I.
I’d say that one of the main things that made me choose to become a doctor was that I felt like I had a kind of natural ability and affinity for the subject. It’s likely that this was a completely false assumption however. It stemmed from growing up in a highly medical background, where a lot of family and friends were involved in the field. As a result I easily identified with the profession. I assumed and it was presumed by many others that I would become a doctor as if it was somehow in my DNA (at this point it’s hard to say what came first. My desire to become a doctor or the fact that everyone around me was saying that I would become a doctor. A kind of chicken and egg scenario).
I recall when I was being taught Biology in Primary School for example and the other kids looking expectantly, as if somehow I already knew all the answers. This continued on throughout high school. There was one time when we were briefly being taught about electrocardiograms and for some reason the other people in the class and also the teacher started to ask me questions about how to interpret them. This low-level reinforcement over many years is likely to have shaped my opinion on medicine and my own identity as a doctor.
When I began medical school it was really just a continuation of school. The only thing that seemed to change from school was the fact that on top of going to a building to learn some random stuff everyday, when I got home my bed hadn’t been made and I had no food to eat. The first three years did not involve seeing patients at all. The theory went that medical students should have a baseline knowledge of this thing called “medicine” before we were even allowed to see an actual patient. At this point in medical school if one of the medical students had seen a patient, it was almost like a yeti sighting. “You saw a patient?” “Where did you see this patient?” “Well, I kind of saw the patient as he was running off into the woods”.
I remember having conversations with my family out of sheer frustration. Why do I have to learn all this random stuff before I can even see a patient? I just want to be a doctor! Why do I have to learn all this stuff which will never be needed? My parents and my elder brother would reassure me from time to time. The most logical answer they were able to provide was something along the lines of earning your stripes, or that it would all add up to making a good doctor or something like that.
Just to give you an idea, here is a (shortened) list of subjects which we had to study before we could even see a patient. All of these had an exam at the end of the course, or you wouldn’t be allowed to progress further in the course:
- Anatomy
- Histology
- Nursing
- Human Studies
- Biophysics
- Biochemistry
- Embryology
- Developmental Biology
- Physiology
- Pathology
- Pathophysiology
- Ethics
- Latin
- Heath Information Technology
- Forensics
- Medical Biology
- Microbiology
- Immunology
There’s eighteen subjects in the above list. So that’s at least eighteen major exams we had to pass to finally move on to clinical medicine and see patients.
Clearly, going to medical school was not what I had expected it to be. However, even though I was really frustrated in those first few years in terms of not being able to see patients, I’d be lying if I didn’t kind of enjoy learning such a vast array of interesting subjects. And because it was just like school again i.e. memorising a large amount of random stuff, I was doing quite well at the work.
II.
After I became a doctor, I noticed something quite odd occurring. Every time I was in a rotation, after a couple of months I got bored and couldn’t wait to move on. For example when I was in General Surgery, I kept thinking “Really? How many more patients do I have to take an abdominal pain history from?”. It turned out that I got bored really quickly seeing patients if they were all similar and had the same sort of presenting complaint. I mean, all that knowledge that I had gathered from medical school seemed to be going to waste! What about all that histology and pathophysiology I learnt? What about all that stuff I learnt about embryology, gut development and yolk sacs? Oh the irony of learning all those subjects before being allowed to see a patient and then not being able to use even a fraction of that knowledge when you do actually see a patient. (As an aside, I suppose this is one of the reasons I’ve specialised in general practice, because you get exposed to all different types of pathology in this career).
Because I kept on getting bored with my rotations it soon occurred to me that medical school isn’t there to teach you how to be a doctor. It’s there to teach you medicine and everything that comes along with it. There is an important distinction here. When people conjure up an image of a doctor in their mind, they usually think of a person in a lab coat or dressed up in scrubs working somewhere in a hospital. The reality is that having a medical degree is so much more than just clinical medicine and what people do in hospitals.
The fact is that having a medical degree is actually very malleable and has far-reaching implications which most people aren’t aware of. If for example you have a medical degree and then all of a sudden find yourself wishing you were a writer you could become a medical journalist to get your career started. If you have an interest in law then you can get involved in medic0-legal careers quite easily. In fact the scope of what doctors can actually do with their lives is pretty hard to comprehend as we can wander off into pretty much any field we can think of and find a place where our knowledge and skills could be applied. Suddenly it now seems that being just a hospital doctor and seeing the same type of patient over and over again seems quite boring (as well as being poorly remunerated in the UK).
