Scandalous lessons

The doctors' tale: professionalism and public trust Donald Irvine Abingdon, UK: Radcliffe Medical Press; 2003 pp 247 £21.95 ISBN 1 85775 977 X

Sir Donald Irvine was at the centre of a series of events that had a profound effect on the relationship between the medical profession and British society. The so-called “Bristol cases,” the murder of countless patients by general practitioner Harold Shipman, the demonstrated incompetence of two gynecologists (one of whom had previously had his licence revoked in Ontario) and the retention of organs without consent by a pathologist at Alder Hey Hospital demonstrated to the public that medicine had failed spectacularly in its duty to guarantee reasonable standards of practice among its members.

Donald Irvine was the President of the General Medical Council (GMC) from 1995 until 2002 — seven key years. His fascinating and instructive book includes a brief autobiography, describes the state of medicine's self-regulation through the past 50 years, documents the cases referred to above in great detail, outlines the public outrage and government response that followed their media exposure and, finally, documents the profession's response.

The autobiographical section is limited but of some importance. Sir Donald describes his own background as a general practitioner who very early became involved in the activities of the Royal College of General Practitioners, including those designed to establish modern training programs, and, more importantly, to impose quality control on the practice of medicine. He was appointed to the GMC in 1990, becoming the first general practitioner to serve as its president in 1995. It is probable that no training could have prepared him for the largely self-inflicted catastrophes that descended on medicine and the GMC. However, it is clear that his training and experience were fortunate for the medical profession and, one might say, for society.

The book outlines failures of medical self-regulation that were apparent to many even before they were brought to light by notorious events. Richard Smith, editor of BMJ, is quoted as writing in 1993 that

time may be running out for the GMC … [T]he risk to the Council is that it fails to produce a system that satisfies both doctors and the public or that its painfully slow procedures are overtaken by speedier events — like a scandalous case or a political campaign to substitute self-regulation with regulation by the State.

In spite of studies and reports, little progress was made in improving regulatory procedures until the storm broke. Attempts had been made to make standards more explicit, and membership in the GMC had expanded to include representation from the general public, but it was obvious that the commitment of the profession to guaranteeing the competence of all its members was lukewarm at best. Irvine refers to the performance of the profession as “tribal” and its organizations as rarely acting in concert. The BMA in particular proved to be a consistent and successful stumbling-block.

All of this changed when the Bristol cases served as the major catalyst. The British government, which had its own problems with quality control (well documented by Irvine), threatened to greatly diminish the GMC's (and hence medicine's) role in regulation.

Sir Donald lived through an extremely difficult time but managed to steer the GMC and the medical profession to a point where the principle of self-regulation was maintained, structures were established for setting and maintaining effective standards, and the principle of re-certification was established. These intrusions into medicine's self-regulation may well improve the system; the NHS has, in parallel, instituted quality-control measures in the hospital sector. Only time will tell whether the new structures will function better than the old, or whether the necessary attitudinal shifts will occur, but the progress made against considerable resistance is impressive.

The book is beautifully written. The story lines are laid out cleanly, and Sir Donald exhibits considerable humility and humour as he indicates where he himself could have acted differently.

There are lessons to be learned from this lucid account. First and foremost, of course, is that if medicine fails to regulate itself, the privilege of doing so will be altered or withdrawn. Second, the consequences of divisions within the medical profession — Irvine's “tribalism” — are serious. The BMA's union function dominated its actions and frequently led to an imperfect response on the part of the profession as a whole. Finally, the importance of trust in the relationship between medicine and the society it serves becomes apparent once more.

This book is a wonderful addition to the story of medicine's evolution in modern times. It should be a must for all those interested in the status of the profession.

Richard L. Cruess Sylvia R. Cruess Faculty of Medicine McGill University Montréal, Que.