Catholic Medical Quarterly Volume 74(2) May 2024

Has Modern Medicine Moved Away from Me?

Dr Stuart Blackie FRCPath

I have had and enjoyed a wonderful career. I do not think I have saved a life directly but I do know that I saved a small number of people from undergoing major life-changing operations from erroneous interpretation of perceived clinical evidence. I hope that I have influenced and benefitted many people, most of whom have never heard of me or my profession and are unaware of what I and my colleagues in pathology have done.

I was trained in the NHS. My family and I have used its facilities. Like everyone else, I admire those working in difficult circumstances in the front line but suspect that the NHS is overbur­dened by an excess of well-paid administrative and managerial staff. However, I have never accorded it religious devotion. I do not consider that those who have used the private sector should thereby be ejected from the moral high ground.

As a general surgical pathologist, I have a wide range of expertise. There is the old medical adage that common things occur commonly. Obviously, I have colleagues who have a deeper and more profound knowledge of specialised fields. I have long been able to recognise the limits of my knowledge and, if a specimen shows features with which I am not familiar, I have no hesitation in giving a preliminary report but referring the sample to the expert in that field.

But the reverse situation also occurs. Colleagues may have a deeper knowledge. I have a broad knowledge. Recently, a lymph node from a case of suspected lymphoma was sent to a colleague for classification. He performed the inevitable battery of immunocytochemical tests – all of which were negative. He referred it to me and I recognized it as a metastatic deposit of amelanotic malignant melanoma, confirmed by immunocytochemistry.

I left the NHS in 1988. However, talking to my colleagues recently, I discovered that the NHS that I left bears no resemblance to that which exists today. The “firm” system, whose reputation was guarded by its participants, was led by the Consultant but composed of the Senior Registrar, Registrar and SHO and pre-registration House Officer has disappeared to be replaced by a shift system. It was not easy, and I do not think there was any merit, when you were “on” for the week­end to note the regular change of nursing and paramedical staff while you were on duty continuously from Friday morning to Monday evening.

As a Lecturer in Pathology, I was trained to cut my own frozen sections. Later, when I had my own pathology practice, I performed this skill regularly. I even had my own portable cryostat and microscope which I could take to any hospital who required my services. I even lent it to the London Clinic when their cryostat malfunctioned.

I recall one Sunday I was contacted by the Clinic because a surgeon, who did not normally use my services, found himself in difficulties while performing a laparotomy and urgently required my presence to determine what he was dealing with. On an accurate diagnosis depends the direc­tion of subsequent surgery and later oncology. I obliged and, notwithstanding the inevitable delay in getting into central London, gave him the answer. I did not have to try and contact an out­of-hours MLSO, something I had never done before, and then wait for his arrival. I was proud to have been able to have contributed to a success­ful outcome. I subsequently discovered that my performing this service, which was only done to help in an emergency situation, something which I considered to be self-evidently positive, was now considered to be totally out-of-order.

I have provided a personal surgical diagnostic service. In my own private practice, I had direct contact with consultants and their secretaries. If there was any difficulty, I could deal with it personally. They had my direct mobile number.

Even now, I try to maintain this. For instance, if a case is complicated, requires further studies or even a referral to a colleague, I will phone the relevant clinician and give my preliminary assessment. A detailed and considered report, subject to expert confirmation will be issued later.

I have withdrawn from certain areas such as neuropathology where genetic information is now more important for the ongoing management of the patient than is morphology, and from pulmonary pathology where there is greater expertise elsewhere. But even in the latter case, I am prepared to help out in an emergency.

When asked to perform a frozen section, I now aim to try to attend theatre early to speak to the consultant beforehand so we get to know each other and await the sample which I take myself directly to the laboratory rather than rely on a courier. The wait can take some time but, unlike my full-time professional colleagues, I have limited other commitments so I am not pressurised by time constraints. I consider this to be a professional approach. I do, however, take pains to explain that my presence as a pathologist in the theatre complex has no prognostic significance!

Judging from the comments I received last year when I was required to request a 360-degree response from consultants, MLSOs and secretaries with whom I come in contact, there is overwhelming support for this approach.

I now find myself in a profession which has been emasculated. It seems to me that in medicine today, the professionalism has been reduced to a job – albeit one that pays slightly above the average and has some job security. It does have an excellent pension scheme in the NHS. Perhaps one way to resolve the impasse in the current dispute would be to increase the immediate take-home pay but reduce the pension benefits.
Maybe it is because the medical profession has eschewed its Judeo-Christian heritage that. in recent years, the concept of clinical freedom has been abolished. To fill the inevitable and resultant moral and ethical vacuum, it has been necessary to replace it by regulation and legislation. The number of documents issued regarding ‘guidance’, ‘best practice;’ and exterior inspections has prolif­erated. This applies to all areas – health and safety, ‘safeguarding’ governance, ‘inclusion’, risk assessments, etc.

This has led to an expensive burgeoning bureaucracy, meaningless Mission Statements and guidelines which restrict judgement and innovation and assist lawyers to confront any ‘deviant’.


