Revalidation and the discourses of discipline and fetishization:

Hierarchical judgement Normalising judgement The examination

“ … the panoptican must not be understood as an ideal building: it is the diagram of a mechanism of power reduced to its ideal form.” M. Foucault. Discipline and Punish (1975) HIERARCHICAL OBSERVATION:

HIERARCHICAL OBSERVATION: … all that we [the GMC] do in the process is actually revalidate a doctor, we make the decision to whether they revalidate and they can continue to hold a licence to practice, so all the key work, the evidence gathering and the processes goes on elsewhere and earlier in the process. … Um there’s lots of other key players obviously but for me it’s, I think you can’t separate it from the individual doctor, it’s ultimately their responsibility to keep the privilege of being on the register. GMCELOM1

HIERARCHICAL OBSERVATION: [The data] that the organisation collects information for money and waiting lists and what it see as its imperative political targets, most of the computing that we’ve got is not set up to make clinician’s lives easier. Or patient’s life for that matter, you know it’s set up to kind of serve the commercial part of the organisation. … but if you go to your GP’s surgery all the notes are electronic, they’re going to call everything up, call up the results, it’s easy to do. Here the notes are an absolute mess, paper records still, volumes of them, not very well filed, getting worse and worse. 1SCLAERM1

NORMALIZING JUDGEMENT: In the old days people could put all sorts of evidence in, now the guidance implies that you only need certain – it’s like the minute you have a tick box, people stop putting in the more interesting things. Yeah, I think the risk is that people will just do the minimum. 1PCAEEF5

NORMALIZING JUDGEMENT: I am absolutely sure that my receptionists select out the patients. … They do it with the best will in the world, but if somebody comes in who is intoxicated, which a lot of my patients are, or angry or maybe has learning difficulties or something like that they just wouldn’t give them a form. I am sure they do it like that. 1PCAEEF6 You’ve got some [cardiologists] who won’t touch difficult cases with a barge pole. That’s not good for patients, but it’s good for their figures. 0SCROM1

THE EXAMINATION: when I sit down with an appraise and a discussion, I trust that the evidence that they’ve brought to me is valid, I trust they’ve not tried to murder anyone, you know they declare a probity statement and I take that at face value, but still I could quite easily be fooled by someone who was determined to fool me. 0SCAERF1

THE EXAMINATION: THE EXAMINATION: To deliberately identify areas that you are under- performing when other people might not have noticed is quite a big thing to ask people to do. To say that actually I am really rubbish with that and I made a mistake with that this year because the patient didn’t complain but I did a significant event but nobody could say it was easy to not do that. But you might not be so honest with yourself. 1PCAEEF6

FETISH: I think it’s becoming, there’s getting to be more regulation and it’s becoming less about you personally, more about the regulations, more about having all the bits of paper and it’s no longer looking at your personal journey through those bits of paper, it’s about just having those bits of paper there. 0PCAEER4

FETISH: FETISH: “[occupational] credentials like other commodities become fetishized as an inherent source of value, rather than seen as a token of underlying structure of social relations” Burris, V. ‘Reification: A Marxist perspective’ California Sociologist (1988) 10: 22-43

Where visibility as a conduit for knowledge is elided with visibility as an instrument for control – an appeal to a benevolent or moral visibility is all too easily shown to have a tyrannous side – there is nothing innocent about making the invisible visible. Marilyn Strathern ‘The Tyranny of Transparency’ British Educational Research Journal :3