Today is blue Monday. Stress and resilience [important topics at interview.]

stress-pencil-croppedToday is ‘Blue Monday’ supposedly the most depressing day in the year – originally thought to be the 3rd Monday in January. It was probably first suggested by Cliff Arnail. His equation has six factors:  debt (d), time since Christmas (T), weather (W), low motivational levels (M), the feeling of a need to take action (Na) and time since failing our new year’s resolutions (Q).

blue monday equation

Although I am not sure how scientific this all is it certainly seems to fit in what we see as GPs and counsellors seem to be busiest and booked up in January.

Of course stress is not limited to just one day a year. It is just that it seems to peak about now. Christmas often brings us face to face with realities of family life [divorce lawyers have their busiest month], credit card bills start arriving and the optimism of the New Year and new year resolutions start fading.

For students, January often means mid-year exams.  Students have left the cosiness of home where they have usually been looked after and return to essay deadlines, exams, doing their own cooking and cleaning etc. First years have got over the excitement of starting University and second and third years have the pressure of knowing that all marks contribute to their degree grades. The short days and the darkness make it hard to get up in the morning and to motivate yourself. Some people do suffer from SAD, seasonal affective disorder where a lack of light can lead to depression.

Stress, anxiety and depression are very common anyway. A new report published a couple of days ago by ICM claims that 55% of interviewees said that stress caused by their employment has an adverse effect on their mental health and day to day life. As a GP 1 in 4 of my consultations are about stress, anxiety and depression. That is far more than any other condition, including all respiratory infections such as ear, throat and chest infections combined!

Medical Schools repeatedly remind interviewers that students and doctors who fail and cause concern do so, not because they are not clever but usually because of stress and a lack of ‘emotional resilience’. The medical course is long, intensive, full of exams and students and doctors constantly see distressing events. Empathy is important but it is always important to keep a professional distance and take care of yourself.  Therefore many candidates if not most, will be asked questions on how they cope with stress or how do they think that they would manage a heavy workload and extra curricular activities.

By now you should have evolved ways of learning, dealing with exams,managing your workload  and developed ways of relaxing. To avoid feeling overwhelmed some people make lists, it is important to prioritise tasks,delegate or even cross off tasks further down your list.  It is difficult but sometimes necessary to be assertive and to speak to people who have unrealistic expectations; for example a teacher who seems to ‘forget’ that you have other subjects apart from hers. Managing time effectively, (using travelling time to read the student BMJ or this blog for example!) is important. Demonstrating self discipline e.g. by getting up early before school for rowing practice would be worth mentioning. It is alsoimportant to have ways to unwind. Exercise is a great way of burning off stress hormones and boosting endorphin levels, as is music and singing. True friendships areinvaluable and bring a sense of self worth. And anyone having difficulties should seek help as soon as possible and realise there is no shame attached to this. Macho – ‘I can cope’, ‘soldier on’ attitudes are very much frowned upon.

Goodbye 2016! My Three Most Significant Medical Events


Zika, the new health threat, is a virus spread by mosquitoes which burst onto the scene in 2016.

It causes only a mild illness and 80% of patients have no symptoms at all but it seems to be associated with disorders of the nervous system, particularly microcephaly in developing foetuses, a condition in which babies are born with small and poorly functioning brains which usually causes mental retardation.

Twenty one countries in the Caribbean, North and South America, including  Florida have been affected and women have been advised not get pregnant in some of these. It has spread on a massive scale in the Americas, where transmission was first detected in Brazil in May 2015. Large numbers of the mosquitoes which carry the virus and a lack of any natural immunity in the population is thought to be helping the infection to spread rapidly.

It was first discovered over 60 yrs ago in Africa but the link between microcephaly and infection was not noticed. This could be because health surveillance is very poor in these countries or because the majority of the population have had an infection in childhood. As a result, by the time girls get pregnant they have already developed resistance to the virus.

junior doctors strike no 2

Junior doctors in England took industrial action for the first time in 40 years.Over 76 per cent of junior doctors voted in the ballot, with 99.4 per cent voting yes. The medical profession overwhelmingly supported their juniors covering their work and joined them on the picket line. The Government declared that changes in the junior doctor contract came about because of statistics that showed increased mortality at the weekend. The Government sought to:

1) Extend “plain time”, the hours in which a trainee doctor receives standard pay, from 7am-7pm Monday to Friday to 7am-10pm every day except Sunday, though he later offered to make it 7pm on a Saturday. This is in order to create the seven day NHS   [normal working for throughout the week] without spending more .

