Medical students enter our workplaces with a fresh view on things – they might see some issues more clearly that those of us who are trapped in a daily work routine have become too accustomed to. But they also enter hospitals and other health care areas as part of a hierarchy that separates us from them. We therefore find it important to break down some of the barriers – this interview with a medical student is part of this effort.
Over the last decades the profession of the doctor has changed massively, first of all in terms of numbers. In 1949 there were 11,735 hospital doctors working in the NHS in England and Wales. By 2018 the number had risen to 109,509, which means that doctors were the fastest growing job category in the health service. With the working class having fought for better conditions and more social power, also more working class kids managed to go to university. Today, the majority of medical students are women, which is another major change.
While the number of doctors increased, their social status has been questioned. We saw a ‘managerial turn’ in the 1980s, when a lot of the administrative power in hospitals and health-related academia shifted from doctors to managers – between 1975 and 1991 the numbers of managers in the NHS increased by 53%, between 1992 and 2002 it doubled again. We also saw a relative wage decline of doctors over the last twenty years. One reaction to this were the recent strikes of resident doctors, which expressed both a wish to defend a privileged professional category and the ‘working class impulse’ to defend wages and conditions. Read a very insightful interview with a striking resident doctor here.
Being a student
I’m a fourth year medical student. Your first two years at medical school are more theoretical. It’s mostly lectures and seminars with some simulated clinical experience added to it. After that it flips and you’re mostly on placement, going into hospitals, going through all the different departments and specialties at the hospital. I’ve just come off of placement in a general practice and I’m going into a psychiatric hospital. I think the overall experience is good. There’s a split in the five years between intellectual and manual labor, but it’s almost like a chronological jump that you make from the first two years to the last three. It’s good to be able to go out and see how the things you’re learning are actually put into practice and to get involved in the way that the hospital actually works. A lot of the stuff that you learn in the first couple of years is basic science and some of it you don’t need to know in order to scrape by the clinical stuff. You could get away with leaving it to one side and just focusing on practical things, like: if someone comes in with these symptoms, here’s a list of different tools, don’t worry too much about exactly what’s going on. This mirrors some of the changes in the actual field to do with “Evidence-Based Medicine” and the reliance on protocols. But if you want to get a grasp of things, then you do have to go back to theory and make sure you have at least a top level understanding of what you’re doing.
I think it’s better for us than for other students in the hospital, like nursing students, because they’re expected to actually start doing things and essentially fill staffing shortages straightaway. People start relying on them to get things done. Whereas I find that for us no one really expects us to be able to do anything practical yet, really. You go out and you have your list of things that you want to see or you want to get done. As long as you know where to go and whom to ask for getting things signed off no one really relies on you. Nursing students are primarily paying for the privilege of having to work on the wards.
Privatisation as such is not so present during the training, e.g. I don’t think that private hospitals and private doctors, who work in the private sector have an influence on the medical course. The university cannot send you to a non-NHS hospital, for example. And you don’t get sent to private GPs. As a student you’re not going to big conferences that are sponsored by companies. You’re not getting lectures from drug reps. I suppose it’s not like America where drug reps are really present. We know that clinical research is often sponsored by private companies, even in the NHS, but as a student, you don’t see that. I think that you can do summer research programs and things like that, maybe then it would be more apparent to you.
Medicine in capitalism
The overall trend of capital is to take labour processes and make them simpler; to break them down and make them more efficient; to decrease the amount of time needed to train the labourer so that you can decrease wages. For a long time medicine was resistant to that, as the nature of the labour was pretty technical and difficult to simplify or decrease the amount of time needed for training or the level of technical knowledge required. Another thing was that the workers (doctors) were by and large a very well organized profession. They had a type of guild structure. They protected their interests very well against the interests of the state and capital. When they were funding the NHS, Bevan said that the thing that made it work was that he had to stuff the doctors’ mouths with gold. That’s starting to break down.
