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Unnatural Selection

Posted by Dr No on 04 January 2011

monkey.jpgBy way of a reply to WD and Dr Boots' latest comments on Dr No's last post.

In Dr No's medical student days, most medical students were WASP males. There was a lot of rugger, and high jinks, à la Daily Hail, only in those days, having studied Latin and so Roman habits, we knew how to throw up properly.

About fifteen years later, about ten years ago from now, Dr No had already noticed a shift away from WASP medical students towards more BME and more female students. He even remarked on it during a tea and biscuits break on a ward round - and a health service fattie, a psychologist of all things, all but exploded, but thankfully didn't, because all the tea and biscuits inside her would have made a terrible mess.

The reason fattie nearly exploded was because Dr No had had the temerity to suggest that the reason for the shift had nothing to do with the 'equality and diversity agenda' nor capable female BME candidates now winning the places they had always deserved, but hitherto been denied, but instead had everything to do with the fact that intelligent male WASP school leavers had already spotted that a medical career was a dead duck, sitting in the water waiting to sink. They were quite simply voting with their feet. No doubt a few, perhaps more than a few, ended up in the City, and gambled not with peoples lives, but with the nation's treasure.

Dr No knows of a recent time when there were two post FY trainees in a particular unit. Both were female, and one BME, the other white upper middle class, of the hockey stick tendency. The former wasn't the sharpest pencil in the box, and spent much of her time in the office doing facebook; the latter was good, very good - and full of how she couldn't wait to finish her current post, and get out of medicine, perhaps for a while, perhaps for ever.

What Dr No thinks is going on here is a form of natural or rather unnatural selection, a variant of his 'survival of the conformist', which we might here call survival of the second best. We might even call it a brain drain. The bright and the capable see the light, and get out, and we are left with second best. (And before medical students and junior doctors start lobbing bricks through Dr No's window, let it be clear he is talking in population terms, not about individual students, many of who are very very bright - including of course you, my dear medical student junior doctor reader.)

But - and it is a big but - at the same time we have seen an explosion in medical student places, and so graduates; and so, as a result, we now have in total more tier two candidates, medical students and junior doctors. So - at great personal risk of being turned to stone by one of the WD's potent spells - Dr No begs to differ in detail from her assessment. He doesn't think there will be a shortage of doctors per se, instead there will be a shortage of doctors willing to put up with NHS and training bullshit, for the others will vote with their feet, and of them not a few become unemployed. But of those, many will not show up as unemployed, because they will be female, and looking after their children, supported either by their partner, parents and/or child tax credit - and so wont claim JSA, and so wont be counted (literally) as unemployed.

Where Dr No does agree with the WD is that there is likely to be a shortfall of available doctors (which may appeal to a cash strapped treasury - see the 'harder noses' link in the previous post), and the shortfall will, maybe already is, being filled by imported half asleep Herr German doctors, and souped up 'practitioners' from lower down the medical ladder. Indeed we are already seeing this happen - back pain referrals from GPs go not to a medical consultant, but to souped up physios, who exercise a diagnostic role that they were never trained or intended to. As the WD observes, this will sometimes be downright dangerous.

Dr No also begs to differ from the detail of Dr Boots’ assessment. For the reasons given above, Dr No doesn't think the problem is so much a failure of the selection process, as a failure, at both under and postgraduate level (over two years ago, for example, the RCPsych was already pointing out that 'just 6% of candidates sitting Paper 1 of the MRCPsych were UK graduates - a stark warning that the longstanding recruitment difficulties facing our specialty are becoming a crisis' - and that 6% isn't a typo: which means 94 out of a 100 candidates were from overseas), to attract the right people in the first place. The smart ones are bailing out. As a delightful old-school consultant of Dr No's once observed, 'one simply can't get the staff these days'. He was old enough to be on the set of Upstairs Downstairs, and was talking of domestic staff. Were he around today, he might have said the same thing about his junior medical staff.

And there we have it: a strange ironical paradoxical situation if there ever was one. An over-supply of medical graduates, some very good, some not so, and in both groups many for various reasons will truant, and of those a number will be unemployed; and at the same time there is a recruitment crisis. Truly, we live in interesting times.


I do agree with you Dr No. I do wish to add as follows

Certain women remain with their kitchen sink and parent and baby parking. I could name a few who currently edit a certain leading medical journal.

PS This isn't controversial enough. If I was writing it, I would spin it slightly differently

a. Some females demand that the workplace bend over for them.
b. There is no reason women with children get preferential treatment - tax credits, child credits etc. Single people do not get such wonderous treatment.
c. Some female doctors and their tendency to drop a sprog assume the rest of the world of doctors should bust a gut doing their work, oncalls etc.
d. The BMJ at present is largely a feminist outfit. It is time it was neutral. Personally, I am quite fed up of reading about women's rights etc. Why can't we read about individual rights as applied to the entire population of doctors.

