In recent months, I have found it difficult to prevent myself from continually blogging about the rise of the new brutalism. The next most pressing issue, as far as I am concerned, is the rapid and entirely unnecessary dismemberment of the NHS. I feel a bit trapped by the state of the world, which feels like a victory for the likes of Hunt and Trump. I need to break free from time to time. Sometimes you have to think about other things. I want to write about something life enhancing occasionally. When I do so in the months to come, I shall probably feel the need to start with some kind of disclaimer to the effect that my failure to blog about Trump, Brexit or the NHS should not be taken to indicate a loss of interest or any improvement in the situation. So that is today’s disclaimer. I have been thinking about the nature of freedom recently, especially in the workplace. I suppose that even this is somehow linked to the rise of authoritarianism.
As a psychiatric trainee, I strongly felt that doctors were far too unaccountable. You had to do something really outrageous to get in trouble with the GMC. The only other line of medical accountability was litigation. The Bolam legal test is not intrinsically unreasonable. Nevertheless, it created a de facto low bar for the deviant practitioner to clear, namely “If a doctor reaches the standard of a responsible body of medical opinion, he is not negligent”.
These days doctors work under much more intensive scrutiny than they did when I qualified in 1980. In fact, these days many clinicians practice in constant fear of vexatious complaint or of a random, uncontrollable adverse event. They fear sanction less than they fear the process of investigation. Investigations can drag on for several years. They can be career destroying, even where the doctor has done nothing wrong. Whilst under investigation it is difficult to change jobs or take on new roles. Quite apart from the anxiety, it is paralysing.
It is not good for patients to be treated by anxious, demoralised doctors. If current trends continue, almost all doctors will be investigated several times in the course of their career. 40% will be investigated by the GMC. Defensive medicine is the inevitable consequence, exacerbating problems caused by NHS organisations dictating a programmatic, standardised, approach to clinical practice. Whilst I have no nostalgia for the situation in the early days of my career, I do not feel we have an appropriate or effective form of accountability now either. No wonder medical recruitment is so difficult in the UK at present. Whatever happened to clinical freedom?
Frank Sinatra’s My Way has long been the most popular piece of music played at funerals, far outstripping all other traditional funeral songs, such as Led Zeppelin’s Stairway to Heaven and Queen’s Another One Bites The Dust. It is played at well over 10% of all UK funerals. It disguises itself as an anthem of rugged individualism and independent mindedness, when it is actually a hymn to conformity. More than 10% of the population are celebrated as free spirits through the medium of the same song as all the other free spirits. This existential joke is closely related to the “You are all individuals”, ”I’m not!” scene in Monty Python’s Life of Brian. The point here is that a large number of Britons regard themselves as ungovernably maverick whilst actually being exactly the same as everybody else.
I think that most British medical practitioners have a very similar mind-set. They may believe that they are going their own way, but in doing so they are going in exactly the same direction as everybody else. This is both a good and a bad thing. The vast majority of UK doctors work within the boundaries of acceptable practice. That is unequivocally a good thing, and is reflected by the fact that only 13% of doctors investigated by the GMC face any sanction at all. The down side is that this herd instinct can make medical practice very difficult to influence. Treatments or procedures that are shown to be unnecessary or ineffective can be very hard to eradicate.
A high proportion of innovation in medicine, and almost all really high quality practice, occurs as a result of individual clinicians making astute observations or having good ideas and trying them out. Unfortunately, even higher proportions of medical disasters, quackery and inappropriate practice arise through very similar processes. The big difference between the two is that innovators and high performing practitioners tend to see the need for oversight and accountability. They do not hesitate to explain themselves. They certainly do not try to evade scrutiny when they are doing something that is different to normal practice. Charlatans, on the other hand, tend to insist that others lack the skills or knowledge to pass judgement on their unique practice and assert their right to unrestricted ‘clinical freedom’.
Clinical freedom is important, but it is not a special form of liberty for doctors. The latter interpretation has tarnished the reputation of the concept. Clinical freedom belongs to patients, who have a right to have standard treatment approaches adjusted to their unique circumstances and needs. They also have a right to know the exact status of the treatment that they are receiving: standard, unusual or experimental? Based on evidence or experience or neither? Clinical freedom cannot properly mean restricted freedom of choice for patients.
Sometime soon it will be necessary to break free from the tyranny of one-size-fits-all treatment regimes. They restrict the usefulness of services and choke innovation and excellence. It is important that we do this without giving the impression that we want to return to unexamined paternalistic practice. It would not be proper to aspire to evade scrutiny. We should fight for more appropriate, transparent and timely forms of accountability.
I have never liked My Way as a song. The lyric has always seemed self-congratulatory and smug to me. Sinatra was a great singer, but he appeared to me to be a weak man. He hung out with very unpleasant friends who, in all probability, controlled him. My Way, my arse. In January, I lost all patience with the song, after it was sung during the first dance at Donald Trump’s inauguration. Quod erat demonstrandum.
When I die, play this song, performed by Joey Ramone, instead.
* I Wish I Knew How It Would Feel To Be Free is best known in the UK as the theme music for Barry Norman’s film programme. It had a whole other life in the USA as a civil rights anthem. This particularly good version is performed by its composer, Billy Taylor.