Surgery will always be a matter of life and death

I’ve nothing against him personally, but when I’m urged to read Atul Gawande’s books about aspects of surgical practice, particularly outwith the technical skills, I wonder what makes him such an expert. Here’s the evidence:

Qualified in Medicine at Harvard in 1995 aged 30

Master of Public Health degree in 1999, then 6 years of residency training in surgery – ie. junior doctor acquiring experience – till 2003.

He spent quite a bit of time from the late 80’s involved in writing magazine articles and working in Democratic politics.

His first book, Complications: A Surgeon’s Notes on an Imperfect Science, came out in 2002, when he was still a junior doctor in training, far from the finished product. The next one Better: A Surgeon’s Notes on Performance, was released 5 years later. I assume he’d been busy in clinical practice for this time, with possibly some of the previously noted extracurricular activities getting in the way occasionally.

w-eugene-smith-dr-ernest-ceriani-following-the-loss-of-a-mother-and-child-during-childbirth-1948
…still a role model

An NHS consultant surgeon, 5 years in, working in a busy hospital is, in my view still very much on the learning curve. ‘Surgical maturity’, I would say, is at least 10 years in. Some people never get there.

Gawande’s Wiki entry implies that from about 2009 onwards he was doing more and more non-surgical things, fair enough, he seems an interested and accomplished fellow, but I feel very strongly that the way you get better in medicine is, I’m afraid, long hours, year in year out, in the wards, the theatres and the clinics. It’s a lifelong thing, even if – as I do – one has plenty of other interests.

One of the classic scenarios in the NHS is the consultant who having got to the top – as it was perceived in the old days – realises that he or she wants to get out. Often ‘management’ and ‘governance’ are the dubious beneficiaries of their career move, which amazingly usually involves telling working clinicians what to do. Not that I’m accusing Gawande of that, but some individuals closer to home, certainly.

Anyway, this preamble is to praise the benefits of long, hard won clinical experience, especially of the surgical kind. There is a significant difference between prescribing a drug – which could do harm – and opening someone up with a knife, which is intrinsically harmful before it gets better, even if everything goes well.

Is there a plausible alternative to working the hours? I think not. Don’t get me started on the world of ‘simulated surgery‘.

All of which brings me to a fascinating interview with both Stephen Westaby (69), heart surgeon and Henry Marsh (67), neurosurgeon. Both have a public profile, both have performed thousands and thousands of challenging high end operations, for the NHS. With respect to the aforementioned competition, these are the guys that I want to hear from. They’ve also written books for the general public, as it happens.

There are numerous gems in the interview, here’s some tasters:

HM:  We have this very complex relationship with patients. It’s not one of straightforward altruism at all; it’s a very difficult relationship. You have to be both hard and soft at the same time. You certainly don’t want to be empathetic. If empathy means you actually feel what your patients are going through, actually . . . you can’t do it.

…the problem is you could spend the entire national income on healthcare and everybody still dies — there is 100 per cent mortality — so you have to decide somehow where to set your artificial floor on that bottomless pit.

…[When he was PM] David Cameron made this speech about we must have “zero harm” in the NHS, which struck me as the most incredibly stupid thing to say because it suggests that when anything goes wrong, therefore somebody’s to blame. The whole point about medicine is it often goes wrong. The decision whether to operate or not, to recommend an operation or not, is all about probabilities, and these are very subjective, difficult judgments. Everything we do is in the face of uncertainty and a lot of the time patients come to harm. It doesn’t necessarily mean that anybody’s at fault. So I thought that was a very, very naive and rather silly thing to say.

SW:  The job is difficult enough without having the press and everybody else on your back. A British heart surgeon had the idea when he became the medical director of the NHS that surgeons’ death rates should be published and available for the newspapers. Let me ask you: which surgeons would have the highest death rates, the worst ones or the best ones? The best surgeons attract the worst patients like a magnet. So if you want to make your best surgeons defensive, you start counting the bodies and putting it into the public arena. My particular branch of the profession is now risk-averse. Fewer heart surgeons want to come to Britain to do heart surgery and the British especially don’t want to do heart surgery. They’re long operations, you can end up operating all night, every day of the week, and it’s taxing and it’s rotten when people die. It’s totally rotten to have to go out of an operating theatre and tell a couple of young parents that their baby’s just died on the operating table. It’s misery. None of us lose patients because we’re careless or don’t care. So I’ve seen my profession wrecked, I’m afraid.

