|Paul McGann plays Martin Harris/Dr Simon Hennessey in Paper Mask (1990, [VHS], High Fliers Video Distribution)|
(Warning: contains plot spoilers!) In his novel A Paper Mask John Collee explores the issue of bogus doctors – that is, people who fraudulently gain employment as doctors and practice medicine within conventional hospital settings or as general practitioners without formal qualifications. Through the actions of his character Matthew Harris, a hospital porter who adopts the identity of Dr Simon Hennessey following the latter’s death, he offers an account of the basis of medical expertise which jarrs sharply with a conventional view of the importance of formal medical education.
Author John Collee is both a doctor and writer of TV medical scripts (see Henry III, W.A. “Going Beyond Brand Names”, Time, Monday 3rd April 1989, pg. 2), including the screenplay for the 1990 film Paper Mask. While both book and film may be considered quite ‘lightweight’ they nevertheless succinctly highlight some of the less frequently discussed bioethical issues implicit in medical practice, though also provide an interesting set of observations on the true nature of medical skill and its acquisition.Though A Paper Mask is a fictional story, it does correspond well with academic accounts of the nature of medical expertise. Collins and Pinch (2005), for example, discuss how both the successes and the unmasking of bogus doctors can tell us about the nature and acquisition of medical skill in a number of areas.
The significance of ‘on-the-job’ learning in the acquisition of medical skill
Drawing on their study of real bogus doctors (as it were), Collins and Pinch (2005) highlight the significance of ‘on-the-job’ learning in a clinical setting over ‘book’ learning at medical school in the development of competent practice of medicine. This, they suggest, is one of the reasons some bogus doctors are able to remain undetected for many years.
|Hennessey is grilled by Dr. Thorn (Paper Mask, 1990, [VHS], High Fliers Video Distribution)|
The importance of on-the-job learning is illustrated nicely in Collee’s novel. As he enters the Casualty department, Harris (passing himself off as Hennessey) is a disaster (see pages 40-49 in Collee, 1987; and 00:20:15 to 00:25:47 in the film version). Relying only on his knowledge and skill as a hospital porter, he struggles to deal with a stream of patients, an unfamiliar environment, and the complex ‘code’ used to record diagnosis and treatment on the Royal Clifton Hospital’s casualty cards. Indeed it is these cards that leads him into trouble with this superior Dr. Thorn (see pages 57-61 in Collee, 1987). However, by the end of the book – which covers approximately 8 months – Harris/Hennessey (hereafter referred to as ‘Hennessey’, for the sake of simplicity) is apparently a competent medical practitioner within the casualty department. During this time Hennessey receives no formal medical education; what he does receive is a crash course in the practical skills associated with a competent medical performance – one of the major components of medical expertise.
However, Hennessey’s expertise in not acquired without the use of medical textbooks (i.e. formal medical knowledge, as opposed to the tacit knowledge and skill learnt on-the-job). One of the interesting features of A Paper Mask is the way it depicts the interaction between these two types of knowledge in medical expertise. The best illustration of how these two come together is in Hennessey’s learning of spoken and written medical code (see for example, events involving ‘basal crepitations’ on page 61and 94-95, and Hennessey’s reproduction of his colleagues casualty card acronyms on pages 86-87 and below). In both these cases Hennessey draws simultaneously on textbook knowledge and experience (including as a hospital porter) in pulling off his performance.
|Harris/Hennessey masters the casualty cards (Paper Mask, 1990, [VHS], High Fliers Video Distribution)|
Another integral part of Hennessy’s successful performance involves the reaction of others around him to his apparent ineptitude during his first days in A&E. The following quote from A Paper Mask highlights the main features of this from a nurse’s perspective: “So much for Dr Hennessey…I can’t believe they let people out of medical school like this. They spend six years filling their heads with theory and they don’t have the first idea about first aid or sterile procedure or normal social behaviour…Most nurses could do the job standing on their heads but instead we have to clear up the mess and repair the damage” (1987: 50). In addition to underlining the distinction between formal knowledge and practical skill, here nurse Christine highlights another of the reasons why many bogus doctors are able to remain undetected: that doctors generally work within a team which functions to prop up the faker and may even perpetuate the deception. Collins and Pinch (2005) also note this phenomena in their study of actual bogus doctors.
