I didn’t realise how much of a medical regulation geek I am until Marty Chamberlain sent me a copy of his new book “Medical Regulation, Fitness to Practice and Revalidation.” As soon as the manuscript hit my mailbox, I cleared my schedule, made a pot of Earl Grey tea, and curled up on the couch as happily as if I was in possession of a new novel by Hannah Kent.
Chamberlain is an Associate Professor in medical criminology. His book, set in the modern-day United Kingdom, addresses the question of how best to protect people in need of medical care from unsafe and unethical doctors – a question of fundamental importance to health practitioners, lawyers, policymakers, and patients and their families.
The supporting characters are familiar to anyone with more than a passing interest in healthcare: Dr Harold Shipman, the GP who murdered over 200 of his patients; Mr James Wisheart, the surgeon at the centre of the Bristol babies scandal; Baroness Margaret Thatcher with her neo-liberal opposition to professional self-regulation; two leaders of the profession – Sir Donald Irvine and and Sir Peter Rubin; and two vocal reformers by the name of Smith – Dame Janet and Dr Richard.
At its heart, this is a story about the General Medical Council and its journey “from gentleman’s club to risk-based regulation”. I don’t think I’m giving anything away by revealing that the journey is not an easy one. In an effort to ensure that every doctor is fit to practise, the GMC devotes huge energy and expense to revalidation, yet only one in ten doctors believe patients are a great deal safer as a result. New initiatives aimed at lifting the quality of care are sometimes met with ritualised compliance rather than meaningful change. Well-intentioned actions result in real harm. The most sobering passage of the book is the revelation that 96 doctors have died while facing a fitness to practise hearing since 2004, at least some of those by suicide.
But there is hope: important steps have been taken towards a more transparent and accountable system, and Chamberlain offers numerous suggestions to guide the GMC forward. Four in particular resonated with me.
First, the insight that process is just as important as outcome in assessing fairness. It does little good to conclude that a doctor acted properly and ethically if they have already been dragged through years of scrutiny and suspicion. Second, that regulation will always be a blunt instrument: whether we like it or not the opinions of peers and the culture of medicine will remain a critical influence in assessing the appropriate standard of care. Third, that perhaps it is fear rather than arrogance that leads doctors to circle the wagons around poorly performing colleagues. When each of us is only one decision from facing a disciplinary tribunal ourselves it is easy to understand how further incursions into professional autonomy might feel like a threat rather than a gain. And finally, Chamberlain alludes to the inter-relationship between regulation, risk and trust – we all want doctors to be worthy of our trust, but is ever-tighter oversight the way to reach that goal?
Throughout, I was struck by the parallels with events in Australia and New Zealand where our own healthcare scandals have propelled medical regulators into a strikingly similar journey. There is much we can learn from each other rather than walking this path alone.
My only real sadness on finishing this book was the omission of patient voice from the narrative. I would have loved to hear more about the critical role patients and their families have played in achieving regulatory reform, and their perceptions of the journey the GMC is on. After all, protection of the public is – or ought to be – any regulator’s raison d’être, and the GMC’s job won’t be done until every patient can be confident that their doctor is “good enough“.
Ultimately, this is a story only part-told. It is clear that the days when doctors were left alone to manage their own affairs are over. Yet Chamberlain hints more than once that “risk-based regulation” may only be a stop along the way towards an ideal regulatory system (and perhaps even a difficult detour?) rather than the ultimate destination. Further chapters of regulatory reform are undoubtedly yet to come. And there is still an opportunity for patients and practitioners to influence how this story ends.