplinary team, however, has usually vanished when something goes wrong, leaving the doctor to assume responsibility (and punishment) for whatever awfulness has happened. In the phrase of Allyson Pollock (public health academic, and director of the Institute of Health and Society), doctors ‘work in teams, but are blamed as individuals’.
In their mission to increase regulation and accountability of doctors, politicians and managers were assisted by the new breed of academic bioethicists who emerged in the 1980s and 1990s. Typical of this new breed is Sir Ian Kennedy, the academic lawyer who chaired the Bristol Inquiry. Kennedy gave the Reith Lectures in 1980, taking as his theme ‘Unmasking Medicine’. His vaguely leftist critique of the medical profession, which argued for patient empowerment, ironically chimed with Margaret Thatcher’s plan to reform the medical profession and the NHS along consumerist lines. Education, local government and social services would be subjected to similar reforms, creating what has been called the ‘audit society’. Kennedy became the quintessential medical quangocrat. One of his many recommendations relating to Bristol was the establishment of a ‘system of external surveillance’, which led to the foundation in 2004 of the Commission for Healthcare Audit and Inspection (CHAI). The CHAI required hospital trusts to provide them with huge quantities of data. The Lancet accused the CHAI of creating ‘an environment of prejudice, anxiety and resignation in the workplace’. The moral philosopher Onora O’Neill used her 2002 Reith Lectures ‘A Question of Trust’ to argue that systems aimed at increasing accountability and regulation of professionals such as doctors had the paradoxical effect of deepening the mistrust they sought to remedy. When the CHAI was closed in 2008, Kennedy lamented that regulation was seen as ‘part of the problem rather than the solution’. The case of Harold Shipman was used to justify the new draconian regulation of doctors, although most privately acknowledged that such regulation would not prevent the emergence of the occasional rogue like Shipman. This new professional elite which emerged with the audit society came to exercise a hierarchical domination of doctors who continued to carry a degree of responsibility which this elite would never have to bear.
Following the collapse of power of the clinician-aristocrats, the vacuum was filled by managers and a new breed called clinical directors, who viewed their role through a managerialist prism. The clinical directors were distrusted by their fellow doctors and manipulated by their managers, so they never achieved the prestige of the clinician-aristocrats. Power within medicine seeped out of the hospitals to the committee rooms and the universities. The new breed of professor was a Big Science Brahmin, and the committee men and women sought prestige in the royal colleges, professional bodies and medical schools. Clinical work was strictly for the unambitious. All of this has left the hospitals essentially leaderless. Managers and clinical directors are nominally in charge, but they are motivated mainly by targets and metrics, and are unconcerned with maintaining the ‘invisible glue’ which once held hospitals together. This lack of leadership, both among nurses and doctors, contributed significantly to the chaos and squalor that eventually led to the scandal at Stafford. Doctors are so divided by factional fighting and boosterism for ‘our’ diseases and services that we no longer function as a cohesive profession pursuing a common good. We have poisoned the well of our craft and our tradition.
