Letters are selected from rapid responses posted on thebmj.com. After editing, all letters are LETTERS published online (www.bmj.com/archive/sevendays) and about half are published in print • To submit a rapid response go to any article on thebmj.com and click “respond to this article”

1 Wakeford R. Fire the Medical Schools Council if you want more HOW TO INCREASE GP NUMBERS GPs. BMJ 2014;349:g6245. (28 October.) 2 Goldacre MJ, Goldacre R, Lambert TW. Doctors who considered MSC plays its part in inspiring but did not pursue specific clinical specialties as careers: questionnaire surveys. J R Soc Med 2012;105:166-76. students to value generalism 3 Durham N. GPs should be able to expand practices to employ hospital consultants, says NHS . GP 2014. 4 NHS England. The NHS five year forward view. 2014. The Medical Schools Council (MSC) values 5 Medical Schools Council. Guidance on outreach programmes medical schools’ autonomy over student released for medical schools and widening access selection, curriculums, and staffing.1 It is a organisations. 2014. complex combination of these and other issues, Cite this as: BMJ 2014;349:g6959 including role models and perceptions of how rewarding a career might be, that contributes to Making careers in general medical students’ career choices. Doctors find specialties attractive or practice more attractive unattractive for many reasons.2 This is why Wakeford argues that “conflicted” medical MALCOLM WILLETT MALCOLM recruitment strategies to medical school must school councils have adversely affected the recognise students’ diverse interests and recruitment of medical students likely to and interesting career structures, can primary aptitudes. Simon Stevens recently stated, “we become GPs.1 Although the academic ethos of care have any real prospect of attracting half of need to tear up the design flaw in the 1948 NHS a medical school is important in determining all new doctors to its ranks. model where family doctors were organised eventual career paths, many other influences Neil M Munro visiting professor, Department of Health separately from hospital specialists . . . GPs affect career decisions before, during, and Care Management and Policy, University of , themselves say that in many parts of the country after undergraduate training (N Munro. Guildford GU2 7XH, UK [email protected] the corner shop model of primary care is past Postgraduate attachment to general practice: Competing interests: None declared. 3 its use by date.” The Five Year Forward View influence on future career intentions [DPhil 1 Wakeford R. Fire the Medical Schools Council if you want more emphasises flexibility, with doctors undertaking Thesis]. Sussex University, 2011). Even in GPs. BMJ 2014;349:g6245. (28 October.) 2 Svirko E, Goldacre MJ, Lambert T. Career choices of the United different roles as patients receive integrated countries with sophisticated primary care Kingdom medical graduates of 2005, 2008 and 2009: care closer to home.4 This aligns with the systems where generalists and specialists questionnaire surveys. Med Teach 2013;35:365-75. 3 Rimmer A. One in eight GP training posts vacant despite General Medical Council’s Tomorrow’s Doctors, have similar earnings, only about a quarter of unprecedented third round of recruitment. BMJ Careers which requires graduates to have a broad recent graduates profess an initial interest in 2014. http://careers.bmj.com/careers/advice/view-article. 2 html?id=20019782. foundation from which they can specialise later. general practice. The failure to fully recruit to 4 Pugno PA, McGaha AL, Schmittling GT, DeVilbiss A, Kahn NB Priorities for MSC include ground breaking UK general practice training this year after an Jr. Results of the 2007 National Resident Matching Program: work on widening access,5 fitness to practise, unprecedented third round of selection suggests family medicine. Fam Med 2007;39:562-71. assessment, and understanding the evidence serious problems with the career itself.3 Cite this as: BMJ 2014;349:g6962 base for selection to study medicine. MSC In countries like the US, where more than three works with colleagues across the health and quarters of doctors specialise, efforts have been The NHS is responsible for the higher education sectors to select the best targeted at selecting school leavers intent on a students to study medicine, so that high career in general practice. The reasons why this crisis in GP recruitment quality patient care can be provided as part of policy does not translate into equivalent numbers In attacking medical schools, Wakeford is the present and future