The GMC through five and a half books

Richard SmithEditor, BMJ

What to talk about?

• Image of GMC– sick and tired of that– it’s a bad sign when you start worrying about your message and

being misunderstood: we all are al the time– psychs not orthopods, proctologists, or urologists

• Future of the GMC– there may not be one, a dismal theme

• Revalidation and governance: a lethal cocktail

• “New professionalism”

The GMC through 5.5 books

• Two written by presidents of the GMC• John Walton’s autobiography• The book to mark Robert Maxwell’s

retirement• House of God by Samuel Shem• Hall of Mirrors by John Rowan Wilson• The Doctor’s Tale by Donald Irvine• The half is my series of articles on the

GMC

Book one: The Spice of Life. John Walton’s autobiography

• Privileged to know four presidents of the GMC, JW being the first

• Ruth’s review--perhaps the best thing we have published in the BMJ during my tenure as editor

• On the day the review was published, Ruth was rung up by four people claiming to be JW

• Two of them were him, the first time saying how much he enjoyed the review, the second time regretting that he’d been lampooned

The spice of life

• A book that tells you every last fact about him but by the end you know nothing about him except that he has a colossal memory

• A book of hidden shallows that remain hidden

• Could become a cult book• People open it, read a paragraph at

random, and burst into laughter

The spice of life

• “On 18 June 1993, I was sitting at my desk in the BMJ’s editorial department on the second floor of BMA House, a fine redbrick pile in Tavistock Square designed by Sir Edwin Lutyens for the Theosophists, when I received a visit from the BMJ’s editor, Richard Smith, the son of Syd Smith, who was a prisoner at Colditz, the notorious German fortress, and brother of Arthur Smith, the well known playwright and alternative comedian.”

• And so it goes for 643 pages• We are still waiting for the sequel

Book two: The quest for excellence. Essays in honour of Robert Maxwell

• I wrote a chapter• Never any feedback--so I think out loud,

indulge myself--maybe that’s why there’s no reaction

• If regulation of doctors is about influencing how they behave there are many factors

• I argued that power and pervasiveness are important

Robert Maxwell’s book

• The GMC has great power but is not pervasive--that is, present daily in the lives of most doctors

• The BMJ is pervasive (well, more so than the GMC) but has little power--there is no penalty for not reading it, in fact there’s a reward--more time

• Peers and bosses, in contrast, have both high power and high pervasiveness--so paying attention to them is vital

Book three: House of God

• Tells the story of the intern year at a Boston hospital

• It’s the Catch 22 of medicine, very black humour

• Published in 1978, 2m copies sold--it is “the” medical book

• Describes the “brutalisation” of doctors, including terrible errors, using patients for a sexual thrill, and even murder

House of God: the laws

• Gomers don’t die: Get Out of My Emergency Room, “a human being who has lost--often through age--what goes into being a human being”

• The only good admission is a dead admission

• If you don’t take a temperature, you can’t find a fever

• The delivery of medical care is to do as much nothing as possible

House of God

• A theme of the book is the battle between the enthusiasts wanting to do everything to everybody, and the heroes of the book who recognise that they should do as much nothing as possible--only then will the patients get well

• “The profession is a disease. It can trap us, any of us…”

• “Most of us had learnt enough medicine to worry less about saving patients and more about saving ourselves.”

House of God

• We were developing a code of caring, helping each other leave early, not fucking each other over, tolerating each other’s nuttiness, and listening to each other’s groans. Each life was being twisted, branded. We were sharing something big and murderous and grand. We were becoming doctors.

House of God

• Toward eleven, something marvellous happened: a run of erotica. One of the few true pleasures of doctoring, when, with the excuse of a medical degree I would move past the fantasy of mentally undressing sexy women, and really do it.

House of God

• The whole pattern of medical education is backwards: by the time we realise we’re not going to be TV docs undressing ripe -titted beauties, but rather House docs disimpacting gomers, we’ve invested too much to quit, and we wind up like you poor slobs: stuck.

House of God

• The main source of illness in this world is the doctor’s own illness: his compulsion to try to cure and his fraudulent belief that he can.

• These people didn’t give a damn about their disease or “cures”; what they wanted was what anybody wanted: the hand in their hand, the sense that their doctor could care.

Book four: Hall of Mirrors

• John Rowan Wilson learnt to write fiction writing obituaries on the BMJ

• Scornful of the medical establishment--many of us here (“mavericks”)

• Novel tells the story of a libel action between two very prominent doctors

Hall of Mirrors

• The younger, bolder one has accused the older one of killing a prominent patient through his own arrogance--through failing to use a diagnostic machine

• A subplot is an attempt to create an academy to create order

• Ironically I learnt about it from a QC, who was advising us on a libel action taken by a very prominent doc against the BMJ

• Reading the book was like reading about my own life--despite it being published in 196x

Hall of Mirrors

• Among the great, he had found, inadequacy was the rule rather than the exception. His uniqueness rested solely in being conscious of it.

