|Crystal ball gazing|
|Monday, 11 March 2013|
When the Editor asked if I would opine on the future of the profession for this issue of Surgeons’ News, I was reminded of the capricious nature of futurology. William Thomson, Lord Kelvin, one of the most prominent Scots scientists of all time, discoverer of absolute zero and inventor of the eponymous scale, famously manifested ‘foot-in-mouth syndrome’ on several occasions, with his uncannily inaccurate predictions – “X-rays will prove to be a hoax", "Radio has no future", and the clincher, "Heavier than air flying machines are impossible."
Edinburgh residents may blame the accuracy on his Glasgow base, Glaswegians on his Northern Irish background… but when presidents of the Royal Society get it so wrong, perhaps you’ll excuse me if my views are off the mark if anyone reads this in 15 years’ time.
The only sure thing about medicine (and surgery) is that everything changes, all the time. When I graduated in 1980, the most common major operation I consented as a JHO was for vagotomy and pyloroplasty. I seem to remember careers being made from the invention of more and more ‘elegant’ operations for peptic ulcers. Barry Marshall and his research put paid to that – and perhaps that’s the real lesson to be learned; that innovation has a price and plasticity of function in medical careers is important. Other recent advances include stenting for coronary arteries and coiling for cerebral aneurysms, both of which have had downstream effects on surgical practise.
The real challenges of the next 20 years have still to be worked out. Technology is already changing the shape of what the profession does and will do, but economics may be even more important in what doctors do in the future. As a geriatrician, you might expect me to remind you of the demographic timebomb, already slowly exploding in Western societies, whereby the tax burden for state healthcare provision falls on fewer within working age. Feminisation, consumerism, generational attitudes and expectations, professional status and pay are all crucial aspects of how the profession evolves. How are we to adapt in order to cope with this?
Faced with a working life of around 40-50 years (surely it will become so?), the ability to train so that a genuine portfolio career is possible seems to me to be the nub of the matter. Each of us within medicine must have and maintain a degree of pluripotentiality that extends through our careers. Many of you will know that there is a review of the shape of medical training underway, under the chairmanship of Professor David Greenaway (see www.shapeoftraining.co.uk). Many of the themes above are being tested with various constituencies in order to try to plan for the next 20-30 years of medicine in the UK. Common issues arising from the first discussions include working hours, flexibility of training programmes, generalism vs. specialism, length of training, consultant-based care, and meeting the needs of the community.
My own view is that any enduring changes will have to be accompanied by a paradigm shift in culture within the profession. To tackle training structures without looking seriously at status, reward structure and job planning during what will be an extended career would be very short sighted – having observed vascular surgeons still participating on on-call rotas at 60+ years convinced me that genuine review of activity within any department needs to take place in the context of many factors, including physical and cognitive function. It is not enough to continue to negotiate job plans on an individual basis, but to match the abilities of post-holders to strengths and weaknesses according to the departmental skill-mix.
It is clear that many technical tasks can be performed by technically trained staff, often to the same standard as by medics. Where our strength as doctors lies is in the realm of the indeterminate, where judgements are made by careful translation of scientific evidence into the patient who faces us across the bed/desk. ‘Carrying the can’ for decision making is one of the most important skills to master during any medical training, as is balancing that with the genuine multidisciplinary team approach that is essential for modern (and future) healthcare delivery. I don’t see any immediate end to that aspect of professional life for doctors, and would encourage doctors to continue to occupy that difficult territory.
After many years observing different units in many specialties in the context of medical training quality management, it is clear to me that the most successful are those which take both the technical and non-technical skills of their staff and give them the same value, both in prestige and monetary reward. A difficult balancing act, you may think, but I have seen it work. What is valued in an individual at age 30 may not be as relevant to them or others at age 55, and the high achieving units all seem to have a similar theme, which is to be supportive to each other and value each other as individuals. I realise that this is somewhat anecdotal evidence, but a broad spread of personality types seems to be a common factor too, though common goals and shared values also seem important for success.
How do we achieve this Nirvana of career progression? Perhaps taking our lead from Sir Dave Brailsford’s ‘Theory of marginal gains’ is the way forward. Having a clear view of where improvements need to be made is a starting point. Then testing the marginal gains in any changes, followed by re-evaluation is the way forward. Using quality improvement methodology might be one way to do this.
Perhaps we need to move away from the concept of end-points in training or careers, and start to embrace the concept of life-long learning in its real sense – that mentoring is not just for the newly appointed consultant or trainee, but that we all could conceivably benefit from regular review and reflection, over and above annual appraisal and revalidation, in order to have a grasp of career planning. I think we will see a much more fluid career structure, with periods of training and service throughout the whole of our careers. Sir John Temple’s statement that medical training is patient safety for the next 30 years may need revision to one that says continual professional development leads to patient safety and a stimulating medical career.
Professor Bill Reid,
Postgraduate Dean for South-East Scotland