Tuesday, November 14, 2006

The General Medical Council - in whose interests?

Figure 1. GMC Guidance improved with a Fig Leaf
The General Medical Council (the UK licensing body for doctors) maintains its purpose is to protect the health of the public by ensuring proper standards in the practice of medicine. But the GMC has an accumulating credibility problem (1-5). Now an important article by Peter Wilmshurst (1, PDF version) adds to the voices (2,3,4,5,6) calling for the Council to be stripped of it's regulatory functions.

The GMC is accused of failing to act in a plausible, timely and consistent manner when ethical guidance is ignored (1-6). It appears to apply its ethical rules in a selective way - depending somehow on ethnicity and membership of a mysterious old-boy's club (1,2,3). The Shipman enquiry reported that the GMC failed to deal properly with Fitness to Practice (FTP) cases, particularly involving established and respected doctors (2,4). Most worryingly, it is accused of assisting in victimization of doctors raising concerns, instead of dealing with those concerns. Sir Liam Donaldson, the Chief Medical Officer, echoes concerns about FTP procedures. In his view, "complaints are dealt with in a haphazard manner, the council causes distress to doctors over trivial complaints while tolerating poor practice in other cases".(2, 5). Former President of the GMC, Sir Donald Irvine, called for the current Council to be disbanded and re-formed with new members (2, 6)

Some extracts from the Wilmshurst paper (1, PDF version)

On the private club mentality in dealing with concerns about doctors

"The purpose of the GMC is to protect patients, not doctors. "adjudications by the Professional Conduct Committee were frequently inconsistent, arbitrary and unjust."

"Justified criticisms have led to changes in the GMC in recent years. ..I believe that many of these changes are cosmetic."

"the obligation GMC members feel to those who elected or appointed them represents a conflict of interest that prevents the GMC from working for the good of the public." "the evidence suggests that the medical profession cannot be trusted to regulate itself."

"I can provide many examples of inconsistency in the adjudications of the GMC. One case involved a professor who had falsely claimed an MD research qualification. .... The GMC decided that this dishonesty of the professor required no more than a private warning."
"Some may ask why the Professional Conduct Committee publicly suspended or erased from the Medical Register a number of doctors, all of whom had African or Asian names, for claiming qualifications that they had not been awarded, but the GMC decided that in the case of a white British professor at a major academic institution only a private warning not to do it again was required."

"Another case illustrates the problems of conflicts of interests and the strength of the 'old-boy' network within the GMC. I reported a doctor to the GMC for financial misconduct. Evidence presented at his hearing before the Professional Conduct Committee showed that the senior management of the hospital at which he worked had discovered his dishonesty and reached a severance agreement with him so that if he left without legal challenge, the hospital would destroy documents related to the fraud....The chairman of the Professional Conduct Committee hearing .. had been the medical director of the hospital at the time the deal to conceal the misconduct was agreed. ... The GMC refused to take any action against its member. Contrary to its rules, the GMC refused to tell me why they were unwilling to take action against the GMC member. The GMC member subsequently returned to chairing hearings of the Professional Conduct Committee.
Can one imagine a situation when a judge stood down from hearing a case because he had helped to conceal a crime and then was allowed to return to the bench?"

GMC Victimisation of those raising concerns

"doctors have a responsibility to speak out if they have concerns about behaviour that might endanger patients. A doctor who fails to bring his concerns to attention may be guilty of serious professional misconduct and may be erased from the Medical Register." "However, rather than investigate my concerns, the institution reported me to the GMC for disparagement".

"A more junior doctor, who had serious concerns, effectively had her medical career destroyed by the GMC. Members of the GMC made unfounded allegations that the doctor suffered from mental illness and made it difficult for her to gain employment. The doctor sued the GMC and some GMC employees maintaining that the GMC broke its own rules and failed to follow its own procedures when blackening the reputation of a person raising legitimate concerns...His Honour Judge Harris likened the GMC to a "Stalinist regime".

