Shrinking: The Recruitment Crisis in Psychiatry

Earlier this year I submitted this piece for the Morris Markowe prize, which the Royal College of Psychiatrists awards annually for the best short essay aimed at public education. Needless to say it didn’t win; the competition was fierce and the piece unremarkable. It tries to address some of the misconceptions around psychiatry, with the aim of getting more junior doctors to apply to specialise in it. I’m publishing it here so it finally sees the light of day and I’d really appreciate your thoughts.

Since I wrote the piece, the Royal College has announced that their recruitment drive is working: 95% of CT1 posts have been filled for the forthcoming year, a significant increase.

Shrinking: The Recruitment Crisis in Psychiatry

When a medical student finally emerges from their cocoon as a newly-qualified doctor, they spend the next two years rotating through a number of specialities. Getting a range of experience on the lowest rung of the ladder can be intense and unforgiving, but all doctors have been through it.

After those two years, there comes a choice: which single speciality would we like to train in further? This conundrum was presented to me last year. I could have worked in the relentless warzone of A+E, stitching up cuts and manipulating fractures. I could have become a surgeon; singular and intense. I could have chosen enduring relationships with patients and reasonable working hours by becoming a GP. I could even been a cerebral anaesthetist, complete with Zen-like calm.

But I didn’t choose any of those. I chose psychiatry.

The reaction was palpable. One of the few friends who could express their feelings about my decision beyond stunned disbelief and scornful profanity told me that it was “a total waste” of my modest medical promise.

My friends were not the only junior doctors to have considered a career in psychiatry to be an unattractive choice. The perennial “Cinderella speciality” is horribly understaffed nationwide, and the Royal College of Psychiatrists has rolled out a 5 year recruitment plan in a much needed effort to increase numbers of applicants and filled posts.

Down the psychiatric rabbit hole

But why is psychiatry so unpopular? There a few well-worn answers to this question. I think most of them are wildly unbased, and disproving them would do our recruitment, and image as a speciality, no harm.

One of the most common fears is of ceasing to be a “real doctor”. Prospective applicants dread the thought of being lost so far down the psychiatric rabbit hole, distant from the rest of medicine, that they’ll forget how many kidneys people have, or which end of a stethoscope goes in your ears. To a degree, this is understandable. Our breadth of knowledge does wane with time. But this is no different to any other speciality. I once knew a cardiologist who had to look up rheumatoid arthritis on Wikipedia. Orthopaedic surgeons are lambasted for not being able to read ECGs, and a gynaecologist wouldn’t have the foggiest idea what to do about your fungal nail infection.

In reality, modern psychiatry isn’t all that far removed from physical medicine. Plenty of the mental changes we see are caused by things like infections, drugs or thyroid problems, and we’re certainly no strangers to blood tests and head scans. Most psychiatric problems can be caused by neurological issues like strokes, dementia and epilepsy. Conversely, some psychiatric problems like anorexia can cause life threatening physical problems, so a thorough knowledge of the brain and body is essential. In addition, our patients are far more likely to suffer from obesity, diabetes and cardiovascular problems (and not just because of the drugs we give them!) so being competent at dealing with these issues is essential too.

The science of feeling

 Junior doctors also avoid psychiatry because they see it as unscientific. I agree that the sheer complexity of a person’s thoughts, emotions and interactions makes the scientific study of psychiatric illness much tougher than studying something discrete like a heart attack. But study it scientifically we do; and to great extent. As well as endless clinical trials of medication, you can’t throw a brick these days without hitting some state-of-the-art research on the genetics or neurobiology of illnesses like schizophrenia. We’re ever closer to understanding the causes of problems like autism, and we also successfully apply scientific methods to the study of things that aren’t inherently medical, like types of talking therapy. Moreover, we get to do lots of “touchy-feely” research on how people feel, which is vitally important and fascinating. No doctor could fail to find something that grabs their professional attention, and there are a lot of opportunities to get involved. In other specialities you’d have to sell your first born child to help with research, but in psychiatry, we seem to get offers every week.

