An intergenerational discussion of "Mediocrity in Medicine; What to do". YNSS

SNI Digital Innovations in Learning in association with the Glasgow Neuro Society

are pleased to present another in the SNI Digital series. Let's talk an intergenerational discussion on mediocrity and medicine from a meeting in Glasgow, Scotland in February 22nd, 2024. This

program was organized for the Glasgow Neuro Society by Muhammad Ashraf and by Hassan Ishmael, who also were its co-moderators.

Dr. Ashraf is the current academic foundation program doctor at the Institute of Neurological Sciences and Queen Elizabeth University Hospital in Glasgow, United Kingdom, in an honorary clinical

fellow

the Wolfson Medical School University of Glasgow and past president of the Glasgow Neuro Society.

Dr. Ishmael is the incoming academic foundation program doctor for the British Heart Foundation Cardiovascular Research Center of Research and an honorary clinical fellow at the Wolfson Medical

School University of Glasgow in the United Kingdom and also past president of the Glasgow Neuro Society. The guests for this discussion are Radiol Kane, who's the consultant neurosurgeon at the

Institute of Neurologic Sciences, Southern General Hospital, and the Royal Hospital for Sick Children, York Hill in Glasgow, Scotland, and Jorge Lassaroff, Emeritus Professor, the Department of

Neurosurgery, David Geffen School of Medicine, UCLA.

and an Associate Director of SI Digital.

Samar Hawes, Professor of Department of Neurosurgery at the Neurosurgery Teaching Hospital in Baghdad,

and with the Department of Neurosurgery at the University of Pittsburgh in Pittsburgh, Pennsylvania, and an Associate Director of SI Digital. And James Osmond, the creator and CEO of SI and

SI Digital, and an Emeritus Professor at the UCLA Medical Center in Neurosurgery. So, good evening, everyone, or hello from wherever you're watching from. Welcome to the second edition of the

Glasgow Neuro times Surgical Neurology International Let's Talk series where we aim to discuss the topics seldom mentioned in medicine and are often sweeped under the rug. And so today's topic is

going to be around whether there is or isn't. the creeping rise of mediocrity in medicine. And to discuss this very large topic, which we're hoping to keep to an hour, we've got myself as one of

the moderators. I'm Hassan, I'm the former president of Glasgow Nural and currently a final year medical student looking forward to joining this lovely profession. And my colleague, Mohammad

Ashraf, it will also be moderating. Hi everyone, my name is Mohammad. I'm

a junior doctor at the Queen Elizabeth University Hospital in Glasgow, I'm really excited to be here. Me and Hassan are gonna be the moderators for this talk. And I think with that, we'll allow

our speakers to briefly introduce themselves. And if I can ask everyone to please tell the audience who they are, what stage of their careers they're at. And can we start with Professor Osman? Yes,

I'm

Jim Osman. I'm a neurosurgeon, I'm 87 years old. And

I don't know what else I can tell you.

founded Surgical Neurology International, and now we're launching SI Digital, which is a video journal in neurosurgery. Let me hear the rest.

Dr. Haas.

Yeah hello. I'm Senator Haas and neurosurgeon vascular neurosurgeon from Iraq. I'm

now moving to US doing fellowship in new PMC Pittsburgh.

Dr. Lazaref.

Good evening everybody. I am Jorge Lazaref. I am a pediatric neurosurgeon now not working anymore in the OR. I am emeritus professor of neurosurgery at UCLA and devoted to teaching, to teaching

critical thinking in the medicine. Thus, this is an important subject for me and I am a follower of the ideas of Dr. Alzman

And finally, our very own Mr. Rookane. Hi, I'm Rodio Pian. I'm a neurosurgeon based in Glasgow. My principal work as a pediatric neurosurgeon, which makes up the majority of my work, based at

the Royal Hospital for Children in Glasgow. I do some limited adult practice in glioma surgery, but principally pediatric neurosurgeon.

Brilliant. So that is our panel for today And I think what will be really interesting is obviously hearing from yourselves about not only from the prompts that we're going to have and also from the

audience, please feel free to ask any questions that come up that you have now, or that you're prompted by throughout our opinions, discussions, questions, whatever you're interested in and will

make sure to share them anonymously with the hosts. And on top of that, with our prompts, we'd love to hear your insight on how potentially things have differed from your time. I know back in the

day that, you know, that sort of thing, thing, but it does help us growing ourselves with. with what we're looking at in this day and age. And with that in mind, I'd like to start off with the

first aspect and all of these are going to be hotly discussed topics right now and sort of the global medicine sphere. And the first one is very topical right now in the UK. And I wonder, you know,

I'd love to hear the insights especially from the guys over in the States about this. We're put a bit of background, currently what just happened in the United Kingdom for the residency program for

those of you in America where traditionally you would be allocated your job for the next two years as a resident based on your performance in medical school throughout your undergraduate studies in

medical school. And coupled with an exam that you set in your final year of medical school. And both of these combined would result in a total score out of a hundred. And based on your score of a

hundred, you would be given a rank across all of the United Kingdom. So you could be ranked number one you could be ranked number 10, 000.

know what's happened as we moved, where everybody will still obtain a rank. However, this rank is going to be computer generated, and you'll be given your job based on preference and a preference

informed system, which is ensure a randomized system that will try to obtain everyone their first choice. According to the UK Foundation program, that will get 79 of individuals their first choice

compared to 73 based on the old merit based system. But I'd love to hear your thoughts on this shift from moving towards performance to potentially randomization, and whether you feel that

could have an impact on the workforce, and I'll open up to yourself.

