Review of Birth and Power

The subtitle of this book is "A Savage Enquiry revisited". Medical inquiries can be savage. Quite why control of doctors unleashes primitive instincts is of concern and the subject of this book. It is not just about the control of childbirth since issues of power apply to any area of medicine. The book's focus is on the problems that arise when doctors disagree amongst themselves.

A Savage Enquiry, first published in 1986, recorded Wendy Savage's perspective on the events surrounding her suspension in April 1985 from her post as Senior Lecturer in Obstetrics and Gynaecology at the London Hospital Medical College and honorary consultant at the London Hospital. The Tower Hamlets Health Authority reinstated her in July 1986 after a disciplinary hearing that lasted over a month in the full blaze of publicity. Her original text is reprinted as an appendix to the present book.

In the new book, she describes for the first time what happened to her when she returned to work. The interpersonal difficulties in her department persisted despite recommendations from various reports to improve working relationships. Ten years from the last day of her inquiry she was told of an anonymous complaint about her management of a further five cases - the same number that formed the substance of her disciplinary hearing. This time, she managed to resist external assessment and the matter fizzled out leaving her exhausted. She went on sabbatical before retiring a few years later, having also earlier become honorary professor at Middlesex University.

The remainder of the book is arranged round the themes identified in the first book. In each section Savage contributes a chapter supplemented by chapters from other authors. She describes the damage caused by gossiping to the reputation of doctors who are wrongfully suspended. Her experience leads her to conclude that such doctors are seen as 'different' or 'difficult', often because they are more conscientious or act as whistleblowers. John Hendy, who was Savage's barrister for the inquiry and has continued to gain considerable experience in medical disciplinary cases at Old Square Chambers, observes that personal malice or professional jealousy may play a role in trumping up charges, but these factors are almost inevitably impossible to prove. Accusations may be intended to neutralise outspoken clinicians from the economic imperatives of management. Furthermore, John Eversley, the trade union nominee to the Health Authority at the time of Savage's suspension, notes that there was an active Masonic lodge among staff at the London Hospital. Suspicions were raised about whether such networks played a part in the surrounding events.

The book indicates how suspension from work can be devastating. One woman surgeon, not yet in a position to divulge the full details of her case, writes anonymously about her experience. She is not unusual in having felt suicidal about her situation. The book also highlights the issue of academic freedom, which is essential if we are to train doctors to think.

Medicine is not an exact science. Attitudes and approaches vary along a spectrum from doctor to patient-centred, and doctor-centred bias can be reinforced by an over-emphasis on physical abnormalities at the expense of dealing with difficult personal issues. The problem is that current debate is polarising medicine in this respect. Inevitably, in any one doctor, there is an interaction between the degree of patient and doctor-centredness. Either pole does not exist in pure isolation. The issue is about finding the proper balance. Ironically, the position of Wendy Savage is closer than most doctors to the appropriate balance required by patients.

Savage also realises that most doctors are sufficiently balanced on this spectrum. She stood against Donald Irvine as president of the General Medical Council. Unlike Irvine, she appreciated that the system is not awash with incompetent doctors. Patient-centred professionalism should not be used as a stick to beat clinicians. Rather it is needed to help defend them against a managerialism that fails to recognise that guidelines and protocols cannot be a complete substitute for professional knowledge and clinical judgement.

Of course there are a few rogue doctors. However, good clinical governance depends on supporting the vast majority of sound clinicians. It actually makes health organisations less safe for patients if this is not the case. As quoted in the chapter by Michael Goodyear, an academic oncologist from Canada, "Cultures of excellence not only value their workforce but let them know they are valued."

Wendy Savage was accused of being non-interventionist. This was primarily because she intervened less with surgery for Caesarian section. Savage was prepared to give women choice about a trial of labour in circumstances in which other obstetricians may have moved more directly to Caesarian. It is still a requirement of the General Medical Council's Good Medical Practice to respect colleagues and not allow personal views to affect professional relationships adversely. In particular, malicious and unfounded criticisms should not be made that may undermine patients' trust in the care or treatment they receive, or in the judgement of those treating them.

Marsden Wagner writes from the international perspective of having been Director of Women's and Child Health at the World Health Organisation. He suggests that the real function of tribunals, such as that of Wendy Savage, is to punish deviant professional behaviour that could threaten the income, practice style, prestige and power of mainstream doctors. Is medicine really in such a vulnerable state? Medicine is hardly a total cultural deceit, but those that point out respects in which it is deficient are vulnerable to being seen as outside the acceptable range of medicine.