THCB

On the origins of Maintenance of Certification in the National Health Service: A Serial Killer

Screen Shot 2014-09-10 at 6.22.08 AMBritain’s most prolific serial killer was a General Practitioner (GP), Dr. Harold Shipman. He wasn’t England’s most famous murderer. That accolade goes to Jack the Ripper. The Ripper killed five women in the streets of Whitechapel. Shipman might have been responsible for over 200 deaths.

Shipman’s legacy to the medical profession was not just a permanent simmering of mistrust. He triggered the introduction of revalidation, Britain’s version of maintenance of certification (MOC).

During Shipman’s prosecution the media scrutiny on physicians was intense. It’s both a beauty of and curse on our profession that we’re assumed to have such high code of ethics yet not spared the foibles of human nature.

“Homo homini lupus” doesn’t spare physicians. Bashar al-Assad was an ophthalmologist. Ayman al-Zawahiri once had taken the Hippocratic Oath.

This means that outliers, inevitable products of a Gaussian distribution, also get past the gates of medical school.

The government set up an inquiry headed by Dame Janet Smith. How could Shipman have gotten away with murder for so long? What were the systemic failures?

The Shipman Inquiry is 5000 pages long, compiled after interviewing 2500 witnesses. It cost the tax payer nearly 21 million pounds. Its conclusion was stunningly bland even if of military precision: doctors need more policing. This is like concluding that the First World War happened because people aren’t always nice to one another; a truism so uniformly true that it ceases to inform policy.

The report called for the General Medical Council (GMC), the prime regulatory agency for physicians, to work for patients, not physicians.

The solution: Revalidation.

Ambrose Bierce said of reflection “an action of the mind whereby we obtain a clearer view of our relation to the things of yesterday and are able to avoid the perils that we shall not again encounter.”

But we’re in a rational age of managerialism. Every rare event is dissected to the hilt for the root cause and the world changed to make sure the event doesn’t repeat.

The politicians promised no more Shipmans. The media wondered what Shipman’s colleagues were doing whilst he was going around overdosing people on diamorphine.

Some physician leaders, for whom vicarious acceptance of guilt on behalf of their colleagues knows no bounds, particularly if that acceptance opens doors to Whitehall (Britain’s equivalent of the Beltway), asserted that physicians must deeply introspect how a Shipman arose in their midst.

If you’d asked GPs then to spend time in the Gulag in repentance for Shipman, they might have agreed. So strong was the shame of Shipman.

Let’s pause momentarily and reflect. Revalidation (MOC) was instituted to catch serial killers.

Time-limited medical license, continued medical education, 360-degree evaluations, maintaining portfolios with goals and objectives and demonstrating that one is up to date with the PARADIGM-HF trial, would have caught Shipman (and might even have nudged Bashar in to dealing more equitably with the rebels).

Shipman was loved by his patients. He was a charmer. Psychopaths often are. He once was interviewed for TV. Shipman would have aced Press Ganey. His Yelp reviews, assuming he didn’t kill his victims before they wrote a review, would have been a near perfect five. He would have been on the speaker circuit for patient-centeredness.

How about making GPs demonstrate they’ve kept in touch with evidence-based medicine? That would have caught Shipman, surely?

Rhetorical questions, as I am sure you’ve guessed. Professional competence and murderousness are conditionally independent. But I’d conjecture that a physician who decides to embark upon a killing spree is more likely to get away if intelligent and professionally competent.

That Shipman knew the lethal dose of diamorphine meant he was aware of the non-lethal dose, and probably the dose that’s just lethal but not incriminating. The problem certainly wasn’t his lack of knowledge.

What if Shipman received a 360-degree review by his peers? That would’ve picked up his murderous intent?

Peer reviewer: “Dr. Shipman, I see you’re up to date with CME. Just one last question. Do you plan on murdering someone?”

Shipman: “Only the Secretary of State for Health.”

Peer reviewer: “Ha, ha! So do I!”

The readers of the Daily Mail wondered why his colleagues failed to detect his psychopathic tendencies. Even if there was an inflection in Shipman’s affect after he killed, does anyone seriously believe this should have lead his colleagues to suspect murder?

Perhaps the ethics classes in his medical school should have emphasized that killing patients is against the Hippocratic Oath. That might have stopped Shipman.

Maybe doctors should be have a regular test which, amongst other things, asks “do you think it is fine for physicians to kill their patients with lethal doses of diamorphine?”

Perhaps Shipman would have been nudged to the “somewhat agree” box from “always agree.”

It needn’t be emphasized further that revalidation (MOC) would singularly have failed to stop the event in response to which it was instituted. Shipman, that scourge of society, was clinically competent. Evil, yes. Incompetent, no.