The nature of medical skill
There are two ways in which the study of bogus doctors and their unmasking can help us to examine the nature of medical skill. Firstly, it can gave give us some insight into what counts as a ‘skilled performance’ in medical practice, and secondly, it can help to illuminate the full range of skills required in ‘being a doctor’.
What counts as ‘skilled performance’ in medical practice?
|Harris/Hennessey at the inquest into Celia Mountford’s death (Paper Mask, 1990, [VHS], High Fliers Video Distribution)|
In both the book and film versions of A Paper Mask, and Collins and Pinch’s academic account of bogus doctors, the courtroom is an important setting within which “what counts as a skilled performance in medicine?” is debated. At an inquest, for example, as depicted between pages 154 and 165 in Collee (1987) and between 01:03:00 and 01:06:45 in the film version, the actions of medical personnel are scrutinised minutely and judgements made about their contribution to the death or damage to a patient. In A Paper Mask, for example, various ‘expert’ witnesses are asked to comment on whether Hennessey’s actions in the treatment of Mrs. Mountford were ‘errors’ or examples of ‘competent practice’. Insofar as the different witnesses disagreed about this, these fictional scenes suggest what counts as ‘skilled performance’ within medical practice is much less stable and settled than one might imagine.
Is there more to ‘being a doctor’ than clinical performance?
Collins and Pinch (2005) discuss the unmasking of bogus doctors at length, and look specifically at the factors leading to their identification as fakes. Their analysis of historical cases suggests that unmasking is only occasionally directly linked to some failure in clinical performance – that is, the exercise of medical skill within the the hospital of GP practice. Collins and Pinch suggest that many bogus doctors are unmasked as a consequence of some slip-up or failure in non-clinical contexts – i.e. in the wider range of social situations where fakes are expected to behave in a ‘doctorly’ manner. This is also reflected in the unmasking of Harris in A Paper Mask. While the specifics of the scenario Collee (1987) invents seem unlikely to occur in real life (while Hennessey is not actually unmasked during A Paper Mask, the final page of the book suggests his downfall is eminent: on leaving his job in A&E for an SHO post in another hospital, he leaves Martin Harris’ passport and documents in his digs where it is discovered by the housekeeper who alerts Dr. Thorn), they share some similarities with the cases described by Collins and Pinch (2005).
Insofar as Harris’ likely unmasking was due, not to a failure of skill within the hospital, but because his actions (i.e. taping another man’s passport to the back of his wardrobe – see page 224 in Collee, 1987) outside the clinic did not correspond to what a doctor might do in this situation. In this sense his failure was not medical, it was social. Thus, examining how and why bogus doctors are unmasked suggests that there is more to ‘being a doctor’ than being a competent medical practitioner within a clinical setting.
Overall, both Collee’s book and the subsequent film Paper Mask are enjoyable portrayals of the trials and tribulations a bogus doctor might face in attempting to remain unmasked – though it should be emphasised that they are both light-hearted fictions that make no claims to represent reality. However, given Collee’s medical background and the correspondence identified above with Collins and Pinch’s (2005) discussion of real bogus doctors, A Paper Mask may serve an illustrative purpose in any teaching which attempts to emphasise the – frequently unacknowledged – contingent nature and bases of medical skill and expertise.
A Paper Mask was written by John Collee, and published in the UK in 1987 by Viking, London. ISBN: 9780670814060. The film version, Paper Mask, was released on VHS in the UK on 14 September 1990 and distributed by High Fliers Video Distribution. Collins and Pinch’s essay “Faking it for real: bogus doctors” appears in Dr Golem: How to Think About Medicine published in 2005 by The University of Chicago Press. ISBN:022611366