III.
In the UK there has been an increasing demand for healthcare. This trajectory of demand vs supply has massively accelerated over recent years. There is clearly a lack of doctors working in the NHS. We pretty much have the lowest number of physicians per 1000 of the population than of any other country in the EU. Now all of a sudden there is a massive incongruence. On the one hand you have massively skilled doctors with a ridiculous amount of knowledge, skills and opportunity who are being paid below market rates. And on the other hand you have the public, who demand more for less from their doctors and politicians who are pushing for the same thing.
To counter this incongruence between supply and demand there has essentially been two strategies which have been proposed.
The first strategy is to make doctors work for at least four years before they are allowed to leave the NHS and cut their salary. As mentioned above, getting a medical degree is not just about working in hospitals. The policy of making doctors work for at least four years in a hospital, if it were to happen, shows how little people understand what a medical degree actually is. Making people with medical degrees work in a hospital is essentially the same as teaching someone how to code and then telling them that they are only allowed to code websites about puppies for four years. It make absolutely no sense as our skills are so wide-reaching
Another strategy is to allow people without medical degrees to do some of the work traditionally done by doctors. For example physician associates both in primary care and in the hospital setting are able to see most straight forward patients, there are now pharmacists that can diagnose simple illnesses and provide antibiotics, there are physiotherapists that will see patients with minor aches and pains without the need of a doctor and so on.
A lot of doctors seem to have a knee jerk reaction against nurse practitioners and other allied healthcare professionals from seeing patients. They are worried about less experienced people making mistakes which doctors will have to take responsibility for as these other healthcare professionals are meant to work under our “supervision”. This is actually a real fear as a lot of doctors face a fair amount of litigation in their careers and already have very high indemnity fees. They also get worried that less qualified people will make inappropriate referrals and do inappropriate investigations wasting time and money, but the data is not yet available to say whether this is correct.
I am sure though that one of the main reasons doctors don’t like the idea of nurse practitioners though is because they’re worried about their own careers being eroded (and also the fact that nurse practitioners earn quite a lot of money for comparatively very little training).
IV.
The problem here is that a lot of doctors have forgotten what medicine is and what our role should be.
A lot of what we do as doctors is extremely monotonous. Talking about chest pains or diagnosing a urinary tract infection gets pretty boring after you’ve done it a few times. There is absolutely no reason why these “easy bits” can’t be done by people without a medical degree. I actually hope that more and more of our work gets taken up by these other health professionals, because if that does happen then people with medical degrees can finally use all of that knowledge and all of those skills to concentrate on actual interesting problems that need our skills.
The tricky paediatric patient suffering with a rare genetic condition up in ICU needs an expert with deep understanding for his management. Setting up a cancer screening service in remote areas of Africa requires someone with both medical knowledge and public health knowledge to set that up. A doctor who can see a gap in the market for an unmet need and sets up a business to solve that problem to help patients requires a thorough understanding of the healthcare system to make it successful.
The world is short of millions of doctors and the gap is only growing. It would be better for the world if doctors weren’t pigeon holed into all the monotony and bureaucracy that is hospital medicine and their skills were used in a better way to meet demand in innovative ways. Thanks to how quickly the world has changed, it’s the first time ever that doctors can leave the large incumbent organisations and do interesting things themselves. Most doctors that do this are likely to be happier, have more of an impact and be more fulfilled with their careers.
Granted, it is a big shift from how things are done right now, but the role of the doctor will change, probably in the space of the next few decades. It is likely that doctors in the future will oversee healthcare rather than get as involved as they are now. Even if this isn’t what ends up happening, it should be what happens and the possibility of more doctors doing this kind of thing will only continue to grow.
Perhaps if this happens then the image we conjure up in our minds when we think of a doctor will change from a person running around the hospital in scrubs to something else. I was so wrong about what it means to be a doctor when I was growing up. It’s not surprising therefore that most people still don’t know what having a medical degree actually means.
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