Links to past scientists

The photograph above is of Peter Mitchell, a gentleman scientist who achieved the rare distinction of receiving an unshared Nobel Prize for Chemistry in 1978. His great achievement was the discovery of how the breakdown of glucose and other nutrients in linked to the production of a high-energy intracellular molecule (ATP). It was an elegant theory, elegantly demonstrated. He was, by all accounts, a great bloke too according to my undergraduate tutor who worked with Mitchell in his labs in Cornwall for a number of years. Sitting in tutorials, I was once removed from this work.

When I moved to take a PhD, initially I was similarly once removed or directly involved with a number or biochemitry giants. These included Arthur Kornberg, Lubert Stryer, Hans Krebs and JRS Fincham. Apologies for the nerdy name-dropping

The world of biochemistry seemed to be one where large thoughts were generated and proofs pursued methodically over several years. There were close connections between the big discoveries and current opportunities.

It may be me but these connections are much diluted at the present. The process of developing a scientific lineage of PhD graduates from a supervisor's early work naturally splits a large field into smaller ones as graduates take an element of that work and run with it. After twenty or thirty PhDs have come out of a lab, the field has been split so often it's looking like a bastardised version of Zeno's paradox.

An example of this was a friend of mine who went to work with a scientist looking at a topoisomerase. By the time he'd arrived, two other PhD students had started and the protein's three domains had been allocated to one student each. Unfortunately, the bit he inherited turned out to be a spacer domain which let the other two domains do all the interesting stuff which made his viva interesting.

The sense of excitment I felt as a newbie undergrad scientist undertaking a short research project, the proximity to big leaps that had been made only ten years previously, waned quickly and for others too and by the mid-90s I was also mutating a wee bit of a protein to see what happened... just like four other groups around the world who were working on the same protein.

Watches

Dr Crippin, probably the most read medical blogger in the UK, chose to introduce a discussion on the worried well and prophylactic screening with a discussion on servicing his watch.

This started quite a lively discussion on "watch porn" which provoked a bit of thought with me (hence the solipsistic tag below).

Men's bling in the mainstream is limited to cuff links and watches. I had a psycho boss for a job I was in for short time and the only positive learning I took from this guy was to choose cuff links with a solid spine. Since then, a pair of Tiffany kidney bean links have been all that I've needed to pass myself off as being "smart" in business and formal social occasions. If anyone is looking for a GBP150 present for a god son or whatever, I would recommend a pair of these. They feel nice and solid too.

On the watch front, it's hard to work in finance in Asia without succumbing to bigging it up on a new watch. Working in Singapore, Orchard Road was always a short taxi ride away and the prices were (relative in the odd world in which you existed) reasonable. The "standard" watch was a "Hong Kong Swatch", being a Roles datejust. This was the entry to a world of hurt where you went from Rolex / IWC (depending on how obscure you fancied yourself and how thick your wrist was) to the nightmarish heights of Vacheron Constantin (pictured above, yours for US$80,900).

Seemed like madness to me... but I couldn't resist shelling out for a Bell&Ross Hydromax, water resistant to 11,000 metres. Stupid, but a good conversation starter in the pub and a fraction of the price of a VC.

Them were t'days

This site has a fascinating run through of some old adverts for drugs that were once commonplace but now are... somewhat less so (depending on where you live).

In addition to the usual commentary on the original recipe for Coca Cola, there are plenty of other eye opening ads for an array of exciting drugs.

I've included the standout (for me) above. Reading the copy on the advert, I was wondering where they were going to go with the "it's hard to make nervous kids take a pill" line and which alternate route they were going to suggest. A suppository never entered my mind.

And then you read the last line and realise that you're supposed to stick these up the kid's bottom before they became nervous. Sounds chicken and egg to me.

On this day in history #1: 1996

My lab books from my PhD and post doc are closest thing I have to a diary. Except for the actual diary I kept from 13 - 15, I suppose.

So: what joys lie in these dozen or so books?

