What happens when medicine sinks in pay and status

As the Soviet Union showed, by the time medicine is fully nationalized, careers in medicine have been reduced to the lowest status level, somewhere around street cleaning.  Learning medicine and practicing medicine (including nursing, pharmacy, technical jobs, etc.), is incredibly time-consuming and, in a society that still has the gloss of being capitalist, costly.  The jobs themselves are incredibly tough, both physically and emotionally.  Aside from the undoubted pleasure many find in helping sick people, the real remuneration for all the time and energy involved in working in medicine is money.  Government, of course, takes that incentive away.  And, absent the incentive, that’s how you end up with this:

An NHS hospital has staff from a staggering 70 countries on its payroll.

The huge number of overseas nurses, cleaners and porters has forced health chiefs to send them on ten-week English courses because many do not understand basic medical phrases.

Among the terms some workers from countries such as Burma, the Philippines and Poland can’t follow are ‘nil by mouth’, ‘doing the rounds’ and ‘bleeping a doctor’.

They highlight the language problems throughout the Health Service, which critics say are putting patients’ lives at risk.

The lessons follow several ‘near-disaster’ cases, including one where a meal was delivered to a patient because a member of staff did not understand that ‘nil by mouth’ meant the man could not eat or drink.

Although all doctors from outside the EU must pass an English language test set by the General Medical Council before they can practise, the same rules do not apply for other hospital workers.

Instead, they are usually assessed on their grasp of the language at interview.

The problem has become so acute at Oxford Radcliffe Hospitals that foreign workers are being encouraged to attend ten-week, taxpayer-funded ‘English For Speakers Of Other Languages’ courses, which are run by a nearby college.

Research has found that up to a quarter of nurses  –  more than 60,000  –  working in London are foreign, with the largest number coming from the Philippines.

Read more here.

While the above report makes clear that the language problem in the NHS involves nurses, not doctors (who must be minimally competent in England), reading the British papers makes it clear that foreign educated doctors carry their own problems.  Training isn’t standardized, many of them commute from overseas and are perpetually jet lagged, and practice values are different.  In a country that makes being a physician worthwhile — which is what America has done for so long — you get the best and the brightest.  Once practicing medicine or being a nurse is about as high status (and high paying) as being a clerk in a government office, you’re going to see the best and the brightest gravitate elsewhere.

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  • 11B40

    I hope that you don’t find this contentious, but one of the things that has puzzled me somewhat about the practice of medicine in this country is my experience with Army medics during my all-expense-paid tour of sunny southeast Asia.  These guys spent six or nine months in medic training, after their basic training, and, between you and me, I would rather have one of those guys looking after me than most of what I have been running into in the medical profession the last half-dozen years especially, the English as a Second Language wonders.  Beside the actual language difficulties, which are obviously very noticeable, I wonder about the cultural awareness.  I remember in one of my 1960s (pre PC) sociology classes listening to the professor talk about how Mediterranean people being more demonstrative in terms of their discomforts than the people of Northern Europe.  Your basic combat medic knows you much longer and much better than any doctor by whom you will ever be treated.
    Milton Friedman, in his “Capitalism and Freedom” has a chapter about how the AMA is little more than a guild which, through its influence over this country’s medical schools, restricts entry into the profession.  While there has been progress in the profession lately, in terms of things like nurse practitioners and such, I still wonder how much we are missing out in terms of adequate medical treatment as a result of medical care being restricted by the AMA guild.

  • gpc31

    My wife has been a high level administrator at two top medical schools and as such, I have gotten to know several deans, professors, scientists, administrators, NIH professionals, etc.  I have been absolutely puzzled by their collective lack of concern over the obvious second order effects of ObamaCare medical education.  How can they neither see nor care about the obvious consequences for the recruitment and placement of future doctors, as pointed out so well by Book?  I mean, it’s not even on their radar screen.  And these are hard working, highly intelligent people who are truly passionate about the quality of medicine.  

    OK, one part of the puzzle is easy to solve:  Political bias.  They are all lovely people in person, but as a group, they are dreary, unself-critical and conformist liberals in academia (but I repeat myself).  So of course they support a Democratic plan.

    But then it hit me:  it goes beyond simple political bias.  It’s the funding.  As long as they get NIH grant money and subsidies, they’re happy.  The stimulus money for electronic medical records is another big bonus, especially with declining endowments.  They care more for research than education.  (Training general practitioners isn’t glamorous enough — wonder how they’ll react to future federal mandates requiring more gps?)

    You could say that they are being bought off.  However, the medical school leadership genuinely does not view itself as coopted by federal money.  Greed only applies to the business world, you see.  Medical research is a higher mission that deserves more funding.  So it is easy for the mandarins to rationalize away their entitlement mentality when it is mixed in with some disdain for, and envy of, the private sector. 

