Is there something rotten at the heart of the medical profession?

We once trusted our doctors unquestioningly. But now, week after week we seem to read headlines about doctors who are incompetent, unprofessional, or worse. And patients are losing confidence.
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Pity the poor doctor who makes a mistake. Perhaps a scalpel slipped. A fraction of a millimetre left or right can make the difference between life and death in Thoracic Park. Maybe the evaluation of a tissue sample on a slide, peered at through a microscope after a 12-hour shift, was not spot-on after all. Or, just possibly, having diagnosed three cases of a particular illness in one afternoon, the hapless consultant assumed that your illness - sharing many of the same symptoms - was the same as the rest.

Pity the poor doctor who makes a mistake. Perhaps a scalpel slipped. A fraction of a millimetre left or right can make the difference between life and death in Thoracic Park. Maybe the evaluation of a tissue sample on a slide, peered at through a microscope after a 12-hour shift, was not spot-on after all. Or, just possibly, having diagnosed three cases of a particular illness in one afternoon, the hapless consultant assumed that your illness - sharing many of the same symptoms - was the same as the rest.

We all make mistakes. The difference in medicine is that we pay for their mistakes with our lives.

Every year, according to the British Medical Journal, up to 30,000 people die in the UK as a result of medical errors. Just last Friday, it was revealed that as many as 55 people attending Woodend Hospital, Aberdeen, for cancer tests may have been given the all-clear in error because of mistakes by a consultant radiologist. But it has not been the numbers, however depressing, that have provoked public wrath and a belated wringing of scrubbed hands. Statistics are easily lost or explained away. Rather, it has been a series of well-publicised individual tragedies.

First, there was the Bristol heart babies scandal, centred on the discovery that 29 babies had died and another four suffered serious brain damage during heart surgery at Bristol Royal Infirmary. Two doctors were struck off, including the hospital's chief executive.

Then, in rapid succession, came the Harold Shipman trial, in which the Greater Manchester GP was convicted of the murder of 15 women in his care; the Rodney Ledward affair, in which a consultant gynaecologist was banned from practising after a series of botched operations in Kent; the case of Dr Richard Neale, another gynaecologist, struck off in Canada 15 years ago but only now being dealt with in Britain; and, most recently, the astonishing example of 78-year-old pathologist Dr James Elwood, whose misdiagnoses of more than 200 patients did not deter him from calling himself a "first class" medical man.

This week, attention will focus on an internal inquiry into the case of Mr Christopher Ingoldby, a consultant surgeon at Pinderfields Hospital, Wakefield, whose techniques, it is alleged, claimed at least one life and left other patients needing corrective surgery.

These and other disclosures over the last 12 months have acted like a defibrilator on the heart of the body politic. Ministers, opposition leaders, officials and institutions are jumping off the table. But can there be a revival of public trust in what was once the most revered of professions without a wholesale change in the way in which doctors are trained, and retrained, and - just as importantly - the manner in which they relate to patients?

To put events in perspective, there are currently some 35,000 general practitioners in the UK and 65,000 other doctors, including consultants, most of them in NHS hospitals. Of the total of 100,000, just 160 - 0.16 per cent - are at present awaiting investigation by the General Medical Council (GMC) the governing body, most of them for relatively minor offences. Many will be cleared; only a handful will be struck off or face criminal proceedings.

Mere facts, of course, do nothing to lessen the pain or anger felt by those who have suffered at the hands of an incompetent doctor. Indignation in the face of an unwieldy or underfunded system is as nothing compared to the rage experienced by someone who has been misdiagnosed or wrongly operated upon. If the feeling is growing that people can no longer trust their GPs or the consultants to whom they refer them, the NHS crisis of confidence can only get worse.

Yet experts say it is not that the number of bad doctors is increasing. Rather, public expectations are rising. Professor Julian Le Grand, a leading health economist at the London School of Economics, has observed the change in attitude from close quarters. "This has been coming for some time," he says. "We have moved into the era of fishbowl medicine. Throughout the world, the era of clinical freedom, in which we automatically trust doctors, is coming to an end. A growing distrust of professionals, combined with budgetary restraints, has greatly increased pressure on doctors.

"In the UK, the culture of deference was largely based on the fact that we didn't have to pay for health care. The NHS took care of us and we trusted its people to do their job. It is very different in America, where expectations are higher, and we in Britain are now going down the same road."

Surprisingly, in the light of the derision heaped upon it when it was introduced by John Major, the Patient's Charter is identified by Professor Le Grand as a key factor in changing the public mind.

"The Patient's Charter was a totally different mechanism to the internal market [also introduced by the Tories] which was seen as the primary engine of NHS reform. It was an old-style socialist command mechanism, with built-in performance indicators. Professionals today feel under greater pressure from the charter than they ever did from the internal market."

Dr Howard Stoate, the Labour MP for Dartford, co-chairman of the all-party parliamentary group on Primary Care and Public Health, is another who believes that changes in perceptions are what have largely created the present moral panic.

"A number of high-profile cases have sensitised the media and the public to expect the worst. It is a bit like the recurring concerns over child safety. The reality is that there are no more mad axemen out there than there used to be - we just hear about them. Mistakes have always been made in medicine. It is not an exact science. In the past, they were not acted upon. Today, failure and death rates are measured and, where there are doubts, there is an investigation. What is important is that we should not destroy trust."

Dr Stoate points out that the Government has already instituted a medical audit and revalidation procedure for consultants which is expected to be extended to GPs next year. This, he says, will mean that doctors will no longer pursue a 30-year career without any review or retraining. It should ensure not only that doctors are periodically evaluated but that they are equipped to understand and implement current theory and practice.

The GMC, meanwhile, desperate not to be seen as an old boys' club, pledged last month to improve its disciplinary procedures. It plans to reduce the backlog of cases waiting to be heard, fast-tracking the more serious ones and increasing the minimum period for which a doctor can be struck off the medical register from 10 months to five years.

The central consultants and specialists committee of the British Medical Association added its weight to this process last week when it stated that "a robust system of appraisal should be the corner-stone of quality assurance". Both bodies could find, however, that new audit regulations being drawn up by the Department of Health, involving "training camps" and independent NHS registration, will, over time, erode their jealously guarded governance.

What is likely to remain, even after all safeguards have been put in place and budgets increased, is the new, diminished level of public confidence and trust. In medicine, in which death is the ultimate mark of failure, the most that doctors can do is their best. Getting them consistently to that level is the challenge ahead.

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