2) To remove the obligation to work to the European Working Time Directive which limits the hours doctors can work. While there is some evidence that patients admitted at the weekend are more likely to die within 30 days, this is a complex issue which is has never been directly linked to junior doctor staff numbers.

Weekend mortality is bound to be greater because only emergency cases are admitted not routine cases. When this is taken to account the ‘weekend effect’ is much diminished and most doctors and experts believe that is is mainly due to a lack of access to investigations such as scans and consultant supervision. Stretching the existing workforce around 7 days may create more gaps during the week days and worsen patient services then.

genetic engineering

On a more positive note 2016 was the year when gene editing started to hold out exciting possiblities. CRISPR-Cas9 is a gene editing technique that uses the Cas9 protein and a strand of RNA to make breaks in strands of DNA.

Then new genetic code is then placed inside the breaks. This can allow the genetic code to be rewritten. It is powerful and reliable, quick and very cheap. CRISPR-Cas 9 “components” can be bought for $30.  Possible applications are numerous, this is why Science Magazine declared the technique its ‘Breakthrough of the Year!’ Researchers at Duke University in the US used CRISPR-Cas9 to delete DNA in mice that was preventing cells from producing a protein essential for muscle function. This causes a human equivalent disease called Duchenne’s Muscular Dystrophy. A virus was used to deliver DNA alterations into the cells of mice.When they injected the therapy directly into the legs of adult mice, it resulted in improved muscle strength. When they injected it into the bloodstream – tests showed improvements in muscles responsible for heart and lung function.

Earlier this year, a group in China announced it was the first to successfully edit the genome of a human embryo. The breakthrough at Sun Yat-sen University in Guangdong showed the errors in DNA that led to a blood disorder, beta thalassaemia, could be corrected in embryos. Gene editing has been used to make mosquitoes resistant to the malaria parasite which they transmit to humans and to make pig organs genetically similar to human organs.

Organ donation. Topical issue of the week – and ethical scenario



It has now been a year since the new  the new Welsh system came into force , residents are presumed to have consented to organ donation unless they positively opt out.

In June the Welsh government said the scheme had already saved dozens of lives after revealing that in the first six months, of the 60 organs that were transplanted, 32 came from people whose consent had been “deemed”. ie  those who choose to do nothing, if they are 18 or over, have lived in Wales for more than 12 months and die in Wales, they will be regarded as having consented to organ donation. Families still have the right to over rule and refuse but it has led to an increase in the desperately short supply of organs. Many  die whie on the waiting list for an organ.

Ethical scenarios regarding organ donation are common – try this one.

An ex-alcoholic patient [who is a mother of two children], a seven year girl, a 75 yr old war hero and a homosexual man need a liver transplant. Who should have it?


A doctor should never be judgemental. As in most complex situations a decision would only be made after consulting with senior doctors, the hospital ethical committee and the hospital legal team and/or your medical defence body. All of these are sources of valuable advice and it is important to share responsibility for any decision with them. Remember doctors work in teams not in isolation.

The case for the ex-alcoholic woman to be given the liver transplant

Some people may say that her illness was self inflicted but that is no reason to discriminate against her. Ex-alcoholics may relapse and start drinking again but many diseases affecting the liver such as auto-immune diseases may also affect a new liver and she should not be denied treatment because of this. Being the only parent to a child is a very important role but it is wrong for a doctor to value one life more than another and positive discrimination may lead to a slippery slope where people in certain important roles, e.g. national leaders, have priority in transplant waiting lists.

The case for the seven year old girl and the war hero.

Some people would say that the war hero has served his country, paid his National Insurance tax and deserves to receive his liver transplant on the NHS. Others would say that he has lived a reasonably long life while the young girl who probably has most of her life ahead of her is more deserving.  The NHS and NICE does sometimes look at QALYs [quality added life years] when deciding to fund certain expensive treatment. If a treatment costs less than £20,000 for each extra year of good health it extends life by, it will be funded. In this scenario the girl would probably benefit by gaining more QALYs than the war hero. However the use of QALYs has been denounced as ageist and it is considered wrong to discriminate because of age.

