Next month the first cohort of doctors will take the knowledge and clinical tests for the new MRCGP (nMRCGP). For the first time in the UK, general practice has an agreed curriculum, a robust and standardised selection procedure, an integrated 3-year training scheme (rather than 1 year training and 2 years of hospital servitude), and a single method of assessment of competence. This is a considerable achievement, and should ensure that all doctors entering general practice have the basic knowledge, skills, and personal qualities needed to flourish as GPs. Selection for medical school and for foundation training is similarly becoming more objective and based on clearer and hopefully fairer criteria.
By coincidence next month is also the 15th anniversary of the death of David Widgery, a charismatic East London GP and nationally known writer and political activist. He entered medical school when selection depended as much on who you knew as what you knew, and it has been suggested that Widgery, even then an unconventional figure, was only able to study medicine because his medical school accepted one ‘risk factor’ every year.2 Apparently his attendance was erratic, and he failed finals on the first attempt. He entered general practice through the back door of locums and salaried assistantships before compulsory vocational training. His ‘traineeship’ as a GP was as assistant to a single-handed doctor who smoked his way through consultations.2 He had no formal postgraduate training and obtained no higher qualifications. This back door was locked in 1979 and has been bolted and barred by PMETB.
Yet Widgery is an influential figure in the history of general practice. During his short career he had a powerful effect on the area in which he worked. Despite not always being easy to get on with, he was admired by his patients and colleagues. His influence and vision of primary care informed by a vision of social justice rather than market forces spread far beyond his locality, particularly through his writing in the BMJ and his powerful and angry book Some Lives.3 The Hackney Empire was packed for the memorial celebration of his life. His influence lives on through his writing and in the community he gave much of his life to. Patrick Hutt, a young doctor from that area, has been inspired by his life not only to write his biography,2 but also perhaps to stay in medicine despite its many alienating features. Widgery's memory also continues to inspire those of us who knew him.
He was a ‘wounded healer’. At the age of six he contracted polio and almost died. The illness left him with a permanent limp and chronic pain, the cause perhaps of his anger, his commitment to medicine, and his use of strong analgesics and alcohol, which may have contributed to his tragic early death.
In Hutt's thought-provoking biography, Heath and Neighbour describe Widgery as a hero, but perhaps ‘prophet’ would be a better term. Prophesying not in the Harry Potter sense of predicting the future with uncertain accuracy, but as in the Old Testament, whose prophets denounce injustice and wrongdoing, and whose lives, speech, and writings transformed their society.
Prophets are not comfortable to have around. They are often outsiders. Amos was a rural sheep farmer whose prophetic calling brought him into conflict with the seat of power in Israel.4 Jeremiah's bizarre public behaviour and ranting would these days undoubtedly gain the attention of the local mental health team. We don't know what substances Ezekiel took, but they must have been pretty powerful, judging from his visions.5
As with all practices, general practice depends on ‘standards of excellence and obedience to rules’.6 Alisdair Macintyre argues that although ‘the standards are not themselves immune from criticism’ and ‘practices never have a goal or goals fixed for all time’, because ‘the goals themselves are transmuted by the history of the activity … we cannot be initiated into a practice without accepting the authority of the best standards realised so far’.6
The new selection and assessment procedures for general practice have been thoughtfully designed to achieve obedience to its standards and rules. But will there be a place for wounded healers in this brave new world? Will robust selection and assessment procedures filter out prophetic figures? I suspect not — the prophetic calling is strong enough even to overcome the straitjacket of PMETB and nMRCGP. We must certainly hope that this will be so, for without prophets like Widgery the world and general practice will be the poorer.
- © British Journal of General Practice, 2007.
