Dumbing down Britain's doctors

The collapse of Britain's online Medical Training Application Service (MTAS) has been widely welcomed. The web-based system was designed to match junior doctors to specialist training posts, but following junior doctors' complaints about a lack of available posts, poorly designed recruitment forms and technical failures in the new online system, it has now been scrapped. However, the real threat to standards of medical practice - and ultimately patient care - comes from the Modernising Medical Careers programme, of which MTAS is merely one aspect.

`If one of my own children had been in that position', UK health secretary Patricia Hewitt told Channel 4 News on the day she finally suspended MTAS, she would have fully shared the distress of the parents of those affected by the series of scandals afflicting the new computerised application system for specialist medical training (1). This curious presentation of the issue from a parental perspective is echoed on the website of RemedyUK, the grassroots organisation of junior doctors that has led the revolt against MTAS, staging unprecedented mass demonstrations in March (2). The site prominently displays a colourful poster proclaiming `Mums4Medics' (with subsidiary slogans, `Dads4Medics', `Partners4Medics', `Everyone4Medics').

By the time they have completed five or six years of medical school and two years of the new post-qualification `foundation programme', the youngest of the doctors applying to MTAS is 25 and many are over 30. Yet it seems that these `junior' doctors are regarded by the health minister as children and that they even regard themselves in similar terms. The infantilisation of doctors implicit in these representations reflects the real threat to the medical profession and to the quality of medical practice posed by the current wave of `modernising' reforms.

Hewitt was quick to emphasise that, though doctors are angry about MTAS, the `underlying principles of Modernising Medical Careers' are widely accepted by both junior doctors and the professional bodies that have been closely involved in the development and implementation of this programme. Before looking more closely at Modernising Medical Careers (MMC), let's briefly look at the MTAS fiasco.

In many respects MTAS is just another National Health Service IT failure: an online system that is vastly expensive, badly designed, difficult to use and which crashes frequently. When the system made publicly available doctors' personal details, including religion, sexual orientation and criminal records, this was more than a breach of confidentiality. It raised questions over why a medical appointment scheme should require that candidates submit such information. Though it is these failures that have led to the collapse of MTAS, its defects go much deeper.

In its modernising zeal, MTAS gives priority to doctors' subjective `learning experiences' and downplays objective indicators of performance. It allocates 75 per cent of its points to 150-word vignettes of clinical cases, in which doctors display fashionable concerns about `reflexive learning', `team-working' and ethical dilemmas. According to critics this amounts to meaningless self-promotion as well as being open to plagiarism (which the system lacks the software to detect). Only 25 per cent of points are allocated to academic or research achievements. Extracurricular activities are marginalised, references sidelined and interviews rigidly standardised.

The elite Academy of Medical Sciences has condemned MTAS for its discrimination against talent and excellence, as `a threat to UK biomedical research and healthcare' (3). For the Academy, MTAS reflects `a mindset in which academic, educational and research achievement are seen as almost irrelevant to the future quality of healthcare'.

It is true that the old system of selection for specialist training posts was susceptible to nepotism, favouritism and discrimination against those from ethnic or other minorities. It is New Labour's signal achievement, in this as in many areas, to have replaced a corrupt and inefficient system with one that is potentially more corrupt and certainly more inefficient - and even more damaging to the morale and standards of the medical profession.

The spirit of political correctness that imbues MTAS has already established deep roots in the modern medical profession. These can be traced back to the adoption by the General Medical Council in 1993 of the document Tomorrow's Doctors, which outlined the `goals and objectives' of a new medical curriculum under the rubric `knowledge, skills and attitudes' (4). While `knowledge' was reduced to a `factual quantum', extensive and detailed attitudinal objectives `reflected the values of the culture of therapy and the demands of political correctness' (5). Launched in 2004, Modernising Medical Careers sought to extend the approach of Tomorrow's Doctors from the medical school into the world of post-graduate medical practice, in hospital and in primary care (6).

The first major MMC initiative was the replacement in 2005 of the traditional year doctors spent as `house officers' in hospitals immediately after qualification with a two-year `foundation programme' (part of which could be completed in General Practice). There can be no doubt that the old system had many flaws: many young doctors were exploited by absentee consultants, obliged to work excessive hours and received minimal supervision or training (to the detriment of both themselves and their patients). The foundation programme sought to replace the old `apprenticeship' model - celebrated in the surgical saying `see one, do one, teach one' - with a closely supervised programme of instruction in the attitudes and values deemed appropriate for the modernised doctor.

