Bad Medicine by Dr No

Dropping Like Flies

Posted on by dr-no

flies.jpgThe Inquisition known for the time being as the General Medical Council is under fire. Its fitness to practice procedures, which for doctors caught on the sharp end of one of Stilton’s prongs feel much like being popped into a beaker of dilute sulphuric acid with a rack of Bunsen burners arrayed underneath, have come under scrutiny because of an apparently high mortality attached to being left to simmer in warm sulphuric acid. Figures available online suggest that there were at least 92 deaths between 2004 and 2012 in doctors under investigation. The denominator – which Dr No suggests should be the number of GMC cases referred to panel investigations – stands somewhere in the region of 2300 (see footnote), giving an approximate average annual mortality rate of 4%. Working age (25-64) mortality in the same period was around 200 per 100,000, or 0.2%. Something is clearly going on. If we apply some crude ‘observed over expected’ numerology to these figures, we get a (very) crude mortality ratio, on the normal 100 base, of around 2000: that is, where we would expect 100 deaths, we find 2000.

This figure is crude – that is, not adjusted for age or sex or any other factor of known or possible relevance – occupation springs to mind, as health care professionals are known to be prone to suicide. Nor does it tell us about confounding or chicken and egg causality – maybe the doctor was under FTP investigation because of irregularities caused by a life threatening, perhaps mental, illness. But, even with due allowance for those lack of refinements, the figure is eye-wateringly large. Something is clearly going on. Doctors under FTP investigation really do appear to drop like flies.

Yet the extraordinary thing is that we know next to nothing about these deaths. The GMC does record deaths in doctors undergoing FTP investigation, but until recently this has been largely as an ‘administrative event’ that triggers closing of the file. No doubt the Lord-of-the-Flies elements in society will claim good riddance – them quacks must have been bad’uns, otherwise they would never have got caught up in Stilton’s machinery. But that is itself an extraordinarily harsh judgement. No doubt some of the doctors will turn out to be bad’uns, but there will also be the innocent who – had they survived – would have been cleared, and those suffering from mental illness which, while it may even have contributed to their death as to their falling foul of the GMC, is hardly cause to turn a blind eye to their fate. Indeed, some have gone so far as to say deaths while under FTP investigation should be ‘never events’ for all health care workers, a laudable aspiration (Dr No is not being tongue in cheek), but one which perhaps should be tempered with an acceptance that some natural and causally unrelated deaths are inevitable.

What is needed is an in-depth enquiry – the proper terminology is a confidential enquiry, which has wide ranging powers to investigate – into these deaths. Dr No is not normally one to support causes or urge action – he sees his role more as commentator, with readers free to draw their own conclusions, and act as they see fit – but on this matter of 2000 deaths where 100 are expected, he is going to make an exception and suggest readers may wish to review and consider signing this e-petition, which calls for just such an enquiry.

Footnote: The GMC’s own annual figures for 2005 to 2011 are available here, here and here. Averaging those annual figures and multiplying by eight (to cover the eight years 2004-2012) gives an estimated 2337 cases referred to FTP investigation over that period.

62 thoughts on “Dropping Like Flies”

  1. Thank you for starting this important petition and for making us aware of these shocking figures that represent untold emotional torture. Why did I feel afraid when I signed it – what does that say about our medical culture? If so many suicides only from GMC investigations I wonder how many through all the other types of investigation. Also other health professionals, students. And what of those who survive…

  2. It is indeed telling of our times and professional culture that many of us (Dr No included) feel a twinge or more of apprehension on putting our names to the petition. But, Dr No likes to think, the risks are minimal. All we are saying the that there appears to be a very high excess mortality and we think that should be properly looked in to by way of a confidential enquiry. We also know that senior members of the profession are equally (and publicly) concerned: Dr Rajan Madhok (BAPIO) has raised the matter in both the BMJ and HSJ, and Dr Clare Gerada (RCGP Chair) is on record suggesting that death while under FTP investigation should be a ‘never event’, so to that extent we are in good company.

