Derm has been a very very popular specialty in the US for many  decades. Some of this reflects work / life stuff, the ability to mix surgery and physician-like diagnostic skills, and because skin disease matters to patients a great deal, and if they purchase their own care, they put a big value on it. (And in truth the fact that acute medicine is deeply unpopular and unsustainable as a longterm career). I have been told similar changes are playing out in the UK, but I hadn’t seen any figures. Here is a summary for ‘medical’ (sic) specialities from the RCP just published in ‘Clinical Medicine’ showing, as for lots of domains, the winds blow east across the Atlantic.

Well, I blogged a few days ago about a medical education paradigm that needs terminating with extreme prejudice.

The world will end before you can read all the papers on student learning in medical education and find ten that actually validate cross sectional data of what students think, with measures of long term learning and competence. The paradigm is a failure. Can we stop.

 

Nay chance. Look at this. Not a measure of learning in sight. ‘Happy charts’. And I think the sun goes round the earth, so that’s OK too. Yes, I know, skip reading the literature, or get therapy.

“Theory without practice makes more sense in theory than in practice” –

 

[simnor_button url=”http://www.tonybates.ca/2014/04/05/learn-to-fly-online/#sthash.xrbzL6vk.dpuf ” icon=”double-angle-right” label=”Mark McGuire quoting ? ” colour=”white” colour_custom=”#fff” size=”medium” edge=”straight” target=”_self”]

Well, imagine if this catches on:

Interesting series of articles in Science on research funding. Worth a read if you are thinking about careers.

Stephen Downes has — as usual— an insightful slant on things. He is commenting in relation to an article here. He writes:

Someone asked me this week whether I thought the skills mismatch really exists. The idea of the skills mismatch is that despite persistent unemployment, there are high-skilled or specialized jobs that go unfilled in large numbers because people with the skills aren’t available. My response was that the existence of hundreds of colleges and universities is de facto evidence of a skills mismatch. So when a publication like the Globe and Mail calls the skills mismatch a fairytale, it is referring to one specific statistic in one particular industry, which may or may not be misleading. But in fact, there have always been skills mismatches, and while we can’t predict precise job markets, we can do our best – government, industry and education – to prepare people to adapt and grow into the new needed skills. “What you can try and do is ensure that you are as resilient as you can be and that you have the broad set of flexible skills that allow you to take advantage of an opportunity when it comes along.”

 

One definition of education (as compared with training ..perhaps) is of course is it is that which provides resilience in the face of change. Better still we might consider using Nassem Taleb’s term, anti-fragility. Humans are not fitted to one ecological niche, rather evolution has selected us for the ability to fit into many niches. We can also not just respond to the environment, but becomes masters of it (and therein lies on occasions hubris). This is one framework in which to view education. Those who believe in medial education as well as medical training, will warm to this approach. The difficulty is defining what aspects of education really do facilitate the ability to adapt. The usual mantras of ‘teaching lifelong learning skills’ I am deeply sceptical of. You can cultivate those attributes, you can signal you value them, but you can’t expect to ‘tick-box’ them.
(more…)

The world will end before you can read all the papers on student learning in medical education and find ten that actually validate cross sectional data of what students think, with measures of long term learning and competence. The paradigm is a failure. Can we stop.

 

[simnor_button url=”http://www.biomedcentral.com/1472-6920/14/56 ” icon=”double-angle-right” label=”No more please ” colour=”white” colour_custom=”#fff” size=”medium” edge=”straight” target=”_self”]

Even with more stock videos of  medical students here

via Status-Q

For me, several years removed from training, the stony bureaucracy and burdensome administration are astonishing. Modern shift patterns have broken teams where peer and consultant rapport made being a junior doctor survivable. Now, rather than judge juniors through a colleague who has taught them and seen them on the job we use anonymous comments from someone on a feedback form. This causes huge distress. The moral contract of medicine, of choosing to do a job out of care and love, has been fractured because of the unyielding training structures that senior doctors have bequeathed.