Well, on this day 13 years ago, it looks very much like I was setting up another in vitro, cell free virus replication assay using recombinant replicative proteins. And, by the looks of the print outs from the scintillation counter stuck in the book at jaunty angles, it this was another failure. Months spent cloning the damned genes and getting them to express and bugger all to show for it. Not to mention: huge exposure to viruses (even the expression system, vaccinia, isn't very nice), radiation (to check for incorporation of labelled nucelotides) and chemicals (scintillant ain't nice).

This experiment, which I had forgotten until now (hooray), took a couple of weeks to set up and involved a myriad of tubes.

Quote from my lab book: "I don't think this experiment worked very well (at all)".

No change there then.

This experiment, which was repeated many times during my PhD, never worked. The following PhD student had to travel to Europe to see how it was done and did get it to work (finally). The key: lyse the cells in situ and stop the reaction ASAP otherwise all the product is broken down. Shame this wasn't in the methods section of their published papers.

Luckily for me I had a number of other projects on the go so the failure of this one did not scupper my whole doctorate.

This is a flavour of why, if asked, I tend to advise my fellow medical students not to aim for bench research. Otherwise I keep quiet to avoid colouring them with my jaundiced view.

More depressing slouches down memory lane later.

Assisted suicide

UK nurses association (Royal College) has changed its position and is now neutral on assisted suicide (not sure when this became the euphemism du jour over euthanasia).

Have a look at the article:

"The move comes as a poll in today's Times found that 74% of people want doctors to be allowed to help terminally ill people end their lives." My bold.

Given that it would be the doctors who would be killing the patients, unsurprisingly the BMA is less keen on the idea. Hopefully, the RCN will stay neutral: it would be a strange situation to have two very divergent positions on this.

Here's the Times' take on this: unsurprisingly, it's viewed as a wedge in the united front of the healthcare profession.

Internships: it begins

So it begins.

NSW has run out of internships.

And so, in accordance with the letter sent to USyd students a while ago (and shown below), overseas students are being told so long and thanks for all the fees. Although, contrary to the comment from Andrew Pesce from the AMA, med students pay for an MBBS, not for an internship.

BTW applicants from overseas now have buckleys. UK grads be warned.

So, 879 students applied for 670 positions. There were 566 places in 2005 which is an ~18% (~20 pa) increase in five years. According to my rough calcs, to honour the COAG guarantee for Commonwealth funded students, we need to get to ~750 which is another 80 places... 14 more per year until 2015.

Next to lose out will be the full fee and interstate students.

So, perhaps by throwing the full fee payers and the internationals to the wolves, NSW may manage to fulfill their promise.

Medical literature 2

Here's another dated memoir, IMO, although I enjoyed this. Well written, interesting, but a lens to view the world of medicine 20 years ago. I used to work in the hospital where Dr Sparrow trained, and I saw the tail end of what you might call "diversified" medical training (ie lots of drunk rugger buggers).

To be honest, with less of a focus on prior exam performance and the like and more of a broader view of what makes a good doctor, it may be that the older intake of students made for better (that is, more rounded) medics than the current crop.

That being said, I'm surprised that the public still enjoy reading about the young masters' antics at medical school, getting drunk, stealing the toilets / mascots of rival medical schools, being "helped" through exams, chatting up the laydeez and generally behaving like a rampaging Dirk Bogarde. But, buy these books they do so perhaps the medical profession should revert to being a paternalistic profession and make the general public feel like they are being wrapped up in a warm, cosy blanket whenever they are admitted to hospital. Doctor know best.

There's good review of the book here.

Medical literature

Not the most auspicious cover in the world: an Ipcress-era Michael Caine / Julian Clarey lookylikey with too much eyeliner stares out, his mouth somewhat ajar. Above, a glowing reference from Maureen Lipman, possibly impressed by the author's numerous -ologies. A Radio 4 book of the week sticker. Yes, we're well into middle class England territory with this one. Give it to your daughter for her 17th birthday pre-med school interview sort of thing.

