10/15/98

Spare the Rod
    by Belinda Parsons

The Melbourne Age 16/9/98

11/2/98

Bad medicine

Sarah Boseley on the disasters that have forced the medical profession into bout of self-examination.

What has happened to our doctors, those men and women with stethoscopes, white coats and an air of comforting authority whom we have admired and trusted from the first time they laid a cool hand on our feverish young foreheads? New tales of scandal, horror and wrong-doing by those people seem to break every day. And to think that we once thought them the nearest thing to saints on earth.

We hear of the GP whose patients' bodies are being exhumed, we learn of the consultant gynaecologist who used his surgical knife with all the subtlety of a mowing machine inside women's bodies and left them broken and bleeding. And what could be more distressing than the Bristol case, in which the arrogance of two heart surgeons led to the deaths of tiny babies whose lives could have been saved if their parents had only known to take them somewhere
else.

There is growing unease. We thought we knew these people. Have doctors changed? Have they disavowed the Hyppocratic oath which debars them from doing harm? Or are the wrong sort of people entering the profession? Junior doctors are on drugs, we hear. A study last month in the Lancet, the
esteemed medical journal, said two thirds of them drink too much, a third of the men smoke cannabis and more than 10 per cent use other drugs, from LSD to cocaine and amphetamines. Only this week, a new study suggested one in 10 doctors could be suffering from an addiction, and the British Medical
Association called for random dope-testing in hospitals and GP surgeries. The NHS Executive is now considering a ban on alcohol on hospital premises.

How can the overwhelming trust the public have for so long felt for their doctors survive? Next week things will only get worse, with the opening of the public inquiry into the Bristol babies case, which will examine in minute detail not only all the deaths we have already heard about, but also the desperately sad stories of tiny children who were brain- damaged, and
adults who died during heart operations at the hospital.

What are we to think? Perhaps something fundamental has happened. Look at the case for the prosecution. In Greater Manchester, Dr Harold Shipman, a GP, has been charged with murder. Not one murder, but four. Not a spontaneous crime of passion, but the killing of women patients in his care. Women who trusted him and put their lives in his hands. He is also accused by police of altering the A 300,000 will of 81-year-old Kathleen Grundy so that he became the sole beneficiary. To the appalled astonishment of local people and the wider public, police have said they are now investigating the deaths of 90 people who were on Dr Shipman's books.

But does the man, who, it must be remembered, has not been tried and is as yet only under suspicion, look like a monster? No, he looks like any hard-working, caring GP.

The number of complaints about doctors from the public, heard at the General Medical Council, is at an all-time high. Last year, the disciplinary body received 2,500 complaints, 500 more than in the previous 12 months. Doctors are being struck off at the rate of two a month.

Rodney Ledward was one of them. The case was shocking in the extreme. The GMC heard of seven years of bungling and botched operations at the William Harvey NHS Hospital in Ashford and at St Saviour's private hospital in Hythe, both in Kent. Women put their trust in him, and he abused it. Mr
Ledward told 54 year-old Jenny Gurney her ovaries were healthy. Five weeks later he took them out without her consent during a hysterectomy and left her with internal damage. She had to have two litres of blood drained from her stomach in a further operation.

The consultant was found guilty by the GMC of damaging women's internal organs, operating without consent and walking away while they were still bleeding. The reaction to the revelations was horror and astonishment that Ledward could have been so arrogant and incompetent (he switched off his
mobile phone after the operation that was to prove his last, and nobody could reach him to say his patient needed help) and that he was not stopped earlier. The first complaints against him came in 1991. This catalogue of disaster is disturbing both for the public and for those in the medical profession who are now working on major, far-reaching reforms in an effort
to stop these horrors happening, and to keep the public's confidence in doctors alive. Trust is the central word. "Patients trust doctors with their lives and well-being," said Jeremy Lee-Potter, chairing the professional conduct committee of the GMC that dealt with Ledward. He echoed Sir Donald
Irvine, the GMC President who had the unenviable task of dealing with the Bristol surgeons.

"At the centre of this inquiry is the trust that patients place in their doctors," he said, as he struck off James Wisheart, a senior children's heart surgeon and John Roylance, the chief executive of the United Bristol Healthcare Trust. Sir Donald has been trying to bring about change for some years. Bristol was a watershed, but only because it crystallised the concerns of the public. There had been a feeling for some time that the
medical profession was out of step with society. Suddenly the stripping away of the mystique from the Bristol heart surgeons showed that even the most caring doctor can be flawed by arrogance or insularity. "Part of the anger with the profession, particularly post-Bristol is a frustration that the sense of trust and certainty doctors give us has somehow been betrayed,"
says Sir Donald.

Dr Ian Bogle - the GP who heads the British Medical Association, which has been working with the GMC and the Royal Colleges on the way ahead - acknowledges the scale of the problem. "There is no way I can do other than accept that some damage has been done by the publicity over the last few
months," he says.

"We have been working with the GMC for nearly a decade to try to put in the structure we now have, which will hopefully reassure the public, patients and ourselves that we can minimise the chances of these things happening again," says Dr Bogle.