The case for the homosexual man 

His entitlement is as valid as anyone else – it would be discriminatory and completely unacceptable to think otherwise.


A doctor should never be judgemental and never value any one life above that of another. For this reason transplants and ‘who gets the organ’ problems are decided in this country solely on:

1. clinical urgency [who needs it most],

2. The best match [whose tissue type is most similar and least likely to reject the organ]

3. the length of time they have been on the waiting list.

Organ donation

There is a massive under supply of organs for organ transplant and each year many patients die while waiting for a suitable organ that may have saved their life.

At present there is an ‘opt in’ system in the UK which means that it is important for people to carry donor cards, sign the organ donor register and make their wishes clear to relatives if they wish their organs to be used to help someone if they die.

A few months ago, because of the shortages of organs NHS Blood and Transplant suggested that people who agree to donate their organs when they die could be given priority if they themselves need a transplant. This, however met with a backlash from the Church of England and patients’ groups, who say ‘such a change would mean doctors treating two patients differently – something which would undermine medical ethics.’



The interviews have started- Sheffield, Oxford and Cambridge



Before the interview you have the opportunity to go on a tour of the medical school and talk to medical students

The interviews are changing to a MMI style format

Common questions relate to

  • knowledge of and interest in study in Sheffield
  • motivation for Medicine
  • evidence of commitment for caring
  • depth and width of interests (achievements in specific fields)
  • communication skills
  • understanding the nature of Medicine
  • medical work experience.
  • topical issues in the press
  • ethical issues

The Medical School states

‘After your interview the panel will grade you on your performance at the interview. Based upon this grading the Admissions Tutor for Undergraduate Medicine will then make the final decision as to whether you are offered a place on the course, held on a reserve list or rejected.  You will normally be notified of this decision through UCAS within three weeks of the date of your interview.’

Why Sheffield?

Sheffield is a well regarded city with a big University. The Medical School was founded in 1828 and has many prestigious alumni including Hans Kreb – who was Professor of Biochemistry and discovered the Kreb’s cycle. Student accommodation is good and relatively cheap and is close to the Medical School.

It is a systems based integrated course.

Cambridge and Oxford

There are usually 2 interviews [often 3 for Cambridge] which take place at the individual colleges and last about 30 min. Additional written tasks may be given. It is customary to stay overnight at the college and have the interviews on different days.

One interview is usually quite science based with 2 interviewers with questions to do with your subject syllabus that test your ability to make deductions and think aloud in a clear logical fashion and summarise your answer. You score most marks from your working out rather than the answer. Your interviewer will often try to guide you as you answer so make the most of their hints. Interviewers are looking for students who have insight into basic concepts. They may be teaching you in small groups for a number of years and want to make sure that you are a likeable enthusiastic student.

The other interview may be more typical of other medical schools with questions about your Personal Statement and books and articles you mentioned

[more information in my book – Medical School Interviews The Knowledge [P101/102]

Video of a mock interview
what Cambridge say they are looking for
They are famous for ‘out of the box’ challenging questions such as:
Why don’t most herbivores have green fur?
What percentage of the world’s water is in a cow?
Why are there so few large predators?
They are not looking for an answer necessarily, what they are looking for is seeing how you respond to these tricky questions-whether you are able to think logically and how you use the information given to you by the interviewers

Make sure your A level/equivalent knowledge is up to scratch
Why Cambridge/Oxford?

Amongst the top 5 Universities in the world with top research institutions and an amazing history of Nobel prize winners and other alumni.

They are both beautiful University cities. You have small tutor groups and some well endowed colleges give grants for travel and trips abroad. The college system means that you socialise with students doing other courses to a greater extent than in other medical schools.

Oxford is a bigger town than Cambridge. Oxford class sizes are smaller but Cambridge offers more places to study medicine.

Learning is mainly lecture based and there is not much patient contact in the pre-clinical years.

The Interviews have started _Kings College London


Kings Medical Interviews

Kings uses MMIs – see my book of worked examples.

‘ One of these station scenarios is designed to assess values and personality based attributes for example: kindness, compassion and empathy, respect for the individual, privacy and dignity, advocacy, decision-making, team working and integrity. Some scenarios are scientifically based and designed to assess information handling and evaluation skills, whilst others will assess knowledge on topical medical issues. Another station will assess the candidates’ ability to deal with an ethical dilemma. Communication skills will be assessed at EACH station.
A standardised interviewer assessment score sheet accompanies each station.’

