Medical Education Reforms in India - Too Little Too Late?

Medical education reforms in India - Too little too late?

India is the second most populous country in the world with a population of 1.3 billion. The numbers are an issue, however, the diversity of our population is an important consideration as well.  This diversity is reflected in almost every aspect of our culture and policy including education; this often is worthy of celebration. However, when it comes to healthcare, this diversity results in fragmentation. Without a unified approach we cannot improve our performance in public health, which lags far behind other countries on nearly every health and human development indices.

Therefore, the need of the hour, is a robust system of medical education, which improves the quality of doctors it produces.

When we discuss health education we need to look at three important aspects:

a) the selection of students,

b) their training and

c) their evaluation when they complete the course. 

Till this year we had problems beginning in the very first step, the selection of students. In a country with multiple certification boards of school education and varying standards, we obviously did not have a single system of entrance examination. This meant every state conducted its own entrance examination. To add to the complexity some of the private medical colleges indulge in malpractices helping students slip through the cracks of such a fragmented system.  One of the most apparent manifestations of such malpractice was the concept of “capitation fee”. A student who had obtained a seat in one such medical college last year stated under anonymity that he “booked” his seat in advance and entrance test was a mere formality. The admission tests conducted by state funded colleges are not free from malpractices either. In the newly formed state of Telengana, the admission test was conducted thrice possibly because of similar issues in 2016, putting the students through a lot of inconvenience and extreme uncertainty.

The National Eligibility cum Entrance Test (NEET) was introduced in 2012/2013 for entry into postgraduate and graduate courses. With the NEET it is mandatory that a student should have a minimum qualifying mark to be in the merit list, which is applicable even to private medical colleges as they also come under NEET unlike earlier times when there were no such criteria. For political reasons some of the states and the private medical colleges appealed against it in the apex court. The court ultimately quashed the exam, calling it illegal. This verdict was unfortunately pronounced after students appeared for the test and exams had to be conducted again by the respective states for admission.

Again after three years it could be reintroduced for graduate entrance in 2016. This year too, plagued by confusions it was conducted twice. Later because of lack of clarity the states were given the option of accepting or rejecting the test. This resulted in windfall for private colleges which increased the fee steeply because parents of children who would have let them repeat the test in the normal course next year, if unsuccessful in the first attempt, crammed for the seats paying hefty donations.

From this academic year we are going to have NEET on regular basis for graduate, postgraduate and specialty courses. This would at least curb manipulations in the conduct of the test because it is an online test. This also ensures the students get a qualifying mark to be in the merit list.

Dealing a double blow to  merit is the system of reservations which being  primarily caste based instead of income based, results in quality medical education being put even further out of reach of meritorious but economically backward students. Even with NEET, this system of caste based reservation has not been done away with.

Moving past the testing process, we find issues with testing methodology too. We still persist with methods which tests only memorized knowledge and not the student’s analytical skill. Likewise ,there is a gap in testing the student’s aptitude. There is no method at the time of admission to check if a given student has what it takes to become a doctor. The Charaka Samhitha, an ancient medical treatise which dates back to 2^nd century BC candidly describes the attribute of a medical student. It states: ”The ideal medical student should be of  mild disposition, noble by nature, never mean in his acts, free from pride, strong of memory, liberal minded, devoted to truth, likes solitude, of thoughtful disposition, free from anger, of excellent character, compassionate, one fond of study, devoted to both theory and practice, and seeks the good of all creatures”. No one could have put down more succinctly what is required of a medical student. Not paying heed to these words of wisdom over the years has resulted in generations of doctors who are poorly informed and unprofessional.

The problems, unfortunately, do not end with selection process and continue into training. There has been no major change in the curriculum, which continues to encourage rote learning. It is not formulated according to requirements of the population which the doctor under training would be catering to, but focuses on a learning a lot of theory. Such a curriculum fails to inspire students, whose studies are getting so diluted that they would choose to read study guides instead of text books. None of these augur well for the training of good doctors. This issue was addressed in the Vision 2015 document, which was drafted by a Board of Governors who took over from the MCI. The blueprint, which covered both graduate and postgraduate education, detailed an entry level exam which is common, a curriculum which has both horizontal and vertical integration where the students are trained in basic sciences, lab sciences and clinical sciences from first year onwards and a nationwide common exit level exam before the degree is awarded. The whole process is yet to be effectively implemented though the document was drafted in 2013.

The infrastructure in government funded colleges leaves a lot to be desired, due to the inadequate budget allotment to health and education. A mere 4.05% of the GDP is spent on health, which funds government hospitals which are supposed to be training the medical graduates. Even what is allocated is not fully spent, due to the leakage of funds at all levels. Added to this is the shortage of faculty who, because of better remuneration choose to work in private hospitals. The private institutions also do not spend their revenue on upgrading the infrastructure after their approval and do not most often have required staff.

Realising the need for the long awaited reforms in medical education, a three member committee of the NITI Aayog drafted the National Medical Commission Bill 2016 which would replace the Indian Medical Act, 1956.This in itself is a topic for discussion. The draft bill, aimed at bringing about a complete reformation has flaws which require immediate correction. The most important one is the issue of fee capping in private colleges, which is not clearly spelt out, which means deserving students inspite of a good rank in NEET, may not have access to most of the seats due to non affordability.

