Credentialing: shifting more costs onto the trainee

Shape of Training has many disastrous regressive elements, not least the introduction of 'credentialing'.  Note first of all that the GMC defines a credential as a 'formal accreditation of attainment of competences'.  Therefore the direction of travel pushed by the government via the GMC and Shape is yet more competency based methods in training.  As if we haven't seen the harms of an over reliance on this deeply flawed reductionist approach in terms of encouraging minimum standards and demotivating trainees....

Look at the extract in the Figure above, it demonstrates concisely just where the cost of credentialing is going to be dumped, it will be the Royal Colleges initially and then, yep you've guessed it, the College will then pass this extra cost onto the trainee.  As if medical training wasn't expensive enough already with student debts, GMC fees, College exams and fees, Training body fees (JRCPTB/ISCP etc), now the government is dumping yet another cost onto the trainee.  It's just as well we don't have multiple recruitment crises at the moment, oh wait a minute....

This excellent piece in the NEJM summarises the lack of benefit of this kind of training bureaucracy and the huge costs involved in maintaining it.  This article relates to 'meeting maintenance of certification (MOC) ' in the US but there are stark parallels with both revalidation and credentialing. 

Much like the Shape of Training's recommendations, there is zero credible high quality evidence to justify the introduction of 'credentialing'.  Arguably revalidation and credentialing are of little, if not zero, benefit to both doctors and patients, while they introduce extremely costly self serving bureaucracies which can also do a lot of harm in a number of ways.  There are many more potential harms to credentialing, including fact that it introduces more employer control over access to training and the quality of training.  The lack of any proven benefit combined with the fact that it appears designed to dump yet more costs onto the trainee make it something that should be firmly rejected by the profession and any reasonable doctor.

Doctors - email your trainee group NOW!

The BMA have produced an excellent statement on the 'Shape of Training' review and a large number of trainee groups have rightly signed up to reject the review in its current dangerous form.  The groups which have signed up are:

Association of British Neurologists Trainees
Association of Clinical Pathologists trainees group
Association of Otolaryngologists in Training
Association of Palliative Medicine trainees group
Association of Surgeons in Training
National Dermatology Trainee Committee
British Junior Cardiologists Association
British Medical Association Junior Doctors Committee
British Orthopaedic Trainees Association
British Society of Gastroenterology Trainees' Committee
Oncology Registrar Forum
Royal College of Obstetricians and Gynaecologists Trainee Committee
Royal College of Ophthalmologists Ophthalmic Trainees Group
Royal College of Radiologists Junior Radiologists Forum
Young Diabetologists' and Endocrinologists' Forum


There are a number of notable groups who have not signed up despite a total lack of interest in consulting their members on this potentially destructive review.  I have collated a list of email addresses for those of you who belong to the following groups, please email them and ask them why on earth they have no supported the BMA's statement:

Medics (Royal College Physicians) Trainees.Committee@rcplondon.ac.uk
RCSEd traineescommittee@rcsed.ac.uk
Emergency medicine EMTA@collemergencymed.ac.uk
Pharmacuetical medicine TraineeSubcommittee@fpm.org.uk
Anaesthetics trainee@rcoa.ac.uk
GPs aitcommittee@rcgp.org.uk
Paediatrics and Child Health training.enquiries@rcph.ac.uk
Psychiatrists ptc@rcpsych.ac.uk

Massive questions remain unanswered on the real motives of Shape......

The problems with the Shape of Training review of postgraduate medical training become more and more obvious by the day.  Today the BMA has released a joint statement on Shape calling for the powers that be to reject the review in its current form:

"We therefore reject the current direction of travel for Shape of Training"

The bottom line remains that the public have never been adequately informed or engaged in the review, and they should have been.  The most important thing is maintaining high quality patient care, for a number of reasons Shape threatens to undermine quality in the name of creating a compliant and flexible workforce.  This appears fundamentally driven by the interests of employers and not the public.

The evidence review was flawed, the review's recommendations are regressive and potentially extremely dangerous from a patient safety perspective, trainees have not been involved, in fact the profession has not been adequately consulted or involved.  The GMC refused my Freedom of Information request pertaining to the documentation of secret meetings involving Ministers and the review's Chair, as did the Information Commissioner.  I have been fortunate enough to recently be vindicated in court and the GMC were therefore ordered to release the withheld documents to me. 

The sad thing in all this is that who is looking out for transparency and the public interests?  Just who is everyone serving in all this?  My personal battle is simply to ensure that all the information reaches doctors and the public, they both deserve to be fully informed of the direction of travel that is being proposed and those running the review should listen to their opinion, not steam roller these potentially dangerous recommendations through against the public interest.