There’s been a big movement to something called evidence based medicine, which is the idea that everything that you’re doing in medicine, you start to standardise it, protocol it, you investigate every bit and you find the evidence: Is this more efficient? Is this more cost effective? You crunch all the numbers and make sure that everything is evidence based. On the one hand, this is a good thing because no one just has their own pet theories any more, and it’s not so much about the charisma of certain physician-scientists. On the other hand, you don’t actually need to understand the reasons behind the protocols in order to follow them. In a sense it’s a generalization of knowledge. I suppose the big thing is knowing when to follow the protocol and when not to follow it. In general though it has enabled people who aren’t doctors to take up a lot of the old professional responsibilities of the doctors, like physician associates (PAs) or advanced practitioners.
Advanced practitioners and other new roles
In the part of the UK that I’m in there are fewer physician associates than in other parts of the UK so I don’t actually see them all that often, but the overall trend is almost inevitable. It’s a way to reduce wages. They get paid more than doctors when they start off, but then over a lifetime, they’re much less expensive. You can have a few physician associates who do the main work and one doctor who supervises them. In a way it points towards what health care in a post-capitalist world is going to look like. There’s going to be a transition to a more social distribution of work and of health care, which allows you to have a massively reduced labour time. In that sense it’s a progressive thing, but in the way that it’s implemented in capitalism, it’s primarily a feature to depress wages. The PAs that I have met, there is a difference in their knowledge. There are things that they miss that a doctor wouldn’t miss. It’s a two year degree versus a five year degree. There’s a big difference. My university doesn’t have a PA program but another university close by has both a medical school and a PA program. I’m told that they don’t share many lectures, but sometimes we meet them on placement.
During placements I will have some sessions with the consultant where they’re doing some teaching. They’ll give a lecture or maybe they’ll take us to specific patients that they’ve picked out and get us to examine them and take their medical history. Besides that I have a list of things that I need to get signed off on, sometimes practical things like taking bloods, or seeing a certain surgery, or a specific disease. There is a big emphasis now on talking to other health care professionals: we have to shadow nurses, pharmacists, OTs, etc. But it’s a one-way thing, the medical students shadow nurses, but nurses wouldn’t shadow doctors.
I find it interesting that there has been a really concerted effort to reduce the power of doctors in the workplace relative to other professionals. For a long time there would have been a culture of “whatever the doctor says don’t contradict him”. Now it has almost come to a point that a lot of junior doctors feel like they have absolutely no power at all in the workplace. I have met junior doctors who have been bullied by nurses. There’s a joke that I’ve heard, they say that we have a ‘flat hierarchy’ in hospitals now, and junior doctors are at the bottom of it! One of the big things that was pushing the strike action from the doctors is a feeling that we’re losing, that medicine is going backwards for us. We don’t have the power or authority that we used to have and that we think we should have.
Rotational training
One of the things that a lot of people complain about is the fact that training in the UK is rotational. Most of the junior doctors you see for maybe six months maximum and then they’re somewhere else. You can’t settle down. It didn’t used to be the case, but it changed in 2005 with a program called Modernising Medical Careers. In the past, getting a job as a doctor would have been like getting any other job. You go for interviews and get picked by the consultants or the senior doctors or whatever. They changed that; the official reasons were to get rid of nepotism or favoritism, so that you couldn’t brown-nose your way into positions. But I think another big element of it was a desire to get doctors to move into relatively unpopular parts of the country. MMC left interviews as a relatively big part of getting consultant jobs, and a much smaller part of getting a training job. But it also added a lot of “objective” criteria like doing a certain number of audits, which rewarded doing various types of NHS grunt work that aren’t really the most fulfilling or useful aspects of medical work, but which need to be done as part of the NHS bureaucracy.
This has now worked its way into how medical students get their first doctor jobs. It used to be that when you left medical school, you were ranked within your medical school: top 10%, next 10%, and so on. Then, you would also do an ethics exam called SJT. They combined these two things and that gave you a ranking. Then you would apply to all your jobs and you would get the job based where you were on the ranking. In the past few years they have removed this process and made it random. You still rank the places that you’d like to go, but then the allocation is totally random. They say they do that so that you’re getting roughly the same quality of doctors everywhere. But people can end up getting sent to the other side of the country, or to a different nation of the UK, even if they have family to look after or need their support systems. And then, once you have a job, you’re still constantly moved about for the next 5-10 years until you get a consultant job.