It's another "diary of a house officer" book. I picked it up at St Vincent's for $6 (that place has got expensive). Inside, the usual tales of know-nothing first day jnr doctors, advice not to need hospital treatment in the UK in the first week of August, scary consultants etc etc. Nicely written, a likeable, modest author, an hour to read, not a lot to learn. Indeed, no insights as far as I can see albeit from my position as a semi-insider.

Thing is, it reads like it comes from another era. It's pre-MTAS, pre-EWTD; an age when the problem for medical graduates was too much work, too much choice. To be fair to the author, he adds a note at the end of the book to acknowledge this which serves to strip the work of most of it's relvence.

I can't see the point of this book. It may as well as been set in a photocopy shop: genuine anecdotes which connect you with the human side of the job are few and far between. Sure, he screws up an misses a PE. Stripping that out leaves a fairly dull and predictable office romance between an older, married more senior man and the office junior to dominate most of the proceedings.

And, like every other intern / HO who has written a book, he becomes a psychiatrist. What's that all about?

Addendum: he's written a follow up about his SHO year, it seems. At this rate, he's going to have thirty-odd by the time he retires, although "my year marking time as an SpR" might not grip the reader so. If he worked on the counter in Boots he'd meet more people and probably have more of an insight in the human condition. The cover of his new book is worse, btw.

Technorati code

Here it is:

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Internships: the overseas student's perspective

Which brings us to the overseas students, poor souls who subsidise the locals. NB, I am not an overseas student.

A straw poll of the overseas students on my course found the following:

1. Yes, they would like to finish their intern training here, please.
2. Indeed, to practice in Australia was one of the reasons I am spending ~A$45k pa on tuition.
3. No, I didn't know that there will be a shortage of training places.
4. What's all this about Groups A, B and C.
5. That hardly seems fair.

This is a position that seems wholly reasonable. There is a degree of caveat emptor, but I would be interested to see how overseas applicants' expectations are currently being managed.

From what I can see, the representatives of the student body are doing nothing to help overseas students.

In my opinion, this is not fair.

Internships: the fate of the slowest wildebeest

This all begs the question: should all medical school graduates be guaranteed a job?

Here are some arguments pro and anti off the top of my head:

Pro:

1. Costs a lot of train a medic: wasted if they don't practice.
2. Entry requirements are very stringent and closely matched to likelihood of success in clinical practice (according to ACER anyway.)
3. Poor students are weeded out during a very intense assessment process whilst undergrads which acts like a four / five / six year job interview.
4. The intern year is a required element of training and should be viewed more as an extension of the medical degree.
   

Anti

1. Some medics who make it through are clearly incapable of practice.
2. A bit of competition keeps the students on their toes.
3. Makes for a fairer playing field with other degree courses (accountants aren't guaranteed an accounting job in the government).

Not sure how I see it; perhaps the arguments are balanced. However, from experience there are a small number students who really do not have the motivation, aptitude or competence to practice (in my opinion, obviusly). So, in the absence of any programme of "rank and yank" during the medical degree, a degree of competition post-graduation makes sense.

But that's not to say I think that 40% of students should go begging which is what will happen if something isn't done soon.

Internships: controlling supply

If I find myself again, like the chap above, looking at pretend chemicals in a flask again for a camera (as I did last on a World in Action HepC documentary - fame!) I will be very depressed. But that is what an F1 who taught me in the UK found himself doing for six months of his clinical training. Please, Lord, let the Australians not get so desperate to keep medical graduates off the dole queue that they resort to that.

The good news is that this doesn't seem to be under consideration at first glance. What seems to be being discussed is the following:

1. Expand the number of public hospital training posts (best outcome, really).
2. GP experience.
3. Private hospitals.
4. Other sites: private rooms, community placements.
5. Change the composition of the intern year (please, no, not research placements).Bear in mind that all states (ex-South Australia) require an emergency medicine rotation and that these posts are already scarce, prepare for a change there.

