The Ulster Medical Journal, Volume 74 No. 1, pp. 3-8, May 2005.

"To see ourselves as others see us"

Presidential Address to the Ulster Medical Society

14 October 2004

Domhnall MacAuley, MD, FRCGP, FFPHNI, FFSEM

Oh wad somepower the giftie gie usTo see ourselves as others see us!

It wadfrae monie a blunderfree us,An'foolish notion.

To a Louse. Robert Burns 1759-1796

DREAMS

We all had dreams, ideals, and aspirations: Caringfor the sick, heroic surgery, becoming, perhaps, aworld famous medical researcher. Most of us donot achieve the dizzy height of our ambitions, butit is useful to measure ourselves against our hopesand expectations. Margaret Cook' put it eloquently"I had a romantic notion of myself in medicalresearch, complete with daydreams ofNobel prizes,reincarnating Marie Curie, winning an immortalreputation." Similarly we have an image of thetraditional family doctor that has changed little overthe years. Life published a photo essay on Dr ErnestCeriani, that set America thinking. In June 1990they returned to Belfast (pop 6500) Maine, to revisitthat story and photographed Dr David Loxtercampat work.2 "He cares about all the right things-aboutlove and honour and ethics and community. He hasfaith in himself, in his profession and in those heserves" These are familiar sentiments. But, in themodern world, we must ask ourselves ifthey are stillrelevant. Time and medicine have moved on.

Contemporary literature can give us some idea ofthechanging role ofthe doctor in society. Nick Hornbyshows us a different world in his novel "How to begood".3 The central figure is a woman, a generalpractitioner: "Listen: I'm not a bad person. One ofthe reasons Iwanted tobecome a doctorwas becauseI thought it would be good-as in Good, rather thanexciting or well-paid or glamorous thing to do. "I'ma GP in a small North London practice". I thought itmademe seemjust right-professional, kind ofbrainy,not too flashy, respectable, mature, caring."

The reality is not, however, a glamorous, prestigiousandhonouredrole in society. NickHornbyportrayedit eloquently through his narrator: "And I'll tell yousomething for nothing. All my life I've wanted tohelp people. That's why I wanted to be a doctor.And because of that I work ten hour days and I getthreatened by junkies, and I constantly let peopledownbecause I promise them hospital appointmentsthat never come and I give them drugs that neverwork. And having failed at that, I come home andfail at being a wife and mother".JohnDiamond, anothercontemporary commentator,who has since died of cancer of the throat, did notshy away from telling us: "We used to like doctors,ofcourse, or have some respect forthem at least, butthat was in the days when there was some communalrespect for people who knew things that we didn't.... We like nurses, because they don't get paidmuch, tend to use the same pubs that we do andwe know that ifwe were willing to spend a coupleof weeks. . . we could do the job just as well. Butdoctors. No". 4

What is a good doctor?A recent edition ofthe BMJ,stried to help us decide whatwe valued in the medicalprofession, and the cover featured some well knownfaces in medicine ranging from criminal to celebrity.But it is difficult to identify what factors determinethe standing ofthe profession. Recent surveys maygive us some insight into public opinion. Trust isimportant in any professional relationship and,in a recent survey 6 92% of the public trust theirdoctors. This is reassuring and, indeed, doctorspolled highest of any profession. But, in anotherpart of this study, the public were more satisfiedwith nurses than with doctors. In a similar poll,commissioned by the Irish College of General

Professor Domlhnall MacAuley, Hillhead Family Practice, 33Stewartstown Road, Belfast BT1 1 9FZ.

© The Ulster Medical Society, 2005.

4The Ulster Medical Journal

Practitioners, the public were asked who they heldin high esteem. Ofthe professions, 72% held nursesin very high esteem in contrast to 60% who heldgeneral practitioners inveryhigh esteem. Perhapsweshould ask ourselves why there is such a differencein the public perception oftwo professions workingin a similar caring medical context. Why does thepublic holdournursing colleagues in higher esteem?Exploring further we find that the public considerdoctors to be helpful, hardworking, committedand patient-focused, but a significant proportionconsidered doctors to be aloof [16%] inefficient[ 13%] overpaid [ 16%] and financially-driven [ 1 9%].Figures worth reflection.In the national survey of patients,7 the publicperception of general practitioners was generallyvery favourable. The vast majority of respondents(around 90%) had positive views of GPs' skills,knowledge, attitude and ability to communicatebut their views on nurses were even more positive.Those with less favourable views of doctors wereyounger people, those living in London and thosefrom minority ethnic groups. The authors warned,however, that to keep that status, doctors will needto measure up to patient's higher expectations ofcare."MEDICINE WILL HAVE TO SAY SORRY FOR ITSPAST MISTAKESAND MEAN IT"

