AIBU to be angry that Government policy means young doctors, nurses and other HCPs cannot find jobs

A wonderful and highly competent nurse practitioner looked after me and my newborn in Kentucky thirty odd years ago. The US system was light years ahead of the UK then - fortunately, or my DD wouldn't be here, nor would I. It never occurred to me to question the expertise of this nurse practitioner merely because she wasn't a doctor.

A great many nurses are vastly more impressive than doctors, in my (relatively extensive patient) experience. I think there can be an issue with doctors sometimes - especially at the junior level - being just a bit too pleased with themselves.

Onemorepiece - the same was said of nurse practitioners when they started being used for tasks traditionally done by doctors. Healthcare evolves and the US has very good track record of using this group of professionals properly. We still have a long way to go.
If properly set up and managed they are invaluable for both patients and the greater healthcare team. There are undoubtedly issues about some of them pretending they are doctors but then the some can be said for some nurses and other AHPs. There are good and bad ones and they make miatskes just like junior doctors - who get carried by their consultants aswell.

i would prefer a resident over a PA but cycylist has actually articulated how hard it has become to deliver care to patients - so much protected time, teaching, zero days and less hours means the work needs to be done by someone - many consultants now do the tasks they did as a junior doctor because if they did not then they do not get done. In some ways the medical profession has shot itself in the foot, so many portfolio boxes to tick we have lost sight of the goal - treating patients safely.

It’s not from a paper (hence my health warning on conclusions!) - just from the GMC database.

gde.gmc-uk.org/medical-schools/medical-schools/medical-schools-and-their-graduates

I was really just offering an answer to the question about the discrepancy in higher surgical training. Attendance at an academically selective school was meant as a general marker, not specifically a schooling effect.

However, McManus seems to show that post-2000 medical school graduates do worse in examinations having correcting for prior attainment. Value added is discussed in that paper.

Which paper are you referring to in your second paragraph?

It's great to have an insight on how consultants think. It helps the public understand the current issues better.

Our experience of a PA was that we were led to believe she was a doctor at first. Unfortunately, it wasn't a straightforward case so she couldn't answer many of the questions and eventually we had to wait for the doctor anyway. From a patient's perspective, that's not great and we lose confidence. If you have waited almost a year for an appointment, then to see someone who lacks the depth of medical knowledge and the ability to deal with the issues is really disappointing. Ultimately, as doctors you run the risk of potential clinical negligence claims and surely that's stressful and ultimately not worth it. I understand that senior doctors are looking at it as a workload issue, but hopefully you can understand that patients look at it from a different perspective having waited a long time for an appointment.

@Marchesman you have stated that “Attendance at a more academically selective medical school has positive effects on entrance to higher speciality training” but I don’t see evidence for that in the study you shared (although I may well have missed it). In fact, the conclusion from the study states “variation in MRCS pass rates between medical schools is largely due to individual factors, such as the academic ability of individuals, rather than medical school factors”. Intuitively it would make sense though, just as grammar schools send more to elite universities than a less academically selective school would.
However, the GMC registration data seems to show something different. Just comparing standard offers for Cambridge with Imperial - former is AstarAstarA, latter is AAA to AstarAA, so one can conclude Cambridge to be more academically selective. However, when you compare numbers in specialty training, given that both universities have similar(ish) numbers in foundation training (544 for Cambridge, 580 for Imperial), Imperial has over 75% more in specialty training than Cambridge (1406 vs 795). Is there a flaw in using GMC registration data that I’m not aware of (am a non-medic so may be reading it incorrectly)?

Thank you Transcontinental - am sure mumsneedwines will be along in a minute to tell you why you are wrong.

WE have got PAs in out Trust because the FY1 jobs were taken away from mainly surgical specialities as deemed not fit for purpose. The departments affected looked at the use of PAs and by and large have integrated well. They looked at the effect on training for the F3 and above grades and found they got more theatre time as the PAs were on the ward. All the surgical consultants I know will not train PAs to perform operations but they do assist if needed.

