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March 08, 2007

Doctors are being stripped of their autonomy - in short they are being proletarianised, argues Theodore Dalrymple

Posted by Theodore Dalrymple

The current failings of the system for selecting junior doctors for further training have been widely reported and have been seen as a further example of government incompetence. Not so, argues Theodore Dalrymple. They are all part of the government's agenda to proletarianise the medical profession, i.e. the agenda to strip doctors of autonomy.

Modern life throws up few heroes, though many villains. I was therefore relieved to see that ten surgeons in Birmingham walked out of an interview panel which was supposed to be selecting junior doctors for further training under the new system of selection instituted by the government, known as Modernising Medical Careers. Britain needs more of this kind of defiance to the increasing dictatorship of ruthless mediocrity.

The fiasco concerning the selection of junior doctors for further training has been widely reported as yet another mistake made by the government, as if incompetence were a full and sufficient explanation.

In so far as there was incompetence, it attached not to the process or system that the government had devised, but to the fact that the press was not in some way prevented or discouraged in advance from reporting its entirely predictable shortcomings and absurdities. The lesson of this fiasco for the government is that in future the press ought to be better controlled, whether by subornation or by some other method.

A policy which does not work can be just a mistake, of course. We all make mistakes, and many of them. Yet when our mistakes fall into a consistent pattern, over many years, we do not call them mere mistakes any more. They become symptoms of defects of character, serious or trivial as the case may be.

What, then, of the government's new, untried and dictatorially imposed new method of selecting junior doctors? It is part of its drive, conscious or unconscious, to destroy the independence first of the professions and then of citizens themselves. Its goal is a perfectly administered state (perfect, that is, in the sense that everything is administered and nothing is spontaneous or developed organically, not perfect in the sense that everything functions as well as possible).

To do this, members of traditionally independent professions, such as the medical profession (but not only the medical profession), have to be reduced to the state of employees of a hierarchical bureaucracy. If possible, they must be proletarianised. They must not be allowed to make rules for themselves, they must not be trusted to develop an esprit de corps or allowed to continue with one if it has already developed, they must not be allowed to develop loyalties to institutions, which should therefore be opened or closed in an almost whimsical or random fashion (the closure of hospitals is therefore of value in itself, quite independently of any savings that are made buy it), and they must be separated as far as possible from any sense of tradition.

Junior doctors, and increasingly senior doctors also, are now shift workers. Of course, this has meant that there is no continuity of care, or very little, in our hospitals: but there is no better way to ensure that young doctors do not believe themselves to be members of a profession with a glorious tradition than to turn them into clock-watchers, and the patients into parcels to be handed on to the next person once the music stops. Doctors are now in essence production line workers, no different from people who work in car factories.

Doctors must be humiliated by being obliged to perform tasks which they know to be of no value. There are few ways better of destroying a man's integrity than by forcing him to do things which he knows to be perfectly pointless and that he does merely because they are a condition of his continued employment. Such a person despises himself, and people who despise themselves make poor rebels against whatever may be imposed upon them. Most doctors now spend at least half their time on extraneous activities, a high proportion of which have no conceivable benefit to patients. Physical castration would probably be less effective.

Then along comes the new system of choosing junior doctors for further training. There wasn't really a serious problem to be solved: the ways of training doctors had been worked out a long time ago, at least in outline, and the system worked well. This is not to say that it could not be improved - all human institutions can be improved - but it did not need to be abandoned wholesale.

The old system of selecting doctors for training had regard to their academic records, their experience, their personal references as to their character and competence, and their performance at interview. What counted were, on the whole, the very qualities that were relevant to the practice of medicine. Of course, human beings being human beings, other factors entered the situation, but the end result was that Britain had one of the finest medical traditions in the world, with a glorious record of scientific discovery and service to humanity.

The new system has raised the dark arts of spin-doctoring to a place of pre-eminence among the qualities required of doctors. Junior doctors are asked to fill in forms that contain questions that have almost no bearing on their actual suitability for training. Their academic records and experience count for very little or nothing. The questions have to be answered on-line; already businesses have arisen, probably run by former bureaucrats, to train doctors to answer the questions "correctly", i.e. semi or wholly deceitfully. As for the interviews of those short-listed as having most successfully spin-doctored their forms, they have to follow a script laid down by bureaucrats, from which the interviewers are not permitted to depart by one jot or tittle. Consultants are reduced to the status of ventriloquist's dummy: and this after 30 years of education and training, and many years of service.

Actually, young doctors in training are already aware of the importance of spin-doctoring, for they have all now prepared what are called "personal statements" to get into medical school in the first place. The preparation of personal statements is largely an exercise in unctuous insincerity, and here too businesses have arisen to teach young applicants how to over-egg their puddings.

A lifetime of this kind of thing will warp any character, and render it simultaneously self-righteous, politically-correct in expressed views, unprincipled and ruthlessly focussed on personal advancement. People with such character will be easy to herd and control: though I am still not quite clear why the urge to herd and control should have become so strong in our political class, who of course share those very characteristics. Perhaps it is the result of an inner emptiness and a lack of deeper culture. But the result is a soft and creeping totalitarianism: not coincidentally, The Times reported immediately after the debacle over the appointment of doctors for training posts that senior doctors now say that they are living in a climate of fear: precisely as our masters want.

