Tiago Villanueva: Medical students should be guaranteed a job on leaving medical school

Tiago_VillanuevaI’ve recently read with great interest the “for” and “against” debate in BMJ Careers on whether doctors should have a guaranteed job upon qualifying from medical school. It sounds reasonable that medical schools train the number of future doctors that is adequate to the needs of the population and that replaces the doctors that retire every year. It doesn’t seem reasonable to me anymore that medical graduates have jobs waiting for them if medical schools churn out more doctors than those that are needed. In the future, the situation may become even more complex due to the growing globalization of the medical profession, which makes it very difficult to plan human resources at a national level. We can’t assume anymore that doctors trained in a certain country remain in that country (I am not including here countries with already high levels of medical brain drain, particularly in the developing world).

However, medicine, supposedly being a “calling/vocation,” and thus more than just a “job,” is a special case, which cannot simply be analysed through the light of market dynamics. If we go by the North American mentality of considering that a university degree is simply a basic tool for personal and professional development rather than a means to a specific end, then medicine does not fit in very well. Even though a medical degree may open up some doors in a non-clinical career paths (such as pharma or publishing), most medical students aspire to be clinicians, and society still expects that medical graduates become clinicians and not something else. Medicine does not have the flexibility of other fields.  Someone trained in, say, literature or languages, can end up doing a broad spectrum of activities, from teaching to translation to being a tour guide. The odds are that a graduate of, say, a sociology or a psychology degree won’t end up doing sociology or psychology.

Moreover, this issue becomes more complicated if we think that in a large part of the world, doctors require a minimum period of postgraduate experience before becoming eligible for full registration and thus entitled to autonomy and independent practice. This is the case, for example, in the UK, where doctors need to successfully complete their first year of the foundation programme in order to become fully registered. Here in Portugal it gets even more complicated, as you need to complete an initial generalist year called “common year” and the subsequent first year of specialty training before becoming eligible for full registration, in other words a “real” doctor. So, if you complete the “common year” and fail to access or complete a first year specialty training post you can’t even prescribe paracetamol.

Doctors that, for some reason, are not able to readily access a post in order to gain full registration are pretty much doomed to either move to another country (and I’ve already mentioned this in a previous blog that, in general, professional mobility is considerably more difficult for doctors than for other types of professionals) or to engage in non-clinical activities.

Some may argue that a system that doesn’t provide guaranteed jobs to doctors helps counter mediocrity. However, doctors already undergo such gruelling assessment during their vocational training that, assuming a country has a sound postgraduate training scheme, nearly all doctors making it to the end of their vocational training programme should have, at the very least, minimum levels of competence and fitness to practice.

I don’t believe that doctors should have a guaranteed job in their specialty of choice. After all, if ideally half of a country’s medical workforce should consist of primary care physicians and 90% of graduates want to become hospital ultra-specialists, then many doctors will inevitably have to end up working in a field that is definitely not their first choice. Nevertheless,  I don’t like the sound of potential prospects of doctors not having a guaranteed job but at the same time not having the right to practice independently which comes with full registration. Medical school seems to me a waste of time and money if there’s not a high likelihood of at least guaranteeing full registration.

Tiago Villanueva is a newly qualified General Practitioner based in Portugal and a former BMJ Clegg Scholar and editor, studentBMJ.