Britain’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.