Any smug self satisfaction evaporates after readinga few lines of "Rebuilding Trust in Health Care.8Reviewing a catalogue ofmedical mistakes, hospitalmismanagement, misinformation, subterfuge, andmurder, the authors showhowthe medicalprofessiondeserves the loss of esteem. Doctors can no longertake respect for granted. If it wasn't all entirelytrue, we could hide behind excuses. While eventssurrounding such dramatic medical scandals asBristol, Shipman, and Alder Hey are familiar, theraw facts make horrific reading. Presenting the casethat we have failed our patients, the blunt messagethat "medicine will have to say it is sorry for pastmistakes and mean it" resonates. In Alder Hey, onepathologist erred but many others in the universityand health service were complicit by their silence. Ifever we doubt the impact ofthese events we shouldremind ourselves that the families felt so strongly,they asked doctors and hospital administrators notto attend the church memorial service.

Major scandals like those above make headlines,but there are many smaller issues that should makeus think. We speak of the importance of medicalconfidentiality. Our behaviour may contradict.

A small study buried in the BMJ9 should jarcomplacency: Medical students listened to casualconversation in the hospital elevators and foundthat caregivers made 18 comments deemed tocompromise a patient's confidentiality on 13 of113 lift journeys with multiple comments on somejourneys. Doctors made the most comments, thenallied health professionals, and then a nurse. Ontwo occasions medical students asked that theconversation be continued in another location.Patient confidentiality was compromised on morethan one in ten liftjourneys. Similarly, we might askhow often medical confidentiality is compromisedby lecturers showing illustrations or presentingmedical histories without written informed consent,or in hospital canteens or social meetings away fromthe hospital.A good doctor or a nice doctor? Harold Shipmanwas clearly a nice doctor, well liked by his patientsand this may be one reason why he remainedundetected for so long. But we must ask how wewould have reacted if he had been neighbouringcolleague. 1°Professor Richard Baker suggested thatwe each look inwards ". . . calling for GPs to takeresponsibility for the killer's legacy and questiontheir trust in each other."We can no longer shirk ourresponsibility to our patients,just by turning a blindeye to acolleague's errantbehaviour, butwemusttakesome collegiate responsibility. In response,'1 ProfSir Graeme Catto, President ofthe General MedicalCouncil, reflecting on our individual responsibilitysuggested that"The doctor-patient relationship mustbecomemore openand straightforward andbemadeless prone to the manipulation and paternalismwhich featured so strongly in Shipman's practice."And perhaps we are each a little guilty, seduced bythe often praised doctor-patient relationship. LiamFarrell, whose satire12 often finds the profession'sweaknesses, wrote about the change in out ofhourscommitment ". . . my patients are getting along verywell without me, thanks very much: any competentdoctor is quite acceptable... I guess most of all Imiss being needed."At the Bristol Royal Infirmary, three doctors werefound guilty of serious professional misconductby doctors' regulatory body, the General MedicalCouncil, for failingto stopheartoperations onbabies,despite the fact that their death ratewasmuch higherthan the national average. Twenty-nine babies diedfollowing heart operations at the hospital. The fateofthe three doctors has been well documented. Butwhat happened to the whistleblower? The NHS hasa long history oftreating whistleblwers badly. Many

X The Ulster Medical Society, 2005.

4

Presidential address to the Ulster Medical Society

whistle blowers find their career, physical health andmental health all suffer and Stephen Bolsin, of theBristol Royal Infirmary, claimed that victimisationarising from his actions cost him his career. Surelyit is time to put into place a system of honesty,transparency and truth, where the whistle bloweris not a victim but respected for his integrity. Weknow why doctors keep so quiet about incompetentcolleagues. They pay a huge price. Is this right?OPENNESS AND TRANSPARENCY

Which are the best hospitals or practices? Inchoosing almost every other service from schoolsto supermarkets, there is some transparent measureof quality. But, when we try to look at options inmeasuring the quality of hospital or medical care,there is little available. In contrast, most doctorsknowtowhom theywould referthemselves ortheir familyiftheywere ill. But, it seems, they are reluctant to letit be known to patients. Patients would value such aresource. Claire Rayner, President of the Patients'Association, commenting on publications from theDr Foster organisation13 which publishes a numberof consumer oriented titles, said "This is a trulyremarkable resource. For the first time, I can findout what I want to know about local health services.It's the most authoritative measure of healthcarestandards available anywhere in the world".

