14 September 2017
Giving Up
Should we be worrying about the medical students or the qualified doctors?
By Lynda Goetz
In an article on 27th August in The Sunday Times, Sian Griffiths and Jonathan Corke reported that 300 students a year quit medical school. An ‘epidemic’ of mental health problems is apparently being blamed. In the past five years, according to data released by medical schools under freedom of information law, 1,600 students have left or been asked to leave, with 1,200 of those leaving with no qualification and the remainder either being awarded a BSc (presumably under the intercalation system, whereby, usually after the first two years, students can do a year in a related subject eg Global Health, Biochemistry etc to acquire a degree before continuing with medical studies) or changing course. An example cited was one Hannah Overton, a former state school pupil, who quit University College London (UCL) after two years. She had been diagnosed with an unspecified mental health condition and claimed she did not receive adequate support to qualify as a doctor.
This article provoked a number of comments online and on Twitter. Most, although not all, were careful to back up any thoughts they had with evidence or illustrations, but opinions varied widely as to whether the problem was ‘students today’ or whether the issue was, in reality, rather more complicated and required more background information. Having two siblings as well as several friends who are doctors, a daughter currently starting her fifth year and final year of medical school, and a daughter who qualified as a vet four years ago, I have more than a passing interest in the subject.
The first thing that most of those commenting on the article wanted was more detailed information and more comparison. Some of this information is rather hard to come by unless one has access to study papers or BMJ (British Medical Journal) articles. However, a House of Commons Briefing Paper produced in March this year (Medical School Places In England from September 2018) was informative and as well as discussing future needs provides information on recent annual numbers admitted to medical school (around 6,000) as well as the numbers of Foundation Year (the first paid training years, equivalent to the old ‘Houseman’ years) places available. Interestingly, a dropout rate of 300 out of 6,000 is a rate of 5%, which is not only lower than the average dropout rate of the general student population, but amounts to only half of the 10.3% of students generally who left in 2014-15 without acquiring any kind of qualification (Times Higher Education Supplement).
So, was this article, as some of the Twitterers commented, simply a piece of Sunday newspaper non-news? Well, in some ways possibly, but there are a number of claims and comments in it and relating to it which do require investigation. Firstly, are things different now from the way they were ‘in the old days’? This was an issue on which a number of viewpoints were expressed, varying from the totally unsympathetic like ‘Penny’, who felt that ‘these precious little flowers’ should ‘work hard like your predecessors did’ and CM, who considered medical students to be ‘vastly privileged’, to those who turned the discussion into an argument about whether state or privately educated kids were more mentally resilient or whether the fact that there were now a lot more women in the profession was the problem. Much of this simply illustrated how easy it is to ‘rise to the bait’ in any online conversation and how wary one should be of trying to make brief sweeping comments on any complex subject.
My two sisters, one now in her early sixties and the other in her early fifties, trained in a different era. The entry requirements however were not dissimilar from those met by my daughters. Interviews were also part of the selection process, then as now. Medical friends of my parents viewed my sisters’ time at medical school and as ‘housemen’ as ‘cushy’ – they only had to do ‘1 in 2s’, not ‘1 in 1s’ (ie on call). A young doctor recalled how his mother, an eminent surgeon, told him she hadn’t left the hospital ‘for a month’ during training. However, although my daughter is not expected to do even 1 in 2s, both sisters have commented that training is now so different it is hard to make comparisons. Medical trainees and junior doctors today may have fewer hours to do, but they do not have the support networks that my sisters and medical friends enjoyed in their time when the system of ‘firms’ was still operational. (‘In terms of medical education ‘the firm’ denotes a form of inter-generational cooperation and learning, which brought together novices who were being inducted and taught on the ward not only by consultants, but also by nurses and junior doctors who took on much of the day to day training of students’ The Demise of the Firm – Anja Timm PhD 2009). The change over the last two decades to institutionalised learning has meant that the ‘sense of belonging’ which the old system inculcated has to a large extent disappeared. This has left medical students and junior doctors, in many instances, out on a limb and frequently with no-one really knowing who they are. The only support network is that of their peers, most of whom may well be equally unsure, stressed and without the experience to deal with the expectations and demands of an increasingly entitled public.
Speaking to some of the young doctors I know personally, this lack of support and respect is something many of them feel strongly. Whereas in my sisters’ early years people were impressed that these young women had achieved the ‘status’ of doctors, nowadays there is not only little awe at their achievements, which in many ways is good, there is (rather worryingly) the threat of legal action should any of them make a mistake. The European Working Time Directive, which was an important factor in the demise of the firm, combined with Modernising Medical Careers (MMC) introduced in 2005 to much criticism and which fundamentally changed the way doctors’ training worked, were together responsible for the effective ‘demotion’ of medical students and junior doctors to shift workers with little continuity in their contact with patients or consultants.
Mental health issues are being discussed more widely generally, and there is no doubt that medicine and veterinary studies both require high levels of mental resilience. As one of the contributors to the discussion resulting from the Sunday Times article pointed out, ‘a medical career needs you to be strong in yourself’. This view was borne out by the response of one of the young doctors I spoke to, who considered that although the support was there if people cared to seek it out, there was a general reticence amongst medical students to admitting to the need to do so because of the implications involved. However, others felt that it was all too easy to become isolated and that in reality one was just ‘another b…y student’ as far as many of the clinical staff were concerned.
The other statement in the article which caused controversy was the figure of ‘about £250,000’ put on the cost of training a doctor – the implication being that those dropping out were wasting taxpayers’ money. This figure was presumably taken from claims by the Department of Health and Jeremy Hunt, but is spurious according to the fact-checking charity Full Fact. The government estimate includes repayable student loans as well as grants to cover tuition fees, living costs and a funding stream for hospitals to host students (which as a number of medical students have pointed out can on occasion amount to little more than being plonked amongst a clinical team for varying lengths of time). Full Fact calculates the final cost to the taxpayer as closer to £163,000.
Junior doctors (including those in their foundation years F1 and F2) as well as medical students are in many cases not happy with the present set up, nor with the changes to junior doctor’s contracts introduced by Jeremy Hunt, which led to the strikes at the end of last year and the beginning of this.
Nevertheless, although the dropout rate in medicine may have increased in the last 10 years, the dropout rate for medicine, veterinary and dentistry, in spite of the high stress levels for such courses, is actually lower than for many other courses. This is perhaps because students themselves have such a lot invested in qualifying and reaching the end (although of course there is no real end as ongoing exams and training is mandatory). That however does not address the more worrying fact that many are moving abroad or away from careers in pure medicine once they have completed their foundation training. This IS a matter for concern and possibly for more research.
Is it the fact that millennials expect a more reasonable work/life balance than their parents and grandparents perhaps accepted? Is it the fact that many more women work, so that there is no one person available to do all those other bits of ‘life admin’ which many wives used to do, causing everyone more stress? Is it that life is simply more stressful now than it was then, in spite of shorter hours? Is it the lack of respect for their professional qualifications in an era when facts are so readily available to all? Whatever it is, we should be concerned that our medical workforce is currently dissatisfied with its lot, in spite of the money (whatever the exact figure) expended by the taxpayer on its training. As the NHS is the monopoly employer in the UK, medics have nowhere else to go in this country if they do not like the pay and conditions. Perhaps the government should be consulting with them more closely to see how it can keep qualified staff on side and happy, rather than treating them like delinquents? Without them, after all, there can be no NHS.
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