• As with many British institutions, sporadic modernisation had been going on in such an uncoordinated fashion over a number of years that any kind of total reconstruction now seemed out of the question.

Hall of Mirrors

• “What is he [the minister] after?”

• “Well, if you want it it one word – coordination. He wants everyone to work together in an organised framework. We’ve said for long enough that the health service was in a stupendous muddle, and I believe he’s seriously determined to set it right. He’s a hundred percent in favour of the Academy of Medicine plan, and ministry support isn’t to be

sneezed at, you know.”

Hall of Mirrors

• There was certainly the basis for a deal [in creating the Academy]. Present power for Max Field, future power for Hartly, ascendancy for the physicians, money for the surgeons, knighthoods and peerages, new multicoloured fellowship and council robes, pomp and circumstance, dinners and symposia, maces and chains of office, gold headed canes, a sense of taking part in the historical process – there was something for everyone.

Hall of Mirrors

• Medical men…simply didn’t attack each other in public. It was a violation of the code, the great unwritten law that the profession, whatever squabbles might occur within it, always presented an unbroken front to the general public…The code might be restrictive, it might conceal inefficiency and jobbery and nepotism, but it was the shield of the profession….Lay interference was the one evil which could never be tolerated. Whatever the cost, the profession must stick together.

Book four and a half: Profile of the GMC, 1989

• “One view of the GMC is that it is a 19th century organisation trying--and largely failing--to adapt to the late 20th century. It is seen as progressively losing losing touch with a fast changing world.

Profile of the GMC, 1989

• The GMC is a slow and cumbersome body that takes no initiatives, but simply responds...The rubber stamping council may be left to operate as a cross between the House of Lords and a branch of the Rotatarians, and those who want to advance medical care in Britain should look elsewhere.

• The council cannot guarantee to the public that everybody on the register is adequately trained and still competent.

Profile of the GMC, 1989

• The GMC is too large: its staff are overloaded, its powers too concentrated, and its communications poor. The council’s many internal problems often seem to occupy members of the council and staff more than the pressing problems of improving education and competence and being seen to serve the public interest.

Delusions of Grandeur, 2000

• If I were the president of the GMC, then I would conclude that there is no option but to continue to put the public interest first, accelerate modernisation of the council, and be bold with revalidation. I would also do everything possible to reduce the backlog of cases waiting to be heard…But I would go to bed at night uncertain either that I would be president in the morning or that the GMC would still exist.

• My main thought was “Thank god I’m not.”

Book five: The Doctor’s Tale. Donald Irvine

• If you write a book don’t ring people and ask if they have read it

• I wonder how many of you have read it--probably nobody’s read it all through but most have glanced at it, perhaps concentrating hardest on the bits that mention them

• Despite a Chaucerian title there is no bawdiness and not a single joke

• Initially ard to see it as a Hollywood movie--although I can see Harrison Ford as Donald

The Doctor’s Tale

• I found it curiously compelling--perhaps because I know almost all the characters, was present at some of the scenes, and have a walk on part--what’s more as one of the good guys

• Wanted to be in a novel: “A bit gorblimey”

• Lucien Freud portrait

The Doctor’s Tale

• A simple tale: “Forward looking GP takes over clapped out organisation and battles with the forces of evil to save it.”

• But he’s not just saving an organisation he’s saving a whole medical profession because the clapped out organisation has the duty to lead the profession

The Doctor’s Tale

• “Inevitably the book is partial”• It’s the maximalists, who want to be “open and

vigorous in furnishing the evidence about their practice” versus the minimalists, most of whom are small minded BMA weasels, who want as quiet a life as possible

• Donald writes of a “cultural revolution”--and I couldn’t help thinking that only Mao Tse Tung and Donald had used that phrase without irony

The Doctor’s Tale

• The book is like a Bond movie in that it accelerates, the odds seem insuperable, and then at the very last minute our hero escapes and the world is saved

• All “three limbs of reform” are “in place”--revalidation, Fitness to Practice reforms, and a new GMC”

Conclusion

• Grame Catto--”the new Bond--or maybe Dr Who--who will have new monsters to battle--monsters that are perhaps as we speak being created in the diabolical laboratories of BMA House, a kind of medical orf.

• Or maybe a more diabolical foe, created not by the BMA, who in the end are rather minor enemeies, but instead by a high court judge with a forensic mind

• I’m looking forward to Graeme’s book--extending the literary tradition of GMC presidents

• Here’s to the new Bond, his organisation, his forthcomoing book, and victory over the forces of evil