Late night thoughts

Late night thoughts #2

by reestheskin on 12/03/2019

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Late night thoughts on medical education #2: Apprenticeship

We have a very clear idea of how apprenticeship has worked over the last nine hundred years or so within Europe. The core ideas are of course much older, and the geography wider. But we have written records of the creation of the various social structures that led to the rapid changes in society that led in turn via the Renaissance to the Enlightenment and modern capitalism. We can trace so many of the norms that have guided my professional life: Royal Colleges, corporations, guilds, “masters and apprentices”, universities, certification and the granting of monopoly, and ‘professionalism’, to name but a few.

Apprenticeship is a powerful pedagogical model, but one that can only take place when a number of conditions are met. In medicine the ‘apprentice’ model is widely discussed, assumed, and contrasted with the ‘bums on seats’ lecture, the latter, the now signature pedagogy of the modern ‘massified’ university. It is also used to justify the high costs of training of education in medicine and some craft university courses.

At the level of higher professional training in medicine (or in the training of research academics) apprenticeship still can work well. There is an asymmetry between master and pupil (the master does know best, but cannot always justify why he knows best); long term interaction between both parties is required; and, at its best the pupils will model their behaviours on the master. Apprenticeship is not passive — it is not ‘shadowing’ (although a period of shadowing may be required); it will require the pupil to undertake tasks that can be observed and critiqued — you cannot learn complicated tasks based on passive observation. Chimps are highly intelligent, and yet learning to crack nuts using stones takes years and years, not because the young chimps do not watch their mothers, but because the mothers never watch (and hence correct) the young chimps. This requirement is not just required for motor tasks but for any complicated set of ‘thinking’ procedures that require accuracy and fluency. In medicine, surgeons are ahead of physicians on this, and have been for a long time.

In medieval times, becoming a master meant more than being a ‘journeyman’ — the level of professional expertise was greater, and it was recognised that teaching required another level of competence, and breadth. The master is not one step ahead on the way to perfection, but several. We prefer those teaching ‘A’ level physics, to have more than an ‘A’ level in physics themselves. And whatever domain expertise a master possesses, we know that experience of the problems or difficulties learners face, is important.

Still, in comparison with say school teaching the demands on the master (with regard to being a ‘professional’ educator) are modest. They know the job — they do not need to check out the syllabus — as they are effectively training people to do the same job they do day-to-day. They probably also have little need of theory and, in a sensible system, their reputation may be accurate.

In higher professional training in medicine, apprenticeship is still possible — it is just that it is harder than it once was (as to why, that is for another day). Similarly, at one time higher education was in large part viewed as a type of apprenticeship. Students were not staff, but they were not treated as schoolchildren, rather they were —at best— viewed as co-producers of knowledge within a university. If you were studying physics, the goal was to get you to approach the world like a physicist might. This may persist in a few institutions for a minority of students, but it is not the norm anymore.

In undergraduate medicine apprenticeship died a long time ago, although its previous health may well have been exaggerated. There is little long term personal interaction, with students passed around from one attachment to another, with many of the students feeling unwanted (‘burden of teaching’, ‘teaching load‘ etc). Staff and students can walk past each other in the street, none the wiser. Apprentices are — by definition — useful. It is this utility that underpinned the business model that formalised training and acceptance or rejection into the guild. But sadly — through no fault of their own – medical students are rarely useful. If they were useful they would be paid: they are not. Historically, students might have got paid to cover house officer absences (I did), but that world no longer exists. Nor are we able to return to it.

Whereas the master has an implicit model of the goals of training, that is no longer the case in undergraduate education, in which literally 500 or individuals are engaged in educating students for roles that they individually have little knowledge of. Instead of personal interaction, over a long time period, based on a common world view, medical schools create complicated management systems to process students, with the predictable lack of buy-in from those who are doing the educating.

There is a deeper point here. Much though a lot of UK postgraduate medical training is poor, it is possible to improve it within a framework that is known to work. Many doctors know how to do it (although the same cannot be said of the NHS). Undergraduate medical education is in a different place (like much of university education). At graduation, you step form one world into another, but just as with caterpillars and butterflies, the structures and environment we need to create are very different.