    Which brings us to a still deeper problem.  They have NO idea about how wealth is generated in the real world.  None.  They live in a budgetary world in collaboration with federal bureacrats:  a land of five year plans and decanal diktats.  A sympatico mindset of top-down planning.  Just shake that money tree!  Never mind how biotech spurs innovation, how much money evil big pharma ploughs back into research, or how wealthy alums manage to acquire the money to give back to their alma maters….

    It gets worse.  My incredibly competent wife and her academic colleagues are completely clueless about the Hayakian knowledge problem.  It is a foreign — nay, alien — concept. The idea that smart, well-intentioned regulators cannot in principle run things simply does not compute.  Why should it?  There is no such thing as price discovery in academia!  What is there to signal and coordinate?  There is only a market for endless memoranda, and we all know how efficient that is.

    And yet she, along with her fellow deans, is frustrated that career federal bureacrats are manifestly misallocating stimulus money for medical research.  Duh.  At least the regulators have a smidgen of knowledge, unlike the anonymous twenty-something staffers writing the legislation for Henry Waxman, who pretends to omniscient self-righteousness, until you reach that pinnacle of invincible ignorance, Obama himself.

    However, incoming medical students get it.  Practicing md’s get it.  Book is right:  the best and brightest will go elsewhere, even if the medical establishment can’t see it right now.

  • Jose

    I work in support of a large medical institution.  The leadership has made no bones about it’s support for Obama care.  And gpc31 is absolutely right;  it’s about the MONEY.
    They would tell you, and probably believe, that their motivation is to make health care more available and affordable.  But the road to all those noble goals is paved with money.  As far as I can tell, they are completely focused on tapping into federal funds, with no thoughts of anything else.

  • http://bookwormroom.com Bookworm

    Absolute right, both Jose and gpc31.  I know several people who work for large medical organizations, and they are thrilled that people will be forced to buy insurance.  They don’t care about liberty or overreaching power.  They’re also too foolish to realize, though, that if they’re required to sell to terribly sick people, and if there are minimal penalties for well people who forgo insurance, it’s not insurance anymore.  The large institutions will just be taking a dime to provide a dollar’s worth of health care.  It’s already happening in Massachusetts.

    Greed, but dumb.

  • http://conservativlib.wordpress.com/ eric-odessit

    I have to offer a couple of corrections.
    1st of all, about the former Soviet Union.  The profession of doctor was always prestigious there.  But it did not mean that the best people got into it.  The government restricted certain groups from enrolling into medical school.  For example, in 1970s-1980s Jews had no hope of getting into a medical school, unless they knew someone high up at the school.  In some places, like my native city of Odessa, locals and people from big cities were not admitted: the preference was given to people from the countryside.  The theory was that they would go back to the country, rather than try to stay in Odessa upon graduation.  By the way, this is why I view the Federal Government taking over the student loans as a very sinister development: the loans can be used to implement Soviet-style quotas.
    The nursing was OK, but much less prestigious.  You did not need to go to university for nursing, but rather vocational school.  The degree in nursing would at best be equivalent to an Associate degree here.
    Now, about Filipino nurses.  There are a lot of them in this country as well.  They are usually good and speak good English.  But I suspect that their English is an American version.  The terms, quoted in the article you referred to, are probably British terms, perhaps even British hospital slang.  I suspect that my wife, who is American-educated and a very experienced nurse, would not understand those terms as well.  But I will ask.

  • http://bookwormroom.com Bookworm

    Thanks so much for the info, Eric.  Regarding the status of doctors in the Soviet Union, I always learned that, as women entered the professional, status declined.  I then learned that, as doctors had less and less ability to provide treatment, status declined (not unsurprisingly).  Having quotas is also going to decrease trust in the system.  I know from doctors here that Soviet trained doctors pretty much had to be retrained, since, aside from a few prestigious specialists, most practiced medicine circa 1955.

    As for nurses, I have to admit to a bias against Filipina nurses that dates back 20-30 years.  In San Francisco, Filipina nurses showed up on the scene in the 1970s and 1980s.  During that era, both family members and I were seriously ill at various times and had to be hospitalized.  While there were undoubtedly lovely Filipina nurses (male and female) who cared for us, so many of them had a “that’s not my job attitude,” meaning that they would not deviate one iota from their prescribed duties, right down to refusing to bring a blanket if it wasn’t in their job description.  Language was also a big problem.  I don’t know about their relationship with the doctors, but I do know that patients couldn’t understand them and they couldn’t understand patients — and that was with the best will in the world on the nurses’ part.

    Funnily enough, regarding attitude, I never got the feeling that it was a problem with the Filipino culture, which I know is a very traditional culture.  Instead, it seemed very much to be a victim issue:  I’m a minority, therefore you’re a bully, and that’s American all the way.