The incurables

I’m often told by other doctors that they could never be psychiatrists because our patients never get better. I just don’t recognise that pessimism when I go to work. The majority of our patients recover completely and move forward with their lives, and the patients that aren’t able to improve fully are frequently helped substantially. Small steps, like relieving plaguing paranoia, easing low mood or anxiety, or helping patients build better relationships with their families are great goals in themselves.  For perspective, endocrinologists can’t cure Type 1 diabetes, respiratory physicians can’t cure emphysema and infectious disease specialists can’t cure HIV. In fact, palliative care doctors, who rightly hold an indispensible place in medicine, rarely cure anything. A large part of any doctor’s work is limiting the pain and suffering incurred by incurable problems. But only psychiatrists get stick for not doing enough curing.

The positives

As well as dispelling mythical criticisms, psychiatry can boast unique positives. The diversity of psychiatric sub-specialities is refreshing and challenging. They stretch from child services, through adult and forensic services, psychotherapy and addictions, all the way to old age psychiatry. Also diverse are the ways we help people: long gone is the cinematic caricature of the drugged-up, forgotten mental patient. The modern manner of care is to mix social and psychological support with a hopefully minimal amount of medication, and contrary to common assumption we learn as much about therapy as we do about tablets. I work with all manner of other professionals, like psychologists, social workers, and specialist nurses. Their vivid opinions, both on what is best for a particular patient, and on psychiatry as a whole, help to broaden my horizons and keep me thinking.

The greater amount of time I have with my patients means that I can get to know them as people instead of as “the gall bladder in bed 6”, like I had to as a medical doctor.  Being entrusted with the information they give me about their astonishing and colourful lives is a tremendous privilege. I’ve met concentration camp survivors, refugees, authors, actors and activists. I have grown. The conversations I have are so much more engaging now too; asking about a chest infections gets tiresome by the 100th time you’ve done it, but talking to someone about the voices they hear and the reasons why they think people want to kill them never gets boring. Bodies are all similar, but minds are beautifully unique.

I’m not totally delusional. I don’t think every junior doctor is a psychiatry convert waiting to happen. But I think psychiatry would have a lot more applicants and a far better reputation if people saw our true face. We are modern, caring, intelligent, energetic and various. But we’re also really short staffed. Come help us out.

About Alex Langford
I am a psychiatrist (now an SpR) based in Oxford after 3 years working in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

17 Responses to Shrinking: The Recruitment Crisis in Psychiatry

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  2. Hi Alex,

    A thoughtful and engaging response to this question. I wrote a similar essay 3 years ago I think for a competition in KSS. I approached it at a slightly different level in beginning to think about motivation and how people are motivated matches up or doesn’t with psychiatry. I have post it here – as I would be interested in your thoughts. Its a bit longer than i remember it being!

    I am interested in what isn’t being said. How much are we creating rationalisations for the widespread fear of mental illness. Its under-understandability, the unknown and unknowable, leaves us feeling out of control, helpless and as medics (generally) I am not sure we are good at handling that. Using a generalisation – the medical profession are problem solvers…we understand problems and we fix them. You have x and you need y.

    For mental health care to be as excellent and nuanced as it can be it cannot be that straightforward and I think this can be difficult for some.

    It asks questions of us around where we derive our sense of power/self-esteem from. Do we derive it from being able to act or do we derive it from just being? It asks questions of us about of our mental health and we still struggle with this. We don’t understand ourselves very well and it potentially asks questions of us we don’t want to answer or can’t problem solve in the ways we are very practiced at.

    Lets talk about fears. Lets talk about what isnt said and we might understand how recruitment in psychiatry. As we approach the change over and start of the new F1s, lets take the mental health of doctors (and all healthcare professional) seriously, front and centre, and we might help them take mental health as a career more seriously. We help each other learn the skills to help ourselves and we might feel less helpless when a person suffering and distressed with depression sits in our clinic.


    • Hi James

      Thanks for your comment. You make a good point, namely that as well as more obvious public miconceptions about psychiatry, there is something intrinsic about the motivations of junior doctors themselves which might be keeping them from applying to the speciality.

      I can identify with this. We are a pretty driven bunch, we like facts, algorithms, dichotomies and bullet points. We like to feel like we know what’s going on, and possibly due to year after year of being put in tough situations, we like to be in control too. We also unquestionably enjoy the social standing and respect we get as doctors, whether we even notice it or not. We like to have our opinions valued and our instructions followed.