End of rant.

A Female Ex Doctor.

Dear Dr No,

I substantially agree with what you say. I have often thought that the decline of WASP (and Jewish) male doctors matches the declining prestige of medical careers, rather than some victory of equal opportunities. I do though find that our BME and female trainees have other useful qualities, and mostly make excellent doctors.

I have had some rambling thoughts on my blog, on the issues facing medicine, and medical careers, if you are interested in my post "0n Medicine and Marriage"

Dr Phil

Dr Phil/Boots - a thoughtful post of yours (feel free to add links in comments if you want to) which interestingly touches on a number of themes covered by Dr No. The early romance and then marital nature of the doctor-profession relationship, and latterly the increasingly common sad ending in disillusionment and indifference, is covered in The Rhett Butler Moment, while the familial nature of the profession (and here, Dr No might further add, as a profession that 'looked after its own', this being, all said and done, a good thing, even if it masks duds drunks and misfits from wider censure) is covered in Alma Mater.

There is also an underlying theme here which is that of trust. Many of Dr No's posts on revalidation have pointed out the destructive effect it will have on trust: see Why Revalidation is Wicked and The Lies of Others. I think we both agree that revalidation is to trust as water is to fire...

It really would be in the public interest to know the likelihood of “Medical Truancy” becoming a major problem in the future. I wonder whether the government/deaneries are publishing full information about applicants, admissions and career patterns in this age of “transparency.” Isobel Allen did two reports in 1982 and 1994 but I don’t know if there have been any since apart from a mention in one of Liam Donaldson's annual reports. The information which might help to give a projection will be there somewhere.

The feminisation of the medical workforce has huge implications for the future staffing of hospitals and general practice. Women doctors will never cover the same range of specialties as their male counterparts. If, for example, 70% female admission to medical school becomes the norm it might be very generous to assume that half of these women doctors go on to consistent full time work in any specialty in any grade during their lifetime. For example most of those working full time will have no desire to become surgeons. Some of the 2-3 session part-timers will spend most of their time keeping log books for training, compulsory appraisals, CPD and, in future, revalidation. Keeping this up to date will probably take the same number of hours per week as it takes a full-timer.

Can we assume we will be able to import foreign doctors from Europe or further afield as we did in the past? As India and China become wealthier, why would they want to come to UK to help us out?

There were many agendas associated with polyclinics, but I always felt one of them was to pool part-time and discontinuous medical resources in one place with a few permanent “supervising” full time medical staff to hold things together.

The public also have a right to know how many tired European doctors are being flown over to cover out of hours, because this is a big warning sign for the future of medicine in this country.

Dear Witch Doctor,

as well as the desire, I think there are real difficulties in maintaining skills when working only a few sessions. To learn these skills, particularly in surgery and other procedure based specialities is very, very difficult indeed.

The other aspect of medical truancy that we have not touched on is post jumping. 15 years ago when someone took on a GP partnership or Consultant post it was for life. Now we seem to get as many consultants applying for posts as newly finished trainees. Only a decade ago this was very unusual, now it is quite the norm. Whilst this is not medical divorce, it is at least serial mogonomy. Sometimes it is an unhappy department that forces someone out, sometimes it is the grass looking greener on the other side.

Thanks for the links Dr No, some interesting strands of thought. In return could I recommend Raymond Tallis 's book "Hippocratic Oaths" . I think him the most astute writer on the ills of British medicine.

Yes, serial monogamy is common in my neck of the woods too in some specialties. It is always quite interesting when a consultant is pipped at the post by a registrar s/he helped train. I think it might be a feeling of loss of autonomy that might be at the root of this perpetual motion within the consultant establishment. But the the grass is not always greener in the other side as far professional freedom is concerned.

I've also commented on some of these issues, partly based on Mrs Dr Aust's experiences as a "lost tribe" doctor turned part-time sessional type, over at Dr Phil's excellent blogpost on Medicine and Marriage.

[I haven't hotlinked it as it annoyed Dr No's hair-trigger spam filter]

Sorry that the spam filter appears to be playing up again. Links normally get through OK - as you can see above, I have already linked to Dr Boots' post - and indeed some of Dr No's earlier posts on the matter. I can't for a moment imagine that the filter thinks Dr Boots is himself spam!

