How Can We Learn from the Killing of David Gray?

OBSERVATIONS

LIFE AND DEATH Iona Heath How can we learn from the killing of David Gray? The opacity of EU legislation may be a smokescreen for apathy General practice can feel very lonely and Paragraph 3 of the preamble to the profession in the host Member nowhere more so than in a strange house the directive makes it clear that “the State”—with the clear implication that in the middle of the night with a patient guarantee conferred by this Directive such linguistic skill can be assessed by one has never met before. The range of on persons having acquired their the competent authorities in the host diagnostic possibility at this first point professional qualifications in a Member country. of contact is enormous and help and State to have access to the same Perhaps even more fundamentally advice not easy to come by. What sort profession and pursue it in another important than all of this is the of economic pressures or professional Member State with the same rights continuing presence of a section within aspirations make a 67 year old doctor as nationals is without prejudice to Annex V of the directive specifically for want to make this situation even worse compliance by the migrant professional general practitioners (5.1.4), who are by taking on out of hours sessions in a with any non-discriminatory conditions treated differently from “specialised different healthcare system in a strange of pursuit which might be laid down doctors” (5.1.3). This seems to country, where consultations must be by the latter Member State, provided perpetuate the historically lower conducted in an unfamiliar language? that these are objectively justified and status of general practice, which is The tragic story of Daniel Ubani (BMJ proportionate.” Safe and effective The UK has one of now completely inappropriate, given 2010; 340:c3326, doi:10.1136/ general practice, particularly out of the best systems of the highly skilled, high risk nature of bmj.c3326), which culminated in the hours, is intensely dependent on “specialty training primary care. It is well time that European unlawful killing of David Gray in February adequate understanding of the context for general practice general practitioners were treated as 2008, is well known but still seems of practice. Any doctor working in these medical specialists in their own right, poorly understood. Dr Ubani was trained circumstances needs to be familiar with in the world . . . and this would allow more stringent in Nigeria but is a German citizen and had the British National Formulary and with yet this does not qualifications to underpin safer free

apparently been working in Germany as the local arrangements for accessing translate into movement. Arguably, the UK has one of a specialist in anti-ageing medicine and secondary care and emergency support. specialty status at the best systems of specialty training

cosmetic surgery in the town of Witten. It follows that these could provide the European level, for general practice in the world, with a How exactly did he come to be admitted the basis of “objectively justified” apparently because lengthy and detailed curriculum and a to the performers’ list of Cornwall and conditions. demanding licensing examination on of a lack“ of political Isles of Scilly Primary Care Trust in July Article 3 of Title I of the directive will on the part the completion of training. And yet this 2007? allows an “aptitude test” “limited to the of successive UK does not translate into specialty status at The free movement of workers is professional knowledge of the applicant the European level, apparently because a founding principle of the European to be made by the competent authorities governments of a lack of political will on the part of Union, and the current legal framework of the host Member State with the aim successive UK governments and because supporting this principle in relation to of assessing the ability of the applicant the procedures laid down in Article 26 of healthcare and other professionals is to pursue a regulated profession in that the directive are tediously bureaucratic. laid out in the somewhat gruelling 121 Member State. In order to permit this A recent position paper from the pages of Directive 2005/36/EC of the test to be carried out, the competent European Union of General Practitioners European parliament on the recognition authorities shall draw up a list of subjects on the evaluation of Directive 2005/36/ of professional qualifications. Earlier which, on the basis of a comparison EC (www.europarl.europa.eu/document/ versions of the directive had been of the education and training required activities/cont/201010/20101027ATT9 criticised for prioritising the free in the Member State and that received 0659/20101027ATT90659EN.pdf) calls movement of goods, services, people, by the applicant, are not covered for general practice to be recognised as a and capital above the imperative of by the diploma or other evidence of specialty across Europe, quality criteria safety of patients, and the 2005 directive formal qualifications possessed by the bmj.com archive on training to be introduced rather than is much more balanced. However, it applicant.” Again, anyone working in ЖЖLocal government will a simple time requirement, standards to is the provisions of this directive that general practice within the NHS requires review doctor struck off in UK, be set for continuing medical education apparently allowed the events that led detailed knowledge of the working of the German medical association in general practice, and the language to the negligent killing of David Gray to healthcare system, and this is certainly says requirements for migrant doctors to be unfold. The problems seem to be, firstly, part of the education and training (BMJ 2010;341:c4653) much more clearly defined. ЖЖLocum GP from Germany is that its provisions have not been used required in the United Kingdom. Only when these are achieved will the struck off medical register maximally within the NHS, perhaps Finally, under Title IV, Article 53, the (BMJ 2010;340:c3326) lessons of the stories of David Gray and because no one acted on the changes; directive states: “Persons benefiting ЖЖPatient died after out Daniel Ubani have been learnt. and, secondly, that general practice from the recognition of professional of hours care firm ignored Iona Heath is a general practitioner, is inappropriately handled within the qualifications shall have a knowledge doctor’s warnings London [email protected] directive. of languages necessary for practising (BMJ 2010;340:c3869) Cite this as: BMJ 2010;341:c6814