HM:  Forty years ago, the power structure in hospitals in this country was very simple. There was a senior doctor, a senior nurse and one manager, and basically the hospitals are run more or less by the senior doctors, for better or for worse. Now you have a whole series of competing pyramids. The management, the doctors, the nurses — more or less autonomous now — the other paramedics and physios and people like that, so there’s a real sense of nobody being in charge. I would go to work in the morning and I wouldn’t know what I was going to do that day because it all depends. Is there a bed? Is there an intensive-care unit bed? Is there a bed on the high-dependency unit? You have to negotiate with each of these individual power structures, it’s deeply chaotic

…Another example is that, after the Stafford scandal [over nursing care] and the Francis inquiry [into it], the General Medical Council wrote to all the doctors saying that when a mistake is made you must apologise and then it said that this is usually the duty of the senior clinician; in other words, whoever makes the mistake, muggins here has to go and say sorry. And then thirdly it added that for an apology to be meaningful, it must be genuine. If the GMC can’t see there’s a problem here — if an apology is compulsory, how can you force it to be genuine? Well, the answer is that it is genuine if the senior doctors have a sense of authority, if they feel they’re trusted and then they do feel responsible for what happens in their department.

Just superb, and not calculated or self-serving, simply real world experience of something very important. Westaby’s line “The best surgeons attract the worst patients like a magnet” is very very true.

I’ll give him the final word:

 

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Praise the Lord (of explosives)

F1.large
..also, moustaches are back, take it from me…

Not all figures in public life are venal and self-interested:

During the entire four war years Lord Moulton worked a ten-hour day and took less than ten days holiday

…that was John Fletcher Moulton, who at the outbreak of the First World War became “Director-General of the Explosives Department”. A terrific job title. He’s interesting too because despite being an extremely distinguished legal brain, he was also a very high powered Cambridge mathematician. The man had a hinterland.

Anyway, I owe this post entirely to the polymathic genius of the very funny and very wise Mark Steyn, who in examining the absurd vicissitudes and mores of our decadent 21st century West, noted:

85 years ago English judge Lord Moulton, said that human action can be divided into three domains. At one end is the law at the other is free choice and between them is the realm of manners. In this realm Lord Moulton said, “lies a domain in which our actions are not determined by law but in which we are not free to behave in any way we choose. In this domain we act with greater or lesser freedom from constraint, on a continuum that extends from a consciousness of duty through a sense of what is required by public spirit, to good form appropriate in a given situation”.

That was from 2016. Steyn returned to it a few days ago, in looking at the current NFL shenanigans in the States. It seems such an obvious concept, but there’s a kind of genius in defining it so elegantly.

I think we can all recognise abuse of this precious and ordinarily fairly accepted aspect of human behaviour, which relies on personal integrity and a degree of trust. The new modus operandi is “what can I get away with?”.  In hospitals I would identify the increasing trend to not come and see a patient when you’re asked to, at the bedside. You probably will get away with it, but it’s a drop in standards, and every now and then, someone will suffer unnecessarily. It’s a genuinely bad development, because attitudes have changed, and nobody is able – in the NHS – to enforce things, it seems. It’s almost an argument for payment according to work done, as in the US and Canada, where you bill for a ‘bedside consult’. Money talks, even if your conscience is staying quiet.

The domain of manners. Look around you.

 

BOzymandias, the nuns and the NHS

ozymandias_by_witchofwest-d3bmzex
It even looks a bit like him…

You don’t have to be religious to enjoy the victory of the Little Sisters of the Poor yesterday, although it helps.

Trump11
*

The media yesterday, in the UK and to an extent in the US, hugely downplayed Trump’s passage of an Obamacare replacement through Congress, even though there are still a few challenges ahead.  The Guardian, as one example, bafflingly are using the picture on the right as their main US headline, at the time of me writing this. We know you don’t like him guys, but was that really the main news event?

Two things happened: the Obamacare replacement already mentioned, the lack of which was being gleefully touted until about two days ago by people who should know better, as an emblem of Trump’s abject failures. The second is Trump’s executive order on religious freedom, which led to the press conference which is shown below. As Trump said, and it’s hard to claim he’s wrong: “I will get rid of and totally destroy the Johnson amendment and allow our representatives of faith to speak freely and without fear of retribution”. (Read this for more background).

