Medical arrogance.

attracted more criticism than usual. Some has been justified. A few doctors have behaved badly; some have been incompetent or rude, libidinous, dishonourable, even dangerous. That it is a small minority that behaves in this way tends to get overlooked: the profession as a whole is discredited. As Shaw wrote: ‘As to the honour and conscience of doctors, they have as much as any other class of men, no more and no less’. There are bad apples among any group of people, professional or not. The term ‘arrogant’ is commonly applied to miscreant doctors, usually inappropriately. The doctor who takes advantage of a female patient is described as arrogant; so is the surgeon who consistently gets bad results; or the doctor who invents patients in order to defraud the NHS; and, much in the news in recent months, the pathologist who removes and stores body parts taken at autopsy. It has become a blanket term to cover every medical peccadillo. Why arrogant? Is it because doctors who do these things are believed to regard themselves as above the law, to feel that their possession of a medical qualification bestows immunity against the normal processes of prosecution? I doubt it. There must be other explanations. One is to do with poor doctor-patient relationships: abrupt, unsympathetic, uncaring attitudes; authoritarian instructions given to patients without adequate discussion and explanation; overt resentment by physicians at being questioned about the illness or its management. These deficiencies may reflect arrogance. To the extent that they still exist, they are trivial compared to what existed 50 years ago when I graduated. Doctors then rarely told patients what was happening to them and discouraged questions – ‘Leave it to me, I’m your doctor’. Many hospital consultants did take themselves very seriously. Junior staff were expected to wait at the hospital entrance for his (almost always) car to arrive, rush to open the door, step back and follow the great man to the ward where a respectful sister and her retinue were waiting for the ward round to begin. This was conducted like a military parade. Beds had to be lined up precisely, all patients ‘present and correct’ – and silent. There was little discussion between consultant and patient: a small group would gather at the foot of each bed, talking softly and using eponyms such as Koch’s or Hansen’s bacillus or Neisserian infection, or terms like mitotic disease or lues to make sure the patient did not know what was going on. Somewhere within this elaborate pantomime there was concern for the patient: it was thought better for them not to know the truth when things were serious, it might retard recovery. I doubt if any doctors today take themselves so seriously. Many are well aware of the limitations of their authority, their subordination to managerial control. More than ever before, they recognise the need for proper communication with their patients. Discussion with the patient and relatives is now an integral part of the consultation process: patients are likely to be told more precisely what is wrong, to a considerable extent offered choices of treatments and encouraged to ask questions. The sort of arrogance that the medical profession might have displayed in my youth has largely vanished. In the wake of the Alder Hey disclosures, doctors who had removed and stored organs and tissues for any purpose were often referred to as arrogant. Leaving aside the aberrant behaviour of a particular pathologist, I don’t regard the removal of tissues at autopsy for later study as evil or shocking or gruesome – despite the Minister’s over-the-top remark that the revelations were the most shocking thing he had ever read. (One wonders how he missed descriptions of the Holocaust, atrocities in Ruanda, Bosnia, Sharpeville, Bhopal, etc, etc, etc.) After completing my house officer posts I spent a year in a pathology department and carried out many autopsies. It didn’t dawn on me that I was being arrogant when I selected and removed various tissues for later study or even for teaching purposes. Consent had been received for the autopsy, and I regarded this as an essential part of the examination. Now it seems this is not enough. Doctors must, in the words of Dr Liam Donaldson, routinely seek specific consent from the bereaved relatives, including ‘details of the tissue and organs to be retained, the uses to which they might be put, and the agreed length of time for organs to be retained’. Would the stricken relatives really like to know that in the course of determining the cause and nature of the disease that led to death pieces of tissue are routinely taken for later microscopic or other examination? That these are usually kept indefinitely in case they might later prove enlightening about this or other deaths? That some tissues might actually be destroyed in the process of n EDITORIALS