Problems in the structure of Irish medical education

14-05 John Speaking 2

[Speaking in the Seanad during Second Stage of the Education (Miscellaneous Provisions) Bill 2014]

I will shamelessly take the opportunity of having the Minister held captive in the Chamber to make a cri de coeur to her in her new capacity as Minister for Education and Skills to seriously examine the structure and number of medical schools in the Republic. To give some background information, in recent years the medical profession in Ireland has done a good job in persuading the rest of the country that we have reached an extraordinary level of international eminence in what we achieve in our medical schools. We have extraordinarily gifted nurses and doctors who have done the country proud when they have gone abroad. They have acted as unpaid reputational ambassadors for the quality of education they received. However, one sometimes has to ask whether this has occurred in spite of, rather than because of, medical schools.

I speak as a University Senator who represents an entity which has several medical schools. I will provide the Minister with some arithmetic. Ireland has a population of approximately 4.5 million people and six medical schools. One can do the arithmetic – we have about one medical school per 700,000 people. In the United States which has the most advanced academic medical structure in the world and the highest number of Nobel prizes, publications, citations, etc. there is one medical school per 2 million citizens approximately. In the United Kingdom there is one medical school per 2 million citizens approximately. In Germany there is one medical school per 2 million citizens approximately. If one adds some of the smaller countries in Eastern Europe which have larger numbers, one will find that the rate is one medical school per 1.5 or 2 million citizens.

We are absolute outliers in any comparison. One could say this must be a great country which places a huge emphasis on medical education and does not spend money on nuclear submarines or arms but on medical schools to educate young doctors. However, we also have the lowest number of doctors per head of population and career level posts in any country in the OECD. It will be apparent that there is something fundamentally wrong with the way we structure medical schools.

I amused myself by going online – I probably broke procedure in so doing – and found that Harvard Medical School’s affiliate campuses, that is, its hospitals, have a clinical faculty membership of 10,000. To the best of my knowledge, the aggregate number of full-time clinical faculty members employed by the six Irish medical schools is less than 100. Most of the work at clinical level is done by people who were primarily appointed by the health service and had varying degrees of enthusiasm and small amounts of time designated for educational purposes.

When I say our bright young students graduate with a great medical education in spite of, rather than because of, the medical schools, I speak not with bitterness but with a cold, hard assessment of what we have. I would fear for the future of medical education in Ireland in terms of reputation if we do not do something about this issue. The world is full of countries which shall remain nameless in which there are degree mill medical schools in which people who have reached a certain degree of matriculation standard and with the financial wherewithal will find themselves in a medical school which will give them a degree which may or may not be recognised in different parts of the world.

I would like to see substantial attention being paid not by the health system which is in a near-unfixable mess but by the education system to the structure of how we treat and train young doctors. Do we have the right number of medical schools? Do we have too many? Is it appropriate to have so few full-time clinical faculty members smeared across such a large number of medical schools whereby we do not have full-time representatives in most medical schools in most of the major disciplines of medical specialisms?

One has to ask what level of scrutiny this might attract and be able to withstand in the event that there are future international inspections of medical schools because what we have in Ireland is extraordinarily unusual. There are downstream spin-off effects from it, one of which is that there is a complete lack of a leadership cadre of doctors in the country. The overwhelming majority of hospital-based specialists work for themselves and the health service. They do not have a boss and are not part of a unit within a cohesive structure. They do not have hiring and firing authority. Essentially, there is no senior specialist with any control over any specialist. When I started off as a young consultant in New York, there were four recognisable layers above me, all of whom, with the right motivation, could have fired me if my performance was inadequate. There is nothing like that here. The net effect is that we do not have people in our profession who have a wide vision of how the health service should be reformed. As a result, managers default into what should be leadership positions.

There are many good reasons for us to try to defend the reputation of our medical schools. If they are to withstand scrutiny, it will require intense reform. There is something seriously wrong in a country that has one medical school for a population of 720,000, three times the European average, which has so few doctors and in which there is almost no full-time clinical faculty. We can debate all day which institutions should be called universities and those that should not, but if we are to fix the problem, we need somebody at a high level of authority to decide that this is something which is very important to our society.

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