Number 1: best outcome if they provide more resources, but otherwise the only way this is going to work is by decreasing resident hours (sounds like the bloody EWTD), job sharing, subspecialty focuses and non-medical placements. This last suggestion puts the willies up me. One, apparently serious, suggestion is a placement in medical administration. This deserves a discussion of its own later. MEDICAL ADMINISTRATION. By the Lord Harry.

But wait: it gets worse. What's this? Clinical research and teaching? No, not coloured liquids in a flask! How on earth will I learn how to take care of patients from more of that. How would a patient feel when being cared for by someone who spent six months trying to get a PCR to work rather than in the ED?

GP training isn't such a bad suggestion for those that fancy being a GP. Unfortunately, Australia seems to be holding up the UK as a reason for why this is good idea: apparently, 50% of FY2 docs spend a term in a GP's practice. Hmm... isn't that because they are short of proper training places too rather than this being a good idea that was generated due to patient need? Unsurprisingly, starting to use GP's rooms all of a sudden to train medics runs into problems with infrastructure and demands on GP's time. But, don't worry, perhaps nurse practitioners can train med grads. Hooray. Oh, and NSW won't provide indemnity for grad in a GP's practice.

Private hospitals aren't such a bad idea but raise other questions of cost and indemnity. Sounds like a proper training, though.

Other: prisons, drug and alcohol services, crisis call centres? Bloody hell.

Suggestion 5 is a cheat: you will change the quality of the output if you make it acceptable to have medical graduates with much reduced medical experience.

Hmm... so, it looks like although Group A graduates are guaranteed an internship, what that internship looks like is currently in the air.

Have to say: I'll be buggered if I'm going back to bench research.

Internships: controlling demand

The first way to reduce the imbalance is to reduce demand. And the best way to do this is, of course, to change the rules so that fewer people are eligible to apply for a place or so that there is a ranking of eligibity.

Key goals:

1. Ensure that those who have been funded through med school by the tax payer complete their training so that the money isn't wasted
2. Ensure that those educated in that State can complete their training ahead of interstate students to avoid "they're taking our jobs" problems.
   

The lowest ranking slice of the salami is the easiest to identify: the international / overseas students. Sure, if there are a few internships left in unpopular places, then they can have those. This takes ~500 or ~14% of the 2014 oversupply out of the equation; it's a higher percentage at the better med schools.

The next lowest is trickier but will inevitably be full fee paying students. They have not been funded by the local funding state, and if they are unable to complete their training then caveat emptor. If med schools take up the full 25% of Commonwealth student allowance, then that's another ~20% or 700 graduates out of the running. Hmm.... aren't some private med schools all fee paying... what will happen to them?

This leaves ~2300 "core" Commonwealth funded students to train. We'll need ~600 more traning places which is tricky but surely the States should be able to increase by 40% over six years?

The graphic as the top is from a letter from those responsible for NSW medical training to the University of Sydney and shows NSW will be doing it post-2011: Group A are guaranteed. Nota bene the appearance of merit selection for Group C... MTAS here we come.

Given that NSW (plus ACT) provided 566 places in 2005, a 2015 demand of ~750 (944 with the full fee payers stripped out) will be a stretch to meet the demands but probably (has to be) doable. However, I would be worried if I were in Group C... making it into Group B will be a challenge (what is merit exactly... grades, extracurriculars...?) but then will there be any postions for Group B to fill? Depends on "additional workforce demand" and given that NSW Health will already be overstaffed with Group A'ers, I'm sceptical that demand will exist.


Let's look at the supply side next.

Internships: numbers

Hmm... back to front graphic.

Here's the deal*: since 2000, the number of medical schools in Australia has doubled to 20. Further, the Fed Government eased the limit on full-fee paying students for med school. Some will use this latitude, some won't so the actual number of grads is subject to a degree of variation.

The forecast is for the number of Australian Resident medical graduates to rise from 1287 in 2004 to >3000 by the middle of the next decade. The total number of intern places in 2005 was 1622 (great if you graduated then). You need to do this year to be accredited.

