Saturday, 5 December 2009

To work in Ireland, the UK, Australia or New Zealand?..the choice facing thousands of junior doctors

Posted by Dr. Thunder:

As a registrar, who has worked in Ireland, the UK, Australia and New Zealand, I thought it might be useful to share my experiences here, in the hope of helping other doctors decide whether they want to trek halfway across the world in order to ply their trade.

I've included my thoughts on each of the countries below, and what they're like to practice medicine in:

Ireland: Oh Jesus. Juniors are still working shifts up to 48 hours. The European Working Time Directive will be implemented shortly, which will reduce the working week of doctors to 48 hours. In order to maintain a service, while halving the hours of medical staff, the Health Service Executive have decided they will simply ask the overworked juniors to work twice as hard while they're on the job. Simple.

They will also be docking 30 mins per day from the wages of junior doctors for their lunch break. Just ask any junior doc if they get a lunchbreak. Even if they do, they're not allowed leave the hospital, and they still have to carry their pager. It's a total joke.
Another disadvantage of being a junior doctor in Ireland is that the media, and consequently the public, think you're overpaid and lazy.

The standard of medical care in Ireland is also likely to fall, as the universities adopt GAMSAT and PBL with gusto. It used to be very difficult to get a place at medical school in Ireland. Now, about 1 in 3 of those sitting GAMSAT get offered a place. Call it elitist if you like, but when I'm old and have a complex medical condition, I want someone who works hard and is brainy as hell treating me. To stop these GAMSAT graduates doing too much damage, nurse prescribing is also being introduced, which required the nurse to do about 6 weeks training to convert themselves into a doctor. Good times.

Patients also routinely wait several days in the emergency department corridors on trolleys for treatment, as there are not enough beds.

In the "pro" column, my family and oldest friends are in Ireland. So, I'll probably end up returning someday. But I'm doing postgrad qualifications so I can hopefully get a post in a university, or be based in Ireland whilw working for an aid agency.

The UK: Also not a great life for a junior. Here you will find an imaginary 48 hour working week. In fact, they monitor you to make sure you're not working extra hours, by getting you to fill out an "hours diary". Essentially, you are expected to lie on this form, so your employer can ignore the fact that you work an extra 10-20 hours per week for free.

My biggest peeve about working in the UK, was the famous "4 hour waiting time". This is possibly the greatest con in the history of medical politics. Essentially, what happened was the labour party government got tired of people complaining that they had to wait 12 hours in an emergency department to get treated. So, they announced

"From this day fortwith, no man, women, child nor beast shall wait more than 4 hours in an emergency department".

WOW, we all thought. That's going to require a hell of a lot of investment into acute services. Right?....Eh, yea,...sure.
Obviously there was minimal extra invgestment. So, what happens is....the patient turns up to a crowded A+E department, and is seen about 3 hours later. So, they have some blood tests taken, which won't be back until 4 hours are long gone. You'd like to get a specialist down to see the patient in A+E, but they won't be able to make it before their 4 hours is up.

The head nurse hassles the junior A+E doc to get this person home or onto a ward. "But I need to get the bloods to see what's going on". Doesn't matter. They cannot be here longer than 4 hours, or the whore-child of Satan shall rise and engulf the hospital in his flames of jizm.
So, you have to send them home and hope to God their bloods/xrays etc don't show anything untoward. Or that the pain doesn't return when the pain killers wear off after they go home. Or you hassle the admitting doctor on the ward to take them, even though you've no clue what's wrong with them.

So, the patient usually ends up getting admitted at 4 hours. Nothing serious wrong with them. But they now have to stay overnight because they've been "admitted".
Every doc who's worked in acute care in the UK will have had a nurse coming in to see them while they're seeing a genuinely unwell patient to remind them that there's someone much less sick outside who needs to be seen NOW as they're going to "breech" the 4 hour target. It's not the nurses' fault. They get it in the neck if these people wait more than 4 hours. Some units improvise, by removing the wheels from the patient's trolley. So, they're no longer "waiting on a trolley" in A+E, they're admitted in a "bed". It's genuinely soul destroying.

What's also soul destroying is the way jobs are allocated to juniors. I still don't fully understand it either. All I know is some amazing doctors are unemployed because of it, and some real muppets are doing well because they can tick the right boxes in their "self assesment portfolio" or whatever it's called. It seems juniors in the UK are rewarded for being good at paperwork, rather than being good at medicine.
Oh, and everyone in the NHS is now a "consultant" of some sort. Everyone is taking on a doctor's role on the cheap, and healthcare is going down the pan.