Many on this thread are unaware of the amount of time and effort senior doctors put into training the next generation, mentoring, guiding etc the next generation. Some do not but the vast majority do much in their own time - but on here anyone not a current FY doctor is a selfish, ignorant unempathetic bastard!

Hopefully this is not going to be viewed as a derail, I have some thoughts about a couple of points raised earlier on the thread.

Do consultants prefer to have PAs rather than resident doctors?
I can't speak for all consultants but personally I do not have PAs and there are none in the department where I work, in fact very few in my specialty as a whole as far as I am aware. However there is no doubt that because I enjoy training doctors and have committed to having resident doctors on the team, I have to accept that there are often days and even weeks at a time when my team is threadbare and I barely see my resident specialty doctor. This is due to a number of things such as their rota with its night shifts and zero days, the number of resident doctors who are now less than full time (LTFT used to be for very restricted reasons but now it is much more open for all to apply), the amount of mandatory off-site teaching sessions they attend, the mandatory personal development time they are now entitled to and take. And this is before taking account of their annual leave, my annual leave, any other leave they have such as study leave, sick leave etc. Quite a lot of the time the resident doctors barely know my patients and tell me that they haven't had the opportunity to take a full history from them. As a consultant it means a lot of my time is spent for example doing my ward round on my own, the ward round medical paperwork and admin is then all for me to do and it takes away from the time that I am supposed to spend doing the very many tasks and responsibilities that are expected of me as a consultant.
So I can see why some specialties or individual consultants could be attracted to the suggestion of having a PA, clinical nurse specialist, advanced practitioner or similar rather than a resident doctor. They are permanent staff so once fully trained the department would continue to reap the benefits, in my department they would not be on the medical on call rota so no zero days or night shifts, they could be trained up for a defined area of practice and could provide continuity of care for both inpatients and outpatients.

Second point - Medical student numbers are being increased due to the need for more doctors - again my personal opinion is that this is likely to worsen the problems before being able to solve them as to increase med student numbers you need to have the clinical placements and clinical supervisors (consultants) available for them. My department takes medical students and we wouldn't have capacity to increase the numbers anyway, in addition the consultants are already very busy and anyone who is able to supervise or teach medical students is already doing so. We don't get any financial recompense for having and teaching med students, somebody does get the money somewhere but it's not me and it also doesn't seem to reach my department. I enjoy teaching and training but it takes me away from my consultant-level clinical and administrative work which nobody else will do for me so there comes a point at which I would have to say no to anything extra.
Likewise when these students graduate and need 2-year Foundation placements,this programme is already struggling to meet demand and there's a waiting list/hastily-put-together job tracks every year. I know this because I supervise FYs and I now quite often get an FY who has been a "placeholder" initially unmatched to a job & only finding out at short notice where they will be working. More FYs means more clinical and educational supervisors needed, if these are to be consultant supervisors I don't know where the additional consultants are going to come from. Anyone of my vintage is either trying to cut down their clinical hours or even trying to leave completely, the willingness/capacity to take on even more training and supervision responsibility is just not going to be there. Each resident doctor should have an hour of face to face clinical supervision per week, for me this amounts to a large proportion of my own working week as I have more than one resident on my team and I work less than full time myself. My job plan (weekly schedule) just doesn't have the flexibility to give more time to a greater number of residents.

Thanks for that Marchesman.

Would you be prepared to explain the pressures to pussyfoot around the issue? I could have a stab at it but suspect it might not end well.

@Millaiss Attendance at a more academically selective medical school has positive effects on entrance to higher speciality training and MRCS part A pass rates, but not on choice of speciality?

