Over recent months there has been an emerging consensus – articulated in reports from the Royal College of Physicians (The Future Hospitals Commission) and David Greenaway’s report for the GMC (The Shape of Training) – that it is time to put into acute reverse the socio-professional trend of the last 30 years of ever increasing medical super-specialisation. In their own ways these reports identify that the needs of a health system in which 70% of the activity is ongoing health maintenance of increasingly aged patients with 3 or more coexisting long term conditions, is not an army of doctors each of which can treat only one thing.

They also identify that the key specialties for managing this population – Emergency Medicine, Acute Medicine, Elderly Care Medicine and General Practice – are all ‘shortage’ specialties, i.e. there are more jobs available than people willing or able to do them by a considerable margin (8% – 22% vacancy factor [source:BMJ Careers May 2013] and that’s before you take into account the demographic time bomb of the mass retirement of a generation of GPs that started their careers during the last big expansion of the specialty in the 70s and 80s). If you move down the training hierarchy the fill rates are even more dismal – with 50% of higher specialist training posts in emergency medicine not being filled.

The ‘solution’ to the problem that is being proposed appears to be to increase exposure to these specialities earlier on in young doctors careers – make them do these types of jobs for longer – and at the same time make access to more specialised training (like cardio-thoracic surgery or neurology) much much more difficult by decimating the number of training places for them, in the hope that more of them will stick with the front line specialties rather than flood into the popular ‘super’ specialties (as they currently do – and always have). This apparent solution however seems to be completely ignoring the fact that a young doctor when faced with the choice of not getting access to the training in the specialty they want would rather up sticks and settle in Australia than to stay in the UK in a specialty that doesn’t interest them. Which is exactly what they are doing – in droves [Source: The Times, Saturday March 7th 2015].

So why is it that young doctors are eschewing the ‘Semi-differentiated’ specialities (my term – referring to the specialities listed above and to which I would add my own specialty of critical care – albeit not a shortage specialty)? What is it about the intellectual, practical and emotional challenge of providing care to patients with multi-system disease, in a psycho-social context that requires the corralling and coordinating of multi-professional multi-agency teams that puts them off? What is it about integrated care that is just so difficult?

Both the reports cited above home in on training as the issue – we are just not training our doctors right – and they propose some really quite radical changes to post-graduate medical training to address this. Whilst this is necessary, I do not think it is nearly radical enough – to really address the issue we need to go back to medical school and examine – who we are selecting; what we are teaching them; the skills we are equipping them with; and the attitudes they are possessed of when leaving medical school.

I have had cause to visit a number of university open days – not their medical schools but their engineering departments (I’ll leave you to guess why that might be). Engineering is a profession that requires the acquisition of at least as much if not significantly more technical skills and knowledge as medical training – the courses are just as intense and nowadays just as long (typically 4 – 5 years with a year in industry). Competition to get in is just as stiff and the bright young things wanting to do it are as possessed of the same desire ‘to make a difference’ as that which motivates those who enter a medical career. What has struck me though is that every engineering course I have looked at not only emphasises the knowledge and technical skills required (The maths!) but also have very large parts of their curriculum given over to the acquisition of non-technical skills – leadership, team work, collaboration, project management, business skills – all of which are required to be a successful engineer.

They are required to be a successful doctor as well – but we don’t teach them. You are selected for medical school on academic performance at the age of 18 – pass through 15 years of undergraduate and post graduate training and emerge as a highly knowledgable, very skilled technocrat – a heroic doctor – any non-technical skills acquired along the way more by accident than design. It is not just the non-technical skills they teach engineers that doctors need either. Becoming a doctor in an integrated care system requires many of the technical skills associated with engineering as well. Understanding complex adaptive systems, industrial process design, informatics and information technology (amongst many) are all skills we require of doctors if we are to ‘industrialise’ modern medicine.

We need to train a generation of doctors that are able to command and corral the multiple professions, agencies and technologies required to support the complex interaction of social, psychological and physical pathologies that represent the disease burden of our patients. We need a generation of specialists too – but specialisms built on a foundation of whole systems care. We need a generation of doctors that recognise that its not good enough just to be brilliant at one thing.

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1 Comment

  1. Great post Roger. Spot on. Having now stopped clinical practise but still deal with clinicians on a daily basis, I couldn’t agree more and recognise this in my previous self. It’s also amazing how little insight we have, as clinicians, into this – we believe we have broad exposure to the world through our patient interactions but the truth is, we live in a very clinical bubble.

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