Most consultants are not interested in the plight of juniors, so it's a lost cause.

It breaks my heart to write the above, as the principles upon which the NHS is based should make anyone proud to live in a country where free good quality healthcare for all used to be a reality.

New Zealand: Lovely place to live. Lovely place to work. My experience was in a hospital that was off the beaten track. But the consultants would come in and help immediately if you have any dramas. Colleagues were supportive, and standard of living was good. Managers actually spoke to us, and consultants backed you up.
I ended up looking after some pretty sick people who should have been moved somewhere else, but they were too unstable to go the long distance. This is a recurring problem in this part of the world, because of the geography. I saw it as an opportunity to improve my critical care skills, and, as mentioned earlier, consultants were generally very supportive, so I never felt out of my depth

Highly recomment NZ as a working environment.

Australia: Great place to work, by and large. If you stay for any length of time, you'll probably end up working in an understaffed remote hospital with minimal senior support. But working in a city is well worth it. Great hospitals. Reasonable workload. Supportive consultants, by and large. Nice atmosphere too. Generally first name terms with your seniors. Hours are not too onerous, unless you work remotely, when you can end up doing 24 hour on-calls.
I usually got a l;unch break in oz, and when I finished late I got paid for it.
On the downside, their politicians tend to use health as a political pawn, as is the case in most countries. For example, the recent swine flu response was 50% medicall driven, and 50% political, which was disheartening.
But, while Ozzie politicians are the same as any others, I'd still recommend it as a place to work.

Major downside is that the universities recruit a LOT of GAMSAT students. IN my opnion, and it's only an opinion, these students are simply not that good. MANY og my colleagues share this view. But it's a quicker way to train, so it will be a case of standards being sacrificed to save money.

Hope that helps. feel free to add your own opinions in the comments box.

Dr. Thunder.


  1. GAMSAT is a bit different in Australia. First of all different universities have different requirements. It's true a couple let in anyone with a passing score, but the big old ones only take from the top. With 5000 people sitting it every year, the universities taking the top 200 of those isn't too bad.

    Furthermore - 85% of people who sit the GAMSAT have already done a medical science degree! You might want a doctor who was really really good at high school maths and english aged 17, I think I'd prefer one with 7 years of training in one field. I don't know where you get the idea that GAMSAT entry is quicker when everyone has to have a degree first, and most of the time, it's a degree in that field. As interns they might suck at cannulating but they sure do know their shit. And you have to be damn hardworking to stay at university and perform at that level for that long too.


  2. The GAMSAT exam for entering medicine is very similar to the MCAT in the USA - mostly exam + interview + GPA, depending on which university you apply for.

    Just because we have graduate medical entry does not mean that we will produce inferior doctors. Do you also think that the US doctors are inferior because they have MCAT and graduate entry?

    The intelligent students with drive will still apply for medicine and complete the course. As long as the quality of the medical course is strong, you will be getting the same students, or at least a similar calibre, and they will have additional life experience and another degree behind them. This other degree, as pointed out, is usually a medical science degree.

    Saying that they won't be as intelligent or hard-working because they have another degree behind them BEFORE they even enter medicine is just ridiculous and insulting.

    My main problem with medical education in Australia at the moment is the sheer volume of numbers they are pushing through, but you will get that even with undergraduate medicine. It is a political and a practical issue, and the students have do deal with the shortfalls ourselves.

    It would be nice to think that the students have the support of their supervising doctors, rather than getting the feeling that they are being snubbed as inferior because they studied for 11 years at university (in my case, minimum of 7 in others) rather than the 5 years that some undergraduate medical students do before they become doctors.

  3. Having taught undergraduate and graduate students alike in the Australian system, I'd say each group has its fair share of winners and losers. Certainly, across the board, there's no difference between. Then again, I may well be biased, as I am the product of an Australian graduate entry school - and am far from rubbish at my job. ;)

    Interestingly, my experience of working in the Australian public system closely parallels your description of the UK and Irish systems. Bureaucracy gone mad, poor working conditions for doctors in large tertiary centres, bed block, over crowding and the like. I suspect you work in a different state than I, which may account for some of the discrepancies.

