Carrie MacEwen’s keynote speech at RCPSG conference

Good morning, and thank you for the opportunity to be here today. It’s always a pleasure to be in Glasgow, the city where I was born and brought up.

It is also where my father, Charlie – a fellow doctor – practised for nearly 50 years. 

A consultant before he was 30, he helped shape ophthalmology services in Glasgow through the introduction of novel methods like microsurgery – using new surgical techniques and of course, requiring the operating microscope. To do so he used his charm to persuade the Marquess of Bute to donate the funds – not bad for a boy from Dennistoun who was the first in his family to go to university.

My father was a real influence on me. Not only in becoming a doctor – I followed in his footsteps as an ophthalmologist – but also in the type of doctor he was.

His registrars described feeling “educated, supported, and encouraged” when being trained by him. He was popular with colleagues and patients alike. And he was forward-thinking in supporting my desire to be a doctor, even when that made me something of an anomaly.

Indeed, it was him who challenged my childhood assumption that, as a woman, I could only enter healthcare as a nurse – a sad reflection of the times. Seeing the satisfaction and enthusiasm he got from his work was also hugely motivating.

I went to medical school in 1975, making the move from Glasgow to Dundee.

At that time, incredibly, there was still a cap on the number of female medical students admitted. This was thankfully lifted by the Sex Discrimination Act, which came into force at the end of that year.

100 years before that, trailblazing women were fighting for the right to attend medical school at all.

In 1873, the Edinburgh Seven, the first women to study medicine in the UK, were banned from graduating. And it wasn’t until 1894 that Marion Gilchrist became the first female medical graduate in Scotland.

Fast forward to 2025, and the picture is radically different.

Today, Scotland has the highest proportion of women among its medical school intake in the UK at 64%, with more women than men working as doctors in the country.

The early pioneers of female education would scarcely believe those statistics – but, no doubt, would be absolutely thrilled!

But behind the headline trend lies a more mixed picture.

While specialties like paediatrics and obstetrics and gynaecology have strong female representation, others, like surgery, emergency medicine and my own, ophthalmology, continue to be male dominated.

And while culture is much improved since the days of the Edinburgh Seven – who were literally pelted with mud by their fellow students – sexism and even sexual misconduct remain the grim reality for too many women in medicine today. 

Culture and outcomes

As someone who has themselves been on the receiving end of sexist commentary and bullying, I can attest to the corrosive impact of such conduct – on one’s confidence, on the cohesion of a team and, crucially, on the quality of care we can deliver.

An environment where you are belittled, where your input is undervalued, where your progress is stymied by other people's small mindedness and biases is not one where you can perform at your best.

Those behaviours cause people to shut down, avoid asking for help and question their judgement.

That's not only damaging to a doctor’s wellbeing – it fundamentally affects the delivery of high-quality care.

That's why fostering healthy working environments is not a nice-to-have. It is central to the safety of our patients.

Nowhere is this truer than in the pressure cooker of an acute care unit, where high stakes decisions, rapidly taken, can make for a fraught environment.

Here, tensions can easily take hold. And without the fundamentals of good communication, open culture and strong leadership, damaging dynamics can quickly come to define doctors’ working lives.

Instead of speaking up, there's a closing of ranks and silence.

Instead of learning from mistakes, there’s a drive to cover them up.

Instead of trusting our judgement as clinicians, there’s a slide to defensive practice, and all the unnecessary and potential harmful interventions that flow from that.

These toxic traits have been shown to contribute to the care in recent, well publicised maternity scandals.

But the reality is that the need for finely balanced judgements, and the grave consequences of getting them wrong – in short, the inherent riskiness of medicine – mean that poor culture can take root in any specialty, in any location. And patient care is the primary casualty.

Add in the immense pressure the service is under – that we’re seeing more patients who are sicker and require more complex care – and it’s no surprise that the health system is creaking.

The picture of patient care 

Our data show that acute medicine is no exception to this.

In 2024, 49% of doctors working in acute medicine in the UK reported that they had experienced compromised patient safety or care. That compares to 40% across all specialties and is worse than the previous year’s figure of 43%.

That nearly half of all acute medicine doctors have experienced substandard care in their workplaces is profoundly alarming. And perhaps explains why doctors in this specialty were also more likely to report intending to leave UK practice before retirement age, including being more likely to plan to practise abroad instead.

Such issues are sadly present across all parts of the UK. But our data show that patient safety is an emerging concern in Scotland particularly. 46% of doctors witnessed patient safety being compromised in 2024, compared with a 40% UK average.

There are also warning signs when it comes to workplace culture. Our data show a larger proportion of doctors in Scotland disagreed that they could influence change in their workplace. And a smaller percentage felt supported by non-clinical management.