On creative accountancy

"...one could suggest that it was not in the interests of GMC members to lose these lucrative expenses by upsetting those who elect or appoint them. This only ended recently when public knowledge of this widespread and condoned practice eventually forced the GMC members to behave in a way more in line with normal accounting practices."

The court transcript from the case of PAL vs GMC, May 2004 before Judge Charles Harris is of interest

JUDGE HARRIS: For myself I don't really see why somebody complaining about the behaviour of doctors or the GMC, if that is what they are doing, why that should raise a question about their mental stability, unless anybody who wishes to criticise "the party" is automatically showing themselves to be mentally unstable because they don't agree with the point of view put forward on behalf of the GMC or the party.

MISS COLLIER: That in itself certainly would not be enough.

JUDGE HARRIS: It is like a totalitarian regime: anybody who criticises it is said to be prima facie mentally ill - what used to happen in Russia.

MISS COLLIER: My Lord, that is very far from the circumstances of this case.

JUDGE HARRIS: Of course it is ...


  1. Wilmshurst P. (2006) The General Medical Council - a Personal View. Cardiology News Oct/Nov 2006 14-15 http://www.pinpointmedical.com/article_read.php?id=57&publication=cardiology-news&link_id=2
  2. http://en.wikipedia.org/wiki/General_medical_council (14/11/2006)
  3. http://www.guardian.co.uk/racism/Story/0,,349543,00.html
  4. Shipman inquiry. Safeguarding patients: 5th report, 2004. Online version
  5. Donaldson, L. Good doctors, safer patients: a report by the Chief Medical Officer. Department of Health, 2006-07-14. [Link]
  6. Current GMC should be disbanded, says former President. Report by The Royal Society of Medicine.[Link]
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1 comment:

Anonymous said...

You will be interested in this book. In the US, the crucifying of doctors does not occur so much at the state board, but in other ways. God forbid we should go down the UK route to add to our problems.

by Carl F. Ameringer

About the Author
Carl F. Ameringer, a former Maryland assistant attorney general, is an assistant professor in the Department of Public Affairs at the University of Wisconsin at Oshkosh.

Book Description
State medical boards are the public's first line of defense against bad medical care. By licensing and disciplining physicians, the boards help maintain high standards in the medical profession. But how well have the boards succeeded in fulfilling their mission, especially in an era of managed care and its attendant impact on medical accountability?
This book offers the first comprehensive political account of state medical boards. Drawing on board records and files, interviews with prominent physicians, and his own experience as former assistant attorney general in charge of administrative prosecutions, Carl F. Ameringer reconstructs the political maelstrom surrounding physician discipline before and after the advent of managed care. He shows how the widening scope of conflict in the health-care field and improvements in case management and reporting techniques led to a substantial increase in the number of disciplinary actions in the 1980s and 1990s. And he describes the battles fought between state boards and their founding professional associations over efforts to prosecute physicians for drug abuse, sexual misconduct, and poor technical performance.
At a time of growing public awareness of both declining professional authority and the growth of government and corporate bureaucracy in the health-care industry, the conclusions of State Medical Boards and the Politics of Public Protection are especially timely.