    Quite agree that it’s not just doctors – other health care workers/students are likely to be affected. And while death is extreme, it is also likely to be just the tip of an iceberg of great stress and terrible suffering, all awash in a Stygian pit of blown careers and busted souls.

    Lastly, it’s Helen Bright who deserves the praise for establishing the petition – all Dr No did was write a post about it!

  3. Thank you Helen for creating the petition – is there a website explaining it? I’m being told by some that the figures seem too incredible to be true (I’ve seen them myself in your FOI request).

    I feel perturbed that our own GMC subscriptions are funding these deaths… Does anyone else get that feeling? We subscribe just the same as we do for College fees, BMA and MDU – all go out by direct debit, all send a journal. It feels as if I’m a ‘member’ .. yet unlike the other organisations the GMC is compulsory (a separate issue of course whether or not we should personally fund the GMC).

  5. The number of deaths does seem very high, even incredible, were it not for the fact the source of the data is the GMC itself. In effect, the GMC has a register of all doctors subject to FTP investigation, and each individual case ‘file’ has to be ‘closed’ by some event, one of which is the death of the doctor. So, in general terms, the ‘case-finding’ is likely to be somewhat better than, for example, trying to pick up the deaths through some remote monitoring service or survey technique (think cancer registries vs scanning death certificates).

    Secondly, there is the Medical Register itself, which one imagines Stilton is under a duty to keep as up to date as possible, which amongst other things will mean removing (‘erasing’ in GMC-speak) doctors who have died, that is to say the GMC needs to know when a doctor has died, so it can keep the Medical Register up to date.

    So, in general terms, ‘case-finding’ should be reliable, so far as it goes. A few ‘cases’ may fall through the cracks, but most will be identified. However, incredible as it may seem on a figure that is already incredible, the number is likely to be an under-estimate of all FTP related deaths. If you look at the GMC’s response to the FOI request, the identified 92 death are doctors ‘erased…as deceased’ who ‘at the time of their erasure, had an open fitness to practise case concerning them’. So the number explicitly excludes any deaths occurring after any FTP proceedings had been concluded. It is not beyond imagination that further perhaps FTP related deaths occur after case closure. Perhaps we should apply ye olde ‘year and a day’ rule, and ask how many doctors were ‘erased as deceased’ not only with open FTP cases, but within a year and a day of the closure of their case.

  6. The more I think about it, the more I appreciate that these are reliable figures. This is nothing like trawling through patient notes or carrying out a clinical audit.

    I agree that number of deaths within a year (and a day?) should be asked for. Also I don’t know if there are other types of GMC investigation.

    Even that word ‘erasure’ is terrifying isn’t it? It has connotations of a person’s identity being ironed out and not just their registration.

    Hands up then who would like to make the FOI request… Perhaps Dr Gerada or Dr Madhok?

  7. Doctors who are erased are pushed onto the margins of society. They find as time goes by that their civil rights in society are non existent. No one listens to them, they are shut out from justice in other ways and become permanently traumatised. The GMC is a corrupt and venal organisation that any self respecting country would have closed down by now. The GMC greatly enjoys torturing those whom it has in its sights. Look inside it as I have. It is beneath contempt, dangerous and life threatening to some. It should be closed down.

  11. I agree that doctors (and nurses) are being forgotten about in the rush to demonstrate complete openness in investigation of medical performance.
    The pusruit of someone to blame along with the confrontational nature of public and GMC enquiries leaves doctors hanging out to dry. As if the job wasn’t streesful enough without the threat of such interrogatiojn and investigation.

  12. The concept of the GMC as an organisation fills me with wonder! I am all for an organisation that looks after the patients well being and polices doctors behaviour and practice. But the GMC is simply an exercise in making money. The organisation is vindictive and inept! Too many innocents get prosecuted too justify the organisations existence and too few corrupt inept doctors are penalised because they are usually manipulative and know how to work the system. Furthermore why do I have to pay for the existence of this organisation which persecutes me! It makes no sense. The solution is simple. All doctors must unite and refuse to pay the extortionate fees that are raised year after year!