  4. I think the problem with GAMSAT is that you can be very clever and get into med school with it. But you can be decidedly average and also get in.
    It's not GAMSAT that makes anyone less competent, but the fact that you can nail it by studying hard for about 3 months.
    Anecdotally, teaching the GAMSAT students in Oz has worried me. I spoke to 2 of my consultants about it recently, and they reckon the problem is that A) entry requirements are not as high as they should be and B) there was very little consultation with practising docs when they designed the course.

    But, locally, the feeling on the ground is that they're not that great (although some obviously are).We had an intern recently who didn't know ANYTHING about the urea cycle, when we were discussing metabolic defects, and he swore they "didn't do it" at med school!
    Like I said in the blog it is, of course, personal opinion. But it's an opinion shared by a lot of other docs.

  5. ...And similarly, in my anecdotal experience, plenty of doctors *don't* share that opinion.

  6. well, then start a blog about YOUR experience!

  7. I'm guessing they don't teach evidence based medicine in didactic courses if you're basing your evidence off hearsay and one intern who didn't know the urea cycle.

    And again, it depends on the university. Some of them have very very high GAMSAT requirements for entry. And anyone who gets into one of those med schools after three months of study for that exam probably has an organic chemistry or medical science degree. I don't think that's a valid argument and I suggest going and having a look at a sample of the science section to see the standard required.

    Furthermore, I don't know a lot about the Australian Medical Council, but I assume they are populated by doctors, and they are the bodies that approve the medical school courses. The fact that nearly all the big sandstones (Melbourne, Sydney, UQ, WA) have converted to graduate medicine should say something. The fact that a handful of doctors can't deal with progress says plenty too.

    For the record, I have an Arts degree. To say I must not be as hardworking as an undergrad is ridiculous - I have had to work twice as hard to keep up in medicine and am as good, if not better, than anyone. There are people coming through grad med with PhDs who will pursue a specialty in that field. Again, I know who I'd prefer as my doctor.

    Please don't tar all graduate medicine participants with the same brush. Please don't let a vocal minority cloud your view. There were crap grads who didn't know the urea cycle before graduate medicine ever existed. One thing we can do in grad med better than anyone else is think for ourselves and not toe the party line just because someone says so.

  8. I suspect the change to Grad Entry in Australia was closely linked to the changeover to PBL-type curricula starting in the mid-90s. If you are going to run a PBL system, then it is a great help to have graduate entrants who

    (i) already know something
    (ii) tend to be better at independent study than 18 yr old school leavers
    (iii) are not going through their inevitable "I'm 18 and away from home at last, wheee, where's the club night with the free alcopops?"

    I teach on a PBL medical course in the UK with a (mixed) undergrad and grad intake, and I would go over to grad-only entry in a heartbeat.

  9. I think the problem of GAMSAT is bigger than isolated examples. Previously, we took the best of the best and we produced very good doctors.

    Now we take people who may or may not be very good. The one thing they have in common is the ability to complete a degree, and to work for 3 or 4 months to nail GAMSAT. Personally, I don't regard either of those to be incredible feats of achievement.

    Would I rather someone who has a PhD than an incredibly bright kid? Probably the incredibly bright kid, as they'll have just as much chance at taking to medicine, and are very likely to have time in their career to do an M.D in something actually relevant.

    I think medicine should be hard to get into. At the moment it's not.

    You can read things into that, that I never said, about arts degrees etc. But the reality is medicine is now not all that difficult to get into. The reason I think medicine should be hard to get into, is because selection should be based on service to the patients, as opposed to making entry to the profession easier.

    making entry to the profession more inclusive from a socio-economic point of view is important. But just making it easier to get into is doing a disservice to patients.

    We can talk about life experience, but our interns are now so closely supervised that they rarely take on any kind of large responsibility that requires "life experience". Same with our residents. Even our emergency department consultants are working until midnight, supervising departments and essentially running the resus areas. Previously a competent SpR could be entrusted with that kind of role.

    We can say what we like about PhDs and previous sciences degrees. But we're not seeing better graduates in my opinion. We can put that down to political agendas, but those of us on the floor who are concerned about standards have no agenda.

    The situation I'm facing is that I bring my residents everywhere. They do not move from my side. My colleagues are the same. I spoke to my consultants about it. They say it's just the way the new grads are, and we just have to keep a close eye on them.

    I'm happy enough with the extra company. But they then get sent to their remote placments, where they get totally abandoned, and the stories they bring back are horrendous.

