Not in Kansas any more: Alan Crockard’s resignation letter decrypted.

Professor Alan Crockard is a neurosurgeon. He was until yesterday also the National Director of Modernising Medical Careers, which may be the crack that’s needed to split open MMC and get some fresh air and new thinkers.

Here is the text of his letter to the Chief Medical Officer, Sir Liam Donaldson, with my emphases and commentary. When I first read it, I thought he sounded like a sincere man, perhaps a bit older and wiser and sadder than before. Like a neurosurgeon who had tried medical education and politics, and found them harder than he expected.

But then I read it again…

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Dear Liam

I wish to resign from my position as National Director for Modernising Medical Careers with immediate effect. I am increasingly aware that I have responsibility but less and less authority.

I know I’m going to be blamed for all this, so I am going to go before I am pushed, but it wasn’t my-y-y-y-y fault.

I care deeply about medical education and training. In 2003 I moved from the College of Surgeons where I was Director of Education to join the MMC team. At the College we developed a competency based curriculum. These ideas rolled over into MMC where the team put together the Foundation Programme which was launched in 2005. It also involved coordination of the stakeholders in curriculum development, training the trainers and carrying out numerous road shows to set the scene for consultants and trainees. It is now considered successful and fit for purpose. In addition the doctors completing the Foundation Programme this year seem as if they will match well into the new Specialty Training Programmes.

See! Look! We got the F1/F2 stuff right.

As a prelude to new Specialty Training, MMC worked closely with PMETB and all the stakeholders to facilitate the new competency based curricula and set the scene for such a radical change in training.

Manifestly, specialty training is an order of magnitude more complex than Foundation,…

Um. The next bit was really hard.

…but it became obvious that the MMC team’s expertise was less used in planning of specialty rollout.

And they didn’t ask our advice - so it’s not our fault they got it wrong.

How can the National Director of the MMC say that the MMC weren’t asked to design and implement the MMC? - AB

MTAS was developed and procured by DH outside my influence.

Not my fault, guv. I wasn’t even there

An email (12 October 2005) to our team made it abundantly clear that Debbie Mellor has been tasked with delivering a recruitment system to recruit junior doctor posts specifically FP1s and ST1s.

Look! Look! It’s her!

I am not clear how far you should (or want) to be involved in this. We don’t want to tread on any toes, but equally we need to be clear about what level of autonomy this Programme has.

The MMC programme has been the subject of an OGC Gateway Review in September 2006 (DH331), they concluded “that the programme has made significant progress since the OGC health check in August 2005″.

“has made significant progress” is not the same as “has been successfully delivered”. A cervix that won’t dilate past 3cm could be said to have made signficant progress. Of course, he’s a neuro-surgeon not an obstetrician.

The report overall was supportive of MMC, but there was one serious red risk. This was to identify a clear break point for the MTAS project beyond which the contingency arrangements should be activated.

I don’t actually understand this, and I am good at understanding management-consultant-speak.

I think he’s saying that the MTAS people had failed to create a “Plan B”, though he may be saying that they had failed to work out in advance when they should say “Plan A isn’t working, we must implement Plan B”.

It’s impossible to tell if he is referring to the technology here (extra server capacity, extra bandwidth stuff like that) or if he is referring to the people side of the process - making sure there were enough people to mark the applications, and so on.

Peerhaps the fullstop is in the wrong place. He might mean “The report overall was supportive of MMC. However there was one serious red risk: this was to….”

Whatever he actually means, he’s clearly still attempting to say “MMC good: MTAS bad”.

It also commented on the unclear leadership between DCMO and two senior responsible officers. From my point of view, this project has lacked clear leadership from the top for a very long time.

And now he’s got the nerve to say I told you so.

Moving to the last few weeks, I have become increasingly concerned that the well intentioned attempts to keep the recruitment and selection process running have been accompanied by mixed messages to the most important people in the whole process the young doctor applicants. I realise that the service must continue to allow patients to be treated and I know little of the law, but it seems to me basically unfair to advertise the possibility of four interviews and then suggest that these might not be honoured. Equally devastating would be the suggestion of some stakeholders, that the completed interviews be discarded and the process be rerun. I accept that in many areas and in many specialties, this round of recruitment and selection has been acceptable. But the overriding message coming ack from the profession is that it has lost confidence in the current recruitment system.

I’m not even going to comment on this last paragraph, it consists entirely of flannel dipped in oil.

With my very best wishes.

Alan

Nothing at all about cutting the numbers of Specialst Training posts.

