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The Royal Society of Medicine was formed 200 years ago this month ‘for the purpose of conversation on professional subjects, for the reception of communications and for the formation of a library’. Since that is still its primary purpose, a ‘time capsule’ such as that offered in this issue of Journal is a fitting way to mark the bicentenary. Contributors have been asked to address the reader in 2055, and I suspect that the way we do things now will look very odd by then. We need only glance over our shoulder to see this.
Forty years ago I entered the wards of a London teaching hospital and recall the Dean's advice on decorum for clinical medical students. Dress in hospital was to include clean and starched white coats, sober ties, white shirts and polished black shoes. Tones at the bedside would be hushed at all times, and certain words were never to be uttered within earshot of patients. Cancer was always to be a neoplasm and tuberculosis an acid-fast infection. There was an anaemia clinic for patients with leukaemia and a mitosis clinic for those with other malignancies. Consultants were minor celebrities and their teaching rounds had something of an evangelical feel to them. The students would sit on any available surface including the floor and the great man (for they were invariably male) would dispense pearls. If I had to sum up the professional attitude we were taught, I would call it compassionate paternalism. Our job was to help patients accept whatever befell them with the least possible anguish.
With this background I qualified into the National Health Service of the 1960s, a heady environment for the young idealist that I was. The absence of any commercial incentives (beyond drug company ballpoint pens) allowed management of patients to be based purely on their needs as I perceived them. The only lines of accountability I followed were to the consultant. All postgraduate training was gathered on the job, and career progression depended heavily on patronage and the passing of College examinations. No postgraduate deans were involved and workforce planning was non-existent. When I became a consultant myself in the 1970s, my practice was entirely unfettered by corporate or clinical governance, and there was no formal requirement for me to provide justification for any therapeutic decisions or prove that I was keeping up to date. Many of my patients were entered into clinical trials. While these were successful in eventually curing many children with leukaemia, ethics committees approved none of them because such committees had yet to be invented. Consent was a matter of explanation and acceptance, and no forms were involved. Most parents were grateful whatever the outcome, so my teachers had done a good job; compassionate paternalism was alive and well. But it was not to last.
Few doctors anticipated the seismic upheaval that followed the disclosure of excess mortality in children undergoing heart surgery at the Bristol Royal Infirmary in 1998. Two seminal public inquiries followed in which the medical profession was found wanting.1,2 There were strident accusations of paternalism, protectionism, arrogance, indifference and inadequate accountability to employers. The management of hospitals and medical schools was also censured. A parallel inquiry into the murderer Dr Harold Shipman rounded squarely on the General Medical Council, accusing it of being protective to the profession rather than the public.3
These criticisms have had far-reaching consequences. Doctors are now required to undergo annual appraisal, on which their remuneration is dependent. Clinical practice is constrained within tightly drawn job plans and national guidelines, and evidence is required that knowledge and skills have been kept up to date. The General Medical Council now reports to a government committee, has undergone radical reform and will introduce regular assessment for the renewal of a licence to practise. Medical education is coming under increasing state control, and postgraduate training is now highly structured and inflexible.
And yet despite all this some things do not change. In the privacy of the consulting room, good medicine still turns on the empathy doctors have for those who are ill and on the trust patients have in their medical advisers. In this setting the politics disappear and things are exactly as they were. It is still a huge privilege to be a doctor. I imagine and hope the same will be true in 2055.