    All I know is the standard I'm seeing is getting poorer.

    GAMSAT may well fit the PBL model, but the PBL model doesn't fit reality.

    These are the conversations that are had in hospitals all over. Sure, we may be able to say we know docs who think GAMSAT is great. But does that matter? If 60% of docs we know are fans of GAMSAT, that still leaves 40% who think it's not the way to train our docs. That's not borne out of any kid of alterior motive. It's just what we see. I kept this opinion to myself when I came to Oz, until I realised most of my colleagues were saying the same thing.

    Someone made a snotty comment about me and EBM. When the reality is that there is no good evidence that GAMSAT works. There's lots of conflicting small studies. But nothing that really shows GAMSATers are performing well.

    Someone else said it was terrible that the senior doctors are not supporting them. Well, I'm not going to just ignore the fact that our grads are coming out unprepared for life on the wards. It would be wrong to do that.

    But of course the GAMSATers and those who teach them will continue to say I'm wrong. Just like when our jobs were being taken over by nurse practitioners. The NPs came onto all the blog sites and told us we were just scared of them, and arrogant, and that they were fantastic.

    The GAMSAT students I teach don't know they're of a lower quality than students I used to teach.

    But, in my opinion they are. There's not much more I can say.

    I think a broad change in medical education needs to be accomanied by a decent evidence base, if we're going to change a decent system. that hasn't happened. And it's very concerning.

  10. Having been around medical schools a long time, and since before the PBL revolution in the mid 90s in the UK and Aus, a comment on "Why PBL?". The "mastermind" was the General Medical Council in the UK, and I would guess it's equivalent in Aus.

    The main drivers were widely understood to be:

    (i) The view that there was "knowledge overload" in curricula that had to be addressed (i.e. by thinning content);

    (ii) This knowledge overload, associated with traditional "2 yrs basic science + 3 yrs clinical" structure, meant students were heavily disillusioned and disengaged by the start of the clinical yrs of the degree;

    (iii) doctors were widely perceived not to have good enough "soft" (mostly communication) skills, and this was the most frequent source of patient dissatisfaction.

    There was also a fourth, though much less stressed, argument that trad curricula did not inculcate "ability to reason and think independently".

    From the above I would say it is clear that "PBL school students will KNOW LESS MEMORIZED FACTS than students from old-style curricula" was part of the design from the outset. We were told this was accepted, and that the gains in other areas were viewed as an acceptable trade-off.

    Now, I'm not saying I agree with all, or indeed any, of the above, but that is what we (by which I mean the folk like me who taught basic science) were told 15 yrs back.

    An awful lot of people did point out the possible downsides to such a change at the time. Apart from being told it was a fait accompli, as that was what the folk in charge of medical training wanted, we were also told that it had been "trialled", though not in the UK. McMaster in Canada, Maastrict in the Netherlands, and Newcastle in Australia were the places mentioned, and indeed I remember folk from all three places flying in to give seminars on how it all worked.

    The other thing that has gone along with the shift to PBL and to integrated curricula, at least in the UK, is the massive expansion of all the medical schools. This is of course an independent reason why entry to medical school has got easier. The place I teach in has nigh-on DOUBLED its intake since it instituted a PBL curriculum in the 90s.

    My personal opinion is that PBL works well for some students, and in particular for a lot of graduate entrants - but it clearly doesn't work for other students. One of the problems we have, which is an oddity given how much easier it has become to get into med school, is a large group of people who are on our PBL course but really wish they weren't because they would have preferred a trad style lecture-based course.

    In the UK we obviously have alot of medical schools, so currently have a wide range of different curricula and entry policies, from trad lecture 2+3 yrs to full PBL, entry at 18 to grad entry as well as "mixed", some schools using GAMSAT and others school leaving exams etc. We even have schools w. no cadaver dissection for anatomy. So we have "diversity", which the GMC seem to be v. keen on. Of course, we DON'T have a national Univ leaving or professional qualifying exam, which has been the subject of much discussion.

    Dr Aust

    PS My better half, who is a battle-hardened general medic, has always taken rather the same view of PBL-educated students as Dr Thunder..!

  11. I don't think you will actually find a lot of students who love the PBL-style of teaching. It is ridiculous, contrived, and relies far too much on the PBL "facilitator" (they don't call the person employed to lead the group a teacher - the students are supposed to teach themselves) and students to cover the content of the course. When I was in the first years of the course, two PBL groups could be in the same week, yet cover two completely different sets of topics.