There were parts of Obamacare that were good in theory, although the victims of the private insurance/Medicare/Medicaid situation that preceded it were primarily the middle classes rather than the poor and indigent. It was the middle classes who didn’t qualify for state aid who were hammered financially. However, Obamacare was always a rotten business model, and that’s all it was. It wasn’t healthcare – that’s provided by clinicians – and it wasn’t even insurance, as there was not enough ‘this might not happen’ element to it, which is the essence of house, car, health, dog insurance, whatever. If the new bill includes adequate coverage for pre-existing conditions, it will be better. Obamacare had had it anyway, even before yesterday’s news.

Perhaps Obama should have been more open about it, and gone for a US NHS, funded from taxation. I’m a big fan of the NHS. I have worked in it for more than 30 years, I don’t do private work, but it is desperately in need of reform. It has suffered terribly from technological advances, in a financial sense – and they’re far from being all good clinically – but also from mission creep, much of it led by the dreaded Public Health cabal and various politicians after an easy boost. It is far from Nye Bevan’s original vision. In a very perceptive Standpoint article on all this, John Torode wrote:

…however much the rest of the world allegedly envied our brave new health service, not one nation of any significance turned envy into action. Pretty well every advanced liberal democracy, from Germany to Israel, from France to the Scandinavian nations, chose fundamentally different models of health provision…..some problems are common to all health services. We live longer and need more, and more expensive, attention for chronic conditions in our old age. Medical science and technology have grown ever more complex and costly. But our rigid, unresponsive, centralised system, designed by state-socialists and run by bureaucrats, serves neither patients nor practitioners. It merely exacerbates the difficulties.

A working Glasgow GP, Margaret McCartney, wrote a great piece on the very real problem, both ethical and financial, of modern healthcare pursuing life at all costs:

Death is inevitable, but frequently seen as an inadequacy in medicine or treatment. Harpal Kumar, the chief executive of Cancer Research UK, said on the radio recently that his aim was to ensure that no one died of cancer any more. But we are still going to die, so what are we to die of? Is every death to be fought back with all of medicine’s might, and to be always considered its failure?

Well worth reading it all, but I digress. Back to BO and the nuns, where it just so happens that healthcare was the field on which he chose to fight. I wrote a blog 5 years ago  that predicted Obama’s demise on this. He picked on the wrong people, and he did it in a stupid and vindictive way.  He may have won his two elections for reasons that are many and varied – not particularly about good governance though – but his signature legislation is now dead. I had a Ford Fiesta that lasted longer than Obamacare. And he completely deserves the humiliation that it brings. Even his buddies in the Washington Post were aghast:

Both radicalism and maliciousness are at work in Obama’s decision — an edict delivered with a sneer. It is the most transparently anti-Catholic maneuver by the federal government since the Blaine Amendment was proposed in 1875 — a measure designed to diminish public tolerance of Romanism, then regarded as foreign, authoritarian and illiberal. Modern liberalism has progressed to the point of adopting the attitudes and methods of 19th-century Republican nativists….Obama is claiming the executive authority to determine which missions of believers are religious and which are not — and then to aggressively regulate institutions the government declares to be secular. It is a view of religious liberty so narrow and privatized that it barely covers the space between a believer’s ears.

Hence the title of this post. Take it away Percy Bysshe Shelley…

I met a traveller from an antique land,
Who said—“Two vast and trunkless legs of stone
Stand in the desert. . . . Near them, on the sand,
Half sunk a shattered visage lies, whose frown,
And wrinkled lip, and sneer of cold command,
Tell that its sculptor well those passions read
Which yet survive, stamped on these lifeless things,
The hand that mocked them, and the heart that fed;
And on the pedestal, these words appear:
My name is Ozymandias, King of Kings;
Look on my Works, ye Mighty, and despair!
Nothing beside remains. Round the decay
Of that colossal Wreck, boundless and bare

The lone and level sands stretch far away.”

 

 and that video. “Incredible nuns…”

 

Free the serfs!!

serfs001
The Foundation doctors arriving at the hospital

In these exciting times, when morons/Lib Dems drone on about the entirely fictitious entities of hard and soft Brexit, I recommend interested parties to read a charming Spectator piece from last year: Reasons to be Cheerful. A symposium on the benefits of Brexit. All of it is good, with contributions from right across the spectrum of beliefs and politics.