      Psychiatry isn’t like this though, you’re right. We (should) play much more of a guiding role, a facilitating role, on a path that we don’t necessarily have much power to change sometimes. And we have to learn to come to terms with the facts that a lot of the time, something isn’t easily understandable, and that we aren’t the experts in it.

      I’ve certainly noticed not only that I don’t get as much automatic kudos as a psychiatrist, but that I don’t feel like I deserve it either. Other professionals, like psychologists and care co-oridinators are just as vital to the process of recovery, whereas in hospital medicine these people get pushed to the peripheries, as add-ons when the doctors need their help. I’m not sure a lot of junior doctors would be ready or willing to give up the cosy pedestal they sit on as revered medical doctors. I certainly had trouble doing so.

      Part of enjoying psychiatry and wanting to train in it may well involve learning to relinquish the habit of needing to be in control and lead the situation. I certainly do think a good psychiatrists knows what he can’t change, and accepts that. I do think that our ethos is different, and the wide range of excellent trainees we do have all share the quality of being able to stand back and realise what their role truly is in the context of someone’s whole life. I suspect trainee surgeons would struggle to do this as keenly.

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  4. It enjoyed reading this. I am not a psychiatrist but trained in the Human Givens, which you may not have heard of and if you have you may be well or quite ill disposed towards it – seeing it as unscientific and unproven probably. We would tend to go with all the tired psychiatry stereotypes that you do a good job to dispel. I suppose I have one thought. Is it often wise for most mental and emotional problems to be pathogise and look for a physical/medical cause? Because the impressions still is that that is what you do and maybe that is wrong. “Not to look at what is wrong but what has happened”.

  5. Mike D says:

    Alex, as a non-psychiatrist I have a couple of questions. I’m actually writing from USA.

    “In reality, modern psychiatry isn’t all that far removed from physical medicine. Plenty of the mental changes we see are caused by things like infections, drugs or thyroid problems, and we’re certainly no strangers to blood tests and head scans. Most psychiatric problems can be caused by neurological issues like strokes, dementia and epilepsy.”

    In the US, the leadership for psychiatry (the American Psychiatric Association) attempted to claim in their new DSM-5 manual (which was ‘rejected’ by our gov. department for mental health, the NIMH) that mental disorders were ‘Brain Disorders’ which did not result from other medical conditions. The quote I took above is used here commonly as an extreme criticism of American psychiatry, to imply they are pretending the symptoms of medical condtions are fabricated ‘Mental disorders’ to sell psychotropic drugs and other brain disurpting treatments.

    As far as I understood, psychiatry is a medical specialy that treats ‘Mental’ symptoms by diagnosing by symptoms and treating by symptom using everything from high currents of electricity to psychosurgery and psychotropic drugs to disrupt (or damage) brain activity to archive a change in ‘Mental’ symptoms.

    I am curious and I have to ask, do you prescribe psychotropic drugs to patients who you have diangosed with other medical conditions before those are treated? How long do patients usually stay on medication?

    While I understand psychotropic drugs may give some patients temporary relief from symptoms that don’t resolve otherwise, these drugs are only approved by gov. regulatory departments (such as our FDA) to be used for typically about 6 weeks. In practice, psychiatrists in the US virtually exclusivly prescribe psychotropic drugs indefinetly, for years at a time (a practice called ‘maintenance treatment’). Technically this is ‘off-label’ and is illegal. many patients wind up with adaptive changes in their brains (because neurotransmitters are a closed system that’s self regulated with feedback) which produce severe drug dependence and other side effects which produce symptoms of ‘mental illness’.

    Because there are no diangostic tests for mental illness, patients wind up being prescribed drugs to treat side effects of the first drug (accidently or on purpose). There’s a growing public perception that psychiatry is a scam is the US. The problem off off-label prescriptions is so huge that the gov. is instead conivicting pharmaceutical companies for the illegal marketing campaigns that result in these long term prescriptions rather then going after the physicians themselves. Each year billions of dollars in Felony ‘Illegal marketing an Fraud’ lawsuits are settled here in the US. However these convictions are applied in such a way that the companies just pay a fine and consider it ‘the cost of doing buisness’ and quickly commit the same crime again. We actually have entire ‘anti-psychiatry’ orgaizations in the US, such as Mind-Freedom Int. which claims 40,000 “psychiatric survivers” (ex patients) who protest the APA’s annual meetings. Growing patient discontent is also perceived as a threat to the future of the profession here. Involentatry treatment and felony convictions are usually the subject of those protests.

