An eminent Irish surgeon likes to tell friends at parties that he wears a bracelet for protection. It names certain towns in Ireland and states that if he happens to be in a road traffic accident needing hospitalisation in any one of those identified: "Please don't operate."

The anecdote is less funny after a week of truly alarming revelations about medical practice by an obstetrician in one Irish hospital and two surgeons in another. In none of the three cases do their Irish consultant colleagues appear to have been involved in blowing the whistle.

An obstetrician removed wombs from an extraordinarily high number of women over a three-year period. The phenomenon was not picked up by his profession and it took vigilant midwives to draw attention to it. Three Dublin colleagues and some local ones backed up the consultant. It was an outside UK consultant commissioned by the North Eastern Health Board who finally reported that something was seriously wrong.

In another hospital, the practice of a general surgeon was reviewed twice by his profession and no restrictions on his activity were recommended. Then a UK consultant - again at the initiative of the local health board - reported a series of poor judgments and decisions, at least one needless death, another lucky escape, some gross negligence and poor patient management. Concerns expressed by nursing and hospital management rather than by consultant colleagues led to the UK investigation.

This surgeon's colleague took early retirement this year after he too was investigated by a committee appointed by the health board following a complaint from the family of a cancer patient. While the committee cleared him of misconduct in relation to surgery on the patient, it found there was a lack of information given to the family, that they had been "ignored" and the surgeon had refused to make himself available to them, complaints backed up by nursing staff.

Nine women who were patients of the consultant gynaecologist-obstetrician Dr Michael Neary at Our Lady of Lourdes Hospital in Drogheda were contacted by their GPs this week and told their cases were now being reviewed. Further contact was made by the North Eastern Health Board in the following days. The implication is that their hysterectomies may not have been necessary.

As the week progressed an increasing number of women were contacting the local radio station LM/FM. Up to 70 women called, saying they had been patients of Dr Neary. Many were distressed at the situation and were very critical of the doctor.

A number were supportive, however, saying he had saved their lives in the past. One patient rang The Irish Times yesterday to say Dr Neary was "an absolutely wonderful, caring doctor".

The radio station appointed a co-ordinator to deal with the women. The health board set up a helpline at the request of local senator Mr Fergus O'Dowd. A number of women who had hysterectomies carried out by Dr Neary are now questioning the treatment they received. It was suggested this week that the women will be able to get access to their files by using the Freedom of Information Act.

Despite numerous attempts this week, The Irish Times received no response from Dr Neary or the North Eastern Health Board. Approaches were made directly to Dr Neary, as well as to his solicitor, offering them the opportunity to put his side of the story.

The hospital, which was run by the Medical Missionaries of Mary until it was taken over last year by the health board, has over 280 beds, including 68 maternity beds. It was founded after the second World War and Dr Neary worked there for more than 20 years. It is believed that the length of time patients are kept in the hospital for various procedures is longer than average in some cases, and a further investigation is under way into that.

THE whole affair, said one doctor this week, "will be very painful for us all as it works through the system but I'm sure that much good will come out of it". Most consultants perform responsible jobs well. Even the very best are capable of misjudgment, as in all professions.

However when it comes to detecting and preventing poor practice there appears to be a serious problem.

The question now is whether doctors should be allowed to continue policing themselves, as they do currently under the guise of the Medical Council. The system of "peer review" under which consultants are supposed to be monitored constantly by each other is also open to question. As the two cases revealed this week showed, Irish consultants are often particularly slow to judge their colleagues harshly.

The majority of consultants would tell you that self-regulation should continue. General practitioners who do not have quite as much power would be a little bit more sceptical, although in general favouring self-regulation.

Many doctors view the Medical Council with grave suspicion. One explained that the anti-abortion groups had organised themselves sufficiently well to get some members elected and that if he were to put himself forward next time "I would find myself answering questions on where I stood on abortion."

Most Irish consultants would baulk at the some of the changes being introduced in Britain in the wake of the Bristol case . The idea of patients being able to look at a league table of hospitals and be able to see at a glance how a surgeon performs at certain operations, or the hospital's overall record in a certain speciality, is anathema to most of the Irish medical profession.

But that day is not too far away, according to Prof Austin Leahy, president of the Irish Society of Quality in Healthcare. "I think eventually people will be able to look at figures for various places," he says, and the profession alone will not continue to regulate itself.

