Dr Chris Day writes:
Two weeks ago, I swabbed my first positive Covid-19 patient during an A&E Locum shift. I must say back then, I hadn’t fully taken in what we as a country will have to face over the coming months. The reports from colleagues in Italy and China are beyond belief.
The UK has been left to fight Covid-19 with half the Intensive Care beds per capita of Italy. Back in 2014, the trigger for my whistleblowing case was my attempt to try and secure more ICU resources for South East London (see Private Eye).
Instead of spending 5 years and £700k fighting /smearing me and damaging whistleblowing law, the NHS could have just fixed the problem. There has never been a more important time for the public and the politicians to understand Intensive Care resourcing and what is decided on their behalf by NHS leaders.
The following is from Janan Ganesh of the FT. The title of the article was “The agony of returning to work in September”.
A personal ambition is to reach the end of my career without having managed a single person.
It seems to me a very sensible ambition, one which used to be the lot of many academics — usually the better ones. He goes on:
Friends who have been less lucky, who have whole teams under their watch, report a quirk among their younger charges. It is not laziness or obstreperousness or those other millennial slanders. It is an air of disappointment with the reality of working life. They will be among the people described in Bullshit Jobs by the anthropologist David Graeber….
A generation of in-demand graduates came to expect not just these material incentives but a sort of credal alignment with their employer’s “values”. The next recession will retard this trend but it is unlikely to kill it.
At one time the words ‘manager’, ‘management’, or worst of all, ‘line-manager’ were alien to much of medicine or academia. Things still got done, in many ways more efficiently than now. It is just that our theories of action and praxis have been ransacked by Excel spreadsheet models of human motivation and culture. It is the final line from the quote that those controllers of ‘managers’ should be scared of:
The next recession will retard this trend but it is unlikely to kill it.
I am generally nervous about doctors or academics working for the government. Not that I think the roles are unnecessary, far from it. But what worries me is when instead of resigning from their academic role, they end up working for more than one master. So, I tire of the use of university titles when the principle employer does not subscribe to the academic ideal. I think if you have been at Stanford and you go to Washington it should be as a regular civil service post. I think the Americans get it right.
But the retiring CMO, Dame Sally Davies, in an interview in the RCP in-house journal ‘Commentary’ speaks some truths (Commentary | October 2019, p10).
I hear non-stop stories from unhappy juniors. In my day, we (consultants) made up the rotas for the juniors, but now administrators do it without understanding all of the issues. I’m told you can’t go back to the ‘firm’ structure because there are so many doctors in the system, but whenever I meet a roomful of young doctors I ask: ‘Does your consultant know your name?’ It’s rare that a hand goes up. We have depersonalised the relationships between doctors and that can’t help the workings of the medial team, or with the patients.
Your mileage may vary, but when I was a junior doctor it was us — not the consultants — who came up with the rotas. But the point she makes is important, and everybody knows this (already). At one time junior doctors didn’t work for the NHS, rather they worked within the NHS for other doctors, for good and bad. I find it hard to imagine that the current system can deliver genuine apprenticeship learning. Training and service may often have resembled a bickering couple, but there was a broader professional context that was shared. I am not certain that this is the case anymore. Whenever people keep pushing words such as ‘reflection’ or ‘professionalism’, you know — pace Orwell — that the opposite is going on. Politics is a dominant-negative mutation.
Shortage of GPs will never end, health experts say | Society | The Guardian
OK, maybe the subeditor is to blame, but spare me the cartel of health think tanks and their pamphlets. Enticing people into general practice and keeping them there is not rocket science. When I was a junior doctor getting onto the best GP schemes around Newcastle was harder than getting the ‘professorial house-jobs’. Many people like, and want to be, GPs. If general practice is dying , it is in large part because the NHS is killing real general practice.
A few years back I wrote a personal view in the BMJ, arguing that an alternative model for dermatology in the UK would be to use office dermatologists, as in most of the first world. It is likely cheaper and capable of providing better care as long as you consider skin disease worthy of treatment. The feedback was not good or in some instances, even polite. The more considered views were that my suggestion was simply not possible: how would we train these people? Well jump on a ferry or book Ryanair, and look how the rest of Europe does it.
There are some general discussion points:
Two personal examples:
I received an orthopaedic operation under a GA at a major teaching hospital. I was in the my mid 50’s, and previously fit. At the clerking / pre-op assessment by a nurse, my pulse and BP were recorded, and my urine was tested. I was asked : “Are your heart sounds normal and do you have any heart murmurs?” (There was no physical examination). My quip — that how could you trust a dermatologist on such matters — was met with a total lack of recognition. I recounted the story to the anaesthetist as a line was inserted in my arm. I also mentioned, for effect, that they didn’t ask about my dextrocardia….( I achieved the appropriate response — to this untruth). Subsequent conversations with anaesthetists confirmed that their opinions were in keeping with mine, and this “was management” and ‘new innovative ways of
As a second year medical student, with a strong atopic background (skin, lungs, hay fever etc). I came out in what I now know to be widespread urticaria with angioedema. On going to the university health centre, the receptionist triaged me to the nurse, because it was ‘only skin’. I didn’t receive a diagnosis, just an admonition that this was likely due to not washing enough (which may have been incidentally true or false…). A more senior medical student provided me with the right diagnosis over lunch.
