We have no doctors (again)

by reestheskin on 09/04/2019

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We have no  incentives doctors.

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:

  1. The various NHS’s in the UK do many things very badly. The comparison is all too often with west of Shannon, rather than that body of land closer to us.
  2. The proportion of ‘health staff’ who are doctors has been dropping for over a century. This trend will — and should —continue.
  3. I write from Scotland: Adam Smith worked out the essential role of specialisation in economic efficiency many centuries ago. Conceptually, little has changed since, except the cost of health care.
  4. The limit on my third point is transaction costs of movement between specialised agents. This is akin to Ronald Coase and the theory of the firm: why do we outsource and when do firms outsource? How do we create — to use a software phrase — the right APIs
  5. Accreditation and a professional registration are there to protect the public. We will only encourage staff to take on the new roles needed  if  there is a return on their personal investment, in return for formal admission to the appropriate guilds. These qualifications need to be widely recognised and transferable, and the guilds will need to be UK wide (or, in the longer term, wider still).
  6. The current system of accreditation for those providing clinical care is bizarre. Imagine, you know a bright and ambitious teenager. You tell her to come and sit in your dermatology clinic for 5 years and, at the end, you employ her in your practice as a dermatologist — initially under your supervision. Well, we know that is not a sensible way to train doctors, but this is indeed the way the NHS is going about training those who will provide much face to face clinical care. Got a skin rash — see the nurse! (for a couple of personal anecdotes,  see below).
  7. The current system of accreditation for a particularly role for doctors is based around individual registration (with the General Medical Council). What the public require is however evidence of registration for defined roles and procedures (using the term procedure in a broad sense, and not just as in a ‘surgical procedure’). If somebody is a dental hygienist they are registered with the General Dental Council. This makes sense. The sleight of hand in medicine is that individual hospitals or practices have taken on the role of accreditation. I suspect if private individuals — rather than the NHS or its proxies — did this, they would be considered to be riding roughshod over the Medical Act (I am no lawyer…).
  8. Accreditation of  medical competence at the organisation level is indeed a possible alternative to individual personal registration. It might even have advantages. But this has not been the norm in the UK (or anywhere else), and the systems to do this are not in place.

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 killing working’.

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.

The not so quiet revolution

by reestheskin on 02/01/2019

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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.


The affair is over

by reestheskin on 26/06/2018

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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?”

Most lawyers don’t make anything except hours.

by reestheskin on 17/10/2017

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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 service training

by reestheskin on 11/04/2017

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“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.”


The crisis in dermatology

by reestheskin on 14/06/2015

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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]

NHS supremo says ‘too early for hindsight’. A little foresight would have helped.

by reestheskin on 26/11/2014

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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.

Not enough hours in the day

by reestheskin on 09/03/2014

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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).
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Clinical skills

by reestheskin on 19/02/2014

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“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.