This means that the prescription of The Shipman Inquiry was parody. It may as well have been written by John Gresham, certainly would have been less excruciating to read.

But here’s the important point: it wasn’t parody. It was politics.

Shipman presented a perfect opportunity, the long awaited straw wolf, for regulators to gain control of the “too big for their boots” doctors, through a sleight of hand that few would notice: conflating the morally dangerous with the clinically incompetent physician.

It gave the GMC boundless power, power that continues to grow under the pretext of protecting patients, and power they seem little inclined in relinquishing.

The physician leaders had loftier ambitions whilst the medical profession was too paralyzed with shame to point out what was blitheringly obvious: nothing can catch a physician serial killer before he embarks on a killing spree if he chooses to deceive.

The only way to prevent a Shipman is by the bokanovsky process in Huxley’s dystopia; i.e. factory production of embryos, tailor-made to become physicians with the right blend of empathy, compliance, and attentiveness to evidence-based medicine.

But, as we find out in the Brave New World, despite a quality assurance program more rigorous than Toyota’s six sigma, sooner or later someone falls through the stochastic cracks.

Revalidation is the dialectic between randomness and democracy’s desire for perfect security. It’s also a product of the constant battle between regulators and managers on one side and the physicians on the other. This is not quite the tension between workers and capitalists that Marx envisaged. It’s a white collar war. Between the importance of regulators and autonomy of physicians only one can survive.

Needless to say, revalidation has not been useless when one acknowledges the real motivations behind its introduction.

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Eliotชาทีมิกซ์เนอร์สซิ่งโฮมplaton20Ben Rush MD Recent comment authors
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Eliot
Guest
Eliot

As a criticism of using MOC to prevent murderous physicians, this article obviously makes sense. But as a criticism of MOC in general, it’s pretty damn silly. Why should doctors ever have to prove their competency, even at the beginning of their professional careers? But if they do have to prove their competency, why should be only once, at the very beginning of a multi-decade long career, and never again? What if a physician experiences brain damage from accident or stroke or other disease? Should this person be legally able to practice as long as they are inhabiting the same… Read more »

ชาทีมิกซ์
Guest

I love reading an article that will make people think.
Also, many thanks for permitting me to comment!

เนอร์สซิ่งโฮม
Guest

I don’t even know the way I stopped up right here, but I thought this post was great.
I do not realize who you might be but certainly you are
going to a well-known blogger if you are not already.

Cheers!

Ben Rush MD
Guest
Ben Rush MD

Two wrongs don’t make a right. Politicians have killed far more innocents than Shipman.

Vik Khanna
Guest

“Revalidation is the dialectic between randomness and democracy’s desire for perfect security. It’s also a product of the constant battle between regulators and managers on one side and the physicians on the other. This is not quite the tension between workers and capitalists that Marx envisaged. It’s a white collar war. Between the importance of regulators and autonomy of physicians only one can survive.” Brilliant paragraph, Saurabh. Only a government commission could issue a 5,000 page report and concluded that the solution to the psychopathology of one man is to hyper-regulate a profession in a manner that is completely lacking… Read more »

Saurabh Jha
Guest
Saurabh Jha

Thanks Vik.

Law enforcement, eh? No wonder your tolerance for BS is a near zero.

Vik Khanna
Guest

The very first enforcement action I took was against the milk industry. Their promotion board in our jurisdiction was marketing to consumers that whole milk was a low-fat food. The basis for their claim was that milk was, by volume, mostly water and since fat made up a small proportion of the overall volume, they were safe to make the claim. And so began the fun of chasing healthcare liars and cheaters. No killers, though. The statute I enforced was commercial law, not criminal law.

Peter1
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Peter1

“One problem with enforcement in this space, however, is that health professionals of all stripes are often very reluctant to speak against physicians, and prosecutorial reticence to pursue them is well known unless the circumstances are egregious.” My wife nurse of 40 years has seen a lot of this. Nurses usually get full critical examination of errors, docs however tend to get the country club gent scrutiny. I think with docs it’s the, “There by the grace of God go I” approach. When she was a head nurse she could not get fellow OB/GYNs to launch an investigation on one… Read more »

platon20
Guest
platon20

Your statements are dubious at best. For doctor run amok there are 10 nurses who have done equal or worse things.

Nurses dont have to get credentialed at hospitals. Nurses dont have their errors tracked in a nationwide database.