The latter example chimed with me, because DR Laurence in his eclectic student textbook of Clinical Pharmacology lampooned the idea that nurses had ‘innate’ understandings of GI pharmacology, a delusion that remained widespread through my early medical career. Now, sadly, similar prescientific reasoning underpins much UK dermatology. The public are not well served.
General practice has been undergoing a quiet revolution in recent years that has had little fanfare: it is now an overwhelmingly part-time profession.
Official figures suggest almost 70% of the workforce work less than full time in general practice – the highest proportion ever.
Did the NHS save your life, or did Doctors and Nurses save your life?
It’s an earnest question. A comment on an excellent FT piece: “Is Britain loving the NHS to death?”
This was a quote from an article by an ex-lawyer who got into tech and writing about tech. Now some of by best friends are lawyers, but this chimed with something I came across by Benedict Evans on ‘why you must pay sales people commissions’. The article is here (the video no longer plays for me).
The opening quote poses a question:
I felt a little odd writing that title [ why you must pay sales people commissions]. It’s a little like asking “Why should you give engineers big monitors?” If you have to ask the question, then you probably won’t understand the answer. The short answer is: don’t, if you don’t want good engineers to work for you; and if they still do, they’ll be less productive. The same is true for sales people and commissions.
The argument is as follows:
Imagine that you are a great sales person who knows you can sell $10M worth of product in a year. Company A pays commissions and, if you do what you know you can do, you will earn $1M/year. Company B refuses to pay commissions for “cultural reasons” and offers $200K/year. Which job would you take? Now imagine that you are a horrible sales person who would be lucky to sell anything and will get fired in a performance-based commission culture, but may survive in a low-pressure, non-commission culture. Which job would you take?
But the key message for me is:
Speaking of culture, why should the sales culture be different from the engineering culture? To understand that, ask yourself the following: Do your engineers like programming? Might they even do a little programming on the side sometimes for fun? Great. I guarantee your sales people never sell enterprise software for fun. [emphasis mine].
Now why does all this matter? Well personally, it still matters a bit, but it matters less and less. I am towards the end of my career, and for the most part I have loved what I have done. Sure, the NHS is increasingly a nightmare place to work, but it has been in decline most of my life: I would not recommend it unreservedly to anybody. But I have loved my work in a university. Research was so much fun for so long, and the ability to think about how we teach and how we should teach still gives me enormous pleasure: it is, to use the cliche, still what I think about in the shower. The very idea of work-life balance was — when I was young and middle-aged at least — anathema. I viewed my job as a creative one, and building things and making things brought great pleasure. This did not mean that you had to work all the hours God made, although I often did. But it did mean that work brought so much pleasure that the boundary between my inner life and what I got paid to do was more apparent to others than to me. And in large part that is still true.
Now in one sense, this whole question matters less and less to me personally. In the clinical area, many if not most clinicians I know now feel that they resemble those on commission more than the engineers. Only they don’t get commission. Most of my med school year who became GPs will have bailed out. And I do not envy the working lives of those who follow me in many other medical specialties in hospital. Similarly, universities were once full of academics who you almost didn’t need to pay, such was their love for the job. But modern universities have become more closed and centrally managed, and less tolerant of independence of mind.
In one sense, this might go with the turf — I was 60 last week. Some introspection, perhaps. But I think there really is more going on. I think we will see more and more people bailing out as early as possible (no personal plans, here), and we will need to think and plan for the fact that many of our students will bail out of the front line of medical practice earlier than we are used to. I think you see the early stirrings of this all over: people want to work less than full-time; people limit their NHS work vis a vis private work; some seek administrative roles in order to minimise their face-to-face practice; and even young medics soon after graduation are looking for portfolio careers. And we need to think about how to educate our graduates for this: our obligations are to our students first and foremost.
I do not think any of these responses are necessarily bad. But working primarily in higher education, has one advantage: there are lost of different institutions, and whilst in the UK there is a large degree of groupthink, there is still some diversity of approach. And if you are smart and you fall outwith the clinical guilds / extortion rackets, there is no reason to stay in the UK. For medics, recent graduates, need to think more strategically. The central dilemma is that depending on your specialty, your only choice might appear to be to work for a monopolist, one which seeks to control not so much the patients cradle-to-grave, but those staff who fall under its spell, cradle-to-grave. But there are those making other choices — just not enough, so far.