The Ellis paper is interesting because individual medical schools are identified, but there are pressures to pussyfoot around this. The GMC - council members typically have little acute clinical hospital experience - takes a particularly relaxed view of the differences between medical schools, and their choice of teaching methods, but they are significant. For anyone interested who hasn't read the Ellis references, it is not only surgical exams that we are talking about here:

"PBL schools have higher historical rates of producing GPs, teach more general practice, have higher F1 preparedness, produce more trainee GPs, have higher rates of ARCP problems for non-exam reasons and have lower entry grades, less traditional teaching, less teaching of surgery, less examination time, lower UKFPO Educational Performance Measure and Situational Judgement Test scores, lower pass rates in postgraduate Foundation exams overall and lower average marks in MRCGP AKT and CSA exams and in MRCP (UK) Part 1. It is clear therefore that PBL schools do differ from non-PBL schools in a range of ways... Even when entry grades and other measures are taken into account, PBL schools (and post-2000 schools) tend to do less well at examinations." McManus et al 2020 (full citation in Ellis, my italics)

For me, the alarming thing here is that "F1 preparedness" is a perception that trainees have (and chimes with their characterisation by BMA representatives as "expert clinicians"). But it correlates with poorer performance by most available metrics.

Furthermore, PBL is more popular with students than traditional teaching, and this feeds into student satisfaction measures, which in turn affect the ranking of medical schools, leading inevitably to less traditional teaching and more graduates finding themselves ultimately confused, out their depths and without jobs.

Thanks for the providing that timeline Clavinova.

Dr Chaand Nagpaul was the BMA council chair from 2017 -2022 and is also on a board of the BAPIO Training Academy.

From that article from 2019 that you linked BMA council chair, Dr Chaand Nagpaul, said: “The BMA is delighted that such a respected body as the Migrations Advisory Committee has listened to the BMA and proposed a bold, but much needed, recommendation to place all doctors on the shortage occupation list.

Thanks for sharing that study @Marchesman - certainly shows that Oxford and Cambridge grads have an edge in passing part A of the surgical exam in question but not part B? Prior attainment as measured by A level results seems to be the most meaningful, which makes sense. I wonder if a post A-level application makes more sense for medicine (perhaps after a mandatory year as an HCA so everyone is going into it with eyes wide open!) Also, following that study’s data source is interesting (one follows through to a GMC database) - it seems that for those in specialty training, from a random selection of universities (including Oxford, Cambridge, some London unis), broadly the same percentage from most unis are actually in surgical training (about 13-15%), so despite doing better in part A of the exam, it doesn’t seem to result in a disproportionate number of those grads actually ending up in surgical training. The only university that looked to be an outlier was Imperial- 20% of their grads in specialty training are in surgical training. There may be others but I’ve not looked at them all - Nottingham and Edinburgh were at the higher end too, but I’m sure there are lower also. I’ve only looked at surgical as that was what was referred to in the study.
But the GMC data also shows overall % in specialty training by medical school. The London unis come out high here (Imperial and UCL in particular, 37%!) with Newcastle also similar. Was very surprised by Cambridge and Oxford though - 10% and 15% respectively. Perhaps I am looking at the data incorrectly as I’m just doing it quickly on my phone, or there is some flaw in the data which medics are aware of, so happy to be told so (I am looking at GMC data for registered qualified doctors by PMQ who are not currently GPs or specialists, and are either in core, foundation, or no specialty training for the total number for each, divided by specialty only). I would be surprised that the % is so low for these 2 unis

That's true about exams in all professions.

Nothing wrong and everything right about any system which filters for merit.

mumsneedwine you've tagged me again.

You have certainly previously said that you didn't go to Oxbridge, within the various tracts about why those two unis aren't to be rated. More than once. You've been very clear. Perhaps you are indeed an Oxbridge graduate but preferred to say you weren't - it's a free world, although I wouldn't be able to see any point in that. And I'm not clear why you're so muddled about the general purpose of and regulations around the MA.

You have however frequently referred to sending hundreds of students to Oxford and Cambridge (you yourself have said hundreds), even though you don't know the entrance requirements for Medicine and became angry when that was pointed out.

As I said before, things like this do unfortunately create a credibility issue generally which is is shame if you're trying to have a meaningful discussion - the very purpose of MN.