Solidarity - Charlie Hebdo

May those who were murdered in cold blood today in Paris rest in peace.

I hope some good can result from today's appalling crimes, in that decent rational people can unite against the misguided nonsense that motivates the misguided fools who commit acts such as this in the name of their make believe 'Gods'.

The 'Dean review' of medical training

I have commissioned myself to review UK postgraduate medical training.  The pre-review steps are complete, I am indeed a fit and proper person, I have 5 GCSEs, I have no conflicts of interest that I am aware of, plus I am genuinely independent of government.  Frankly who could compete with that?  The terms of reference have been decided by myself, these being to 'review medical training in any way that I see fit', excellent, now let us begin.

The first step of the review is complete, this being the evidence review.  I conducted a systematic review using the latest 2015 PRISMA guidelines.  The search terms were 'UK medical training'.  I excluded all studies that did not exactly predict how future patients would need to be treated, hence this search yielded zero studies.  I have therefore concluded that there is an inadequate evidence base upon which to determine any exact strategies for medical training reform.  This means that I shall be 'first, doing significant harm' by ensuring that my plans will be major structural reforms that will tear up everything we have in place and start from a lovely blank slate.

Now for the second step, the consultation process.  This is now complete, I have tweeted for input and there were zero responses.  I have asked the cat, who did not respond with words, I have also asked my wife who is currently watching Eastenders and not interested.  Therefore my own personal opinion shall drive the review's direction, excellent work.

Now for the final 'Dean report', this is now complete.  I have deliberately kept things simple, firstly the principle of the review is 'to create a world class training system which catalyses commissioning based patient safety augmentation collaborative excellence brilliant wonderfulness'.  There is no way anyone could disagree with that principle, but perhaps I need to mention pathways and flows?  There's no time for consideration or reflection, let's stick with that simple principle.

Finally the recommendations, these have yet to be decided and really are they that important?  Surely like in MMC and the Shape of Training it is accepting the principles that is key?  If one can accept the noble principles then surely any recommendations following will be good news for everyone, by everyone I mean myself that is.  Anyway I think that's sensible, let's leave out the recommendations, I'll simply decide those behind closed doors once you have accepted the principles.   You can trust me on this, look at the review's methodology thus far, it's rigorous beyond the Cochrane collaborative.  I may or may not have had secret meetings with those secret important people who commissioned the 'Dean review' in the first place.

Great, now that's all sorted, training's going to be so much better, I am also particularly looking forward to my knighthood, Sir Dean, that really has a good ring to it.......

Inaccuracy and Obfuscation - the facts thus far

 

I do not have all the answers, as I do not have all the facts and I do not have the knowledge of a legal expert.  However this piece is simply designed to summarise some of the key facts relating to the Meirion Thomas saga, so that you can use this to make up your own minds, and realistically we will all need more information before we can do this with any degree of certainty.

Firstly I wrote some recent pieces criticising the coverage of events by the Daily Mail and the Spectator.  The chief reason for criticising their coverage was that they told only one side of the story and ignored some key aspects of it.  Both the Mail and the Spectator ignored that Mr Meirion Thomas’ arguments contained factual inaccuracies, were not solidly based on evidence and were widely dismantled by more reasoned objective work elsewhere by the likes of the RCS and Margaret McCartney.  It was also strange not to mention the legal element to this affair when they were overtly criticising the Royal Marsden’s actions.  Therefore my chief arguments were not about the rights and wrongs of Mr Meirion Thomas’s or the Marsden’s actions, it was with the biased and stilted coverage by the Mail and the Spectator.

Secondly to my limited understanding of the law in this area, it is worth remembering throughout that I am not giving an opinion about whether I think the law is morally right, or whether anyone’s actions are morally right or wrong, I am just describing the legal aspects of this case according to the limited facts we have available.  It is worth remembering that we do not know the exact terms of Mr Meirion Thomas’s contract, we do not know what has gone on behind closed doors in discussions between him and his employer, and we do not know what the exact outcome of these discussions have been.  Let us just note what the Royal Marsden have stated:

“Following two articles that appeared in the Daily Mail on Thursday 20 November and in the Sunday Mirror on Sunday 23 November by Professor Meirion Thomas, The Royal Marsden NHS Foundation Trust would like to make it clear that Professor Thomas’ views are entirely his own and in no way reflect the opinion of those working at The Royal Marsden.