1194 BMJ | 4 DECEMBER 2010 | VOLUME 341 OBSERVATIONS

ETHICS MAN Daniel K Sokol Of interviews and examination machines Incessant assessment at medical school risks the loss of the skills of reflection, deliberation, and communication among tomorrow’s doctors I was once paid a neat little sum to give sound communication skills characterise Medical students today are a lecture. It was no keynote address to a the good doctor, alongside a firm grasp accustomed to multiple choice distinguished audience in the Caribbean of medicine and sound clinical skills. The intellectual questions, short answers, and bullet but a talk to 200 or so school leavers Doctors in 2010 differ in many ways from points. There is little scope for originality. who were preparing for medical school their counterparts in 1910, but these well from which Examiners are often not permitted to interviews. Why an ethicist? Because it qualities remain as relevant as ever. In the “medical students mark down for consistently poor spelling is not unusual for 20% of an admissions West the views of patients and relatives draw their views or ungrammatical constructions. In

interview to be about ethics. A good bear more weight today than they did and beliefs on the some medical schools the old fashioned answer displays maturity and nimbleness a century ago, ethically and legally. In art and science of essay has virtually vanished, deemed

of thought and lifts the candidate above our large, multicultural cities the views medicine is getting too subjective by educationists. the rest. A poor one can signal the end of are more diverse than in 1910, with a dangerously Although much emphasis is put on oral the road or, at best, an uphill struggle for broader range of beliefs about life, death, communication skills, written skills are shallow.“ At this the rest of the interview. Most candidates health, and illness. Crucially patients now rate the cultivated overlooked, even though doctors have make an acceptable but unimpressive have a voice, and doctors must know to write on a regular basis. Marking doctor will soon be effort, usually far too one sided. how to listen to, evaluate, and respond to hundreds of exam scripts is a soul The ethics questions at admissions the views of patients, relatives, and even a thing of the past sapping experience, but for an examiner interview tend to be the old chestnuts. Do colleagues. with an ounce of respect for language it you think people should have the right to The skills of reflection, deliberation, can be exasperating. When the students die? Should we allow people to sell their and communication must be assessed eventually qualify as doctors they are organs? Should parents be allowed to at interview and instilled into the under pressure to publish. It is no surprise choose the sex of their baby? Generally it medical student, because they form that many find writing articles taxing. I is not so much the candidate’s position part of the skill set of the well rounded wonder whether long serving editors of on an issue that matters as how he or she doctor. There is, however, another medical journals have seen a decline in articulates and justifies that position. reason why these skills must be taught: the standard of English in submissions An answer suggesting that the issue medical schools are still universities, over the past few decades. is straightforward will not impress: and one of the fundamental purposes In 1925 the US reformer of medical “Definitely. Parents should be able to of a university is to teach students to education Abraham Flexner wrote that choose the sex of their baby.” “Why?” think. Although pathology, anatomy, “scientific medicine in America—young, “Because it’s their choice, isn’t it?” In physiology, and other scientific vigorous, and positivistic—is today sadly my experience about 50% of candidates disciplines are tremendously important, deficient in cultural and philosophic adopt this black and white approach. a medical degree should be more than background.” Eighty five years on the Good candidates will tease out the learning about clinical medicine. As deficiency is greater still. Students complexity of the issue, providing the the poet Saint-John Perse wrote, “C’est and the new generation of doctors, most compelling reasons for various de l’homme qu’il s’agit” (roughly, “The the vast majority of whom are bright positions and explaining why they prefer subject matter is man (humanity)”). and talented, are let down by a system one position over others. The following has been said before of medical education so obsessed These questions inject the fear of God but is worth repeating: there are too with concrete, measurable outcomes into some students because they are many assessments in medical school; that it transforms many of them into difficult to prepare for. Therein lies their too much learning by rote, not enough semiliterate examination machines. value. Candidates are often so rehearsed thinking. Every few weeks students sit The intellectual well from which medical that without such questions the panel is yet another exam. Although I despair students draw their views and beliefs on none the wiser at the end of the interview. at students asking, “Will this be in the art and science of medicine is getting Still, it is possible to practise answering the exam?” they are not to blame for dangerously shallow. At this rate the treacherous moral questions. You need, becoming exam machines. They are cultivated doctor will soon be a thing of most of all, a willingness to see the merely playing the game. Occasional the past. various facets of the question and the assessment may drive learning, but I thank Henry Mance, Philip Sedgwick, Ronald ability to argue a position and, if asked, incessant assessment dulls the mind, Sokol, Catherine Quarini, Anna Smajdor, and Zuzana Deans for comments on an earlier draft. the opposite position. suppresses curiosity, and stifles Daniel K Sokol is honorary senior What has this got to do with being creativity. Students have little enough lecturer in medical ethics, Imperial a good doctor? Everything. Clarity of time to read, study, and explore “for bmj.com archive College London thought, awareness of the point of view of pleasure” without the Damoclean sword All of Daniel K Sokol’s [email protected] others (even if you disagree with it), and of assessment dangling overhead. columns are available online Cite this as: BMJ 2010;341:c6899

BMJ | 4 DECEMBER 2010 | VOLUME 341 1195 OBSERVATIONS

MEDICINE AND THE MEDIA What next for public understanding of research? It’s a given that researchers must explain their work to taxpayers, writes Geoff Watts, 25 years after a Royal Society report recommended this. Taking the principle further, however, is controversial

