The engineering university curriculum focuses on the acquisition of non-technical skills, like leadership and team work. These are essential for doctors too but we do not teach them, they are acquired along the way, says Roger Stedman.
Over recent months there has been an emerging consensus – articulated in reports from the Royal College of Physicians’ Future Hospital Commission and David Greenaway’s report for the General Medical Council, The Shape of Training – that it is time to put into acute reverse the socio-professional trend of the last 30 years of ever increasing medical super specialisation.
In their own ways these reports identify that what a health system, in which 70 per cent of the activity is ongoing health maintenance of increasingly aged patients with three or more co-existing long term conditions, needs is not an army of doctors that can treat only one thing.
‘There are more jobs available than people willing or able to do them by a considerable margin’
They also identify that the key specialties for managing this population – emergency medicine, acute medicine, elderly care medicine and general practice – are all “shortage” specialties - there are more jobs available than people willing or able to do them by a considerable margin.
BMJ says there is a 8-22 per cent vacancy factor and that is before you take into account the demographic time bomb of the mass retirement of a generation of GPs that started their careers during the last big expansion of the specialty in the 70s and 80s.
If you move down the training hierarchy, the fill rates are even more dismal – with 50 per cent of higher specialist training posts in emergency medicine not being filled.
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Specialising early on
The “solution” proposed appears to be to increase exposure to these specialities earlier on in young doctors’ careers to make them do these types of jobs for longer.
At the same time, access to more specialised training (like cardio-thoracic surgery or neurology) is being restricted by decimating the number of training places for them.
This aims to encourage more young doctors to stick with the frontline specialties, rather than flood into the popular “super specialties” (as they currently do, and always have).
However, this apparent solution seems to be completely ignoring the fact that a young doctor, when faced with the choice of not getting access to the training in their preferred specialty, would rather settle in Australia than stay in the UK in a specialty that doesn’t interest them.
Which is exactly what they are doing, in droves.
‘They would rather settle in Australia in a specialty that doesn’t interest them than stay in the UK’
So why is it that young doctors are eschewing the “semi-differentiated” specialities - my term referring to the specialities listed above and to which I would add my own specialty of critical care, albeit not a shortage specialty.
What is it about the intellectual, practical and emotional challenge of providing care to patients with multisystem disease, in a psycho-social context that requires the corralling and coordinating of multiprofessional multiagency teams that puts them off?
What is it about integrated care that is just so difficult?
Both the reports cited above focus on training as the issue – we are not training our doctors right – and they propose some really quite radical changes to postgraduate medical training to address this.
While this is necessary, I do not think it is nearly radical enough to really address the issue we need to go back to medical school and examine:
- who we are selecting;
- what we are teaching them;
- the skills we are equipping them with; and
- the attitudes they are possessed of when leaving medical school.
I have had cause to visit a number of university open days, not their medical schools but their engineering departments. Engineering is a profession that requires the acquisition of at least as much, if not significantly more, technical skills and knowledge as medical training.
The courses are just as intense and nowadays just as long (typically 4-5 years with a year in the industry).
Competition to get in is just as stiff and the bright young things wanting to do it are as possessed of the same desire “to make a difference” as those motivated to enter a medical career.
What has struck me though is that every engineering course I have looked at not only emphasises the knowledge and technical skills required, but that they also have very large parts of their curriculum given over to the acquisition of non-technical skills: leadership, team work, collaboration, project management and business skills - all of which are required to be a successful engineer.
They are required to be a successful doctor as well, but we don’t teach them. You are selected for medical school on academic performance at 18-years-old, pass through 15 years of undergraduate and post-graduate training and emerge as a highly knowledgeable, very skilled technocrat – a heroic doctor.
‘A doctor also requires many technical skills associated with engineering’
Any non-technical skills acquired along the way are more by accident than design.
It is not just the non-technical skills they teach engineers that doctors need either. Becoming a doctor in an integrated care system requires many of the technical skills associated with engineering as well.
Understanding complex adaptive systems, industrial process design, informatics and information technology (among many) are all skills we require of doctors if we are to “industrialise” modern medicine.
We need to train a generation of doctors that are able to command and corral the multiple professions, agencies and technologies required to support the complex interaction of social, psychological and physical pathologies that represent the disease burden of our patients.
We need a generation of specialists too, but specialisms built on a foundation of whole systems care. We need a generation of doctors that recognise that it is not good enough just to be brilliant at one thing.
Dr Roger Stedman is medical director of Sandwell and West Birmingham Hospitals Trust