Dr No made no secret of the fact that Dropping Like Flies was a quick and dirty assessment of whether the apparently very high number of deaths among doctors subject to GMC Fitness to Practice investigations was something to be concerned about. He concluded it certainly was, because on that crude assessment – crude because there was no attempt to adjust the figure for factors that might influence the death rate – it appeared that these doctors were at least fifteen times more likely to die than ordinary members of the working age population. The ratio of fifteen to one was, he believed, an approximate answer to the right question rather than a precise answer to the wrong question. It was, he argued, so gross in scale as to make it very unlikely, though not impossible, that the finding had arisen either by chance, or by a sufficient number of unadjusted for factors, such that being caught on Stilton’s prongs was not one of them.
But even then chicken and egg questions abound. Perhaps the doctors had come to Stilton’s notice because they were already impaired not just in their practice, but also in heart and mind. But still, fifteen to one is one hell of a ratio, and prima facie, it demands further investigation. This, indeed, was the purpose of Helen Bright’s ePetition calling for a confidential enquiry into the deaths, which closed yesterday with barely 2000 signatories – less, to put it in perspective, than one percent of all registered doctors on Stilton’s List. The small number would be laughable were it not so lamentable. Why is it that we appear to care so little about the fate of these doctors? Even the great Clare Gerada, who last year gave public attention to the deaths, this time round found that she had other, bigger bicycles to ride.
One possible reason for the apathy, Dr No suspects, is a lingering belief that these doctors, who tend to be old, male and foreign, are the runt of the profession, tattered coats and stinking goats who – though this never be said openly – somehow deserve their paltry fate. Add no smoke without a fire populism, and a Denningist regulatory awe of the law – better to bang up a few innocents than the law be impugned – and perhaps, just perhaps, it becomes a little easier to imagine that some might look the other way when Stilton’s goons cart off a colleague to a looking glass world not of Byzantine light but by eponymous darkness.
All that is as it may be. If Dr No is going to succeed at poetic allusions, he will have to lock himself up in the tower more often. Meanwhile, he has returned to the mortality ratio, to see if he might improve its veracity. Dropping Like Flies needed quick and dirty, and for that Dr No used the all working age mortality as the standard population to determine the expected number of deaths. But such a determination takes no account of (within working age) age, a major determinant of mortality, and perhaps likely in this case to lower; expected mortality, and so increase; the ratio, since the population pyramid for the medical profession is pear shaped – more younger people – than the general population, which is more barrel shaped, with ages spread more evenly across the working age age-bands.
Unfortunately, although we know the age and sex of those who died, and of doctors overall, we do not know the age distribution of those at risk, the doctors caught up in Stilton’s petticoats. There are proxy data (time since primary medical qualification) available, but they cover only two years, and the bands are broad and combine both sexes. But one thing we do know is a doctor’s socio-economic class, itself another major determinant of mortality, with those in lowest socio-economic class almost twice as likely to die as those in the highest. Doctors, ipso facto, are socio-economic class one (NS-SEC1: higher managerial and professional), and so can be expected to have a significantly lower working age mortality than the general working age population. So what happens if instead of using all working age mortality as the standard, we use that of SEC1, and so in effect compare FTP doctors mortality with that of their peers in SEC1?
Of course the ratio is going to go up – with even more doctors are dying than we might expect – but Dr No was unprepared for the extent of the rise. The mortality ratio (see footnote for calculation) rises to a staggering 3077 – FTP doctors die at over thirty times the rate of their SEC1 peers. Thirty to one. If that isn’t reason for Lady GaGa to get off her bike and put her shoulder to the cause, then Dr No doesn’t know what is.
Footnote: Data sources and calculation: we know that at least (the figure is almost certainly an under-estimate, and yes older male doctors are over-represented) 91 FTP doctors died over eight years, however only 64 (including one 24 year old) of those were working age (M 25-64, F 25-59), giving an average rate of 8 working age deaths (64 ÷ 8) per annum. We also know (from the GMC’s annual FTP Statistics reports) that the population at risk – doctors undergoing FTP investigation – was around 282 each year, both sexes, with some over working age, so let’s say pro rata (age 64/91; gender 81/91) were of working age and male, giving us a revised population at risk of around 180 males and 20 females. For 2008 (middle of the period), age-standardised working age death rates per 100,000 for SEC1 from ONS were around 137 for men and 88 for women. Applying these rates to the population at risk, we get an ‘expected’ figure of 0.26 (no, Dr No doesn’t know what 0.26 of a death looks like either), and putting this under the observed deaths (O/E) gives us a ratio of 30.77, or 3077 when rebased as normal to 100.
Footnote to the Footnote: the roughly 90:10% male:female split in the FTP deaths is somewhat mirrored (85:15%) in GMC data covering three years of FTP activity by gender (links here), such that Dr No considers it sufficiently robust to include gender (also a major determinant of mortality – see figures above) in the analysis. The 3077 ratio thus takes into account both SEC and gender for working age FTP doctors (we have compared FTP doctor mortality with that of SEC1 peers of the same male/female distribution), and, until such time as we have more data, Dr No believes the thirty times more deaths than expected represents the best available estimate of the excess mortality attached to FTP investigation.