We received a letter from a medical student describing how promotion in medicine does not seem to be according to merit but according to a kind of nepotism. We asked two doctors at different stages in their careers for their comments.
It's not what you know but who you know
EDITOR, I am currently at the bottom of the medical hierarchy here at Southampton and have been moved to write because of the depressing number of times I have been told it's not what but who you know that counts. Anecdotes and uncheckable "facts" seem designed to water down the earnest and conscientious among our number, sending the overtly ambitious on to the rugby field or into the yacht club to network like advertising executives.I try to take a balanced view: that medicine is largely meritocratic is plainly true given the frequency of exams and appraisals in medical careers. There is tremendous scope in medicine, and any effort given seems to be handsomely rewarded.
But what about opportunity?
The playing fields of any career are rarely level, but how does medicine compare? How valid are these stories about the "daddies' boys and girls," the rugby club committees, and the career enhancing potential of being a deckhand on a consultant's 60 foot yacht? Should "order of the brown nose" be on show in the display cases of most or a few consultants and other eminent doctors?
I'd like some open debate on the matter, which will at least blow away most of the stories doing the rounds.
JOHN O'DONNELL
First year clinical student
Southampton Medical School, Southampton
Fundamentally there is no such thing as a level playing field. Every privilege has its price and in medicine the powerful make the novice pay more than his or her tuition fees. By signing up for medical school you have already compromised your freedom to behave in an autonomous way, having accepted that your peers have the right to judge whether you should have rights to practise and also whether to remove those rights once gained. It would be comforting to suppose that this happens on a rational basis, and it does . . . partly.
A meritocracy presumably relies on some objective method of assessment of human merit, which, once applied, can be used to apportion power. While educationalists can (and do) spend entire careers debating the validity of various forms of assessment, such assessments can only hope to measure compe tence, knowledge, and skills at the time of the assessment.
This is much more difficult to measure, as it relies not only on having the qualities that define competence but also on the motivation to apply them in the best interests of patients, year after year. Furthermore, knowledge and skills atrophy unless continually revised and updated, so an import ant element of performance is a willingness to participate in continuing education over the course of a career.
As objective measurements of performance are conspicuous by their absence, those who are responsible for selecting and nurturing new generations of doctors must make judgements on subjective grounds. In Britain there are many examples of honourable attempts to make this process as rational as possible.
The General Medical Council, which is responsible for undergraduate medical education and for registering doctors, has published criteria that define the qualities than an independent practitioner must possess, and the royal colleges, which are responsible for defining and maintaining professional standards in the specialties, produce detailed documentation on requirements for independent specialist practice.
But their implementation requires expert judgement to compare the qualities of the aspirant with those outlined in the documents. In any case, however hard the consultants and general practitioners responsible for training try to implement these judgements fairly, it is inevitable that there will be some imprecision and slippage.
In medicine, Eglin's law provides a plausible explanation for the endemic sexism and racism that obstructs the career progression of women and people from ethnic minority groups, and the peculiar psycho logical homogeneity of many specialties, which seems to be directly proportional to the competition for entry to that specialty. What of systems that take an opposite view? The Californian psychotherapist Carl Rogers deliberately refused to award diplomas to those he had trained. He wanted them to continually earn their privileges as therapists by demonstrating their usefulness each time to the clients they served, rather than relying on the status of the diploma on the wall.
Applying such a policy to the medical profession would demolish it, but we should not ignore the insights of the approach. Although legislation has enabled patients to have a simple way of distinguishing trained doctors from quacks, it cannot ensure that doctors seeing particular patients are up to date, communicate well, and have empathy, all of which are characteristics that patients rate highly. Ironically, evidence suggests that medical school removes the last two qualities from medical students and does little to inculcate the adult learning skills necessary to remain up to date.
If the price of a job is a weekend admiring the coast from the deck of a large yacht, or (in the worst example that I know of personally) joining the same church as the professor of surgery, then this may be a price worth paying. This will change you, but compromise is a necessary part of peaceful coexistence in a complex society.
If you feel that you cannot square such compromises with your conscience, then don't do it, and find a consultant who is more in tune with your personal philosophy. Being true to your principles, and open about them, should earn respect: if it does not, then you are almost certainly applying to work for the wrong person.