Here is my favourite, because it begins to address a problem that’s blighted British medicine, the EWTD and the associated serfdom of medics in the NHS. It doesn’t mention the equally pernicious New Deal junior doctors’ contract, but it’s a fine start. The author is one of the great British medical writers, Theodore Dalrymple (AKA Anthony Daniels), a terrific writer and experienced clinician, with quite a fan club online (1, 2). Here he is:

No one wants to be treated by a dog-tired doctor, but even less does he want to be the parcel in the medical game of pass-the-parcel that is now commonplace in our hospitals. The European Working Time Directive has transformed doctors into proletarian production-line workers, much to their dissatisfaction with their work and to the detriment of their training and medical experience. It means that doctors no longer work in proper teams, patients don’t know who their doctors are and doctors don’t know who their patients are. The withdrawal of the directive would improve the situation.

Every working doctor that I know would recognise the problem described. Whether abandoning the EWTD (I would) and introducing a more sensible hours regulation would help is a moot point.

But we now need to at least have the conversation.

The SNP: decline and fall (4)

15. Objective evidence that the SNP are very bad at grown up government things.

I should have put this in yesterday’s batch of Nat failure and cock ups, but perhaps it deserves a post of its own. All governments work within a necessary system of checks and balances, without which the SNP dream of a tartan totalitarian dictatorship would quickly emerge. Many of them are beneath the radar – advice from government lawyers, things like that. In terms of public display though, the latest NHS round up from the sort-of-independent Audit Scotland, from the end of October, contains some depressing gems. I can do no better than quote from the Lib Dems (something I never thought I’d write):

Last week, the First Minister told us that she wants to be judged on her record. This week, Audit Scotland published a damning report on her government’s record on the NHS. The SNP claim to have protected investment in our NHS. Audit Scotland say that funding has been cut in real terms by nearly 1% over the last 7 years. Two health boards have been forced to take out loans from the Scottish Government just to break even. The SNP claim that things are getting better in our health service. Audit Scotland say that national performance against key targets and standards is getting worse. Waiting times targets have been missed and missed again. Health boards have experienced huge problems in recruiting and retaining qualified staff. Territorial health boards spent £284 million in 2014/15 for temporary workers, an increase of 15% from the previous year.

Quite. As the Auditor General for Scotland pointed out:  “The Scottish government has had a policy to shift the balance of care for over a decade but, despite multiple strategies for reform, NHS funding has not changed course. Before that shift can occur, there needs to be a clear and detailed plan for change, setting out what the future of the NHS looks like, what it will cost to deliver and the workforce numbers and skills needed to make it a reality.” That’s more than 10 years of talking crap about change, which is always just around the corner. In fact the much heralded Integration of Health and Social Care Act – wholly owned by the SNP – came into reality in April, and no-one’s noticed any difference yet.

It’s not actually the current health minister’s fault – she is just the latest incumbent of the office in an arrogant administration of people who are cocky, but not…competent. And it’s not just in health either. So demented is the obsession with money in Scotland’s taxpayer-subsidised universities, Scottish students are being blatantly disadvantaged in favour of lucrative fees from elsewhere, one third of places go to non-Scots, and it’s getting worse.

The Scottish NHS is fixated on arbitrary targets, well beyond the sensible ones relating to emergency care and cancer treatment. It’s missed them all, with one happy exception, the ‘drug and alcohol treatment is being delivered on time’.

Just as well really

 

rab
I’ve no complaints

 

 

You may appeal to my authority

There are plenty of people making hay over credit agency Moody’s declaration that the UK economic outlook has turned ‘negative’. This may or may not be correct. The rider that there will be  “a prolonged period of uncertainty” doesn’t look like a particularly insightful comment, whatever their data sources. It’s not that long ago – February 2013 in fact – since Osborne’s economic approach was hammered using (Moody’s) removal of its Triple A credit rating. This was because “the government’s debt reduction programme faced significant “challenges” ahead”.

Well, something must have happened that was unanticipated by the agencies if  Moody’s rival, Standard & Poor only yesterday, after Brexit, decided they would remove the Triple A status, apparently joined by Moody’s, as well as  Fitch (the third big agency). One suspects that Moody’s original claim had been rather overdone (and possibly this one too). Had they in fact restored their Triple A rating in the interim? It looks like it.

