Don’t Complain, You Knew What You Signed Up For…

Unpacking the flawed logic behind the most persistent anti-strike argument

Earlier this week, The Times released a poll claiming that resident doctors have now lost public support. Polling data suggests most respondents were not in favour of doctors pursuing further strike action following the government’s most recent offer. But should you be brave enough to wander into the comment section beneath the Times article, you’ll find comment after comment laden with sarcasm, and the usual array of ad hominem attacks hurled in our general direction.

Luckily, most of these comments can be quickly dismissed as lacking any intellectual depth. However, one particular objection repeatedly emerges that deserves some attention:

“Well, you knew what you were getting into. Why become a doctor in the public sector if you didn’t want public sector pay with all of its limitations?”

Consent Done Backwards

At first glance, this argument seems somewhat coherent, relying on the idea of a social contract: you accepted the terms, so why complain now?

At the core of this objection, however, lies an assumption that is fairly problematic. In philosophy, they call it retrospective consent. This is the idea that by agreeing to something in the past, you are forever bound to its terms, regardless of how things evolve.

This fails on several fronts. First, as all medics know, consent is not permanent. Secondly, when conditions change, so does the context of the original agreement. You may or may not remember John Rawls from an ethics class at school (and vaguely recall that he said something about a veil). Rawls argued that justice requires certain background conditions to be met. If these conditions are eroded over time, by say chronic underinvestment or real terms pay cuts, then it is just for that agreement to be reviewed.

Just Imagine

Let’s use our imagination and do a thought experiment: Imagine inflation runs at 20% for the next decade, but doctors’ pay remains frozen. Would proponents of the “you knew what you signed up for” argument claim that no one has the right to strike? That a decision made in good faith ten years ago permanently waives your right to negotiate fair terms when circumstances change? Surely not. And if not, then the whole argument starts to unravel.

Philosophers sometimes speak of the fallacy of equivocation: when a single word is used in different senses within the same argument, leading to a conclusion that doesn’t follow. That word here is “choose” — or more precisely, “chose.”

To say that someone chose to be a doctor does not mean they endorsed every consequence of that choice as fair or acceptable. That’s not how choice works. People choose careers for a number of reasons—altruism, family tradition, fascination with science etc, and these can change over time.

And let’s just think more broadly about this argument for a second. Taken to its logical conclusion it serves to undermine labour resistance and industrial action in their entirety. If workers were forever bound by an agreement they originally accepted - no one, in any profession, could ever strike. That’s not fairness, that’s obedience.

Emotion Disguised as Ethics

So why is this argument so persistent? Why do otherwise reasonable people continue to deploy it with a sense of moral certainty?

The answer seems to lie more in psychology than philosophy. More often, it functions as a way of reasoning emotionally or simply expressing disapproval. This is about people being upset, upset about the inconvenience or upset about others asking for more pay.

Perhaps there are genuine reasons why they think the strikes are morally questionable—this argument however doesn’t seem to be one of them.

Wes’ Plan To Reform NHS Leadership Pay

As resident doctors cast their ballots, headlines emerged revealing that over 1,500 NHS executives are earning salaries in the excess of £100,000. In response to this, Wes Streeting has unveiled a new “carrot and stick” strategy aimed at underperforming trusts. Under the proposal, hospital leaders who overspend or preside over long waiting lists would be blocked from receiving pay rises, while those meeting key performance targets could be rewarded with bonuses.

Has our friend Wes given a moments thought to how he will account for the many quirks of geography, demographics, and socioeconomic disparities that play into a hospitals performance? Hospitals in leafy suburbs with wealthy donors are hardly fighting the same battles as overstretched trusts in rural or deprived areas.

Sure, some hospitals might excel in patient satisfaction but lag in other areas like innovation—or thrive in urban areas while rural hospitals grapple with older populations and fewer resources. Will these nuances be accounted for? We hope this doesn’t turn in to more bureaucratic noise whilst solving nothing other than draining precious resources.

Diagnosed But Not Better: The Role of Labels In Modern Medicine

When is a diagnosis actually helpful?

Early diagnosis and detection is lauded in modern medicine. The earlier we detect, the more we can prevent - or that’s how the story goes at least. But in her new book, The Age of Diagnosis, neurologist Suzanne O’Sullivan argues that our tendency to jump to a diagnosis has detrimental effects on our healthcare system and the population that it serves. This diagnostic reflex of needing to label and define symptoms may be undermining the goals that medicine is meant to serve.