Can you explain a little bit more about the performance system? Is everything the same except one is randomly to sign and the other is personally chosen? Or can you explain the difference a little

more or am I missing something? No, you're right. Nothing else has changed. The remainder of the system is exactly as it was traditionally The only difference is the way you obtain your rank is

now computer generated rather than through your medical school grades and this final exam

I, well, there's not too much difference. I don't know, 79

against 74. Well, it will consider 47 to be below below 50. No, so 79 to 74.

And the, and that the system has already been applied or is going to be applied. It's already in motion, the system

It's called the instance here, so this is the first year they do this, and the intention behind this is to sort of level out the playing field

in a sense where traditionally individuals who would obtain a higher score would apply to more in-demand centers like London, and that was the traditional belief, whereas now, because everyone's on

the same page, everybody can apply to what they deem as the place that they want to have as their number one You know, everybody can apply to hypothetically London, whereas traditionally London

would always have very high requirements compared to some other more rural centers. And so, the foundation programme's argument is this will create a more equitable system where it will be given the

same opportunity to go to different centers. However, from the student perspective, it's been deemed very controversial in that your performance in medical school no longer matters, and it doesn't

matter what you do You're going to end up in either the hospital you get is now undecided in your hand. I'd love to hear your thoughts on this, Dr. Hollis, if potentially you have any insight on

this or what your thoughts on this?

Yeah, I think with every new system, there should be discussion for the basis and advantage and definitely the

practice of that new system will help everyone judge more that is it

a successful new addition or maybe it's, as you said, it's theoretically proposed to aim for equality in general, but at the same time will affect some of the high ranked people or high ranked,

let's say high achiever people. Yeah, I think based on the initial estimation, it may be a system to may face some struggling initially May face some struggling initially. but eventually, if it's

flexible enough, it will adapt to the finding. I cannot say yes or no, is it good or bad? From the cover only, I think people affected are more

arbiter to describe what this means to them. But in general, yeah, I think if you aim to high around institutes or higher-range specialty in general, you need to be satisfied with the system that

whenever I put an effort, there is an outcome of equal amounts. That's my general opinion about it.

I would like to ask you something that's OK.

I'm sorry. Go ahead I

think that the system theoretically will improve that the quality of work, because so far, based but you mentioned London being the preferred site of choice for the brilliant or the bright minds.

Now with this system, you may have a very bright mind or minds in a hospital, I don't know, Bristol. I'm saying Bristol just because I know that town, Bristol,

I don't know, or any other town who is not as so hospitals and those areas will be benefit, will actually benefit from the inflow, random inflow, from the bright minds, from the medical schools.

It reminds me a little bit and forget me for the analogy. I mean, the worst team in the national football league can choose the best player from the college, right? so that the best college player

doesn't go to the champion. the worst team and those teams elevate and race and two or three years or five years after they are that they good teams. So I think that eventually this could be

beneficial for the quality of care and the quality of education alone the United Kingdom because those individuals who would not have gone to a supposed class B university now are there and okay and

and they have to work.

Radi what do you have to say about this? Okay so I suppose I'm coming from the UK perspective I have no involvement in the foundation program whatsoever so what I'm doing is speaking from personal

opinion and haven't had the issue thrown at me just trying to come up with some ideas just as a first point of information and I never applied to London it was the last place on earth I would apply to

to be quite frank with you and that is intended for all events for the London And, but what I would say is they can all come up to Scotland and come to the Great Centre in Glasgow and, you know,

their wage is going to be much higher as a junior doctor. But let's start with the first point. It's the foundation program, which is really about getting sort of signed off and full accreditation

as a doctor, where you work for us two years so that that's, that's the objective of the program

And so, you know, should we, you know, are we really changing the career, you know, strategy or trajectory of anybody on that. I'm not sure you actually do that too much with the foundation

program and in theory, you shouldn't be, you know, you should be just aiming to complete the foundation program complete the experience of being, you know, a competent junior doctor So, in one

sense, I can understand where this, I mean, the figures look quite funny where you seem to have better allocation. And, and so. It's funny, if it's a UK-based system, we still have to remember

that people have families and geography and friends and locality. So I don't like the fact that if I was just applying that I could be thrown somewhere where I had never been before. Because doctors

aren't just doctors, they're human beings with families. So there's risk in that. Although I'm not sure whether there's sort of locality boundaries designated in it. I mean, this is, again, the

pursuit of objectivity, you know, for fairness, inequality, and that is a noble thing. But we shouldn't make sure that we're doing something actually that could be damaging medicine. I don't see

huge regards with this here, but I'm sure if I was finally a medical student, I'd probably be deeming this the national slaughtering, as opposed to the lottery, because it seems pretty scary to me

that you're just going to be picked out like a random person If you have, you know, if you listen to people, um. like Malcolm Gladwell, one of these great thinkers, you know, American Deus Guy,

you know, he's actually a Canadian. And he would be a strong advocate if you listen to him and read his books. He would actually be a strong advocate for this that

in the opening of equality and chance it actually does improve all parts of the system. And he would give lots of great arguments that are not going to go around that At this stage, it doesn't cause

me significant concern 'cause I don't think where you're getting placed in the foundation program is going to have a huge, or shouldn't be having an impact to where you subsequently apply and where

you see your career trajectory going. What I don't like is the fact that we sort of are turning people into numbers. Doggers are humans and they are humans and we have to remember that and respect

them like that there So, you know, I can see a merit and I've But the fact that if you just labeled every single person as a number and allocated them randomly around the UK, I have a wee bit of

concern about that.