My point in all this is that these agencies are big businesses in themselves, with their own agendas. When they get it wrong it gets less publicity. Even uber-liberal cat loving Nobel economic guru Paul Krugman thinks it’s overdone :

“…right now all the talk is about financial repercussions – plunging markets, recession in Britain and maybe around the world, and so on. I still don’t see it. It’s true that the pound has fallen by a lot compared with normal daily fluctuations. But for those of us who cut our teeth on emerging-market crises, the fall isn’t that big – in fact, it’s not that big compared with British historical episodes. The pound fell by a third during the 70s crisis; it fell by a quarter during Britain’s exit from the Exchange Rate Mechanism in 1992; it’s down about 8 percent as I write this….This is not a world-class shock”

These appeals to authority, in this case credit ratings agencies, are an omnipresent feature of modern life, hugely abetted by the intrinsically unreflective nature of much of the internet and its social media. That is not to suggest that all such pontifications embody the fallacious appeal to authority – but clearly some/many of them do. Nearly all of the EU referendum campaign was built on unreliable speculation on both sides (which is why this was the single best argument I read on the topic).

I call it the Formula 1 argument. F1 as we know and (possibly) love it, is a suitably important sounding name for the fastest level of motor racing. It is overseen by FIA (Fédération Internationale de l’Automobile) otherwise known as the Association Internationale des Automobile Clubs Reconnus,  where the last word means ‘recognised’. Recognised by whom?  In other words, although FIA has historical precedent, it is essentially a self-appointed authority. There is nothing to stop the entire set of F1 teams decamping to a brand new tournament calling itself whatever it wants. Boxing has already recognised this, which is why there are currently four ‘world’ authorities – the WBC, WBO, WBA and the IBF. Big bucks all round with their many different titles to fight for.

Football is the same. Let’s dump FIFA and invite all the countries to play every four years in a new tournament, preferably in somewhere with an appropriate climate (not Qatar). We can call it the Mundial. Who decided a bunch of corrupt phonies like FIFA should still get the prize? The main reason of course is that like Formula 1, like boxing, there is a very healthy living to be made from the many lucrative sidelines., and it’s worth clinging on to.

And you get it in medicine, all the time. The phrase ‘top doctors’ is regularly trotted out, and is frequently associated with the most paternalistic self-important drivel. One of my favourites is when the grandly named King’s Fund pronounces. They self describe as a “health charity that shapes health and social care policy and practice”. Perhaps they do produce the odd good idea that no-one in the NHS would come up with, but in reality, they are a private body with plenty of well paid staff, some of whom may have a sketchy knowledge of actual health care delivery. An acquaintance of mine went for a job there, and it was very revealing. The key thing is the brand name, which relates to a long lost charitable fund named after King Edward VII (died 1910). Somehow, if it was just called ‘private NHS advisory think tank’ – a more accurate description – I feel its authority may appear diminished.

And on that note, what about the ‘Royal’ colleges of medicine, surgery etc? The presidency of these bodies is undoubtedly a classic bully pulpit, but what are they for? The answer is that they organise the odd educational event, they run (very good and necessary) postgraduate exams, and they produce not very good journals. None of this comes cheap. They also, however, choose to proclaim on NHS issues where they may or may not have any real insight. Naturally they tend to get a media hearing, and sometimes a governmental one. This lapses rapidly into ex cathedra nonsense in many cases, and gets the NHS nowhere.  An academic colleague of mine, who is extremely competent, distinguished and sensible and did himself hold high office in such a college, wearily confessed to me recently how disillusioned he was by the institution “I’m not sure what it’s for these days”. Like most clinicians, he now favours his own specialty organisation when it comes to practical issues, and for very good reasons.

What makes an ‘expert’ and thus an ‘authority’ has been debated and often healthily derided in the EU referendum, one of its more beneficial side effects. As is often the case, Thomas Sowell provides the necessary wisdom.  On balance, Eddie Izzard probably doesn’t make the cut.

So Moody’s, FIFA, numerous ‘royal’ institutions and many, many more, maybe your time is running out. It’s long overdue.

heath_rob_pp
This is what a real expert looks like

 

 

 

 

 

Medicine – beauty amidst chaos

The work of medicine can be grim. Death, pain, madness, addiction, mutilation, indignity are all around you at times. How one copes with it as the objective medical practitioner is hard to define**. I personally feel that the ancient rite of passage of the dissection room in first year had considerable merit in this regard. Its abandonment in most UK medical schools means that current and future generations may be missing out on something other than knowing anatomy. Likewise, the cosseted world of the junior doctors’ contract and hours regulations means that the fruitful maxim, ‘they can always hit you harder’, becomes less true by the year.