So, the situation is going from one extreme where there were plenty of spare internships for overseas grads to fill the gap (many from the UK), to one where there is a 50% shortfall unless training places are increased.

NB: this number excludes overseas / international students at Australian med schools: another ~500 on top of the ~3000.

So: how to solve the problem? As the veteran who has been at the receiving end of a number of expensive management consultants' reports when I was a BSD I Banker, I am well equipped to solve this one. You'll need to understand the BCG supply / demand relationship, though, and it's tricky. Here's the choices:

1) Reduce the demand for internships
2) Increase the supply of internships.

I'll add a third:
3) Discard the weak.

Clever stuff. I'll address each in turn in different posts.

*Much data used here and in later posts is taken from an Medical Journal of Australia briefing paper and from another report found here. Sorry: don't know how to post the article itself.

Internships: elephant in the room

Will I ever get to see a gomer?

Like many countries, Australia has looked to improve the supply of local medics / break the power of the medics (depending on your outlook) by increasing the number of medical students. Massively.

This has been done both by increasing the number of places in existing medical schools and by allowing new med schools to be set up. This has been done by the Federal Government.

Thing is, following your MBBS, you need to spend time as an intern to be accredited. Without the internship, there's not a lot of clinical practice you can do. Thing is, the State Governments look after the provision of internships.

It will not surprise many to hear that the two levels of government have not coordinated their efforts which means that there'll be lots and lots more medical students by 2012 but only a few more internships.

As things stand, it's likely that:

- Overseas students will be told to go home (after dropping A$300k on an education here)
- Inerstate graduates will be told to go home (!)
- "Non-traditional" internships will appear (GP, research, private hospital)
- At some point, there will be an MTAS style system to replace the current ballot (you think your grades don't matter... then they suddenly do)
- You'll be reading about nice middle class children being unable to find a career.
- Overseas applications will not be accepted (goodbye, escape route from the UK).

The depressing thing is, I've seen all this already in the UK. At least then, UK grads could kid themselves they could come to Australia. Not after 2010 they can't according to a letter to Sydney Uni med students (I'll try to upload this letter later).

The worst thing is that my fellow students don't realise this. Most overseas students don't realise this, which is worse for them because their home countries have just the same problem and probably won't let them come home for an internship because they are overseas trained.

I did a lot of research on this issue before taking the plunge and going back to study. I'll try and summarise this info in a few posts rather than all in one go.

Return from a break

Apologies to the 100 people or so who have looked at this site for the gaps in posting. First off it was exams, then a break which meant that I wasn't so busy and was living up to the aphorism of "if you want something doing give it to a busy person". Not that I haven't been busy being Daddy Daycare, but it isn't the same.

Results came out a bit ago and so time to reflect... all for the benefit of my portfolio because I will have forgotten this by next year.

My prep for these exams was much patchier than for those I took in the UK. I managed three or four days proper study between child and partner care (I have to cook a lot, which is tricky due to my immediate family being vegetarians) which wasn't sufficient. I managed to get the flashcards going and a mini whiteboard was handy so I'll keep that approach to the rest of the exams. I think I'll have to annotate as the term progresses from now on: making notes took up too much time and left precious little for proper revision.

The outcome was pretty good. Although the exam was much vaguer than the UK one, which was a bit of a trivial pursuit exam at times (esp. the spotter), I manged to up my % a bit. Some of the questions were tricky indeed: the only way I knew one of the answers was because I'd done it before. It hadn't been taught to us here. That was probably the only prior knowledge that came in handy!

Kids on this course being, I think, brighter (or at least better at exams) than at my old med school, I dropped a couple of centiles from my ranking but still did well enough should grades determine internships (more of that later...) I'd like a Top 10 finish: perhaps with the experience of this format I'll manage to hop up a couple of spots when this differential between 1st and 2nd years become leveled out (we take the same exams). I'd be interested to see how I performed cf my own year rather than year 1 and 2.

Hmm... I'll probably fail the next exam after writing all that. Serve me right.