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“Number one: you can never have sex. Big no no! Big no no! Sex equals death, okay?
Number two: you can never drink or do drugs. The sin factor! It’s a sin. It’s an extension of number one.
And number three: never, ever, ever under any circumstances say, “I’ll be right back.” Because you won’t be back.”

These are the rules that one must abide by to successfully survive a horror movie, as described by Randy to his friends in the movie Scream (1996). In a similar way, my number one rule for surviving a career in medicine is: “Don’t get struck off by the General Medical Council (GMC).”

Many of us enjoy being scared and there is indeed science behind this [1]. When we get scared, we experience an adrenaline rush followed by a release of endorphins and dopamine resulting in a euphoric state. Also, in a secure environment such as when we watch a scary movie, our brains evaluate it as a “safe” fright, telling us we are free from risk so that we can relax and enjoy the experience.

The bogeyman is defined as a person or thing that is widely regarded as an object of fear. In horror movies there are many (hopefully) fictional bogeymen that have given me an enjoyable scare including Michael Myers (Halloween), Jason (Friday the 13th [2]) and Freddy Kreuger (A Nightmare on Elm Street). However, for me, and probably many other doctors, the bogeyman I am most scared of is the GMC. And the GMC, unlike other bogeymen, is not fictional, is ever-present, and can strike at any time, without warning. My brain has also evaluated my situation as not being free from risk.

 

 

But if I don’t do anything wrong to warrant referral to the GMC, why should I be scared? Firstly, in a similar fashion to my low-grade underlying fear of the police, I am worried about being investigated for something that I didn’t actually do. Dr Richard Kimble in The Fugitive (1993) was unjustly accused of murdering his wife, and in the A-Team television series four members from a US Army special forces unit were court martialled for a crime they had not committed. Admittedly these are fictional cases, but there are plenty of real-life instances where people have been punished when they were completely innocent. Therefore, with the GMC one of my main concerns is one of false allegations.

On our first day working in A&E in London as senior house officers (SHOs), the consultant gave us an induction talk. One of his pieces of advice was that for, any intimate examination, to always get a chaperone and to document not only that the examination was chaperoned, but also who the chaperone was. He advised that this would offer some element of protection, should a false allegation be made. But this talk was the moment that first sowed the seed of concern that a false allegation was a realistic possibility.

Some would say that this fear of a false allegation is excessive and irrational. Therefore, to try and put my fear into proportion, what are the odds of receiving a “Rule 4” letter from the GMC informing me about a complaint, what are the potential outcomes of any investigation, and is the GMC an organisation that operates with honesty and integrity? What would Statto, the resident statistician on the BBC2 television show Fantasy Football League, make of the stats?

Well, the latest statistics from the GMC show that in 2020 the number of registered medical practitioners (RMP) was 337,317 and the total number of complaints to the GMC was 8468, which is equivalent to 2.5% of RMP receiving a complaint. This has risen from 1992 when the percentage of RMP receiving complaints to the GMC was only 0.9%. Essentially, what these figures show is that now, as a doctor practising in the UK, you should expect to be the subject of a GMC complaint at some point in your career, which is a pretty sobering thought.

The worst potential outcomes of any GMC complaint are erasure from the register or suspension. Although this number is relatively small compared to the number of complaints, a much higher number are investigated, and these investigations can and often do go on for many years. During that time, accused doctors who are ultimately exonerated can experience financial hardship from funding their own defence, being unable to obtain a new job or renew a contract, loss of private practice and interim orders preventing them from earning a living before any potential hearing. There is no provision for any compensation for doctors who are subsequently found to be not impaired.

Furthermore, doctors who are investigated by the GMC are at a higher risk of mental and physical health problems, a higher risk of death, and death by suicide [3]. This increased ill health is also seen in other family members, with the spouse often being affected as a consequence.

