September 15, 2020

The rainbows drawn by children at the beginning of lockdown and blue-tacked to the living room window are starting to look rather yellow at the edges, as the brief flurry of love for “our NHS” starts to fade. The pandemic rumbles on, and all the while the healthcare recruitment crisis grows ever more acute. A recent survey undertaken by the Doctor’s Association UK asked respondents “where do you see yourself working in the next one to three years?” Shockingly, almost two-thirds of doctors said they would be leaving the NHS.

The Covid-19 crisis is one reason for this exodus, but only one. Although a majority of doctors surveyed reported that the Government’s handling of the pandemic had made them more likely to leave the NHS, a much more significant factor was the lack of a real-terms pay rise. And indeed, at the beginning of this year, just before the pandemic took hold, an article in the BMJ warned of the threat of “Drexit (Doctor-Exit)”, described as:

“… the exponentially growing trend for doctors to walk away from their jobs in the NHS, either to new healthcare systems overseas such as Canada, Australia, New Zealand or perhaps worse, into new professions altogether, leaving behind their well-trained medical brains. This exodus has been gaining momentum for several years with the workforce now at breaking point.”

I’m a medical school drop-out. I applied for reasons that were, in retrospect, a bit silly; I liked both arts and science subjects, and thought (wrongly, as it turned out) that a medical degree could neatly combine the two. Also, I really did want to “help people” — pat, I know, but true.

I got in, I disliked it, I failed my first-year exams and, rather than resitting them, I decided to leave. The experience has left me with a very patchy knowledge of the human body (for instance I know a surprising amount about the anatomy of the thorax, and next to nothing about the anatomy of the head). But it hasn’t left me with any feelings of wistfulness — because I don’t know a single junior doctor who is happy in the job.

At the end of last year, I met up with four old friends from medical school, some of whom I hadn’t seen since I left. All of these women are highly capable graduates of UCL, one of the best and oldest medical schools in the world. But only one of them intends to remain in NHS clinical practice. One is leaving to do private cosmetic work, one is going into hospital management, and another is leaving the profession altogether. I also know several doctors who have emigrated to South Africa or Australia, enticed by a higher salary and a lower cost of living.

And why on earth wouldn’t they? As I know all too well, the desire to “help people” may be genuine, but it doesn’t always last. Medical students are selected for the three magic traits that together produce a highly desirable worker: high intelligence, industriousness, and good communication skills. With these talents, almost all could go and work in the city and earn lots of money if they wanted to. Or they could choose a lower paid role that offers a comfortable work-life balance.

Medicine can offer plenty of money and some flexibility (a part-time GP still has a pretty sweet deal), but first you have to spend five or six years studying, followed by many more years training, and with your choice of job and location severely constrained. A friend of mine was desperate for a foundation years placement within striking distance of her mum, so that she could call on her for childcare during long overnight shifts. But she was at the mercy of an NHS bureaucracy that obstructed this eminently reasonable request every step of the way. No wonder young doctors are so angry.

Pay is a large part of the problem. Post-austerity, doctors’ salaries dropped by 8% between 2010 and 2015. New graduates now leave medical school, flushed with pride at their achievement, only to be greeted by a basic salary of £28k, well below the sum needed to buy a home in the most expensive parts of the country.

But there is also that far more slippery and sensitive issue of status. Although the public do still consistently put doctors and nurses at the top of the list of most trusted professionals, the long term shift from a paternalistic to an egalitarian model of doctor-patient relationship has come with costs. Medical students are warned of the risks of acting in the bad old style: striding imperiously down a ward and giving orders with no regard for the patient’s preferences. But in the bad new style, patients consult “Dr. Google” before arrival, take no heed of a clinician’s expertise, and dismissively use her first name.

Health Secretary Jeremy Hunt even suggested that the NHS should do away with “stuffy titles” because he believed that a hierarchical team structure led to more mistakes. Of course, Hunt also imposed punitive contract changes that triggered a general strike among junior doctors, the first such industrial action in 40 years. Bad pay, bad conditions and not even a “stuffy title” to provide some self-respect — no wonder the medics I know still refer to Jeremy Hunt in Cockney rhyming slang.

How much of this drop in status is to do with the fact that, for the first time in history, medical school graduates are majority female? Germaine Greer wrote in 1999 that “[p]restige and power have seeped out of professions as women joined them. Teaching is already rock-bottom; medicine is sliding fast”. A 2009 study of US census data from 1950 to 2000 backed up Greer’s claim, demonstrating that as professions become female-dominated, pay and prestige both drop.

As a rule, I am suspicious of any explanation for a complex social phenomenon that leans too heavily on individual malice. I know full well that the gender pay gap is overwhelmingly not the result of sexist recruiters, but rather of biology: put crudely, women have babies, and babies don’t get along well with full-time jobs. But the usual explanations for the pay gap still don’t quite explain why so-called “occupational feminisation” seems to be the kiss of death when it comes to professional prestige. Maybe there really is something about women qua women that inspires a lack of respect in patients, bosses and politicians.

And things could yet get worse. The automation revolution is expected to have a dumbbell-shaped effect on the economy, with very low skilled and very high skilled jobs first in line to be replaced by artificial intelligence. So truck drivers, fruit pickers, and factory workers will lose their jobs, but so will lawyers, accountants, and — yes, possibly — doctors.

Funnily enough, I’ve heard on the grapevine that a medic I was friends with at UCL has now left clinical practice and is working for a tech company trying to develop robot doctors (she never did like patients much). The broader project is going well: AI can already outperform radiographers at some tasks, and recently a computer-controlled robot successfully performed intestinal surgery on a pig. Right now, “Dr. Google” is just an annoyance for doctors; soon, though, it could be coming for their jobs.

Although not entirely. David Goodhart’s new book offers a useful way of thinking about the coming impact of automation, with the blow likely to fall hardest on what Goodhart calls “head” (professional) and “hand” (manual) jobs, leaving “heart” (care) jobs mostly unscathed. Medicine is, to some extent, a combination of all three, since the role requires a combination of brains, dexterity, and bedside manner. But it has traditionally been classed more within the “head” category which, as Goodhart argues, currently enjoys a dysfunctionally high level of income and prestige.

“Heart” jobs will survive automation because they involve the kind of human touch and warmth that machines cannot easily imitate. The heart component of the doctor’s role is therefore likely to survive, even if a patient can step into a full-body scanner for diagnosis, take a pill perfectly tailored to their genetic profile, and undergo surgery carried out by a robot controlled by a surgeon on the other side of the world, or even no human surgeon at all.

Even with access to the most sophisticated AI, doctors will never be entirely redundant, since patients will still need someone to hold their hand and direct them towards the waiting machines. But think: if doctors have lost all of the high status “head” roles and are left only with the “heart”, is anyone really going to continue using their “stuffy titles”? Their prestige, already diminished, could hardly survive such a development. Doctors could find themselves sunk to the status level of nurses, another majority-female profession who are loved, trusted, but also regularly disrespected (not least, I’m sorry to say, by doctors).

Doctors don’t want sentimentalism. The ones I know didn’t mind the “clap for carers”, but they didn’t like it much either, since the gesture did nothing to change their working conditions. While they still can, many will reject bad pay and falling status by voting with their feet, as two-thirds apparently intend to. But with the rise of automation, their options may become more limited. This historically stable and lucrative profession is in trouble, and a sincere desire to “help people” might not be enough to save it.