Commentary: The Doctor’s Dilemma: a response

Liam Donaldson

Chief Medical Officer, Department of Health, Richmond House, 79 Whitehall, London SW1A 2NS, UK. E-mail: Liam.Donaldson{at}doh.gsi.gov.uk

The central thesis in the Preface to The Doctor’s Dilemma1 was, of course, that a profession that had a direct and pecuniary interest in the treatment of its patients could not be trusted to act in their interests.

It is said that Shaw’s hatred of doctors stemmed from a bungled operation on his foot.

Shaw would never have acknowledged in 1911 that the bad doctors were in the minority. The experience of the last 90 years and particularly the years since the foundation of the National Health Service (NHS) have provided many reasons for the public and patients to trust the profession which serves them. A State funded, State employed medical workforce (one of Shaw’s ‘recommendations’), improvements in undergraduate and postgraduate medical education, an increasing emphasis on standards, and an ethical basis for research all represent major progress.

So how much of Shaw’s cynicism about the professions’ attitude towards poor practice could be sustained in assessing today’s medical profession?

His infamous charge1 that medicine is a ‘conspiracy against the laity’ was actually levelled against all professions, although the former was, of course, the main focus of his ire. However, he made the more specific comment about the medical profession being: ‘a conspiracy to hide its own shortcomings’.

This notion of ‘hiding of shortcomings’ does have a relevance to events in the NHS in the last two decades of the 20th century when a series of medical scandals hit the headlines, often for weeks or months at a time. The Enquiry into the Bristol Children’s Heart Surgery Service2 did not just chronicle the inappropriate and inadequate response to the high rates of death associated with heart operations but pointed to a ‘club culture’ that had stopped the problem being confronted. In the case of a gynaecologist, Rodney Ledward, whose poor standards of care and arrogant behaviour led to his being struck off the Medical Register by the General Medical Council, the subsequent independent enquiry3 catalogued the wrongdoing but also pointed to deep-seated cultural problems and described doctors as behaving as ‘gods’. Many other incidents of poor practice around this time were characterized by a seeming reluctance to bring the problems to the surface and deal with them. Problems of poor practice often presented with a major adverse event but when the chronology was clear, there were earlier concerns that had been ignored or inadequately addressed.4

Shaw made little attempt to sympathize with, or understand a profession which sought to protect its ‘bad apples’. He tarred all with the brush of conspiracy. In reality, whilst closing ranks was part of the reason that poor clinical practice continued to be so badly dealt with even with the advent of the NHS, there were human and bureaucratic factors at work as well. In the small closed social world of a local hospital or practice, concerns about a doctor’s standards of practice create great conflict for those involved which they can find difficult to reconcile.5 The instinct to think the best of a professional colleague, the wish not to appear vindictive, and the thought that, ‘there but for the grace of God, go I’ are often reasons to hesitate rather than to blow the whistle. Inflexible and daunting disciplinary procedures have also been a barrier to action.6

The medical scandals in the British NHS in the late 20th century did not amount to a conspiracy to hide shortcomings but they certainly were a watershed in professional and public attitudes to poor practice. They put the concept of professional self-regulation under the microscope.7 They forced reform of the traditional NHS approach to weak clinical performance.8 They led to a widespread acceptance within the medical profession that the power of the patient—the ‘laity’—must become the dominant one in the provision of health care.

If he sat in judgement today on these changes, Shaw might be impressed by the extent to which the medical profession and the health service has become much less tolerant of poor practice and much more open and pro-active in dealing with it. Moreover, the protection given to the ‘laity’ through clinical governance and the statutory duty of quality9 would perhaps have removed any lingering doubts he may have had about conspiracies. His logical and analytical mind would also surely have appreciated the evidence and the experience that demonstrates the much greater relevance of weak or dysfunctional systems in provoking medical errors and lapses in standards of care than the actions of individuals.10 He might also have approved of the major role that public health—the only strand of medical (as it was then) practice that he viewed benevolently—is playing in modern health services around the world.


    References
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 References
 
1 Shaw GB. The Doctor’s Dilemma. New York: Penguin, 1946. Extracts reprinted Int J Epidemiol 2003;32:910–15.[Free Full Text]

2 Kennedy I. Learning from Bristol: the Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984–1995. London: The Stationery Office, 2001 (Cm 5207).

3 Ritchie J. The Report of the Inquiry into Quality and Practice Within the National Health Service Arising from the Actions of Rodney Ledward. London: NHS Executive South East Regional Office, 2000.

4 Donaldson LJ. Doctors with problems in an NHS workforce. BMJ 1994;308:1277–82.[Abstract/Free Full Text]

5 Donaldson LJ. Doctors with problems in a hospital workforce. In: Lens P, Wal G van der (eds). Problem Doctors: a Conspiracy of Silence. Amsterdam: 10S Press, 1997.

6 Department of Health. Supporting Doctors, Protecting Patients. London: Department of Health, 1999.

7 Smith R. Regulation of doctors and the Bristol inquiry. Both need to be credible to both the public and doctors. BMJ 1998;317:1539–40.[Free Full Text]

8 Department of Health. Assuring the Quality of Medical Practice: Implementing Supporting Doctors, Protecting Patients. Leeds: Department of Health, 2001.

9 Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998; 317:61–65.[Free Full Text]

10 Department of Health. An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS. London: The Stationery Office, 2000.





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