October 1, 2022

BY SAURABH JHA

If forced to choose Britain’s two biggest contributions to civilizations, I’d pick the Magna Carta and the vaguely instructional “fuck off.” If permitted a third, I’d choose “managerialism.” Brits are good at telling others what to do. Managerialism is how the Brits once ruled India. Buoyed by the colonial experience, British managers felt they could rule doctors. 

The new Viceroy, the manager-in-chief, is the General Medical Council (GMC). The GMC is a physician watchdog, funded by doctors, which works for the public good and is answerable to…well, I’ll get to that later. Their relevance rose exponentially when the psychopathic Dr. Harold Shipman, a charming, clinically adept, general practitioner, killed over two hundred patients. Never again, said the managers. They promised to keep the public safe from dodgy doctors with aspirations of Jack the Ripper and Sweeney Todd.

Recently, Dr. Manjula Arora, a doctor of Indian origin, was in GMC’s crossfire. Though I don’t know Dr. Arora personally, I’d hazard a guess that she didn’t migrate to the UK to emulate Harold Shipman. It’s also unlikely, and this may surprise some, that she left India for fortune and glory – doctors in India do well fiscally when you factor in the living costs. She may have been motivated by greener educational pastures in the UK, the sort that produces managers and doctors. 

How did the GMC save the vulnerable British public from the “dangerous” Dr. Arora? Her story is part tragic and part comical, and both comedy and tragedy jostle for the upper hand. One evening Dr. Arora asked her healthcare (Mastercall) Information Technology (IT) for a laptop. She said that she had been promised a laptop by the medical director. The IT department e-mailed her medical director (MD) and asked whether she had truly been promised a laptop.

The MD balked at the insinuation that he had broken his promise to Dr. Arora since at no point had he used the “p” word. At this stage let’s reflect on the gravity of the charge. Any parent knows that you never say the “p” word to your kids. I have threatened my kids with mythical monsters when they falsely accuse me of promising. Once, I confiscated their ice cream for accusing me of breaking my promise. The medical director reported Dr. Arora to the GMC for falsely accusing him of using the “p” word. 

The GMC, far from mythical, considered whether Dr. Arora, a first-class doctor with thirty years of experience, was an imminent threat to the public for lying that she had been promised a laptop. For who knows what a doctor who lies about the “p” word can do next? She might administer potassium to her patients and go on a killing rampage. 

The GMC has its own court in which it prosecutes dodgy doctors – the Medical Practitioners Tribunal Service (MPTS), or tribunal. Allegedly independent of the GMC, MPTS is supposed to be GMC’s wise Solomon, dispensing justice disinterestedly on facts and precedence. Busy people assembled displaying their finest lapels and imbibing the wisdom of the Magna Carta decided whether Dr. Arora was fit to be a doctor. On trial weren’t Dr. Arora’s clinical skills, or patient-centeredness, or whether Dr. Arora could manage an acute abdomen. On trial was her understanding of the word “promise.” It was a trial of semantics. Did she lie that the medical director had promised her a laptop? 

It turns out that the medical director hadn’t promised Dr. Arora a laptop. He said she may get one in the next round of purchases. Since “may” comes with “may not,” Dr. Arora was literally wrong that he had “promised” her a laptop. 

The “Promise”

This is what the medical director emailed Dr. Arora. (Emphasis mine) 

“We don’t have any laptops at present, but I will note your interest when the next rollout happens. Technology is advancing, we may soon be able to allow clinicians to use their own computers, watch this space.” 

The “Lie”

This is what Dr. Arora told IT. The medical director is referred to as “Dr. B” in the MPTS’s transcript. The MPTS doesn’t disclose the name of the accusers, only the accused. (Emphasis mine)

“Oh right, because he [Dr B] didn’t have a laptop and he sent me an email that the next time it’s available he’ll give it to me, so you have laptops and I thought it’s best that I take one because I don’t want too many people to be involved, just him and you directly, because it’s my … it’s [Dr B] who has promised it.”