The GMC recently spelled out the duties and responsibilities of doctors in a booklet called Good Medical Practice, which has gone to everybody in the profession. Those who breach this ethical, moral and professional code could be hauled before the GMC, they have warned.

It tells a doctor that patients have a right to be told if something has gone wrong, that they must be honest, listen carefully to their patients' needs and not abuse their trust. The doctor must keep his skills up to date. The Government now means to ensure he or she does by sending specialists into hospitals to make sure doctors' skills are up to standard.

We have always expected all these things of a doctor, and it is a measure of the changing times that they need to be spelled out in print. But what will fundamentally alter things, if it works, is the duty the GMC has now laid on doctors to blow the whistle - to tell the bosses if one of their colleagues is not performing properly.

It was only the fact that the consultant anaesthetist Stephen Bolsin, who now works in Australia because, he claims, ranks closed against him here, was prepared to become a whistleblower that the Bristol scandal was exposed.

One of the most disquieting aspects of the Bristol case was the sheer arrogance of the eminent people it involved. They appeared to feel inviolable, untouchable.

The reformers need to topple such patrician doctors from their ivory towers. There is far less of a problem with the younger doctors. Medical schools now teach them how to break bad news to a patient or relatives - how to talk to them on their own level, not at one remove.

Sir Donald says he is determined to "change the culture". Doctors have to be aware of the expectations of the outside world, and not only how they match up to them, but how their colleagues do as well. "We're developing a culture in which it is not only possible but seen as responsible, to be listening,
to be open when things don't seem to be right," he said. "To confront it. This is not about whistle-blowing. It is about early detection. When things aren't quite right, the best and most supportive thing must be to say we seem to have a problem here." Unfortunately, this did not happen with Rodney
Ledward. It was only because other consultants were called in to put right the damage he had done that his inadequacies were made public. There are those who wonder if self-regulation can be made to work at all, since it did not work with him.

Sir Cyril Chantler, Dean of the Guy's, King's College and St Thomas' Hospitals' Medical and Dental School, is another reformer who does not underestimate the scale of the problem. "I think there's a whole spectrum between those who don't think there is a problem and those who are as aware as we are that there is," he said. "And there are some people who would
define the matter differently.

"When something went sour is difficult to know. There comes a moment when you suddenly wake up and realise something has changed. But you don't realise, until you look back, how much has changed. The recent spate of cases at the GMC, including the Bristol case, has concentrated everybody's minds, but I think people have been trying for some years in all parts of
the profession to get people to recognise that we need fundamental change."

In a lecture he gave this month in Illinois, Sir Cyril, who is a children's kidney specialist, called for a "fundamental re-examination of the role of physicians in our society". Both he and Sir Donald think the fantastic advances in medicine of the last few decades have helped destabilise the cosy relationship that patients had of old with their doctors: "Medicine
used to be simple, ineffective and relatively safe. It is now complex, effective and potentially dangerous. The mystical authority of the doctor used to be essential for practice. Now we need to be open and work in partnership with our colleagues in health care and with our patients."

Patients want old-fashioned values from their doctors, says Sir Donald and not just the latest technological wizardry. But that is where medicine and society are out of step. Now that doctors have advanced science at their fingertips, they have forgotten how to talk to the patient. And one of the things they have failed to explain is that, as Sir Cyril puts it, "doctors
do not save lives, although we can on occasions help to prolong them". Physicians need to remember their role as the "amicus mortis", he says- "the friend who tells you the bitter truth and stays with you to the inexorable end". The new relationship between doctor and patient - friends,
equals and mortals - can only be hastened by the huge amount of information about medical treatment now available to the lay public, particularly on the Internet. Every doctor now has a story about the patient who arrives and tells the medic what his problem is and what the best treatment will be, he has read it on the net, and he's right.

Claire Rayner, chair of the Patients' Association, thinks the damage to the profession done by all the scandals may be limited. "People have lost a certain amount of reverence for the profession, but many, many people say they have a marvellous relationship with their own doctor. People do have
enormous respect for those they know and believe are good." But she admits they are much more affectionate towards the GP, who they know well, than the hospital doctor. She thinks people do not like the secrecy that hospital doctors seem to be immersed in - they feel that if something goes wrong,
they will not be told and they certainly will not get redress. "People say, they look after their own, don't they, and they are making too much money," she said.

After all the horrors of Bristol, it was the issue of merit awards which affronted the public, she said. They could not believe that James Wisheart was given a merit award worth around A35,000 a year after the inquiry began.

It was Frank Dobson, the Health Secretary, who read the public mood accurately and insisted he would find a way to remove the award. If the reforms that the GMC and other bodies have set in train do not satisfy the growing public disquiet with doctors, he has already indicated that he might
not be averse to looking for more radical solutions himself. There is everything to play for.
The Guardian (UK)
Website: http://www.guardian.co.uk/
� Copyright Guardian Media Group plc.1998

11/02/98

Measles