The next major feature of the bill which may be self defeating the purpose of improving the quality is the proposal of allowing “for profit” medical colleges. Though the rationale for this may be the need for increasing the number of colleges to meet the demand, this would once again bring in the private players whose intention of starting a college would be commerce. We have now 426 colleges, nearly half of which are private. One proposal that frequently comes up to overcome this problem is to upgrade large district headquarters hospitals to teaching hospitals.

If we need to have a medical education system that would be comparable to the rest of the world, we need to pay attention to student selection which should be purely merit based, infrastructure, training and their evaluation. This is the only way to produce doctors who would be able to face the unique challenge s faced by the society and health care industry.

Dr Usha

Physician

Hyderabad, India

All views in the above write up are the personal views of the author (and not that of this blog site)

©M HEMADRI

Follow me M HEMADRI on Twitter @HemadriTweets

M Hemadri’s mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 

A Discriminating View of the Doctors' Staffing Crisis in the NHS

We are going through extraordinary times for the NHS, especially so for doctors. From my perspective, this reflects the effect of not getting it right for everyone from the beginning.

The NHS as a care delivery model is fantastic. Tax funded, free at the point of care delivery, delivered at more or less the same standard across the country. It is so special, no doubt about the model/pathway.

The issue comes when it comes to staffing that delivery model. There was simply no staff at any time to deliver this model. So quite simply, as was always done in British history, the UK looked abroad for resources (the detriment to other countries by this policy is till today ignored by the UK). For healthcare the crucial frontline resource - the doctors were simply imported, poached, stolen (you can choose whichever word you want depending on the perspective) from abroad. India being a country which has medical education delivered in English following a British system of medicine was a natural target. For ages, even till today many IMGs end up as GPs in inner city and deprived areas. But it is the hospital medical hierarchy where the glaring disparity hits you.

There was always a surplus of registrar and senior registrar posts compared to the consultant posts (there was a permanent pyramid). Now that may be a problem in itself leaving people without opportunities. What happened from the mid 1970s onward, the demographics of the pyramid shifted. In the registrar and senior registrar grades there were mixed ethnicity with plenty of IMGs but very few of the IMGs went on to become consultants. The locals were in line for progression to a consultant post barring unforeseen circumstances and the IMGs were to remain permanently as registrars and senior registrars barring unforeseen circumstances, till they retired or died. These were later called staff grades and associate specialists. Name change and plenty of warm talk but the intention and roles remained the same. 


In the late 1980s and early 1990s I have heard numerous that local graduates holding registrar and senior registrar posts stated openly, loudly and clearly that they will put up with difficult conditions and low pay because it is only for a relatively short time before they became consultants. Meaning, that locals will progress on to higher pay and the IMGs will remain on the lower pay. This suited a brilliant care delivery model to be delivered at a low cost using a rubbish discriminatory unjust medical staffing model.


Of course, this strategy would have worked except that more consultants were needed and there were not enough local candidates. By late 1990s early 2000s the system woke up to this and created more medical school places and in my view with the hope that this local - IMG differential would continue. Where it went wrong primarily is that they underestimated the impact of women entering medical school, like most men, most women are excellent doctors but firstly they also want a good lifestyle (in contrast to men who in my view were often married to their careers) and more importantly physiology demands that many women choose to have children. So workforce planning went for a six; more IMGs were needed and the flood gates were opened in the early and mid 2000s. 


You see, now, suddenly, the pay for doctors is thought of as high, suddenly evening and weekends are no longer want to be considered as premium pay time. When medicine was overwhelmingly a white, male profession with IMG men manning the lower ranks these were not issues, doctors pay was relatively high compatible with their education and contribution, weekends were precious. The demographics change to equal number of women and a large number of IMGs and the values change.

The next wrong calculation comes from the fact if UK thinks they can import their way out of this mess. I don't know about other countries but many Indian young doctors are very wary of coming to UK; the training opportunities have increased in India, the economic opportunities have increased in India and lifestyle is improving in India - the exchange rate alone is no longer attractive.

To me it seems that the establishment does not want medicine to be an elite profession as it was when it was white male dominated. This makes it distinctively unattractive. There was always discrimination, there still is; the difference now is that there is FOI, there is corporate social responsibility and transparency. In the past we knew IMGs failed exams but we did not know the numbers, we always accepted that we did not reach the necessary standard, we were expected not to reach the standard, we were brought up being told that we could not reach the standard. None of that bullshit anymore. We know the numbers which are spread immediately all around the world by email, whatsapp, fb and twitter. We are asking questions; does the Indian IMG paeds reg trained in UK and taking the exam in UK have a higher failure rate in the UK version of MRCPaed than the Indian paed trainee who takes the exam in India never having worked a day here? Does the MRCGP International AKT MCQ have a longer time to answer their question than MRCGP UK which puts IMGs at risk of failing a 'purely knowledge exam'? We suspect an adverse use of linguistic bias. We know that Scottish, Irish etc need a grade c in English equivalent to IELTS 6.5 but IMGs need an English standard much higher, yet found fault with their language. We know the students in England do not need English A levels to get into med school. The standard for IELTS for IMGs was not set by administering to a group of local FY2s, it was actually set by an equivalent of a large focus group sitting around a table and deciding what was an acceptable standard; what a marvelous way of standard setting (accompanied by truck loads of stats on why that kind of standard setting was valid, the whole lot I found dubious, okay, to put it politely, it was very highly subjective)

The senior doctors including senior IMG doctors seem to have a distinct mentality that is not quite in sync with the younger doctors and their aspirations. The true cost of discrimination against women, discrimination against IMGs is now biting back.

