Do we pay doctors too much? Do we keep good people out of medical schools by insisting on excessive entry requirements? Is it time we let a little air out of medicine’s exalted position among the professions?
Professor Alan Gilloran of Queen Margaret University in Edinburgh answered “yes” to all three questions during a recent evidence session at the Scottish parliament. He cast doubt on whether the existing high medical-school entry requirements produced the best doctors.
Professor Gilloran said there was a duty to question the professional hierarchy that places medicine and law at the top. He told the education and culture committee:
I think we all have a responsibility to actually challenge our established orthodoxies in terms of, why is medicine (seen as a pinnacle of achievement)? I mean, it is plumbing for God’s sake.
The As have it
I wouldn’t argue with Gilloran’s point that society should in some way review and consider how it wants to reward the attractiveness of different careers. That’s what elected representatives are for.
But I’m afraid the professor is wrong in other respects. Take the issue about university qualifications. We have a reasonable amount of evidence that demonstrates that the higher your academic achievement before you come into medicine, the better you will do in terms of exam performance. This holds for both undergraduate and postgraduate medical training.
Indeed, academic achievement is our single best guide to who will succeed at medical school. Any suggestion that we should drop the requirement for top grades to become a doctor needs to overcome this problem: they maximise the chances of securing the qualifications required to go into practice and raise the standards attained.
Change in medical schools
None of this is to say that softer medical skills like empathy and the ability to communicate have not risen up the list of priorities for medical schools over recent years. Schools know these skills are both important on entry and need to be taught and enhanced.
The likes of the Stafford Hospital scandal, in which poor care led to the deaths of up to 1,200 patients, also demonstrates the importance of having doctors who have the confidence and determination to stand up for what is right in a system that sometimes makes it very difficult.
But we needn’t prioritise these other qualities at the expense of academic rigour, partly because the career is so popular. Fortunately we can select not only bright doctors but also those with softer skills and sound values.
The attainment gap
Insisting on this academic backbone admittedly raises other problems. In particular, social mobility has waned in recent years and medical schools are among the worst offenders, essentially because the variation in quality and attainment in British schools is so stark.
Medical schools are under political pressure to fix this, but this is counterbalanced by a need to select students on a transparent, fair and meritocratic basis as described in the Schwartz report of 2004. If you select an applicant with lower grades because they come from a worse school or poorer background you must reject someone applying from a privileged background. Most medical schools are keen to widen access as much as they can, but also risk the charge of social engineering.
But perhaps we teach too much in medical schools. Perhaps we could simplify the courses to make it easier for weaker students to succeed? Not in my view. You can’t overestimate the importance of having a broad grounding in medicine, whatever kind of practitioner you become.
Even if you specialise, it’s critical to have a sound understanding of other areas – if only to limit the need to seek help from the other specialists all the time. Indeed, the healthcare system has arguably become too specialised, and there is now a trend to refocus on creating generalists.
On the other wrench
Let me turn to this headline about medicine being “plumbing, for God’s sake”. Undoubtedly there are some roles that can be carried out by people with less extensive training. This is why we’re seeing the rise of nurse practitioners and physician associates.
Imported from the US, the rationale is that you don’t need to train everybody in the science or to critique what they are doing so much. You can train some in a more mechanistic way, which works well for many simpler tasks that follow the expected pattern.
Examples include coronary artery bypass grafts, when surgeons delegate the job of stripping out the veins to be plumbed into the heart; or inserting intrauterine contraceptive devices. But when something goes wrong and people get out of their depth they typically default to the doctor to make the decisions and carry the responsibility.
A surgeon doing a heart operation might be plumbing on one level, but along the way they will have to make finely judged decisions about the condition of the heart, the anaesthetist’s advice on how sick the patient is, and so on. That requires an immense amount of understanding, skill and experience.
That’s why we don’t spit people out of medical school straight into top jobs. We expect them to train for a further five to ten years, studying much of this time. And many new consultants still don’t feel fully prepared for their role even after so much training, which is one reason why a new junior-consultant grade is emerging. If medicine was mechanistic and simple, they wouldn’t be feeling like that.
Beyond that, doctors are constantly required to keep up with the latest developments and technology. It’s a career that requires major life-long learning, which is surely easier for the brightest and best motivated scholars.
It all comes down to money
This also explains the remuneration situation, of course. We might choose to be more like, say, Cuba, and pay medics more modestly. This would create a more equal society, but you might rue the day.
A number of the bright young things that you have trained might decide they were better spending their time doing other things. A British medical qualification is a highly transferable asset after all and New Zealand, Australia and Canada all offer more attractive terms to medics than here in the UK.
There is already a dash to retirement, so if we decided to slash doctors’ salaries in the UK, it would be an interesting experiment – but also a brave one. I know who I will look for when my internal plumbing goes awry and I would hope to find them in the NHS.