An impressive bodyswerve past the fact that there are significant question-marks about the likely effectiveness of the Specialist Training.

A complete blank on his responsibility as National Director of MMC for the changes introduced by MMC. He associates himself only with the bits that have gone well.

No hint at all that the transition from old to new has been forced through.

All in all, an unpleasant bit of blame-mongering. By contrast read the letters of resignation of the MMC’s student advisors.

I am really curious to know why he chose to resign right now. Maybe he wants to return to Western Australia where he is Professor of Surgical Neurology. Who knows better than he does where our most ambitious and determined doctors are going? Maybe it’s all been a Cunning Plan.

Modernising Medical Careers isn’t Working

I know, I know, I’ve got too much time on my hands, but a little light photoshopping is a nice displacement activity while I sit around to see whether or not the rumour is true that Crockard is going to resign. I doubt it. [It is! He has! Woo Hoo! - Way to go Lindsay Cooke!]

In the meantime, I’d like to draw your attention to two informative and thought-provoking comments I’ve received on my blog entries.

Vinay Shanthi has posted a detailed explanation of exactly how we’ve stitched up the International Medical Graduates. See these goalposts? No. You don’t. We’ve not just moved them. We’ve taken them away. (My sarcasm).

And the Witch Doctor raises some particularly interesting questions about Feminising Medical Careers. What a radical thought.

In the meantime I will leave you with a portrait of someone who is neither an IMG nor a woman, someone in fact who is positively 19th century in his sleek, smug paternalism. See the books, indicating learning. See the gentle smile, indicating kindly wisdom. See the eyes, so farsighted, so sincere. This gentleman, who would no doubt prefer a properly gilded frame instead of a shoddily photoshopped one, is Professor Steve Field, Regional Postgraduate Dean of the West Midlands. A clever white man.

We do have one reason to be grateful to him.

He ran the West Midlands Deanery so shabbily that the West Midlands Surgeons, may their light-sabres always thrum, refused to indicate the candidates selected by MTAS, thereby turning the whole sordid mess into a News Item.

Thanks, Steve.

Unasked questions

Very occasionally something interesting turns up on the list of search terms people have used to find my blog. A couple of days ago someone searched for “question NLP never asks”. It’s almost a zen koan, and it’s certainly an interesting search term for a thinking NLPer. All NLPers should be thinkers, though sadly this is not so.

There are of course two sorts of questions one never asks. Actually, make that three.

The first sort are the ones which there is no point in asking because if, by happy chance you are told the truth, you won’t believe it: Does my bum look big in this? Have you stopped seeing her? Do you really love me?

The second sort are the questions which will rock the boat. The US Military has made not asking questions its official policy on homosexuals in the military: “Don’t ask, don’t tell” indeed. In these cases, it is better not to know the truth. These are the questions that Tessa Jowell presumably didn’t ask her husband.

The third sort though are the interesting ones. These are the ones we don’t ask because we don’t think in those terms. These are the questions that inhabit our blind-spots, whatever they might be.

It’s been a while since I’ve had a koan to play with, and without getting too thought-for-the-day about it, I am now asking myself “what questions don’t I ask?”

It’s easier to see the back of your own head without a mirror.

Lords, Ladies and Politicos

I’ve just spent an hour or so going through the biographies of the members of the House of Lords. Well, those whose names begin with the letters A-F. (It seemed to me that it might be worth writing to members of the House of Lords as well as to MPs and local papers and so on about the whole MMC thing) . They’re a pretty rum bunch, I have to say.

There really is no such thing as a “Typical” Lord, but there are some Types.

The Activist

The men big up their early jobs as postmen or lathe-turners and also lay great stress on their activities in a Union or in Local Government. The women may have spent a few years nursing and lots of years telling other people how to nurse. Some activists were loonie-leftie counsellors in the basket-weaving-black-disabled-lesbian-creche days of the GLC. Others have a long career fighting real problems such as ethnic minority rights.

The Career Civil Servant

Remember Sir Humphrey? He’s now Lord Oleaginous of Patronage.

The Hereditary

Public School, the Royal Agricultural College, a year or two in the Army, and a life either animal husbandry or merchant banking. Or both. No jokes about buggery or the collective noun for bankers being a wunch, please. Mind you, one of the youngest of them lists his career as “artist” and his interest as “keeping bees”.

The Engineer or the Scientist

I was suprised by the number of engineers who end up in the House of Lords. On the other hand, engineering covers quite a wide range of activities: construction, petrochemicals, bio-engineering, even manufacturing. I found it rather comforting to see so many science degrees though.

