Medical education versus training, redux.

Stephen Downes has — as usual— an insightful slant on things. He is commenting in relation to an article here. He writes:

Someone asked me this week whether I thought the skills mismatch really exists. The idea of the skills mismatch is that despite persistent unemployment, there are high-skilled or specialized jobs that go unfilled in large numbers because people with the skills aren’t available. My response was that the existence of hundreds of colleges and universities is de facto evidence of a skills mismatch. So when a publication like the Globe and Mail calls the skills mismatch a fairytale, it is referring to one specific statistic in one particular industry, which may or may not be misleading. But in fact, there have always been skills mismatches, and while we can’t predict precise job markets, we can do our best – government, industry and education – to prepare people to adapt and grow into the new needed skills. “What you can try and do is ensure that you are as resilient as you can be and that you have the broad set of flexible skills that allow you to take advantage of an opportunity when it comes along.”

 

One definition of education (as compared with training ..perhaps) is of course is it is that which provides resilience in the face of change. Better still we might consider using Nassem Taleb’s term, anti-fragility. Humans are not fitted to one ecological niche, rather evolution has selected us for the ability to fit into many niches. We can also not just respond to the environment, but becomes masters of it (and therein lies on occasions hubris). This is one framework in which to view education. Those who believe in medial education as well as medical training, will warm to this approach. The difficulty is defining what aspects of education really do facilitate the ability to adapt. The usual mantras of ‘teaching lifelong learning skills’ I am deeply sceptical of. You can cultivate those attributes, you can signal you value them, but you can’t expect to ‘tick-box’ them.

Specialist practice is to some degree about different things. There is often an element of being a terminally differentiated cell, rather than a pluripotent one. The great dermatologist is (sadly) akin to the stratum corneum squame that will end up on your carpet.  So, in what I have read of the Shape of Training material (and I have not read it repeatedly because it my tastes in fiction are limited) there seems to be a belief that after about of 4-6 years of training you are a standardised specialist widget, and that somehow you can then flitter between specialist practice and gatekeeper medicine. This is nonsense, and flies against all we know about expertise. (In any case, post-crash, who really warms to the idea of an economist understanding human expertise or behaviour; or being able to lecture on domain expertise). It does of course allow people to pretend that increases in consultant numbers mean that the level of expertise has increased; and that continuous exposure is not a determinant of competence. I do not think these statements are true. In the past there were lots of highly skilled senior registrars available near 24 hours a day, many of whom had lots of experience and a type of day-to-day clinical immersion that many modern consultants do not possess. Completing the rite of passage of specialist training just means you can practice without continuous supervision— not practice independently (or at least, you shouldn’t be allowed to practice independently).

The data is not beyond challenge, but what data there is and common sense, tells you that in many areas of medicine, clinical skills go on rising for 20 years or so beyond obtaining a CCST. John Burton, in his textbook for undergraduate dermatology, pointed out many years ago, that in dermatology at least, the older consultant is more likely to be right that any well read registrar. He was right: I thought this when I was young, and I still agree with it now that I am….old. And I would think the same of my colleagues in dermatopathology, psychiatry and surgery, and any branch of medicine heavily dependent on a knowledge of patients and cases. Experience is not all that matters— but it is profoundly relevant: medicine is not a formalised system, waiting for the next Richard Feynman to point out we got it all wrong.

One problem is how you incentivise this long and slow acquisition of expertise, after being certified as a widget. How can you get people to acquire those diagnostic skills for rare rashes, when all the money-men earn the quick bucks doing botox, or keep the managers happy by seeing more patients per unit of time? If you want expertise based on long term study, and in the words of a NEJM editorial, ‘thoroughness’, you have to signal it (so all know of it), reward it somehow, and pass it on to the next generation. The NHS and its army of HR commissars neither recognise the question, nor want to know the answer.