Medicine and Politics

My politics influence the sort of doctor that I am. I do not believe that you can separate politics from medicine. In this area I will post items which are current -either being discussed in the news or based on my own observations.

Some pithy advice to graduating medical students

Three years ago I stood in front of an audience similar to this and my message was one of optimism. We had never had it so good. The University had completed a major capital building programme, our merger had been hugely successful and our graduates were entering a world where their skills were highly sought after.

Yet in the space of a few years everything has turned upside down. Although you are protected as graduating medical students, your colleagues in other disciplines are entering an external environment where graduate unemployment has been the highest for over 20 years. We as an institution are facing cuts of at least 25% form one of our main funding sources. Many of you will have read that it is likely that tuition fees may rise to levels that will make it very difficult for you to consider a University education for future generations – perhaps even putting studying for degrees like medicine out of the reach of everyone except the richest. I am sure that all of you feel that we face an uncertain future.

Consider first the fact that in our society today, of the 600,000 students who reach 16 each year, more than 300,000 fail to get five GCSE’s at grades A-C. Most of those who fail to achieve those grades come from the lowest social groups. When it comes to preparation for entry to leading higher education institutions, only 0.2 per cent of pupils on free school meals – just 176 children – achieved three A Grades at Advanced Level out of total of nearly 30,000 learners. The fact remains that despite numerous government initiatives, only 40% of young people in this country have the opportunity to study at University. At research intensive Universities like Manchester, the number of students from lower socio-economic groups remains pitifully small. And in your specialty of medicine, the number of students from lower socio-economic groups is smaller still. So let’s put the uncertainty that you all feel into perspective.

Every year, through an alumni program, we sponsor about 20 students from Uganda and Bangladesh to come to study in Manchester or take part in one of our distance learning programs. It is part of our programme of equity and merit scholarships where we hope to give the brightest students from countries where they do not have the opportunity or the resources, to benefit from a Manchester education. I have interviewed some of those students and they all understand the life transforming impact of the educational opportunities that they are being offered – not just for themselves and their families but for their country. It is a small program – we only have the resources to support 20 students. Over 1000 apply for the program in Uganda – all of them highly intelligent and quite able to qualify to study at this University. They know that “Education and work are the levers to lift up a people.”

So you are privileged because you have been given an opportunity which most young people have been denied. But the most optimistic thing about these students is that the reason they value this opportunity so greatly is that they see themselves as a force of change in their countries – they are not corrupted by the limitations of the real world and its insurmountable problems – they imagine solutions. They learn so that they can change the world around them.

And if there ever was a time when change is so desperately needed it is now. We are facing not just an economic crisis but a moral one. We are the fourth richest country in the world yet inequalities between those at the top of our society and those at the bottom are the greatest that they have been for over a 100 years. Think of the fact that you are graduating in a city where less than a mile away in the area where my practice is based, children are still denied through poverty the opportunities that you have had. Where the proportion of people who die of smoking related diseases is much higher than in other parts of the country. Where men and women have a much lower life expectancy simply through the accident of where they were born. The average life expectancy of men brought up and living in Rusholme is ten years lower than people who live in the richer parts of Manchester. We have a board in our surgery where we list the people who have been under our care and died in the past 4 weeks. What continues to surprise me is how the names of young people still continue to appear in that list. I still recollect reading the post mortem report of a child who died at the age of one from severe vitamin D deficiency, a disease that we have known about for over 100 years and which can be treated easily.

When the welfare state and the NHS were created over 60 years ago, the ambition was to address the five social evils of ignorance, want, idleness, squalor and disease. Danny Dorling one of the foremost researchers on health inequalities in this country argues cogently that fighting these evils have been replaced by five key precepts that now uphold an unjust system that perpetuates extreme inequality – elitisim is efficient, exclusion is necessary, prejudice is natural, greed is good and despair is inevitable.

Last year, two researchers from Nottingham and York – Richard Wilkinson and Kate Pickett produced a seminal text on Inequalities, showing systematically how societies which are more equal almost always do better. The facts speak clearly for themselves. Britain is one of the most unequal societies in the developed world; The richest fifth of our population have an income of more than seven times than that of the poorest fifth. The same ratio for Japan and Finland is just over three. Wage inequality between the richest and poorest is now as great as in 1854 when Charles Dickens was writing Hard Times. And this is a recent phenomenon – the income gap measured using the Gini coefficient shows that income inequality is 40% worse than it was in 1974 – and we have the crime statistics, the mental illness, the teenage pregnancies, the obesity, and the literacy scores to prove it.

Something is profoundly wrong with the way we live today. For the past thirty years we have made a virtue out of material self-interest: in fact for many this now constitutes whatever remains of our sense of collective purpose. We know what things cost but no longer have an idea of what they are worth. We never ask abut fairness or justice or morality. These used to be the political questions and it seems that we no longer pose them because they are so difficult. Better to retreat into glib answers about deficit reductions, welfare scroungers and everyone having to suffer the pain of profligacy. We need to change the parameters of the debate if we are going to bring about a better society or a better world.