The rising number of complaints to the GMC and increased litigation is also having a worrying effect on the fundamental way doctors practice medicine, which is impacting on patients. There is evidence that doctors are now more likely to practise defensive medicine where patients are over-investigated and over-treated, and high-risk interventions and the most unwell patients are avoided.

The GMC has also come under criticism in court rulings and journals for failing to carry out justice properly. There have been many high-profile cases (Professor David Southall, Professor John Walker-Smith, Edouard Yaacoub) where GMC decisions to erase doctors from the register have been overturned following High Court judgements. There are also cases such as Dr Bawa-Garba, where the general mood amongst doctors is that an incorrect decision has been made. As Martin Luther King once stated: “Injustice anywhere is a threat to justice everywhere” [4].

There are also certain demographics which can put a doctor at an increased risk of GMC referral, investigation, and sanctions, some of which are also suggestive of an element of injustice. These demographics are as follows: being over age 49, male, being of Black and Ethnic Minority, and having qualified in medicine from outside of the UK.

Lastly, there is the thorny issue of funding of the GMC, which is predominantly covered by doctors through annual subscriptions. In 1972 this was £2, but by 2021 it had risen to £408, far exceeding any inflation. Not only are doctors expected to fund the organisation which regulates them, investigates complaints, and explicitly works in patients’ best interests and not doctors, but also pay for the rising costs of membership of a medical defence organisation to provide legal representation in the event of any complaint. The fact these two fees are graciously deemed tax deductible by the HMRC only marginally pacifies the perceived injustice of the situation.

So, in summary I believe that the GMC being the bogeyman I am most scared of is justified. It has the potential to destroy my livelihood, destroy my health and those of my loved ones, and may even kill me. It is also subliminally affecting how I practise medicine in a negative way every day. Ironically, I also pay to keep it in existence. My three kids are all showing no signs of wanting to be a doctor. I have mixed emotions about this, but one of the reasons I am pleased is that they will not be looking over their shoulder every day for the bogeyman that stalks me.

In the movie Candyman (1992), Helen, a graduate student, discovers the story of the Candyman whilst researching urban legends. The Candyman is a spirit who can be conjured up and kills anyone who says his name in front of a mirror five times. For readers who like a scare, my challenge to you this Halloween is to say “GMC” in front of the mirror five times. “GMC, GMC, GMC, GMC….”. I know I can’t do it, can you?

Don’t worry though, “I’ll be right back” for Dec/Jan with a festive message. Happy Halloween!

 

References:

1.    Zald DH, Cowan RL, Riccardi P, et al. Midbrain dopamine receptor availability is inversely associated with novelty-seeking traits in humans. J Neurosci 2008;28(53):14372-8.
    This paper explores why some people may enjoy fear more than others. Dopamine is a hormone which gives rise to pleasure responses in the body and autoreceptors in the brain tell the body when to stop producing dopamine. Zald and his co-workers showed that thrill-seekers tend to have fewer autoreceptors and therefore produce more dopamine. As Zald explained: “Think of dopamine like gasoline, you combine that with a brain equipped with a lesser ability to put on the brakes than normal, and you get people who push the limits.”
2.    Friday the 13th was the first slasher horror movie I watched whilst on an A-level Biology field trip to Norfolk in 1989. It was one of the highlights of the week which was otherwise spent throwing quadrats around windswept sand dunes and traipsing knee deep in mud through salt marshes. Viewing this film also set in motion my obsession for checking inside wardrobes and under beds for bogeymen if I am ever alone in the house at night before bedtime.
3.    Hawton K. Suicide in doctors while under fitness to practise investigation. BMJ 2015;(13):350.
4.    It would be good if there was the perception that the GMC followed the guidance for all doctors whose origins are uncertain but often attributed to Hippocrates (460 - 370BC), the Father of Medicine: Primum, non nocere - first, do no harm.

 

 

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Peter Cackett

Princess Alexandra Eye Pavilion, Edinburgh, UK.

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