A cautionary tale for potentially dishonest doctors
BMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1298 (Published 23 May 2022) Cite this as: BMJ 2022;377:o1298
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Dear Editor
It is with great disappointment that I read Dr. Sokol’s article.
The missing context is the unfortunate case of Dr. Manjula Arora, the victim of a 2.5 year ordeal where a slew of accusations were found to be unproven. The remaining accusation, that she mischaracterised the phrase “interest is noted” as “promised”, was not only found proven but resulted in a one month suspension. A suspension that seems to have provoked a near universal outcry from the British medical profession. This is merely the latest, though most egregious, case in a long line of examples of racial discrimination by the GMC, including Omer Karim where this was found proved by an employment tribunal. A finding, it should be noted, that the erstwhile regulator continues to deny, showing such lack of insight that a doctor would expect to be struck off.
In truth, it appears that the best way to avoid persecution by the GMC is to be white. In that case all allowances will be made and excuses accepted. If you are not white then you had best hope you are lucky or have the great fortune to migrate to a country with a less racist regulator. Small wonder so many within the BAME doctor community believe the GMC to be not fit for purpose.
Competing interests: No competing interests
Dear Editor
Sokol’s opinion piece (1) sounds so baffling that I resorted to the responses for clarification. The response from Victoria Moore (2) and her link to the case notes were intriguing.
As discussed previously (3) it seems this may be another case where the unwritten rule of the GMC to refer any allegation of dishonesty to MPTS has been used.
Reading the MPTS findings (4) it is clear Dr A had embarrassed the managers of the service by pointing out with her actions that the service was not managing and that another physician on shift were not pulling their weight resulting in an understaffed service. A referral to the GMC seems utterly disproportionate for a workplace dispute, and it seems baffling the GMC entertains a workplace dispute. However, the false allegation that Dr A had been dishonest about not having memorised an operating procedure, padded out with another allegation that she had been dishonest in interpreting the meaning of an email led to the automatic acceptance of the case by the GMC, and automatic referral to MPTS (5).
Presumably MPTS now had to make a finding to justify the referral to the GMC and not expose the flawed referral process. It is not clarified what other roles the former CEO of the out of hours provider held, or whether these other positions had influenced the GMC’s decision to accept and refer this case to MPTS, or whether the MPTS had taken account of the previous history that led to this referral for dishonesty.
It is perplexing to think anyone would be dishonest to obtain a work laptop, the purpose of these devices is to do more work, who in their right mind would be so desperate they would be dishonest about obtaining one?
Just as baffling as the case seems, the sentencing followed the practice of lacking insight (presenting mitigation or denying the charges) and the medieval practice of pillory as “a deterrent” (the sole purpose for the punishment as no patients were harmed from Dr Arora receiving a work laptop).
To the public the period of one month may seem short, but for the doctor involved it means automatic removal from the performers list, readmission of this is governed by NHS England (often the organisation that made the referral) and PCSE. Readmittance to the performers list is therefore likely to take at least 3 months. Conditions for readmission to the performers list can be added by NHS England or PCSE as further punishment. Additionally, suspension of membership of the defence organisation is likely to follow which, prior to the 2019 crown indemnity for GPs, would mean the doctor would not be able to ever work again. For GP contractors it means automatic termination of the practice contract. One month suspension is not one month, this punishment lasts months if not years.
(1) Sokol, D. A cautionary tale for potentially dishonest doctors BMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1298
(2) Moore, V. rapid response. https://www.bmj.com/content/377/bmj.o1298/rr-0
(3) Callahan H. Closing the feedback loop on GMC referrals. https://www.bmj.com/content/373/bmj.n1269/rr-2
(4) https://www.mpts-uk.org/-/media/mpts-rod-files/mrs-manjula-arora-12-may-...
(5) GB Professionalism & Keeping out of Trouble, General Medical Council. YouTube 21 November 2019 (26 minute mark: "this will always lead to some kind of tribunal")
Competing interests: No competing interests
Dear Editor,
Daniel Sokol has started an interesting debate, and one that is long overdue. He has taken a view that some may consider extreme and manichean. Why exactly are doctors held to absolute standards of behaviour that other professional groups are not? Why is it more important that a person trusts their doctor more than their lawyers, journalists or politicians?
I write this on a day when our own Prime Minister has re-written the ministerial code, removing all references to honesty, integrity, transparency and accountability (1).
Whilst I appreciate that trust is an integral part of the doctor-patient relationship, Sokol uses terminology that is religious: he describes a 'spectrum of sins', talks of how 'society’s faith in doctors will collapse' and of 'the sanctity of the doctor-patient relationship'. Perhaps these analogies were once valid, but are they now?
I think we need to reconsider and redefine what 'bringing the profession into disrepute' actually means, in order to set reasonable and achievable human standards of behaviour for our profession and stop the GMC sliding into absurdity and disrepute itself. Perhaps behaviour outside of our professional role (barring egregious examples) should no longer be subject to regulatory oversight?