I tend to agree with Radi. I think you said it at the beginning, Hassan. And that is you work very hard in medical school to get the highest match you can. And then you want to go and you want to

get the best residency or the best place to go. And if by doing that, you get the highest score, you would have the highest chance of getting to the place which is the best. And that's called

excellence.

The opposite of that's mediocrity. And the real question then is, why aren't the medical schools or are the places that they're applying to equal? And the answer is they're not. And so because

they're not equal and they don't have the same level of excellence, what they want to do is achieve it by penalizing the people who wanna strive to be excellent to go and help them achieve that. So

I think this has been an indictment of the schools, not of the individual. And this gets back to the fundamental issue of this meeting, which is mediocrity. So if I'm in a system like this, why

should I work so hard? 'Cause in the end, it doesn't make any difference. That's called, excuse me, socialism And

the problem is everybody in this call has come from a socialistic system.

And so it's pretty hard to say that the people in the call or maybe in the audience can sit down and say, well, maybe we should have a different system because you're outnumbered. The question is,

you wanna get what you want. First of all, you gotta get to the fundamental principle. The patient wants the best doctor they can have.

And how do you get to be the best doctor? In this system, are you gonna be a good doctor? Well, you could be. You have to work very hard, even though you aren't in the place where you wanna work.

But if you had the other options available to you, you might even be able to become super excellent.

And so that's what you're thinking about So it boils down to a very common problem today in the world, which is diversity, equity, and inclusion.

And what's the end result of that? Well, it's a complicated problem. But the end result of that is, are you promoting mediocrity?

There's a question from the audience, Professor Rosman, someone would like to remain anonymous, but they've essentially said, how do we address this in a UK system to the main fair, whereas in

the previous system on merit basis, individuals who did very well would go to traditionally considered prestigious locations or dean reefs. And that would mean that if we use breeds as a metric,

those who are at the bottom desk cells would be allocated to horse parts of the country. And then the cycle would perpetuate because if you're using that as a metric, it means the worst doctors

would go to the bad areas and then those areas would get worse. Any comments on that? Well, this is what I mentioned before that the other areas, the un-service areas, we actually think that we

are talking not about the bush. There are hospitals, municipal, university hospitals that are not rank as high as the other ones. And they will benefit to see one of the brightest minds and the

brightest minds will actually benefit sometimes from going to those places, you know We

have, it's some procedure in our group. I think that between saying yes or no, I agree with the comment of this

recent

listener.

Well, I think you're riding, you have some thoughts. Yeah, it's quite a difficult issue because, you know, you've got to see it. You got to see it. So you're all sort of stakeholder side, you

know, absolutely the core of the whole argument. And even, you know, and I looked at the term mediocrity is actually, you know, what is mediocrity? Because if we're all signed off and we're all

competent enough. Well, you know what, the majority of us are going to be mediocre Because we're going to be in the middle of the normal ocean curve. You know, if I had to compare myself against

peers, I don't think I'm some world leading expert. I certainly don't claim myself to be one. And you can only be in the top, you know, when you get into standard deviations, you know, top 3.

So the rest of us are going to be mediocre The problem is sociologically, and it's a word phenomena that we're talking about is. we needed a thing, what the actual point of mediocrity is, because

the majority of medicine is going to be mediocre in comparison to their whole cohort. And it's the bad eggs at the bottom of the couple of standard deviations you want to kind of remove. And I'm

just playing that sort of just for a bit of a swift flippant to the argument. But ultimately, patient safety is the most paramount concern. And patients actually have, to me, a higher level of

involvement and picking how this happens. But if you have invested your time in medical school and you've worked very hard, I can sense frustration if you think, what was the benefit to do that?

And therefore, could this de-incentivize that type of thought as you're going through your training? I don't think medical students and people who enter medicine by and large are of that attitude

They are, you know. They're persevered, they are intelligent, they are competitive. And I don't think all in all that the downside really is going to be that a bunch of people that, well,

what's the point? I'll just try and skim through. I don't think that I can't back that up. That's just a personal impression. And as I say, this is a very early stage selection. Okay, so it is,

this is just into the generalality of being a doctor And so it's not that it's, it shouldn't in theory, you know, drive where you can and can't go in your future careers in theory. But you know,

I do look at it and think, well, if it was me, I wouldn't want to just be thrown at the other end of the country of the UK where I had never been before, or told family and friends associated or

the things that you do outside of life. I find that a wee bit of a challenge. So I think, I don't think there's a binary I can wait answer to any of this. Mr. McCain, you mentioned mentality,

and I think that rather nicely segues us into our next prompt, Hassan, would you change? So essentially, for a background of the audience, there was a tweet at one point by a senior surgical

resident who's just at the end of his training, and it was essentially that he expressed great pride that a junior who, again, an international audience in equivalent of an intern or an FY2,

stayed behind after his shift to see a trauma neurosurgery. And he had obviously lauded this individual and said that this is excellent work ethic. That's certainly one mentality. But this tweet

created a lot of fire on Twitter, and it had a lot of polarizing views, which we have sort of shared here, where people had certainly critiqued this individual by saying, why should one be staying

extra? Why shouldn't all exposure to training happen within a nine to five? If we have bosses who are sitting at the top who have the expectation to stay extra or stay late, does that not mean that

people, Perhaps other commitments might be. discriminated against and I think I would like to get your opinion on that, how

this reflects with the mentality, perhaps you guys grew up or trained in. What if you had any comments from this?