Dr Boots mentions Article 14/CESR. In general terms, this is an excellent way to (a) stress yourself up wonderfully (b) waste extraordinary amounts of time teasing out the arcane nature and meaning of the requirements and (c) burn money as it were newspaper. Since the Stasi took over PMETB's functions, it now presents the combined old PMETB Article 14 plus Stasi CESR figures here. Only the CESR element has been 'spun' by injecting the CEGPR figures (with their very high 94% success rate) into the table. If we take out those misleading (as far as Article 14/CESR figures are concerned) CEGPR figures, we get (for the period Sept. 05 to Sept. 10) 3819 Article 14/CESR applications, of which 1986 (51% - over half) were rejected. Now the table lists some 110 specialties (excluding general practice), and so in crude terms the 1853 successful applicants average out at 370 a year, or 3 per specialty per year.

Dr No appreciates these are crude averages, but they make the point - not exactly great odds, given a total population of nearly a quarter of a million registered doctors...

Dear Dr No,

I had an interesting chat with our College Lead on article 14 applications at a conference last summer. It certainly is an expensive (£2,000) application, and very time consuming to produce a competency portfolio containing all the same evidence as a CCT applicant, and all in the last five years. 52% pass rate is quite high, and many of the remainder of the applicants get told that they need to get further evidence of competency in area X or Y.

We are regularly approached by staff grades wanting to cover these areas as a condition of taking up a staff grade post. In all but name these become further trainee posts. If we did not agree to this we could not fill the posts. Many of those who failed to get through first time will come back before long with a better portfolio and will get CESR. It is in the language of the times not failure but deferred succes. I am glad that it is an arduous process, it is for our Trainees so to be at the same level it should be for article 14.

A further issue is whether these CESR's are considered to be equal to CCT by Consultant appointment panels. These candidates are generally older, and not well published, but on the other hand have above average experience, and are usually strong on departmental audit and governance issues. In my College role on Consultant AAC's I have seen this viewed both ways. As long as the panel is reasonable in it's views, and there is a legitimate reason that research is important then I support the panels decision.

I think that the post 2007 WBA based curriculum makes CESR more straightforward, and with dumbing down of training there will be a much more even playing field. I have an excellent Article 14 locum consultant at present, who would be the candidate to beat if we can persuade the trust to advertise a substantive post.

I am interviewing for a consultant at Big City University shortly. There is a DGH Consultant applicant, two article 14 applicants, 3 SPR's on the shortlist. It will be interesting to see how the interview pans out. A substantive consultant with CEA would be a significantly higher payband, and management reps on the panel may favour someone more naive and malleable. Experience verses enthusiasm and potential.

I expect that in 5 years staff grades will be extinct, all either having CESR, or retired, though like salaried GPs there may be a place for those who want sessional work, but far less admin. It even appeals to me a little!

Dr Phil

I can't really see how hospital staff grades will ever be extinct as long as there a preponderance of women doctors of childbearing age in the system. At the moment all independent GPs are accredited as trained and that training at the moment is much shorter than consultant training. A woman doctor who wants to be a GP can usually be fully qualified before she starts a family and therefore be fully qualified as an independent practitioner when she returns on a sessional basis.

Most women doctors returning to sessional work in a hospital specialty will not be fully trained and many are not looking for consultant status anyway. If staff grades vanish then they will need to be reinvented and given another name.

I need a little help here as not being a doctor, I lack knowledge relating to career breaks from medicine.

Regarding the doctor whose sad story I highlighted, as he is registered with a licence to practice on a GP register and for whatever reason he was blocked from returning to general practice - are all doors now closed to him within medicine itself? Is his only option Big Pharma or other such pursuits that he probably does not wish to enter; or, are these options closed too? If applying for such posts, would he have to declare that he is no longer able to practice?

What professional body would support this GP? Any? Or, are all these professional bodies the same as those that supposedly exist for the benefit of nurses, but in reality only exist to serve themselves?

It appears a littly crazy to me that good doctors are being blocked from returning on the whims of their PCT, when there is a reported shortage of trainee doctors applying for registrar positions and new GPs applying for posts plummeting.

With regards to Dr Phil's last comment - I get the impression that in many cases, a sessional GPs lot is not a happy one. It is probably true (?) that in many cases the GP is not sessional by choice as partnerships are few and far between? There is a constant turnover of sessional GPs at the practice I attend - and they generally leave after a year or two when finally finding a partnership opportunity.

But, my main concern is for GPs who are denied returner placements (unless of course for crimes and misdemeanours) and effectively, are denied their career. Who speaks up for them?

Anna :o]

Dear Anna,

I am not involved with General Practice, but the general principle is that retraining posts are possible those returning to work after a break, particularly pertinent with the feminisation of the workforce, and needing to update skills.

Quite why your doctor has been unable to access this is not clear, there may be some issue of which you are unaware. If registered and Licensed the Locum posts in a group practice would be the obvious place to start.

It would be possible for this doctor to retrain in any speciality, via applying through MTAS, except (paradoxically) General Practice as he is already trained!)

