Gradaute medicine as a science conversion course?

[Caius]

Hey everyone,

I've been wondering: does it make sense to see graduate medicine as a science conversion course (for those of us from non-scientific backgrounds)? I ask because one of the reasons I've been considering medicine is my frustration with the uselessness (in a practical sense) of carrying out a research career in my subject (law).

To give you a sense of why. Imagine I am an academic whose specialist area is medical law and ethics. Over a period of twenty years, I publish many papers in legal journals calling for the introduction of a measure I believe to be justified (philosophically, morally, etc.), some change to the UK's current system of organ donation, say. Making it opt out rather than opt in, suppose.

My career ends and the proposal is never adopted. Some young scholar begins publishing papers vigorously disagreeing with my ideas.

In such areas of research, the disputes are (or so they seem) endless. There is no consensus, no agreement. Moral philosophers still debate questions raised by the Greeks thousands of years ago. Do scientists do the same? Not to the same extent. The ideas of Galen are not studied today by scientists today as seriously as those of Aristotle are by philosophers.

I'm talking about progress. There has been some moral progress. The realisation of the falsity of racism is of this kind, for example. But this has owed much to cultural forces. Moral knowledge seems to be much harder to come by than scientific.

I worked in a hospital laboratory. I shadowed a firm. I possess some idea of what life as a doctor is like. I don't know whether I have it in me to be a good physician, but something tells me I am more suited to working in science than law. Is graduate medicine the right route for me? I'm not sure.

Thoughts?

[psych1984]

Caius

This is a question I asked myself some time ago and in the end I decided to pursue grad med. I am about to start this September so offer my opinions from the perspective of someone who isn't qualified but has been in a similar position.

From what I can see and speaking to others graduate medicine cannot be really seen as a science conversion as they isn't a great deal of variation in the way in which material is taught. Most courses have exactly the same modules minus the student selected ones in phase one and just compress the time in which the modules are covered. You still cover the same amount of modules than someone on a traditional 5 year course would do. Generally speaking the start of most courses is mostly academic with clinical phase marking the start of a much greater emphasis on practical clinical skills.

Whether or not medicine is the way forward for you is a rather personal question I guess. Does the thought of life long learning and studying appeal to you? Do you like working with people? Will you enjoy learning about the human body? Medicine is not a hard and fast science like physics. When you introduce the human aspect into it produces much variance in the outcome even if the same treatment is applied. For example two patients who are identical in physiology but who have different personalities may react differently to certain treatments. There is a greater placebo effect for invasion procedures like injections than for pills even if no actual active treatment is applied. We can only estimate with a certain level of confidence that certain things will happen based on previous research and observations.

Most people who observe medicine in practice will often wonder whether they would want to be a physician but as any qualified medic will tell you its also about can I put up with being a medical student? Can I live with going from a position of responsibility to have very little? No pay for 4 years? Getting myself into lots of debt? Studying as a full time job?

If you're thinking even despite on the sacrifices I am still prepared to give it a go then maybe medicine is for you. It's also important to remember that no one ever has 100% certainty whenever they are going to do something new. I have definitely decided to take up my place in September but still have second thoughts about whether I am doing the right thing occasionally.

[adriantoll]

Caius - A great series of questions. I should say from the outset that I haven't started any medical training either - I'm starting 1-year A-Levels in September with a view to starting a 4-year degree in 2011.

I have simliar concerns to you. My first degree was an MA (Hons) in Experimental Psychology, which included quite a few outside courses in philosophy, including moral philosophy. I'm still fascinated by the questions those courses raised - as you say, many of those problems seem to be intractable, on a societal level at least. My second degree was a BA in Sculpture - which was an attempt to make philosophical objects to help me think about the questions raised by philosophy. The degree did help my thinking but, as it turns out, it was more to do with art's generalised powerlessness to make coherent moral arguments (which has a good deal to do with the state that the art world is currently in) that gave me something to react against.

I'm interested in two things in terms of medicine - the scientific component, and the engagement with morality in a concrete, practical way.

From talking to a number of my friends, both students and qualified professionals, there does seem to be a large component of science - although how big a component of your work this ends up being will depend on things like whether you do research at the same time, and what you specialise in. The process of diagnosis is a very logical procedure although, as psych1984 points out, you have to deal with big variations between people - but this is something that, again, can be tackled logically. There are some pretty clear directions for outcomes - based on your actions, someone gets better, they stay the same, or they get worse. There are some gradations in that of course, but it's nowhere near as slippery as societal morality. Also, advances in things like scanning technology have allowed very clear progress in diagnosis and treatment in areas like neurology and paediatrics. Most of these gains have a clearly "good" outcome - longer, healthier lives for people. An ENT surgeon I spoke to said that one of the biggest kicks he gets out of his job is getting a diagnosis right - it's an intellectual challenge for him to use his scientific knowledge so he can treat his patients in the most effective way possible.