The Trial of Semantics

The tribunal wondered whether Dr. Arora truly understood what “promise” means. Dr. Arora said since English isn’t her first language she doesn’t always get the semantics 100 % accurate. The GMC disagreed and said Dr. Arora was in fact very articulate and had a good command of the language, noting she was “very easily able to answer questions in cross-examination,” that she was “able to formulate arguments very well,” that she could “adapt her evidence as she went along,” that she was “able to anticipate questions.”

Dr. Arora was asked whether the medical director had promised her the laptop, yes or no. She replied, “It’s the connotation that I had taken from it.” 

Then Mr. Carl Hargan, representing the GMC, with all his intellectual might, asked her a question which’d make schoolmarms proud. He asked if there was a “huge leap” between the phrase “note your interest” and a promise. Dr. Arora had no answer. She was stumped by Mr. Hargan’s brilliance. As was the MPTS.

The Verdict

The tribunal agreed with the GMC that Dr. Arora understood the meaning of the word “promise.” The Tribunal, “determined that, in the specific use of that one word, on that one occasion, she had been dishonest.” Which meant that she lied. 

Now, the tribunal had to decide if Dr. Arora was fit to practice medicine. So, it went through case law and sought the Shipman Report. Remember Shipman? Yes, that serial killer. That report states that “dishonesty” is a reason to question a doctor’s fitness to practice. For this “lie,” technically an exaggeration, the tribunal found Dr. Arora unfit to practice and suspended her for one month. 

Kafka meets Edmund Blackadder

Let’s pause and take a deep breath. Britain is a country where the Prime Minister can lie about partying in a lockdown he instituted, but an overworked doctor gets punished because she misuses “promise.” 

At this stage American readers are probably seething in incredulity – what the fuck? You ask. Even if she lied, so what? You may believe that I’m making stuff up. No, this isn’t a Monty Python script. This isn’t Dolores Umbridge holding a kangaroo court in Hogwarts School of Magic. This is the judgment of the tribunal of the watch dog of the most prestigious profession in a once upon a time super power – the one you expelled on the 4th of July. 

I’ll leave the irony that in a country which gave us Shakespeare, who gave us boundless metaphorical permutations, we have a trial about semantics! I have noticed on Twitter that Brits are increasingly becoming more literal and a tad dafter, as a result. Brits are better off staying metaphorical. But even allowing for these comical secular trends, the trial of Dr. Arora takes stupidity in the British medical profession to a level one struggles to comprehend. 

From protecting patients from murderous doctors, the GMC has gone to protecting the Oxford English Dictionary from brown doctors. The GMC is the best example of the slippery slope. The British public may wonder why the watch dog which was supposed to protect them from bad doctors has deprived them of a good doctor, just when there’s severe staffing shortage in the NHS, and even severer shortage of physician morale, post pandemic. 

There are three breaches of common sense and basic adult behavior. First, the medical director reported Dr. Arora to the GMC for, at worst, an exaggerated interpretation of his generosity. This could have been resolved locally with a stern “no, I didn’t promise.” He could even have confiscated her ice cream. Second, the GMC, instead of throwing the complaint back at the medical director with the scorn it deserved, thought the charge fit to investigate the doctor’s fitness to practice. And third the guilty verdict passed by the MPTS, after an intense academic deliberation. A true Mad Hatter party! 

Why wasn’t the issue left between employer and employee? My guess is that the medical director couldn’t remove Dr. Arora because she’s a good doctor. The only way of punishing competent doctors in Britain is going  after their moral character and reporting them to the GMC.

Why has the GMC become so farcical? One explanation is that the GMC is racist and the treatment meted to Dr. Arora is just another example of systemic racism. There’s certainly merit here but there’s a deeper problem which needs solving and that is the GMC isn’t accountable to anyone. In theory, it works for society, but as Margaret Thatcher correctly understood, there’s no such thing as society. It’s a nebulous entity that’s thrown around but means nothing. Being accountable to the public means being accountable to no one. 

