Modernising Medical Careers: on babies, bathwater and the risks of early specialisation

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
Is
Dead.

Quite.

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.

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5 responses to “Modernising Medical Careers: on babies, bathwater and the risks of early specialisation

  1. Doing things fast is what counts.

    Not experience!

    Definitely not quality.

    I’m a late bloomer. I was 28, mother-of-three and had more than 10 years of experience from basic health care when I entered med school. By no means I was the oldest one in my year. We were from 18 to 43 years of age when we started. The 18 year old is professor now, the 43 year old is still a nurse, I think. Maybe she is retired. Nowadays the admission rules prevents this kind of diversity, as do the pack back schemes for the student loans.

    When I was 36 I entered the academy, and now – hopefully- my thesis is to be coming to it’s end. Due to my age I’ve been unable qualify for many benefits and stipends for “young researchers” and I’ve worked “as usual” during my way to achieving this PhD.

    The whole system is made for picking up the “young ones” directly from high school, squeeze them in to the academy, brain wash them and make them obediant little slaves. The bribe/treat is some fine title/position before the age of 30.

    I actually think that my pre med school life made me a better doctor, a more open minded and listening doctor with less of prejudices. I don’t take things for granted, and know that text books and blood tests are good but not always tell the whole truth and nothing but the truth.

    That and my unabililty to keep my big mouth shut may explain why I´m still a junior while most of my peers are long time consultants…

  2. Oddly enough over here there’s been an expansion in ‘post grad medicine’ accellerated courses for people with previous degrees.

    I had one operation prior to being a doctor, and one afterwards, the experience was totally different. The experience of symptoms when you know what they are is totally different. I think I’ll blog about it – once I’ve failed my exam on Tuesday.

    I think the experience of being ill prior to being a doctor is actually really useful, if you go into medicine at 18 the chances are that you won’t have been.

  3. I’d much rather it was the politicos arses rather than their souls, piles and a hernia are great levellers I would imagine.

  4. A friend who is a midwife said that at her hospital now staffing levels are such that things will be OK if nothing unexpected happens, but they are not completely sure that they could cope with complications and crises. She said it’s very stressful.

    It seems to me that removing so much experience and especially the varied experience in different areas could lead to doctors who can cope if nothing unexpected happens. We have had illness in the family where there were crises and the doctors needed to call on all their expertise in a hurry, a patient with cancer can have life threatening complications that are not directly cancer related, a few short rotations in different areas don’t seem enough to me.

  5. You prove my point exactly Dragonqueen. Thank you. (I never did learn to keep my big mouth shut either).

    >> I think the experience of being ill prior to being a doctor is actually really useful, if you go into medicine at 18 the chances are that you won’t have been.

    Like the sinner and the bishop, eh, Z? I hadn’t thought of that.

    Gregardener, I regularly wish for a device which would show someone all of the consequences of their actions, an adaption of Douglas Adams’ Total Perspective Vortex. I would put Tony Blair in there and wipe the fucking smile of his unctuous fucking face once and for fucking all.

    (Breathe in, Aphra. Breathe out.)

    Sarah, you so right. There used to be a saying that pilots are just there to switch on the autopilot except for the 15 minutes a year when they earn their salary. It’s grim when applied to the NHS, isn’t it?

    Thanks, all, for reading and commenting.

    Aphra.

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