We’ve seen some of these issues play out in this very region with the recent review into emergency departments (EDs) in NHS Greater Glasgow and Clyde.

But, as the report made clear, problems identified in EDs reflect a wider sickness in the system, where substantial and sustained pressure is eroding the quality of care.

Our duty to each other as doctors

These stresses are structural and multifaceted, and there is no silver bullet that can cure them entirely.

But it is my view, and the view of the GMC, that healthy culture and strong leadership are among the strongest safeguards we have. And while wider questions of resource, staffing and budget require time and money, the way we behave towards one another costs nothing at all.

It doesn’t necessarily come naturally to us doctors to be demonstrative. But, as in the turmoil of the pandemic, a sense of shared purpose can be a powerful tonic in difficult times. That cohesion and camaraderie are a shield against the strains of our working lives. And when difficult decisions lie heavy, a kind word can turn your day around.

Doctors should be able to expect courtesy, compassion, and clarity from their employers, but also from their peers. Tone may be set from the top, but culture is the product of the individual behaviour of every person in a team. As clinicians, we have a duty to treat our patients as we would want our loved ones to be treated, but also to treat each other as we ourselves would want to be treated.

Compassionate regulation

At the GMC, we believe that need for compassion also extends to us and the way we carry out our role.

As a regulator, we recognise that we are not in a popularity contest. Our primary purpose is to uphold patient safety, and that means taking decisions that can be very difficult, may be highly contested, and can have a profound impact on individuals’ lives.

But while we may not expect to be liked, we don’t want to be feared either.

Fear is not conducive to good practice, because when fear drives decision-making, self-preservation becomes the overriding impetus, rather than the best interests of the patient.

So practising from a place of fear is not only harmful to a doctor’s mental wellbeing, but it also affects the quality of care they provide.

The reality is that it is highly unlikely that a doctor will ever be investigated by the GMC. And, if they are, it is even more unlikely that they will face a sanction. Of the over 400,000 doctors on the medical register, only 67 were removed last year (with only two of these cases relating to incidents that happened in Scotland).

But I know that statistics are not as powerful as emotion, and the fact remains that a perception persists of the GMC as punitive and ‘out to get’ doctors.

That's why we've been looking critically at our processes, to minimise fear and increase trust.

Until now, we’ve been hindered by the legislation that underpins our regulation, the Medical Act.

Now 40 years old, the Medical Act makes stipulations including requiring us to fully assess every complaint we receive. That includes those that don’t raise serious fitness to practise concerns, or won’t meet our legal thresholds.

Fortunately, there’s change on the horizon, and the UK government has committed to reforming this legislation.

In the meantime, we’re looking at what we can do ourselves to change the way we work.

Ultimately, we want to spend more of our time and resources on supporting doctors to prevent issues arising in the first place, rather than dealing with the fallout when problems occur.

Our outreach teams have been central to this, delivering sessions to nearly 2,000 doctors in Scotland in 2024 around things like professional behaviours. We’re also continuing to expand our Welcome to UK Practice induction workshop for international doctors, reaching over half of the newly employed internationally qualified doctors in Scotland last year. And we’re working on the ground with employers to improve local resolution of concerns – to ensure the cases that come to us really warrant a GMC investigation.

We’re also improving the way we communicate, so we’re less legalistic and more ‘human’ in our correspondence with registrants and the wider public.

And, crucially, we've been focusing on fairness and cultural competence.

In 2019, we published research showing that internationally qualified doctors were two and a half times more likely to be referred to the GMC by their employer than their UK-trained colleagues. Black and ethnic minority doctors were more than twice as likely to be referred than their white counterparts.

So, in 2021, we set a target to eliminate disproportionate employer referrals by 2026, and we’ve been pleased to see progress made year-on-year.

We've also rolled out training to all of our decision makers on the impact of a doctor's background on their communication, attitudes and behaviour. This is considered and taken into account when investigating concerns.

Given UK health services’ heavy reliance on international talent, we see this work as absolutely central to being the most effective regulator we can be. And we’re committed to embedding the principles of fairness and compassion in everything we do.

Conclusion

The profession of which we are part is changing and we, as its regulator, are changing too.

We've come a long way since my father prevailed on the Marquess of Bute to show his largesse and help develop a modern service. And, in the 50 years since the cap on female medical students was lifted, we’ve come even further still.

Change is at the heart of medicine. As doctors, we stand on the shoulders of all those who’ve gone before us – drawing on their successes, and their mistakes, to develop our understanding, improve our techniques and drive forward progress.

But what remains immutable is the sacrosanct responsibility we, as doctors, have towards our patients. Fulfilling that duty well relies on our skill and expertise, yes, but also the wider environment in which we work. And ensuring that those environments are open, supportive and inclusive is the obligation we – be it employer, doctor or regulator – all share.

Thank you.