The Lawyer

A couple of law degrees, a distinguished career, a choice of wigs. Why practice law when you can make it?

The Media Type

These ones have the flakiest or luvviest CVs. I am sorry, but being an advertising agent does not make you one of the great and good. The press barons make this lot look seedy, and when you think how seedy the press barons are, that is quite an achievement.

The Lords are an educated bunch, most of them have good first degrees, (though there are a depressing number of economists on the red benches), and a fair number of them have Masters or Doctorates too. I was particularly impressed by the Physicist who mentioned that he had 14 honorary doctorates.

I’ll tell you something else about the Lords. They are all incredibly well connected. They are networkers par excellence, (apart from the bee-keeping artist). They get involved. They sponsor this, and chair that, and are members of the other, and have been doing it for two, three or even four decades.

Secretly, I’m rather impressed. Some of them are quite clearly deeply experienced professionals: intelligent, educated and probably wise. Others are slimy brown-nosing politicos. There were a fair few of them I’d like to meet. By and large, I was surprised by the diversity in the Upper Chamber.

PS - If you fancy a stint looking for doctors in ermine, please start at the letter L, and post the names of whoever you find in the comments. Not that I’m cadging, or anything.

And now for something completely different

A while ago I wanted an image of powerful, self-contained womanhood, and I scratched around mentally for women I know. Not my former boss - she presents a strong persona, but it’s brittle and overlays a lot of uncertainty. Not my friend C who has become one of the most resilient women I know - she’s too daintily feminine, lovely though she is.

Eventually I remembered the model from a life-drawing class some time in the mid 1990s. She’s remained a personal icon ever since. I felt like a change of mood in my blog, and I thought you might feel the same, so here she is.

She was French, very strong, very compact. Her head was in proportion with her body and she did not in fact have deformed shoulders. (It’s a combination of foreshortening and the angle of the light. Of course it is.) She came in, undressed, sat herself down immediately without settling herself for balance or comfort, and then stayed completely still for an hour.

Killing Polar bears - right or wrong?

First off, please look at this cutsie-wootsie video of the ickle wickle polar bearcub.

See him kiss his “foster-father”. See him get his head stuck in a towel. See him wave his paws at the camera. Could anything be swe-e-e-e-eeter?

Whoever is putting these videos together isn’t missing a trick, and Knut is genuinely as cute as a button.

Worryingly though, I can follow the logic of those who say that he should be put down. At the moment he is roughly the size of the Andrex Puppy and because he is younger he is even sweeter. However polar bears are not labradors, and he’ll grow up into one of the world’s largest living carnivores. Now, I’m not sure how wise it is to take actions which will result in half a tonne of poorly socialised and un-castrated carnivore living in captivity. Maybe the Germans are raising Knut as an answer to Trident. These are creatures which will attack a Nuclear Submarine:

No, I do not think it is appropriate to just kill him simply because he’ll end up insane and possibly violent, with Species Identity Disorder (or whatever the term might be), but neither is it appropriate to anthropomorphise him into a cuddly toy. You, I, and the others who think he’s cute aren’t the ones who’ll be taking the risks involved in caring for him and keeping him safe and as sane as possible for the next 40 years. Anthropomorphising polar bears is what led to the situation in the first place: his mother was a circus bear, but she rejected him. Presumably she was worried about how breast-feeding would affect her figure in a tutu. Babe has a lot to answer for.

As a postscript to this, my grandfather was returning to the UK from India some time before the First World War. He was given custody of a bear-cub half-a-tadlet older than Knut here to take it to London Zoo. But how to feed it? In the end, they ordered a bucket of porridge several times a day and dunked the bear in the porridge, took it out and let it lick itself clean. I guess we’ve come on a way in how we treat animals since then… Of course we have.

That sinking feeling

I’m going to have to go MTAS cold-turkey if I am going to be able to reclaim my life. (I’m lucky to have the option, of course).

There are various petitions going around at the moment, one of which calls for the resignation of the architects of MTAS. I originally thought that a bit draconian and that it was aimed at the wrong target anyway. MMC is the problem, MTAS is just a symptom. However, I do now think those involved in designing MTAS should resign, and here’s why.

Have you come across the concept of “Sunk Costs”? You have, even if you don’t know it. A sunk cost is money that has already been spent, it is money that can never be recovered. When you’re throwing good money after bad, then the bad money is your sunk cost. When you cut your losses and run you leave your sunk costs behind. Or take them with you if they are student loans, of course.

In this case, the money that the government has invested in training UK doctors is a sunk cost.

