Late night thoughts on medical education #1: we have no doctors

Today’s (Scottish) Daily Telegraph ran with a story about the shortage of paediatricians in Scotland. The Herald had a similar story, too. It is not just paediatrics that has major shortages. The same can be said about dermatology, radiology and a host of other areas of medicine. And that is not to mention GP land, which normally seems to attract most ‘government’ attention.

I find none of this surprising. The NHS has long been in subsistence mode, eating the seed corn (or to use that other phrase, ‘eating its young’), spending its moral and cultural capital at an alarming rate. Management is notable by its absence, whereas the administrators think they are ‘managers’, in part, because they can’t administrate and stay sane. By lack of management I meant those functions of management we see in most corporations or freestanding institutions. Changes in demography have not happened suddenly; the relation between age and health care provision, has been well known for a century or more; the impact of family structure and geography on care provision of elderly relatives evident since the early 1960s; changes in work force have been growing  for at least 40 years; and UK medicine has a long history of ignoring why people wish to leave either the UK (or want to leave the NHS). The attempt to run health care as a Taylor-like post-industrial service industry using staff who value their autonomy and professionalism, may not end well for doctors — or patients.

All the above, management should have been grappling with over the last quarter century: instead they have been AWOL. Meanwhile, politicians engage in speculative future-selling, where electoral vapourware is often a vehicle for the maintenance of political power. Given the state of UK politics (as in the BxxxxT word), it seems reasonable not to give politicians the benefit of the doubt any more. As individuals, no doubt, most of them mean well, and love their kids etc, but the system they have helped co-create, cannot command respect (that is now electorally obvious).

There are however some aspects of this that bear on what keeps me awake at night: how we educate — and to a lesser extent—how we train doctors.

• The UK has not been self-sufficient in physicians since the birth of the NHS, rather choosing to import staff from the rest of the world. Despite this, doctor numbers are low in comparison with many other advanced economies. More dermatologists in the city of Vienna than in the UK……
• Manpower estimates AFAIK, seem to reflect realpolitik rather than be based on bottom up data. Whatever is estimated is decided by the ‘realistic medicine’ availability of cash. Our politicians and the commissars of the medical establishment do not dissect animals in order to learn how the world works, they sacrifice them to the gods of political power, hoping some of the blood runs off on them.
• The idea that you can plan on the basis that ‘x’ is the number of doctors you need in 10, 20, or40 years seems foolish. Hayek was not wrong about everything, even if Uncle Joe didn’t read him. Dead reckoning usually loses out to a good GPS system.
• Most importantly of all, you must overproduce doctors. There are various ways you can think about this, but the current system of taking a bunch of 18 year olds into medical school and assuming that attrition will be low, will breed complacency. You cannot build any organisation that is worth working for when the ratio of applicants to vacant posts is less than one. And to miraculously imagine you can get the figure right over a score of years, is well….(and no, the running mean isn’t the right figure, here).
• Medical education is claimed to be expensive and rate limiting (a Mr Hunt line, I think). There are various comments to make. First, the figures are inflated for political effect and possibly for accounting reasons. Claims that it costs £x to produce a consultant write off all ‘work’ the individual has done on the way to that position. By contrast, the NHS subverts market rates for many jobs done by ‘juniors’. And, as for undergraduate medical education, we know most of the money is an accounting sleight of hand. If you ask could we do it better, for less money, I will tell you for free.
• The comments in the last point not withstanding, it must be an immediate goal to reduce the cost of medical education; and to think how the workforce of non-physicians can piggyback on what we know about training doctors. These conversations were alive half a century ago, and we have made little progress. The key issue is straightforward enough: without national accreditation, these posts will not encourage candidates to undergo training — you don’t need to read Gary Becker to get this, just talk to those who leave nursing — there are enough of them)
• Even with more fluidity within professional careers, you need to allow for sideways movement and retraining of many middle aged doctors. You need to encourage staff, and move our focus from competencies(ugh!) to skills.
• Without funnelling a lot more students into medicine as a career, little of what I have said above will make much difference. There are ways, but that is for another day.

Nothing new under the needle

After needles and morphine were deployed in the American civil war, as many as 100,000 veterans were left addicted. In 1895 scientists at Bayer, a German pharmaceutical firm, began selling a strong morphine compound called diamorphine. To market it, they called it “heroin” from the German word meaning heroic.

Article in the Economist on oxycodone dealing with — well not medicine — but business

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Well, words from the past, to remeasure the future. I am on (a sort of) sabbatical for six months. There is a project, about which I will say more later. My writings here will change, too.

De Selby’s numerical calculations

My experience of Irish government state employees at the ‘border’ is that they aim to be the antithesis of ‘hostile’. It is not a bad USP. Passing through Dublin or Cork is an enjoyable experience: “Welcome home Jonathan’, is not the most formal salute; or, in the case of my wife, “Lisa — from Mulfulira—I remember you”. But this aside in the Economist, brings a little of the Flann O’Brien to the party.

In the 1970s, when contraceptives were still banned in the Irish republic, a family-planning campaigner went south with 40,000 condoms in his station wagon; his insistence that they were all “for personal use” was met with good-humoured banter by an Irish police patrol.

The Border: The Legacy of a Century of Anglo-Irish Politics. By Diarmaid Ferriter. (reviewed in the economist)

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Quoted in Carel Stolker, ‘Rethinking the Law School’ 

According to a British survey among first‐year law students, the word that best reflects the students’ general attitude is ‘disengaged’. This disengagement is caused particularly by the lack of human connection in almost every educational practice, from teaching methods to our formal assessments. There is extraordinarily little formal human interaction in our first year.

This is a business model. Just not one you would want to emulate. At least Stolker’s home institution, Leiden, has an excuse.

This is from an article in the THE. Catherine Heymans is a physicist at the University of Edinburgh, who works on “dark energy”. She is planning to leave the UK to work in Germany (yes, Brexit). But what caught my eye was this quote describing one of those lightbulb moments (pun intended)

Question: As a physics undergraduate, how did you feel when the theory of dark energy first emerged?

Heymans: ‘It was 9am, and I was sat in a lecture theatre waiting for our lecturer to turn up – he was late. Eventually he ran into the room and said: “We’re not going to be studying high-energy astrophysics today, because the most amazing paper has just been published – you have to see this stuff.” It was new data that showed that the expansion of the universe was getting faster and faster, which could only be explained by extra, unseen “dark energy” in the universe.’

It is an interesting test for whether you believe in the ‘research led teaching’ trope. Or is it: will this be in the exam?

Noting that 1,500 people had travelled to Davos by private jet to hear David Attenborough talk about climate change, he said he was bewildered that no one was talking about raising taxes on the rich.

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No, not that sort of (dermatological scale). Adam Tooze quoted in FT Alphachat (or another link).

In three years China used more cement that the USA in the whole of the 20th century.

And when they say you are a dreamer, a fool, and deluded, I will use a nice inversion by Lincoln Allison:

Of course, you’re assuming that none of this will ever happen. But you assumed that Brexit and Trump would never happen, didn’t you? 

(Smashing things is however easier than building things).

 

Seen in George Square. I get the Econ101 bit, the 1984 reference, but… And no, I can’t manage crosswords either — although I shared a flat with somebody who, as a student, refused to leave his bed until he had completed the Telegraph crossword. There were studies, and then those other studies.