(1) https://www.theguardian.com/politics/2022/may/27/boris-johnson-changes-m...
Competing interests: No competing interests
Dear Editor
I anticipate Dr Arora will lodge an appeal, and as her defence she can insist she is judged according to the "Johnson Dishonesty Standards", as commonly adopted by our Prime Minister. Her acquittal is bound to follow.
Competing interests: No competing interests
Dear Editor,
Dr. Qureshi`s rapid response [1] to Daniel Sokol [2] brought to mind a distant memory of when I lied during a medical (dental) encounter. It, too, involves a bereavement: that of my mother, when in my early `teens. When the treatment (using a pedal driven drill at that time!) was finished, the kindly dentist asked me if I was now going back to school. Instantaneously, I realised I couldn`t tell him the truth, which was that, no, I would be going to my mother`s funeral later that morning. Instantly, I also knew that if I did tell the truth, I might well lose my composure and burst into tears. In retrospect, I can see that it was therefore in both our interests that I lied.
Each and every encounter between health professional and patient is different. Many complex interacting factors come into play which will govern each person`s behaviour, on the day, in this professional partnership. [3] Both Dr. Qureshi`s and my anecdote involves a bereavement and an empathetic concluding exchange: in one case from patient to doctor, in the other from dentist to patient. This suggests to me that both parties in these consultative encounters have a responsibility to behave in a professional manner. But, on the other hand, should we always deny ourselves a human exchange? As fellow human beings, the cold clinical mode of communication from start to finish, not wrapped fore and aft by more personal words, would seem to me to be a miserable way to engage, one human being with another. [4] For others to censure these lies is too destructive of caring partnerships.
Refs:
[1] Zeshan Qureshi. The nuance of dishonesty. (Rapid response to [2]) https://www.bmj.com/content/377/bmj.o1298/rr-5
[2] Daniel Sokol. A cautionary tale for potentially dishonest doctors. 377:doi 10.1136/bmj.o1298
[3] Smith R. Patients “taking back control.” BMJ 2022;377:o1204 https://www.bmj.com/content/377/bmj.o1204
[4] Michael Modell. The Death of Humane Medicine. BMJ 1994;309:1668 Medicine and Books. (Review of Petr Skrabanek`s The Death of Humane Medicine.)
Competing interests: No competing interests
Dear Editor,
The General Medical Council sets out standards of behaviour expected from doctors. [1] Item 65 states: `You must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession`. Honesty is the basis of trust in a relationship. An honest person tells the truth. As cited by Sokol, the GMC seeks honesty not only in an individual doctor`s relationship with patients, but also requires that a doctor behaves honestly in order to maintain the public`s trust in the profession [2]. An `off duty` doctor is still `a doctor`: surely it follows that the doctor should uphold a high standard of behaviour at all times.
But we have to acknowledge, since we are all human like Adam in the story, that scrupulous honesty at all times and in all situations can be a difficult goal. But that shouldn`t stop us from striving. And also, perhaps, from being merciful in our judgement concerning doctors` standard of honesty when caught in an off-moment? `There, but for the grace of God go I` .
But, where to draw the line? Currently, we can see a sorry example of how failure to tell the truth by people holding high office can lead to loss of reputation both of the holder and their institution. Slipping standards, lowering of values, turning a blind eye must be resisted if doctors are to remain top of the list of noble professions.[3]
Refs:
[1] Daniel Sokol. A cautionary tale for potentially dishonest doctors. BMJ 2022;377:o1298
[2] GMC. Good medical practice. Domain 4. Maintaining Trust. Act with honesty and integrity. 65. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/goo...
[3] Buffett J. Top Most Respected Jobs 2022. zety.com 11 Feb 2022
Competing interests: No competing interests
Dear Editor.
I would like to thank Daniel Sokol for starting this debate, and their reflections from their experience as a barrister and a medical ethicist. It's a helpful addition to the current discussion of Good Medical Practice whereby principles held for years are open to being challenged. I speak from my own experience having worked in the NHS for a decade and as a second-generation Pakistani immigrant.
I would like to add my own reflections on how we frame dishonesty: as an absolute duty or a relative one. You may be surprised to note how often a degree of dishonesty can be considered an acceptable cost to maintaining other duties as a doctor. Let me illustrate this with an example from my own clinical experience.
Whilst I was working on a neonatal intensive care unit, my dad passed away. He had a slow decline. I was travelling to see him in another city after 12 hour shifts. I was distraught at the loss I suffered, leading to significant psychological distress. Yet I carried on working as I was still able to competently perform my job.
After I'd assessed a baby, a parent saw that I didn’t seem as upbeat as other members of staff. They asked me how I was doing. I said I was OK, and thanked them for asking. I wasn't OK, and was going through the hardest psychological challenge of my life. However, the patient was not my friend or my therapist. I was there to take on a professional role. If I had, as your argument suggests, divulged the truth, the whole truth and nothing but the truth, I would have placed an unreasonable burden on the family, and undermined public faith in the profession.