Theodore Dalrymple is a writer and worked for many years as an inner city and prison doctor.

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Superb article. I'm a hospital doctor in London, thankfully now senior enough to have escaped direct involvement the process described, though of course it will affect us all, for the reasons stated. You omitted to mention the fact that the Govt has also done away with the old general medical and surgical house jobs- young doctors will in future go straight from medical school to a specialty. Once in that specialty, there will be, as far as I can tell, virtually no chance to ever retrain in another specialty should one wish to do so. The inevitable result will be that the doctors of the future will lack the breadth of training and experience that many have now. I do hope the public wake up to this sooner rather than later.

For some time I've been searching for a phrase to describe the pointless, valueless "personal development plans" and suchlike which we are all now compelled to write for the approval of ignorant bureaucrats, and which every doctor I know considers an absurd waste of time. I think you've nailed it- "an exercise in unctuous insincerity"- priceless. The "dictatorship of ruthless medicority" is a choice piece of wording, too. The same phrases, incidentally, could be applied to most of our current political and social discourse. This is not coincidental.

Posted by: Nick M at March 10, 2007 03:57 PM

I throughly enjoyed reading your article. It is a very well articulated discussion of some of the concepts behind MMC and highlights the process of increasing governmental control over our professional training. There is currently much discussion regarding the administrative failures of the application and shortlisting process. As the teething problems are ironed out I feel it is important we continue to discuss the implications of having the standards of our professional training essentially controlled by our government. As a profession we should continue to insist that all doctors strive for excellence and must avoid the potential for mediocre training in a system designed with the significantly conflicting agenda of service provision.

Posted by: Rani at March 12, 2007 05:06 PM

though I am still not quite clear why the urge to herd and control should have become so strong in our political class

Because there are too many women in that class, who don't have enough children upon whom they might exercise this drive properly.

Posted by: Common Reader at March 15, 2007 10:24 PM

Absolutely fantastic article! Why can something not be done to remove the running of the NHS from the government - the bank of England did this with interest rates. It is time for the medical profession to follow suit. The government can still decide what budget to give the NHS but its running and the training of doctors should be left to those who have an interest longer than 4 years!

Posted by: Joanna Thomas at November 4, 2007 04:16 PM

I whole-heartedly agree with the gist of your article, Dr. Dalrymple, as I worked at St.Giles Hospital, London (in the STD clinic) in the early '80s and would never forget the wonderful experience of the ethos prevailing then.

Posted by: SD Goh at November 5, 2007 12:58 PM

I agree with all you have said, but I'm a little surprised at what you have not said - at least, not yet.

To be proletarianised is to move from self-employment to employment by someone else - and more specifically, from producing value through organisation of your own skills and materials, to producing through skills and materials owned by others - and producing not necessary use-values, but profitable commodities.

The way you put it, one might imagine that our new employer would be the state, but in that case, what's new? For doctors, the state has been a virtually monopoly employer ever since 1948, yet despite all the dire warnings of the BMA at the time (which I well remember) this enslavement never took place - until the 1980s, accelerating ever since. What happened then? We began to be shifted from public service, back into the marketplace.

I hope you will take up this wider and even more urgent topic. You write well, your column in the BMJ is always entertaining. I hope you will also educate. In this age of dangerous political illiteracy, we certainly need it.

Posted by: Dr Julian Tudor Hart at February 7, 2008 04:46 PM

I quite agree with the sentiments expressed by Dr Dalrymple. As a relatively young Consultant, I remember well the forthright integrity of my seniors while in training, and find the willingness of my mealy-mouthed contemporaries to embrace the new mediocrity, in the interest of their self advancement, quite distasteful and alarming. I do, however, feel that the profession has been distinctly complicit in the process by allowing itself to be led like sheep, insufficiently making the argument to the public (our patients) and lacking in asserting it's own autonomy with respect to the politicians and bureaucrats.

Posted by: Seth Bhunnoo at March 5, 2008 10:11 PM

Dalrymple speaks with regard to a profession he knows intimately, though he rightly remarks on a wider phenomenon. The near fetishistic obsession with personal development plans, pointless questionnaires, useless training and so forth is killing off initiative, good judgement and the application of common sense in large companies too. Forms forms forms is the mantra. Small businesses usually manage to avoid most of this nonsense, having no bureaucratic apparatus (a big clue). I often think of the small business as resembling the best organizational model - there is a very small state element, and irrelevance is treated with the derision it deserves. Even here though there are occasions when the few staff employed are put on expensive training courses that represent poor value. The mistake is not typically repeated though. A key reason for this is that it is one's one money that is being spent. In large organisations there are budgets, which do provide for some restraint but where a clearly identifiable bureaucracy exists you are almost guaranteed to be wasteful. No one asks the most important question: do we really need to do this? - the answer implies a layoff for those engaged in fake work.

Posted by: cybn at August 9, 2010 01:48 PM
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