Sir Francis Bacon, it is said, was the last Englishman to have read every book ever written. In the early 17th Century it was possible, if you were rich and leisured, to do so.
We have no choice but to specialise now: 206,000 new titles were published in the UK in 2005 which is 565 per day. (Distractingly, the USA only managed 172,000 in the same year which is an alluring statistic for a US-sceptic like myself). The British Library holds over 150,000,000 items. One could hardly read the catalogue.
It is a cliché that we know more and more about less and less; it is a cliché because it is true. We have no choice. But that does not mean that we should specialise before we have to, or that early specialisation is better.
You cannot learn more in a fifth of the time
My first issue with MMC is my simple disbelief that no schedule of improvements can produce a five-fold efficiency gain in training. (Specialists will qualify as consultants after 6,000 hours of post-grad training instead of the current 30,000 hours). I’d believe that a 20% improvement might be possible; maybe even that someone could be trained to the same standard in two thirds of the time. But not in one fifth. Who the hell are they kidding? If anything smacks of penny-pinching it is this. It is simply not possible that this approach will produce better educated specialists.
Losing the benefits of experience
My second issue is that the baby of experience is being thrown out with the bath-water of time. (My god – I am turning into Humphrey Littleton). It is of course fully in line with the management mantra that “you cannot manage what you don’t measure” because Hewitt’s crew have conveniently failed to devise a way to measure experience. Call me a traditionalist, but the combination of CVs and references seems like a good place to start, and I am sure that the wise and devious question-setters at the Royal Colleges could examine for experience if they were so minded.
I once heard of a conversation between a clergyman who was ordained late in life and his bishop. The clergyman said “I am worried that I cannot preach about theology” to which the bishop replied “you have 50 years of sin behind you, preach about that and if they want theology call me in”. When you are dealing with people in extremis here is no substitute for experience, and this is what MMC is ripping out of our medical training system.
Generalise first then specialise
More fundamentally: I am sceptical that early specialisation is good in the first place. There is a lot to be said for generalising first. I am assured that the following joke is funny:
Qu: “What’s a holistic orthopaedic surgeon?”
A: “One who looks after the whole bone”.
It puts its drill-bit neatly on the problem: if you are going to specialise it is much better to specialise from a broad-based understanding of the subject. If you don’t, then you may miss what John Cleese would describe with graphic appropriateness as “the bleeding obvious”.
Oddly, after I had started writing this, I read the following in The Elephant and the Flea by Charles Handy:
“‘The fox,’ said Archilochus, ‘knows many things but the hedgehog knows one big thing.’ …. Life is long” adds Handy. “We should keep our options open for as long as possible.”
I’ll admit that I am one of nature’s foxes, but we live far longer than they did in Archilochus’s day. We can afford to give the hedgehogs more to think about before they specialise.
What the doctors lose
The benefits of having a rounded practice (rather than just a rounded curriculum at Med School) are two-fold. Firstly it makes it easier for them to think and treat holistically (a useful concept we should reclaim from the flower-sniffers). Secondly it makes specialists less vulnerable to changes in medical technology. For example, specialists in Upper GI surgery (that’s stomachs and gullets to the rest of us), are now hardly needed because new drugs treat stomach ulcers medically. A problem if Upper GI is all you’ve ever done; not so much a problem if you are a general surgeon who can return to bowels, (mmm, you’d concentrate on the top end if you could, wouldn’t you?).
In the words of Patrick Barrington:
A bustle-maker can’t
Make bustles for his aunt
If the bustle-maker’s aunt
It is not as if doctors don’t have the time to generalise first. These days we are all living longer and will have to work until we are older. Doctors face a good 40 years of practice when they graduate. What on earth is the benefit of keeping them in the dark and forcing them like celery? They aren’t ballet-dancers or footballers: they don’t peak at the age of 18 and retire at the age of 30. There is no benefit to us, as patients, if they qualify younger and I find it hard to believe that there is any benefit to us as tax payers.
Do you want to know the thing that I find richest about all of this?
Politicians are the ultimate generalists.
May their souls drift from waiting list to waiting list. Forever.