They still make house calls . . .

I have just read the report of the Shipman Inquiry. Everybody in the UK knows all about it, but for our more provincial readers in the colonies, Harold Shipman was a kindly family doctor in a small English city. His patients adored him because he took extra time with them, really knew how to listen, and even made house calls!

It turns out there was one small flaw in his practice style: he murdered hundreds of his patients over a period of 15 years. Dame Janet Smith, who led the official inquiry, confidently attributes 215 murders to the beloved healer, but is certain there were many more. Shipman started out killing old and sick people, acts which might conceivably be explained as mercy killings, but that was just for warm up. As he gained confidence and refined his modus operandi, he killed healthy and middle aged people as well. The majority of his victims were women but he had no particular standards. His preferred method was a lethal injection of a synthetic opioid, but he occasionally used other drugs. His unusual career came to an end only when he forged a crude will purporting that one of his victims had left him her considerable estate. The deception was obvious and quickly led to the discovery of his unusual approach to medical ethics.

The good doctor, nevertheless, maintained his innocence to the last and has given no hint as to his motives. Last year, while serving several dozen consecutive life sentences (they eventually stopped bothering to prosecute him), he claimed one final life, his own.

Now, one should be cautious about drawing general lessons from this extreme tale.

It is certainly true that Dr. Shipman's deviant career was only possible because of the strong deference and respect paid to physicians. He was nearly caught on several occasions but people proved only to happy to accept his fairly awkward lies.

It also reminds us that physicians are of course human and reflect human variability. Medical schools and residency programs do make some effort to identify depraved, irresponsible or impaired trainees but these efforts are not necessarily systematic nor very dilligent, and the responses to problems that are identified seldom terminate careers. Once a physician has a license, it is close to a lifetime appointment. In Massachusetts recently, physicians have lost their licenses for serial sexual abuse of patients, basing their practices on the sale of prescriptions for narcotics, and in one rather droll instance, leaving a patient on the operating table while the surgeon went to cash a check so he could buy cocaine. But most doctors who are abusive or incompetent just move to another state, and if they find difficulty obtaining employment (which they often do not) they can always go into correctional medicine, i.e. "taking care" of prisoners.

There are signs this is beginning to change and that both state authorities and the profession itself are taking more seriously the problem of unfit physicians. However, as Dame Janet has written about Britains' General Medical Council, which polices the profession in the Old Country, it has perpetuated a culture of mutual self-interest among doctors.

Physicians do value the interests of their patients highly, but patients usually don't come first when there are other doctors to protect.