Poor clinical performance may be the medical issue of greatest concern to the general public and the press, but most doctors realise that clinical performance and welfare of patients often come second to the interests of institutions and loyalty to colleagues.
Our major medical institutions have placed their financial interests before the welfare of patients
The public might reasonably expect that a clinician will possess good or at least adequate clinical skills. Yet within our system those attributes are valued least. Distinction awards have traditionally gone to those who have reduced their clinical responsibilities to find time for speaking at conferences, committee work, and medical politics. Increasingly, universities appoint to posts that are nominally for academic clinicians, doctors who moved soon after qualifying into basic science, commonly molecular biology. The main requirements of the universities when appointing a professor in a clinical specialty are not clinical skills, a record of clinical research, or teaching ability but whether the applicants can attract large research grants and publish in journals with a high citations rating.
Clinical research does not receive high citation ratings. Many of the basic scientists appointed in recent years to replace retiring clinical academics have been awarded the honorary NHS consultant contract that their predecessor held. When making these appointments the universities see no detriment to the training of medical students by reducing the numbers of clinical trainers. More worrying for patients is the fact that the medical schools are unconcerned by the prospect of appointing a molecular biologist to a post with clinical responsibilities.
Because they hold an honorary NHS consultant contract those appointed have been eligible to appear on the specialist register, though they had little or, in some cases, no clinical experience in appropriate training posts at registrar (or senior registrar) level. In many cases their clinical experience and training would normally have been inadequate for them to be eligible for accreditation. In many cases they could not have been appointed to a substantive NHS post. Many recent university appointees with honorary NHS contracts undertake the clinical duties of the predecessor, but they are often considered by colleagues and juniors to have inadequate training.
Thus, for example, there is a professor of medicine in Britain who is responsible for acute medical emergency admissions but whose most senior clinical training post was at senior house officer grade. We therefore have a paradox—medical centres of excellence headed by doctors with inadequate clinical training. The patients of many of these academics would be in a dangerous position if it were not the case that the junior members of the teams have rather more clinical experience than their bosses. This raises another difficulty. Many of these professors have specialist registrars attached to them for training. How can they provide that clinical training when the service provision relies on the fact that the trainee is better trained than the trainer?
There can be no doubt that if the consultant is inadequately trained in a consultant led service patients are placed at risk. The implications for the future are dire. Junior doctors and medical students receive the message that clinical training and competence is not valued by the profession and that it is not an important requirement for advancement. Indeed, time and effort spent in acquiring such skills is wasted. How can we expect to improve clinical services?
This situation exists only because our major medical institutions have placed their financial interests before the welfare of patients. Universities and medical schools and their associated NHS hospitals, the medical royal colleges, and the General Medical Council have been prepared to place on the specialist register inadequately trained doctors. While academics and medical school representatives are so disproportionately represented on the royal colleges and the General Medical Council this corrupt situation will remain. Full time clinicians who might end this iniquity have the least time and inclination to seek nomination to such committees and, if they stood, are less likely to be appointed than the high profile academics on the ballot papers.
Of course, when it comes to revalidation, the academic lacking clinical skills will have less difficulty obtaining enough continuing medical education points than clinicians working in hard pressed clinical services. The academics attend, indeed they speak at, the meetings that service requirements prevented busy clinicians from attending. When a clinician manages to attend a society meeting, he may hear the clinically incompetent academic advise him how to do his job as a clinician. The frequent absence of the clinically incompetent academic from his base hospital at such meetings may be the best way to improve patient safety.