Just for context, would you briefly explain to everyone the difference between firm-based training and what we have now? Because the UK has seen a radical shift in how trainees effectively work and

are allocated to rotations? Yeah, sure. I'll do that. And then I'll take my stance on this side

or interpretation of it. So I trained in what was an older system called Kalman training And essentially, I would have done my post-graduate, there wasn't two years of foundation training. It was

one year over the call of junior house man. And I would have done six months surgery, six months medicine. And then went on to surgical training as a senior house officer. And I rotated through

many different specialties, but always on six month placements really. So you're in a longer time and tend to be stuck with one group, you know, one consultant,

maybe four or five SHOs and a few juniors below you, and

you were a little community of practice, really, which is really beneficial because you get to learn, to work, to build trust and actually integrate yourself into that community of practice. Then

I went on what would be six years of the higher surgical training in your surgery and one year in a fellowship, which is outside the UK program before So all in all, I probably would have done 14

years or something like that of postgraduate training after qualifying. It's currently changed now so that you do two years foundation and then in theory and it's streamlined. So you would apply for

the speciality. So when in your surgery, that would be eight years. So in theory, you should really be able to be competent and fully trained by 10 years No, you know, what is enough and what is

not. It's kind of difficult. So we come back to the Twitter feed. The first thing is, I mean, Twitter is hilarious. I mean, I do read it,

but you're dealing with very simplistic people try to simplify binary arguments that often have require the intellect of an amoeba to be able to sort of have a point on

it. But what this, somebody's indicating that time served or the amount of hours worked or overworked is the currency to make you better. And, you know, of course it isn't that simple. There's

no way training is that simple and this single issue is not. But clearly, let's take the argument if you're taking over the time of training. The more hours spent doing something, the more

expertise and theory you should build. But you shouldn't be doing something to the point where you are working beyond CFRs or beyond safety. And so, what comes as a sociological pressure, am I

impressing my bosses? Well, surely if they're relying on this type of simple statement, I don't think you're being sort of nurtured in the right way. You've got to be safe and you've got to be

sensible. And so working crazy ours might sound too

so difficult. And it's hard to argue that that is a sensible way. However, different people get different fatigue at different times. They have different backgrounds to their lives. Some will

have families. There's lots of issues outside of work that also curtail your availability to work. What you want is an ideal program that will give you all the experience and the necessary time to

complete so that you become a completely functioning, independent and competent, safe doctor at the end of it. And this war on Twitter, which talks about ours based, and certainly I did do a lot

of ours

And like that scenario operating beyond 24 hours, I find it harder to advocate for. But there would be a whole pile of my generations and generations above me will go back to the kind of Monty

Python sketch of the Yorkshire dads talking in my day, what we did was better. I don't think, I think these systems are evolving and correctly so they need to change. We need to be, you know,

you should never be starting. But as you evolve, you need to be checking what you're doing is not sacrificing excellent quality to it.

This is at the two way road because your consultant, as you say, as you call, or your attendee, as we call here in the United States, has to also be aware of those circumstances. So those needs,

he has to be open. He or she has to be open. Here in the United States, there is a limit of number, of which the resident, but not the attending, can work per week. And so the residents, and

it is punishable by law. I mean, the society of teaching or something punishes those departments that let the residents go over the working hours. And we often had cases, in long cases or cases

that started late, going into the at the midnight. And the resident has to unscrap and leave, because otherwise there will be over the hours that they have to clock every day, you know? But this

is at a two-way road. And I said that at a two-way road, in one time here in the United States, one

of the most prestigious residency programs was of Dr. Osama Almefti. He was in Arkansas in that time and one of our residents. Unfortunately, he came to us, interview with him, and Dr.

Allethamethi or Mr. Allethamethi, as you call it in England, told him you come home, you are my first year resident, you come home, and your wife is there with a, with a luggage and giving you

the alternative, me for the wife or neurosurgery. Which one do you choose? And Taurash, who came to us, he said, I go with my wife to which Dr. Aletymethik tell him you are in. We want you to

come and be our resident. So this is at the two way road. If the attending doesn't have that frame of mind, doesn't matter how many rules you just write, but if the attending is as my

distinguished colleague just said, okay,

things will actually change. Those are very, very individual cannot be regulated. You know, I think that the United States we do wrong in regulating those number of hours. But it's also regulated

in the UK. We've got the European working time direct. It's not right, Mr. O'Kade, that it poses the same restrictions on paper to the United States. But the individual

is not following that. That's where the controversy came. This is where this was a senior fellow was with applauding the initiative that this person took. Going out with their working hours to do

something and from that stem the ideal, does this make them the better trainee, or does this make them the better doctor? I wonder what your thoughts on this, Mr. Osmond.

So who are you have some thoughts? Yeah. Yeah.

Sam or.

You have some thoughts about this.

