Medical professionalism

Margaret McCartney

It used to be seen as embarrassing, extravagant, foolish. But improving your looks under the surgeon’s knife has now passed the stage of social unorthodoxy to become something acceptable, appealing – even fun. Just think of the rise of Botox parties, where a nurse wielding the syringe will come to you (and the host gets a discount).

In Los Angeles, studies of women found that more than two-thirds of respondents were interested in having cosmetic surgery. In the UK, a study of female university students showed that low body mass index, lack of body appreciation and media influence were predictors of a desire for cosmetic surgery. Indeed, one US study links watching TV makeover shows with a more favourable attitude towards cosmetic surgery, as well as an increased pressure to try it. This does not necessarily prove cause and effect, but it does raise the question of how people acquire enthusiasm for these procedures.

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Margaret McCartney

The UK General Medical Council has today published new guidance on conifdentiality for doctors. From reading press reports over the weekend, I had thought that there had been dramatic changes. But having read it, I realise this is not so.

The right to confidentiality has never been absolute, but there has never been any doubt that breaking it can only be done in specific circumstances where the danger to others or the public is high enough to justify it.

One example is driving. If someone is medically unfit to drive, and persists in doing so despite advice to the contrary, the doctor should inform others. In practice this is made easier by the DVLA, who have clear guidance on what to do. In many cases, when the doctor tells the patient that they must report their driving against advice to the DVLA, the patient agrees to tell them him/herself.

Margaret McCartney

Uncaring, slapdash staff; patients left in pools of vomit or faeces; falls resulting in cranial bleeds, despite the supervision of nurses. The Patients Association’s recent dossier of nasty nurses is scary stuff, and it has made hearts sink all over the National Health Service.

The Patients Association is unusual for a charity in that it seems purely devoted to criticising the NHS. As anyone who has ever had a professional appraisal will know, there is useful, constructive criticism, and then there is another kind, which pours scorn without offering solutions.

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Margaret McCartney

In July this year, Debbie Purdy, a 46-year-old woman suffering from multiple sclerosis, won an important victory in the debate on assisted dying. Purdy was concerned that her partner would be deemed culpable should he accompany her to the Dignitas clinic in Switzerland in order to die. In response, the House of Lords asked Keir Starmer, the director of public prosecutions, to clarify the legal position. He is due to unveil an interim policy later this month; a wider public consultation will follow.

Objections so far to assisted dying seem to have been largely religious. My own unease is far more practical. The first concern I have relates to society’s ability to reliably and enduringly interpret the law. Take, for example, the issue of abortion. When the Abortion Act came into effect in 1968, it was not intended to sanction abortion on request. This is widely acknowledged, even by Sir David Steel himself, who introduced the original bill. That two doctors’ signatures were required before a termination could proceed was meant to safeguard against this outcome.

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Margaret McCartney

My eldest and I have been giggling at a book “F in Exams: The Funniest Test Paper Blunders”, which includes such gems as:

Q: Name two religions.

A: The Force (Jedi) and Football.

This amused us greatly.

What’s the difference with this next multiple choice one?.

Q: Which of the following explain(s) the physiological relationships between qi and blood/xue. 

A: Qi is the source of all material in the body and blood carries the energy

B: Blood is the source of all material in the body including Qi

C: Qi drives blood moving and blood carries Qi

D: Qi flows in the channels and blood is stored in organs

E: Qi produce blood and blood is the mother of Qi

Well, this is a real exam paper, and it isn’t funny. It is an exam paper from Salford University’s Traditional Chinese Medicine course. The wonderful David Colquhoun gives access to the full paper plus the story behind the Pittilo report

This report would, if implemented, create lots more nonsense exam papers funded by a lot more public money  – and would produce practitioners without the absolutely crucial skill of how to assess evidence and reject or use it appropriatly. 

As a GP, this makes me very concerned – after all, if someone has a degree, and is “regulated” by the government, surely you’d think the “treatment” on offer works? Sadly, and worryingly, no.

The public may now respond to the Pittilo report.  Please do.

Margaret McCartney

The start of August: new doctors in jobs. The plight of the junior doctor is supposedly now improved with the advent of the  48-hour working week, as dictated by the European Working Time Directive.

Sensible this may sound, but there has been no simultaneous increase in doctor numbers to make up for the shortfall in hours. Many juniors complain that the decrease in training time, plus the split shifts they now work means little coherent teamwork and lousy morale. Added to this is the tagging along of clipboard-carrying administrators to find out who is staying after their shift should have ended.

Professionalism is probably one of the most important attributes of a junior doctors work and I don’t think that comes on the o’clock. Mind you, the news that RemedyUK have won the right for a judicial review on the GMC’s refusal to investigate the doctors who allowed the Medical Training Application Service fiasco to happen should cheer juniors up.

Infamously, in 2007, thousands of doctors failed to get jobs after the application system awarded more points for writing essays on being a good doctor, and less for academic ability, achievements or experience.