The new programme is `trainee-centred, competency-assessed, service-based, quality-assured, flexible, coached, structured and streamlined'; it is managed and structured, progressive, robust and seamless; it is `outcome-based' and evaluates `observed behaviour, skills and attributes'. No doubt some of this jargon conceals valuable educational and clinical activity, but it is difficult to believe that all the ticking of boxes reflects any improvement in the rigour of medical training. What remains unquantified in this system is the quality of doctors' clinical knowledge and their experience of taking responsibility in treating and caring for patients.

The 1858 Medical Act, which is established the General Medical Council, sought to establish a system of medical education that produced a doctor who, on qualification, was a `safe general practitioner'. This concept of an independent and competent general practitioner symbolised the confidence of the modern medical profession at the moment of its emergence in the nineteenth century. By contrast, the `never quite competent' doctor, one who requires continuous formal instruction and regulation, monitoring and mentoring, support and counselling, symbolises the abject state of the profession in the new millennium. While the junior hospital doctor of the past may have been used and abused, today's doctors appear to have lost all initiative or autonomy in relation to their own professional development and in relation to their patients. If tomorrow's doctors are reduced to the status of children, to be patronised by politicians and parents, as well as by their trainers and tutors, the future of the medical profession is in jeopardy.

For the Academy of Medical Sciences, MTAS is `an object lesson in what happens when we take medical education out of the hands of those who value objective academic achievement and put it in the hands of those who wish to create a uniform and biddable workforce unencumbered by the spirit of inquiry needed to challenge dogma and central directives'. The consequences of this lesson are not confined to MTAS, but go back through MMC to Tomorrow's Doctors, and the wider framework of medical education and training established over the past decade.

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Australia: The Melbourne medical meltdown continues

Gran dies after sent home alone

A GREAT-grandmother died alone hours after she was discharged from a Melbourne hospital and shuttled home in a taxi wearing just a nightgown. Ann Barbara Pitt, 91, died from heart disease on April 3 after she was sent packing from the Royal Melbourne Hospital where she had been admitted 12 days earlier for a tissue infection. Ms Pitt's distraught daughter Judy Liddy found her in a pool of blood on the floor of her Coburg home 15 hours after the discharge.

Ms Liddy will lodge a formal complaint with the Health Services Commissioner over the case, which comes amid rising concern about discharge quotas at the hospital. "I felt her shoulder and it was so cold I knew she'd been dead for ages," Ms Liddy said. "I'll never get over it as long as I live. "It haunts me every day and every night."

Health Minister Bronwyn Pike has been under mounting pressure since revelations the Royal Melbourne had imposed discharge quotas to achieve cash bonuses under the Government's hospital funding scheme. Documents show it aimed to discharge about 490 patients between mid-May and July to qualify for the extra cash.

Ms Liddy said the hospital had given her just one hour's notice of its decision to eject her mum at 5.30pm on April 2. "I don't believe she was well enough to be home," she said. Ms Pitt had suffered cellulitis, a condition that commonly affects the elderly or those with weak immune systems. It can be caused by infection, which medical experts say can put extra stress on the body including the heart. A coronial report cites coronary heart disease as the official cause of death. The autopsy attributes the blood loss to a fall, Ms Liddy believes.

Ms Liddy agreed to have her mother sent home by taxi - which she paid for - because she did not have enough time to make other arrangements. She hurried to meet her mother at home and found that she had been sent home without her purse. After helping her resettle, Ms Liddy set out to find the missing valuables. She returned the following day about 10.15am to find her mother dead in the hallway. "I ran out into the street screaming for help," Ms Liddy said.

She complained about the discharge, but the hospital said it could not respond because the case was before the coroner at the time. It said it could not find Ms Pitt's missing purse, but weeks later returned the item, which had been found in a stationery cupboard, Ms Liddy said.

The Health Services Commissioner is assessing Ms Liddy's complaint. Complaints to the commissioner increased eight per cent last quarter. About 62 per cent of complaints accepted for assessment relate to treatment procedures, including misdiagnosis, negligence and inadequate treatment. A Royal Melbourne Hospital spokeswoman extended condolences to the family and said patients were discharged only when clinicians deemed them ready.

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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