Elizabeth Paice (dean director at the London postgraduate medical deanery and chair of Conference of Postgraduate Medical Deans) was reported on the 16th of March as saying that to pull be plug on MTAS would be “a huge waste of time and NHS money”. She’s referring to sunk costs, but interestingly she doesn’t appear to get that. This is not a surprise though.

You see, the scary thing about sunk costs is that it is much harder to walk away from your own sunk costs than it is to walk away from - or move on from - those created by other people. Sunk costs don’t just represent a financial investment. Sunk costs also represent an emotional investment. In this case, Ms Hubris has a political, professional and reputational investment in the whole hideous thing, as have others of those involved. When you have that much tied up in previous bad decisions, you end up being in denial, as any self-help book will helpfully explain. You are in - as the jargon has it - a “high responsibility position”.

In your personal life no-one else can take the decision for you. In commercial and public life someone else can take that decision, and very often someone else has to. This is because, if it is your fault, you will tend to continue throwing good money after bad. You ego, or your denial, won’t let you do anything else. Let me quote from some academics (van de Heijden et al) on the subject, fortunately this time they write in reasonable English:

Straw and Ross showed that the tendency of high-responsibility individuals to escalate commitment was particularly pronounced when there was some way to develop an explanation for the initial failure, such that the failure was viewed as unpredictable and unrelated to the decision-maker’s action (for example, the economy suffered a setback).

Bazerman et al showed that groups who made an initial collective decision that proved unsuccessful then allocated significantly more funds to escalating their commitment to the decision than did groups who inherited the initial decision.

That, ladies and gentlemen, is why I believe that the architects of MMC and of MTAS should resign. It is not because they have f**ked up, (though they have). It is because new brooms sweep clean. We will only get decisions about MTAS - and about MMC for that matter - which are based on the future and not on the past when those originally involved have gone.

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van de Heijden, K., Bradfield, R., Burt, G., Cairns. G., Wright, G. (2002) The Sixth Sense: Accelerating Organizational Learning with Scenarios. John Wiley and Sons, Ltd. Chichester.

Straw, B.M. and Ross, J. (197 Commitment to a policy decison: a multi-theoretical perspective. Administrative Science Quarterly 23: 40-64

Bazerman, M.H., Guiliano, T and Appelman, A. (1974) Escalation in individual and group decison-making. Organisational Behaviour and Human Decision Processes 33: 141-152

“You may already have lost….”

Yet another MTAS horror story. This is all moving too fast to keep up with.

The recent announcement by MTAS guarantees all doctors one interview at the deanery of their choice, and at the same time it abolishes Round 2. If you have already been interviewed by more than one deanery, you can choose which deanery you want to consider you. Your application will be withdrawn from the other deaneries.

This puts candidates who have already attended more than one interview in an obscurely difficult position.

When the candidates were selected for those interviews, it was still officially assumed that the MTAS form had fairly selected the better applicants; Round 2 would plug gaps if there were any unfilled spaces. By the time the interviews were taking place the official line had changed: it was decided to actively keep places open for Round 2. Now, three or four weeks after the first interviews were conducted, Round 2 has been abandoned and Round 1 has been extended. So the expectations of the interviewers about the availability and assumed quality of alternative candidates has been turned head over heels several times during this process.

I’ve just been contacted by a junior doctor who has been through this mill:

“I don’t know which deanery to put as my first choice. The interviewers had the option to tick a box saying that they would not employ you. I am really worried about this. After the Round 1 interviews were arranged, they decided that they had to keep places open for Round 2. I’m worried they ticked the box as often as they could to keep places open for Round 2. I said something really stupid in my question about [subject] to a Consultant [Specialist] who’s a known stickler. How do I know he’s not ticked the box in order to keep the place open for Round 2? If I say that Deanery’s my first choice, then I might choose a Deanery that kicked me out of the system just because they could. Before this, I only needed one job offer from one of them. Now I’ve got to guess which one it might be.” (My emphasis).

This is no madder, I suppose, than any other example of MTAS madness. But what a completely vile situation to be in.

If all of this is complete gibberish to you, you should be aware that the government initiative “Modernising Medical Careers” means that there are more specialist trainee junior doctors here now than the government is willing to provide training posts for in August. The government seems to want to use them as ward-fodder (though even that is uncertain) but perish the thought that they will help the junior docs broaden and deepen their skills with specialist training. The system which selects the lucky ones who will go to the ball, MTAS, is in the process of imploding under the weight of its manifold sins and wickednesses. In what other profession do you get one thirty minute chance and only one which determines the maximum level you can possibly achieve during the next forty years of your career? Very modern, I must say.