Late night thoughts #1

by reestheskin on 05/03/2019

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Late night thoughts on medical education #1: we have no doctors

Today’s (Scottish) Daily Telegraph ran with a story about the shortage of paediatricians in Scotland. The Herald had a similar story, too. It is not just paediatrics that has major shortages. The same can be said about dermatology, radiology and a host of other areas of medicine. And that is not to mention GP land, which normally seems to attract most ‘government’ attention.

I find none of this surprising. The NHS has long been in subsistence mode, eating the seed corn (or to use that other phrase, ‘eating its young’), spending its moral and cultural capital at an alarming rate. Management is notable by its absence, whereas the administrators think they are ‘managers’, in part, because they can’t administrate and stay sane. By lack of management I meant those functions of management we see in most corporations or freestanding institutions. Changes in demography have not happened suddenly; the relation between age and health care provision, has been well known for a century or more; the impact of family structure and geography on care provision of elderly relatives evident since the early 1960s; changes in work force have been growing  for at least 40 years; and UK medicine has a long history of ignoring why people wish to leave either the UK (or want to leave the NHS). The attempt to run health care as a Taylor-like post-industrial service industry using staff who value their autonomy and professionalism, may not end well for doctors — or patients.

All the above, management should have been grappling with over the last quarter century: instead they have been AWOL. Meanwhile, politicians engage in speculative future-selling, where electoral vapourware is often a vehicle for the maintenance of political power. Given the state of UK politics (as in the BxxxxT word), it seems reasonable not to give politicians the benefit of the doubt any more. As individuals, no doubt, most of them mean well, and love their kids etc, but the system they have helped co-create, cannot command respect (that is now electorally obvious).

There are however some aspects of this that bear on what keeps me awake at night: how we educate — and to a lesser extent—how we train doctors.

  • The UK has not been self-sufficient in physicians since the birth of the NHS, rather choosing to import staff from the rest of the world. Despite this, doctor numbers are low in comparison with many other advanced economies. More dermatologists in the city of Vienna than in the UK……
  • Manpower estimates AFAIK, seem to reflect realpolitik rather than be based on bottom up data. Whatever is estimated is decided by the ‘realistic medicine’ availability of cash. Our politicians and the commissars of the medical establishment do not dissect animals in order to learn how the world works, they sacrifice them to the gods of political power, hoping some of the blood runs off on them.
  • The idea that you can plan on the basis that ‘x’ is the number of doctors you need in 10, 20, or40 years seems foolish. Hayek was not wrong about everything, even if Uncle Joe didn’t read him. Dead reckoning usually loses out to a good GPS system.
  • Most importantly of all, you must overproduce doctors. There are various ways you can think about this, but the current system of taking a bunch of 18 year olds into medical school and assuming that attrition will be low, will breed complacency. You cannot build any organisation that is worth working for when the ratio of applicants to vacant posts is less than one. And to miraculously imagine you can get the figure right over a score of years, is well….(and no, the running mean isn’t the right figure, here).
  • Medical education is claimed to be expensive and rate limiting (a Mr Hunt line, I think). There are various comments to make. First, the figures are inflated for political effect and possibly for accounting reasons. Claims that it costs £x to produce a consultant write off all ‘work’ the individual has done on the way to that position. By contrast, the NHS subverts market rates for many jobs done by ‘juniors’. And, as for undergraduate medical education, we know most of the money is an accounting sleight of hand. If you ask could we do it better, for less money, I will tell you for free.
  • The comments in the last point not withstanding, it must be an immediate goal to reduce the cost of medical education; and to think how the workforce of non-physicians can piggyback on what we know about training doctors. These conversations were alive half a century ago, and we have made little progress. The key issue is straightforward enough: without national accreditation, these posts will not encourage candidates to undergo training — you don’t need to read Gary Becker to get this, just talk to those who leave nursing — there are enough of them)
  • Even with more fluidity within professional careers, you need to allow for sideways movement and retraining of many middle aged doctors. You need to encourage staff, and move our focus from competencies(ugh!) to skills.
  • Without funnelling a lot more students into medicine as a career, little of what I have said above will make much difference. There are ways, but that is for another day.