Why am I telling you all this? Because as you graduate I want you to reflect on these inequalities and consider the personal responsibilities that should make you informed and engaged citizens. You can through your actions and the choices that you make in your future career, especially in your chosen profession, do things that can make a difference. You are fortunate because most of you will be entering an organisation in which there had been unprecedented investment over the past 10 years. The Health Service is unrecognisable from what we had 10 years ago. I have witnessed the difference for my own patients who now have access to care with time limits which were unimaginable 10 years ago. The way that we are organised, the way that we work in teams, the changing roles of the professions, has been transformed. All of this might be under threat because of the economic recession and my plea to you is not to be bystanders. Work together with your colleagues and other professionals to preserve what has been achieved. Perhaps, as never before, you will need to be involved in politics as well as the professional role that you have been trained in. You will have to question and challenge the prevailing orthodoxy.

We come to Universities not only to further ours careers, but to become citizens. And in order to make good citizens, our responsibility as your teachers has been to educate people capable of building just, humane and sustainable human communities on a small and exceedingly dangerous planet. Knowledge, wisdom and humanity to translate the Latin motto of the University is what we have tried to impart.

You may find it surprising if I say that the knowledge that you have acquired is secondary. With the total quantum of human knowledge now doubling every six years or so, higher learning is not essentially about acquiring a body of knowledge. It is about learning how to learn, about being open to new worlds of thought, improved ways of doing things, new technologies, new paradigms, new problems. A learning disposition is the most precious outcome of higher learning: without it, a university education has a frighteningly short half life.

In less than 4 weeks many of you will be starting your clinical practice. It will be exhilarating and frightening. You will be exposed to human suffering and love and hope in a roller coaster of a career. You will laugh and you will cry and over time you will become wise. But you must never loose sight of the fact that as doctors you have a special responsibility to develop and maintain your professionalism. What this means simply is that your values must encompass compassion, altruism, team working, integrity, excellence and social justice. At the end of this ceremony you will be asked to affirm what is in effect a modern version of the Hippocratic Oath which will include a commitment to professional competence, to honesty, to confidentiality and to improving the quality of care. But as our future doctors I think you have an additional responsibility – that is to use your knowledge not only for your own and your families achievement but for the betterment of society, for tolerance and understanding.
Our founding statement read out when we created the new University in October 2004 stated that we wanted to make our University a place where students, whatever their backgrounds, learn to pursue truth through rational inquiry; where researchers engaged in discovery are also teachers; where research is valued both for its own sake and for the betterment of the world; where academic freedom is encouraged and protected; where the cultivation of cognitive skills, independence of mind, intellectual integrity and artistic expression promotes understanding and appreciation of the best that is known, thought and created in the world; and where students and staff are encouraged, as responsible citizens of their own societies and of the international community, to embrace fundamental human and civil rights as the only just, sustainable basis for a humane civilization.

That is the challenge that we now set you – to use the knowledge that you have gained not only for your own and your families achievement but for the betterment of society, for tolerance and understanding. Education is what will help us to innovate, to challenge bigotry and to embrace fundamental human and civil rights and meet the challenges of the future. You have gained knowledge, you will learn wisdom. Use that knowledge and wisdom. You have incredible opportunities both in the NHS and in academia. The world is your oyster.

I want to end by giving you some advice – advice that I gleaned from Atul Gwande who wrote a incredible text on how we should aim to do Better in medicine. Recognising that most of what we do in our job is talking to strangers – his first bit of advice was to Ask an unscripted question – find out something unusual about the patients and colleagues you are dealing with- it will enable you to make a human connection with that person and you will start to remember them. The second piece of advice is Don’t complain – I have already talked about how privileged you are but that is not the reason you shouldn’t complain. It’s boring, it doesn’t solve anything- better to discuss ideas and problems that you can do something about. The third bit of advice is Count something – don’t forget that ultimately you are scientist and counting helps you understand things – be aware of your complication rates if you become a surgeon, of mistakes that happen, of what happens to our patients as a result of the treatment you give them. If you count something interesting, you will learn something interesting. The fourth bit of advice is Write something. It may surprise you to consider that the systematic publication of ‘fragments‘ of scientific work from the many has probably produced a store of collective know-how with far greater power than any individual could have achieved. If you learn to write you will make yourself part of a larger world – part of a community and it will be a sign of your willingness to contribute something to it. Finally Change something: look for the opportunities to change- recognise the inadequacies in what you do and seek out solutions.

Gwande ends his book by saying
‘So find something new to try, something to change. Count how often you succeed and how often you fail. Write about it. Ask people what they think. Keep the conversation going.’

Simple and pithy advice perhaps but advice nonetheless. It is your future now and you must become the architects of the change that you seek.

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