Who are the best doctors? For a start, we are unsurewho the good ones are. Appraisal is the proposedqualitymarkofprofessional competence and alreadysome branches ofthe profession are well advanced.The quality of training and appraisal of doctorsis sometimes compared to airline pilots althoughsome mischievously suggest that doctors onlyuse this when it suits them. A letter to the BMJ 4puts this comparison into perspective: Imaginetwo airlines: In the first, Airline A, 'pilots undergoregular flight simulator skills tests, including rarelymet but crucial challenges and a thorough medicalexamination. Airline B, in contrast, has informalpersonal development plans agreed privately with acolleague, maybe oftheir choice, supportedby cabincrew andpassenger surveys ofthe gentleness oftheirlandings and the clarity of their communicationstogether with a self declaration of sobriety, health,and honesty. With whom would you fly?The relationship between doctors and the drugindustry is complex and difficult. No one wouldargue that we need a vibrant drug researchprogramme to maintain progress in therapeutics.But we must question the close, and sometimes tooclose, relationship between the drug industry and

the profession. It is difficult to defend a wealthyprofession that seems unwilling to fund its ownmedical education without considerable financialsupport from the pharmaceutical industry, whereinfluential consultants are funded to attend medicalmeetings in exotic foreign locations, andthat doctorsare wined and dinedby representatives almost everynight of the week. This complex relationship wasthe subject ofan entire issue ofthe British MedicalJournal. As Ray Moynihan,15 one ofthe key authors,observed "Food flattery and friendship are allpowerful tools of persuasion".

"No free lunch" is an organisation that campaignsagainst this cosy relationship.16 A presentationaccessible on their website points out that giftsfrom the pharmaceutical industry are not withoutstrings, carry entitlement, and are demeaning to theprofession. They include examples ofthis pervasivepersuasion. In contention, the drug industry willargue that they invest heavily in research, andthey do, with 22% of their workforce employedin research. But 39% are employed in marketing.Marcia Angell, former editor of the New EnglandJournal of Medicine addresses the topic in herbook: "The truth about drug companies. How theydeceive us and what to do about it.17 Next time youare invited to a drug sponsored event in a luxurylocation and offered good food and wine, imaginewhat the restaurant staff might think of you. Theyare your patients.

CARING FOR EACH OTHER

In this caring profession, do we care for each other?The British Medical Association, in their report"Racism in the medical profession. The experienceUK graduates"'8 tells it as it is: Racism is manifestin access to training and careers, and in norms ofacceptable behaviour. The system is sustainedby thereluctance oftrainees to complainandthe widelyheldviewwithinthe professionthatproblems encounteredby trainees from an ethnic minority are due to validreasons such as 'notunderstanding English culture'.But, surely, the medical profession is not deliberatelyracist. The report19 of the Department of Health[2003] Medical and dental workforce census Englandillustrates the pattern ofemployment. White doctorsare over represented in the consultant grades andnon white doctors are over represented in the staffgrades and associate specialists. Esmail 20 points out,in a BMJ editorial, that he has rarely met doctorswho are obviously bigoted, but many who denythe problem of racism but act in ways that result in

© The Ulster Medical Society, 2005.

5

6The Ulster Medical Journal

certain groups of people being disadvantaged. Hisquotation from "A suitable boy" by Vikram Seth21is apt: "If it is only bad people who are prejudiced,that would not have such a strong effect.... It is theprejudices of good people that are so dangerous.""What people think is not what matters - what theydo is what matters and in that respect the medicalprofession in the United Kingdom has a long wayto go." In Northern Ireland, we have had relativelyfewer doctors from ethnic minorities than in otherareas in the UK but we should still ask ourselves ifthere has everbeen discrimination on race or, indeed,on grounds of religion.

We aim to give the best medical care to all patients.But it seems we have different standards in dealingwith our colleagues. A qualitative study of generalpractitioners22 in Northern Ireland, highlightedthe problem. The authors described a perceivedneed to portray a healthy image to both patientsand colleagues, that there was embarrassment inadopting the role of a patient, and that this attitudeimpeded access to healthcare for ourselves, familiesand our colleagues. There was an expectation thatwe would work through illness and that we wouldexpect our colleagues to do likewise. The strengthofthe message was in the quotations: "unless you'reunable to get out of bed you'll crawl in and work"and "a terrible sense ofduty ofletting your partnersdown ifyou don't go in" and that "doctors feel theyshouldn't be sick ... you don't want to go and seeyour local psychiatrist in case one of your patientsis sitting beside you".