It seems to me that there are also moral balancing acts, however - for example, given some recent research that suggests SSRI anti-depressants are no better than placebos for mild depression, should GPs continue to prescribe them? After how many weeks from conception should women be stopped from having an abortion? Many of these decisions are made above the level of individual doctors - the terms limits on abortions is a good example - but are moral questions nonetheless.

Then there are grey areas that are about judgement rather than morality - if someone has a condition that can be ameliorated by a particular kind of medication, but that medication has serious side effects, how do you and the patient balance those two elements, even when they might be as different as severe debilitating headaches vs a burning skin rash? In this example, as I understand it, this is much more of a conversation between patient and doctor than it used to be.

The thing that really made my mind up was that most of the time there's a clear spectrum of good (the patient's condition improves or is even completely cured) to bad (the patient's condition gets worse or they may die), and the procedures you employ are generally backed up by a great deal of serious scientific research. There are exceptions, of course, but from what I've gathered talking to friends in the medical profession, they are definitely exceptions.

A couple of things that I found interesting while thinking about this:

1. A book called The Deadly Dinner Party: And Other Medical Detective Stories by Jonathan Edlow. I loved this book for the insight it gives into the process of diagnosis. Of course these stories are all picked because of their exceptional nature, and all cases you encounter won't be like this, but it at least got me enthused.

2. The site Bad Science: Bad Science
This is an amusing, infuriating blog written by a doctor who rails against the dreadful way that science, and particularly medical science, is portrayed in the media - but also against bad scientific practice in the medical profession itself. For example, the way that scientific trials of drugs are carried out by the pharmaceutical industry in such a way as to make what look like impeccable clinical trials turn out in exactly the way that they want. (There's a book of the same name that collects his columns, which might be more readable than the blog if you want to read more than a few pieces).

I hope that train of thought is of some help! As psych1984 and another mature student I spoke to said, most people don't ever stop questioning why they're studying medicine - but perhaps that's the nature of people who want to go into the medical profession, and the nature of the medical profession itself...

[Caius]

Thanks for replying both of you.

You've given me plenty to think about.

This is where I am at the moment.

I'm thinking there are some pretty strong reasons against GEM. Do I want to spend 4 years living in poverty, studying more fiercely than I ever have in my academic career in the hope of obtaining a job as a junior doctor? A job which is difficult, stressful, marked by long hours, and not particularly financially rewarding?

When I put it in these terms, probably not!

Well, I still have a while to decide.

I'm going to keep my options open whilst getting some more experience: practical and theoretical. This is probably the best way to make up my mind.

[adriantoll]

Mmmm. I always wonder about it when people say "four years of extremely hard work, only to be a junior doctor" - because surely the goal isn't being a junior doctor, it's being a doctor. That happens after six years, so another way of looking at it is "four years of hard work and poverty, followed by two years of hard work and slightly less poverty, followed by a lifetime of extremely interesting work and a very good salary"? I look at the whole process as a six year chunk, rather than four - which means that my eyes are on the prize that I get after six years, rather than being disappointed in being a junior doctor after four...

God knows though - until you're in the middle of it all, it's probably difficult to comprehend quite how much hard work it is...

[psych1984]

I echo adriantoll's points caius. Best to think about it as 6 years of hardship rather than something which is permanent. Most of my friends who are medics struggling with foundations and there was a lot of mention of quitting in those two years but this quite promptly stopping once they got on the specialist training. Keep your eye on the prize as adriantoll said.

If financial gain is the only motivating factor in a career then one should not choose medicine. This is not to say that money is not important and one should only consider interest and job satisfaction.There are much easier ways to make money. As you will know law is much more lucrative and to some extent so is accountancy and finance as well as numerous other career options. Personally as a health professional I love the feeling I get when a patient gets better, that to me is priceless. Others like the thrill of diagnosis and understanding the science behind it all. I think it would be very hard to stay motivated for 4 years if all I had on my mind was earning a good salary at the end of it. I think you're right in gaining more experience this will help you to find out where you motivation lies.

For me the decision is simple in a way. Could I look back on 20 years time having not taken up my offer, not given it a go, and not regret it or think "I wonder how life would have been as a medic". I'd rather regret something I have done rather than something I didn't do but could have. There are advantages to being a mature student, one of which is that you can always go back to your old career if things don't work out.