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BMJ. 2007 June 16; 334(7606): 1276.
PMCID: PMC1892483
Past Caring

Jobs for the boys

Wendy Moore, freelance writer and author, London

Climbing the greasy medical career ladder used to be so much simpler. Before the advent of tedious form-filling, maddening technical hitches, and the unseemly scramble for too few posts, obtaining a plum job for life was governed by an application system that everyone could understand: nepotism.

For centuries, all that was needed for an aspiring trainee physician or surgeon to secure a lucrative countryside practice or a top post at an eminent teaching hospital were the right family connections. In a spirit of continuity only equalled by The Forsyte Saga, medical dynasties ruled supreme. While the Chamberlens kept their midwifery practice in the family for five generations, so the Monros—the unimaginatively named Alexanders I, II, and III—maintained a steely grip on Edinburgh University's chair of anatomy for a remarkable 126 years.

Admittedly there were disadvantages. Impatient sons and nephews had to bide their time until dad or uncle retired through ill health or died—although given prevailing medical ignorance this need not be overly long.

And naturally the system proved unpopular with anyone lacking appropriate blood ties. Devoid of illustrious ancestors, surgical apprentice John Flint South gamely accepted the appointments procedure at St Thomas' when the death of his tutor Henry Cline created a vacancy in 1820. “Several of the other hospital apprentices sent in their humble petitions to the Governors to be chosen their surgeon, I among the number,” he wrote, “but it was a mere matter of form.” Cline's cousin, Joseph Henry Green, was duly elected to the job.

With no recognition of merit, experience, or competence, the system was similarly unpopular with patients—should they live to voice a complaint. When William Lucas succeeded his father at Guy's in 1799, his butchery became so notorious that one trainee was put off surgery for good: the young John Keats sought employment elsewhere. After witnessing Lucas amputate a leg from the wrong direction, leaving a generous flap of skin on the discarded limb and a protruding bone on the stump, even the amiable South conceded that his operations were “generally very badly performed, and accompanied with much bungling, if not worse.”

Ultimately, for all its commendable simplicity, the system became discredited under intense media scrutiny. Lancet editor Thomas Wakley crowned a sustained campaign against nepotism with a dazzling exposé in 1828 of a fatal operation to remove a bladder stone by Bransby Cooper, inept nephew of the esteemed Astley Cooper, at Guy's. Despite Bransby's victorious libel suit, the jury's derisory award of £100 damages made plain that relative values were no longer sufficient recommendation for a medical job. Uncle Astley's pleading that young Bransby would make a “brilliant operator”—given time—would probably cut little ice even today.


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