Doctors with disabilities describe a similarexperience. A piece in the jobs supplement ofthe BMJ23 describing career barriers in medicinehighlighted how doctors with disabilities felt that"It is difficult to talk about your weaknesses .. . Weare expected to conform to a certain standard andI think if you have a weakness you keep it hidden,you don't want to talk about it.' More alarming:'[You] would expect tolerance from doctors, but thisis the worst group when dealing with their own ...most people don't want to know. .. medicine has a"survival of the fittest" style.'

Not all doctors remain inthe profession. In their studyof doctors leaving the profession, Mike Goldacreand colleagues24 found that 15% of graduates werenot working in the NHS two years after graduation,18% after 5 years, 19% after 15 years and 23% after20 years. And their feelings: "Those who left feltdispensible and that no one cared what happenedto them. Their treatment in the NHS contrasted

starkly with their experience ofworking as doctorsin othercountries and in the private sector". This yearwe see the introduction of the European WorkingTime Directive which has greatly changed medicaltraining. Some senior consultants feel that 58 hourseach week is too little for adequate training andhospital administrators worry about staffing thehospital. Few seem to consider that 58 hours ofwork each week is so much more than we wouldexpect of any other profession. And, on top of thiswe expect junior doctors to undertake additionalstudy and prepare for postgraduate examinations."What is the role of doctors in the future? A lot ofpeople who are burning out are some of the mostsensitive, thoughtful and caring people, We want asensitive, caring, thoughtful organisation, yet weare driving people like that out".25

CHANGING FACE OF MEDICINE

General practice is undergoing some major changeswith a new contract in 2004 and a recruitmentcrisis. Many general practitioners have their ownstories to tell, but recent quotations from the BMAJunior members forum26 might make us think: "onehospital consultant said to me that theMRCGP wasgiven away with cheese and crackers", "this attitudethat GPs are second-rate doctors is dissuadingpeople from entering general practice", "why doyou want to be a GP? That will be the end of yourlife". Similarly, medical students from Dundeeand Leicester universities at a BMA conference onrecruitment:27 "lecturers often gave the impressionthat GPs spent their whole day referring patients tosecondary care . .. medical students do generallylisten to their exciting cardiology lecturer". If wewish to see a monetary reflection ofthe importanceattachedto general practice research withinthe widermedical research community, we need only lookat the tiny funding allocation to general practiceresearch in Northern Ireland compared to overallmedical funding.

"My son the doctor" are famously the four favouritewords of Jewish immigrants to America. Thisheadlined an article in The Times28 discussing thefindings of a study by Goldacre showing that ofUK-domiciled, UKtrained graduates, thepercentageofnon-whites increased from 1.6% of graduates in1974 to 21.5% in 2000 and will approach 30% by2005. Whitemen comprise little more than a quarterof all UK medical students. It seems that the malewhite doctor is endangered, soon to be extinct. CarolBlack President ofthe Royal College ofPhysicianscourted controversy in stating:29 "Women did

© The Ulster Medical Society, 2005.

6

Presidential address to the Ulster Medical Society 7

better than men at medical school but there was nofemale dean of a medical school, no female headof a department of surgery, and no female headof a departmnent of medicine in the UK." "Familycommitments made it more difficult for them to riseto the top of the profession".PUBLIC PROFILE

The medical community has another skeletonlurking: Research misconduct. Various shades ofresearchmisdemeanor include duplicate publication,salami publication, authorship (order, gift, andghost), plagiarism, fraud, conflict of interest. Somecases have made national and international news.Thecase ofMalcolm Pearce is probably the best known.But Peter Wilmshurst, an indefatigable detective ofmedial research has described what he consideredto be institutional corruption in medicine.30Doctors may claim that the media is responsiblefor the bad press.3" One study of the national pressfound that numbers ofnegative, positive and neutralarticles has increased significantly. The ratio ofnegative to positive was 2.33 with no change overthe period of the study. The number of lines ineach article and the median ratio of the numberof lines portraying negative to positive was 2.98with no significant change over time. Data suggestthat newspapers respond to incidents rather thandeliberately hounding doctors. There were notunexpected peaks in negative reports in 1986-7 andin 96-2000.

CONCLUSION

Medicine is not all that we might hope. There areproblems, and problem doctors, that we cannotignore. Richard Smith, editor of the BMJ for 13years was never afraid to address the controversialissues and pointed out: "Medical systems anddoctors are measured not by how they manage thegrateful patient brings whisky but by how they carefor terrorists, monsters and the marginal".32 In aworld that neglects the poor, where the greatestepidemiological risk factor is social inequality andwhere we read ofdoctors' complicity in torture, wedo need to ask some serious questions.

