Heterodoxy and Hegemony Part 1

“Career structure is shackles for the young designed by their elders”.

Our professional freedom is being steadily eroded. Our working lives are increasingly bounded by external constraints. Annual appraisal is enough of a paperwork headache without considering the GMC’s recently unveiled plans for revalidation.

Micromanagement by the Grey Suits from our Trusts reaches new heights (or lows, depending on how you look at it). Regular circulars arrive from said clipboard-wielders, bearing illogical dictats or mandating protracted training courses on hitherto mundane tasks. My wife, recently appointed as a consultant at a Trust not far from my own, had to attend a mandatory one-hour session on hand washing. I jest ye not. What next? Perhaps an enforced course on “Combating ano-olecranon dysagnosia”?

More pertinent to our radiological work, training in a subspecialty or introducing new techniques or modalities to local practice often now require some kind of formal box to have been ticked: attendance on a recognized course; compilation of a logbook of x cases; training at a particular accredited centre of excellence.

In many respects, medicine is merely catching up with the rest of the NHS. The overt bureaucratization of the NHS has been an unstoppable rollercoaster for a time. Doctors rarely say that they can’t do something because they “haven’t been on the course”. However, juniors do now say, “I don’t know that patient, I’m covering the other side of the ward”, so who knows what the future holds?

An oft-repeated maxim is that we should raise professional standards and improve standards of practice. This truism is undeniable - our punters deserve the best quality care we can give. Attempting to raise standards is also a constructive way of dealing with the increasingly fashionable sport of doctor bashing. As a result, tightening control on training, accreditation and re-accreditation of specialists is now the unquestioned predominant method for the powers-that-be to solve the ills within medicine.

This isn’t the whole story though. I would contest that this “tightening control thus protecting patients” motif is being used as a stick to beat us.

Firstly, it seems that the more furious the turf war between specialities, the more hoops the wannabe practitioner has to jump through. For example, being judged competent in defaecating proctography is significantly less hotly contested than sexier techniques like carotid stenting. No one will ask to see your logbook of 300 venograms from the last year whereas ARSAC will want to see your annual reporting figures for PET/CT “to maintain competency”.

Secondly, it tends to cost doctors more than other specialities, or even other professions. The monopoly status of accrediting bodies and perceived richness of doctors allow limitless charges. Witness the spiralling rise in C(C)ST fees, exorbitant GMC fees in addition to the modest annual sum charged by our own dear RCR. These enforced fee hikes are particularly galling, given recent admissions that medical training budgets have been unashamedly raided to bail out NHS debt.

Such perceptions do invite criticism of our medical highers and betters. These gripes mainly circle around protectionism issues: stifling the growth of a modality, Ivory-tower elitism and monopolization of private practice.

However, my major concerns about all this excessive regulation are much more fundamental. My concerns are over the hegemonic assumptions that (i) more structure in training and education is better and (ii) counting numbers of cases is a valid way of assuming competency.

For those unfamiliar with the term, I use “hegemony” to mean “…not only the political and economic control exercised by a dominant class but its success in projecting its own particular way of seeing the world, human and social relationships, so that this is accepted as “common sense” and part of the natural order by those who are in fact subordinated to it”.

This is where heterodoxy enters in. It is the antonym of orthodox, describing someone at variance with established belief; “cynicism with knobs on”. The heterodox do include swivel-eyed conspiracy theorists as well as Trotskyite anarchists. However, I must distance myself from such subversives. I merely believe it is good and healthy to critically reflect on the social hierarchies within our profession.

(read on in Part 2)