Bad Medicine: Medical student numbers

Des Spence

doi:10.3399/bjgp17X690305

Here is an interesting fact. In 2011, only 50 out of 30 000 pupils receiving free school meals were accepted into Oxbridge, compared with 60 from the final year of 300 from Eton College.¹ Oxbridge is deemed to be the zenith of academic achievement and parents use hushed reverential tones when they even mention the word. But I’m good at statistics and, if you consider the spread of IQ in the population, it is statistically impossible that Oxbridge are accepting the most able students based on merit. There is a confounding factor at play: schooling. Many pupils gain admission by old-fashioned cheating, help with coursework, extra tutors, support with writing personal statements, and the slew of additional activities like piano lessons to pad out the CV. It’s not what you know after all, but who you know. Here I should declare a conflict of interest: I am one of the free school dinner kids and these numbers irk me deeply!

So what does this political posturing have to do with medicine? A lot. Medicine is the most elitist profession with 25% of the intake from private schools and 80% from professional or senior management backgrounds (with Scotland being the least socially diverse nation).² We are selecting doctors from a very narrow band of the population, making the profession homogenous and bland. Again, the same Oxbridge argument holds true: it is statistically impossible that we are selecting students on the basis of merit. It is privilege at play, with medicine seen as a trophy degree.

So we have a recruitment crisis in general practice and shortages of doctors throughout many medical and surgical grades, and we are spending £3.7 billion on agency staff to plug this workforce gap.³ There seems an obvious solution. Medical degrees are oversubscribed with many qualified applicants rejected on a largely arbitrary selection process. The course is onerous but not difficult. Why don’t we simply train more doctors?

It costs over £200 000 to train a doctor.⁴ Complete undergraduate training amounts to £57 000 in tuition and £151 000 in clinical placement, which is essentially peanuts in the context of current agency costs.

There are plans to increase undergraduate numbers by 25%⁵ but this will be inadequate. Demand for medical care is increasing and working patterns mean that more part-time working is the norm. We should double the current 6000 to 12 000 medical students — only costing about £1 billion and bringing the UK graduate numbers in line with other European countries.⁶ There would be a potential risk of medical unemployment, but why should only doctors be protected from the risk of unemployment? So why isn’t the profession agitating and promoting this logical economic argument for a massive expansion in medical numbers?

It is self-interest. Economic scarcity of doctors means we artificially inflate fees, protect private practice, and maintain status, but it is a brake to change and innovation. We demand more work–life balance while clinging to outdated notions of status and position. We can’t have it both ways — something has to give.

We need more medical schools, to expand the ones we have and overhaul the outdated, thoughtless, and rote undergraduate teaching experience. Having many more doctors would reduce elitism, which would only be good for doctors because it is the jarring dissonance between the realities of the job and youthful expectations that make so many doctors miserable.

We are wasting potential. Medicine needs a different skillset and a lot more spice.