Um, yeah, I was, I was listening to the chat. It's interesting. It depends on the perspective differently. And I can, I would just want to share one. Point that may be related that From my

training, I trained in Baghdad at the center of the most busiest trauma center. Around the last few decades, decades always war war. And the point is that. Uh, I have a privilege to be at that

center. So you can choose being at your best or just regular. And I think that point may be related to the topic today day because I feel sorry for people starting at the paraphrase. their

residency, for example, because they don't have the choice to think of subspecialty early, for example, we all doing everything at general neurosurgery, how you can think of specialty as a

resident, if you are in a peripheral center, doing very less subspecialized procedures. So I think that's the point having, so starting residency in a center with basically the maximum potential

available, that will give the people the choice. Some people are, as you say, they prefer to be on the safe side and doing by hours. That's it. But I think most of the dedicated people, I don't

think it's for a time in our residency, we think, how many hours I did today, no, at all If I say that, I

will say one of the.

a huge blast injury we continue for for consecutive days doing surgeries for 79 patients presented at the same time from major blast injury, all with all required head injury. So for that, yeah,

I'm saying this not complaining, it's part of your achievement, it's part of your interest in speciality. But again, some people prefer to be just doing enough, some not, that's in general. But

again, that's offered only on the center that have all the specialities.

Can I ask Sam, or Sam, or you've trained a thousand students who want to

go on and go further and get the best residents they can. They're at at varying different levels. How do you think they would respond to a system where no matter how hard they worked in the end, a

computer would choose?

Sorry. Yeah, I think that's why I describe and it depends on the person. So some people always aim high. So they, I think they will be affected with such roles that try to randomize everything

seeking equality. And I think people end in neurosurgery always aiming high So that maybe in general such speciality will be affected more and more. That's, that's my opinion on that. If I can

make a couple comments about this, I'm going to make one comment in general. And that is, if you're motivated, like Sam or has just said, it doesn't matter where you go, you could become

excellent. And I've seen that I've, I've been with people all over the world. I've been people who've had no education and have been superbly successful. I've been with people who started out,

remember taking care of a young man who was on drugs in the service he was on in the ship. And he said, I'm going to, I'm not going to live my life this anymore. I want to get the best to be I can.

And he worked very hard. He's head of a cardiovascular surgery section in a major or a medical center. So I think a lot of it in the end does depend upon the individual, but the environment can be

discouraging So I think there's another principle here and that life is biologically, life is competitive. Life is

competitive. And if your competition is,

you think the person next to you, you're wrong and all over the world, extremely bright purple people in many countries who are working very hard to succeed and will succeed. And they will be

better than you are if you don't work as hard and try to achieve as much. because in the end, excellence should dominate. And if it doesn't, and if your country has an idea where excellence isn't

what you want, you become a mediocre country. And there are many of them in the world. And it's the same for politicians. If we're gonna choose them, it doesn't really matter. We haven't shown

that you're excellent in anything. You're gonna wind up with mediocre people. And the last assumption that's made here as neurosurgeons are people who wanna go into residency are always well

motivated. That's based on past experience. If you put in this system, why wouldn't they go into space research? Why wouldn't they go into engineering or technology? Why would they go into a

system where their desires to be excellent are being thwarted?

So you can't judge the future by the present

And if you look at history, Biologically, those who are superior survive and lead unless they have a system that's corrupt that puts somebody else in charge.

There's a comment from one of the audience members who's asked, there's a growing debate about the balance between promoting diversity and ensuring meritocracy in medical training programs. Critics

may argue that there is an overemphasis on diversity and that could compromise the quality of medical education and patient care. How do you respond to the concern that efforts to increase diversity

in say, neurosurgery residencies may inadvertently contribute to rise in mediocrity? Dr. Osmond?

Well, that's what I told you at the beginning.

I'm for diversity. We've taken people from all over the world for years because bright people exist everywhere.

If you, if you didn't, if you wanted to run a football team based on diversity, you'd fail because in America, we have all black people on football teams. Well, I don't think that's fair. I

think we ought to have oriental people, Asian people, Chinese people, people, we ought to have all kinds of people. They don't do that. But it's okay to do it simply sells. That's not logical

So I'm naturally because I'm personally

in favor of listening to people everywhere. That's never a problem. It's only a problem because

people aren't thinking that way. Equity, I don't agree with that. Everybody shouldn't come out the same because in the end, you have mediocrity and nobody wants to excel Inclusion, everybody

should be included. I agree with

that. Right now, we don't have everybody included. In fact, Black Lives Matter is an example of everybody not being included. It should be all Lives Matter. So I think you've got to get your

term straightened out here in your logic. Some of the things that are being, that are being

espoused today, are not being espoused equally to everybody. So where's the logic there?

Mr. King, do you have any comments?

Yeah, I kind of, I support what's just been said, then, you know, it sounds like a very Twitter feed type of question to me in that it's sort of bringing things up very simple and that, you know,

you want the system, it's open to everybody and everybody has a chance provided they show and demonstrate that they are the top dog, you know, that that's fine, that's evil I think in a societal

term, and it's a bigger question, is does everybody get an equal chance in society through education, through background, through offering, well, clearly they don't. So therefore, the system

has inherent bias before we put bias potentially on it. I think I think we have, I mean, I wouldn't do any counter evidence to suggest that there is concern that, you know, certain people are the,

I don't think there's a really true agenda that we are selecting diversity. but actually I'm ignoring the merits and the strengths of candidates. I don't think that's a real proven fact and

certainly selection systems. I've been involved in the UK, I'm sure it happens, but I can't account for the figure. It is excellence you want to achieve. There is a baseline the way you want all

your trainees ultimately to come out, that they are good competent doctors and each of them will have an area of expertise. I don't have an expertise throughout all of neurosurgery. I have areas of

interest that I have motivation for, and therefore I work harder for them. I update myself much more, but I wouldn't call myself an expert in fixing spines. In fact, I wouldn't want you to say

that I could fix a spine. I think that would be a dangerous thing. And so you've got to think of the system. It should be fair. There is a society thing to the background, but I don't think we

have an inherently unfair where we are seeking diversity and then actually running out of meritocracy, I suppose, to fall in with the theme of the debate.