  14. Editor’s Note: comment edited to remove potential copyright infringement (linked post had been cut and pasted verbatim)

    Interesting blog here: Monday 13 May 2013: Occupational hazard-links between professions and suicide risk have changed over time. Suggests ‘traditional’ high suicide risk professions including doctors have lowered their risk in recent decades. If the high death rate amongst FTP doctors is partly due to higher suicide risk then that suggests the contrast is even more stark…

  15. Perhaps the overall suicide risk is lower due to the higher proportion of women in the profession? The risk for men could be the same (or higher).

    I’ve searched but the petition isn’t being mentioned in the press (1,073 signatures). Came across more GMC horror stories in another petition (has no date and looks as if signing is public). Click on ‘view signatures’ to read the comments.

    http://www.petitiononline.com/phipps/petition.html

  17. That enquiry is not only crucial to doctors wellbeing, it is also important to shed light what led to the referral to GMC.

  19. Thank you Dr No.
    May I suggest you ask ‘survivors’ of this barbaric process!
    It’s not just the GMC.
    It’s the opprobrium, the lack of support from employers and colleagues, downright abuse, the public nature of the investigation, the ‘balance of probabilities’, the (fear of) loss of a career…..
    I’m only surprised it’s not more!

  20. Dr Know does no directly of a number of individuals who have been detained at Stilton’s Pleasure, and has also received private communications from others who have been through the same crushing mill. What is striking, at least to Dr No, is the similarity of the accounts: the bullying bruising habits of Stilton’s goons, the double jeopardy nature of ‘the (GMC appointed) psychiatrist will see you now’ sub-routine, and the sadistic ways of the GMC lawyers. The whole process appears to have everything in common with medieval witch-hunting, and nothing to do with considered and proportionate modern approaches to professional regulation.

    Those who have read Dr No’s other posts will know that broadly summarised his views are that external regulation is an industry doomed to failure. Stilton’s racks will get ever longer, and his vats of hot oil ever hotter, but still the big ones will get away, while an ever increasing number rank and file will get hung drawn and quartered to no possible benefit to anyone, let alone the poor doctor whose personal and professional entrails get splattered.

    What we need now, Dr No suggests, is a dossier of despair in which doctors who have been through Stilton’s dark and satanic mills give accounts of their experiences. Informally this is already happening, but the accounts are diffused and the cumulative impact of their collation lost. Dr Bright, a veteran of those dark and satanic mills herself, might be prepared to host such a dossier on doctors4justice.net: all that would be needed is a post as a ‘collection header’, with personal accounts added as comments. There would need to be some attention to detail, including but not limited to inhibiting multiple postings of the same account, and attention to concerns (both ways) about anonymity. But it should by no means be beyond the wit of man or woman to achieve it, and with its achievement we would have a hard-hitting dossier of human despair that might, just might, cause a press largely indifferent to a statistic of 92 to perk up at the harrowing and all too human cost of a modern-day variant of witch-hunting.

  21. Excellent idea – a compilation of experiences is needed. It would be a harrowing read no doubt 🙁

    One day someone will make a voice recording in the public interest… public interest is of course an excuse they enjoy hiding behind so they might appreciate the tables being turned on them!

    Meanwhile the petition has 1284 signatures: http://epetitions.direct.gov.uk/petitions/54034 with about 6 weeks to go.

  22. I am a Medicolegal Champion for doc2doc. Having read Dr Nos’ views and subsequent comments it seems clear to me that this issue should be raised on doc2doc(possibly it already has been but I can’t access the search facility due to a technical problem and I don’t immediately recall). How reliable is the collated data? Have you received any response whatsoever from the GMC in relation to the figures? I will raise this on doc2doc, but will look into it a little more closely first. If anyone can assist me with information please email me at: kirked@justice.com

    EK 08/10/13

  23. Hi EK, great that you’re interested. Doc2doc as in BMA? Helen posted there and was editorially quashed before she could take a breath. This made me wonder. A search of BMA + GMC reveals they are mates. Great as I pay both – maybe a discount is in order? Please do try again as it is so difficult for this issue to be aired and it is effectively invisible. Seriously, there would be more signatures on the petition if we had gone out with clipboards.

