Regular readers will know that Dr No is an advocate of Auric’s Law of Causes – happenstance, coincidence, enemy action – and it so happens that Auric’s Law has been met, indeed exceeded, in four out of four recent NHS encounters by family and friends of Dr No. In each case, the care provided was either partly or wholly inadequate and/or incompetent; and, by Auric’s Law, he concludes these adverse experiences did not arise by chance, but by malevolent force. The malevolent force was the NHS, or more specifically the doctors who provided (or in some cases did not provide) the care. All four cases happened in, or were related to, secondary (hospital) care, but more often than not the GP was also involved in, or at the least complicit with, the deficient care. In all four cases, either the patient or a relative was a doctor, and so an ‘expert witness’, able to ‘read’ what was going on. How much more poor care, one wonders, goes on, but is unnoticed, because the witnesses are lay, and lack the knowledge to read the signs?
Regular readers will also know that no one supports the NHS more than Dr No, and so the opening paragraph – which in effect says Dr No’s recent experience of the NHS is that it is crap – poses the obvious question: why on earth does Dr No support a service that is crap? The answer is: he does not – and hence this post. Instead, he supports what the NHS should be, and in the eyes of some, once got close to achieving. But today, with the help of Auric’s Law, he has come to appreciate that his cosy notion of a wonderful NHS is based more on rose-tint than reality.
The decline and decay of the NHS, and indeed British Medicine, because the two have for the last half century and more been one and the same, has come about, it seems to Dr No, because of two developments. The first, which he is not going to cover here, because he has more than covered, and will continue to cover, it elsewhere, is the introduction of a market, and all that markets entail, into what is a national service. The second, which is not entirely unrelated, is what, for want of a better phrase, Dr No calls the deprofessionalisation of doctors. Much, but not all, of the responsibility for that deprofessionalisation lies at the hands of medical educators and regulators, for it is they who are responsible for setting the curriculum, perhaps better put these days as tooling up the production line, and so are responsible for the doctors that fall off the end of that line; and today’s product, it seems to Dr No, is deficient in three core attributes: responsibility, authority and autonomy. In each of the four cases of poor care Dr No observed or has been told about, it was deficits in one or more of these core attributes that gave rise to poor care.
No doubt long and learned books can be written about the matter, but by way of an introduction, Dr No suggests there are two core trends that have given rise to today’s deficient, indeed defective, doctor. They are in their way fetishes; and like all fetishes, have the power, as it were, to distort the normal flow of events.
The first fetish is that of the team-player. This is the fetish that has above all else done so much to destroy traditional medical practice. It is the one that has given rise to that abomination, ‘the team’ – a can of incestuous scorpions if ever there was one – and all that follows: protocols, patient pathways, noctors and poctors, and the abolition of doctor to doctor referral. It is the poison that has given us the doctor who dare not speak his or her mind, for fear that ‘the team’ will sting the doctor; and the doctor who crumbles, and in so crumbling fails to do his or her duty to the patient, in the face of all powerful pathways and protocols. How far, we may observe, have we strayed from the proper doctor: a doctor with responsibility, authority and autonomy.
The second fetish is that of the doctor-communicator. This abomination, which is exactly what it is when it is given primacy – and which, we might add, gives an entirely new spin to the phrase spin doctor – holds that, above all else, a doctor must be a good communicator. The care may be crap, but so long as the doctor communicates well, then all shall be for the best in the best of all possible worlds. It allows, indeed encourages, the triumph of PR – public, or rather patient, relations – over care. It elevates warm, effective communication above arduous and proper doctoring. It promotes message management skills above basic but essential clinical skills – and in so doing gives rise to the doctor who is a master of spin, but a dunce at basic medicine. How far, we may again observe, have we strayed from the proper doctor: a doctor with responsibility, authority and autonomy.
That, then, is Dr No’s diagnosis of the ills that have overtaken British Medicine, and so the NHS. The prognosis is guarded, even bleak.