A fabulous care delivery model designed six decades ago by the local population for the local population in UK did not consider the career prospects of IMGs and did not care that women were not part of the game for a long time are now completely flummoxed when IMGs are waking up and women are demanding a different kind of atmosphere. 


I wait to see if the lessons from past atrocities will be learned, I wait to see if because of the change in demographics medicine will be deliberately made into a lesser profession. I am not optimistic about the people becoming just. Why am I not optimistic? Let us look at the current routes into UK for IMGs - the MTI and the PLAB.


The whole MTI premise is based on getting people into UK to fill in rotas. It would be very difficult to provide any proper training in two or three years; especially when MTI doctors are not deanery numbered trainees for whom there is still to some extent funding for training. When I look around, I find that most new entrants into UK are in rota fodder posts and not in any proper training posts. I am not sure if there are large number of MTI doctors who are undergoing specialised training  (say for instance in pancreatic transplants), I suspect most of them are at SHO and junior registrar levels.

Let us say that a doctor goes back to India after MTI and applies for a job in a corporate hospital in competition with a CCT holder - who will get the job? Let us say an MTI completed doctor applies for a job anywhere else in the world (middle east, australia, etc) what kind of a job will (s)he get on the basis of MTI? Has anyone asked these questions? My personal feeling is that in most of the cases a typical MTI doctor after the completion of the time and leaves UK as per the rules is unlikely to be a strong candidate for any job anywhere in the world (I am sure there will be exceptions to this assumption).


So what is the use of MTI posts? 


The next is PLAB route doctors who more often than not spend years in a variety of non-training posts. My advice to young doctors who come to UK after PLAB process is 'take a formal training post or do not take a post at all in the UK'.


If still doctors from India want to come to UK via MTI or accept a non-training post via PLAB then the only logical reason for that would be to use UK as a temporary staging post to analyse and access opportunities in the rest of the world eg prep for USMLE etc.

UK should stop looking at IMGs as rota fodder. The system should change to provide every doctor who enters UK only formal training posts with the intention of making them a consultant or a GP; there may be some who eventually choose not to practice as a consultant and take up a senior non-consultant post, that would be a matter of personal choice and not a systematic denial of opportunity. This means at junior levels there are only training posts. Well, will this ever happen, I wish it would but I am pretty certain it won't. The system is designed for and habituated to exploitation of the IMGs; that system is unlikely to shock itself by changing even when it faces its own existential crisis.

So unless there is a technological solution there is going to be an ugly muddle impasse in the NHS for a long time to come.

©M HEMADRI

Follow me on Twitter @HemadriTweets

My mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 
till 31 December 2016 all my earnings from the sale of this book will be donated to charity  http://successinhealthcare.blogspot.co.uk/2015/11/standardised-management-conversation.html

 

QuizUp and the dangers of Unconscious Competence

I have recently been playing QuizUp. It is an online quiz which you can play real time against other people from all parts of the world. There are innumerable topics and categories with thousands of people playing it.

I chose a topic that was familiar and another one which was not familiar. What I learned was something many of us may already know. But are we applying what we already know? Are we harming people by not recognising and applying what we know in a proper manner?

When I start playing QuizUp even for very familiar topics such as medicine or healthcare I had to read the questions slowly because the style and format of the question is different for each question. Some are direct, some are linked with directly topic related pictures, some are related with general pictures from news and social media that relate to the topic, some have humour, others have pun and so on. Then comes the answers there are very technical answers from some questions, lay answers for some, humorous answers for others and so on. So even when I understood the question perfectly well and knew AN answer which was right, THE answer that was right for QuizUp took time to learn. Of course there is the issue of learning the answers that I did not know before. 

Now, once these were learned, the issue became one of speed, because even if I knew all the answers if I did not answer them fast enough I would lose. At this point, I began winning a number of matches/plays/games. But also loosing a number of them because the speed itself caused errors due to many reasons including the jumbling of answers and the pressure involved in a fast recall and response to a touch screen.

At this stage, there is enough knowledge, memory, recall and speed which then moves on to pattern recognition. Most often there was no need to read the questions or the answers the responses came automatically, fast and correctly. It was on auto-pilot and very successful.

My scores were soaring, the whole thing was getting a bit monotonous, repetitive and pointless. This is when QuizUp decided to update the questions so there were a number of new questions thrown in. Obviously I had to go through the sequence described above for these new questions. That is when I discovered that I not only had trouble with the new questions in terms of knowledge, speed etc. Because the new questions had been interspersed with the older/original ones I was struggling with the older ones as well.