REFERENCES

1. Cook M. Time to stand and stare. Profile. BMJ CareerFocus 2004; 329: 8.

2. Loxtercamp D. What makes a good doctor? Practicingmedicine the old-fashioned way. Life 1990; June.

3. MacAuley D. Book. How to be good. BMJ 2001; 323(7310): 458.

4. DiamondJ. Doctors are much saferthanthey seem. SundayTelegraph 2001; 28th January.

5. Theme issue: What is agood doctor andhow canwe makeone? BMJ 2002; 324(7353): 1537.

6. MORI. Trust in doctors. 2004 Available from:http://www.mori.comlpolls/2004/bma.shtml

7. Department of Health, Great Britain. National report onthe results ofthe national survey ofNHS patients. 2001.Available from:http://www.dh. gov.uk/PublicationsAndStatistics/PublishedSurvey/NationalSurveyOfNHSPatients

8. MacAuley D. Book. Rebuilding trust in healthcare. BMJ2004; 328(7430); 54.

9. Vigod SN, Bell CM, Bohnen JM. Privacy of patients'information in hospital lifts: observational study. BMJ2003;327(7422): 1024-5

10. Baker R. Implications of Harold Shipman for generalpractice. Postgrad Med J 2004 80(944); 303-6.

11. Comerford C, Shipman Report calls for less frightamongst doctors. Doctor Update reference. http://www.doctorupdate.net/du_refarticle.asp?ID=1 5039#

12. Farrell L. The good old days. Soundings. BMJ 2004;329(7456): 59.

13. Dr Foster online guide to health services in the publicand private sectors. Homepage. Available from:http://www.drfoster.co.uk/home/whatisdrfoster.asp

14. Wakeford RE. Appraisal makes for effective revalidation(official). BMJ 2003; 327 (7407): 161.

15. Moynihan R. Who pays for the pizza? Redefining therelationships between doctors and drug companies. 1:entanglement. BMJ 2003; 326(7400): 1189.

16. No free lunch website. Available from:http://www.nofreelunch.orgeaboutus.htm

17. Angell M. The truth about drug companies. How theydeceive us and what to do about it. Random House.2004

18. Cooke L, Halford S, Leonard P. Racism in the medicalprofession: the experience of UK graduates. Availablefrom:http://www.bma.org.uk/ap.nsf/Content/racism

19. Seth V A suitable boy. Harper Perennial. 1993

20. Department of Health. Medical and dental workforcestatistics for England. 2003. Available from:http://www.publications.doh.gov.uk;/stats/mdwforce.htm

21. Esmail A. The prejudices of good people. BMJ 2004;328(7454): 1448-9.

©) The Ulster Medical Society, 2005.

8 The Ulster Medical Journal

22. Thompson WT, Cupples ME, Sibbett CH, Skan DI,BradleyT. Challenge ofculture, conscience and contracttogeneral practitioners' care oftheir own health: qualitativestudy. BMJ 2001; 323(7315): 728-31.

23. Cohen D, Herbert K. Equality and diversity in theworkplace. Career barriers in medicine. BMJ CareerFocus 2004; 329: 116-7.

24. Cooke L, ChittyA. Why do doctors leave the profession?BMA Health Policy & Economic Research Unit 2004.Available from:http://www.bma.org.uk/ap.nsf/Content/retention

25. Cross P. PriMHE suspect. BMJCareer Focus 2004; 329:28.

26. Foster M. Family doctors bid for greater respect. BMANews 2004; April 24.

27. Student told general practice 'second rate'. Pulse 2004;Sep 27: p13.

28. Goldacre MJ, Davidson JM, Lambert TW Country oftraining and ethnic origin ofUK doctors: database andsurvey studies. BMJ 2004; 329(7499): 597.

29. Heath I. Women in medicine. BMJ 2004; 329(7463):412-3.

30. Wilmhurst P. Institutional corruption in medicine. BMJ2002; 325(7374): 1232-5.

31. Ali NY, Lo TYS, Auvache VL, White PD. Bad press fordoctors: 21 year survey of three national newspapers.BMJ 2001; 323(7316): 782-3.

32. SmithR. Medicine's complexity: exhaustingorinspiring?Editor's choice. BMJ 2004; 328(7431): 0-f.

X) The Ulster Medical Society, 2005.