    Many students wish for MORE didactic teaching and set requirements than there currently are. Imagine being let loose in the middle of everything medical and only being given loose guidelines about what to learn, and then having the exam be so random that it is almost nonsensical. I did not have ONE major cardiology component come up in ANY of the exams I did in first and second year.

    Unfortunately with this style of teaching, you will get students who are still focused on just "getting through exams" and are too worried about the present to take time to learn things that will be important to them later in their careers. Things like anatomy and the finer points of pharmacology (or the urea cycle). Not everybody is like this, but some are. Actually, quite a lot are.

    I'm afraid that letting a massive number of students into the course will result in a higher number of people who don't score that well getting in. You can't take the best of the best when you have so many thousands getting in each year, in what is quite a small country.

    The best of the best will still be there in the course with the rest, trying to work out what the hell it is that we all have to learn in order to be competent doctors and jumping through the hoops and ticking the boxes.

    If they are the best of the best, then they should excel at their time as junior doctors and get into the specialties that require brighter people who have a real passion for their work. With numbers like they are, competition will be fierce.

    A lot of the students hear that their course is inferior all of the time from the older doctors. It really grinds and gets quite frustrating, especially when the older doctor offers no assistance and no solutions. They just stand back and complain that things aren't as they used to be. We have to deal with the course that we are in, spend a lot of time hearing doctors gripe about the course we are in, then we come on-line and read that we are also inferior. Angry responses are probably the standard knee-jerk reaction.

    So, Dr Thunder, how would YOU change it so that the courses only accept the best of the best? GAMSAT may be a strange way to get in, but it is still competition-based.

    In my humble opinion, we need to change the course a LOT. (I'm not just talking about making it easier to administrate because they now have a gazillion students in the one year. "There are too many of you to do X competently" is not a valid excuse when YOU are the university who decided to expand numbers that much and are STILL expanding.) If we are going to accept so many people, we need to make sure that they are at least taught properly. We are certainly being taught differently to previous doctors.

    I'm afraid that you, Dr Thunder, and all of your colleagues, are the ones who get the joy of helping the students make up the gaps in their training as you see it. Good luck.

  12. To address the points made by dr Aus, I would agree that the reasons you listed above are some of the reasons why med education was changed. Having said that, the GMC in the UK are utterly out of touch with the views of most doctors, or at least most doctors seem to have a low opinion of the GMC.

    Saying things like "doctors don't have good commuinication skills" (as the GMC did) and assuming that there's something inherent in the personalities of med students that makes them poor communicators was, frankly, retarded.

    In my experience, the spectrum of personality within the medical world is the same as society in general...some are tools, some are angels, most lie somewhere in the middle. But People remember a rude doctor more than they remember a rude shop assistant.

    The GMC never considered that rude doctors were tired doctors. I know that once I hit exhaustion levels, I'm much less civil than when I'm fresh. Ask my family what I'm like after a week of nights. The new grads are certainly no less grumpy when they're under presssure.

    I think the medical hierarchy did the students a disservice by somehow implying that there is something wrong with med students. They're mostly kids. Or WERE mostly kids. To judge them at the age of 18 is pretty harsh.

    BUt whatever the reasons for introducing PBL, it's not fit for purpose. Though we must distinguish PBL from GAMSAT.

    Our consultants at med school used to call PBL "fuck off and find out yourself" medicine.

    I think our students deserve better.

    To answer The Girl's question about what i think should happen....I think school leavers should be judged as they are, based on their exams. I think graduates should be judged on their results. Double first in a good quality science subject. As things stand, we have the ridiculous situation (in the UK anyway) where someone who gets a 2:2 in dentistry or veterinary can't even sit GAMSAT, whereas someone with a 2:1 in photography can.

    This needs fixing.

    But from my position of no-power, I can only teach. When I do my week of nights, the students know to meet me after handoever. I stay back for an hour every single morning and teach, either by tutorial, or by bringing them to see patients. I mostly teach by tutorial if they're GAMSAT/PBL students, as their shortcomings are in the factual stuff.

    I do much more teaching than almost anyone at my hospital, and stay back maybe 2 or 3 nights a week teaching students. I want to work in medical education eventually and love teaching.
    But the students are starting out at a significant disadvantage.

    They're not getting much in the way of didactic teaching at the universities, so I try my best to plug that particular gap while they're on rotation.