Why Kings?
King’s College Medical School is the largest medical school in Europe and has facilities to match. As well as excellent research facilities it has a wide range of sports clubs. These include hockey, football, rugby, cricket, tennis and netball. Rowing takes place on the river Thames by Chiswick Bridge, 800m from the University of London boathouse. The Strand has a rifle range and Guy’s Campus has a swimming pool and
gym and many music, singing and dancing clubs. ‘I am very keen on contributing to student life and would like to join ————— club.’ is always a useful phrase to use.
There are many excellent libraries and the Hodgkin Library at Guys Campus is open twenty four hours a day As well as other medics you will be able to meet a diverse
group of students from many other countries studying many subjects – the humanities and arts as well as sciences. It is located in the heart of London – just under the new Shard, the tallest building in the UK. London is a varied, vibrant city with many museums, galleries and shows to enjoy. There is a diverse population with lots of inequalities in health, with wealthy areas along the river but with a lot of poverty around the teaching hospitals. The high immigrant population means you will be able to see many diseases such as sickle cell [Kings has the leading sickle cell unit in Europe] and TB. Having three campus sites increases this variety.
It uses mainly lecture base teaching with a strong emphasis on anatomy dissection and little PBL. PBL can be hit and miss with some PBL groups and facilitators being better than others. PBL often does not cover the whole syllabus and can leave gaps in knowledge. Students do get the opportunity to see patients with first years making GP visits within the first couple of months so although learning is traditional your interest in patients and their stories is also catered for.

It repeatedly features as one of the top 25 universities in the World (QS World Rankings) having placed 21st in 2010. Kings has had a proud record of 10 Nobel Laureates in the staff and alumni of King’s who made major contributions to 19th-century science, medicine and public life in general. They include:
.James Maxwell, one of the world’s greatest physicists
• Florence Nightingale (1820-1910) founded the world’sfirst professional school of nursing at St Thomas’
Hospital in 1860
• Joseph Lister, Professor of Clinical Surgery at Kings from 1877 to 1893, introduced an antiseptic system which changed the practice of medicine and drastically reduced mortality rates from major operations.
Maurice Wilkins and Rosalind Franklin at Kings, made crucial contributions to the discovery of DNA’s structure in 1953, which Watson and Crick found invaluable. In their honour, today KCL has the Franklin-Wilkins building, the main part of the Waterloo Campus.


‘Three parent baby treatments’ to start!


It is time to start making babies from three people, according to scientists advising the UK’s fertility regulator. The creation of babies using DNA from three people, should be allowed. The IVF technique involves replacing maternal faulty mitochondria with those of another woman.

Many say three-person IVF could eliminate debilitating and potentially fatal mitochondrial diseases that are passed on from mother to child.Opponents say it is unethical and could set the UK on a “slippery slope” as it is the first treatment that will permanently alter genes and involves a change in the germ line [inheritable DNA] .

tough mitochondria

Mitochondria, as all of those studying biology know are the ‘batteries’ of the cell providing the majority of energy from respiration. When mitochondria become faulty there are a range of problems from muscle weakness, heart disease and early dementia. About 1 in 200 babies born will have mitochondrial disorders. Doctors have tried to rectify these by injecting donor mitochondria into faulty cells but this has not been successful as they are so small and easily damaged.

tired mitochondria

Mitochondria are probably the remnants of a symbiotic relationship with bacteria. They were probably bacteria that were engulfed by cells; these cells then had a massive evolutionary advantage being able to generate 15 times as much ATP [the energy currency of a cell]. Mitochondria are the same size as bacteria, also contain circular DNA, have bacterial type ribosomes and enzymes and have a double membrane like bacteria.

mitochondrial disease 2

Mitochondria are outside the nucleus and are not involved in fertilisation of the sperm and egg nuclei.  Mitochondria are solely inherited from the mother– the egg cell mitochondria present in the cytoplasm will form the foetal mitochondria.  Doctors have recently developed techniques to prevent mothers passing on mitochondrial diseases to their children. In this new technique the nucleus from a fertilised egg cell will be placed into a donor egg cell with normal mitochondria that has had its nucleus removed. The nucleus will contain genetic information from the parents – mother and father and the enucleated egg cell [egg cell without a nucleus] from a third person. The newly formed embryo will thus have genetic information from the original two parents and genetic mitochondrial information from the donor –‘three parents.’ This will cause a genetic change in the mitochondria which will be passed down the line to other generations.3 parent baby