After all, he says, "is there anyone who would trust the bankers to police themselves, or solicitors or accountants? The reality is that the public will not tolerate internal audits if they are not transparent or have not had multi-disciplinary validation. Surgeons alone cannot validate surgeons."

Medical sources say that the Department of Health already has figures for procedures that are being carried out in hospitals around the country. However "they have no idea of the quality. We have fallen behind in this area because the profession does not have its heart in it."

One doctor pointed out that if a drug company wished to launch a new drug it had to spend millions of pounds, conduct extensive clinical trials involving thousands of cases, and publish results. "But if some yob decides that he has found a new way of taking out an appendix or kidney there is nothing to stop him. It is the last area of whim."

One GP explained that if she wished to refer a patient to a consultant she only had reputation to go by. "I have no idea of that consultant's mortality rate, their rate of postoperative complications. The only thing I have to go by is reputation."

Another doctor pointed out that private patients are even more vulnerable than public patients. "If I wanted to carry out an audit of in-patient activity in the Mater Hospital I would be able to do it, but I couldn't do it in the case of private patients."

Prof Austin Leahy said the Royal College of Surgeons in Ireland was in the process of introducing a voluntary quality assurance programme for Irish surgeons. In the future, he said, it might become compulsory - which would require a change in the law - but he believes it is better to start on a voluntary basis.

Surgeons will be able to see how their statistics compare with others and eventually, he said, people should be able to look at figures from hospitals all over the country and how they rate for different procedures.

Clinical audits do take place in individual hospitals, but the information is not reviewed. Prof Leahy says that in Beaumont Hospital, where he works, there are conferences to discuss cases and the number of deaths. "Our statistics are regularly examined. There is a lot of audit going on at the moment. Surgeons have to be involved in it or they will not get sanction from the RCSI." In the New Year the major teaching hospitals in Dublin, Cork and Galway are going to take part in an evaluation, including survival after operation.

"A journalist will have their work looked at by a news editor, a sub-editor and maybe others. If their work is not good they may be fired by the editor. Doctors don't have that sort of evaluation. "On the other hand if a doctor decides to treat a patient a certain way, you don't want hospital management interfering with his clinical judgment. Patients want to sit down and agree a plan of management and they want the doctor to deliver that. However the doctors need to ensure that what they are doing is up to international standards."

Another doctor argued that there should be league tables, and suggested such tables of Caesarean rates for Irish maternity hospitals would provide interesting reading. "Of course we don't have them. I think our rates are high and for the wrong reasons - there is needless intervention for legal reasons."

Ireland, says Prof Leahy, is "probably a little behind" other OECD countries in monitoring the performance of the medical profession. A recent survey found that only a quarter of hospital managers have a quality scheme in operation. A majority felt that any steps they might take to make improvements in their hospital would not require much money.

Another doctor said that as a person who advocated patient involvement and wanted to see clinical audit he was viewed "with some suspicion and as a bit of a nuisance . . . There is a hell of a lot of suspicion out there and of course it is not helped by the fact that so many law suits are being taken against doctors."

Questions have been asked this week about who should judge the case of the consultant obstetrician. A review is to be carried out by three members of the Institute of Obstetricians and Gynaecologists. But, is it right that he be reviewed by his Irish peers? According to one very eminent obstetrician it should not be his peers, but instead, an impartial group from outside the country. The doctor under review is a member of the Instititute of Obstetricians and Gynaecologists, along with the vast majority of his colleagues.

But a Dublin obstetrician, who is a member of the executive of the institute, said he was not in favour of this course of action: "The institute is a fairly toothless group of people. They are not very authoritative. I think they should stay a million miles away from it."

The institute is primarily concerned with development of the speciality, postgraduate education and training, and has been involved in developing continuing medical education for obstetricians. However this is a voluntary system.

Other consultants are adamant that Dr Neary's cases should be reviewed by Irish colleagues, not outsiders. They say Irish consultants are familiar with how medicine is practised here, while outsiders do not understand the nuances of practice in a particular country.

Dr Neary has already received support from three Dublin colleagues who wrote a report which was at odds with the outside report commissioned by the health board. However one consultant suggested this week that those three colleagues may not have had access to all the files.

This consultant was also was critical of the fact that the institute had not been more pro-active in reassuring women who may have concerns following the revelations this week about the removal of wombs and ovaries. "I really don't think this pussy-footing around is doing anyone any good, neither ourselves nor the patients." When contacted by The Irish Times this week the institute refused to release the names of its executive members.