My understanding is that the appraisal system was brought about largely as a result of the crimes of Dr Harold Shipman. However, it is generally agreed that he would probably have passed his appraisal with flying colours. As he was manifestly a clever individual, he could easily have disguised or manipulated evidence, and it was only the failure of other professionals to query his requirements that led to his being able to continue as he did for so long.

When the concept of annual appraisal was first mooted, I was concerned. It seemed to me that it might lead to the de-professionalisation of the profession. Appraisal is now required by all. As such, it is a cumbersome procedure as it has to encompass all possibilities. The phrase that ‘a camel is a horse devised by a committee’ comes to mind.

Appraisal has now become a major industry in its own right and occupies hours of work by both the person being appraised and his appraiser collating all the evidence.

In contrast, in private practice, you are being continually appraised professionally by your colleagues. In private practice, if I were to provide a poor service, my colleagues would send their work elsewhere and my practice would simply have withered on the vine.

Whereas a true professional would attend meetings, read journals, etc., to actively keep abreast of developments, the necessity to provide documentary evidence for appraisals only encourages physical attendance at such functions. I felt it to be demeaning to have to queue up at the end to collect such documentation. It reduces such occasions to just another box ticking exercise.

When the concept of appraisal was being discussed, the topic of patient feedback was brought up. When I raised the question how a pathologist could get feedback from patients, the whole audience laughed!

I was, in fact, asked by IDF to consider training to become an appraiser but considered that it would be hypocritical as, at that time, I disapproved of the concept. I turned down the opportunity despite the loss of significant potential income.

I like the quote of Alexander Solzhenitsyn, “The simple step of a simple courageous man is not to take part in a lie, not to support deceit. Let the lie come into the world - even dominate the world ­ but not through me.”

My first appraisal confirmed my fears.

On being “appraised” by a senior colleague, he learned of the details of my practice at that time and became intensely jealous. This appraisal, my first, therefore permanently destroyed a previously harmonious personal and professional relationship. It never recovered.

I have since discovered other examples. These have taken place after I had been appointed a consultant and have no direct experience of them so my knowledge is based solely on what I have read.

Annual Review of Competency Progression (ARCP)

The ARCP at its best involves multiple senior clinicians (who know the trainee well) with the best interests of the trainee featuring in their assessments. It should recognize achievements, identify areas for improvement and help trainees who need more time to train or more support. In many places it functions like this.

However, the ARCP can be used as a mechanism to bully trainees and even exclude them from training. I understand that a case going through the courts raises the fear that an influential person can use the ARCP to introduce unfounded doubts over a doctor’s temperament, suitability, probity or competency. The onus then falls to the trainee to prove these opinions are false. The ARCP documentation provides a lasting record of the doctor being assessed. It has the appearance of being very rigorous. Therefore, if the outcome of an ARCP smears a junior doctor, it is an easy stain to create and a difficult one to remove.

Recently, some curriculums have been changing, including the addition of a similar assessment (which allows for greater subjectivity) called the Multiple Consultant Report (MCR). It has been described as ‘the same as a rugby tie’ intimating that if you get along with the people in the club you get your paperwork signed off to progress.

Another box ticking exercise

The Care Quality Commission is another example. To take a personal example. My laboratory was located in the lower ground floor. (Everyone else called it a basement). I had informed the CQC that I had, in my laboratory, a desk, computer and a microscope. A young man from the CQC came to inspect me. I showed him my desk, computer and microscope.

He noted that he had to come down stairs to do so and inquired how patients negotiated the stairs. I told him that they came in bottles! The young man did not see the absurdity. However, what I realized was that a man in his early 20s, with no clinical experience, knowledge or expertise, had the power to close me down immediately.

This emasculation has happened on my watch. I didn’t (couldn’t?) do anything about it. I was naïve to think that the older/wiser heavyweights of the profession, who knew the right people and were more conversant with the levers of power would sort it out. I now suspect that they were themselves merely examples of our flawed humanity and, susceptible as we all are, were possibly “bought off” with money, merit awards, enhanced pensions and/or “Honours”.

The BMA would have been no help. My only experience of them was to ask for advise in dealing with bullying (that followed a disastrous appraisal I mentioned earlier). However, I learnt that it only functions as a trade union whose main function now is to encourage ‘diversity’ and ‘inclusiveness’.

In a military campaign, it is generally the senior officers, the generals, who devise the overall plan and appropriate strategy to decide the thrust and direction of the army to accomplish their objective. It is down to the lower ranks, second lieutenants or even sergeants to encourage the men at the front and to adjust tactics and short-term objectives as required in the fog of war.

In contrast, in the NHS, it is the sergeants who give the orders and tell the generals what they need to do.
And one final difference. The generals were once Second Lieutenants and have some appreciation of their needs, difficulties and duties. Most of the NHS managers do not. I have heard it described as a Malignant Administroma

Life Issues

My daughter was inspired by me and, after obtaining a degree in Oxford in Modern History, entered the graduate school of GKT and has a locum consultant post in Palliative Medicine, one of the more caring branches of the profession.