I was struggling to answer questions that I used to answer automatically and correctly within a second. I was getting them either slow or wrong. I was UK top ten for a particular month in the topic and was getting stuff wrong. Interestingly, because I was already way up top ten it really did not matter, I did not drop too many ranks if at all. Mind you, I am talking about marginal differences here. The nature of the game and my overall rank meant I was still winning but not as efficiently as before.

The worrying thing was that the minute I stopped pattern matching my scores fell.

The last point I wish to draw your attention to is this. I was concerned about the efficiency of my wins and started reviewing my questions by reading the question and answer in detail after playing each game. I was surprised that I was neither fully aware of the wordings of the question nor the logic of the answers; I knew what the question was and what the answer was that is knowledge but while answering them repeatedly my knowledge formed the basis of pattern matching but as the pattern matching became dominant potential and/or real drops in awareness of knowledge and on some occasions of knowledge itself happened.

Pondering on the above gave rise to some worrying thoughts and certain concepts which may be negatively affecting some of us.

Many of you with some knowledge about education and learning methods will recognise the model where we are

Unconsciously incompetent

Consciously incompetent

Consciously competent

Unconsciously competent

These are called the four stages of learning or four stages of competence and linked with the concepts around the Johari window.

Is there a risk with Unconscious Competence?

You would have noticed from my above description that like any learning or skill my QuizUp journey moved from Unconsciously Incompetent to Unconsciously Comptent. Educationalists and trainers want us to be unconsciously competent, it is supposed to be the highest in the hierarchy of learning and competence.

Here is the worry or the risk.

Many senior experienced older doctors are unconsciously competent, i.e. where we actually want them to be. When we want them to incorporate something new into their routines we are pushing them back to conscious competence. We are aware for that for the new skill there is a learning curve, we accept that. I am not sure if whether while the new skill is being incorporated their performance with their established skills fall, even temporarily; and if it were to fall whether we even notice it as it is likely to be subsumed in the averages of their overall numbers/performance which had a good baseline to start with.

But, here is the more worrying aspect. Due to some unfortunate reason if any of the senior established busy doctors were referred for an assessment of their knowledge and competence (say to an agency such as NCAS) these doctors are tested for their conscious competence when their daily practice is in the domain of unconscious competence. Add the pressure and stress of going through the formal assessments that decide the fate of their careers, these doctors often unsurprisingly come out as lacking in knowledge and skills, i.e. incompetent.

I have no empirical research or data to show this. I can only hypothesise based on my observation of my play of QuizUp that I really enjoy and am good at to some extent. Also, this phenomenon of slipping back into conscious competence may be limited only to me and not the rest of the world (though I doubt it) and so this whole concept may be relevant only to me.

However, my concerns are two fold. First, in teaching new skills to the old dogs we may be negatively impacting on their overall competence at least temporarily (while their new skill competence gradually improves – learning curve) and while this may be happening we may not be able to recognise it. Secondly, once these doctors are in difficulty, we may be testing the skills of race car driving with a normal driving test template and failing them in both.

Whether this is purely theoretical or not, it is worth putting some research into this. It may be beneficial to both patients and doctors.

M. HEMADRI

Follow me on twitter @HemadriTweets

Subjectivity is the curse on examinations for UK doctors - get rid of it

Subjectivity is the curse on examinations for UK doctors - get rid of it

There is currently a controversy raging in UK healthcare about doctors. For many years it was known and was passively accepted that if you were of Black or Minority Ethnic origins more so if you were an International Medical Graduate (IMG - a doctor with a primary medical qualification outside the UK or European Union) facing a Royal College examination you would have a much lesser chance of passing the examination. If you were of BME or IMG origins and were of a generous persuasion you would call this sub-conscious bias but most called this racism, whether it was racism or not. If you were representing the establishment you put out phrases that are superficial gibberish, such as 'reasons are multi-factorial and complex' but certainly not racism.

The issue came to a head with the MRCGP examination where in the new version of the examination the differences between white and non-white candidates were so gross that you would notice it even if you were colour blind.

The medical post graduate examinations conducted by the Royal Colleges are essentially about medical knowledge both theoretical and applied. Given that these are knowledge tests, why did the results show racial differences? We will not discuss racial supremist reasoning here.  Many of us will remember the days before the MCQs - the essay answers were often a demonstration of your wizardry in medical English. Apparently even in the MCQ based knowledge tests we can use linguistic jugglery so that a non-native English speaker comes out as having poor medical knowledge - we are not discussing that further here.

The curse of subjectivity

Applied knowledge in medicine is tested in vivas, OSCEs, with patients and simulated patients. Here the marking is done by examiners, that is where subjectivity comes in despite current best efforts, subjectivity is ruining careers.

The rest of this blog post is about subjectivity (the collection of the perceptions, experiences, expectations, personal or cultural understanding, and beliefs specific to a person - Wikipedia)

The sad paradox is knowledge especially in medicine is objective but part of the testing process of this knowledge is subjective. The tension that results from an objective topic tested subjectively is where the fundamental flaw lies. Where subjectivity exists, there bias exists and hence unethicality at the best and fraud at the worst exists.