    Psychiatry in the US is so engulfed with conflict of interest, kickbacks and bribes (individual psychiatrists are often given gifts, bribes, or commisions from pharma companies as incentive to prescribe drugs off-label), and ‘illegal marketing and fraud’ convictions reported on frequently by news stations that it has become public knowledge and a source of extreme embarrasment for practicing psychiatrists in the US.

    I was curious if the same endemic problem was occuring in britian?

    I don’t know much about psychiatry outside the US, the DSM created it’s own alternate reality for psychiatry in the US, and I understand the entire rest of the world uses the ICD, published by the World Helath Organization.

    • Hi Mike

      Thanks for the comment-

      What I meant was that in practice, psychiatrists spend a fair amount of their time surrounded by physical medical things like blood tests and scans, and that organic disease can cause a lot of psychiatric problems – not that they are the cause of all of them.

      Psychiatry is the medical speciality that deals with mental changes – be these caused by an organic change (like Alzheimer’s, for instance) or a “functional” change. The best way to treat these changes is to fix the cause – getting rid of the organic disease or reversing the psychological change – though sometimes we can use medication to help ease suffering regardless of the cause. I feel when done right and cautiously, this is humane.

      I’m not sure of the US licensing laws; psychiatric medications are not designed to be given for just 6 weeks – most of them are prescribed with the intention to be taken for much longer – with benefits found up to years – but of course we should use as little medication as possible, for as short a time as necessary, because no drug is free of adverse effects. We should involve patients closely in these decisions.

      I am convinced – by a lot of research evidence – that psychiatric drugs can be used to help people when prescribed responsibly. But we cannot let this go too far – in America especially, the trend to widen the definitions of some conditions to allow for more people to be given drugs, probably with a large pharma incentive, has gone too far. The boundaries at which we see drugs as being potential helpful have crept further and further away from reality.

      But we don’t see so much of this in the UK – our NHS is a free service, the doctors are paid the same amount no matter how much or little they prescribe (and we’re also all very busy), so we have no reason to push drugs on people that we feel don’t need them. Our disconnection from financial gain allows us to be relatively objective.

  6. Mike D says:

    Alex, thanks for the thoughful response.

    I don’t quite understand what psychiatry is trying to do though. Psychotropic drugs get their effect from inducing some degree of neurologic dysfuction. Specifically the frequency and amplitude of neuronal firing is altered non-uniformly due to the presence and action of feedback mechanisms, which is disruption that can seen on a QEEG. Neurons will also alter their connections based on their degree of activation within a particular circuit (this is how neural networks normally ‘learn’ to perform information processing). The result is drug-induced extra ‘wrong’ synaptic connections, and/or lost connections that cause all kinds of problems in the fuction of the brain. This is most spectacularly pronounced in antipsychotic drugs which cause huge acute and progressive structural changes by dimishing neuronal firing. In this case Glial (support) cells are additionally deleted from the brain.
    (This is an example where a drug may be subjectivly helpful, but is causing progressive brain damage. Antipsychotic drugs are generally not approved for ‘maintenance treatment’ in the US but are almost always used this way.)

    These changes can’t been seen by subjective diagnosis, and may never be detected.

    Is this not just trading one subjective symptom for an entire new created problem? Which in this case, may likely complicate further diagnosis and treatment. I don’t understand what psychiatry is trying to accomplish.

    • Hi Mike

      Thanks for your thoughts.

      In short, I do believe that antipsychotics have clearly been shown to lead to longlasting changes in brain structure and function if they are prescribed for long enough – though I’m not sure if this is true for other types of drug.

      And also, you may be right in stating that a lot of psychiatric drugs don’t work by directly reversing an underlying neurochemical imbalance – some are still very keen on this idea, some are very much against it – in truth the evidence is not totally equivocal.

      My point would be that we have to think of what’s best for the patient when giving drugs, and include them in that decision if at all possible. Even if the drug won’t fix the underlying problem, even if it might lead to changes in brain structure if given for a long time, sometimes this might be better than not giving it at all. It depends on the patient.