Doctors, then, are changing. Their work by and large stays the same in its broad themes. You have to be able to cope with the dark side, which includes a significant attrition rate amongst our own – illness, fatigue, family crises, scandal etc.

Some of our coping mechanism comes from our personality and our background, some is learnt. Some relates to personal beliefs, often religious.  Either way, you have to acquire it in order to function. Here is a vignette from Lermontov’s A Hero of Our Time, a mini masterpiece of selfish young man nihilism, written long before trite pale imitations like American Psycho. The hero, Pechorin, is preparing for a duel in the Caucasus mountains, seconded by his worried doctor friend, Werner:

“Why so sad, doctor?” I said to him. “Haven’t you seen people off to the next world a hundred times with the greatest indifference? Imagine that I have a bilious fever, and that I have equal chances of recovering or succumbing. Both outcomes are in the order of things. Try to regard me as a patient stricken with a disease you have not yet diagnosed–that will stimulate your curiosity to the utmost. You may now make some important physiological observations on me . . . Isn’t expectation of death by violence a real illness in itself?”

This thought struck the doctor, and he cheered up.

A true and shrewd observation, which most medics will recognise: the awfulness of illness and death is mostly genuinely fascinating, and can be its own reward, in a strange way.

cauc4
Pechorin country – the Gergeti Trinity Church in the Caucasus mountains

.

**As an afterword there is a good quote from Russian/Armenian/American author Vera Nazarian, the parentheses are my own contributions:

“If you are faced with a mountain, you have several options.
You can climb it and cross to the other side (doctors who can do the job, but who get out into management etc ASAP).
You can go around it.
You can dig under it.
You can fly over it.
You can blow it up.
You can ignore it and pretend it’s not there (usually become Public Health ‘experts’ in the UK).
You can turn around and go back the way you came (doctors who don’t cope and drop out of the tough specialties) .
Or you can stay on the mountain and make it your home (the frontline doctors of any challenging specialty who stick it out).”

[I’m still working on career analogies for the middle four *]

*see first comment below

 

 

 

Why do you want to be a doctor?

doctor-in-the-house-series-large-poster-950
Then…

A few months ago I was talking to a friend who is a gifted surgeon, urbane, humorous, well published, popular with staff and patients and has plenty of outside interests. With us was a similarly accomplished colleague, with stacks of quality publications and a recent presidency of one of the main surgical bodies, a man at ease with politicians, journalists, difficult clinical problems – in short, a very admirable doctor. We had just agreed, in all sincerity, that none of us would get into medical school these days.

In fact, the whole rigmarole of medical school entry in the UK is one of my pet hates. It is absurdly popular, and quite possibly for the wrong reasons. A different colleague holds the view that one reason why so many GP’s seem pissed off is that they spent the first 25 years of their existence being told – with some justification – that they were the intellectual elite of the nation. Their adult day to day tasks frequently fail to meet the expectations that this raises, made ten times worse by the now discredited GP contract rewarding all the least fun and professionally dissatisfying aspects of the job.

My sympathy with the striking junior doctors is limited, for which I tend to take some stick. One of the most bizarre aspects of it to me is that I was walking on air when I graduated as I was a doctor. I now had intrinisic special skills. I could in theory work usefully anywhere in the world. There was a certain status that came with the title – something the current juniors would be wise not to take for granted. 30 years later I still feel that way, the ‘special feeling’ has barely diminished. None of us was that bothered by, or interested in the details of the rather brutal contractual obligations. We had money in our pockets, and much of the work was its own reward.

By that way of thinking the current strike is crazy. It’s already morphing into a leftie hatefest of the worst kind, which won’t end well. The juniors’ terms and conditions are infinitely better than they were even 20 years ago. Are they really saying that after a colossal input from the rest of us – as taxpayers and willing subjects for their education – they will withhold their services for emergencies because a small part of the particular terms and conditions of their work with the monopoly employer in the UK displeases them? Do none of the strikers feel that ‘doctor vibe’ I mentioned earlier? Are they now all the serfs that the New Labour mob in cahoots with the General Medical Council of the early Noughties intended the doctors to become?

Perhaps they are.