Can I just give you a quick example, Hassan, if you don't want to go on, I'll talk to you. I'm mentoring a young man who is, went to medical school. They went to medical school in what's called

the offshore medical schools in the United, I'm sure of the United States. He did well in medical school, but he had trouble getting a residence. He didn't get one, went on to business school,

exceeded in business school, worked in laboratory medicine, wrote papers, did an excellent job, got a teacher's award, was wanted to go into business and wanted to work for a high tech company.

Eventually it took him a long time to get there interviewed. Eventually the company wanted to cut some of the workforce because they were losing money. He was one of the people, then he was hired

back And he worked very hard.

He did the work of five people. He was in a team of people. He would always not only do his work, but everybody else's work. He was always at the top. He was for India. He was very gracious with

people. People are from India are extremely gracious people. Well, he was brought and criticized because while you're being too nice to people and you don't really need to wear a tie, you don't

need to be formal. And basically what they were telling him is he was setting such a high standard that they wanted him to become media ochre like the rest.

Now, we've interviewed other people who have the same story. It's not a one story.

What do we don't see with the system that you're putting in?

Next question. Definitely, no. I think it is time for us to go to the next question, which I think is really interesting actually. And I think it leads on. with the idea that I think we've

already touched on, but I'd love to get some more of your opinions on this. And it goes back to more of a systematic approach to things where in the training programs now, and I'm sure I wonder if

our American colleagues, especially can comment on this, there's a checkbox approach to your training where potentially there's a prioritization of quantitative quality where you have to meet

certain continuing magical education objectives. And what's starting to happen is individuals are starting to favor getting these signed off as quickly as possible without potentially looking at the

program as a whole, but rather considering their training as checklisted and the faster they finish this checklist, the sooner they'll be done and the sooner they'll be competent rather than

potentially the approach of embracing the program and it's embracing the checklist. And that's what this continuing medical education refers to. I wonder if I could get some of your thoughts on that.

And more importantly, if there's a way that you could potentially change the way that training is done to avoid. this checklist thing, because there's the danger that you become not patient

centered, but objective centered. And I wonder, Jorge, if you might have an opinion on the starting of yourself. Yeah, no, we do the, I think this is also personal, no? I mean, which type

of, if you just want to do the checklist for your continuous medical education, that will also present other areas of your work You will work six hours when you can work eight, you will write a

lousy paper when you could do a better thing, no? So I think that is only one aspect of the overall personality of the individual, no? There are those, so I would not necessarily regulate that.

I will try to start off on the bottom and make better doctors or better professionals, right? And when comes the time for the, for the chit list. it will come naturally that you will do this best

CME and you will really be frustrated when you don't miss. I do my CME through the New England Journal of Medicine and when I don't get all the answers on that the first round, I am very upset.

And my wife knows that. So, but that is the question person and has to be individually oriented

It's individually oriented.

That's been interesting. I wanted to say, Samir, if you potentially have thoughts on this, I mean, you've trained many people and obviously you yourself are once a trained need. Did you have to

go through the seminar pathway of continuing medical education to achieve your eventual competencies? And if so, do you feel that this direction is the right way or are we moving too far in a

certain direction? You're asking me that?

Yourself or Samir or Rogi, I suppose? No, no, I think you are reading one of the questions, okay, no, no, I leave that to Samir or Dr. Aspani. Yeah,

that's that's an interesting point, actually.

I think a lot of what we discuss right now is standards, keeping the standards versus the standard deviation, which is people on the extreme versus at least we need the minimum standard. I think

those are more systematic ways. maintain the standard which is at least if you want to be in your surgeon you have some certain number of surgeries and and you list what are the required or example

for now in United States the fellowship I'm applying I'm applying now we we have a list of procedures and number for each procedure that should be done so I think this is if we want to take it from a

positive perspective this is a good way to maintain a minimum acceptable standard yeah at the same time I don't think there is much in the system giving the opposite way that okay if I can't do this

standards early enough can I move to the next step earlier I don't think this system in general is more flexible to that I don't know sometimes people can't think that okay but the time is also an

important factor. Whatever you can do, how many number of surgeries, but if you do the residency in two years, your mind may be not mature enough to deal with patient complications and those

things. So maybe time is also an important factor. So you can't consider the time as a slowing option, but at the same time, it's experience, yeah, I don't

know. I wonder, Mr. O'Kade, this is perfectly LinkedIn with I think some of your thoughts on the idea of the time of the program and checklist, which I think you've been involved in yourself Do

you have any opinions on this? Yeah, so I mean, obviously the system in the UK has moved to what is sort of said as competency-based, so it was to remove the time so that you could, if you were

some amazing human being or a superhuman being, you could learn to do all these procedures in three days and be signed off in theory. I mean, we know it has to be complete nonsense 'cause there has

to be, and you do not develop expertise in a short period of time. It's years, years, and experience, and seeing multitudes of basins. So there certainly is a tick box phenomena that is going on.