      Think of morphine as a comparator – it doesn’t fix the underlying problem, and if you give it for long enough, or irresponsibly, it will do harm – but it’s still tremendously useful if used well.

      We need high quality research to delineate the effects of these durgs, both long and short term, and we need to be honest about what we find in order to use our drugs well.

  7. Mike D says:

    Thanks for the reply Alex,

    It sounds as if the benefiting from long term drugs is exceedinly rare from what you described.

    I am concerned that psychiatric diagnosis is simply not accurate, reliable, or precise enough to make a rational ‘risk to benefit’ assessment. Historical evidence from past treatments heavily supports this, though I won’t go there for now. Some of those treatments are still in use today and are still involuntarily adminstered (like ECT).

    In the 1970’s, the Rosenhan Experiment in the US brought into focus how poor the reliability of psychiatric diagnosis really was. Although psychiatric nosology was created and revised regularly, the problem was never really addressed in a meaningful way. Both the ICD-10 and the DSM-5 have poor reliabilty in terms of replicating one psychiatrists diagnosis or outcome assessment by another psychiatrist.

    It is worth noting, structural changes in the brain produced by antipsychotics correlate with severity of psychiatric symptoms. Structure and Function of the brain will affect ‘psychiatric’ state. Here are 6 replications of that correlation for reference:

    Am J Psychiatry. 1998 Dec;155(12):1711-7.
    Int J Neuropsychopharmacol. 2011 Feb;14(1):69-82. Epub 2010 Aug 12.
    Neurosci Biobehav Rev. 2012 Aug 10. [Epub ahead of print]
    Schizophr Res. 2012 Feb;134(2-3):165-70. Epub 2011 Dec 16.
    Expert Rev Neurother. 2011 Jul;11(7):943-6.
    Arch Gen Psychiatry. 1998 Feb;55(2):145-52.

    It’s also worth noting, structural and functional changes occur with all psychotropic drugs that have been studied to that end, namely Antipsychotics, Lithium, Sodium valproate, and SSRI Antidepressents. Lithium stands out from the others as structural changes (brain expansion) do not reverse when the drug is discontiuned – even with short term use. (I don’t know if Lithium is apporved in the EU; it is used for ‘bipolar disoder’ in the US)

    Anyway, in summary, this is the reason I don’t understand what psychiatry is trying to do. I do not think there will ever be any ‘high quality research’, as psychiatric observations are poorly reproducable. This can never be fixed either. Only objective observations are scientific, and can be reproduced reliably by another observer. Without science, there is no progress. The only objective outcomes seems to be bodily dysfuction or damage (including the CNS) at present. I think this is why psychiatrits have to lie or omit things in practice to make patients more receptive to taking drugs. This is what I find confusing and distressing.

    • Hi Mike

      Thanks for the reply – I’m very pushed for time this week so I’ll have to keep my reply breif.

      There is considerable evidence that longer term psychiatric medication can be helpful; in fact many of our drugs don’t have a demonstrable effect until years down the line, when things like suicide rate and maintained remission can be reliably calculated.

      As for Rosenhan, it’s a colourful study but doesn’t say what many think it does. In reality I don’t think it pointed out that psychiatric diagnoses were unreliable because one could pretend to have them (I could easily lie about having headaches, chest pain or numbness and spend weeks in hospital) but I do think it pointed out that psychiatry was too keen to treat symptoms alone, without concentrating on how the person actually was – Rosenhan’s were fine and never needed the harsh treatment.

      As for the links you posted, correlations always work both ways. It could be that those with the most severe illness needed more drugs anyway, so the drugs weren’t the only thing causing the changes. We do now know (despite what others will tell you) that there are many changes in brains caused by psychiatric illness alone.

      Despite what you say, quite a lot of psychiatric illness is reliable, reproducible and amenable to high quality study. Anorexia, OCD and autism are just a few examples of relatively clear peaks that stand out in the mountain range of mental disturbance. Some diagnoses (ie DMDD in the DSM-5) are just nonsense but the majority are more than well evidenced over decades of research.

      We have to be better at using our drugs responsibily – weighing up the risks of side effects and possible long term harm against the undeniably good effects they can have if used well.