Peter1
Guest
Peter1

You’d have to explain your use of “dubious”?? “For doctor run amok there are 10 nurses who have done equal or worse things.” Then they are unemployed. They have much more oversight and each bad event is investigated and appropriate action taken. Nurses loose license easier than doc. “Nurses dont have to get credentialed at hospitals.” They have to apply for jobs and if hired have abundant oversight. Every day is a “credential” day. ” Nurses dont have their errors tracked in a nationwide database.” State tracking not enough? How about previous job reference. The usual question from new employer… Read more »

Michael Godwin
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Michael Godwin

With all the closed circuit TVs abounding in the UK, surely they could put them in the GPs’ offices? Not like the UK isn’t already a police state!

Perry
Guest
Perry

No wonder Scotland wants to secede.

Saurabh Jha
Guest
Saurabh Jha

Ha! Ha!

BTW, Paul Krugman doesn’t seem to think that independence is a good idea, economically.

I’d agree.

Perry
Guest
Perry

Aye, Laddie. I don’t usually agree with Krugman, but I think he’s right there.

Michael Godwin
Guest
Michael Godwin

Cleary, Shipman wasn’t in favor of independence either. For his patients.

Saurabh Jha
Guest
Saurabh Jha

Yes, but he committed a lot of murders in their homes, as part of the home visits.

That’d take surveillance state to a whole new level of definition.

allan
Guest
allan

“Home visits and death.” You are sparking my “paranoia”.

How could that happen in this country? Vertical integration? A large company that insures a large number of people that are treated by the company’s own doctors in the company’s own hospital where all stand to make a profit on cost savings.

What would happen if that large company were to include hospice care? Could there be an early shift in the direction of hospice care where diamorphine becomes a money maker (or in reality a cost saver)?

Saurabh Jha
Guest
Saurabh Jha

Technically speaking they would gain by keeping the patient alive for as long as possible to keep billing them for non-lethal doses of diamorphine.

Home visits used to be very commonly done by GPs particularly in small, towns with small communities in the North of England, where Shipman practiced.

allan
Guest
allan

Yes, I see your point in FFS. They want these people alive as long as possible and as long as the money keeps flowing in. That is generally why people request medical care, to remain alive and comfortable. But, what if the insurer is an HMO where denial of treatment means profit?

What would happen if the HMO owned the hospice center and refused to adequately treat those in pain or with expensive chronic illness? Could they induce the unknowing patient into hospice by offering more comfort and then potentially provide benign neglect or even a bit of assistance?

allan
Guest
allan

Saurabh, a very proficient job that I intend to use in reference. Government apparently doesn’t have all the answers.

Saurabh Jha
Guest
Saurabh Jha

Thanks allan.

We may not agree who runs to government but we do agree that more regulations will not provide the citizens the security that they sometimes desire, after a catastrophic event such as this.

Perry
Guest
Perry

What does it say when a guy like me who practices Occupational Medicine manages to pass the Family Practice Boards every 7-10 years? (Hint, I’m not that smart). Oddly, the first recert exam I took after practicing Industrial Medicine for about 5 years, I did decent on the OB/Gyn part and worst on the Occupational Med part. I have a friend who is a smart and good physician who has also been doing mostly Occ Med. He was unable to pass his recert and now practices without it. While it may not hurt him in his current employment, if he… Read more »

@BobbyGvegas
Guest

“He seemed like the Doogie Howser of India, able to crack the country’s best medical school, and work there as a 21-year-old doctor. Anoop Shankar later claimed to add a Ph.D. in epidemiology and treat patients even as he researched population-wide diseases. He won a “genius” visa to America, shared millions in grants, and boasted of membership in the prestigious Royal College of Physicians…”

http://www.nbcnews.com/news/us-news/ivory-tower-phony-sex-lies-fraud-alleged-w-va-university-n199491

Talos
Guest
Talos

Within the American Board of Family Medicine, the first Board to require recertification, there is a small yet significant faction against the idea of recertification starting to rise, to the point that the Board President issued an email to all diplomates regarding the value of Board certification, including the “evidence” that Board recertification and MOC is good for everyone. It made me laugh and cringe at the same time. After reviewing the data presented regarding MOC and board recertification, I found the studies to be self-serving and weak in their correlations. I believe in continuing education, though the Board exams… Read more »

Saurabh Jha
Guest
Saurabh Jha

The tension between regulators and physicians is very similar in the NHS.

The farcical thing is that there is no reason why Shipman would not have passed revalidation (MOC).

So despite the regulatory overhaul society is still at thread from random evil outliers.

Perry
Guest
Perry

No killers prompted this process in the States, it was our “own” Crtification Boards that started this. Most states I am aware of already have requirements for CME to renew a medical license. This, apparently is not enough, we have to expend time, energy and money to recertify every 7-10 years with MOC in addition to taking a test. Our vaunted Board leaders assure us that this really shouldn’t be that time consuming or financially draining, however, I’m not sure how many of them are in full-time private practice, and their salaries are in the mid-high six figures. Because my… Read more »