This is not just my opinion. I have had feedback from bereaved parents whose doctors have shared their own psychological distress over the child's death. Parents have expressed upset that their opportunity to grieve was taken away and that they were being forced to comfort a healthcare professional, who by being honest when asked how they are doing, hadn't maintained professionalism. Honesty here compromised public faith in the profession.
Honesty is important, but a relative not an absolute duty. Additionally, the perspectives of the public on honesty are more nuanced than your article suggests.
Competing interests: No competing interests
Dear Editor
After taking particular care to explain the nature of a cardiovascular risk to a patient during my clinic this morning, I decided to arrange a repeat lipid blood test. On the phlebotomy request form I wrote ‘for annual monitoring’ despite it only being 51 weeks since the previous set of results. After espousing the benefits of a healthy diet, my own lunch consisted of a chocolate bar eaten hurriedly at my desk. I must remember to confess to my appraiser that the chocolate wasn’t ethically sourced when reviewing my PDP on sustainable healthcare.
At the end of another busy day, I arrived home to see my 5 year old daughter just before she was about to go to bed. She showed me a picture she’d drawn at school and I told her it was the most beautiful drawing I’d ever seen. She seemed happy but the bedtime routine was interrupted by a telephone call. Answering the unknown number, someone asked me whether I’d ever been involved in any accidents. I replied that I hadn’t, even though I remembered falling off my skateboard aged 7.
Then, feeling too exhausted to go to the gym, I ended up breaking a promise to my mother to exercise three times a week. As the evening progressed and I sat down for dinner, I told my partner that the meal they’d made was once again absolutely lovely. This sparked a memory from a few months ago when I was at a restaurant. The waiter asked me if everything was ok with the food. I politely nodded and replied it was great, despite it being a bit spicy for my liking. After a period of reflection, I still decided to leave a tip.
Lying in bed and unable to sleep with the potential consequences of my actions earlier in the day, I made the cardinal error of checking my work email. I was thankful there were no notifications of any pending performance investigations and that I’d survived yet another day of honesty and integrity without bringing the profession into disrepute.
Competing interests: Blogger at http://unexaminedmedicine.org
Dear Editor,
Dr Sokol provides an interesting discussion of the importance of honesty in the life of a doctor, based on a wealth of professional experience. He discusses the importance of honesty in the doctor-patient relationship, although previous articles have discussed rare occasions where this may be breached, both for the sake of the patient and also for public safety. This honesty should extend to other settings where professional expertise is offered.
Although claiming the title of “dentist”, as Adam initially does, indeed breaches the law, he might be unfortunate to be prosecuted for this, given that he was not offering dental care but rather excusing himself from providing medical treatment. His apparent clarification of being a trainee dentist may also excuse him, as the law only relates to being a registered dentist.
The full content of Good Medical Practice paragraph 26 states "You must offer help if emergencies arise in clinical settings or in the community, taking account of your own safety, your competence and the availability of other options for care.” The viewer of this TV series may feel some sympathy for the protagonist, who indeed fulfilled his duty in this regard by identifying both his fatigue (and potential lack of competence), and also another option for care in the form of a GP and the likely proximity of ambulance services in central London.
In addition, recent years have demonstrated the divergence that our political leaders have had from anything resembling the honesty that the GMC expects from doctors. The list includes but is in no way limited to allegations relating to lockdown parties, COVID fraud, PPE fraud, partially documented newspaper payouts, peerage appointments, leaking classified information to foreign powers (twice), incentives for approval for housing developments, the progress or otherwise of international trade agreements, traffic offences, paedophilia and sexual assault.
Of the examples of victims of dishonesty by doctors that Dr Sokol discusses, the insurance industry has been investigated by the FCA for deliberate delay in payouts related to COVID, and there have also had well-documented concerns regarding both the police and Facebook.
The question therefore might arise as to whether doctors should be held to some higher standard in both their professional and social lives, or whether raising concerns to the GMC about matters that have no professional bearing could be regarded as vexatious. Finally, it is worth considering whether the phrase ‘bringing the profession in to disrepute’ is too nebulous and unquantifiable to be used in the matter of considering someone’s continued career and mental health.
Competing interests: No competing interests
Re: A cautionary tale for potentially dishonest doctors
Dear Editor
The publicity uses the doctor's request for a lap top as the hook on which to hang her. Dr A should not have had to beg for the equipment necessary to do her work. If the GMC document had been referred to by journalists it would probably have been less damaging to her as it is obvious there are/were serious problems with the service.
The GMC begins by stating Dr A came to the UK in 1993 or 1994. They had enough information to state her arrival accurately by date. This was also repeated in consideration of her character.
The GMC (oddly) states that they must acertain (subjectively) the state of her knowledge or belief as to the facts....it is not a rquirement that the belief must be reasonable.
...must determine whether the conduct was dishonest by the (objective) standards of decent ordinary people. There is no requirement that the doctor must appreciate what she has done was dishonest.
The Doctor seems to have had different 'understandings' to others involved rather than 'beliefs'.
Competing interests: No competing interests