“Don’t write for the New Scientist before you Also at the seminar was a past executive get your fellowship of the Royal Society. secretary of the British Science Association, If you do you won’t get it at all.” In an age Peter Briggs. As the man who ran CoPUS of near incontinent communication about in its early days he was well placed to anything and everything it’s difficult to recall know how often it had attracted criticism. that this antiquated piece of advice to junior But some of its innovations continued scientists once had foundation. It reflected a and thrived. He mentioned the fellowship view, widely held in the scientific and medical scheme through which, every year, a dozen establishment, that talking to the media was scientists get the chance to spend a few not the thing to do. Discourse on such matters weeks working in print or broadcasting was best between professionals. One of the and then—so it’s hoped—go back to their developments that helped sweep away this laboratories and spread the word that fusty, inward looking attitude was the Bodmer dealing with the media can be a rewarding report of 1985. and even pleasurable experience. The subject of a 25th anniversary seminar The final speaker, Mark Dyball of the held at the London School of Economics People, Science, and Policy consultancy last week, the geneticist Walter Bodmer’s group, chose a handful of quotations influential report on the public understanding on science and society from the Bodmer of science was commissioned by the Royal Walter Bodmer: influential report report, put them beside others from more Society (http://royalsociety.org/Public- recent documents, and then challenged his Understanding-of-Science/). Its core message along with the much heavier pressure applied audience to identify which were which. The was to researchers: that they have what by the Bodmer report and other calls for task was not easy; so how much had really amounts to a duty to communicate with change, the earth moved. The trickle of press changed, he wondered? His own view was the public and to the Royal Society itself, information has since become a deluge. that change had occurred, but he cautioned which should, said Bodmer, encourage and Speaking at the LSE seminar, the former against exaggeration. facilitate this. Hence was born the faintly Guardian journalist Tim Radford reflected on The concept of public understanding Orwellian sounding Committee for the Public the quite extraordinary public ignorance about began to fall from grace when critics pointed Understanding of Science (CoPUS). science that he encountered when, long ago, out that dispensing pearls of scientific insight For journalists working in the pre-Bodmer he made his abrupt career change from the arts to a grateful public was not enough. Science era, circumstances were vastly different from pages to the science beat. Quoting the title of is a social enterprise, much of it funded by those of today. I was part of a journalistic a paper chosen at random from Nature he also the state. Scientists, besides telling everyone delegation that went to remarked that even when what they’re about, should also be listening lobby the then secretary What researchers plan to do researchers had begun to the public. Hence the newer notions of of the Medical Research next should also be subject to to appreciate the need dialogue and public engagement in science— Council. No names public scrutiny, discussion, and— to communicate they of two way communication. and no date—I’ve no still a sticking point for many were hampered by the An even more recent development is intention of betraying scientists—sanction inherent complexities of “upstream engagement.” This catchy little confidences—but we their subject and of the term, which has yet to make much impact met him in a club in Pall Mall and explained language used to discuss it. outside science policy circles, questions that, although the MRC funded a great deal of The sociologist Hilary Rose reminded her the assumption that attention should be excellent research, very little effort was made audience that limited efforts at fostering a focused only on what scientists are doing to let anyone know about it. Could this be wider understanding of science had begun now. The upstream bit is to suggest that what rectified? The man was charming and obliging long before Bodmer. Nineteenth century researchers plan to do next should also be and said that he thought that something could engineers and scientists, for example, would subject to public scrutiny, discussion, and— indeed be done. But he was also puzzled: why sometimes share their knowledge of the still a sticking point for many scientists— did we want to know about this research? natural world in public lectures, often to a sanction. Public engagement is now firmly on This jaw dropping question took us all by predominantly working class audience. The the agenda; its upstream extension is still a surprise. Was he really unaware of the public’s British Association for the Advancement of work in progress. interest in what scientists and doctors got up Science (forerunner of today’s British Science Geoff Watts is a freelance journalist, London to in their laboratories? Apparently yes. What Association) took up the cause, serving the [email protected] effect our little delegation had I can’t say. But, needs of a rather different audience. Cite this as: BMJ 2010;341:c6862

