Abstract
Medical education in the UK had a good reputation, attracting a large number of UK students and with many coming from other countries to train here. Sadly, there is now evidence of a diminished number of applicants both from the UK and also from abroad. Perhaps, for slightly different reasons, there has also been a significant fall in the number of doctors offering themselves as expert witnesses. Applications to expert witness courses have fallen, and solicitors are finding it harder and harder to find good quality doctors prepared to advise and give evidence in court. Overall more and more of our best young doctors are leaving the country.
Why is this, and can we do anything about it? There is probably a wide range of contributory factors but three in particular may be worth looking at. Firstly money, secondly risk and thirdly the manner of training.
Money should perhaps be counted not once but twice, the cost of training and professional remuneration. Medical education takes a good number of years and training costs money. The cost is both because the trainees do not in their early years contribute very much to relieving the workload and the teachers can do less clinical work and a significant part of the teaching is not simply ‘watch what I’m doing’.
‘Trust me, I am a doctor’ is a nice classical mantra, but the doctor who thinks that they cannot make a mistake is dangerous. Whilst young doctors should be encouraged to strive towards perfection, they also need support and backup if they have done their best. The pressure currently on services increases the risk of things going wrong, and the management ethos is to prove that it was not the lack of resources or management that caused the problem. Doctors sadly have constantly to look over their shoulder for fear of carrying the blame. Professional insurance can only help to some extent. All the evidence points to a steep rise in medical negligence cases, ‘the culture of blame’. Many young people do not want to carry this risk whatever they do and choose other careers.
Expert witness work that is publicly funded is now paid at a very limited rate, and experts can be sued in court for unintentional errors and may even risk being struck off if the error is regarded as very serious. Many of the most able doctors are now increasingly asking themselves, ‘should I risk my career for this?' It should be noted that the brightest are often the cheapest to employ because they apply fewer irrelevant assessments.
Is there a change in the nature and framework of teaching medicine? Well as noted above the less time-consuming, the cheaper it is. There’s also a curious pressure. There are many tasks that doctors do that can be carried out by less expensively trained people. With good quality assessment and appropriate supervision, the risks are probably little different. However, when the assessment and monitoring is also carried out by people with narrower training, the error rate is likely to increase. The full range of possible causes and explanations is missed more often as is the initial appearance of complications. How do you therefore reduce the gap in error rate between the good medical trainee and the good ‘paramedic’. One way is to upgrade the training of the non-medics, but hold on, that puts the costs back up. The other is to reduce the cost of medical training with more stereotype learning and ‘tick box’ methodology. That unfortunately reduces the training to consider all possibilities even the rare ones.
So can we do anything about it? We can all contribute to creating a constructive environment that will assist in the return to supporting young people in this profession. The Medico-Legal Society and its Journal are looking to give support as far as they can. Encouragement to come to the monthly meetings has attracted students. We would like to see more of them. It is hoped that within this environment they can speak openly and bring new ideas and contribute to discussion without fear of criticism or retribution. The Journal is now endeavouring to include an article written by a medical student as often as possible. This may be from the UK or beyond. It may be a review or report of a research project or a commentary on an issue. The quality has to be good and the subject relevant to the interface of medicine and law, but the editors will advise on this. Publications are useful in career development but also can help encourage people to think innovatively and to participate in discussion of ideas.