Subjective assessments must not have a place in career make or break decisions such as exit examinations or in any arena where career progress or ability to practice the chosen profession can be stopped. Subjective assessments do have a place and can be used for progressing in learning and development - some of which are known as formative assessments. Must not be used for stop-go decisions where only objective assessments should be used.

Reducing or Eliminating subjectivity

Examiners in vivas, OSCEs, patient encounters, interview and other areas currently suffering due to subjectivity, are generally given questions - they should also be given answers and as long as the candidates answers fit in with the recognised accepted answers the candidate passes, when the answers fit in with recognised unacceptable answers the candidate fails and where the answers fit in with recognised borderline, a published formula for accepted number of borderline for a pass or fail should be defined (no, this is not the 'borderline method' that is used in standard setting).

This may beg the question whether vivas are needed at all - verbal communication is essential in all walks of life and especially so in healthcare; a candidate should be able to answer effectively and accurately under stressful verbal conditions and hence vivas are needed but the subjectivity of the vivas must be eliminated.

Subjectivity cannot be sometimes avoided but when forced to use it the answers should be 'force fit' in a pre-defined uniform manner and the candidates be assessed against that uniform force fit. The candidate does not have to know what the defined force-fit answer is but all candidates would be marked against the same answer.  

Lets look at an example: Let us assume that in a scenario where there is a certain level of oxygen desaturation which does not impact on life or limb but where a candidate has to act - say an peripheral oxygen saturation that has fallen from 98 to 89 but where the patient is otherwise very stable. The candidate has to make preparations for an adverse eventuality but there was no need to act immediately. Let us also assume that currently this is subjective and hence an assessor would mark someone and this would be variable (depending on the other skills of the candidate). Let us try a force-fit answer for this scenario - the examiner would be given a set of answers and would give the candidate a mark for each correct answer, for instance, a) the patient if conscious was asked if she was okay within two seconds 1 mark

b) the pulse oximeter probe was checked and re-applied within 4 seconds

c) capnograph reading checked within 6 seconds

d) the oxygen flow and any gas mix ups were checked within 8 seconds

d) airway tube position checked within 10 seconds

e) airway change kit and reversal drugs asked to be brought in and kept ready with 12 seconds

etc. You get the picture.

These answers may not be based on evidence because there is no evidence to base it on. However, for the purposes of the assessments the answers are defined on the basis of agreement between examiners and are used uniformly with all candidates. Then the chances of the examiner being influenced by mastery of the language, social status of an accent, the image projected by clothes, the false confidence provided by a charming smile or colour of the skin would be less.

Subjective experts are simply socially acceptable influential frauds providing a certain voyeuristic celebrity value when they are reviewing wines, films or restaurants. Techniques similar to those have no place in medical examinations. It is of course a completely different story that the British are not able to trust the training provided to their young doctors for somewhere between a minimum five years (in the case of general practice) or an approximate minimum of twelve years in the case of surgeons that makes an 'exit' exam essential to cross check knowledge (which is then pretty badly due to the subjective components). In the USA exit exams are not mandatory, they are voluntary, the Americans obviously have a great degree of confidence in their trainers, trainees and training system. The British system needs reform and a commitment to eliminate subjectivity when the stakes are high could be core to whether the UK will ever have a equitable outcome in examination results.

 

© HEMADRI

 

Follow me on twitter @HemadriTweets

This blog has argued for reducing or eliminating subjectivity from re-validation http://successinhealthcare.blogspot.co.uk/2012/11/revalidation.html

We have discussed differential results in surgical Royal College examinations http://successinhealthcare.blogspot.co.uk/2012/12/exit-exam.html

Warning: Legality could be injurious to health

This particular blog post is fictional. Any resemblances to any person living or dead or incidents current or historical are purely coincidental.

Warning: Legality could be injurious to health

It was the saddest day of his life.

Let us start from the beginning. Bill was a brilliant student at A levels, he was also a stickler for formality, rules and process. This stood him well and he was very highly thought of as a scrupulous, proper, law abiding young man. He went on to study medicine, completed junior general training and got into specialty training – all very smoothly. His specialty also involved working in the operating theatres.

Bill found within a few weeks of into his registrar job that his work never ever finished at 5 pm.  Bill being Bill, thought he will simply leave at 5 pm as long as there was no patient he was directly dealing with was acutely ill. He did that for a week. Bill then found his training was getting adversely affected. Consultant ward rounds continued after 5 pm, if he did not join in he cannot learn. Patients for elective surgery were admitted after 5 pm, if he did not see them he will not be ready for them for the next day. Theatres routinely over ran easily to 7 pm sometimes longer, if he was not there he will lose out on the training.

Bill discussed this with his consultants who looked at him as though he was an alien zombie. When he insisted on resolution they told Bill that he is free to leave at 5 pm if he wished to do so, some of them insisted that he leave at 5 pm so that he did not breach his hours. Bill’s logical argument was very simple, substantial training happened after 5 pm so to take consultants’ advice and leave at 5 pm means that he will never get the training he deserved. So Bill refused to leave on the grounds of training needs and claimed payment for extra time on the basis of actual time spent working at the hospitals. Boy, this was resisted by the management. Bill was born different, his documentation was perfect, they had no choice but to pay him. The managers gave the consultants a hard time because of this issue; the consultants did not take it lightly.