This affects what the HFEA describes as the germ line. Tampering with germ line is illegal and to many conjures up the spectre of eugenics and slippery slopes which lead to ‘designer babies‘. It requires a change in the law to make it legal. HFEA [the Human Fertilisation and Embryology Authority] involved the public in consultation  which had been generally in favour of a change in the law.Parliament then legalised the controversial procedure last year.

A baby has been born as a result of using the technique in Mexico but it is a new procedure and risky. Prof Robin Lovell-Badge, one of the researchers who reviewed the evidence, recommended putting the procedure  in to practice.”We’re not going to learn much more now unless you try it out for real basically – it’s at that stage,” he said.”There’s no reason why it shouldn’t go ahead now, but do it cautiously on selected patients where the risk of having a badly affected child is very high.” Click on the link to read about the parent who lost 7 children to a mitochondrial disorder.

mitochondrial disorder

Why Be a Doctor?


The NHS is crumbling and suffering from underfunding, litigation is soaring as patients are encouraged to expect more and more doctors are being expected to plug the gaps, work harder and longer hours. Respect for professionals has decreased.  The Doctors and Dentist’s pay review body has been told that there will be no wage increase for years because of Brexit.  Jeremy Hunt has  succeeded in alienating junior doctors who now cannot even carry out the threat to move to Canada [the Canadian immigration website has crashed because of all the people wanting to emigrate there after the Trump victory in the USA.]  So why become a doctor?

Why do you want to be a doctor? This is the common question at medical school interviews and the hardest to answer properly.

1. Working with people

If you are a people person, medicine is the right choice for you. You will meet a wide range of people from environments and cultures you would not normally encounter. Keep your mind and eyes open and it will enrich your life.

Doctors without doubt play an important part in the life of people and are often present at times they will always remember. This is gratifying but carries a special responsibility.

In the course of your studies, you will be able to improve this skill even if you do not have a particularly developed affinity towards working with people. During your studies, but also later in hospitals, you will meet a lot of people besides patients – patients’ families, medical staff, technicians, administrators etc.

2. Plenty of opportunities upon graduating

This reason is rarely stressed properly, but it truly is so. A medical degree does not lead to a job but lots of different types from not just surgery, paediatrics – those traditionally thought of as carried out by doctors but public health, management, research and teaching.  You have a widely respected degree and it keeps you options open .

3. Teamwork

The camaraderie between doctors, nurses and other staff has been described as being similar to that between soldiers. Lots of bonds will be created, you will have successes together and will watch patients die together.  During your studies, but also later in hospitals, you will meet a lot of people besides patients – patients’ families, medical staff, technicians, administrators etc.

3. The ability to help people 

The most doctors would say that there is no greater joy than the one you feel when you manage to help a very sick patient or when a group of scientists discovers a new medicine for a certain disease.

I personally love the strong medical ethical framework of being a doctor – particularly in the NHS. in which  all patients are entitled to free and equal access to heath care.’ The ill make up one of the most disadvantaged  groups in society, it is a moral duty to help them and I have the good fortune to be paid to do this.

4. Doctors are needed

There will always a need – we wont be replaced by google, in fact at the moment google seems to create more consultations by causing worry than reduce them. Doctors are in demand world wide. There is much uniformity of medical science. Upon graduating from a medical college in Europe you can find a job and work in any hospital in South America or anywhere else in the world (unlike some humanistic subjects). Furthermore, the major part of medical literature is in English, the most of the medical terms are in Latin. You will get acquainted with English and Latin in the course of your studies so that words like vertebra or clavicle will be nothing new neither to you nor to a doctor on the other side of the world. A lot of  countries that have forbidden or restricted employment of foreign citizens do not apply this decision to doctors.

In most cases medicine students get a job sometimes the very day they graduate.