Now, whether that is useful or not is probably quite debatable. And I think actually it's use is probably user dependent. You could easily seek somebody just saying, Sign me off. And a boss who's

not interested in signing off. And so that system has failed because you probably could allow incompetence or dangerous people to come through. And I have no doubt that sometimes these type of

things happen. That's probably a reflection on the workforce certainly here in the UK and the huge challenges we have with trying to manage and not just patient care, but training needs of people

going through training. And that we aren't properly resourced, or everybody's not properly resourced to be a full time trainer It's just not. given there there is no reward for them. And so, you

know, it's a governmental issue that they need to take that on. And the tick boxes can be useful and I'll tell you from my experience where I find the most useful

is in dealing with trainees in trouble, in that you can use that highlight and generate discussion The other thing about competency or tick box, sort of type of assessments is that it clearly cannot

cover the entire domains of knowledge skills and attitudes, which are really the three areas that are going to make you as a human being a competent doctor You cannot, you cannot assess for

everything, and historically what was done was your boss or your consultant or attending would say, at the end of the training yet they are satisfactory to be signed up and that was a system that

worked very well. Of course, it is prone to potential. conflicts of interest, if one person is giving a say so, and a trainee and a boss don't get on, that could be conflicting.

But I think we do use both systems here, and if done correctly, I don't think they are destructive, but unfortunately, both from the trainer's side and from the trainee side, who can just see it

as, this is what I need to do to get the bare necessity to come through, which is not. You should be actually saying, there's a trainee, or any trainee should be achieving. How can I be my best?

You look around what best, and then you go, how can I get to the top of my game? I'm not concentrating what other people are doing. I won't stop until I feel I can do no more to super myself.

Well, I agree with Rodney, but Rodney, but I think the problem is if you curtail people's incentive they're not going to have that. You're going to select people who won't have that desire. On

the continuing medical education, there's some very good evidence that's come out in the United States, which tried to examine people after they left medical school with regular testing. And they

found out that it is a very poor correlation to what they are actually doing. And as a matter of fact, the only positive thing is that people are conducting the testing or making more money than

they did in the past. But the system has failed. And so it's not a reasonable way to do that. So I think a better system is - and it gets to a real flaw in society.

For example, let's say I had Rodney. And here's a man who is a pain specialist for pediatric patients. I can't think of a specialty that's really unusual. I've never met one before. And so if I

put him in a test, which asks him to tell me about Mitchell, by Stoma, and what's secure for this disease or that genetic disease, and he spent his entire life working on pain mechanisms in people

and children and so forth, that's unfair. And the way the best way to do that is to have personal interviews. And that also gets back to how we interview people going to medical school. And

personal interviews, I can understand Rodney's background I can see what he's done, say, gee, he's really worked out. He's done it. Exam doesn't test his skills. So I think this is a result of

technology. We want to quantitate everything. And in the end, we've missed it. So that's a flaw in technology. And that's the system we started out discussing. We're talking about people and

individuals. It can't measure that. So if it can't measure it, it ignores it. That's what technology fails

I wonder then if I actually almost wraps us up very nicely with I think what my last question for all of you will be and I want to I want each of you to sort of address this whether you think going

forward based on both your experiences as trainees as medical students as attending is, you know, and consultants and also as trainers. What do you think could be do you think the system needs

solutions and if so, would there potentially be any that you can think of that would make the health care system as a whole not on an individual level and as a whole A welcoming place that is also

meeting rigorous standards for patient safety. Now that is a big question and it really just somehow do you have any solutions, I suppose, for my discussion. And I'll open up the floor I won't

pick on anyone in particular if anybody has anything to say on that.

Jorge, what do you think? Jorge? I think in a more like I have to start picking on people. I wonder,

Jorge, I'll start with yourself 'cause you're the closest to me. Difficult question to ask, I know, but you've all had great illustrious careers and I wonder from yourselves, are there solutions?

And do you think we need solutions? Or do you think we're fine the way we're going?

Yeah, this is the same as with love. No, love, I mean, do you, do you love your friends or your wife or your spouses or do you, so you are accordingly in that manner. So if you laugh, if

you're happy with your ethical career or with neurosurgery or you love the brain or you

laugh, I say, I heard recently prestigious pediatric neurosurgery prestigious pediatric neurosurgeon. saying that he had it already with the myelomeningocellus, he wants to focus only on epilepsy.

Well, so you don't laugh, pietenurosurgery,

because the laugh of the pietenurosurgery is

the myelomeningocellus, the huge head, the monstrous head, and now we do this, and then the subdual dark hands, and we have to shrink the skull and talk to the craniofacial. And

that is an issue that is inbred, and often happens through teachers and through mentors. And

the very smart audience here will actually understand the

story I will tell

you Dr. Osmond can leave the room and.

they can leave the audience. I was a fellow for one month with Dr. Osman in Detroit in doing microvascular, which was basically in murder in rats by suturing the carotid artery, you know, and I

do remember one day we are there with a Mexican fellow in the dorm where we lived, and a person comes and introduces himself as Mr. Fantino, I think, and he says, Dr. Osman operated my wife

yesterday. I asked him, What can I do for you? And he said, Dr. Osman says, I have two foreign fellows that I didn't have a chance to take them for dinner. Why don't you take them for dinner?

And what that has to do with CME, with excellence, with the with learning neurosurgery, those of you who understand it will make the association immediately. The role of the mentor is crucial.