Editorial Reviews
From The New England Journal of Medicine, November 4, 1999
This book is a good introduction to a very important subject, little known to most physicians. Written by a former Maryland assistant attorney general, it gives an overview of the history of physician discipline and state medical boards. The legal and political aspects are covered with brevity, clarity, and thoroughness. Medicine, as befits a profession, disciplined itself well into the 1960s, principally through licensing, credentialing, and the award of hospital privileges. As Ameringer points out, the American Medical Association, hardly a radical voice, noted in 1932 that seldom were individual physicians willing "to prosecute a breach of ethics that affects them personally but little but which may affect the profession of medicine in a major degree" for fear of committing "professional suicide." Incompetent or impaired physicians with influence were often shielded or quietly released from the staff of a hospital, free to practice elsewhere.
In 1952, author Philip Wylie publicized the issue in a Redbook magazine series and a medical-economics article entitled "Doctors' Conspiracy of Silence" (a theme revisited in the book Problem Doctors: A Conspiracy of Silence. Peter Lens and Gerrit Van Der Wal, eds. Burke, Va.: IOS Press, 1997). In 1961, an American Medical Association committee again concluded that "disciplinary action by both medical societies and boards of medical examiners is inadequate." Robert Derbyshire, a former president of the Federation of State Medical Boards, found that only about 0.06 percent of licensed physicians were disciplined from 1963 to 1967.
Ameringer goes on to trace the period after the enactment of Medicare and Medicaid, when federal and state regulations as well as consumerism increased. The assertion of authority over the profession by the Federal Trade Commission in 1978 raised the specter of prosecution for restraint of trade when physicians acted against one another. This issue surfaced in the 1988 case of Patrick v. Burget in Oregon, in which it was judged that a physician's hospital privileges had been revoked "in bad faith." As a result of that decision, any medical organization involved in discipline had to proceed under state authority.
Ameringer describes the way in which in the past 20 years the majority of state medical boards have made the transition from small-scale operations to bureaucratic organizations that are capable of managing "large and growing caseloads." He reports statistics from the Federation of State Medical Boards showing that the rate of discipline of nonfederal physicians who treat patients rose from a steady state of 1.2 per 1000 in the period from 1969 to 1978 to 7.8 per 1000 in 1995. He discusses three case studies involving battles that state boards had with medical societies around three especially contentious issues: the handling of physicians impaired by substance abuse or physical or mental illness, sexual exploitation of patients and other boundary violations, and the definition and the means of proving professional incompetence. In concluding, Ameringer touches on the current attempt by boards to assume oversight of health maintenance organizations and on the concern that cost containment may have diminished society's focus on the quality of care. Because of increased board activity, albeit uneven among the states, he sounds an optimistic note.
Having served as secretary of Maryland's Board of Physician Quality Assurance, where I became acquainted with Ameringer, I am less optimistic. I wish he had delved more deeply into such issues as the fact that the necessary burden of proof for breach of a standard must exceed a preponderance of the evidence; the long delays in processing cases (months to years); the practice of plea bargaining at the behest of prosecutors; the use of case-by-case peer review by unpaid, untrained physicians; the inflation by boards of the numbers of physicians disciplined as a result of piggybacking on disciplinary actions taken by other state boards; the reluctance of committees or programs on impaired physicians not only to share information but also to assess the competence of doctors; the practice of voluntary license surrender, which stops investigation for alleged offenses that are usually very serious; and the lack of programs to refer physicians for retraining and other corrective actions.
The main problem with state medical boards is the lack of a middle ground between discipline and the dismissal of a complaint. Given the seriousness of any action to a physician's livelihood and self-esteem, board members lean toward dismissing complaints when peer reviewers judge that a single lapse, although unfortunate, is possible. They rarely trigger an investigation of a representative case sample. In sum, what we now have are three inadequate and poorly communicating systems for dealing with error, incompetence, and unethical behavior: a health care environment that is reluctant to admit error for fear of litigation; a tort system that too often harasses good doctors while failing to deal with many instances of poor care; and an elaborate system of medical boards.
Ameringer is to be commended for opening a window on a complex issue. What he does not say is that if medicine is ever to recapture the moral high ground, it must assign more credibility to the process of quality assurance. To improve the field and encourage greater involvement of physicians will require special training in epidemiology and data analysis, compensation for a physician's time, protection from reprisal, tort reform, a change in the Federal Trade Commission's approach to the medical profession, and more robust clinical research.
Reviewed by Peter E. Dans, M.D.
Copyright © 1999 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

"An excellent study of the regulation of the medical profession, one in which political science concerns predominate. His account centers on the changing role of state medical boards from earlier this century to the present... Physicians interested in the area will find the book well worth reading."-- Journal of the American Medical Association