The time came to ‘assess’ and ‘report’ on Bill which were used at annual progress meetings. These used to be called RITAs before now called ARCPs. Bill’s numbers, performance, success rates, patient feedback and anything clinical were spot on average. Bill’s consultant reports were full of masked vitriol on how his attitude, behaviour, cooperation, et al were not compatible with a surgical career. This was pointed out to him and he made tremendous efforts to improve. Every time he was assessed externally he had no issues on any of the ‘soft skills’ assessments. But he would not stop claiming for staying after contracted hours. Every hospital that made him work after 5 pm paid up; the consultants from the hospital wrote badly about his approach to life.

After 6 years of completed training with same average clinical rating as his peer group, Bill was denied his completion of training certificate due to five reports that faulted his attitude. Bill cannot get into the specialist register; Bill cannot be a substantive consultant in the NHS. His colleagues with his level of performance and achievement and some with lesser performance and achievement were signed off.

All because he followed the country’s law and the NHS rules. The message his colleagues got from their seniors was that people who followed the law can be severely, career damagingly punished. The message other trainers and managers got was that they can break the rules and law with impunity and use their power to penalise the person who caught them out. Bill can go to employment tribunals and the like but when he has at least half a dozen consultants who have already written badly and a dozen managers willing to write badly – he faces a lost cause. In a world where the subjective decimates the objective - he is a lost soul.

Has he learned his lessons that legal and rule based behaviour does not win and not submitting to the whims of the powerful was harmful? We do not know yet. This sounds like a case of operation successful, patient died; only here it will be training successful, career died. Bill hit the target, its the ricochet and the debris that maimed him.

Bill is at a crossroad waiting to change careers.

Oh by the way he also happens to belong to a minority ethnic group.

I think this quote from John le Carre (in his book The Constant Gardener) will probably be very appropriate here "Nobody in this story, and no outfit or corporation, thank God, is based upon an actual person or outfit in the real world. But I can tell you this; as my journey through the pharmaceutical jungle progressed, I came to realize that, by comparison with the reality, my story was as tame as a holiday postcard."

©M HEMADRI 

Follow me on twitter @HemadriTweets

PS: The loose ends such as throwing in the ethnic minority, etc are there to be filled in, if and when I get to write this story in full

Generalists

GENERALISTS FOR UK HEALTHCARE - WILL IT WORK?

A rethink of training is happening. We debate that here.

In the USA most doctors undergo four or five years training depending on whether they are medical or surgical fields and become 'generalists' (family practitioner, internal medicine physician or general surgeon). They provide the bulk of care in their areas. Some of course choose to sub-specialise into ever narrowing areas for which they undergo a further 2 to 3 years of 'fellowship' training. When it comes to care delivery the patients do have a choice (at least in theory) of seeing their Family Practioner, 'generalist' or sub-specialist; the family practitioner and/or the Emergency Department has the choice of referring patients to generalist or sub-specialist as the situation demands. Of course the generalists refer on to the specialists as needed.

Moving from the mature economy USA example to the advancing economy of India the situation is more or less the same. Doctors after their MBBS are allowed to practice as GPs and recently there is a trend of emerging opportunities to train further to become an advanced family practitioner. Many doctors obtain post-graduate training and become 'generalists' general physician, general surgeon, etc. Some obtain sub-specialty (though the Indians love the term 'super-speciality', they never call their narrow field as a 'sub-specialty') and become cardiologists, vascular surgeons, et al.

In the UK there has been in the guise of rather misguided and seemingly always wrong work force planning, the training system has, since Calman, delivered 'sub-specialists' to deliver care in the NHS. There are no more 'general physician' or 'general surgeon'. In theory a collaborative approach of all these good people is supposed to deliver high quality integrated care to the patient at the front line. In practice it falls and fails often and more. 

At the real front end where direct care is delivered by the trainees and sub-specialty doctors the sub-specialist attitude becomes a big problem. In these young doctors' minds they are very keen to learn their sub-specialty skills and they are not interested or do not have have the time to learn or deliver 'general care'. What it translates into are junior doctors who are unable or unwilling to do 'general' care. I have heard from many about numerous instances of junior doctors and non-consultant doctors being unable to do things like supra-pubic catheterisation, torsion testis, embolectomy, etc despite being on call for their relevant generality in DGHs (or even teaching hospitals). The 'sub-specialist' has to be called out to deliver what is essentially general care.

There are strong arguments for the UK sub-specialist model, mostly emotional. An example such as 'would you like to obtain the best care from the most highly trained person or be messed up by a generalist?' However since we do not train generalists in the UK we do not know what kind of care a generalist might deliver; since there are other countries training generalists, we know that generalists do deliver a high standard of care. What we also know is that care can slip between sub-specialists, care can slip due to non availability 24/7 of sub-specialists in every hospital, care can slip due to difficulty of access to sub-specialists (in the version of centralised care in major hubs) and sub-specialist based care is costly. 