Appointing staff is the most uncomfortable part of my job. I always join an appointment committee with unease in case I contribute to a wrong decision. We have a duty to do right by the candidates, but our main responsibility is to the patients on whom the lucky winner will be unleashed. Almost as important is our duty to the staff with whom he or she will work.
The size of our burden depends on the seniority of the post. If we appoint a bad house officer the patients and staff will suffer for only six months. If we make a mistake appointing a registrar the pain will continue for two or three years. Appointing the wrong con sultant will bring misery to generations yet unborn.
How do I know if we have appointed a bad house officer?
I may receive comments from patients or general practitioners, or that ominous request from the ward sister: "May I have a word in private, please, Professor?" Sometimes I form my own opinion. I dictate my own discharge letters - a nocturnal penance but a good way of checking on the team. In works of hospital fiction, ever popular on television, one disaster can blow apart a young doctor's future. (In tonight's episode of "Paralytic Ileus," loveable Dr Richard Cranium sneezes into arch-consultant Mr Cardboard's coffee and becomes a ship's doctor into Sulawesi.) In real life this is rare .
Most of us have made one or two horrible mistakes early in life and our career survived even if the patient did not. What counts is the overall impression the doctor makes on a whole range of people - patients, con sultants, secretaries, house officers, nurses, porters, registrars - who watch us all the time. If several of them independently tell me that a particular doctor is kind, conscientious, and calm I would be foolish to ignore their opinions. They sometimes say the opposite, which may make me rethink my opinion of a sycophant who has buttered me up while being nasty to everyone else.
Students often fail to realise that this assessment process begins before graduation. Clinical attachments during the final undergraduate years give consultants a chance to form impressions of how students will perform as junior doctors. Student and consultant can also decide whether or not they like each other, and a social invitation may be part of this courtship behaviour.
Some consultants do prefer to be guided by exam performance, and in some countries this is how house jobs are allocated. In Britain, however, there is healthy scepticism, not only about whether swots make good doctors but also about whether a professorial house job is a blessing or a curse.
I can see the attraction of some kind of points system for giving the most academic students the pick of the house jobs, but I don't like the idea. It would en courage a belief, already too deeply ingrained in our profession, that in a doctor the brain counts for everything and the heart for nothing. In the armed forces and in business, selection boards look for qualities beyond a flair for multiple choice questions. Medical schools, however, make no attempt to assess their students' charm, initiative, character, resilience, compassion, humour, creativity, or even literacy.
For the time being, then, I think I should rely on subjective assessment. Having formed my impression of the quality of a student or a young doctor, what use should I make of the knowledge? Should I try to help the good ones get on in their careers? Should I try to protect other hospitals from the lazy or incompetent?
Consultants rarely lock horns over the rival merits of undergraduates, but most will try to help a good student - by giving advice, for example, or by men tioning him or her to other consultants. It would be hard to stop this networking without installing bug ging devices in all the car parks and in all the theatre changing rooms in the country.
Enthusiasts for level playing fields in medicine are on dangerous ground because they are thinking less of patients' interests than of students' and doctors' interests. Job applicants' rights are already protected by law, and in my experience interview committees are sensitive about fairness, particularly in matters such as equality of opportunity for women and people from ethnic minority groups. Shy people, by contrast, are not shielded by legislation, but for every consultant who likes hearty sports persons there is at least one who likes aesthetes. What we all like, however, are students who get on well with people rather than those who sit in their rooms brooding over imagined injustices.
Their resentment is eased if the winners of life's glittering prizes are the most worthy in the eyes of the class - medal winners (of course) or students popular with their peers. If a job goes to someone perceived as a creep the class is outraged. In the real world, your fate usually depends on people a little higher up the hierarchy than you are. It is only prudent to get along with them. It is also foolish to antagonise your peers, if only because one day they may be on your appointment committee.
As a student you cannot tell which consultants have the most influence with their colleagues. Owning a large yacht, for example, would automatically disbar a consultant from being taken seriously by me or any other professor. Give us credit for a little perceptiveness.