5. Safe job.

Nearly all medical students get a job as son as they graduate. Yes it takes a long time but many such as those who do accountancy of law have to do post-graduate study and those with degrees in humanities my have to work for free as an intern on qualifying. It is a job that requires  a lot of sacrifices and personal investment and you have to be prepared to travel. Nevertheless a job will be there.

6. Life Long Learning

The end of medical studies does not mean the end of learning. Quite the opposite – your degree  provides you with basics for further knowledge and skill development. This is both a challenge but can help to retain interest. Some of what I learnt a medical school is now known to be wrong, a lot has become obsolete or less important.

7. Respect

Ok the age of deference is over. Doctors are no longer thought of as gods with the power to give life as perhaps they were thought of once and a good thing too. However medicine  still tops the charts as the most respected job you can do; far far above that of a politician – take that Jeremy Hunt!


I really recommend listening  to

radio4  ‘Why become a doctor by Kevin Fong, particularly episode 3

The Interviews have started – Birmingham




Please let me know when other medical schools start interviewing


Birmingham have organised interviews in a MMI format with 6 stations lasting 6 min each and a longer 8 min smple calculation statiion. Last year there was a station assessing your motivation for medicine, communication skills and ability to empathise, an ethical scenario, logical reasoning, scientific understanding and interpreting a scientific problem – data interpretation. Your team working skill have been assessed in the past using role play.

Past questions have included;

Tell me an example when you saw a doctor using good communication skills.

What have you struggled with?What do you think you will struggle with at medical school?

What role have you played in a team?

What are the demands place on doctors?

What makes a good doctor?

What convinced you to do medicine?


Why Birmingham?

Birmingham Medical School is one of the largest and oldest Medical Schools – it takes 320 British students a year. The national student survey showed an impressive 91% satisfaction rate. There is patient involvement even in the first year with community attachments in General Practice from the start. Birmingham is a vibrant multi cultural city with good opportunities to see a variety of diseases such as TB and HIV. There are many cultural opportunities such as theatres and living costs are cheaper compared with London.

Birmingham has a modular systems based programme with patient contact from year one. There is a small amount of PBL but teaching takes place in a variety of styles from lecture-based, seminars, tutorials, laboratory work, clinical practice and bedside demonstrations. Role plays are frequently used [OSCEs]. – check by reading the prospectus


Ethical issue of the week – abortion

assisted suicide

Abortion is always a highly charged issue in American elections but it is also dominating the political agenda elsewhere

The  Rebuplicans won both houses of Congress and Trump has said that he would nominate ‘pro-life justices’ [there are likely to be as many as three vacancies] to the Supreme Court. Even one pro-life justice appointment may change the present balance and lead to the over throw of  the court’s landmark 1972 Roe v Wade decision that established a woman’s right to an abortion in the US [in states that allow it].  Trump has also promised to repeal provisions in the Affordable Care Act [nicknamed Obama Care] that require insurers to cover contraceptive services and stop them charging women more than men for insurance [women tend to cost more than men because of contraception, gynaecological and obstetric care]

Abortion in Poland is already illegal except in cases of rape or when the woman’s life is in jeopardy, or if the foetus is not compatible with life once born. Most women wanting an abortion travel to Germany. Last month the ruling party proposed legislation to completely outlaw abortion. Marches and a strike by 30,000 women seem to have led to the legislation being abandoned.

Abortion is a very emotional subject. It is the only procedure that a doctor can opt out off in the UK. When taking about abortion remember that your personal beliefs should not affect your treatment of a patient. Even if you disagree with a patient who requests an abortion the GMC makes it clear that patient should be treated with consideration and empathy. It may be reasonable to ask her to consider other options if she does not seem completely sure  but she has the freedom to make her own mind up and there should not result in any significant delay.The patient should be quickly referred to a colleague who is willing to help her.

The Abortion Act 1967 [UK] makes abortion legal up to 24 weeks gestation,

1 If there is greater physical or mental risk or harm to the mother by continuing the pregnancy.

2. At any stage if there is serious risk to the health of the mother

3. At any stage if the foetus is likely to be born with severe physical or mental abnormalities.

Pregnancy and delivery is more dangerous than a termination so reason number one suggests that provided the pregnancy has not gone far there is effectively abortion on demand. However late terminations, beyond 12 weeks are rare. 90% are before 12 weeks in the UK.

The major organs are formed by 12 weeks. We think that the foetus may begin to feel pain at 20 weeks when the nervous system begins to mature. When recognisably human life truly begins is very controversial.

