Non PC work: An anatomy of the Twaterati

No, not politically correct work- although you’ll find some of it advertised in the Guardian job pages.
No, not patient centred work as although you’ll prattle a lot about it, you’ll get ever further from actually meeting a patient.

No, this piece is about the growing phenomenon of that oxymoron- a doctor who doesn’t see patients- a non patient-contact doctor. (NPC) It’s spectacularly easy to be the best doctor in the world when you are not seeing patients. You cannot make as many mistakes, and your medico-legal risk is lower. (Recognised by lower medical defence/insurance subscriptions). In this essay I want to scope the problem for readers.

Now we know there are some doctors who find patients messy and disagreeable, but these types tend to go off into NPC specialities such as chemical pathology. There are doctors whose prime interest in medicine is the scientific challenge and good luck to them working in background specialities and being honestly NPC. They still help patients, but not as obviously or directly as those who see, investigate and operate on patients.

However there is a growing group of doctors who are moving into NPC work. There are jobs and roles appearing which involve ever less contact with real patients with real problems. These jobs allow people away from the hard grind of frontline medicine and into the routine of endless conferences and meetings. These jobs involve coming in closer to centres of power and influence, and ever further away from actual patients.

So for example one professor of general practice had done so little general practice that he wasn’t able to do expert witness work in courts. How absurd can a title get? The man who is supposed to research and put forth his views and learning about general practice does so little of it that the courts say he knows nowt about it.

Where do we find these NPC doctors?

Well the queen bee is Dame Carol Black, Chair of the Academy of Medical Royal Colleges. No QUANGO is quorate unless she’s on it. Then we have people like Professor Sir George Alberti and Sir Liam Donaldson. Professor Sir Michael Rawlins at NICE is another NPC doctor.

But there are many, many unco guid folk listed above. They tend to congregate in the Royal Colleges, the BMA, and increasingly in PCTs where they are “medical directors” or “advisors” or “clinical engagement leads.” The Deaneries which are supposed to guide post-graduate education also attract a lot of NPC doctors.

Now there is a need for the profession to be educated, trained, represented, regulated, revalidated, appraised, researched, negotiated for and so on. So there is a positive intention behind all these NPC jobs. All these jobs take a lot of good doctors away from front line medicine and away from delivering services to patients. The time spent on them is taken away from patient contact time.

There is a downside risk to these jobs. Firstly the hardest thing any doctor does is deal with patients. Anything else is easier than this, and meetings with other clean and well heeled middle class professionals in seminar rooms is easier than a patients, and the crumbling NHS monolith.

Thirdly it’s very easy to be sucked into a subtle shift from being a doctor with an extra role to becoming a doctor whose role is to represent power to their members. So the shift from being an ordinary animal, into one more equal than the others occurs imperceptibly, but an outsider can spot that it has happened.

The appartchiks describe this shift as “constructive engagement” with the “necessary” and “overdue” “processes” of “modernisation” James Johnson fell for this and Dame Gill Morgan said of his departure,

“The relationship with the Department of Health is fragile and if Mr Johnson's resignation causes the BMA to move to pointing out problems rather than helping work out solutions, it would significantly weaken the influencing position of the BMA.”

Well if collaboration with the enemy brings us results such as MMC and MTAS why the fuck would any doctor want a constructive relationship like that? It’s like confusing a demolition job with a construction site.

There’s always been a tension between those of us who actually do the work, and those who talk about the work. That tension has grown recently, especially as New Labour has tried to co-opt all medical bodies into a “progressive coalition” I hate how the left wing use the word progressive as a mood word rather than answering “Progress: Towards what exactly?” When allied with “dynamic” I want to know what is driving them.

The dissociation between real doctors who do real medical things such as talk to patients and treat them, and academic types who study us at work as though we are a species of strange animal in a foreign land is growing. There is no “We” in medical research at present. Read research and you find that real doctors are negligent de novo, they don’t follow protocols, they forget bits of guidelines, they don’t do things by the book. They miss opportunities they are “ideally placed to take.” The researchers seem unable or unwilling to understand why their papers viewing us through the distorting lens of their pet theory, disease or interest are not greeted as revealed truth by the front line of medicine.