“Professor Thomas has expressed his personal views about GPs and health tourism in the Daily Mail and Sunday Mirror respectively without consulting staff at The Royal Marsden. We do not share, condone or support the views he has expressed. It is important to state that all individuals are entitled to express a view. They are not however entitled to speak on behalf of an organisation without that organisation’s consent. Professor Thomas did not seek or receive this organisation’s consent to either article.

“The Royal Marsden is very proud of its good working relationships with our GP colleagues, particularly through our GP engagement programme and referral process, and we value their experience, knowledge and the excellent contribution they make within the NHS.”

The difficulty in interpreting any of this is that we are not privy to the full information; hence some speculation is simply not sensible or wise.  It is worth remembering the facts about what was written in that the Mail article named the author as a ‘Royal Marsden consultant surgeon’ and it was never stated this articles were his personal view.  Some would argue that it should be assumed that the articles are his personal views, there is a great difficulty with this argument as he does mention his specific employer and job title, he talks about work relating to this specific employer (Lansley opinion) and he may have used a photograph on Trust premises, and he does this without stating that the articles are a personal view.  I will freely admit this is not black and white, but to suggest that it is clear these articles are his personal view is absurd and in denial of the facts.  The facts significantly close down the distance between Mr Meirion Thomas’ personal opinion and his employer, the Royal Marsden, and from the Marsden’s statement it appears that this is a significant factor in their actions thus far.  It is therefore likely that Mr Meirion Thomas' articles breached Trust media policy on more than one occasion and the terms of his contract with the Trust.

The legal arguments about reputational harm are likely relevant.  If employees have been judged to have caused significant harm to their employer’s reputation by their actions then this would be another avenue by which the Royal Marsden may choose to act.  There is certainly a reasonable case for arguing that Mr Meirion Thomas’ articles causes reputational harm given their disparaging nature.  Certainly Mr Meirion Thomas does not meet the legal definition of a whisteblower and would not have a credible case if he used a public interest defence to justify his articles.  However from what has been stated it appears likely that the Marsden felt Mr Meirion Thomas had breached his contract of employment by ‘speaking on behalf of an organisation without that organisation’s consent’.  It remains unknown which exact details in the articles led the Marsden to this opinion regarding speaking ‘on behalf’ of an organisation. We also do not know precisely what action has been taken by the Royal Marsden, the talk of confidentiality or ‘gagging’ clauses may or may not be true.

In purely legal terms given the available information it appears that the Royal Marsden have acted properly and to suggest otherwise would appear to be rather evidence free.  It is also worth noting that I have not yet given my opinion on whether I think the Marsden’s actions are morally right or the most effective course of action, this has not been my motive, I am simply trying to give my readers as much objective information as possible with which to make up their own minds.  Perhaps I shall do this at some point, but at the moment I do not want to confuse these simple arguments, I want more information before coming to any definitive moral judgements on this complex affair.  If people have an issue with the Marsden’s actions then they should either point to specific legal arguments or direct their arguments towards the legal system, and not the Royal Marsden.

Suspicious omissions from the Mail and Spectator

It is interesting that the Spectator and the Daily Mail have both sided in rather stilted fashion with Mr Meirion Thomas, the surgeon who wrote articles for both of these publications, strange no other publication has joined in the rose tinted defence, I cannot imagine why, I really can't.  Anyway sticking to the basic facts, the Spectator and Daily Mail both have experienced Editorial teams.  Yet despite this in the Mail Mr Meirion Thomas was described as 'of the Royal Marsden Hospital in  London' and in the Spectator 'a consultant surgeon with the NHS'.  Interestingly in one of the Mail pieces a photo of Mr Meirion Thomas was used and it looks suspiciously like he was on NHS property at the time.  The following chunk has been taken from one Mail article demonstrated that Mr Meirion Thomas also clearly wrote about matters relating to his NHS role:

"Because I am a senior consultant in an NHS hospital, Mr Lansley sent me an early outline of his plan for reorganisation and asked for my advice.

I told him: ‘GPs are the problem in the health service, not the solution.’

He did not ask my advice again, but instead pressed ahead with his misguided scheme."

What is the importance of these details you ask?  Well they are vital when it comes to employment law.  Here is a chunk of media policy from a standard NHS Trust:

"If you are approached to speak to the media in another capacity (i.e. for a professional body, trades union or charity) you may do so. However, if this occurs in a way that will link you to the Trust, e.g. using the Trust address, mentioning your role at the Trust, or filming in your department for a back-drop, we would ask that you contact the communications office so that the Trust is aware of the media interest."

