I wrote this several years ago for a publication that I will not name. I doubt it was their sort of topic, but reasoned it was still worth a shot. It was, but they didn’t want it. I have written similar sorts of things before for WONKHE (see here) and the Times Higher who edited my draft to make it almost unreadable (IMHO).
I was gossiping to a friend and former colleague over dinner recently on this very topic so thought it worthwhile to post.
Why does training doctors cost so much?
Undergraduate medical education is expensive. Quoted costs are in excess of £200K per graduate, with most of this money flowing directly to the NHS rather than the medical school. Each annual clinical placement fee, the money that supports a student being taught within a NHS clinical environment, costs the taxpayer as much in salary as a newly qualified junior doctor. Scant attention is given to whether this system represents good value, or whether radical reform is needed.
The touchstone of medical education in the UK was that of the 1950s London teaching hospital and associated medical school. The first two years were spent on the foundational sciences— anatomy, physiology and pathology— within the attached medical school, followed by a three year clinical apprenticeship on the wards of the paired hospital. It made organisational sense. The medical school was literally where the dead bodies were, and the ward (“the bedside”) was where the patients were, as primary care was underdeveloped. It was a small world. There was only a handful of specialties, with most doctors being generalists, and the annual class size was often under forty per year. A similar number of consultants delivered most of the teaching.
The goal of undergraduate education, and the purpose of each medical school was to produce doctors ready to enter independent and unsupervised practice on the day they passed medical finals. I remember being taught by a GP who recounted how twenty-four hours after graduation he attended a birth in a patient’s home at 3am necessitating the use of forceps. In this intimate community, students were true apprentices: many had been paid an honorarium — as I was in the early 1980s — to cover more senior doctors’ absences. This world no longer exists.
Three changes stand out. First, most diagnostic and therapeutic decisions are not now taken at the bedside but in a consulting room either in an outpatient clinic or in primary care (‘office’), but most teaching is still fixated on hospital inpatients. Second, pace Adam Smith, the productivity gains from the division of labour, reflected in the explosion of specialties and sub-specialisms are impossible to cope with in an undergraduate course, which increasingly is made up of a myriad of short weeklong or biweekly attachments. Imagine a music degree where you have to learn a new instrument every other week. By graduation, any single student might have been taught by between 300-500 individuals, many without domain expertise or deep experience of teaching students, across ten or more hospital sites. Third, the license allowing independent and unsupervised clinical practice is no longer university graduation, but the award of a certificate of specialist training whether as a hospital consultant or a GP six-to-ten years later. The idea of a generic doctor who can or should practice independently is an anachronism. I speak as somebody who chaired a medical finals exam board for eight years keenly aware that I, close to thirty-five years from my own graduation, would be unlikely to pass. How could we reform this process?
Apprenticeships only makes sense within the context of a paid job. The purpose of any pre-clinical teaching is to prepare students for the cacophony that is the clinical workplace. That is all. The pre-clinical syllabus can be stripped down, and entry to clinical training via a national entrance exam. Universities can offer premedical degrees that cater to it, or even one-year masters, but we should take a lesson from law or accountancy and allow those with other degrees to sit the pre-clinical qualifying exam (even if based on private study or tuition). As for the clinical apprenticeship itself, employ staff just as is the norm in other apprenticeships. Start slow, keep it personal, and build up expertise over time. Just as you wouldn’t expose the novice pilot to aerial combat on their first day, allow the apprentices to work in office practice rather than inpatient wards, and let them carve their own path. There is a thousand year old business model that supports a financially viable reciprocity between on the job apprentice learning and value to the employer. The exams that confer specialist certification 6-10 years later will be the only national guardrails required.
As for money, it is an open secret among those who have organised undergraduate clinical teaching that most of the NHS money allocated to clinical teaching is diverted into direct clinical care. The layer upon layer of obfuscation that allows this would make even those who run tax havens blush with envy. The irony is that if students were employees — as I suggest — and specialised early, and trained within the environment they will later practice in, they would learn more, cost less, and fewer might be tempted to join the exodus to sunnier climes or leave medicine prematurely.