workforce, including of GPs include factors that attract students aiming at the wrong target.1 Medical schools general practice. Members of MSC head their away from primary care towards specialties could do more to promote general practice as respective medical schools, each of which during training, such as positive experiences a career for their graduates, but the current has an education lead, several of whom are during placements, career earnings, status, and recruitment and workforce problems in NHS primary care physicians. Education teams drive academic eminence. In addition, factors within general practice in the UK are not caused by the admissions and selection, with input from a medical schools, including denigration of general actions of medical schools. range of medical disciplines, including general practice by undergraduate teachers and medical Newly qualified doctors are not applying practice, and the public. student peers, detract from this career path.4 for general practice training schemes and GPs play a central role in the medical workforce. It is unclear whether recruitment is influenced established GPs are retiring early because MSC will continue to play its part, working with mostly by the training system itself or by current GPs’ working conditions have deteriorated Health Education England and others to inspire perceptions about UK general practice. Small substantially in recent years. The volume students to value and select generalism. changes to the system may have little impact and complexity of their work has increased, Iain Cameron chair, Medical Schools Council, Woburn if the root cause lies in the reputation of the and many general practices have seen large House, WC1H 9HD, UK career in both professional and public eyes. reductions in their practice budgets.2 [email protected] Only through improved understanding of the The Department of Health and NHS England Competing interests: I am chair of the Medical Schools Council, dean of the faculty of medicine, University of Southampton, and a career drivers in medical students and young (and their equivalents in the devolved nations) professor of obstetrics and gynaecology. doctors, and inclusion of these in more enticing are responsible for this, not medical schools.

the bmj | 29 November 2014 21 LETTERS

Medical schools do have a role in promoting Richard Wakeford life fellow, Hughes Hall, Cambridge primary care, but the current problems in UK Author’s reply CB1 2EW, UK [email protected] primary care can be rectified only through a Cameron states that the Medical Schools Competing interests: I have been an academic assessment adviser to various medical and dental bodies, specialist as well as fairer funding mechanism for general practice Council “values medical schools’ autonomy generalist, since 1984, and I was training programme director for in which both workload and population health over student selection, curriculums, and the West Cambridgeshire GP Specialist Training Programme from 3 2005 to 2011. I’m also an ageing patient anxious that I may not needs are taken into account. staffing.” Of course. Just as the Country have a GP to consult when I need one. Azeem Majeed professor of primary care, Department Landowners Association values foxhunting. 1 General Medical Council, 1967. Recommendations as to Basic of Primary Care and Public Health, Imperial College Since Brotherston’s 1967 recommendations Medical Education. London, London W6 8RP, UK [email protected] it has been accepted that, for undergraduate 2 McManus IC, Wakeford RE. Data linkage comparison of PLAB Competing interests: I am professor of primary care and head and UK graduates’ performance on MRCP(UK) and MRCGP of the department of primary care and public health at Imperial medical education, “identity lies not in examinations: equivalent IMG career progress requires higher College London. I am also a GP principal at the NHS general the path, but in the goal.”1 Doubtless the PLAB pass-marks. BMJ 2014;348:g2621. 3 Wakeford R. Annual report (August 2012-July 2013) on the practice of Dr Curran and Partners. proposed National Licensing Examination will 1 Wakeford R. Fire the Medical Schools Council if you want more results of the AKT and CSA assessments. Royal College of GPs. BMJ 2014;349:g6245. (28 October.) clarify the goal for medical schools and widen General Practitioners. 