The royal colleges of medicine launched a staunch defence of their position this week.
The colleges, which look after the postgraduate training and qualifications of doctors, were under attack for refusing to allow a British anaesthetist who qualified as a consultant in the United States to hold the same status in the United Kingdom.
The colleges have also been criticised for failing to sound alarm bells in the case of three surgeons who were disciplined by the General Medical Council after 29 children and babies died following heart surgery at the Bristol Royal Infirmary.
Senior figures in the medical establishment have hit back at their critics for failing to suggest an alternative method of administration. "I would ask 'who else?'," said Sir Sandy Macara, who chairs the British Medical Association.
The point was echoed by Peter Lachmann of the Academy of Medical Sciences. "We have to make sure that the cure is not worse than the disease," he said.
There are more than a dozen royal colleges, covering areas from general practice to psychiatry. Some of them are ancient organisations - the Royal College of Physicians was granted its royal charter centuries ago by Henry VIII in 1518. Others are more recent. The Royal College of Anaesthetists was established in 1992.
The colleges control entry into the highest levels of the profession. To achieve consultant status, a doctor practising in the UK must pass the entrance exams and obtain a certificate of completion of training to be accepted for membership in the relevant college. Because of this, few doctors are willing to criticise the system.
One exception is Richard Horton, editor of the medical journal The Lancet. Dr Horton has described the colleges as "arrogant and largely unaccountable" organisations that "protect doctors and not patients". They are dominated by older men.
Last week, Richard Kaul launched legal action against the royal colleges. Dr Kaul spent five years at medical school in London and a year as a house officer before leaving for the US, where he qualified as a consultant anaesthetist. But his qualification is not recognised in the UK.
His solicitor has been quoted as describing the decision by the royal colleges as "arbitrary". Dr Kaul is trying to force the Specialist Training Authority, which operates on behalf of all the royal colleges, to reveal the reasoning behind its decision. The case will be heard in the autumn.
The British Medical Association will issue guidelines on identifying and dealing with problems in the wake of the Bristol cases.
ROYAL COLLEGES: STUCK IN THE PAST OR FIT FOR THE FUTURE?
The royal colleges are headed by councils elected by members. All of them (apart from those for midwives and nurses) are dominated by men.
Royal Colleges Men on Women on
the council the council
Anaesthetists 22 3
General Practitioners 52 12
Obstetricians and Gynaecologists 29 6
Opthamologists 26 4
Paediatrics and Child Health 31 11
Pathologists 20 6
Physicians 31 9
Physicians of Edinburgh 17 0
Physicians and Surgeons of Glasgow 24 2
Psychiatrists 37 16
Surgeons 20 4
Surgeons of Edinburgh 13 2
Radiologists 20 1
Midwives 0 21
Nursing 5 19
'I am not at all sure that the royal colleges always did what was best in the past. But now they are almost competing with each other to demonstrate that they are fit for the future. I am content that the colleges are now effective and responsible bodies'
Sir Sandy Macara, chair of the BMA
'The stench of arrogance that taints medicine owes as much to the complacency and self-satisfaction that pervades the royal colleges and the British Medical Association'
Dr Richard Horton, editor of The Lancet
'The colleges are criticised for protecting poor doctors, for failing to protect patients, for betraying medicine, for operating restrictive practices and for undermining standards in the NHS. In fact, the colleges are working very hard to do just the reverse'
Roddy MacSween, chairman, Academy of Medical Royal Colleges
Leader, page 13