    That's the only useful thing I can do.

  13. Agree with a lot of Dr T's comments about communication. It is asking an awful lot to expect 18 yr olds to have loads of empathy and insight into the human condition, as it just isn't what being 18 is about. One of the things that you do see being in medical education in the same place over a period is how much people change through their University years. The students you teach in yr 1 have grown up an amazing amount even by undergrad yr 3 or 4, let alone when you meet them after a couple of years in the workplace.

    Re. course content and design, one doesn't have that much power even running bits of medical courses (even quite large bits like semesters) - the curriculum style was decided well above (and before) me. As the bloke handling one chunk of a curriculum I do what I can, as did my predecessors. So e.g. I try and ensure that the lectures (really - several a week, even in a PBL system) are on useful topics (e.g. things students find difficult to grasp, or need to know about but often miss). I also try and make sure I ask people to give them who will do a good job. We also run DR anatomy (largely unchanged from the old days) and physiology/ pharmacology lab classes (also very similar to in pre-PBL days) on relevant things that we hope integrate with/ reinforce the PBL/lecture bits of the curriculum. So our PBL set-up actually includes didactic content within the constraints we are given. I doubt we are that atypical.

    I would also try to make sure the PBL "facilitators" (or whatever word we are using this year) have a good crib book, which explains the cases and lays out as best we can the background basic science and the basic science / clinical connections. And the facilitators are told to "push" these to students in whatever way seems appropriate if students are missing the point, or are not getting deep enough into things.

    Of course, an Achilles heel of PBL systems, essentially unavoidable unless you tell the PBL tutors to say nothing at all, is that all tutors are not equal. But then, neither were all lecturers in the old set-up. And neither were, and are, all the clinicians students encounter on the wards, see Dr T's comments.

    BTW, Dr Thunder may be interested in this view from the UK, written a few years back by a medic, which echoes some of his views (sorry - big PDF).

    PS Not sure how many places in the UK are using GAMSAT, and whether the ones that do use it alone as an entry determinant - I suspect not, actually. At present a lot of graduate medical entry in the UK is still to "general entry" (i.e. not specialist grad entry) courses, with the requirement being a 2i, usually in a science subject, plus some relevant work experience and also requiring an interview.

  14. I agree with most of the comments on here and for the most part I don't like PBL either.

    There is also no evidence that undegraduate high performing school leavers do any better than graduate entrants either.

    What there IS beginning to be evidence for, is that a high GPA in the prior degree leads to better outcomes post-graduation. As such, medical schools in Australia at least, are beginning to use prior GPA as a selection tool, which is something I agree with.

    And yes, medical school is now easier to get into across the board because the places have at least doubled. Even the high school leaving mark has dropped here. Med school SHOULD be hard to get into, I agree. I studied for a year for the GAMSAT and worked my guts out to get in.

    While there *are* people who can study for the GAMSAT for three months, like I said, they often have a pretty high powered medical science degree, for which GAMSAT is just revision. High school kids study for one year for their exams, most university graduates have essentially studied three years for the GAMSAT.

    I agree though, that some medical schools have entrance requirements (i.e. min GAMSAT score) that are too low - the problem isn't the gamsat, it's the entrance requirement. This worries me also.

    And I still say you can't tar all grads with the same brush. My comment about EBM wasn't intended to be snotty. There are spectacularly good graduates coming out of grad medicine who I think are completely underappreciated at the expense of the few bad eggs.

  15. Perhaps the wider question for undergrad medical education (leaving aside the grad vs undergrad and the level-of-achievement to be admitted issues) is the perennial one of resourcing. We all agree the UK system has doubled medical student numbers compared to c. 15 yrs ago. (I'm curious what equivalent figures are elsewhere, though it sounds similar from some of the comments).

    Fairly evidently, there has not been a doubling of resources to pay teachers/lecturers, "buy" clinical staff time for teaching, build bigger lecture theatres and labs etc. At my Univ we have the same size lecture theatres and labs now as when we had half the number of students, though we manage by running shifts in the labs and podcasting lectures. We also have less academic staff with what I would call "broad expertise and experience" in medical-related basic sciences, who are probably the folk you most want as early yrs PBL tutors. The virtual disappearance of pre-clinical academic staff able to teach anatomy is a particularly well-recognised trend.

