In praise of young doctorsBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e4549 (Published 11 July 2012) Cite this as: BMJ 2012;345:e4549
- Iona Heath, president, Royal College of General Practitioners
The healthcare system, much more often than not, treats young doctors badly, and yet the commitment and dedication of the vast majority remain exemplary. How long before these enduring qualities are snuffed out?
Problems begin early, as the structure of education invites teenagers to think that all that matters in the making of a good doctor is an understanding of science. Science is, of course, necessary, but it is never enough in a profession that seeks to understand and alleviate the huge diversity of human suffering.
At university, the emphasis on science and the linear reasoning of cause and effect persist, leaving little room for the exploration of doubt and the nurturing of that probing scepticism necessary to explore the gaps in the current state of scientific explanation. Students are encouraged to record their reflections but are seldom invited to question the fundamental assumptions about the nature of science and medicine. And, for students in England, there is the additional burden of huge amounts of debt not faced by previous generations, as a result of the policy on student loans.
Clinical education seems to be based almost entirely on the acquisition of competencies—small aliquots of skill that can be practised, measured, and certified. As Della Fish and Linda de Cossart pointed out in their 2007 book Developing the Wise Doctor,1 this is all about epistemology (what the potential doctor knows), and almost no attention is given to ontology (who he or she is). There is an unexamined assumption that the list of required competencies will add up to everything that society expects of doctors, but the faltering confidence of young doctors, undertaking their first professional roles, makes this look questionable. Medical ethics seems to be too often taught on the basis of the four principles popularised by Beauchamp and Childress,2 so that even ethics risks being reduced to a series of boxes to tick. Again this is epistemology triumphing over the more arduous but infinitely more worthwhile ontological approach that would be grounded in the ethics of virtue and could do so much more to nurture the known aspirations of students entering medical school.
Once put to work in hospital wards, young doctors face the full panoply of difficulties involved in the transition from student to the grave responsibilities of a doctor. Many feel that they are inadequately supported at this stage, and it is distressing to note that the erosion of personal continuity of care for patients is paralleled by a similar erosion of consistent, team based support for novice doctors. The European Working Time Directive means that hospital work is now shift based, so that the responsibility for patients must be passed from one junior doctor to another, and the vital opportunities for trainees to learn from the results of their own actions are severely undermined. Medical educationalists emphasise the importance of learner centredness, but this seems rarely enacted during these early years in hospital.
Applicants moving into general practice training posts are ranked on the basis of a sophisticated array of selection tests, and the most apparently able have the first choice of posts. For allegedly sound educational reasons, but more likely for simplistic organisational ones, it is no longer possible to apply for posts individually and compile one’s own bespoke training programme. The result has been a substantial loss of flexibility in the system. Little account can be taken of the young doctor’s personal relationships and other responsibilities, so that trainees may be allocated posts that are miles away from their partner, friends, and family. Those assessed as being least able, including many coping with the additional disadvantage of being international medical graduates, end up in the least attractive and often the remotest training posts. This seems yet another manifestation of Julian Tudor Hart’s inverse care law.3 Young doctors are repeatedly instructed to be patient centred and to adapt their approach to the life circumstances of the patient. Are they not entitled to a little more of the same consideration?
Finally, and most threatening of all to the composure of young doctors, there is the rapidly changing culture of medicine. The legacy of the well intentioned emphasis on the evidence base of medicine has been the proliferation of guidelines that, abetted by the indiscriminate incentives of performance related pay, have been slowly transmogrified into tablets of law. A few weeks ago, while discussing the overtreatment of older people towards the end of life with a group of GP specialty trainees, I had the disturbing experience of being told by no fewer than three of these young doctors that they were frightened that, if they did not follow the guidelines, they would end up in the newspapers. These fears are fuelling overdiagnosis and overtreatment and are effectively destroying the confidence of many young doctors, so that they no longer feel able to make the sort of courageous professional judgments necessary to tailor the treatment to the needs, aspirations, values, and context of the individual patient. Something seems to have gone very wrong.
Back in 1993 Jerome Kassirer, editor of the New England Journal of Medicine, warned, “The health care system will not work for patients unless it works for doctors.”4 The truth of that prediction is being played out across the NHS right now. Astonishingly, despite all the problems, wonderful doctors continue to emerge from a system that seems to offer little support for their best qualities—but young doctors and their patients deserve better. And, as I grow old and frail, I want a doctor who thinks and questions, not one who feels obliged to blindly follow protocols.
Cite this as: BMJ 2012;345:e4549
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