The Hypocritic Oath

The Hippocratic Oath

The Hippocratic Oath goes back a long way. One version I have seen in the past contains the line

“First, do no harm”

Sadly in recent years, accelerating with the formation of NICE and the PCTs, the oath really needs to be reworded

“First, spend no money”

The current “version” of the Hippocratic Oath used in the UK is the GMC Guidance On Good Practice . However if you actually read what doctors are supposed to do and compare with what they actually do, you may find just a few discrepancies.

There’s an old saying

“What do you call the doctor who graduated bottom of the class?”

“Doctor”

Undoubtedly some doctors are incompetent, sometimes to the point of being dangerous.  Some may have been competent forty years ago but have read nothing since to update their knowledge. However even when their colleagues will admit this “off the record” they are likely to band together to protect the incompetent in the face of lawsuits or other disciplinary action.

One thing I noticed within industry is that two distinct types of people get to “the top”. Some do so by being very competent and getting there on merit. The others, which seem to be predominating, get there by being so incompetent that they do not waste any time or energy actually doing their job and so can spend all their time playing office politics. They will employ competent people, usually in much lower positions and on lower pay scales, who actually do the work they get credited for.

People who are just mediocre will tend to go off and find something else to do.

Unfortunately in the medical (and other) professions, by the time people discover that they are only mediocre they will have spent so much time and money on training that they are most unlikely to find other more suitable employment.

Some doctors are arrogant and narcissistic and actually take pleasure in denying diagnosis and treatment to patients they regard as “unsuitable” or “undeserving”. Not many go to the extremes of Dr Harold Shipman and actively murder their patients when they believe they are due to die, but plenty will refuse treatment on other than medical grounds.

Some doctors are excellent even to the point of being mavericks and fighting against the system. This can have major downsides. see the story of Dr Anna Dahlqvist who came close to losing her job before being recognised as having been right all along.

The really really sad thing is that many many doctors are thoroughly competent, efficient, helpful and personable but are actively dissuaded from using their competence by restrictions placed on them, usually by non-medically-qualified people like accountants.

It’s not at all uncommon to hear patients reporting doctors, nurses and other medical professionals saying things like

“Of course a low carb diet is a good idea, I do it myself but I’m not allowed to tell you this!”

or

“Obviously you need to test your blood glucose but I’m not allowed to prescribe test strips for you, you’ll have to buy your own. And I didn’t tell you this . . .”

or

“Your improvements are remarkable but I have to tell you that a low carb diet is not recommended and I can’t support your choice. However, off the record . . .”

Here are some examples from the GMC Guidance which doctors often have little choice but to disobey

You must give priority to the investigation and treatment of patients on the basis of clinical need, when such decisions are within your power. If inadequate resources, policies or systems prevent you from doing this, and patient safety is or may be seriously compromised, you must follow the guidance in paragraph 6.

Paragraph 6 says

If you have good reason to think that patient safety is or may be seriously compromised by inadequate premises, equipment, or other resources, policies or systems, you should put the matter right if that is possible. In all other cases you should draw the matter to the attention of your employing or contracting body. If they do not take adequate action, you should take independent advice on how to take the matter further. You must record your concerns and the steps you have taken to try to resolve them.

Hmmm, complain and lose your job or keep quiet. yes some doctors have been threatened with termination of employment even for things such as “writing too many prescriptions” or “making too many referrals” so it’s little wonder they toe the Party Line even when they know it is not to their patients’ benefit.

Here’s another one

To fulfil your role in the doctor-patient partnership you must:

1. be polite, considerate and honest

2. treat patients with dignity

3. treat each patient as an individual

4. respect patients’ privacy and right to confidentiality

5. support patients in caring for themselves to improve and maintain their health

6. encourage patients who have knowledge about their condition to use this when they are making decisions about their care.

5 and 6 often fall by the wayside when you have financial or dogmatic restrictions imposed upon your treatment, which knocks over 1.

To communicate effectively you must:

1. listen to patients, ask for and respect their views about their health, and respond to their concerns and preferences

2. share with patients, in a way they can understand, the information they want or need to know about their condition, its likely progression, and the treatment options available to them, including associated risks and uncertainties

3. respond to patients’ questions and keep them informed about the progress of their care

4. make sure that patients are informed about how information is shared within teams and among those who will be providing their care.

Well that ain’t going to work when you are instructed NOT to request the tests you need for financial reasons.

How can you keep patients informed about the progress of their care when you have been told NOT to prescribe test strips, NOT to request Full Lipid Panels, NOT to request HbA1c for “nondiabetics”, and only to tell them to eat a high carb low fat diet which you know will cause rapid progression in their condition?

You are effectively told to make them worse and not measure the progression.

In order to “save” money an increasing amount of work is being devolved onto nurses. This would be no bad thing if it meant the doctors could concentrate on serious stuff while the nurses deal with routine stuff including routine prescriptions and tests. But again this falls over when the nurses are restricted by protocols and encouraged to fob patients off by refusing them tests, refusing them test results except for “it’s normal” or “it’s a bit high” and treating informed patients – or patients who want to be informed – as a nuisance.

Again I’ve seen similar within industry – ISO 9001 involves writing Procedures for every job and ensuring that the Procedures are followed.

This has the result of improving the performance of the incompetent to attain mediocrity.

However it also has the effect of diminishing the performance of the excellent by preventing them from innovating or applying their knowledge to solve problems, unless of course they are able to sit through enough Meetings and Steering Committees to be able to change or improve the Procedures. And of course supplying “evidence” that the Procedures can be bettered is fraught with danger as by definition this implies that you are not following said Procedures, which may be a disciplinary offence.

Another piece of Managerial Psychobabble works like this: if you attempt to solve a problem you have Taken Ownership of the solution. However by definition this means you have also Taken Ownership of causing the problem, and the blame. Far better to blame a department whose fault it obviously isn’t. Then the fact they are unable to provide a solution proves they were at fault all along.

This resonates clearly with current beliefs about Type 2.

Give patients a diet which is guaranteed to express the diabetic/thrifty/emergency genes in all carriers. When this has the expected effect, blame them for becoming fat and lazy. When they get worse even more rapidly, blame them for not complying with the diet. Above all do NOT provide a simple solution, like eating a rational amount of carbohydrates and providing sufficient test strips that the patient can ascertain exactly what their own anatomically correct carb level is.

The same applies to other cardiovascular diseases, and obesity: if the diet isn’t working don’t blame the inappropriate diet, blame the patient.

Thus the NHS is actually creating more work for itself, aided and abetted by the Diabetes Charities and other bodies such as the FSA, the American Heart Association, the British Dietetic Association, the British Heart Foundation and all the rest.

I believe this will reverse in time, but far too late for me and for many others who are currently condemned to unneccesary suffering and an early demise.

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