“YachtMaster Instructor”
Wow, respect! You can certainly teach those medical educators a thing or too about good ‘planning’ for one thing Master! Or how about team spirit? ‘Real’ teams I mean of course where everyone has ‘one’ goal, to get the boat to shore, in one piece, safely safely, and enjoy the trip at sea too. Or maybe how without strict discipline the boat can and is likely to face trouble and danger … or the value of a ‘well done sailor’ either top down or bottom up … with a smile
Auric’s Law? I’d always believed that this was the unwritten rule that UK doctors’ mouths, since Bevan’s declaration in 1948, must always be “stuffed with gold”
Rat – there may well be more than one Auric’s Law – but, as a member of SPECTRE, Dr No follows Goldfinger’s Auric Law – for now.
There is nothing wrong with stuffing one’s mouth with gold, if it is well deserved … it should be encouraged too
After all, reward should suit the endeavour, or they’d be no successful economies at all, or any achievement or innovation to celebrate
I like happy >._.<
In spite of apparent differences of opinion earlier, it seems that Dr No and those commenting are now closer to agreeing on the essential attributes of an independent medical practitioner.
The problem arises with the imposters, or the fetishes as Dr No calls them, that are being imposed upon us by those who have not gained our respect. The good and noble vocabulary of communication, teams and leadership is being debased. Perhaps the fetishes should be renamed by putting “f” standing for the “f word” as a prefix to the terms.
I.e. f-communication, f-teams, f-leadership would help distinguish the debased form from the noble form of these words and would help prevent doctors and patients alike from becoming confused.
N.B. The “f-word” being “fetish”
Of course.
Dr No is spot on and the couple of misplaced comments on communication tried to spin Dr No’s comments out of context to make a very bad point.
Communication is important but context please, these days students spend far too much time learning politically correct things like communication skills, governance, audit etc and the basics are forgotten.
The point about team players is spot on also, this culture of happyclappyness is the perfect environment for top down bullying as no one is ever allowed to speak out against poor practice or bad care. It is much more healthy to allow a healthy exchange of different opinions.
The best point is that of medical deprofessionalisation and this has come for many reasons, two big ones being shoddy educationalist regulation by the GMC and EWTD.
Competency based training has replaced getting some decent experience and the results are not good, despite what the educationalists may say….
“Competency based training has replaced getting some decent experience and the results are not good”
Totally agree, as I have always said before. Yes you need protocols and competency procedures but there must be also room for the doctor to think and innovate on their own and, as you say, gain from hands on experience and not just machines and simulations, docs are very intelligent lot after all. However, that is one thing, that needs serious attention, and the importance of communication is another, and you can never get enough of that, hence, like clinical experience, communication should be a lifelong endeavour too – and a smile does make the medicine go down.
Good medicine is about both, and a free to operate and criticize doctor too.
In Dr No’s early days, there were protocols – the active management of labour springs to mind – but there was nothing remotely related to competency based training. Instead, we just did as much as we could. Any delivery; then any episiotomy repair (DN was an oddity – he preferred controlled tears) (all this before formal qualification); then, as an SHO, forceps, then LSCS – we were baying at the heels of our registrars to let us do it. We felt mostly well trained, and hungry for the feel of steel and catgut in our hands. We were driven to become proficient, even the best, and knew it was only by doing it that we would ever become so.
There were serious flaws in that system, but, all considered, it bred real surgeons and doctors. Nowadays, we have ‘all will be well in the best of all possible worlds’ doctors, who don’t know their arse, let alone their patients arse, from their own or their patient’s elbow. We need to find a middle way.
Aim = Safety
Hence, competency based training, if done correctly can and will save lives Dr No, the problem is, as we discussed before, the lack of proper leadership to ensure that kind of training is done properly [Anyone can sign you’re competent!], then there is this specialty within a specialty within a specialty which turns a doc into a production line machine and eventually cancels their ability to think at all, leading to safety problems, or the very thing you set out to better … and frustration, and stagnation and low moral … etc, not forgetting having to return cases back to GPs for re-referals and spend more instead of less as you thought you would! The other day I heard an ST3 doc say “Why did I study medicine for over a decade just to end up doing what a vocational course can teach an amateur to do at the end?!” This doc was right too! It is a grave mistake to take your brightest and turn them into dump machines, but that’s training a la MMC now!
So, we all here agree on a fundamental aspect; bring back doctor training to excellent British standards as was before!
Not the 100 hour week though, but a doc who is rounded in knowledge and hands on experience and not stuck in blinkers, just like the top docs and professors, who are now a dying breed!
Oh dear!