4 Lambert T, Goldacre R, Smith F, Goldacre MJ. Reasons why 2 Majeed A, Rawaf S, De Maeseneer J. Primary care in England: the path. coping with financial austerity. Br J Gen Pract 2012;62:625-6. doctors choose or reject careers in general practice. Br J Gen 3 Majeed A. General practice in the : meeting The problem’s nub is that arrangements Pract 2012;62:e851-8. the challenges of the early 21st century. J R Soc Med for undergraduate and postgraduate medical Cite this as: BMJ 2014;349:g6977 2013;106:384-5. education are not inter-articulated. Medical Cite this as: BMJ 2014;349:g6967 ATLAS OF CARE schools are not encouraged financially to recruit and train towards NHS workforce Discrepancies between data Increasing GP numbers is needs. There need to be introduced feedback loops based on workforce requirements on various PHE websites not that simple into their funding stream and feedback O’Dowd reports on the atlas of care, the The lack of primary care representation on the loops based on analyses of graduates’ new Public Health England (PHE) Healthier Medical Schools Council and medical school subsequent performance (on recruitment Lives online tool.1 In using the tool we have websites is interesting.1 However, this is just tests for specialty training, for example) into encountered fundamental discrepancies one aspect of a complex problem and does not their curriculums. Medical schools also need between data on the various Public Health explain, for example, the variation between feedback from major specialty examinations England websites, including Healthier Lives medical schools in the proportion of graduates as to any details associated with differential and GP Fingertips. entering primary care. graduate performance, such as Membership As an illustration, within our local clinical The GP Task Force Report and research papers of the Royal College of General Practitioners commissioning group (Dorset), the proportion have called for studies on why this difference (MRCGP) and Membership of the Royal of patients with diabetes in whom the last 2 3 2 exists. What role does selection to schools play Colleges of Physicians. glycated haemoglobin (HbA1C) was less than (nature) and what role do the schools themselves Absence of articulation and feedback 7.5% (59 mmol/mol) in the preceding 15 play (nurture)? Do we take truly undifferentiated has led to 25% (about 1000/year) of UK months (Quality and Outcomes Framework “stem doctors,” as they have been described, graduate applicants to GP training being (QOF) 26 for diabetes) is recorded as: and mould them during their time at medical regarded as “unappointable” and rejected • Healthier Lives website: 56.6% school, or do these students already have strong by the selection system (data provided by • GP Fingertips website: 66.4%. preconceived ideas? Many studies have looked at Health Education England after a Freedom Should the GP Fingertips data be correct, factors that influence choice of specialty.4 of Information request). This scandalous then our clinical commissioning group would We know the recruitment figures. What situation results in local education and rank 12th out of 211 groups rather than 162nd. we don’t know is why 11.2% of Cambridge training boards recruiting international In response to our query, Public Health graduates were appointed to GP training in medical graduates who collectively cause England attributed the discrepancies to 2012 compared with 38.5% from Keele.5 considerable additional costs and difficulties, the use of exception reporting, specifically: Investigation into the differences between such as failing the MRCGP Clinical Skills Healthier Lives uses QOF intervention rates the “worst” and “best” performers in terms of Assessment at eight times the UK graduates’ that include exceptions, whereas GP Fingertips producing future GPs will probably shed light on rate.3 uses QOF achievement rates, which GP how we can improve recruitment, and seems less I criticised medical schools’ recruitment payments are based on. radical than firing the Medical Schools Council. approach on their websites, which clearly Exception reporting is used to exclude Simon R Thornton academic clinical fellow in primary and universally focuses on careers other than patients from QOF payments for various care, University of Bristol, Bristol BS8 2PS, UK general practice. Of course there are many reasons—clinical and other—although all [email protected] reasons for the shortage of GPs, as other patients have a working diagnosis of diabetes. Competing interests: None declared. correspondents note, and research is needed The use of QOF as a tool for incentivising 1 Wakeford R. Fire the Medical Schools Council if you want more 4 2 GPs. BMJ 2014;349:g6245. (28 October.) (as urged in 2012 ), but recruitment, the start quality in primary care remains contentious. 