THE Telegraph ran an alarming article last week on the General Medical Council’s proposed update to the ‘Good Medical Practice’ guidelines. As TCW has reported, it suggested that doctors who have been questioning the government’s pandemic policy might have cause for concern.
Searching for the changes from the 2013 guidance, I was struck that the first seven bullet points are the same as before. Had they been followed throughout the pandemic, they might have provided much-needed patient-focused care:
‘As a medical professional I will:
- Make the care of patients my first concern.
- Work effectively with colleagues in ways that best serve the interests of patients.
- Act promptly if I think the safety, dignity or comfort of patients or colleagues are being compromised.
- Treat patients as individuals and respect their dignity and privacy.
- Listen to, support and work in partnership with patients, to help them to make informed decisions about their care.
- Provide a good standard of practice and care, and be honest and open when things go wrong.
- Work within my competence and keep my knowledge and skills up to date.’
The tragedy was that throughout this period, medical professionals were (or allowed themselves to be) completely sidelined in decision-making for their patients, and abandoned patient-centred care in favour of government guidelines. Yes, they were busy, but I have been shocked at the number of doctors I have spoken to who gave little thought to the potential societal harms of lockdowns or masks and were completely unaware of whether these measures had any real impact on spread of SARS-CoV-2. Equally concerning was their lack of interest in readily available medicines which could perhaps have helped their patients, and added to this their unconcern over vaccine safety. The disturbing truth is that under Covid policy the unique doctor-patient relationship has been pushed to one side.
This leads to the question of how the ‘good’ items retained in the new guidance will be interpreted? Taking them in turn we come first to:
‘Domain 1: Working with colleagues
- You should take action, or support others to take action, if you witness or are made aware of bullying, harassment, or unfair discrimination.’
Though the GMC are most likely thinking of racism and sexism in the workplace, the test is whether this paragraph will cover the harassment of those doctors who declined vaccination, or the discrimination by NHS trusts which disallowed any mask exemptions.
‘To help keep patients safe you must:
- contribute to adverse event recognition
- report suspected adverse drug reactions.’
Sadly, we know that didn’t happen. Were doctors reminded by the GMC of the importance of completing Yellow Cards on any new drug? Were they organising prospective studies of post-vaccine myocarditis in children? There is no evidence of either.
‘Domain 2: Working with patients
- You must listen to patients, take account of their views, and respond honestly and openly to their questions.
- You must share clear, accurate and up-to-date information, based on the best available evidence, about the potential benefits and risks of harm of available options, including the option to take no action.
- You must not unreasonably deny a patient access to treatment or care that meets their needs.’
Despite this guideline there have been many reports of GPs over the last year refusing vaccine exemptions despite severe reactions in their patients to a first dose, yet surely this was just such a case for considering ‘the option to take no action’.
I personally was told by my GP that he was not allowed to prescribe me a budesonide inhaler for early treatment of Covid-19 as it was not on ‘the NHS list’, but he was happy to give me a private prescription! Yet there is a published Oxford trial showing benefit. And despite advocacy by a number of individual doctors and scientists, has a public health department anywhere run a campaign to encourage Vitamin D usage? Not to my knowledge.
‘Domain 4: Maintaining trust
When communicating publicly as a medical professional you must:
a. be honest and trustworthy
b. make clear the limits of your knowledge
c. make reasonable checks to make sure any information you give is not misleading
d. declare any conflicts of interest
e. maintain patient confidentiality.
This applies to all forms of written, spoken and digital communication.’
Changed from the earlier 2013 guidelines is the use of the word ‘misleading’ in point (c) – the previous version said, ‘make reasonable checks to make sure any information you give is accurate.’
This is the section that has created most anxiety: making ‘reasonable checks’ that the information you give is not misleading will be open to interpretation, particularly in this world of claimed misinformation and disinformation where Twitter, Facebook and YouTube act as censors. More worryingly, the GMC actions over the past year already suggest they may construe anything which runs counter to government advice as ‘misleading’.
The addition of point (d) is therefore to be welcomed.
‘Manage conflicts of interest
a. Conflicts of interest may arise in a range of situations. They are not confined to financial interests and may also include other personal or professional interests. You must not allow any interests you have to affect, or be seen to affect, the way you propose, provide or prescribe treatments, refer patients, or commission services.
b. If you are faced with a conflict of interest, you must be open about it, declare it formally, and be prepared to exclude yourself from decision making.’
It certainly would be interesting to see how far the vaccine rollout would have proceeded if members of Sage and JCVI with any links to the pharmaceutical industry had been obliged to exclude themselves from decision making.
It seems happy to ignore the ethical question of rewarding GPs per patient they vaccinate.
On the surface, the proposed changes appear minor and not unreasonable. But, as ever, the proof of the pudding is in the eating. How will the GMC actually apply its own guidelines? Will it leave Twitter and fact-checkers to decide what is misleading? What will count as ‘misleading’ – to tweet links to government data? To question government policy?
Cases like that of Dr Sam White leave a large question mark over the GMC’s approach. I cannot stress sufficiently that GMC must not over-reach itself, to the detriment of free speech and open scientific debate.