1196 BMJ | 4 DECEMBER 2010 | VOLUME 341 OBSERVATIONS

Danny Alexander, FROM BMJ.COM George Osborne, and Vince Cable Five a day and two a night are all on the Demos advisory Kirsten Patrick is delighted about a new initiative council to enthuse youngsters to exercise. “Yesterday my six year old son demonstrated to me one of the daily workouts that he and his classmates do between lessons at school,” she writes. “They use a programme called five a day fitness. The class LOBBY WATCH Jane Cassidy follows five minutes of dance or fitness moves demonstrated by an ‘instructor’ projected up on to the white board via a laptop. My son’s favourite is ‘workout,’ a pretty complex sequence of dance Demos moves, crossover steps, twirls, star jumps, and wiggles. Almost as good, he says, is ‘disco.’ There’s Who are they? focusing on issues involving family and society; also ‘robot,’ ‘hula,’ and ‘march,’ and a trio of chill However much it tries to move on, Demos will violence and extremism; the public interest; out options, ‘stretch,’ ‘balance,’ and ‘breathe’ . . . be forever linked to the Labour boom years. political economy; public finance; and political The kids just do it in their school clothes on the It was credited with helping to shape the ideas on both left and right. Its mission, it says, carpet in the classroom. No need for changing, concepts of New Labour and Cool Britannia, is to challenge the traditional “ivory tower” no need for special props; just gravity and their and Tony Blair was at its launch. It was model of policy making by giving a voice to bodies. They’re being reminded daily that they have founded by the academic Geoff Mulgan and people and communities and involving them bodies appended to their brains. This can only be a the Marxism Today editor Martin Jacques in closely in its research. good thing.” 1993. Mulgan got a job at Number 10 when Labour swept to power in 1997. What does the government think of them? Julian Sheather thinks that a glass of wine, or two, The former Labour MP and economist Kitty is conducive to reflecting about life, and finds himself confronted with an interesting dilemma: What do they do? Ussher is now the director of Demos, and the “Over lunch recently a friend asked me what I Recently Demos has been involved in two former health secretary Alan Milburn and thought were the moral harms of addiction. What high profile projects examining death Labour MP Jon Cruddas are advisers. However, was it about addiction, rather than the more regular related issues. On 30 November Demos Demos has moved to forge links with the satisfaction of ordinary appetites, that attracted a headquarters in London hosted the launch of coalition government. Its last director, Richard particularly moral unease?” he asks. “There is of the Commission on Assisted Dying, chaired by Reeves, left to become Nick Clegg’s special course an extensive literature on the harms of the the former lord chancellor Charles Falconer (BMJ adviser just after the last election. substances most liable to abuse. Physical harms; 2010;341:c6622). The commission is calling for The coalition government’s business harms to health. The social costs are also high. evidence to consider whether a system should