    Add to this the push for Univ staff (both clinical and non-clinical) to maximize research income, and what you have, by any definition, is a system under strain. There is a certain academic analogy to Dr T's one about "communication fails as fatigue increases", which is that the undergrad student experience tends to decline as staff have less time for students. Students also often feel "adrift" in large courses. It is quite striking in the recent UK Univ student rankings that smaller medical courses tended to score better than bigger ones.

  16. I'm considering a year abroad at some point in my registrar training and this post gives a very useful perspective.

    Thanks Dr T

  17. I have to say that I agree in part with you. I can only relate this to my own personal experience, so feel free to dismiss it.

    I missed out on doing medicine by about 15 points in my leaving cert. I became a physio instead and after several years, went back and did medicine with a bunch of 18 year old school leavers. Am I a better doctor than the rest of the "kids" I qualified with? Yes, because my primary degree was medical/paramedical science based.

    I'm now an SHO who has worked in Ireland and Australia. I find that the grads who's primary degree was science based know their stuff a lot more than the grads who did arts degrees etc in college. I also find that the majority of grads have more cop on than some of the high points achievers. Students who don't know their stuff are generally the ones who spent their college days in the pub and I don't really feel it has anything to do with having done well in your leaving cert or having sat the GAMSAT.

    Then again I would be biased towards the grad students, wouldn't I? As you may be towards the school leavers, Dr. Thunder.

  18. I'm actually a grad student.

    I think physios and pharmacists make great doctors. But i think we need physios and pharmacists in their own right. Locally, we've lost 2 of our hospital pharmacists to GAMSAT this year.
    We're seeing more student who just missed medicine and end up doing one of the paramedical courses, in order to get medicine. We're losing nurses and radiographers etc.

    There are some excellent GAMSAT grads. But my point has always been that you HAVE to be very good to get in through GAMSAT.

    Would you have been better off starting med school 4 years earlier, rather than doing physio? You'd have been better off starting med school. The brilliant youngsters who have to go and do another degree before they can start med school would, in my opinion, be just as well getting on with it and starting med school.

    We don't tell people to go away and get some life experience before starting nursing or physio, so why medicine?

    It's about places. It's not about quality, in my opinion.

  19. But don't these (graduate entry) routes offer a way in for people who, for whatever reason, didn't quite get the grades at school leaving? Or just didn't interview brilliantly? {I'm thinking here mostly about people who do Biomed Sci degrees, rather than "defecting" physios/pharmacists, which is not a phenomenon I've noticed in the UK).

    We get quite a few students in our biomedical BSc science programmes who had the raw grades at school leaving for med school but didn't make it past the app form/interview process... but this process, apart from being inevitably pretty subjective, has had a lot of probs in the UK, e.g. would-be students cribbing/buying the "personal statement"!

    Anyway, we tend to view mixed entry (undergrad and grad) as giving people a useful second chance (post-degree) to "re-compete"... given that it is some sort of combination of ability and commitment that you are looking for for medicine.

    Generally I would agree with the earlier commenter who said you see a range of students ability-wise with both u/grad and grad entrants. Over the years, medical students that I've found myself looking at and think "I reckon you're in the wrong degree, mate" have been mostly u/grad entrants... but since the ratio of u/grad to grad entrants in our school runs about 9:1, that is probably just the much bigger sample size.

    Anyway, I'll shut up now as I think I've hi-jacked the thread enough..

  20. I'm not against grad entry per se. I'm just of the opinion that GAMSAT doesn't really give us the cream of the crop. Medicine should be about getting the best we can. There's an admin guy in my job who has a science degree and is bored. He says in 4 months he can anil GAMSAT and he's probably right. BY scoring just above the average, you can get a place. In Ireland, 1 in 3 get in.
    I think we shoudl be looking at people's performance in scientific undergrad degrees, and making the cutoff much higher.

    I think we shoudl be expanding the places to bring in more of the high achieving kids who miss medicine by a few points, and keep the grad places for the very best grads.
    If you cock up in school, the fair enough, get a second chance. BUt you shoudl have to work damn hard for that second chance.
    The UK still has only a reasonably small pool of grads at med school and they do well.
    But IN Oz, there's lots of grads. And, there's lots of them from pharmacy,physio etc.

    I feel GAM SAT has been tailored to give people a second chance, rather than getting the best doctors.

  21. Do you mind me asking what your primary degree was Dr. Thunder?

    Having read your response, I actually agree with you a lot more than I thought I did. I also think that the points system should be made more flexible to allow those who missed out on medicine by a few points but who are intelligent, hardworking people a chance.