Margaret McCartney

What do you do for a living? I confess that, when asked this question, I have lied many times. At parties, at gyms and at dinners, I’ve been reluctant to talk about being a doctor, often for the sake of whoever I’m with, as I invariably start moaning about NHS politics.

The question of whether or not to lie when called to do a professional duty is easier. Of course one should tell the truth. Still, I do know a few doctors who will admit to pausing, or feigning deafness, when medical services are requested over the tannoy at 30,000ft, hoping that someone else will get there first.

What I find astonishing is that so many health professionals seem to be in the air. One study from the Federal Aviation Authority, a US government body, found that in 85 per cent of mid-air medical emergencies there was a doctor, nurse or paramedic willing to assist. But what can the sky-high practitioner actually do? There are varying amounts of varyingly useful medical equipment on board. Some planes carry defibrillators, and several provide links for crew members to telephone medical advice lines.

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Margaret McCartney

An interesting survey has been published by the Foundation for Mental Health. It’s called “Death of the smoking den, The initial impact of no smoking legislation in psychiatric units in England in 2008.”

In the introduction to the report, Louis Appleby, the National Director for Mental Health is quoted as having said in 2007 “The rest of the NHS is going smokefree. What message would an exemption for mental health wards send out about the importance of the lives of mental health patients?”

However, the survey uncovered widespread problems with the implementation of a smoking ban in psychiatric units in England. Most respondents indicated the ban had been only partially effective, with only 15.6% of responding units claiming complete effectiveness.

It’s an interesting area, and one deserving of more research. I’d like to know what patients think of the ban. Part of the problem is that some patients are admitted on an involuntary basis to psychiatric wards.

It is easy to see why the stress of being very unwell paired with that of not being allowed to leave, never mind smoke could end up seeming like both an intolerable violation of personal liberty and an immediate difficulty in trying to build therapeutic relationships with staff. In short. this would not seem the ideal time to stop smoking.

In many other areas of challenging behaviour, compromises are made, for example methadone substitution for heroin, the supply of clean needles for intravenous drug use or sterilised equipment for people who are driven to cut or harm themselves.

Without necessarily agreeing with any of these, I think it’s crucial that nurses should be able to use their professional judgement as regards smoking cessation for their psychiatric inpatients.

Margaret McCartney

Many people will be aware of the high profile examples of research misconduct which have occured over the past few years – for example, the Korean cloning research which was found to be fake. But what about the research we don’t know is fake or doctored?

A systematic review and meta-analysis of survey data has recently been published in PLoS One – journal of the Public Library of Science:

“How Many Scientists Fabricate and Falsify Research? A Systematic Review and Meta-Analysis of Survey Data”

This concludes that “A pooled weighted average of 1.97% (N = 7, 95%CI: 0.86–4.45) of scientists admitted to have fabricated, falsified or modified data or results at least once –a serious form of misconduct by any standard – and up to 33.7% admitted other questionable research practices. In surveys asking about the behaviour of colleagues, admission rates were 14.12% (N = 12, 95% CI: 9.91–19.72) for falsification, and up to 72% for other questionable research practices.”

It isn’t cheery stuff. But most research is never going to attract the attention of the media, and most research findings can only hope to make a little light go further. Some of the reasons (although not justification) may be in the cultural expectations of research, for example “Among research trainees in biomedical sciences at the University of California San Diego, 4.9% said they had modified research results in the past, but 81% were “willing to select, omit or fabricate data to win a grant or publish a paper”. If followed through, it’s very shocking.

Margaret McCartney

My interviewee has asked for her surname and current place of work not to appear here.

Louise is the perfect science pin-up girl: blonde, slim, and dressed in denim and boots when I meet her on campus. She works as a university teacher, facilitating medical students in “problem based learning” sessions. I have arranged to meet Louise to talk about the time she left medical research a few years ago to work as a “drug rep” with a major pharmaceutical company.

Prior to this, her specialty was in developmental and molecular biology. She had specialist interests but also a family, and wanted to stay in one place. “I was in a panic, and there were no research jobs. I mentioned to my GP that I was thinking about working as a rep – and he was positive about it.”

So what happened after she had signed up? Training – and there was no expense spared. “We were flown down to Heathrow, put up in a very nice hotel – I think at the time there was about 20 others – all in single rooms, £120 a night, three or four nights at a time. I would say about 2/3 of the training was on sales – the psychology of selling. Maybe one third was on the pharmacology, and physiology side – that was the bit I was most interested in.

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Margaret McCartney is a Glasgow-based GP and FT Weekend columnist. She started writing for the Life and Arts section in 2005 and moved to the magazine in 2008. She also has her own blog: www.margaretmccartney.com/blog

Clive Cookson has been a science journalist for the whole of his working life. He joined the FT in 1987. Clive, the FT's science editor, picks out the research that everyone should know about. He also discusses key policy issues, from R&D funding to science education.

Andrew Jack is pharmaceuticals correspondent, covering the industry and public health issues. He has been a journalist with the FT for 19 years, based in London, Paris and Moscow

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