Let’s not kid ourselves, banning banter isn’t going to solve the staffing crisis

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A recent piece of research published in the British Journal of General Practice found general practice and psychiatry to be the two most ‘bad mouthed’ specialties in medical school. This has lead to a tangible effect on choices of graduates, leading to the staffing crises in psychiatry and general practice, say the respective heads of their Royal colleges. This has led to a #banthebant campaign, calling that all students stop mocking these specialties.

The data  actually offers a more complex picture than the simple reasoning offered by the two presidents, with surgery actually at a comparable level of bashing and even ahead in some categories as psychiatry and general practice. And yet, surgery continues to be a competitive and oversubscribed specialty.

In addition, whilst there is no data about banter between practitioners, I am sure that from many people’s anecdotal evidence that the specialty that itself has the most practioners of banter is surgery itself, with the stereotypical orthopaedic surgeon that knows more about how to mock a medical student than they do about general medicine.

Clearly this issue cannot simply be related in such a simple fashion, much like increased weekend mortality being caused by weekends.

Whilst the numbers of doctors opting for psychiatry and general practice have the lowest proportion of fill rates, it is notable that both specialties themselves offer an unparalleled work life balance, evident in the absence or scarcity of night shifts and on-calls. Whilst this may be a reason to call these specialties soft, a work life balance is very much a prized object in the world of healthcare and these specialties offer some of the best.

What does make these two specialties different is the nature of the work involved in them. Both of them place a much higher emphasis on risk and patient contact than other specialties. In terms of risk, both these specialties need to make calls on whether or not a patient can be safely sent home or need further escalation, with the potential risk that a patient may be harmed if the wrong decision is made. In contrast, other specialties are able to rule out risk in the majority of their diagnoses by investigating and ruling out possibilities. Whilst this may lead to patient harm via over-investigation, it leaves any doubts on the practitioner’s mind clean.

The second emphasis on patient contact is seemingly not an issue when considered a soft skill by many medical students. However, the fact is that other skills like taking blood or even performing surgery quickly become ingrained via repetition. They reach a point where a large majority of the act itself is done automatically without conscious effort, much like driving a car. No one disputes that it is an intricate ability, but the level of stress that one experiences whilst doing it is routine Patient conversations on the other hand, have a tendency to be unpredictable, and require a two way engagement process. They require thought and consideration, and no two are ever the same. We might have the same set of goals each time we take a history, but we are never going to reach those goals in the same way.

Now, why are these two areas so salient? Because they also correspond with skills taught badly in medical school. Students are taught to investigate, to diagnose and to manage patients. They form the foundation of the skills that we use as doctors. The problem is that GP and psychiatry require additional skills that the majority of people do not develop in medical school and this leads to their lack of uptake later on.

The problem is also worsened in the way we choose our students and how we test them. Students are graded on learning knowledge in minute levels of detail that have almost no practical importance, and yet we reward them for this. Medical schools also place undue emphasis on rare diseases a the cost of time that could be spent on grasping skills such as the ability to identify an unwell patient (a skill that is often learnt too late in FY1).

A ban on banter is not going to solve any of these issues, and is in practice nearly impossible to police. Whilst a nicer work environment helps everyone, flat out banning something is also never going to solve a problem that has numerous other contributing factors. Energy would be better spent campaigning for other things like more spots for medical students or ensuring that doctors have a fair contract that balances their careers and their lives. Medicine is at risk of becoming a career option that only the sadistic aim for; we need better doctors than that.

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