The lazy stereotype of hospital consultants as pinstriped bullies has proved remarkably enduring, and impervious to the grim realities faced by contemporary doctors. Doctors now – just like their patients – are pawns in a global business. Peter Bazalgette, author of The Empathy Instinct, and most famous for the dubious distinction of bringing the vulgar and exploitative Big Brother to British television, believes doctors work in an environment as cocooned from reality as the ‘housemates’ on his TV show. He l
aments the ‘tendency in doctors towards grandiosity and omnipotence’, taking as his example of this tendency the fictional surgeon Sir Lancelot Spratt, played by the great James Robertson Justice in the Doctor in the House films, seven of which were made between 1954 and 1970. Spratt, writes Bazalgette, was ‘the bombastic, aggressive, megalomaniacal surgeon… [who] harassed the nurses, terrified the junior doctors and treated the patients like unfortunate serfs’. For most of history, however, doctors were not held in high esteem, and the prestige of the profession during the golden age is probably a brief historical anomaly. From Molière to Shaw, doctors were portrayed as pompous, ignorant, greedy and useless. Ivan Illich observed that for all of history before the French Revolution, doctors earned their living as artisans. He had a low opinion of the medical profession, whom he regarded as more concerned with their income and status than the health of their patients: ‘Doctors deploy themselves as they like, more so than other professionals, and they tend to gather where the climate is healthy, where the water is clean, and where people are employed and can pay for their services.’ The Flexner Report (1910) into medical education in the US and Canada documented the shockingly low quality of medical education at the time. A. J. Cronin’s 1937 bestseller The Citadel was a portrait of the lamentable standards of British medicine between the wars. The erosion of status over the last thirty years has simply put doctors back in their rightful historical place, and they are unhappy. Complaints against doctors to the General Medical Council doubled between 2007 and 2012. The NHS paid out £1.4 billion to settle medical negligence claims in 2015–16, a figure which has more than doubled in ten years. There have been several high-profile cases of doctors convicted of gross negligence manslaughter. The London surgeon David Sellu spent fifteen months in prison before having his conviction overturned on appeal. Hadiza Bawa-Garba, a paediatrician nearing the end of her training, was convicted of gross negligence manslaughter in 2016, following the death of a six-year-old boy called Jack Adcock. Her professional training log, which encourages trainees to write ‘reflections’, was used in evidence against her. The medical profession in Britain has been outraged by the treatment of Sellu and Bawa-Garba: the mouse may yet roar.
You might argue that the happiness and morale of doctors is of no concern to anyone outside the profession and their families: this has been the view of politicians, managers and the media. A functioning health-care system, however, cannot exist without a strong and well-supported medical profession. Doctors – particularly GPs – are retiring early; a GP friend of mine quit his NHS practice in his mid-forties simply because he could no longer bear the behaviour of many of his patients. The end of deference very quickly became the start of insolence. Doctors often blame politicians, managers, journalists and lawyers for their woes. While it is true that these groups have not been well disposed to us, we have mainly ourselves to blame. We conceive of ourselves as powerless victims of uncontrollable external forces, but this is false. Our complacency and collective cowardice have placed us where we are now.
Decisions that used to be routinely taken by doctors are now often referred to the courts. The cases of Charlie Gard, Isaiah Haastrup and Alfie Evans, which have received extensive media coverage in Britain, are broadly similar. All three baby boys had severe, irreversible brain injury, and could not survive outside an intensive care unit. The doctors involved quite reasonably advised the respective parents that further intensive care was futile, and that the children should be allowed to die ‘with dignity’, as the trite modern formula puts it. In all three cases, the parents would not agree and exhausted every legal avenue in a battle against the doctors and hospitals. They also conducted parallel publicity campaigns via the newspapers and social media. The courts ruled in favour of the hospitals in all three cases; all three boys have since died. These cases were presented by the media as an ethical dilemma, but there was no dilemma in any case. A dilemma implies a difficult choice, picking the best, or least worst, of two or more alternatives. There was no alternative scenario in which Charlie Gard could have survived and enjoyed life outside the intensive care unit of Great Ormond Street Hospital. The problem was not an ethical one, but one of authority and expertise. Hospitals have always dealt with severely brain-damaged children and their parents. Each case, until now, was a private tragedy. The doctors and nurses did the best they could and, when the moment arrived, told the parents that it was time to let go. What has changed is the refusal of contemporary young parents to take the doctors at their word, to accept their authority and their experience. Why is this happening now? There are several reasons: the gradual disappearance of deference to professionals and authority figures; the democratization of knowledge via the Internet; the new distrust of ‘experts’ and the inflammatory effects of social media.