Notably Mr Meirion Thomas was not writing on behalf of another body such as a union, he was writing as an individual, however this was never made clear by either the Mail or the Spectator, a fact I find rather strange given their editorial experience.  In fact the Spectator went as far as saying in their recent one sided defence 'he insisted on being described simply as an NHS surgeon', this is suggestive that the Spectator may well have advised him of the negative implications in naming the NHS, I also wonder what he was advised by the Mail.

There is a lot of case law relating to employee being disciplined for speaking out against their employers.  However there are certain situations when it can be justified.  For example it is fine if you are speaking for a professional body or union, Mr Meirion Thomas was not.  It is also wise to make it clear one is speaking as an individual and not name your employer, Mr Meirion Thomas did not do this.  It is also unwise to use a photograph taken on your employer's premises, Mr Meirion Thomas may have been unwise on this.  If one is a whistleblower one can justify speaking one, sadly Mr Meirion Thomas comes a country mile short of meeting any legal definition of a whistleblower.

When one effectively speaks under an employer's umbrella and risks harm to that employer's reputation by making ill informed and disparaging comments, then one has a recipe for being on extremely dubious legal ground.  In this situation one's employer has a very strong case in bring disciplinary action against the employee, just as appears the case with Mr Meirion Thomas. 

In summary the fact that the Mail and Spectator have totally ignored the key issue of employment law is highly suspicious, they are no idiots when it comes to legality, meaning the likely explanation involves Mr Meirion Thomas being a victim of media exploitation.  Note that a story carries far more weight as 'surgeon X from hospital X' or an 'NHS' surgeon than a 'surgeon writing as an individual without his employer's approval'.  The Mail and Spectator had much to gain, Mr Meirion Thomas had much to lose, I wonder.

Overall the talk of 'gagging' and 'free speech' by the likes of the Mail and Spectator is both disingenuous and highly obfuscatory.  It appears highly likely that the Royal Marsden have acted entirely properly and have simply acted to protect their reputation by disciplining an individual who threatened to undermine that reputation by disparaging his medical colleagues.  The talk of abuse, GMC referral and the rest is all a neat distraction tactic, there are idiots on both sides throwing around needless abusive insults.  The bottom line here is that employment law is the key and it dictates that employers have every right to act to protect their reputations in cases like this.

Guy Adams of the Mail responds

This is how the noble journalist Guy Adams responded when I made a perfectly reasonable comment on his ill informed piece on Mr Meirion Thomas.  I would like to thank him for his kind response and also for blocking me, as in doing so he has made my point perfectly for me.

There is one rule for the Mail and one rule for those of us who deign to politely criticise the Mail.  The Mail's criticism is all reasonable and justified by definition alone, however anyone criticising the Mail is written off as a 'troll' engaging in 'ad hominem abuse'.  Nice.  Anyone paying money to read this paper should really think twice, can you trust people who behave like this?

The total ignorance and hypocrisy of the Dail Mail

The Daily Mail has a long history of supporting some rather malevolent causes.  Today their journalistic standards continue within the gutter of hypocritical bile that the seem to fondly dwell within (note this link will not give the Daily Mail any hits if you are concerned about this).

The Mail's story today presents one stilted side of a story, and uses quotes taken without permission and totally out of context from Twitter and a private members forum.  I am not sure how the Mail accessed the comments on this private forum, certainly someone has breached the website's terms and conditions.  There are a number of other problems with the Mail's article and I shall attempt to summarise them below.

Firstly like the Spectator piece defending Mr Meirion Thomas, there is no mention of employment law.  It is interesting to consider that the Mail editorial team allowed Mr Meirion Thomas to be described as working for the 'Royal Marsden', making it clear he was employed by a particular NHS Trust.  It is standard NHS media policy for any doctor who writes as such a Trust employee should run the articles past the Trust media team, it seems clear that Mr Meirion Thomas didn't do this, therefore playing him in a very dubious place in terms of his contract of employment and the law.

Secondly the Mail makes no mention the the baseless evidence free slurs that Mr Meirion Thomas launched at female doctors and General Practitioners in recent articles.  The Mail simply describes his article as a 'comment article criticising...', if the Mail is going to use this angle then many of the quotes taken without permission from Twitter and Doctors.net should simply be called 'social media comments criticising' not 'slurs' and 'ad hominem attacks'.  

Not only does the Mail lazily apply its dubious form of logic in a totally selective fashion, but it then deigns to read into what a random bunch of social media posts mean as an 'overall message', truly bizarre given that the Mail has just cherry picked the most juicy and ignored the bulk of reasonable opinion that exposed Meirion Thomas' articles as evidence free nonsense.  