The role of the mentor is crucial. You might have a fantastic seat, but the ground is not propagated or somebody doesn't water you daily. And that is what makes that the whole difference. You

learn to laugh data profession through seeing others who love the profession. And then you start enjoying. And then doesn't matter, of course, you have to do a CME. Yes, you just do it. You

have to stay 25 hours. You just stay 25 hours.

Mr. Akin, any thoughts if you had a sort of closing remarks or big system that's changed, you think? Well, yeah, it's an effect to the training scheme Like, there is nothing that's perfect.

and you should be striving to improve. I mean, you know, if you're doing the same thing as you do in five or 10 years ago, you're out of dish and that there's no difference to that training. I

mean, first of all, it needs considerable investment and you have to remember the stakeholders involved in that as government. And a government is a five-year, you know, that's the full life,

not the half-life of any government in action before they're held to account at the electorate. And so they don't see long-term goals, you know, they don't see things that might have to develop

over 20 or 30 years, which is what we're trying to achieve. These are long-term projects. So government never thinks of it nor has interest in it, and certainly I would criticize what's gone on in

the UK, and that, you know, it's all good on the paper exercise that suits government who likes to look at very simplistic things, but it's not the reality. And also, you know, it's the

environment, you know, this community of practice I referred to is not just You're great mentor because I have been influenced and directed my career. It's actually been just by two or three people

that I really linked with who guided me and guided me as a whole human, not just in my neurosurgical part, also were there to listen to me about my aspects of life, things that were going on with

family and to help with that there. And when I also expand that out, it's not just the great mentor, the great consultant or attending or professor. It's the environment of the allied health

professions you work with, all of these things have a huge impact. If you are happy, you're going to learn. It's going to be encouraging, and it's going to help you develop across all sort of the

domains that you need to be, to be an excellent clinician in any aspect. And also, I may add, I'm sorry for taking too much time, but if you are happy, in this sense, if you're really, I'm

sure, remember when you start dating your current spouses, They were the moment that she. who or she said, no, I don't think and you persist it and you persist it, right? And that persistence

out of life is what is the main difference between a great neurosurgeon and an average neurosurgeon.

A happy neurosurgeon and not a happy

neurosurgeon Dr. Osman, any comments? Well, let's let Sam, let's, Sam, or talk. Sam, or go ahead? Yeah. I totally agree with Dr. Oke and it's a, it's a, it's a whole thing beyond just

simply education checklist, but commenting on the checklist just to say that if we, if we want to put in a way, a fair way that using checklist at entry level will maintain the minimum standards.

However, nobody should think that they have any role in having a safe and brilliant surgeon as an outcome. This should be combined together. Okay, it makes sense in general. And as the professors

say, its mentorship has a huge value on that, because I just, Dr. Okin says

that it's not mentoring skills only. It's communication, how to convince your mentor to give you the trust So you can operate on his behalf first, and then how you convince your patient, how you

convince your patient, you're in complication, and especially major complication. So I think the whole process

deserves more weighted humanity skills and communication and passion, rather than just checklist. Checklists are good for entry level I think that's my opinion.

Well, I wrote a paper about 10 years ago. It was an editorial, which was entitled The Greatest Opportunity Your Life. And if I were in your shoes today, you are facing what I think is the

greatest opportunity I've ever seen people have in my life. And it's wonderful that everybody around you is pursuing mediocrity. Because what it means that you should do what the fellow is doing

there, work hard, stay late, work more hours, do whatever you can, because the goal is you're trying to improve yourself to be the best person you can be. It doesn't matter what anybody else is

doing. And in the end, it's not gonna matter where you wind up 'cause you're gonna work very hard at that. Although I know you would wanna work at, go to the best place and the best institution to

do that. Your competition is a world. And basically in the end, your competition is yourself. Because the goal is, am I doing the very best I can? And I wouldn't really worry so much about, if

the rest of the world's mediocre, it's gonna go right down the drain with mediocrity. But you will be in demand, and your skills will be cherished by many people, and you'll never have to worry.

And I think with that we can conclude it, I would first and foremost like to thank all our speakers who took a time from their busy schedules to

give us insight because we have all of you at different stages of your career and certainly I think just eyeballing the audience. There's a lot of medical students and junior doctors, and I'm sure I

can speak on behalf of them. We are very grateful for the insight and the wisdom you have imparted to us To the audience, I'd like to say thank you for coming. It's a Thursday night so you're all

very keen. There is another SNI. Let's talk that we have previously done with the medical school and Professor Osman. We will send everyone the link to the website and our previous talks. And if

everyone can keep their eyes out on our socials, there will be many more to come. Lots of controversial topics, things that you guys want to talk about. You let us know and will organize the

sessions. So thank you all for coming Thank you.

One point here is that the number of people are at the meeting and the last meeting eight times that number. we're the one who eventually saw it on video. So the extent is quite large. That's right,

the ripple, congratulations. Thank you. We hope you enjoyed this presentation.

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Please send your questions or comments to oshmansnidigitalorg. Thank you

"Let's Talk": Mediocrity in Medicine; YNSS series; Resident Education

James I. Ausman, MD, MA, PhD

Jorge Lazareff, MD

Samer Hoz, MD

Mohammad Ashraf, Mb.ChB

Hassan Ismahel, MB.ChB

Roddy O'Kane, MbChB

SNI Digital®, the Global, Interactive, Peer-reviewed, New Video Journal of Neurosurgery and Neuroscience-2024 Edition; "Innovations in Learning" for the 21st century

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