    Re the information, the links in Dr No’s explanation on here will lead you to the FOI request and the expected mortality rate. The numbers are stark: this is not hypothesis but actual deaths. The gmc has now announced its own internal inquiry thanks to Helen’s petition yet it had already gone into partnership with the BMA for counselling services…

  24. These statistics relating to deaths of doctors under investigation by GMC are truly alarming.

    The Association of Surgeons of GB and Ireland (ASGBI)has long held the view that the GMC is, with regards to it’s disciplinary function, inadequate and unfair .

    See ASGBI newsletter, no 27, Sept 2009 for comment about the GMC based upon an article entitled “Is the GMC fit for purpose”

    (Go to ASGBI website, select publications and scroll down until Sept 09 issue reached, or contact ASGBI direct and they will supply a reprint)

  25. My experiences of Medical Misfortune mirror many. A close friend, a kind sensitive doctor (I am not!) killed themselves after a minor much locally publicised complaint..”Why?” ..One wonders?
    Many Doctors under duress are “brittle” in Schopenhauerian terms and break too easily.

    Another I knew, took a fatal overdose just a week after a patient said in a crowded and witnessed waiting room..

    “Call yourself a doctor
    You are bloody useless”

    Obviously the final straw and quite trivial really. So why do they do it?

    … Perhaps from isolation from years of study, perhaps just the way Medicine is structured. The Legal Profession and Politicians seem far more able to cope with duress or misfortune, I have my own theory on “Why?” and it is not derogatory to these two noble Professions at all.

    My Medicine noir fact and fiction blogs may be of interest to some. Although my target audience is not the Medical Profession.

  26. Dr No was somewhat irked last weekend to discover that a favourite remark of his – better an approximate answer to the right question than an exact answer to the wrong question, which he coined in the 1990s while under the stewardship of that stickler for precision, Professor Walter Holland – had in fact already been long attributed, incorrectly as it turns out, to the well known numerologist John Maynard Keynes (the true origin is thought to be ‘It is better to be vaguely right than exactly wrong’, coined in 1898 by an entertaining cove rejoicing under the name Carveth Read).

    These musings arise because Dr No has received a well meant (and well received) critique that the data and calculations used in the original post were verging on the sloppy, and so offered an Achilles heel to those who would poo-poo the very high excess mortality among doctors subject to FTP investigation. Dr No used the figures he did (from poverty.org.uk) because they are both ONS based and readily available, unlike ONS data itself, the discovery of which tends to be a project of Byzantine perplexity. Dr No took the view that the poverty.org.uk figures were ‘good enough’, and provided, as they did, an approximate answer to the right question, rather than an exact answer to the wrong question.

    Nonetheless, a day or so after posting, Dr No did, for the sake of robustness, extract original ONS data and re-run the calculations, and was satisfied the original post figures were indeed good enough, and so did not merit a re-write, something which in general terms Dr No tends to frown upon: once posted, a post stands. That said, for those who do want to verify the original figures and calculations, here they are (from the ground up, for those not familiar with the methodology):

    Mortality ratios (including of course Sir Jar’s infamous Hospital Standardised Mortality Ratios) are ratios between the observed number of deaths and the expected number of deaths (O/E), conventionally multiplied by 100, such that a mortality ratio of 100 means the observed number of deaths match the expected number. A ratio greater than 100 means more deaths than expected, a ratio less than 100 means less deaths than expected, ‘all other things being equal’.