2 Health Education England. Securing the future GP workforce: of the educational process, has fundamental But our main concern is that from a population delivering the mandate on GP expansion. 2014. 3 Lambert T, Goldacre M. Trends in doctors’ early career choices importance. health outcomes perspective, the inclusion of for general practice in the UK: longitudinal questionnaire If the medical schools continue this exceptions more accurately reflects the quality surveys. Br J Gen Pract 2011;61:e397-403. 4 Lambert T, Goldacre R, Smith F, Goldacre MJ. Reasons why unguided behaviour, they will be failing of care delivered. Failure to consistently doctors choose or reject careers in general practice: national the taxpayer, the medical profession, and analyse and display the ranking for any surveys. Br J Gen Pract 2012;62:e851-8. patients. Perhaps at the annual residential given clinical commissioning group can have 5 UK Foundation Programme Office. F2 career destination report 2012. meeting on 26-28 November the Medical important local “political” repercussions. Cite this as: BMJ 2014;349:g6968 Schools Council may reflect on this? The publication of metadata and adoption of

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consistent analytical standards would go some Mathieu Boniol professor and senior statistician, preferences, not mine. Some well informed way towards resolving this problem. University of Strathclyde Institute of Global Public people choose screening; I am concerned that Health at iPRI, International Prevention Research Claire Lehman public health registrar Institute (iPRI), Espace Européen d’Ecully, 69130 Heath’s strongly expressed preference might [email protected] Ecully Ouest Lyon, France well translate in practice into a new version of David Philips director of public health Competing interests: None declared. “doctor knows best.” Sam Crowe assistant director of public health Full reference details on thebmj.com. Dave Lemon senior analyst We need to acknowledge that helping 1 Smith RA, Duffy SW, Gabe R, Tabar L, Yen AM, Chen TH. The Simon Fraser public health registrar, Public Health randomized trials of breast cancer screening: what have we individual patients to make decisions that are Dorset, Vespasian House, Dorchester DT1 1TS, UK learned? Radiol Clin North Am 2004;42:793-806. right for them, in the way that they want to make Competing interests: None declared. 2 De Glas NA, de Craen AJ, Bastiaannet E, Op’t Land EG, Kiderlen them, is a complex and difficult task. Trying to 1 O’Dowd A. Atlas of care shows poor performance in treating M, van de Water W, et al. Effect of implementation of the mass diabetes in England. BMJ 2014;349:g6564. (4 November.) breast cancer screening programme in older women in the help people not to fear death is a major additional 2 Langdown C, Peckham S. The use of financial incentives to Netherlands: population based study. BMJ 2014;349:g5410. challenge. As Heath says, doctors may well help improve health outcomes: is the quality and outcomes (14 September.) framework fit for purpose? A systematic review. J Public Health 3 Autier P, Boniol M, Middleton R, Doré J-F, Héry C, Zheng T, et al. not be the best people to meet this challenge. 2014;36:251-8. Advanced breast cancer incidence following population-based In attempting to meet it, we should beware mammographic screening. Ann Oncol 2011;22:1726-35. Cite this as: BMJ 2014;349:g7080 4 Bleyer A, Welch HG. Effect of three decades of screening of increasing the medicalisation that Heath mammography on breast-cancer incidence. N Engl J Med criticises, by extending the remit of “healthcare” MAMMOGRAPHY SCREENING 2012;367:1998-2005. 5 Lousdal ML, Kristiansen IS, Moller B, Støvrin H. Trends in breast to encompass yet more aspects of human life. Advanced breast cancer rates cancer stage distribution before, during and after introduction Louisa Polak general practitioner and PhD student, of a screening programme in Norway. Eur J Public Health 2014; North Hill Medical Group, Colchester CO1 1DZ, UK and screening effectiveness published online 4 March. [email protected] Cite this as: BMJ 2014;349:g6358 Competing interests: None declared. Swedish trials on mammography screening of thebmj.com • Letters by Tabár, Kopans, and De Glas 1 Heath I. Role of fear in overdiagnosis and overtreatment—an women aged 40-74 years indicated that two essay by Iona Heath. BMJ 2014;349:g6123. (24 October.) and colleagues. 