Which brings me back to why they wanted to do medicine in the first place, as a sense of vocation is possibly dropping down the list, and to how the UK medical schools select them. The majority of juniors are indeed talented and committed individuals, but something has changed. Here is an excerpt from the great Theodore Dalrymple, writing in Spectator Health, on the decline of informal recommendations and selection in medicine:

This kind of selection by boastfulness now affects even the choice of medical students. It is not that their intellectual quality has gone down: on the contrary, it has probably gone up. But what is now required of them to gain entry to medical school is morally repellent, much worse than any possible defect that existed before. They now have to make a ‘personal statement’ about why they should be admitted, and this, of course, results in the most odious conformism; a kind of psychological cloning, as well as an invitation to untruth.

The son of a friend of mine applied to medical school and was turned down. He was told that, though he was academically qualified and admirable in many ways, his personal statement was not impressive enough. So he went a tutor who told him how to write his personal statement when he re-applied to the same medical school the following year. (In the world of spivvery that we have created, there is an allegedly private-sector opportunity in every procedural requirement.)

Having made his ‘personal statement’ more impressive with the paid help of his tutor in this dark art, he was admitted to the school that had refused him the year before. Needless to say, he had not changed in any way other than being a year older: but in a world in which the virtual is more real than the real, self-presentation has replaced theology as the queen of the sciences.

My solution would include adopting the perfectly good North American model (which includes Canada), and make all medical school entry postgraduate. Dalrymple’s precise phrase “odious conformism; a kind of psychological cloning” is part of the current problem.

ds
….now

Junior doctors shouldn’t strike – here’s why

munns
*

Although I’m a BMA member, as I suppose we all need protection, I try to avoid the British Medical Journal, a truly PC rag, although it very occasionally prints something of genuine interest. Hence I rapidly flip through the back copies from time to time, and this piece caught my eye.

It’s the best summary of the junior doctors’ issues – and the strikes – that I’ve seen, and having been written in early January, it’s already proving prophetic. The NHS is the UK monopoly employer, and these fresh medics are not all going to go to Australia. The proposed increase in medical school places is a good idea too, though it won’t happen. My beef is how many places go to non UK students (a lot). I would make it a postgraduate degree, if I could.

The author is slightly maverick Glasgow GP, Des Spence, who usually tells it like it is. He works in Maryhill, home of such gems as Munns Bar, and I would imagine he’s a very busy clinician. Certainly a grounded one. A separate BMJ profile of him is enlightening:

Who’s been the best and the worst health secretary in your lifetime?

No one. It makes little difference in the reality of day to day. The work is the same irrespective of the government.

If you were given £1m what would you spend it on?

I could pretend that I would give it all away to fight for world peace and combat global warming . . . but we all know that’s bullshit; that’s not how people really work. I’d have a big party, give some away, save some, buy a black Jaguar F-Type, and generally spend it irresponsibly. Life is for living.

 

The title of the article is “The strike is a bad idea”, and it is one of the few contrary arguments to the whole strike thing in months of BMJ’s. There are, inevitably, tons of counterarguments  by juniors which tend to be a bit solipsistic, though they would deny that. Here is Spence’s timely piece:

I have significant sympathy for Junior Doctors and understand why they have decided to strike. Older Doctors might moan about how it was “tougher in our time” but comparing the past with now is an apple to oranges affair. Expectations are different, shifts are different, the generations are different and our societal culture is different. Striking, however, is the wrong course of action. Consider.

Could evening and weekend care be improved in Hospitals and in General Practice? The answer is yes. And the pressure to provide a 7 day style NHS service is an unstoppable cultural juggernaut of expectation, in tune with so many other services we now take for granted in modern society. Doctors would be best to simply accept this as the new cultural norm and negotiate from this position.

And will striking for a few days make any difference? We are employed by the state. Our employer can at any time change our conditions of employment with reasonable notice. This happens all the time in the public and private sector. Unless Doctors are truly willing to strike for a sustained period, we will not change the resolve of our employer. This Strike is a protest only. But will this protest curry favour with the public to force the government to change?

Many of the public do have great appreciation of what doctors do. But do they have sympathy for our working conditions and pay? (which ultimately is how this dispute will be presented in the media). Doctors might loathe the Daily Mail, but the Daily Mail does not lead public opinion but reflects it. Many of the public consider us overpaid, with great job security, being largely trained for free, having a gold plated pension (unimaginable to most in the private sector), enjoying a high status, and all this paid out of their pockets through taxation. Do we really expect any sympathy for the strike? Regrettably the strike will serve only to inconvenience the public and undermine our professional standing. The strike is simply out of step with the current mood of many in the country, coming out of a sustained period of austerity. Ultimately employers can and will impose a new contract. And Doctors won’t leave in high numbers for there is still lots of milk and honey in the NHS.