secretary, Vince Cable, and his fellow Liberal Direct costs to the health service, less definable exist to allow people to be assisted to die and Democrat MPs David Laws and the chief harms to the social fabric. No dispute here, on the whether any change in the law was needed. The secretary to the Treasury, Danny Alexander, are whole, but not quite what we had in mind. To take consultation will run until September 2011, and all on the think tank’s advisory council. Joining only my life and the lives of those close to me, what a report will follow in October. them are the Tories George Osborne, chancellor is the nature of that fear, that bogey, that haunts us The campaign group Dignity in Dying helped of the exchequer, and David Willetts, the steady mid-life topers? Numberless, reader, are the set up the commission, with funding from minister for universities and science. times I have heard a friend, wine in hand, wonder Bernard Lewis, the founder of the River Island Julian le Grand, chairman of Health England whether his or her glass or two a night amounts to addiction. So what, I wonder, is going on?” fashion chain, and the author Terry Pratchett. and a social policy professor at the London Demos is providing administrative and research School of Economics, is also an adviser. Richard Smith hopes that next year’s UN meeting support. The commission will act entirely will shine a spotlight on chronic disease, a topic independently from the support organisations How influential are they? hitherto shrouded in obscurity. “It might surprise and financial backers. Its conclusions will be The early association of Demos with New Labour you that chronic disease is such a major threat formed on the evidence received, says the think is likely to remain in the minds of the present to the global economy,” he writes. “One of the tank. government, limiting its influence among some big problems for ‘those of us concerned about Dying for Change, a Demos pamphlet ministers. chronic disease’ is what to call it. What we mean funded by Help the Hospices, came out in is ‘cardiovascular disease, diabetes, chronic mid-November (BMJ 2010;341:c6508). It says Where do they get their money from? obstructive pulmonary disease, and the common that few people get their wish to die at home Funding is not accepted from political parties. cancers’—not the many other diseases that doctors rather than in hospital and estimates that an Backers are diverse, ranging from big business know to be chronic, including not only neurological, investment of £500m (€590m; $800m) a year names, including Pfizer, to charities such as the rheumatological, and psychiatric conditions but would fund community services, allowing 50% Multiple Sclerosis Society. also, of course, AIDS and tuberculosis. We’ve of people to die at (or in places close to) home. adopted the narrow definition because these problems account for 60% of global deaths and are Jane Cassidy is a freelance journalist largely caused by the same risk factors—tobacco, What agenda do they have? [email protected] poor diet, physical inactivity, and alcohol.” Demos seeks to influence policy making by Cite this as: BMJ 2010;341:c6810 • www.bmj.com/blogs

BMJ | 4 DECEMBER 2010 | VOLUME 341 1197