Certainly I do not defend all the criticism of Mr Meirion Thomas, some of it has been below the belt, however it is also worth remembering that much in his flawed articles was below the belt.  The Mail's utter hypocrisy is staggering, one one hand criticism of Mr Meirion Thomas' writing is lazily labelled 'aggressive' and 'ad hominem', while the evidence free slurs within the original articles is totally ignored and erroneously spun as justified 'criticism'.  Essentially the Mail has trawled the social media and private members fora, and the worst 'ad hominem abuse' it can find is the word 't***', that says it all really.  

In summary the Mail has done a very good job in humiliating itself with the woeful journalism contained within the aforementioned piece and I would like to congratulate them for this spectacular own goal.  I have not abused Mr Meirion Thomas myself, I simply think his evidence free smears against various professionals were unhelpful, harmful and highly ignorant.  I disagree with the referral to the GMC but those who did refer him had a right given that GMC guidance did appear to be breached.  However it is clear that Mr Meirion Thomas has put himself onto some very dodgy ground in terms of employment law, I can't imagine why both the Mail and Spectator have totally ignored this key issue.  Maybe the Mail will now selectively quote my blog or tweets, then accuse me of 'abusing' people, who knows, what I do know is that I will not be silenced by the Mail's biased hypocritical gutter journalism.  

'Prof' Meirion Thomas and the 'Spectator'

The 'Prof' Meirion Thomas saga is complex and I shall not attempt to address all the details in this piece.  For more detail simply use 'google' and read away.  I am no fan of Mr Meirion Thomas, he is in fact no longer entitled to use his honorary 'Professor' title as it lapsed back in 2012.  He has written several rather ill informed and ignorant pieces around the NHS in respected sources such as the Daily Mail and Spectator, there is no hint of sarcasm in my tone I may righteously add.

Whatever one thinks of his words, he is entitled to his opinion, no matter how misogynistic, sexist, ill informed, ignorant, hurtful or just plain wrong that opinion is.  The Spectator ignorantly claims that no one has 'tackled' his comments, a total distortion of the reality which has seen his words totally dismantled by objective evidence based opinion throughout the media.  The Spectator's attempt to obfuscate and hide from the truth are embarrassing, labelling Meirion Thomas a 'whistleblower' is a total abuse of the word.  He is entitled to free speech like all of us, unless he crosses the line of the law.  It is worth bearing in mind that it is not just criminal law that Mr Meirion Thomas has to respect, but he is an employee of the NHS and as an NHS employee he has to respect the law of his contract of employment.  He certainly hasn't been criminal with his ill informed opinion, but has he ignored the terms of his employment contract?  Of critical importance is the clear fact that the Spectator claims that:

"he insisted on being described simply as an NHS surgeon"

This is pivotal.  Firstly it is important to realise that this is what the Spectator claims, I do not know whether the Spectator is being strictly honest with its words.  However it remains abundantly clear that Mr Meirion Thomas effectively used the description of 'NHS surgeon' and it was not made abundantly clear, as any competent Editorial team should well appreciate, that he was speaking as an individual and not for his employer, the NHS.  Therefore Mr Meirion Thomas has ended up on very tricky legal ground with his employer, the Royal Marsden.  This is something the rather biased and stilted Spectator piece completely fails to get across, there is a thing called employment law and although there is a thing called 'free speech', this is not unbounded and it most certainly does not allow one to appear to speak for one's employer in the media, effectively what Mr Meirion Thomas has ended up doing.

So in summary don't believe the nonsense written Mr Meirion Thomas and the dubious justifications of his ignorant scaremongering in the Spectator.  Free speech is not absolute, Mr Meirion Thomas is an NHS employee and as such must respect his contract of employment.  It is is clear that for whatever reason, whether down to Mr Meirion Thomas' ignorance or the Spectator's desire to exploit his NHS reputation for page hits, or perhaps a combination of the two, it was not made clear to readers that Mr Meirion Thomas's writing was merely the opinion of an individual.  I doubt we shall ever hear the truth behind the Spectator's editorial fiddling and what the Royal Marsden has actually stipulated about any future articles by Mr Meirion Thomas.  The Spectator claims that he may not publish again:

"at least not without submitting the text to the hospital’s management for approval"

Without knowing the full details it is impossible to justifiably criticise the Marsden's stance on this.  They are not necessarily seeking to 'shut him up' as the Spectator likely unfairly states, they may very well be simply ensuring that he accurately states he is writing as an individual in the future, so that readers are not knowingly misled into thinking his ignorant ill informed bile may have any kind of NHS seal of approval.