One of the big consequences of that is that junior doctors do not feel rooted in the workplace. PAs, on the other hand, are hired on a permanent basis. They get to know their consultants and they get to know everyone on the wards. People then tend to give them things to do that strictly speaking should have gone to the junior doctors – because they’re the ones who are going to have to do it as consultants. In the end it’s the PA who gets to go to theater and assist in a surgery while the junior doctor is out doing discharge notes. This is ironic as the way that the PA profession was sold to doctors was that it was going to be the reverse: “with PAs you don’t have to waste your time doing discharge notes anymore, you can focus on your training”. Then there is the fact that you have to pay for your exams. That’s £4,000 just to sit an exam once. And a lot of them have really low pass rates. Then you have to pay for your GMC registration, the regulator. There’s a real distrust of the regulator because the GMC is pretty racist and arbitrary in how it goes after doctors for really petty reasons while leaving horrible and egregious behaviour to fester for years in some cases.
The BMA strike
So there are a lot of grievances, but the BMA wanted to make the strike just about pay. The rationale was: “Yes, we have all these other problems, but with the strikes in 2016, we had been too disorganised. We had tried to make it about everything else. There was confusion about the message and it weakened the overall strike effort. Be on message. It’s about pay. Well, anything else we’ll worry about later”. In a way I think that’s a good thing. I mean, these ‘Doctors Vote’ people were fairly organised and streamlined. They managed to get the hegemony, the power in an old institution, so fair enough. But at the same time it was very much like “it’s our way or forget about it”. You can’t underestimate what they achieved. From a Reddit forum to a total achievement of power. I think every junior doctor seat in the council is a ‘Doctors Vote’ seat and they have the vast majority of seats on the main council, as well. The people at the head of ‘Doctors Vote’ were good about being open and communicative and they were pretty sensible when it came to negotiations – but now the organisation has become a bit of a straitjacket, e.g. the emphasis on being anonymous. Now it just seems exclusive. Where I live the BMA is still a little bit of a careerist organization for people who want to have things on their CVs. So we haven’t had quite the same success in terms of the strikes.
Labour migration
Another thing that needs mentioning is immigrant doctors. That’s another big controversy. There used to be a thing called RLMT, which was a labor market test. Basically, before you accepted a job from a non-British graduate doctor, you had to check that there wasn’t a British graduate who was available who could do the job, but then they scrapped that test. It is now starting to become an issue because part of the problem with the shortage of doctors is that it’s not actually a shortage. The shortage is mostly at the very top with consultants. I suppose there’s not really so much a shortage of trainee doctors, for example. What the government tends to do about the shortage of doctors is that they open a new medical school. But the problem isn’t that we don’t have enough medical students. The problem is that there are not enough training pathways to train consultants. But that’s expensive. So it’s becoming increasingly difficult to train in the specialty that you want to train in. It means that there is now very intense competition for training places and still a shortage, because lots of people will say, “well, I can’t do the specialty that I want to do. So I’m going to go to Australia, Ireland, America or New Zealand”. You have a situation where a lot of third world country universities are training Britain’s medical doctors and then Britain’s universities are training all of Australia’s medical doctors. Most of the doctors who come in are from countries like Pakistan or Egypt or India. A lot of them might already be consultants, and they’re coming in to fill in consultant posts. They do locum duties and fill the gaps and in general they’re much happier to accept lower conditions than a lot of the UK trained doctors. Many junior doctors were able to make a lot of money by working locum shifts and then use that money when they took a pay cut to enter training later. The locum shifts have dried up now. So I think there’s a concerted effort among some doctors to try to get the labor market test back, but the state has an interest in being able to hire doctors from abroad regardless. They get the benefit of pretty well trained doctors that they haven’t had to pay for.
