American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, June 6, 2016

What the Junior Doctors' strike in the UK can teach us on this side of the pond

The United Kingdom's National Health service has been facing something of a crisis over the last several months. For those of you unfamiliar with what's been happening (the issue hasn't really gained any media traction here in the U.S.), a majority of the country's 55,000 junior doctors have been holding regular strikes. In the UK, the way in which doctors train is very different from the U.S., with often over a decade spent as a “junior doctor” before reaching Attending level. So-called junior doctors therefore deliver most of the nation's frontline care.

What's the dispute all about? In a nutshell, the Conservative Party which won last year's general election, led by Prime Minister David Cameron, did so with a manifesto pledge to deliver a “7-day NHS”. Various figures were quoted by the Department of Health for why care at weekends was inferior to weekdays, including increased mortality rates (which junior doctors heavily disputed). The government then proposed a new contract for doctors, which would essentially try to increase staffing at weekends. Unfortunately, this was without allocating any extra resources or staff for the change. In fact, the government was actually trying to class weekends as “normal working days”, so that they wouldn't attract a premium pay rate as they currently do.

Junior doctors were outraged, claiming that this would actually decrease their pay by up to 40% (no wonder they threatened strike action). Neither are they paid staggering amounts in the first place. The Secretary of State for Health, Jeremy Hunt—who incidentally has no background in health care—became the most vilified person in the UK within the medical profession.

Negotiations between the government and the main doctor's union, the British Medical Association (BMA) broke down, and Jeremy Hunt then enraged doctors further by threatening to simply impose the new contract from August. A wave of industrial action and strikes followed. After a major impasse, with untold damage done to the morale of the profession, the government as of last week finally agreed to return to negotiations.

All along the junior doctors argued their case from the perspective of patient safety, and the general public on the whole have been supportive. However, it would be disingenuous to pretend that pay wasn't the major issue (and to be fair who wouldn't be outraged if their pay was slashed by so much along with an increase in workload?). If the exact same contract had been proposed along with a very significant pay increase for working more weekends, we unlikely would have seen such a fuss.

Following the news in the UK closely, I felt very sorry for the doctors. I left the NHS shortly after graduating from medical school but still have lots of friends working over there. Many are junior doctors who will be greatly affected by the new contract. Their plight can teach us a few things on this side of the pond:

1) The danger of over-centralized control

The UK's NHS is one of the most heavily centralized health care systems in the world. Founded after World War 2, few other countries have followed this model. What it is, however, is very fair. But as idealistic as the principle of the government delivering high quality care absolutely free at the point of use, the danger of a system like this is that the healthcare system will be used as a political football by politicians. One of the first commentaries I ever wrote on this subject, almost 10 years ago, was about how the Prime Minister of the UK can almost be blamed for the spread of methicillin-resistant Staphylococcus aureus (MRSA), whereas blaming the U.S. President for this would be unthinkable! Doctors in the UK are completely at the mercy of the prevailing political winds, and politicians likewise maintain a ridiculous amount of control. Another example was when the UK Secretary of State for Health announced several years ago that no health care worker could wear anything below the elbows (a “bare below the elbows policy”). This grabbed the newspaper headlines as the politicians wanted, and overnight the UK went from having some of the smartest dressed doctors in the world, to banning all suits, shirts, ties, white coats, and even watches—in every hospital across the country (with flimsy evidence as to its effectiveness).

2) Leaders with no experience of health care

In the United States, despite the problems we face, at least CMS/Medicare do have many current and former clinicians in prominent positions. The UK's health service is, on the other hand, totally at the whim of an executive that has no experience whatsoever in healthcare. Most of them are career politicians who frequently shift between different cabinet positions every year or 2.

3) The power of physicians banding together

The latest news from the UK is that the government is returning to the negotiating table. This is after months of junior doctors piling on the pressure by banding together. Although I am not in favor of unionizing and believe that it would lower the prestige of the medical profession, there is a lot to be said for organized action under any umbrella.

4) Getting everyone on side

The doctors in the UK successfully gained public and widespread media support by framing their argument as one of great patient care and safer hospitals. Nobody—no bureaucrat or business person—can ever argue successfully against that.

5) Freedom

One of the things that first drew me to the U.S., and still holds true even after the big changes in health care over the last decade, is that physicians in America hold a massive and unprecedented degree of freedom in choosing their working environment. There's working for a multi-specialty group, university, academics, VA/government, locum work, non-clinical endeavors, and yes—even today—private practice. Compare that to the UK, where the private sector is tiny and doctors are essentially stuck with contracts that are dictated by the government, fewer job opportunities, and less room to innovate.

Hopefully, speaking with solidarity for the UK's doctors and fully aware of what a demanding and challenging profession medicine is, their problems will be sorted out very soon. But as different as the American and UK health care systems are, there's indeed a lot of lessons U.S. physicians of all specialties can draw from what's happened on that side of the Atlantic.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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