2 Aronowitz R. The converged experience of risk and disease. to four rounds of screening could significantly Milbank Q 2009;87:335-542. reduce the risk of being diagnosed with FEAR IN OVERDIAGNOSIS 3 Frank AW. The wounded storyteller. University of Chicago Press, and dying from advanced breast cancer.1 1995. Beware of medicalising the fear 4 Scott S, Prior L, Wood F, Gray J. Repositioning the patient: the Because stage at diagnosis is independent implications of being “at risk.” Soc Sci Med 2005;60:1869-79. of treatment efficacy, the trials concluded of uncertainty and death Cite this as: BMJ 2014;349:g7077 that the introduction of screening in general populations would be reflected by a reduced incidence of advanced breast cancer and Risk factor medicine as driver mortality from breast cancer.1 of fear and overdiagnosis However, De Glas and colleagues show that mammography screening of Dutch women Heath is right to argue that we have to face up aged 70-74 years has only a modest influence to our fears of uncertainty if we want to limit on the incidence of advanced breast cancer.2 overdiagnosis and overtreatment.1 I think that US, Australian, and European studies in one major driver of these fears comes from communities with a long history of screening the development of medicine that is based on and a high participation rate, where women the identification and treatment of risk factors MATHILDA HOLMQVIST MATHILDA have attended more screening rounds than and from blurring of the boundaries between in the Swedish trials, report similar findings I strongly second Heath’s call for clinicians to be risk and disease.2 Indeed, being at risk of for advanced breast cancer, including very more tolerant of uncertainty, and agree with her disease is increasingly confounded with having large or metastatic cancer.3‑5 The quasi stable that this requires courage, particularly given the the disease itself.3 This is one reason why incidence of advanced breast cancer over prevalent culture of blame.1 the diagnostic criteria for several conditions time is not compatible with screening having Nobody could disagree with the have been widened, thereby increasing the a major role in the reductions in breast cancer recommendation that people should be proportion of individuals who are potentially mortality seen in most high income countries. screened for their potential to benefit from risk worried by their health. Admitting the limits of This situation contrasts sharply with reducing interventions “only when medical what risk factor (predictive) medicine can offer that seen for colorectal and cervical cancer care is appropriate and will produce more at an individual level could help prevent several screening. Marked declines in the incidence benefit than harm.” Most clinicians are well of these problems.4 5 of advanced forms of both these cancers, as aware of the harms of swapping Sontag’s “good Arnaud Chiolero senior lecturer in epidemiology, well as mortality, are seen where screening passport” for a provisional “at risk” one.2‑4 Lausanne University Hospital, 1010 Lausanne, is widespread, which agrees with results The snag with Heath’s recommendation is that Switzerland [email protected] Competing interests: None declared. of randomised trials. For breast cancer, defining and evaluating “benefit” and “harm,” 1 Heath I. Role of fear in overdiagnosis and overtreatment—an the discrepancies between trial results and hence deciding when “medical care is essay by Iona Heath. BMJ 2014;349:g6123. (24 October.) 2 Chiolero A, Paccaud F, Aujesky D, Santschi V, Rodondi N. How to and epidemiological data can probably be appropriate,” requires more than just courage prevent overdiagnosis. Swiss Med Wkly [forthcoming]. explained by the Swedish trials overestimating and certainly more than just statistical facts: it 3 Aronowitz RA. The converged experience of risk and disease. reductions in the risk of advanced cancer requires a complex weighing up of preferences. Milbank Q 2009;87:417-42. 4 Ioannidis JPA. Genetic prediction for common diseases: will and of cancer death associated with Like her, I would prefer to avoid preventive personal genomics ever work? Arch Intern Med 2012;172:744-6. mammography screening. drugs. I am aware that this inevitably colours 5 Davey-Smith G. Epidemiology, epigenetics and the “gloomy prospect”: embracing randomness in population health Philippe Autier professor and research director the way I talk with patients about screening research and practice. Int J Epidemiol 2011;40:537-62. [email protected] but try to keep this to a minimum, because the Cite this as: BMJ 2014;349:g7078 Cécile Pizot statistician conversation should centre on the patient’s ЖЖOBSERVATIONS, p 24 the bmj | 29 November 2014 23