    I didn't gain entry through the GAMSAT. But having met and helped educate some GAMSAT-ers while I was in Australia, I found that those who just weren't up to scratch were generally dropouts by the second year of the programme. Rather than a sizeable portion of school leavers in my year who finished their internship and swore never to work in healthcare again.

    In short, I think that the general concept of the GAMSAT is good, but does need some tweeking. Those who have primary degrees in paramedical disciplines have a lot to offer medicine (and not just this "life experience" bullshit. However, I'm not too sure what exactly an arts student would have to offer...

  22. I did a Biomedical Sciences degree. I agree with you,Pixie, about grads of certain disciplines having a lot to offer.
    I disagree about high dropout rates. I'm not sure about Oz, but the official RCSI rep on said, on the health sciences forum, that they have a virtually zero fail rate for GEM students. That makes me suspicious. Though I htink we all know the GEM students in Ireland and Oz seem to be learning less material.

    I don't think the problem is graduate students. I think, though, that having a 2:1 in a photography degree and the ability to study GAMSAT for 3 months, doesn't trump the youngester who has spent their teenage years studying hard (and these are the most difficult years to give up)and missed out on medicine by getting 5 As and a B, rather than 6As.

    When I was applying as a grad, we had to submit all our academic records from our degree, and I had to get a double 1st, as well as a ball buster interview. There were 150 applicants and 10 of us were accepted.

    While I was advantaged by having some prior science knowledge, I never had the academic sharpness of those youngesters who nail straight As in their school leaving exams.

    In Ireland, we had people with almost maximum points in ther school leaving exams who didn't get a place, while someone with a 2:1 in an average degree from an average uni/college could get a place.

    So, my problem is with the standard required by GAMSAT,and the skimmed medical curriculum in a lot of places, rather than grad entrants themselves.

    Though, if pushed, I would expand places for school leavers, before I would expand grad places.

  23. So what college/country do you think would be a good place to do grad medicine? Britain? I'm interested to know because my younger sister (who is working as a nurse), wants to study medicine and doesn't fancy doing the traditional degree like I did (and as I presume you did). She wants to do it in UCD, but as their grad entry programme is in its infancy I'm quite wary of it.

  24. I guess people have to make up their own mind where to go. But, in general, I recommend following the pathology. London, Glasgow, Edinburgh, where the health of the population is poor in many parts. And Oxford/Cambridge get lots of people with odd diseases sent to them for treatment, so it's a good learning opportunity to see nice signs.
    In Ireland, my experience is that Trinity is producing the best grads. But that's just my opinion.

  25. This is some crock! I got enough LC points for medicine (590) but did an arts degree. Got a very high GAMSAT and am heading to RCSI in September.
    And I'm therefore going to be a shit doctor just because I didn't want to do medicine at 18.
    Laughable. And sour grapes for nerdy little 18 year olds like yourselves who work their asses off for medicine and then see a 'back door' open up for other people. Get off your amazing LC high horse - I did years ago. If you're in the same frame of mind you were in at 18, I feel quite sorry for you.
    Try sitting the GAMSAT, Dr Thunder & Co. and see what you get....
    Also UL is the only full PBL- style Grad Med course in Ireland and 2 people failed RCSI Grad Med last year so your attacks on PBL can't really be used to tar the other schools.

  26. Annymous, I have never had a problem with students like you (personality aside). You sat the LC with your peers,a nd you came out in the top 1% or so.

    My problem with grad entry is nothing to do with you being a grad. You would be mre useful t the world of medicine had you started medicine at 18, but that's another issue.

    My problem with gradmed is that it's now relatively easy to get in, and our future docs don't have to be particularly academic or hard working. that's not to say all gradmed entrants are not very good. It's just that you don't HAVE to be.

    Again, despite the fact that you would never have the balls to call me "a nerdy 18 year old" to my face, I'd reiterate the fact that I was a graduate entrant.

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  30. I did really enjoy this post but try not to be too harsh on GEMs, not all are great but then again, neither are all Undergrads. If you form the opinion that most of them are not up to par, you may do some a disservice/ignore genuinely good meds. (For example, top of my class all years in my original Neuroscience degree [1st class honours all 4 years]). I know you're not saying they're all stupid or anything like that but I'm willing to wager that I'm better than a lot of UGs.