The doctor-nurse-patient relation
On the wards the doctors have direct contact with the head nurse, during ward rounds. I think a lot of the other communication between nurses and doctors will just come from the notes. You get the sense that most of the time the doctors don’t really have the time to be doing the ward round either. So there is also little communication with patients, at least in hospitals. There’s a lot of theorizing about talking to patients and getting to know their social background. There are study modules on psycho-social influences, but it’s more of a tickbox. The point of medicine in a bourgeois society is to patch people up just enough that they can return back to the environment that they came from and reenter the labor process. It’s not really built or designed to address the fact that this person is in hospital with very severe osteoarthritis because they’ve been working in a factory for 50 years and they still need to go back to it. Or that people are depressed and sick because their family is in the Philippines and they haven’t seen them in ages. Social factors get acknowledged and especially in GP practices. So when I come to GP practices, they’re very aware of the community, they know more about the situation of the patient and what they’re doing – but there’s not really all that much that they can do other than try to slap a Band-Aid on it and send them back. Especially with poverty, alcoholism and so on. It’s not like in Ancient China, where they used to pay doctors when patients remained healthy and stopped paying doctors once people got sick, which is a different incentive structure. Doctors now feel that they have to achieve targets set by management, you are disciplining yourself and just try to shove patients through the process: “Can I get this patient off the ward by ordering more scans? Could they be discharged earlier if…”. The hospital wants to cut corners and the doctor absorbs the personal liability for it.
Who becomes a doctor nowadays?
Who becomes a doctor nowadays? – I would say, mainly women. In my medical school class there are easily 85% to 90% women. I remember my first day and the first lecture, it seemed that I was the only bloke there. In terms of background you tend to find that actually a lot of people who wouldn’t have been able to enter into medicine before are now able to. They make it easier for people from certain backgrounds, also backgrounds of poverty. It is also easier to come back to studying later in life. Another big thing is that the internet has made knowledge that you would have gotten if your parents were a doctor or from knowing doctors in your social circles more generally available to everyone. There’s advice for interviews and exams online, for example. Of course, living in poverty is still going to make getting good A-Levels massively difficult. And even when you do get in, I actually think the bigger difficulty is that there’s a lot of aspects of medical school that are fairly expensive. So for one thing, it’s a five year degree. And if you’ve already done a degree, you’re not getting another loan to do that. You’re going to have to cough it up yourself. It’s also a massive amount of lectures, seminars, and studying on your own that you have to balance with maybe doing a part-time job. On top of that placements can be pretty far away. For the last placement I had to get on a bus for four hours every day. So that can be pretty hard if you’ve got kids, if you’ve got a job, if you’ve got anything else going on, or if you’re caring for your parents or whatever.
Why do people become doctors?
I’d say for a lot of people, especially working class people who were able to do well at school, it’s almost like they couldn’t think of anything else. Medicine is still the prime example of a stable, aspirational, middle class career in a lot of people’s minds. Then I think there is a level of humanism, of left liberal aspiration, of wanting to help people, but also having a certain security and position. A lot of people come in and then realize that actually there’s not as much security and stability (and pay!) as they might have thought that there was. People then consider leaving and going into finance, consulting, anything else really. In terms of politics, people are not very politicised. That’s my experience. Many of the international students are pretty wealthy people, because they have to be able to afford the international fees. Many of them seem very depoliticised and disconnected. Then you also have the usual university politics, many students are left wing, but more culturally left wing. They’re interested in LGBTQ and so on. The thing that stands out is abortion rights. People will be very invested in that, because that’s something that connects left wing political values and medicine. There’s a pretty big pro-choice grouping and they demand more abortion training as part of the course. That’s one of the few examples where students express the need to change the curriculum. In terms of wider working class politics of leftist politics in that sense I don’t think that there’s anything happening. I thought Palestine would be a bigger thing for them, but as far as I can tell, there’s nothing, at least in my part of the country. I think part of the problem is that after your second year, everyone gets split up and sent to different places. After a while you don’t actually feel all that connected to everyone else on the course, and so little opportunity for large-scale organising around anything. There’s very little connecting the dots between medicine and politics, which is really different to somewhere like America. When I talk to American medical students, a lot of them think about politics and the way that it connects with medicine and insurance in America. In the UK, there’s a sense that we already have ‘our NHS’ and that as long as it doesn’t get ‘privatised’ then we will be fine. There’s no need to actually change anything, except maybe giving it more money. But then very little attention is paid to the ways in which it is already privatised, and the way in which it links with wider politics.