The real solution is this. Doctors don’t want to work 50 hours a week. Life/Work balance is more important than money to the current generations of Doctors. And currently we have widespread medical staffing shortages across the NHS. So we need to train perhaps twice as many more Doctors as undergraduates. This costs around £250k per Doctor, but is a notional expense to the NHS which currently spends annually £3.3 billion on agency medical staff (enough to train an additional 12 000 Doctors a year!).

Vastly more Doctors would improve work life balance, broaden the diversity of our bland homogeneous middle class profession and reduce the unhealthy status and entitlement that blights so many lives. The law of supply and demand would certainly reduce pay in time but most would find that an acceptable trade off. Medicine took most of my young adult life, a situation that we no longer have to tolerate. Dear BMA, call a strike for a doubling of doctors in training. Now that would be worth picketing for.

Hard to argue with that.

Maryhill
A quiet corner of Maryhill

 

 

Junior doctors, Trump, and the Overton Window

OvertonLRG
Overton himself, looking good

These junior doctors, eh? Their ridiculous contract ‘negotiated’ by the canny BMA, who steamrollered the Labour government of the day, creating an unworkable melange of the European Working Time Directive and the New Deal, that has badly damaged training, introduced perverse financial incentives (possibly more later) and made hospital rotas (and therefore safety) very difficult to organise. Ever wondered why you can hardly find a doctor at night in a hospital ward? Even the BMJ acknowledges there’s a problem. This is a detailed and very prescient piece on the mess, from NHS ophthalmologists in 2006.

However, that’s not my main point, it’s just one of the most familiar, and egregious, examples of the EWTD, which in theory might affect any of us. A perfect example of how being in the EU has all sorts of unanticipated effects.

The point is this: 10 years ago, if you raised concerns re the EWTD, you were told that it was ‘non-negotiable’, because our membership of the EU was set in stone. The overt implication was that would never, ever change, and very few people questioned it. UKIP were barely on the horizon.

Look at it now. A pro-Europe Prime Minister with a majority is pressing on with a referendum to potentially leave the EU. This is the Overton Window in action. In 2007 the official government view (via a question in the Lords) was reluctantly expressed, by Lord Triesman as: Parliament may amend or repeal any existing Act of Parliament, including the European Communities Act 1972. There is no formal procedure for withdrawal in the EU treaties, nor are there any provisions in the treaties or any other international obligations which affect the ultimate ability of the UK to withdraw from the EU. However, given that the UK has been a member of the EU for more than 25 years, and its laws and economy are intricately bound up with those of the EU, the Government would in practice have to negotiate the terms of any departure over a lengthy period. Otherwise known as: ‘forget it, it won’t happen’. Yet here we are.

The Overton Window is best described as the range of policies acceptable to the public, or more specifically, to quote Wikipedia: a range of policies considered politically acceptable in the current climate of public opinion, which a politician can recommend without being considered too extreme to gain or keep public office.

This week’s main example is of course thanks to Donald Trump, and despite the reflexive Trump hating in the media (and I’m not a Trump supporter), I think he rather cynically made his comment about Muslims and immigration to shift the window. What he actually said was slightly more nuanced than has been widely reported. Specifically: Donald J. Trump is calling for a total and complete shutdown of Muslims entering the United States until our country’s representatives can figure out what is going on. That was Trump moving the window, and already the discourse is changing. A lot of US media types think it will allow the more moderate Ted Cruz to hoover up votes from this part of the political spectrum. They may be right. This beautifully presented discussion by David French is worth reading.

Another current example lies in the reporting of the futile Paris climate change love in. It’s not just the BBC, Sky and ITV are reporting it without any sense that there is a very real and growing debate over the validity of the assumptions that lie behind it. In TV terms at least the Overton Window has shifted to the climate-change-is-real-any-action-however-expensive-or-impractical-is-good axis. Dissent is simply not mentioned. That is probably an example of the TV media’s OW being in a somewhat different position to that of the average punter, on reflection.

No-one at all, back in 2005 when NHS medics were wrestling with producing EWTD compliant rotas, would have predicted that we would now be discussing the possibility/probability that we could dump the reason for the EWTD, yet here we are, and a good thing too.

Control the window, you control the debate.

 

OvertonWindow
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