Of course my favourite argument is costly care is generally not beneficial at a system level.

The UK is now at the closing stages of the 'Shape of Training' consultation to explore potential future models of training that would suit UK requirements. No favoured models have been decided yet, no decisions have been made. The consultation includes a model where more generalists would be trained to deliver the bulk of care across locations. Even within this model, UK would obviously still train sub-specialists but their numbers and the location of work could be limited.

There are many reasons why the idea of generalists would not work. First and foremost is the culture in UK where the current sub-specialist model is seen as inherently superior and in those circumstances change becomes frustratingly difficult. Sub-specialists seem to carry more glamour, power, earning opportunities and even respect; hence it is a natural aspiration for most doctors; even many general practitioners in UK want to be 'GPwSI'. Broad knowledge seems not be valued as much as deep knowledge (and by the way, broad does not equate to superficial).

However, it is important to question whether in a small country (at least relatively in terms of population and geography) with current economic difficulties it is possible or reasonable to train and maintain sub-specialists 24/7/365 in every location that care is provided; which we will have to do if we have to deliver high quality of healthcare to our population. With care being delivered outside conventional settings closer to the patient and community with concepts such as tele-health, virtual consults, hospital at home, becoming real; with technology enabling remote diagnosis to be made (smart phone ECGs and blood tests at super-store car parks); with Dr Google and crowd sourcing having the potential to be more accurate/knowledgeable than individual specialists we do need to think if the training of doctors in UK needs to move to a 'generalist' model.

I am in support of training generalists who would have in the hierarchy of NHS appointments have a higher or equal level as specialists. They should be charged with the specifics of designing and delivering high quality of care (including management responsibilities). A generalist would be far more likely to interact closely with the patients, general practitioners and specialists than now - that would be a boon and a refreshing change to the passing-the-parcel that is currently played with patients due to a system that is divided into very narrow specialties. There will of course be the rare generalist who is blind to her/his limitations who can be very dealt with proper systems in place.

What do you think will work for UK/NHS? Are generalists a good idea?

©M HEMADRI 

Follow me on twitter @HemadriTweets

Info:

Shape of Training: http://www.shapeoftraining.co.uk/

I provided oral evidence to the Shape of Training consultation as a part of BAPIO team and hence we had a specific remit to support the interests of IMG and BME doctors apart from providing general views on the various proposals and our own views as individuals. This blog does not discuss contents of BAPIO's evidence to the consultation; the above are my personal views.

Examinations for doctors - time to think differently

I wrote the article below in 2006. I was not blogging at that time so it just lived in my computer. When you read it please be in a 2006 frame of mind. The article 14, the new rules for surgical exit exam, the impeding new contracts for doctors especially for SAS doctors and so on.

Once you have read it, cross reference it to the recent GP exam results.

We need an end to the monopoly of examination providers for post-graduate doctors. We need a plurality of avenues to demonstrate knowledge.  Why should every university in UK not have a knowledge test for specialist doctors?

The link to the intercollegiate website cited in the article will not work, you may want to search their website for the current link or otherwise check with them.

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THE EXIT EXAMINATIONS: IS IT TIME TO HAVE A DIFFERENT THINKING?

The surgical royal colleges have decided to allow any candidate who is able to muster the references of two consultant surgeons to take the intercollegiate exit examination. The colleges would see this as a response to the changes in the rules that have happened due the PMETB to allow a fair opportunity to anyone who wants to demonstrate their proficiency in surgical knowledge. The General and Specialist Medical Practise Order that created the PMETB was passed in April 2003 and there have been wide consultations before and since. It has taken three years to arrange a new format which is likely to change again very soon, in view of the MMC reforms.

While it is clear that the 'standard of knowledge' should be the same for surgeons entering the specialist register one has to question if the actual examination should also be the same. Whether different formats for differing groups/sub-specialties were considered is not known. Whether any surgeons who are not in training were consulted before these changes is not known. If any of the 'mediated entry' candidates who have taken these examinations in the past were consulted is not known. A close look seems to reveal the need to have some radical, new and different thinking about who should take which examinations and who should offer them.

HISTORY OF WHO PASSED AND WHO FAILED

The point about consulting the past candidates is rather important. The evidence for the importance lies in the figures available in the Intercollegiate Speciality Boards website (http://www.intercollegiate.org.uk/html/results.html) where between 1998 and 2001 the overall pass rates in the intercollegiate surgical exit examinations was 70% for mediated entry candidates, 76% for type two trainees and 96% for type one trainees. We should keep aside the issue of mediated entry candidates for just a moment and look at the glaring difference of pass rate between type 1 and type 2 trainees. Most type two trainees worked to similar rotas in similar hospitals with similar consultants and mostly for similar number of years. Some differences do exist in their pathways such as type one trainees spending more time in teaching hospitals and type one trainees having experience in some research, while many type 2 trainees also have such exposure not all of them do. Opportunities for courses, learning etc are all similar. However, when it comes to examinations type 2 trainees did not do well. It begs many obvious questions, the foremost of which is why trainees with such similar pathways did not fare similarly at the examinations. If type 2 surgical trainees had equivalent training to type 1 trainees, as an admission to the examination implied till recently, why did they not do well? If we accept that the examination was a true reflection of their training and knowledge then was the process that selected them was wrong? If we accept that their pathways were not as similar as described here then why were they allowed into the examination on the basis of ‘end of training’ ‘exit’ examination? Knowing that type 2 candidates fared badly what changes were made to address that situation? If they were genuinely poor why were they selected into specialist registrar posts, if they continued to be poor why were they not stopped from progressing through their training which enabled them to take the examination?