 

Margaret McCartney on the dismal and worsening state of postgraduate education and training in the UK. The title ‘Frankly, it is not much fun’ are her words, but the words that spring to my weary mind are those of William Blake: ‘A dog at the master’s gate, predicts the ruin of the state.’ And so it will come to pass.

As far as I can tell most medical students do not know much about how undergraduate medical teaching is funded. This is not all together surprising, because it is complicated, and owes much to historical norms and structures that are now been swept away (at least in England). Everything about student finance appears confusing, even the 9K fees in England are not straightforward. How can increasing fees from 3K to 9K end up costing the government more? Hardly intuitive. (For more on tuition fees see ‘Explained: how is it possible to triple tuition fees and raise no extra cash?’ or have a look at Andrew McGettigan’s book.)
Funding of undergraduate medicine appears complex because more than one funding stream is used, and there is likely lots more cross-subsidy. So, whereas for a course in Modern Languages, the student pays fees (or at least the government does on the student’s behalf, and then the government of government proxy levies additional tax on the student when they graduate), there is no other significant stream of funding. Other monies may be involved —capital costs, endowments or even research funds— but the bulk of the cost of the course has to be met from what students pay. If not, there has to be cross subsidy from elsewhere. This financial architecture seems relatively straightforward in comparison with the situation in medicine.

In medicine the student may pay 9K (not in Scotland, of course) and in addition the Higher education funding council puts in another ~10-12K. So, a total of ~20K per student per year, for 5 years. All well and good. However, clinical teaching in hospitals and GP practices is also supported by a funding stream that comes via Health Boards—independently of the University. This money appears to exist at the aggregated level, but is much harder to locate at a lower unit level. It is called ACT in Scotland, and SIFT in England. The sums of money are very large, and are designed to reimburse the local NHS for all the staff time and facilities that are used my medical students. I do not know exact figures, but most clinical teaching is probably delivered by NHS rather than university staff (the ratio may vary with the type of teaching). For instance, a Health board or series of health boards with 840 students (280 for each ‘clinical’ year) might receive ~20K per student/year. Facilities will obviously include capital costs, but the bulk of money one would have thought would be accounted for by doctor time.
I do not know of any high quality empirical studies of where this money goes, but it is generally accepted by those on the ground that most of this money is not used to actually deliver teaching. I have heard senior NHS figures accept it is hard to justify the bulk of this funding in terms of its apparent intended purpose (the story of how those amounts were arrived at, I will leave for another day, save to say they were not very sound). However, whatever the original rationale or justification for the scale of the funds, this is what the tax payer is contributing, and what they are being told is being used for training future doctors (‘we paid for their training!’). The reality is that some of us think most of this money is not actually being used for this purpose; and the suspicion is that an ever increasing bureaucracy eats into it. Hard data would resolve this issue.

There are however other movements of money between universities and the NHS. Clinical academics deliver NHS work, but the universities are not generally reimbursed for this work. Individuals might however receive clinical excellence payments, which are in addition to their university salaries. In terms of the ‘direction of travel’ I suspect such payments may not enhance student teaching very much, but rather focus academics minds on research and on taking on NHS wide tasks. Just to add more complexity, a significant proportion of clinical academics receive their salary from the NHS, although this may come via the university payroll (the NHS gives the money to the university, who then pay the individual academics). I do not know what proportion of clinical academics are funded this way—people used to quote up to 40%– but I have tended to assume this percentage may have dropped over recent years. Overall, academics comprise less than 5% of consultants, but in larger teaching centres the figure will be higher. They are of course to varying degrees, part time clinicians.

The headline figures in summary for fees are that 20K a year is coming from the student and government direct to the university, and for clinical students the government is paying perhaps another 20K via NHS health boards. This makes quite an annual figure of 40K, but the headline figure takes little account of hidden cross subsidies. In the NHS, some of this money is diverted to treat patients; and in the universities, if the data from the US that Rich DeMillo quotes is correct, it is likely diverted into research.

A lot of money. How things could usefully change, I will leave for another day. If you can correct any of these figures, please let me know.