An aside. Of course, even those who have achieved the most in research do not alway want to work for nothing, post retirement. I heard the following account first hand from one of Fred Sanger’s previous post-docs. The onetime post-doc was now a senior Professor, charged with opening and celebrating a new research institution. Sanger — a double Laureate — would be a great catch as a speaker. All seemed will until the man who personally created much of modern biology realised the date chosen was a couple of days after he was due to retire from the LMB. He could not oblige: the [garden] roses need me more!
“Certainly, for frontline doctors like us who are used to wrestling with clunky NHS IT systems, the biggest surprise of the malware attack was not that it happened but why it had taken so long. It is an irony lost on no NHS doctor that though we can transplant faces, build bionic limbs, even operate on fetuses still in the womb, a working, functional NHS computer can seem rarer and more precious than gold dust.’
“Core surgical training in the UK has been dubbed “core service training” because many trainees believe it does not provide enough surgical experience. At the southern tip of Africa, I felt I was being taught to operate, not to just watch and hold retractors. My commitment and progression were judged on hard work and merit, not on how many courses I had attended.”
Fairly dismal reading here and here. Much of what has happened in the UK is a result of a health service that is not based around clinical need, and in which most decision makers might as well believe in fairies. The mistake is to imagine that we got into this mess because of a lack of money. We got into this mess for much the same reason that much of UK industry has collapsed: the people making decisions have no technical competence in the relevant domains. If it was left to the NHS, BMW would not employ engineers (‘its just process management, isn’t it, so let’s reorganise the workflow, and set some targets?’).
‘Health policy is in tatters. Markets haven’t worked, inspection hasn’t worked, demand management has failed, morale at an all-time low and workforce planning botched. The sky is dark with chickens coming home to roost. The NHS is now all about muddling through’. Roy Lilley calls it right. But what is a young graduate or student to do? [link for this post]
So the English NHS is to stop paying GPs to diagnose dementia. The NHS supremo is quoted as saying, ‘I think it’s too early for hindsight. We need to look at the dementia diagnosis rate through the year before we do that. It is not driven by patient preference, but by different levels of focus on this topic. ‘ Well forget hindsight, a little foresight would have helped.
A long, long time ago, I was sitting in the biochemistry coffee room in the medical school in Newcastle. Roger Paine, a professor of biochemistry came and sat next to me. I knew of him, but he didn’t know me. He was a FRS, I was a dermatology research registrar taking my first steps in learning some wet bench science in the Medical Molecular Biology Group there. Coffee rooms work, as do Aeron chairs. Sometimes you need to talk, and ramble around what interests you; and sometimes you have to sit alone, and dream. If you don’t, you will do ‘kit’ science, or act out being an administrator by conducting randomised controlled trials.
We got chatting—we shared a mutual colleague—and he expressed his puzzlement to me about how medics managed to do any research. He pointed out what with seeing patients, and some undergraduate teaching and postgraduate training, how on earth could you hope to do any meaningful research. I listened, not wanting to hear what he said. And I should point out, he was a keen collaborator with medics, nor stand-offish in any way.
Many years later, in another setting, I was talking to another successful scientist, a geneticist, also a FRS. We knew each other reasonably well, and by this stage I had been working in wet-bench science for a dozen years or more. Some modest successes, and plenty of failures. He told me that because he knew the details of many clinical medics research careers very well, he would be loathe to ever approach any of them if he needed medical care. He had the highest regard for them as academics, and researchers, but he too couldn’t see how they could carry on all the various activities expected on them. (And no doubt be able to go to the cinema once in a while: Steven Rosenberg, a one time Chief of Surgery at NIH, in his autobiography, describes how he would struggle to leave Sunday evening free of lab and clinical duties, so that he could go to the cinema with his wife).
“What of attempts to improve skin cancer diagnostic skills in primary care, or to develop GP specialists as seen in Australia or the UK? There are various points to make here, and perhaps a lot of wishful thinking about how the problem could be solved if only ‘GPs’ knew more about this or that subdomain of medical knowledge. In truth, such blandishments, must be frustrating to many GPs: there are only so many hours in the day. There are studies showing that it is possible to improve diagnostic skills over the short term following organised tuition (cited in Rees (16)). To find anything else would of course be surprising: if we expose intelligent people to formal tuition or learning, we expect short-term performance to improve. But, the critical point is whether this improvement is maintained, and what aspects of performance suffer because they have been replaced by training in another domain (16). There is no free lunch. If we run a course on skin cancer, then the rheumatologists, cardiologists etc. will all want to run courses. And much of what we know about such one off tuition is that in the absence of consolidation and feedback, the benefits are short lived only. How many of us remember all the history and geography we learned at school?” Here.