Medicine is difficult—there are no shortcuts
BMJ 2024; 387 doi: https://doi.org/10.1136/bmj.q2163 (Published 03 October 2024) Cite this as: BMJ 2024;387:q2163All rapid responses
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Dear Editor,
In this age of fast-paced scientific discoveries, it is almost inevitable that results are demanded of immediately. This has led to increasing pressure on university lecturers to churn out graduates as quickly as possible. it appears that the medical establishment is no exception. The rising need for medical graduates to serve an increasing populance is pushed even farther governmental policies that primarily looks at the doctor to patient ratio as an indicator of success of policies. It is therefore heartening that the simple observation of how difficult medicine really is is echoed so heartily by the author and his readers.
The inclination of the generation Z and their relience on anything and everything technological does not help. In their effort to entice current and potential students, universities have taken steps to include more gamification and enhanced realities in the curriculum (1). While these modules have their merits, over-relience will ultimately lead to detachment from what clinical medicine really is about. Virtual reality would certainly not replicate what bedside manners, empathy, and compassion is all about (2).
We need to resort to reestablishing medical education as a form of apprenticeship. The advent of information technologies has almost done away with the traditional books and manuals to be replaced with online charts, videos and lecture notes. The medical apprentice no longer needs to know what to learn from lecturers. Rather, they need to know how to think like a healer they seek to become, That can only come from repetition (2) and trial and error. Guiding our apprentices is what we ought to be doing, no matter how long it takes.
Reference:
1. Mir MM, Mir GM, Raina NT, Mir SM, Mir SM, Miskeen E, Alharthi MH, Alamri MMS. Application of Artificial Intelligence in Medical Education: Current Scenario and Future Perspectives. J Adv Med Educ Prof. 2023 Jul;11(3):133-140. doi: 10.30476/JAMP.2023.98655.1803. PMID: 37469385; PMCID: PMC10352669
2. Schuwirth LW, van der Vleuten CP. Challenges for educationalists. BMJ. 2006 Sep 9;333(7567):544-6. doi: 10.1136/bmj.38952.701875.94. PMID: 16960212; PMCID: PMC1562480.
Competing interests: No competing interests
Dear Editor
“Life is short, and art is long.” — Hippocrates.
Shortcuts are dangerous.
It hasn't changed in 2400 years.
Competing interests: No competing interests
Dear Editor,
'Medicine made easy' carries risks and dangers of 'qualitative dilution'. So eruditely stated - all the trials and tribulations associated with 'Medicine'.
The exclusivity and uniqueness of 'Medicine' may be difficult to ascertain in terms of numbers, cadres and job equivalence, time schedules, payments and expenditure, and cost-benefit, cost-effectiveness and such other formulas and practices of Modern Management. Yet in running services and systems on a large scale basis, these and such yardsticks are invariably employed. The solution lies in experts/ knowledge being a part of the decision making process or vociferously doing so. Technology/ AI may appear to have made the job easy, but that does not deter from knowing that 'physician' and 'associate professional' differ in delivery of medicare. Health services globally are in a flux, particularly post automation / AI Era, but maintaining the balance and perspective is crucial and vital.
Prof Murar E Yeolekar, Mumbai (Fmr Dean, King Edward VII Memorial Hospital & Director, Medical Education & Reseach, Municipal Corporation of Greater Mumbai). 7.X.2024.
Competing interests: No competing interests
Dear Editor,
I completely echo what Professor Elder has written, and more widely I commend the Royal College of Physicians of Edinburgh for their leadership and advocacy when it comes to maintaining high standards in medical education and patient care. Doctors have been criticised for conflating concerns around "patient safety" and lowering standards in medical training, but in my view these two concepts are inexorably linked - doctors who benefit from good training will deliver better, more time and cost efficient care to patients.
The widely proposed argument that reducing length of the medical degree increases accessibility for people from different backgrounds given the year saving in tuition fees seems flimsy. There are many ways this could be achieved whilst maintaining high educational standards, including reviewing tuition fees and/or the use of grants and bursaries.
There are also concerns that reducing undergraduate medical degree length to 4 years will not meet international standards, and as such medical graduates would not be able to gain employment as a doctor abroad. During a time when we are losing large swathes of our medical workforce to Australia and New Zealand, this new initiative seems a somewhat timely and tempting solution to the doctor retention crisis - but at what cost?
This issue is muddied as were are living in a time when intense debate rages around whether you even need a medical degree at all in order to practice medicine, and even ambiguity around what "practicing medicine" actually means. So perhaps shortening medical degrees feels relatively palatable in comparison. My concern is that this is the death of high standards in medicine by a thousand cuts, and that there has not been enough consultation or transparency around these decisions. This feels like something a group of skilled, motivated professionals should feel strongly about - and many do. Although understandably for a busy, burnt out workforce, issues around high quality training might not feature highly on their agendas when they are struggling with accessing the basics within stretched NHS services.