      Afraid I can’t commit to answering at length any more – quite pushed for time – but thank you again for comments.


  8. Mike D says:

    Alex, thanks for the response, sorry you were pressed for time.

    I don’t particularly feel the need to defend Rosenhan’s experiment in paricular. However his counter argument to what you said was that patients were only released under the pretense the medications produced a remission an average of 19 days after admission. All patients were drugged and there was *never* (emphasis on that) any admission the patients were not sick. Certainly this doesn’t happen in medicine anywhere else, and really would stand out as intensely bizarre. The patients only pretended to gain admission, but then acted normal until release.

    However this was back in the 70’s. We have trials for the ICD-10 and DSM-4 that show diagnosis is not particularly reliable in either manual, or congruent between classification systems.

    If we take the kappa value of 0.80 for schizophrenia from the ICD-10[1], and pretend this represents an 80% chance diagnosis is congruent between two raters, there is a 20% chance a patient will be misdiagnosed. 1 in 5 patients will therefore receive the wrong diagnosis. Kappa doesn’t actually translate that way though. The coefficient of congruence was 0.48 for schizoaffective disorder, and 0.56 for unipolar depression, so how much worse is that?

    If you notice, there is nothing published that uses conventional statisitcal analysis to determine the realibilty of psychiatric diangosis. We use statistical analysis for everything else in science, specifically to calculate with what degree of confidence we have that our sample of observations did not happen by chance. We then use this Confidence Level to determine with what degree of confidence we have that our sample represents a larger population of observations that that sample is part of. There is a minimum requirment of what is considered acceptable in the scientific method, a cofidence level of at least 98% must be reached, which is 3 standard deviations. this leaves a 2% chance observations in a sample occured only by chance. .

    Kappa is not part of statistical analysis, but was bascially invented or adopted by the people working on the DSM-3 (notably Dr. Spitzer). Perhaps to hopefully end that internal perception of a crisis of reliabilty in the 70’s.

    Kappa, however, can be shown to have unacceptbale limitations with mathmatical proofs that it’s expression used to compute the probability of agreement by chance is inappropriate. In other words, worse limitations that Statstical Analysis didn’t have were added to an invented mathmatical formula to ‘beat’ a better system already used internationally for science.
    A company that makes statistical software outlined the limitations of Kappa and came up with a better soultion.
    “Kappa Statistic is not Satisfactory for Assessing the Extent of Agreement Between Raters”

    Click to access kappa_statistic_is_not_satisfactory.pdf

    “We do now know (despite what others will tell you) that there are many changes in brains caused by psychiatric illness alone.”
    I think i’m one of those others. There are very few publications that take into account the effect of medications on patients. Addtionally the drugs are still doing harm if they make the underlying problem worse. There’s no way to rationalize this away, More Harm is simply More Harm. The drug just appears to help in a poorly reproduceable way which isn’t congruent with the opinion of a neurologist who can measure more then psychiatrist can.

    Addtionally, our NIMH recently published the results studies that determined antipsychotics actually prevent recovery and worsen illness in many patients.

    Sorry for the flood of references, but i just wanted to show i’m not fabricating anything.

    I hope that clears up my position on psychaitric diangosis and it’s reliabilty. I have actually looked at the reliabilty that is published, and that’s my concern. The evidence that treatments work is only as good as the label of illness. This is somewhat poor, so delibratly causing objective harm for a subjective benefit could never be scientifically or morally justified.

    I do stand by my opinon that lying or ommiting is neccessary for the psychaitry to work in practice. In the US this practice is edemic, and was the subject of my original question. If a physcian should ever have to lie about how their treamtent works, or how well it works when it carries the risk psychotropic drugs do, and still force it on the patient even if the patient is rational but declines this is a *very* strong indication something is fundamentally wrong.

  9. Alex, I can’t contribute much in the way of intellectual discussion here, but I do admire your patient centred approach and open mind. Like us nurses, you seem to be balancing art with science and it’s good to see someone so passionate about their specialty. We need more people like you in healthcare. Good luck with your career 🙂

  10. kamal says:

    Mike D I totally agree with you, out of interest, are you a doctor?

  11. kamal says:

    hi Mike, I think you’ve made some good points. Out of interest are you a doctor, if so, which specialty?

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