They have great conferences on “Getting research findings into practice” and “Clinical engagement” and “removing blockages to road to progress” They talk about “involving all stakeholders” but forget to include doctors as one of the stakeholders. The very need for such conference demonstrates the problem. If research really answered questions clinicians wanted answered it would get translated into action far more quickly.

The interaction between the researchers and the royal colleges and guideline writers develops as a “close knit, interlocking meshwork” Yes it is a case of birds of a feather flocking together. In the past most real doctors could see that these people were decent doctors, and were actually trying to make things better. The research filtered down eventually, even to Little Muddlecum DGH.

Now we have a medical establishment funded by pharmaceutical funded research, the ESRC (anything politically correct) and MRC (Anything to do with DNA). The journals are competing to get the best trials in their journals and are at risk of becoming the marketing arm of big pharma. It’s a limited menu that goes into informing guidelines for practice. Written on a GOBSAT basis, (good ol'boys sat around a table), often pharma sponsored)

As you can see there’s currently vast scope for many roles in medicine beyond actually doing the work. It’s good for some doctors, providing variety and entertainment. It’s often dignified as “A portfolio career”

However at the top end of the royal colleges and BMA (all funded by the majority of doctors who do real medicine) there is currently a cadre of doctors very distant from their medical roots. These people are wielding power and influence against their colleagues (And MMC and MTAS are the festering sores here, although NICE, the GMC, AoRMC and PCT medical directors may join that hall of shame). There is a group of “Twaterati” emerging, and the profession could be better for a high phosphate clear out of many of them. Getting the CMO’s scalp would be progress here.

The Twaterati are backed up by the “clipboarderati” who come round and do things such as “Quality control” “safety checks” and “QOF validation visits” Most of these are PCT appartatchiks working under the orders of their local commisars.



The fault line in all this is between standing up for the profession of medicine, which is worthwhile and what the BMA and colleges should do (We’re doctors and we pay for them) and some in the colleges who think their role is to advocate for the NHS, a clapped out breaking down delivery system for medicine. Medicine existed long before the NHS and will exist long after it. It is a noble and valid profession with its own particular and useful viewpoint on events. We want our representatives to give this perspective clearly and directly and to speak medicine to power.

As doctors we need to be clear that we are in favour of good (effective and accessible) medicine provided at a fair cost to patients. (Whether the cost is paid up front or by tax or insurance)

We also need to be clear that “change” “progress” “Plans” and other such government paraphernalia are not synonymous with “improvements” For too long now the colleges and BMA have not dared criticise the detail of government’s plans. The colleges and BMA have become effeminate, ineffective poodles, tickled under the chin by government ministers sitting on Blair’s sofa. The BMA and the colleges have been the dogs that have failed to bark and howl on behalf of their members, whilst idiocy has become DH official policy

In the end it comes down to my consulting room. The Twaterati may prattle for ever about “improved care” “better and more patient centred pathways” “better guidelines” and “cross sector respect and co-operation” They may become ambassadors for whatever crap the DH is spewing out this week. The Clipboarderati may come round and monitor my compliance (sulky and surly as it is) with the “next great leap forward in the NHS”

But the real test is, “Do the twaterati, the apparatchiks and the clipboarderati actually do anything that helps me get a better result with and for my patient?” To treat the patient better? To relieve the chronic time pressure in GP surgeries? To allow specialists to explain operations more thoroughly? To enable clinics to function as meetings between two humans rather than as two operatives (patient and doctor) along a management mismanaged conveyor belt? To enable hospitals to deal with their workload more effectively?

On this the answer is currently a resounding “NO”

The current NHS reforms are now a hindrance to the good practice of medicine and this is bad for doctors and patients. The medical twaterati who have collaborated and enabled these reforms have got ever further away from the hopes, fears and expectations of front line doctors and patients. The growing dissociation between the ordinary members of royal colleges and the BMA and their doctors, first and foremost.

There's enough other people who can and should advocate for patients and for the NHS as an organisation that the doctors should have enough confidence to be themselves and do what is needed. The NHS is a venue for medicine, not medicine itself.