As such these issues are often not discussed widely amongst doctors day to day. In many places there is a general feeling of ambivalence and powerlessness. These decisions are happening around us and it is not clear most of the time who is making them, and more importantly why. Do we actually think doctors need less training, or is this a workforce solution? Do we actually think Medical Associate Professionals can make accurate diagnoses and safe treatment plans after a 2 year course, or is this another workforce solution? There will be a wide variety of answers to both these questions, but we should at least be able to have the conversation and our views be heard and influence policy before it is implemented, rather than these initiatives rushed through without proper consultation or consideration.
To be blunt, it is our job as doctors to safeguard medical education and training against market forces - no one will do it for us. As highly skilled professionals we do understand the challenging economic environment we are in. We should be given the opportunity to reconcile how we maintain high medical training standards within the current climate, rather than have initiatives thrust upon us then get treated like naughty children when we question them.
In summary, yes: Medicine is difficult - there are no shortcuts.
Competing interests: No competing interests
Dear Editor
The described political concept of "productivity" as a remotely conceived, industrial vision for NHS care particularly resonated with myself as on occasion, a night shift caring for a particularly complex patient (and often their family) can challenge and teach you more about your style, communication skills and compassion as a Doctor than to barrel through a patient list. Whilst the latter may look more "productive" on paper and the former rarely thanked by those who have not experienced such a situation themselves, for me it is those human moments that hope to underpin a successful career in Medicine.
Thank you.
Competing interests: No competing interests
Dear Editor,
Finally a concise repost to those promoting "doctor lite".
Medicine is hard, challenging and scary--at whatever career stage one is.
Iain Stewart FRCP
Competing interests: No competing interests
Dear Editor:
The greatest miracle that occurred last century was the great arrival of new electronic resources, computers, cell phones, the world wide web, HTML, script languages... We are still witnessing a great electronic revolution leading us to the emergence of new paradigms, in all sectors of contemporary society. In the health sector, we are passing from a time when the operative dynamics of the doctor in practice were made from his knowledge, acquired from his teachers of undergraduate or postgraduate subjects in medical training schools, or from what he acquired daily in his internship or residence, as a product of his own experience with patients, or applying procedures according to what he daily read in the results or discussion section of scientific medical papers, published in high-impact journals, of data produced by in vitro research, or with experimental animals, in large laboratories, or clinical research in hospitals, or from information published by specialists in various areas of the health sector, presented and analyzed by them in the classic narrative reviews that appeared in yearbooks such as the Annual Review of Medicine (1).
We live in the era of evidence-based medicine, observational research, systematic reviews, meta-analyses... After the decade of the nineties, the arrival of the internet and the creation of interactive websites radically changed the dynamics of the doctor in practice. It is not necessary to use the brain to store a lot of information. Many everyday medical procedures are performed faster and with more precision, using electronic resources rather than processing information stored in the cerebral cortex. In the BC years (before computers) it was difficult for doctors to make the mathematical calculations necessary to determine the fractional dose of a drug for a patient or to diagnose the type of acid-base disorder in an intensive care unit. In the AD years (in the digital era) patients are monitored with electronic devices and very rarely mistakes are made that can lead to complications, or worse to the patient’s death.
Medicine is difficult mainly because many rules and regulations of the political and financial world do not allow the doctor to do what really needs to be done to solve those difficult problems that arise as a logical consequence of the individual and collective bad people’s behavior in society and the ugly and unnatural social-cultural patterns that are officially promoted. Most of the time there is no correspondence between natural laws and social ones, because unfortunately, politicians, who have the power to legislate do not know how the natural world really works.
In countries like ours, the administration of the health sector is in the hands of many unscrupulous people who think more of this sector as a large financial market where the doctor can be exploited. There is a crisis in the normal dynamics of the health sector functioning. Since December 1993, Law 100 (2) was introduced in Colombia, the implementation of which in practice allows the transfer of health care services to Health Care Provider Companies (EPS), which act as intermediaries between users, now commercial customers and clinics, hospitals, centers, and other health dispensaries. These new institutions (EPS) have the dominant role in the economic and financial, to the detriment of the operational staff of the health sector. This new dynamic has generated a lot of corruption and inefficiency. In practice, many patients complain and feel disowned and poorly cared for. In many doctors, a process of dehumanization and anger towards EPS is noticeable.
References.
1. https://www.annualreviews.org/content/journals/med. Annual Review of Medicine.
2. https://www.funcionpublica.gov.co/eva/gestornormativo/norma.php?i=5248. Ley 100 de 1993.
Competing interests: No competing interests
Dear Editor
Dr Elder reports that the volume of "published research and guidelines is now said to double every 60 days".
An internet search confirms that this has indeed been "said", but I have been unable to find a primary source for this figure.
Lots have things have been said on the internet. To make this claim convincing, a link to a primary source is needed.
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Dear Editor
Great article.
May I summarise
Wisdom is a product of knowledge and experience
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Re: Medicine is difficult—there are no shortcuts
Dear Editor
I couldn't agree with Andrew Elder more. I'm 51 and only over the last few years do I really feel I've got a grip on the job. The combinations and permutations of medical practice are enormous. Efforts to reduce training times have previously failed and probably only succeed if the scope of the practitioner's worked is limited. When the proverbial hits the fan someone with many years of experience will end up getting a 'phone call. I can't see this changing in my lifetime.
Competing interests: No competing interests