O’Sullivan has observed a growing surge of (predominantly young) patients who arrive not with symptoms, but with a growing list of diagnostic labels. These labels are not incorrect, but they are not particularly helpful either. These patients are not healthier or happier since receiving their diagnosis. In actuality, they may even be worse off…

Epistemic Progress?

One tempting explanation for this phenomenon is epistemic progress. Science knows more now than it ever did. Surely this is all a result of medical advancement. Perhaps this is true, but what if the rise in (certain) diagnoses has not had the result we hoped.

As medics, we hate the term ‘uncertainty’ as it reduces the amount of control we have. A diagnosis offers a way of managing uncertainty. It gives clinicians a solid ground to stand on, or perhaps even a billing code depending on your healthcare system. Slapping on a diagnosis onto a ‘thing’ creates the illusion that we have understood it and worse, it can suggest that we have done something meaningful for the patient.

The concept of ‘overdiagnosis’ is often misunderstood to imply that the patient isn’t ‘really’ sick - but this narrative is one O’Sullivan is fervently pushing back on. She’s not questioning the accuracy of a diagnosis, but it’s utility. If a diagnosis neither guides effective treatment nor improves the patient’s experience of their illness - does it risk simply becoming an identity and then risk doing more harm?

The Spectrum of Human Experience

Have we zoomed in on conditions that may not warrant intervention, so much so that we have pathologised traits that were once considered within the spectrum of human experience. The rise of mental health conditions such as anxiety, depression, ADHD, ASD may represent a long-overdue recognition of previously overlooked cohorts, but they may also reflect a cultural drift of pathologising traits that were once considered part of the human condition.

Here is a simple On-Call devised premise for when early diagnosis improves outcomes: If 1) the condition would have worsened if left untreated 2) the treatments we currently have are effective and 3) the harm of diagnosis (labelling, stigma, overtreatment) doesn’t outweight the benefit.

Now ask yourselves: how much of what we currently diagnose (especially in low-severity, high subjectivity conditions) - fails this test?

“There is a fault in our TOIL for working Bank-Holiday System - nearly all of the shifts I have worked on Bank Holidays have been long day 12 hours shifts, however my TOIL I have received for them has always been counted as a standard 8 hour normal working day with the medical rostering team not budging”

“The play specialist is the greatest thing to ever happen to paediatrics since penicillin”

“For the sake of all colleagues, The NHS mandatory training should include a section about the difference between REPLY and REPLY ALL”

What’s on your mind? Email us!

Some things to review when you’re off the ward…

The UK government plans to rename physician associates (PAs) in the NHS to prevent patient confusion, following a review led by Professor Gillian Leng. The current title has been found to mislead patients, undermining trust in the medical profession. Proposed new titles may include “physician assistant” or “doctor’s assistant,” and PAs will be required to clearly state their non-doctor status to patients. (The Guardian)

The Royal College of Nursing’s official response to the public sector pay deals announced by the government was to call it a grotesque decision that again favour doctor colleagues.

The number of formal ADHD diagnoses in Britain hit 800,000. That’s nearly 1% of all adults, and 2.3% of children receiving a formal diagnosis. The NHS note that the condition still remains underdiagnosed with an estimated 2.5 million people in England being likely to have ADHD.

Weekly Poll

Last week’s poll:

Do you think that locally employed doctors (LEDs) should be a on different pay framework to doctors in training pathways with rotational placements?

…and whilst you’re here, can we please take a quick history from you?

Something you’d like to know in our next poll? Let us know!

£2,100 Since 2005: Is London Weighting a Myth?

The £2100 ‘London-Weighting’ Premium has increased by approximately 0% since 2005, with all other costs inflating out of control. Using RPI as our measure of inflation, this would be £3028 in real terms today.

This begs the question: What is the London ‘weighting’ actually for? Nurses receive an extra £7000 for jobs in London, but the London weighting for doctors is a measly £2100 more. Some say that London weighting isn’t for cost of living. It functions to help prevent an undersupply of staff in critical roles. We know that doctors want London jobs irrespective of the additional weighting.

From a public health perspective, it clearly makes more sense to incentivise working in underserved rural areas. London is one of the well-staffed, well funded areas of the UK.

But hang on if we use this supply and demand argument, aren’t we opening the door to an uncomfortable piece of irony. The data shows that medicine as a profession will always be oversubscribed at the undergraduate and speciality training level. So would proponents of this argument suggest that as medicine will likely always be oversubscribed, we should direct our attention and funding away from doctors and towards other NHS roles that are having recruitment difficulties?