When so many questions exist in the issue of type 2 registrars, there are even more for mediated entry candidates of the past and especially possibly for non-training post holding candidates of the future.

THE DEBATE IS INTERNATIONAL AND ABOUT THE FUTURE

The debate is not simply about the present UK based SAS doctors, FTTA, LAT and LAS posts who intend to take these examinations under the new regulations. The future also demands some answers. Some of the colleges have taken upon themselves to hold these examinations in many parts of the world. The demand for such examinations exists. Would the colleges allow non-training doctors from abroad to sit the intercollegiate exit examinations? This opens an even wider debate whether surgeons not in non-training posts from anywhere in the world would be allowed entry in to the specialist register partly on the basis of a test of knowledge that UK Royal Colleges offered. That is not to say that such surgeons should not be allowed but to wonder if the GMC, PMETB and royal colleges have the resources to probe the credentials of such candidates so thoroughly that the British public can be assured of quality in real time practise and not success in a paper work exercise. Perhaps the easy way out is to ‘rule’ on application, that the applicant is in need of further training, which is in reality will be difficult and expensive to challenge by overseas applicants.

INTENTION VS REALITY

The law in the form of the PMETB rules allows for various types of demonstration of knowledge, specifically to enable a variety of suitable candidates to enter the specialist register. The surgical colleges instead of taking the cue and innovating, have changed the entry criteria and the format to allow non-training surgeons to sit the same examination. Instead of exploring and enabling diversity that the law demanded the situation is now quite simply similar to tying the hands of a challenger and then putting him into the boxing ring. The example of an SAS doing excellent breast work for years taking the exit examination as an opportunity and achieving a predictable failure can be foreseen very clearly. To state that it is the responsibility of the candidate to ready themselves in all aspects before appearing for the examination sounds very reasonable but in reality very cynical. To then retrain the candidate due to a PMETB refusal or an examination failure and on the successful completion of 'training' and/or 'examination' only to be employed to the same job but possibly a higher title seems bad logic and an extreme waste of resources.

There is also a general perception that the current format of the new examination could be interpreted as being that of a different standard than the recently expired one. There is a suspicion that the goal posts are set differently in preparation for the MMC changes.

MONOPOLY

In the UK there is only one form of test of knowledge. There is only one body that provides it. This situation may be appreciated as offering uniformity. On the other hand it could also be considered as a monopoly of provision. The general view of monopolistic provision is that it is unhealthy. The intercollegiate format could also be perceived as cartelisation of sorts. The reality of a very small number of people involved in taking these examinations may prevent such a thought stream from developing into meaningful progress.

Surely the royal colleges have huge experience in designing examinations and though a challenge could devise a range of 'fit for purpose' examinations which would be of equivalent standards to enter the specialist register. The law allows it though does not require the colleges to do so. Coming from a different angle would it not be logical to wonder why a breast specialist has not taken a specific exit examination in breast surgery and so on? The urologist does.

More and more of assessments are being delegated and devolved to local deaneries who then sub-delegate to individual trusts and consultants in the form of in the work place assessments. As a logical futuristic extension some consideration may be given to decentralising the test of knowledge to be provided by a range of alternative providers. This may be not only a great market opportunity but also an opportunity to demonstrate leadership and vision, for universities and private educational systems to device such tailored high standard tests of knowledge as they have already done in the CME/CPD areas.

CONCLUSION

No one argues the need for good knowledge before entering the specialist register; it is no doubt a must. The entire debate is about the demonstration of that knowledge. The intercollegiate surgical exit examination is one of them but it is probably suited only for the current type one trainees. That examination's suitability for others including type 2 trainees and their derivatives, the future MMC defined ST post holders, SAS surgeons, MMC generated non-training post holding surgeons, overseas non-training post holding surgeons is unclear, though many will take it due to lack of alternatives. There may also be reluctance on the part of the ‘higher’ authorities to accept alternatives.

It is time to realise that 'similar' and 'equivalent' do not have to mean doing the same things or taking the same examinations. It is possibly the time to wonder about the paucity of alternatives to demonstrate knowledge. With the large increase in the number of medical students and the possibility of expansion of ‘consultant’ numbers, it is time for the good and great of the medical profession, though the surgical example is illustrated here, to lead in thinking, policy and practise rather than to react and respond as shown repeatedly with some of the glowing examples such as Calman, EWTD, PMETB and MMC amongst many others, with many issues arising from them still remaining unresolved.

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©M HEMADRI 

Follow me on twitter @HemadriTweets