Incidentally I haven't any need to 'stalk' (by which I assume you mean use the search function). I never need to use the search function and am not the sort of person who cares sufficiently to 'stalk' (Isn't it against the guidelines to accuse a poster of stalking?). The combination of you being such a dominant/ frequent/ voluminous/ call it what you will poster on these threads and my extremely good memory means that I simply remember (I remember the tiniest details of all sorts of random stuff which has happened and been written decades ago ( in rl I mean, which I'm slightly more focussed on than MN but the memory helps identify inconsistencies here too)). Also, small point, but presumably if I had 'stalked' (which as I say I haven't) then I would have been able to verify that you have not written that you were an Oxbridge graduate.

@mumsneedwine you must stop saying that passing exams doesn't matter. Any doctor with the ambition of becoming a consultant will quite rightly have to pass difficult professional exams. This is the reality, and saying that you can be a good doctor without doing that is saying that you should remain in the lowest grades forever.
Hoping to be cured by empathy is like hoping to be cured by homeopathy, it only works if you take the medicine as well.

@Thisismetooaswell it's only important to those that think it's important. No one other than a few snobby people on here cares at all. Passing exams is one part of being a doctor, although as the complete failure of the MRCP exam fiasco shows, it makes no difference to doing the job well. But the echo chamber voices on here will know better. They are the minority and if they are doctors I really hope they never treat anyone I care about. The lack of empathy and elitist rubbish they display is sad.

@Auchencar 😂😂 my dear girl, I have never said any such thing. I have 2 degrees but don't like to brag as don't have 6 A stars. Weirdly my comp taught that things other than academics were important. Again, your stalking of me it's a little weird, maybe try and get a hobby ?

It is very interesting to read that, despite what we have been told, it does in fact matter where you get your medical degree.

And that maybe the more integrated teaching method is not so well thought of ? (although appeals more to DC)

https://www.cambridgestudents.cam.ac.uk/your-course/graduation-and-what-next/cambridge-ma

These are the rules for Cambridge.

https://www.new.ox.ac.uk/oxford-ma

Another explanation.

'Upon application' v 'given one'/ 'wasn't going to refuse it'/ 'V v weird'

'three years after graduating' v 'a year after graduating'

'MA' v 'MSc'

That's without the repeated denigration of Oxford and Cambridge (obviously some people go and hate it or are sent down - those are the ones who generally criticise the unis as institutions, fair play) and the confusing statements that you didn't go there. Perhaps you went to Trinity? The easiest way to check these things if you've forgotten is to fish out your degree certificate which names the institution.

https://en.wikipedia.org/wiki/Master_of_Arts_(Oxford,_Cambridge_and_Dublin)

This is for you mumsneedwine.

The wiki page throws up a few small conflicts to the lawyer's eye between your various posts but latitude is a wonderful thing in a liberal world.

You can have a MA for free but certainly not a MSc.

You've frequently said on various threads that you didn't go to Oxbridge so were you being coy or have you just remembered that you did, after all.

I have to admire your flexibility with detail mumsneedwine :)

@JulietteBravissimo @Millaiss
I cannot imagine practising medicine without a grounding in anatomy, physiology, biochemistry, pathology, bacteriology and pharmacology. However, changes in A level science curricula several years ago caused students to be less well prepared for university than they needed to be (there is considerable literature relating to this). Science faculties adapted and took on what had previously been taught at school, and logically medical schools should have done the same, extending their didactic science curricula. Instead many did the opposite, either with more self directed learning or early patient contact. For new universities this was and is a godsend because the necessary non-clinical academics and facilities are expensive, and impossible for them to recruit and build.

Once, it really didn't matter which medical school you went to, now it will pay to be more careful and consider only ones that are part of universities that have well regarded science faculties. The list is much longer than just Oxbridge and a couple of London medical schools. Having said that, I think now all medical schools introduce students to patients too early and most have latched onto problem-based learning.

"Does performance at the intercollegiate Membership of the Royal Colleges of Surgeons (MRCS) examination vary according to UK medical school and course type? A retrospective cohort study." BMJ Open 2022;12:e054616. doi:10.1136/ bmjopen-2021-054616

@Needmoresleep sorry wrong tag 😂