There used to be a retainer scheme which applied to General Practice and theoretically to all other specialties. This allowed a doctor who had taken a career break to become competitive for a substantive post by placing them in a supportive environment for a small number of sessions each week. Some restrictions such as length of time on the scheme, age of the candidate and other portfolio work elsewhere applied.

Someone had to pay for this. The posts were partly government subsidised. GP practices were often were happy to pay part of the salary for an extra pair of hands because one of the conditions that had to be fulfilled was that the applicant had to be a fully accredited GP. They were just “brushing up” rather than being trained, and they could be very useful in a practice.

In reality, very few retainees applied for hospital specialties and some years ago the retainer scheme was reconfigured to become “The GP Retainer Scheme” Almost all applicants were women doctors.

Getting back into hospital training to become competitive again was more difficult and involved applying for a supernumerary post tailored to individual needs which would enable the candidate to compete again for substantive posts. Money was a limiting factor in establishing a large number of these posts.

Here is current information from the London Deanery regarding terms and conditions of the current GP retainer scheme.

Boots - The mechanics of these exclusions that both Anna and Dr No have seen happen are simple. The deanery requires the GP returner to undergo the same assessment as every other GP training applicant. This seems fair enough, until you realise that the assessment is highly tuned to young inexperienced doctors who have more often than not just completed their FY training, whilst the returner may be a very experienced mature practitioner, who does know an awful lot - but it is very different to what their junior colleagues know, and so doesn't even get a look in (consider your knowledge and skills now, and how they compare to today's FY trainees): and as a result he or she fails. The deanery airheads then declare themselves powerless to do anything about it, because, all said and done, rules is rules, and it is more than their job's worth to interfere.

A GP who has failed a GP returner application isn't going to get on the Performers List (or will be booted (sic) off if they were on it) - and so GP locuming is not an option. His or her general practice career is over.

WD - comment snap! - but we need to distinguish here between the GP retainer scheme and the GP returner scheme.

Witch Doctor and Dr Phil.

I have spent several hours across days researching in an attempt to make sense of the situation of the GPs story I told.

I think Dr No's explanation has hit the nail right on the head; for as well as playing hookey, 'my' GP had committed the mortal sin of being old, being in his mid-fifties. If memory serves me well, he was blocked on the grounds of Efficiency(?) in that his practice was regarded as out of date after an absence of more than three years.

Catch 22 here, for how can he bring his practice up to date if he is blocked from a returner placement? That said, with years of learning behind him, he had no doubts about his clinical capabilities - just honestly accepting that his admin would be rusty.

I think the real problem was his age. Interestingly, advice and information on the Performers List Section 4.1 Equality and Fairness states "There is no place for discrimination........age...."

Oh Yeah!

Anna :o]

I agree that the scheme does not work well, but it does exist. Our masters requirement of microdocumentation of competencies is quite off putting to doctors of my generation. Our FY2 is used to it, we are not. The process of compliling this sort of portfolio is both daunting and tiresome.

I am too young to retire (and actually enjoy my job most of the time) but I know a few doctors just half a decade older, and with oodles of experience who are planning to hand in their notice in the next year or two. Take the pension before it is attacked further, skip the austerity misery, forget revalidation, be free to play golf each day. I fully understand the temptation.

The exodus from the profession will be more dramatic than MTAS, and once again not reversible.

Dr No has been saying for a long time that revalidation will kill the profession as we know it. Tragic as the Remedy tribe are (and Dr No is an individualist, not a statist, in the 'No Man is an Island' way, and thus one involuntarily unemployed doctor is one too many) the fact is - as he pointed out recently - the tribe in question is but a very small part of the whole profession.

The total numbers are absolutely shocking. By the provisional estimate of the sinister architects of revalidation, one in twenty doctors who choose to jump through the revalidation hoops will find themselves caught by those hoops, their career blighted, possibly destroyed. Many many more - those who know they will get caught, others perhaps approaching retirement and reluctant to face the ignominy of quasi-assessment by a once colleague, now Herr Responsible Officer, will each privately come to their own Rhett Butler moment, and quit. The exodus will be measured not in hundreds, or even thousands, but tens of thousands.

That this is going to happen is clear to anyone with three neurones. Yet the government, the Stasi, and those in the profession who espouse 'Revalidung macht frei!' fail to see it. That means either these people have only two neurones (and they aren't talking to each other), or they do know exactly what is going to happen, and want it to happen, but deny it in the interests of propaganda, that the cull might be most effective when its time comes.

The last paragraph is of course Dr No asking in his usual rambling way the classic conspiracy or cock up question. Whatever the answer to that often never completely answered question, what should concern us now is the practical effect if revalidation happens:

Tens of thousands of doctors will leave the profession over the space of a few short years.

Go figure, as they say...

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