Student discontent
Our university used to have a system for determining where your placement was, where you would rank the places that you wanted to go and the order that you wanted. And then you would submit that, and it would come back and they would try to put you in a place where you want to go. Last year they decided to change it to make it a completely random allocation. You don’t get to choose, you don’t get to submit your choices or anything like that. This was apparently told to our student representatives, but they were told to keep it a secret. Which I think most of them did, but then it started to come out through gossip and rumors and things like that. There were some individual responses of discontent. It wasn’t like everyone got together, but some people tried to organise a concerted effort against the change. Then the management of the medical school started holding a really complicated system of votes over what to do next.
They wanted everyone to just give up, because the voting process took ages and in the end you have to organise accommodation for your placements in time and so on. There’s no will to oppose it in a very strict way, because at the end of the day, if you want to be a doctor, you got to play by whatever they’re saying.
Another thing that causes friction is that we have a system of exams, a system of progress tests, which are frustrating. At the beginning of the course we have an exam that’s a fifth year exam, that you would do at the end of your medical school. You sit there and think “I don’t know what these words mean”. I think their idea is that you watch your marks go up. You start off doing quite badly and then you improve as time goes on. But the problem with that is that we weren’t being tested on things that we were actually learning. So on the one hand, there are lots of things that we learned that we had no incentive to really properly learn, e.g. like basic sciences, which are not going to be in the exam. So I’m not going to learn it because even though I should learn it, if I spend time on this and don’t try to get my marks up in other things, other people will beat me. It’s graded on a curve and I don’t want to be at the bottom 5%, because I would have to re-sit the exam.
In terms of student representation there’s the student union, then there are student representatives who we elect as a degree course and then I think we have year group representatives that represent specifically your year vis-a-vis the medical school – I think it’s two representatives for 300 students. And then you have BMA reps to the medical student council and the regional meeting. So you have these very complicated levels of representation that basically are career things. It’s a thing you could put on your CV that while you were at university, you did all this stuff.
Revolutionary medicine
In terms of revolutionary politics I think a lot about what kind of medicine we might have in the immediate post-revolution period, the dictatorship of the proletariat situation versus what are we eventually going to have in the actual communist world, when you don’t have commodity production, capital and profit and so on. I think in the immediate term you’re going to have to do things like abolishing professional licenses and patents and trying to take the things which capital’s already doing and develop them further in that direction, meaning, the socialisation of knowledge. You will have to go back and clean up all sorts of things that happen from the influence of the private sector, for example the way in which pharmacology trials are run to make the drug look as great as possible. You have to address the social issues that cause very severe health problems and hospitalisation. So that people aren’t working in very dangerous factories with no safety precautions. You will have to regulate social production so that you’re not producing all of this very damaging food, so that people can actually eat healthily. And then beyond that, I think it’s just further breaking down the actual complexity of the process, which should make it easier for people to learn. Many things in medicine that have this mystique around them – like surgeries – are not all that complicated when you get down to it, and it’s not impossible to imagine that a wide dispersal of knowledge in this sphere of knowledge is possible.
In the meantime we have to greet the process of proletarianisation (becoming normal wage workers) of doctors and the fact that their strikes injected some energy into the workers’ movement. As a result, nurses question why their pay dispute didn’t go further and people might develop the idea that a general health union for all professional groups might be a good idea. In terms of research, bypassing the academic publishers and putting your research out in an open source way so that people can access it very quickly is a good start, too. It happened a lot in the pandemic, but there’s no reason why it should stop other than the profits of academic publishers and Big Pharma. Again, this could include all groups of health workers, not just formal researchers. I think having teaching sessions within the hospital that are organised by people to teach information from their profession to other people would be great. I go to lots of teaching sessions in the hospital where it’s a big room and most of it is empty – it’s just those medical students and the consultant teaching things. It would be good to get nurses, health care assistants, even porters involved, too. I suppose this could be done like public education for working class people used to be organised by the workers’ movement: from the history of the labor movement to basic things like physics or chemistry, so that people understand the labour process that they are involved in, and maybe the potentials for it in a future, emancipated society.