Doctors have been wrong-footed by all of this. The orthodoxy that ‘communication skills’ solve all such problems has been shown to be a hollow fantasy. Many of the doctors and nurses who treated Charlie Gard received death threats and were spat at by ‘supporters’ of the family; some have not returned to work. Michael McDowell, the Irish barrister and former minister for justice, criticized doctors and hospitals for routinely referring cases to the High Court which they should deal with themselves. By choosing the legal route so often, doctors have tacitly conceded that they no longer have the authority – the bottom – to make, and stand by, these difficult decisions. What are they afraid of? These conflicts are now so common that professional mediators have emerged. Dr Chris Danbury, an intensive care specialist in Reading, is a registered mediator and is regularly engaged by hospitals to negotiate with families. He gives us a flavour of the challenges involved:
This [case] involved a young father in his early twenties who had an untreatable, progressive, ultimately fatal neuro-degenerative condition. He had been transferred back from his local neurosciences centre to his local hospital. The regional centre told the local hospital that he was coming back for palliative care, but had told the family that he was being transferred back to be closer to home. When the receiving intensivist talked to the family for the first time, the family became outraged at the mention of palliative care and denied that it had ever been mentioned by the neurosciences unit. By the time I visited the hospital, there was a 29,000 signature petition calling for continued treatment. The hospital was being picketed by 250 people.
After talking to the clinicians, I asked to speak to the family. Initially hostile to the idea, they finally agreed. I then had to persuade the hospital to let me talk to the family without either police or security present. Eventually I ended up opposite 18 members of his family. Following a challenging start, I listened and talked to them for three hours. The following week, in the COP [Court of Appeal], the judge asked whether the situation could be resolved without him hearing the case. Despite the objections of the trust’s barrister, the other two barristers felt that it was worth a try. As one of the experts in the case, I then spent around eight hours talking to the family and the clinical team. As the day went on, it became clear that the distance between the two sides was narrowing, and by the end a plan had been agreed by everyone. Treatment would continue, although some of the more invasive treatments (including CPR [cardiopulmonary resuscitation]) would not be offered. As a result, he went on to live for another couple of years.
Although I may not possess the saint-like patience of Chris Danbury, I have some experience of such conflicts, having spent most of 2012 engaged in prolonged disputes with two families. The struggle ended with the inevitable and unpreventable deaths of both patients. It was a wearying, dispiriting experience, which I survived only because I shared the burden with a sensible, courageous and supportive colleague. The hospital did not have a formal process for dealing with such quarrels, so we were left isolated and unsupported. The continuous, well-meaning advice from the Clinical Risk Department was to organize Another Meeting: it seemed inconceivable to them that such difficulties could not be overcome by Another Meeting
and what they like to call Effective Communication Skills. But, as the doctors at Great Ormond Street Hospital (Charlie Gard), King’s College Hospital (Isaiah Haastrup) and Alder Hey Hospital (Alfie Evans) found out, meetings, mediation and communication skills have their limits.
The unwritten social contract between patients and doctors has broken down, and it’s time we drew up a new one. Society, however, isn’t clear on what it wants from doctors. Our patients want us to be simultaneously decisive yet humble, knowledgeable but not patronizing, empathetic, patient, available (both physically and psychologically), and so on. It would be difficult to find a single individual who embodies all of these qualities, which is why we feel a vague sense of inadequacy. We might channel some of the energy we currently devote to awareness campaigns to opening a dialogue with our patients. Richard Smith, then editor of the British Medical Journal, wrote about ‘the bogus contract’ in 2001. This contract is based on patients believing that modern medicine can do remarkable things; that doctors can easily diagnose what is wrong, know everything it’s necessary to know, and can solve all problems, even social ones. Doctors know that these beliefs are childish, and that the contract is bogus. They know that modern medicine has limited powers, that it’s often dangerous, that they can’t solve social problems, that they don’t know everything, that the only thing they really do know is how difficult many things are, and that the balance between doing good and harm is very fine. The bogus contract is the inevitable result of decades of medicalization of life. During my professional lifetime, medicine annexed old age, substance abuse and childhood behaviour. The late great historian of medicine Roy Porter wrote in The Greatest Benefit to Mankind (1997): ‘Today’s complex and confused attitudes towards medicine are the cumulative responses to a century of the growth of the therapeutic state and the medicalized society.’ In the seventeen years since Smith wrote about this bogus contract, doctors’ unhappiness has only deepened, and their status has drained away. Perhaps we should start awareness campaigns with slogans such as ‘Medicine Has Limited Powers’, ‘Death Is Inevitable’, ‘Old Age Is Not a Disease’.
Can Medicine Be Cured Page 15