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Not all good doctors are natural researchers

By Mindo - 20th Mar 2020

A thoughtful postgraduate training system would recognise the diversity in our talents and not just focus on research

A school teacher of mine, who was consistently interesting if not always sweet, made much of his fondness for excellence. It was, he reminded us, when standards ever so slightly dipped — not an act, but a habit: We are what we repeatedly do. He casts a long shadow and I agree with him today, even if I struggle to live up to the standard.

And excellence, not mere okay-ness or quite-good-ness, but electric brilliance, is something that has always swept me off my feet in medicine.  The shining lights of my student and NCHD years seemed to have medicine running through not just their brain, but their blood. One mercurial consultant was a tour guide through the highlights of medicine on every post-take ward round, sliding between the origins of The Pickwickian syndrome and Waldenström macroglobulinaemia and calculating a patient’s APACHE score while introducing himself.

In my own field, oncology, the best are master negotiators who can listen to what the patient wants, judge what is realistically achievable, and find the right pace to carry everyone to a common ground. And for some, excellence is neither in the clinic or on the wards, but in the lab or the lecture theatre. Regardless, what is clear is that when you allow people to play to their strengths and brilliance to blossom, the payoff for that person, their colleagues and their patients is huge.

And it is this truth which underlies why the current system for postgraduate training in Ireland is so distinctly unsatisfying. In decades past, due to a scarcity of consultant jobs and a well of eager applicants for each post, there was a need for objective measures to compare well-qualified trainees. Research output was an obvious pick and thus oral presentations and first-author publications became the currency of choice for Irish graduates.

This carried some obvious benefits. Irish trainees moved to centres of excellence with glittering research records and brought their skills back with them. Many who remained abroad reached positions of influence and have been ambassadors for our country. But there are glaring problems with our method too.

The students of a graduating medical class represent a fizzing hodge-podge of personalities, strengths, and attitudes. All of us, looking back, can see that some were best at bedside, some with tools in hand, some at the bench, and some simply when opening their mouths. And yet, for those who wish to succeed in hospital medicine, all must instinctively cast themselves as ‘researcher’. Few Irish consultants will have laboratory or clinical research as the majority, or even significant minority, of their workload. And yet virtually all consultants will need to present ample evidence of research they have published to get a job, in particular for posts in prestigious hospitals.

By contrast, those who demonstrate brilliance in clinical care, teaching or leadership, making a huge difference to others’ lives, may have precious little to show for it at their consultant interviews. Many will neglect these talents, which consequently wither. It is plainly not a sensible use of human time for hundreds of trainees to carry out research in which they have little interest (and which is frequently of little value) as a requirement to get clinical jobs where it is not a useful asset.

This is not to knock the value of research. Rather, Irish medicine will thrive when those doctors who are intrepid researchers are recognised and given the focused support to reach their full potential. And all trainees should have some experience of it as part of a rounded education. But most will not be career researchers and we should stop moulding our metrics of success around this fiction.

A thoughtful training system would recognise the diversity in our talents and how we could gain by harnessing them. A flexible system would allow trainees the freedom to set themselves ambitious goals within the framework of a training scheme. And a system that prized excellence would have clear measures of excellence in every sphere, with rewards coming to those who achieved it, whatever their strength. Thoughtfulness and flexibility have historically been in short supply in Irish medical training: I wonder if we allow them in, would excellence shortly follow?

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