My fear, however, is that my daughter’s expertise will become redundant if the Voluntary Euthanasia Society (now renamed Dignity in Dying) were to succeed in their aim to change the law by passing legislation through the House of Commons. Already there is a “domino strategy” in place to put pressure on legislators to change the law nationally in the House of Commons with consultations in Tynwald in the Isle of Man, The States Assembly in Jersey and in Scotland where it is supported by Sir Graeme Catto, former pres­ident/chairman of the GMC (and patron and chair of Dignity in Dying). And as the Abortion Act shows, they only need to succeed once.

But this is not the first encounter with “life” issues.

I might never have gone into pathology. As a medical student, I loved obstetrics. It was, though, a Senior Registrar in O & G who took me aside one day and said that I would never get a consultant post in O&G, or even be shortlisted, because they had sussed that I would not do abortions.

That, of course, would never be given as the reason. That would be illegal and, even in those days, in theory, I could have sued them. If a reason had to be given, there would, no doubt, be 1001 options from which to choose.

But I can sympathise with the wise advice I was given. If I was not prepared to accept the contract to be a hit-man, then, in all conscience, I would have had to go against the GMC ruling that I would then be obliged to provide the name of someone else who would, i.e., to nominate another ‘hit man’. Personally, I think it is up to the party issuing the contract to do that.

My career would have been short.

Whether the circumstances which led to the conception of a child were moments of ecstasy or pure terror, the fact remains that this same child conceived is the one person who is manifestly completely innocent. It goes against natural justice that the innocent party is singled out as the one to pay the ultimate price.

When the 1967 Act became law, the idea then was that destroying a child in the womb should be restricted to cases of tragic necessity. But it rapidly became something available on-demand. Nowadays, the period in a child’s life when he in most at risk and in danger is in the first nine months after conception. By definition, a safe abortion is one in which the prime aim is that only one person is killed!

The legal ability to procure an abortion has become considered to be almost a fundamental human right. Abortion is considered more sacrosanct than free speech. Anyone who disagrees with this comes up against the Cancel Culture.

But note that, before people can legally kill, they first dehumanise. The unborn are categorised as a foetus, an embryo, or “a clump of cells”. This is an example of concentration camp language. “They look like humans, but they're not. They're Jews...".

Hopefully, abortion will soon be regarded as something that belongs to a tragic era that is now coming to an end. I wonder if future generations will look upon us with the same feeling of horror that we look upon the slave traders. Will statues will be pulled down and buildings renamed?

It is interesting to note that to be appointed Minister of Health requires no medical knowledge or expertise. However, doubts about their suitability for their position in high office are immediately raised if the previous voting record of the Minister concerned has not thrown their full weight behind the abortion industry.

Managers considered doctors to be elitist. Politicians consider doctors part of the problem, not part of the solution, to challenges in the health service. One wonders if it was merely a cynical decision was made in Whitehall to strip doctors of their uniform, the white coat, to reduce the influence of doctors in the NHS. In contrast, nurses continue to wear their uniforms without anyone raising the spectre of an infection risk.

But, bearing in mind that we now live in an era in which ‘white’ and ‘male’ is often followed by ‘privileged’ is now a term of abuse, maybe no medical school would now accept me - despite my surname! That, I think, is the tragedy of the present situation.

Truth cannot contradict truth. In the search for morality, and doing “the right thing”, perhaps we need to delineate with increasing clarity the respective fields of competence, methods and value of the conclusions of science and Judeo-Christian theology on which are society was, until recently, based according to their respective nature and it is the one answer that is being deliberately excluded by secular society.

Science takes things apart to see how they work. Religion puts things together to see what they mean.


It must be a truism that, on their death bed no-one thinks that they should have spent more time in the office – particularly if it simply involved routine box ticking.

In contrast, however, if you were genuinely helping people, improving their lives or prospects, or resolving their problems or fears, then I do believe that time spent in the office/surgery/clinic/laboratory has been time well spent.

However, hopefully I will have a few more years before I do arrive at my deathbed. Bearing in mind the old observation that “Everyone is out of step except our Johnny!”, I have examined the ethos and the logic behind my concerns and have come to the conclusion that they are timeless and so these are not the regretful musings of a tired old man, a dinosaur, who has been left behind while medicine has ‘moved on’.

Do I try and keep my small flame burning in the darkness hoping that it will not be smothered by blanket bureaucracy before the pendulum of opin­ion, forced by ‘events’, swings back in my favour? Or do I hand in my licence and merely accept defeat? My preference is for the former.

But the decision may be taken out of my hands as my fate may well be decided by a manager. Managers, of course, have no equivalent of the GMC. They may be good or bad but there is no right of appeal against their decisions, which are final.

I may have to take comfort in the saying:

For when the One Great Scorer comes
To write against your name
He marks – not that you won or lost
But how you played the game.


These comments were written before the case of Lucy Letby broke in the media.
In the light of these revelations, I do not think any observations have been invalidated.