Grand-theft Junior

Before I begin, I want to clarify my situation in relation to junior doctors – well, let’s put it this way; I once was one and when I was, I never liked the term ‘junior’ and today, when I speak with doctors who have not yet reached the heady-heights of consultant or general practitioner, I usually say ‘trainees’ instead. Note – not all trainees are actually in ‘training posts’ a term developed by the academic masters sitting in nebulous ‘deaneries’ across the country, but, my take is, that everyone who isn’t yet a consultant or GP (by which point it is often too late), is still learning – growing, developing. (Yes, consultants can grow too – it is just a much slower and painful process).

Anyway…

On Thursday as I mentioned yesterday, I was back in Doncaster.

When there I saw lots of old friends and colleagues – some of whom knew about my departure, others who didn’t.

One former colleague, in joking, in passing, but sincerely, said, ‘I hope you aren’t stealing our juniors.’

What he meant by this relates to the massive pressure placed on specialist doctors in their final and penultimate years encouraging them to commit to a career in a certain hospital.

You see, doctors, especially physicians working in ‘acute’ specialties are in short supply and consequently, like any system of supply and demand are valuable. Some hospitals will do anything to attract new consultants (in place of the many locum doctors who populate the system today, supplying shareholders with holidays in Tenerife (see yesterday’s blog)).

And, here, was a suggestion that Doncaster, now it has come of age, gained the title ‘teaching hospital’ – any trainees passing through their doors are ‘theirs’ – when I first came to Doncaster the situation was different and only very recently has it changed, with trainees previously heeding the siren call of Sheffield – the local teaching hospital and adding to the very significant numbers of geriatricians, gastroenterologists, and so on there.

Well – my point, and this I guess is me taking part in the whole guilt / pressure game (which I am sure most medical registrars can cope with – pressure-management being a pre-requisite for the role) – is, that we have an imbalance across the South Yorkshire hospitals. And, like in nature, imbalance doesn’t tend to result in a positive state of wellbeing – too many caterpillars and the lettuce is gone;

Yes, I have already suggested – the future for the NHS is uncertain; will we one day have a two tier hospital system like in America – where the rich get state of the art, high cost (and likely medicalised) care and the poor are left with what is left-over, or, will we achieve some sort of balance where the specialist care, the research, the monoclonal antibodies, lasers and robot surgeons are at play and the majority of care where people receive care – are hospitals functioning at the level of the person, offering the best for all?

When I first went to Doncaster, ten years ago, the flow of new consultants was strongly towards Sheffield; this has now shifted, and the course is probably equal, Sheffield and Doncaster – what has happened is, the organisations in the middle, such as Rotherham have lost-out; for some reason, in terms of physicians more than anything, and the system has as a consequence struggled.

What is the answer?

Well, I feel it is a fair, equal distribution of new consultants working across the sites, perhaps sharing practice and expertise, a little like the model of person-centred care we are demonstrating in our education sessions – such that each hospital has what it needs to provide not just the safe care we and our patients deserve, but care that is of high quality.

I don’t want to pressurise anyone, and I doubt this blog has the power to sway people to any great extent, yet, I felt that I needed to explain here my position.

If we do nothing and the flow to Sheffield then Doncaster continues, Rotherham and, likely Barnsley will continue to struggle – this will mean their patients i.e. the people of South Yorkshire not receive equivalent care, ultimately resulting in a tipping-point that is bad for everyone;

This isn’t an advert for trainees, or an attempt to redress the ‘theft of juniors’ argument, more a conversation-starter, making the situation explicit, as without this we will bumble on, one step forwards, two back and no one will win.

There is a classic Game Theory game* –

‘The prize is $20. Everybody is free to bid; there are only two rules. The first is that bids are made in $1 increments. The second rule is, the winner of the auction, wins the $20, but the runner-up must still honour his or her bid while receiving nothing in return. In other words, if you are second best you lose everything.

Here is what happens:

At the beginning of the auction people bid… a flurry of offers.

The pattern is always the same – as soon as it reaches the $12 or $16 range… and, it is clear that everyone else has had the idea to bid and win the money for less than its value – people start getting jittery and drop-out; all except the two highest bidders.

Without realising it the bidders are locked in, one bids $16, the other $17; the $16 bidder must offer $18 or lose $16. At this point the participants aren’t playing to win, they are playing not to lose.

The auction continues… $18, $19, $20.

The rational decision would be to accept your loses and stop the auction, but, neither will back-down, the momentum keeps the bidding going.

Inevitably the bidding continues, $21, $22, $23, $50 – the record in one instance was $200.

This is loss aversion.

There are actually two phases to the auction… the $2 phase when everyone is wide-eyed and optimistic, expecting a quick-win, then the final phase where the bid passes $20 are the bidders are digging a deeper and deeper hole. This, is the loss aversion.

Is this what we want? One overall winner with everyone else losing?

Imagine the ‘South Yorkshire Trust’ – the mega hospital where you go for everything.

I can’t see into the future, but I reckon that this is a long-way off and the likely suffering particularly of patients, i.e. the failures required to reach that point will be so painful, I’d rather not contemplate.

So, let’s put egos aside, let’s instead think of the patients and the staff – for the latter, working in an unsustainable system is not much fun and, come together, instead of opting for winners and loser (this is healthcare after all!) – let us support one another for the benefit of all.

*Adapted from ‘Sway’ by Ori and Rom Brafman, Virgin Books, 2008.

fmri loss aversion

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