The irony is that the medical director sent Dr. Arora the email “promising” her a laptop on Christmas Eve. It’s the time of the year when even the loathsome Scrooge lightened up. What then emboldened the medical director to be a tattletale? What motivated him to try to destroy Dr. Arora’s career and her family of an income source? Why so much hate in his bosom for his colleague? 

The tempting answer is that he’s a prick of the sort that takes years of mastery. But that doesn’t explain. To understand the medical director’s behavior, we must understand the GMC because the two are linked, causally. The GMC’s power has become absolute both by design and intention. The GMC hides under the carapace of “protecting the patient,” and in this dumbed down, sentimental medical world, nothing is more sacrosanct than the dull truism “it’s about the patient,” a truism so banal that it serves little purpose other than providing assholes moral sanctuary. 

But even here the GMC falls short. How can it claim to be protecting patients when it deprives patients of competent doctors? Instead of treating patients, Dr. Arora was defending her over use of the metaphorical license, thanks to her boss and the GMC. 

The GMC is not only a farce and bully in its own right, but also encourages bullying – this is a feature not a bug. It’s like bellows to ember. It flames toxicity in the workplace. It nurtures vindictiveness and pettiness in the NHS, like agar to bacteria. This is the only example I know of in the modern world of trickle-down vileness. The threat of reporting to the GMC is how the clinical directors control their minions. It’s not about patient safety, it never was. It’s about the power of managers and their control over doctors. 

Mr. Hargan said that Dr Arora had ‘brought the medical profession into disrepute,’ ‘breached a fundamental tenet of the profession,’ and that ‘her integrity could not be relied upon.’ Mr. Hargan said that “that a finding of impairment was necessary in order to maintain public confidence in the profession.”

Let’s unpack this. The other role of the GMC is to protect the reputation of the medical profession. And doctors with unconventional extracurricular interests can certainly damage the reputation of the profession. But if Bashar-Al-Assad, a former ophthalmologist and current Syrian president with a fondness for chemical reactions, doesn’t make people wonder if their ophthalmologists were going to spray tear gas once they dilated their pupils, I’m fairly certain Dr. Arora’s patients won’t second guess her prescriptions because she mistook “watch this space” for “I promise you a laptop.”

Mercifully, even the MPTS accepted “Dr Arora had not set out to be dishonest, and that she had not set out to mislead.” There’s dishonesty – lying about killing your patients (Harold Shipman) and there’s dishonesty – lying about being promised a laptop (Manjula Arora). Are British regulatory agencies too thick to make this distinction, or does this distinction not matter?

Society is better off when the likes of Mr. Hargan are grading high school essays than deciding physician misconduct. I’m certain Mr. Hargan is far too clever to believe his own nonsense. So why does he think doctors will believe his BS? Where does he get the audacity for such contempt of doctors’ intelligence?

To put it bluntly. The GMC doesn’t give a rat’s tail what doctors think. And why should they? All they care is that doctors give them their annual check, which doctors do, religiously. 

What’s the solution? 

Hand wringing and whining, at which doctors excel, won’t work. Despite the outrage, doctors couldn’t reform the GMC when the GMC sued the MPTS, its own judiciary, because it handed Dr. Bawa-Garba her license after her sentence. British doctors need to borrow a slice of timeless American wisdom – follow the money. Americans long realized that logos, ethos, and pathos don’t work with our species. If you want institutions to behave, fund them to behave, and if you don’t like how they behave, defund them. Money, or the threat of losing it, can reform the GMC in minutes. Appeals to their better angels will take eternity. 

Doctors should form a watch dog, run by practicing doctors, which monitors and holds accountable the GMC and MPTS – a meta-tribunal of sorts. If the GMC refuses to submit its decisions to an external agency, doctors shouldn’t pay their dues. Of course, this won’t be easy. Of course, it’ll need organized leadership. And of course, some doctors will opt out of collective resistance because it doesn’t affect them. But it’s the only solution. It’s the only way to tame the GMC. The GMC is a threat to the morale of doctors. The GMC isn’t fit to practice. Reform it or create an alternative. 

@RogueRad is a former NHS doctor

The transcript of the entire circus can be found here

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