The end of Obamacare? Why is it so controversial?


A republican view of Obamacare.

Today Donald Trump’s campaign manager Kellyanne Conway said the President-elect is considering calling a “special session” of Congress on the day he’s sworn in to repeal President Barack Obama’s health care law.’ Why is the Affordable Health Care Act  ‘Obamacare’ so controversial?


Before Obamacare  fifty-eight percent of the population had insurance, mostly via their work but employers were not obliged to provide health insurance. Even if they were covered insurance companies may insist on exclusion clauses so pre-existing illnesses and some diseases were not covered. Those with long-term conditions sich as diabetes would find it difficult to get any insurance. Medicaid and Medicare are government schemes which cover the elderly and the very poor.  However this left a substantial number of poor and middle class Americans uncovered. Fifteen per cent  of Americans were  completely uninsured. Inability to pay health care bills was and still is by far the commonest cause of bankruptcy.Patients are routinely turned away from hospital if they cannot pay for treatments. Hence stories such as the series ‘Breaking Bad’  where a chemistry teacher starts producing drugs to pay for his cancer treatment which would of course be free in the UK.



Obamacare now covers 22 million Americans.  It forces all Americans to have health insurance, but offers subsidies to make coverage more affordable and aims to reduce the cost of insurance by bringing younger, healthier people into the  system. Only about 5% of Americans no longer have health insurance and pay the fines. Republicans have complained that it is an intrusion and people should have the right not to buy health care. It should be their choice not to spend money and take the risk.


It also requires businesses with more than 50 full-time employees to offer health insurance. This is a very significant cost to many businesses

The law creates state-run websites like online travel and shopping sites – where individuals can compare prices as they shop for coverage.

No one can be denied health coverage including those with pre-existing health conditions. It allows young people to remain on their parents’ plans until age 26 and expands eligibility for the government-run Medicaid health programme for the poor. It has also banned the practice of charging women more than men.


Why is Obamacare unpopular when it seems to have achieved so much? The answer is cost.The US spent $3.2 trillion in 2015, approximately $10,000 per person. The equivalent of over 3 months earnings after tax for the average citizen, more for a couple with a single earner. Although Obamacare subsides it a little, if you are suddenly made to pay that sort of sum when you had not bothered about insurance before it is bound to hurt.

The USA spends 20% of its GDP, $1 in every $5, spent in the USA is on heath care.This is three times as much of its  GDP as Britain which spends on average $2802 per person. Despite being the only developed nation without having universal coverage it has the worst health care statistics of all the developed nations according to WHO [the World Health Organisation and The Commonwealth Fund [a highly respected American Think Tank]. We in the UK have high life expectancy, despite spending far less.

According to the study carried out by The Commonwealth Fund , health care spending per person is highest in the U.S. not because Americans go to doctors and hospitals more often, but because of greater direct access to specialists and greater use of medical technology and health care prices that are higher than in other nations.

The wealthy in the US get too much medicine. For example  the last president – G.W. Bush was found as a result of routine screening to have a blocked coronary artery and opted to have a stent put in although stenting arteries in patients who have no symptoms  has not been shown to be beneficial and the proceedure is risky: it can cause heart attacks and strokes. “’This is really American medicine at its worst,’” said Steven Nissen, head of cardiology at the Cleveland Clinic in Ohio  . . .  ‘It’s one of the reasons we spend so much on health care and we don’t get a lot for it. In this circumstance, the stent doesn’t prolong life, it doesn’t prevent heart attacks and it’s hard to make a patient who has no symptoms feel better’”  The third commonest cause of death  was found be due to iatrogenic deaths [deaths as a result of medical intervention] in the USA.  The uninsured of course get no care and many cannot pay for the medicines.

All countries face enormous challenges with regard to health care. All developed countries have rapidly rising health care costs because of an ageing population, obesity and increasing technology. Enoch Powell, a former Health Secretary declared spending on health ‘a bottomless pit’ and indeed it can be.I am profoundly grateful to work for the NHS and have the NHS look after me if I get ill. It does have problems and faces major challenges and we should all strive to improve it. However like virtually all doctors, I am proud to work for the NHS and truly appreciate the fact that I never have to add to a patient’s distress by demanding payment!