    To calculate a mortality ratio, then, one needs the observed number of deaths, and a way of estimating the expected number. Since all manner of things can influence mortality, a further sophistication is to standardise the ratio. Conventionally this is done at the very least for age, age being one of the biggest determinants of mortality (hence age standardised mortality ratios) and often for other factors – say co-morbidity – that undoubtedly have an influence on mortality. In short order things can get rather complicated, and the calculations subject to vagaries in the underlying data (one of the flaws in Sir Jar’s HSMRs), and furthermore the estimation of confidence intervals (and so interpretation) is prone to a certain elasticity of method.

    None of this need bother us here, for the simple reason that we do not know the age distribution (or anything much else, for that matter) of the 92 doctors who died while under FTP investigation. We can however surmise that they are all very likely to be of working age, and thus we might use working age mortality rates to estimate the number of expected deaths. Dr No fully appreciates (and indeed pointed out in the original post) that this is a very crude calculation, but…better an approximate answer to the right question…

    ONS do make available, if that is not to strain the word available too far, summary tables in Excel format of death registrations: the 2012 tables for England and Wales are here. Table 1 of the spreadsheet gives mortality rates (per 1000 population) by age band for 2002, 2011 and 2012. Taking working age to mean 25-64, mortality rates range from 0.3/1000 for women aged 25-29, to 12.7/1000 for men aged 60-64. Increasing age (and being male) is indeed bad for your health.

    If we assume (we need to do a fair bit of assuming, so let’s make it upfront) that the age/sex distribution of working doctors is similar enough to that in the general working age population, then in principle we can estimate the expected number of deaths among doctors, assuming they have the same mortality rates as do the general working age population.

    The ONS figures are in fact more fine-grained than we need – it breaks down mortality into five year bands, whereas we want overall mortality for 25-64 year olds. If we assume (not a completely unreasonable assumption – see here) that the numbers in each five year age/sex band are broadly similar, then a simple unweighted average of the mortality rates (there are other methods, but let’s keep things simple) will give us an approximation of the overall mortality rate for 25-64 year olds. If you have downloaded the ONS Excel spreadsheet, you can do the calculation yourself: enter “=average(B18:G26)” in an unused cell and you will get the average overall mortality – 2.9/1000 – for 25-64 year olds, based on the years 2002, 2011 and 2012.

    We can estimate (from GMC figures linked to in the original post footnote) that around 290 doctors a year (actual figures: 2005:310; 2006:335; 2007:196; 2008:359; 2009:319 2010:314; 2011:212; average:292) are referred to FTP panels. Applying our average general working age population mortality rate of 2.9/1000 means we would expect around 0.8 (yes, Dr No doesn’t know what 0.8 of a death looks like either) deaths per year. In fact, we observed 92 deaths over an eight year period, when we would expect 6 deaths (0.8 x 8 years, and dropping those pesky fractional deaths), giving us an observed/expected figure of 92/6 = 15, or a crude mortality ratio of 1500 when multiplied, as is usual, by 100. Where we would expect to find one death, we find 15.

    This figure is indeed smaller that that given in the original post (20 deaths where we would expect one) but Dr No took the cavalier view that 20 was ‘near enough’ 15 not to merit a re-write of the original post; and the number, whether 15 or 20 where we would expect one, is so ‘gross’ as to make its own point. Furthermore, the number is almost certainly an underestimate. The GMC may not be aware of all relevant deaths, and its figure excludes deaths occurring after FTP investigation – the so-called year and a day deaths – in which the FTP investigation played a part. We have also done a fair amount of assuming – for example, that the age/sex distribution of doctors matches that of the general working age population (Dr No suspects active doctors are weighted towards younger ages, meaning less expected deaths; similarly, being members of the more affluent classes suggests less expected deaths, with both factors tending to increase the ratio – ‘E’ is smaller so ‘O/E’ becomes larger, even if some other factors – more males? – may tend to lower the ratio) but the number, be it 15 or 20 or more, or indeed less, remains an approximate answer to the right question, not a precise answer to the wrong question. Dr No rests his case, and so the case for signing the petition:

    http://epetitions.direct.gov.uk/petitions/54034

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