The rather fabulous picture accompanying this post comes from Cal whose blog is called Of Short White Coats and Stethoscopes.

Flutterby butterfly

I feel slightly awkward in my own blogspace these days. It’s been whizzy-fun checking my blogstats, especially after Dr Crippen larged me up two weeks in a row, but he described me as a medical blogger, and I’m not. I’m passionate, but not medical.

My original foray into medical blogging was because I had things to day that no-one else was saying at the time. I wanted to explain MMC to those who weren’t affected, and cast some light on MTAS for those who were. I’ve done that. The West Midland Surgeons, may their scalpels always be sharp, awoke the national press into the realisation that it is about having fewer specialist trainees and not just about another NHS computer cock-up.

I feel I’ve done what I can usefully do. Others are closer to events and better informed. I have - since I can never resist using jargon - stopped providing any value-add. And I have stuff to say about other things anyway.

I do have a couple of MMC-related posts brewing. One is an explanation of why I believe that the architects of MMC and of MTAS should resign, but I need to check a couple of references for that one first. The other compares medical careers before and after Ms Patronising Hubris got her fingers on them, but I’m not publishing that one until I’ve worked “post-modern” in as a decent pun. I have no doubt there’ll be others when some other aspect of this lunacy strikes me.

You see, the tagline of this blog is “danger of eclectic shock”. The dictionary defines “eclectic” as “made up of or combining elements from a variety of sources”. In days so long gone I hope you don’t remember them, there used to be a small advertisement in the newspapers asking if you were “worried about your butterfly mind”.

I’m not.

I miss it, and would rather like it back, please.

Thinking Bloggers

That nice Dr Crippen has tagged me with a meme. He’s a bit fierce about it. He says:

The participation rules are simple:

1. If, and only if, you get tagged, write a post with links to 5 blogs that make you think.

2. Link to this post so that people can easily find the exact origin of the meme

3. Optional: Proudly display the ‘Thinking Blogger Award’ with a link to the post that you wrote

This has put me on my mettle, rather. I am easily distracted so just about anything can make me think. However there are blogs that do regularly prod my mental horizons in different ways, and here are five of them strictly in alphabetical order:

1) A Boy Revealed writes about his transition to physical maleness. It’s not an easy journey. He is transitioning while at Med School in the USA. Some days he’s pissed off. Some days he’s excited. Some days he’s vulnerable. It would be patronising to describe him as “brave” because bravery implies some kind of choice. He’s just doing it. That ruthless facing up to inevitability is something that I deeply respect.

2) Then there is Compartments. She writes intelligently and insightfully about her compartmentalised life, giving us glimpses of her work as an escort, what she gets out of it and how it affects her. I like her honesty and self-awareness. She’s someone else I have considerable respect for, and she writes a blog I come back to again and again.

3) Jessi - whose strap-line is “What is this life but a Passionate Engagement?” - What, indeed. This is a blog that leaves me facing my own prejudices in the mirror and blinking. Jessi has all the intellectual and personal attributes I value or find attractive: self-awareness, compassion, wit, a sense of humour, a passion for life, the ability to think, the ability to write. She is also deeply and thoughtfully Christian. Try as I might, I cannot dismiss her or her faith. There are few things in this world that give me greater internal cognitive dissonances than intelligent, thinking Christians. I like her, and I like her blog. It would be so much easier for me if I didn’t.

4) Solnushka next for sheer eclecticism. A virtue (ha!) I value highly. Sol, again, is one who writes with insight and wit, allowing me glimpses of things I’ve never thought about and experiences I’ve never had. Her recent description of how to be noticed if you play the double bass is a delight, her reflections on culture shock intrigue me, and I just plain love her stories about Russia.

5) You are Sleeping - irreverent, arrogant, angry, pertinent, impertinent, witty, economical, deft, funny. A man who can do more with a ten word caption than I can do with a thousand words and footnotes. I bow before him.

I’m going to give a special mention to Reed; her way with a metaphor is a wonder to behold and her blog is always a delight. Her occasional opinion-pieces are tours de force of articulate passion. If I’m plugging others, I am damn well going to plug hers. Special mentions also to Bloglily, Charlotte Otter, Diana Higgins and the Eerie Apricot because they open doors onto considered and interesting lives being lived at some mental, cultural or emotional distance from mine. And they write well.

So, an eclectic mix, as you’d expect. There are others, but these are the blogs that most regularly provide grist for my mental mill.