Irvine heals the wounds

ABOUT TWO months into the General Medical Council's hearing of the case against the three doctors involved in the Bristol heart surgery disaster, Sir Donald Irvine let slip a remark that earned him a sharp rebuke from the doctors' legal defence team. "We are not dealing with statistics here, we are talking about children," he said.

It was the smallest sign of irritation from the man who, as president of the GMC, carries the mantle of the Doctors' Judge - and the onerous responsibility that goes with it. But it casts a glimmer of light on the personal agenda that has driven him from humble beginnings as a family doctor in Northumberland to the highest medical post in the land.

For Sir Donald, doctoring requires constant self examination to ensure that things are being done right and are understood by the patient. This is not just a personal credo. It is also a habit. Throughout our 90-minute conversation in his central London office, one phrase recurred: "Does that make sense?" he inquired after each carefully measured point.

There is something else unusual in his demeanour. With his immaculately groomed silver hair and half moon spectacles he fits the image of the eminent practitioner dispensing wisdom from on high. But his manner is earnest, rather than patrician. He sits on the edge of his chair, leaning forward for emphasis, the sweat standing on his brow in his effort to put his points across. Friends describe him as a worrier. One can only wonder at how he coped with the pressure of the eight-month Bristol hearing. Some see him as pompous and over-formal, but this is probably nervousness about getting the tone wrong. Friends say he has relaxed under the influence of his second wife, Sally, a planner with the former Greater London Council.

As the first GP to become president of the GMC, his election in 1995 signalled the end of the domination of the council by the consultants and royal medical colleges. It allowed him to apply his passion for getting people to look at what they do, which he had exercised over two decades as a member and chairman of the Royal College of General Practitioners. His view that the GMC has a duty to act wherever there is evidence of a breach of duty has led to accusations of vindictiveness. Critics of the GMC's decision to pursue the case against the Bristol doctors say the three have been made scapegoats for a wider institutional failure. In reply, Sir Donald indicates the list of more than a dozen issues at the end of his judgement on the case - covering standards, training and monitoring of performance.

He said: "The case raised issues of how we handle modern health care. That is why we see this list of points as so important. We looked at three of the players. I absolutely agree with the Government that the wider perspective should be revealed in a public inquiry.

With the possibility, though it is diminishing, of an appeal, he will say little more about the case beyond the fact that it was a tragedy which was harrowing for all concerned. It was a test case which we are unlikely to see again. But a greater tragedy will ensue if we fail to learn the lessons. Bristol was a disaster waiting to happen. The lesson that Sir Donald wants all doctors to learn is that self-regulation has to start with every individual doctor and work up from there. It means a constant process of self-examination, testing one's performance and behaviour and that of colleagues against agreed standards, responding appropriately to patients' needs. This must involve every medical team, every general practice and every hospital.

"The point medicine has got to change is this defensive, protective, inward-looking attitude. There is a huge cultural change to be made in the profession. In medical schools the emphasis has been on acquiring knowledge and skills but behaviour towards patients is just as important."This echoed concerns that run back more than 30 years to his apprenticeship in his father's practice in the mining village of Ashington, Northumberland, in the 1960s.

"My father was very highly respected and it was all built on service and commitment. I worked in a practice where good relations with patients were the bedrock."

He is seized by the idea that we have all, doctors and patients alike, become dazzled by the onward march of science and technology to the point where they are in danger of driving out the traditional values of kindness, listening and caring that people, rightly, expect from medicine: "Patients want doctors who are kind and respectful, up to date and who know what they are doing."

Arrogance is the commonest failing that causes doctors to come before the GMC, he says, but it would be an over-simplification to pretend that arrogance was the root cause of the ills that the Bristol case has exposed. Many doctors do not understand why, when they are doing their best to bring all that science can offer to their patients' care, they are still criticised. Yet the opening up of new sources of information on the Internet, the advance of technology and rising expectations make it imperative that doctors know how to guide and care for their patients.

"There is almost a belief that medicine can do anything. I don't think we have done enough to explain that there are limits to what it can achieve. It is an obligation on doctors to explain as well as listen."