Globalisation causes the migration of all types of workers, including healthcare professionals, who may opt to seek richer pastures in the form of better paid and pensionable positions in countries other than their own. Dr Tertius Lydate in Eliot’s 19th century novel Middlemarch, while starting out with lofty ideals, rapidly became mired in financial difficulties and was constrained to seek more lucrative pastures outside Middlemarch. Maltese doctors are also poorly paid, and unless the local authorities ameliorate working conditions, the ongoing medical brain drain will worse with catastrophic consequences for the local NHS.
Globalisation is fashioning a workforce resettlement that also encompasses the medical profession, and Maltese doctors are no exception to these migrations. We shall briefly review Tertius Lydgate, a medical character in George Eliot’s Middlemarch, a protagonist who even in the 19th century, clearly demonstrated the possibilities and implications of such migrations.1
However, we shall first briefly review the background to doctors in English literature up to Eliot’s period. Medics in English literature were initially viewed with irony and treated with disdain, and one of the earliest such characters is Chaucer’s ‘Doctour of Phisik’ in his 14th century Canterbury Tales, a knowledgeable man who is depicted as avaricious and in league with apothecaries who overcharge patients for cheap medicines. By the time we reach William Shakespeare’s period (1564-1616), attitudes had somewhat improved, despite the chaotic mess that medical regulatory affairs found themselves in, example, quacks and empirics practiced widely and unsafely, the distinction between physicians and surgeons was blurred, the Physicians Act of 1540 defined medicine as also encompassing surgery, giving the physicians the right to operate, and a Guild of Surgeons had existed since 1369 while an older Guild of Barbers included members who practiced either exclusively as surgeons and tooth-drawers or only shaving and hairdressing. Moreover, apothecaries were members of the Grocers’ Company. This tripartite system of medical practice in Tudor England was evidently highly confusing and a 1512 Act of Parliament had acknowledged that a vast number of untrained individuals were practicing medicine, stating that none could practice medicine in London or within a seven-mile radius unless graduates of Oxford or Cambridge or upon having passed an examination by the Bishop of London or the Dean of St Paul’s Church.2
Overall, Shakespeare appears to have thought highly of physicians who are mentioned as learned doctors, while viewing surgeons with a jaundiced eye, with, for example Dick Surgeon in Twelfth Night discovered in a state of drunken stupor when most needed. By the beginning of the 19th century, the traditional medical responsibilities of physicians, surgeons, and apothecaries were being replaced by new and well-schooled practitioners who could perform all of these roles. George Eliot’s fictional Dr. Lydgate is one of these novel medical practitioners, and is one of Middlemarch’s protagonists. His dilemmas, at work and at home, are used to illuminate social, psychological, professional and moral problems. Lydgate is first mentioned well into the novel, in chapter 10, and although an aristocrat, is poor, ambitious and somewhat arrogant.
The noble doctor had deliberately kept away from London’s big city intrigues, jealousies, social jockeying and the jostle for celebrity status. He starts off with lofty ideals that include the running of a fever hospital in rural Middlemarch for free and the performance of medical research into the causes of fever and other illnesses. This causes the town’s medical establishment to treat him with jealousy and suspicion and Lydgate’s practice consequently develops very slowly. While Lydgate is a moral man, like us all, he suffers from a number of small prejudices and moral failings that are related to the necessity of balancing self-interest with that of other individuals and patients.3
Lydgate’s downfall occurs when he falls in love with, and marries, a pretty and highly decorative but thoroughly impractical woman who is used to a rich lifestyle. She quickly depletes his savings and goes on to mire him in dire financial straits, dragging him progressively deeper into debt. Lydgate finds himself eventually implicated in malpractice during the death throes of one of his patients due to a potential conflict of interest that would have yielded him substantial financial benefit, releasing him from debt.
The eventual victory of society, personified by his wife Rosamond, over Lydgate’s integrity is inescapable. Lydgate is forced to seek more lucrative pastures than Middlemarch among London’s high society, abandoning his high ideals; a perfect Aristotelian tragic hero.4
Modern doctors are highly trained professionals, and expect to live reasonably comfortably. Furthermore, the inevitable contacts with peers in private practice, and fêting by drug and medical companies, suggests certain expectations of medical life. Pressures on the home front are equally unavoidable, with soaring property prices, and costs of maintaining a household with dependants that may comprise a wife and several children, including the latter’s schooling costs.
All of these are exacerbated by the poor Maltese NHS pay scale. This situation has come about partly because the Maltese socialist administrations in the 1970s and 1980s regarded China, North Korea and Libya as ideal role-models, hence civil service pay scales were reduced and percentage wage increases were replaced by cost of living wage increases across the board, significantly lowering salaries and pensions of some of the best trained professionals in the country. Unfortunately, despite many years of non-socialist administration, pay scales have often failed to retain brain power that is highly appreciated and even actively head-hunted by medical agencies.5 This also results in a significant financial loss to the country since the local authorities themselves have estimated that a medical students costs at least Euro 95,000 to train in tertiary education expenditures alone.5
Also in UK NHS style, Maltese NHS salaries have traditionally been supplemented by private practice, and therefore specialities which attract little or no private practice tend to have difficulty recruiting trainees and specialists who prefer to move overseas in far better salaried and pensioned posts.6
Several solutions are available, and some are inherently unacceptable to the medical profession, including a lowering of future prospects that may, perhaps, be inculcated at the training level, a disingenuous expectation. First rate professionals cannot be expected for work for second rate salaries and the choices are stark. The danger of such deals was aptly highlighted by an eminent local retired pathology and ethics professor who pointed out the possibility that Maltese doctors may decide to take it upon themselves to decide what fraction of the 40-hour NHS week amounts to their salary, since an employee who believes he or she is being defrauded by one’s employer is not morally wrong to diminish the work commitment to that employer, and that this would not be an unethical stance.7
This is probably more acceptable to individual doctors than the drastic lowering of one’s standard of living or running up ruinous debts. The final alternative is emigration as clearly shown by Balzan et al. with 50% of medical graduates leaving the island to continue studying or work abroad but only 7.5% return.8 The current Maltese administration has accepted the reality of this brain drain,5 but the response to train much larger numbers of doctors is hardly likely to solve the brain drain problem as this will further exacerbate the local brain drain and contribute to the influx of well trained doctors to richer countries, particularly the United Kingdom (English is Malta’s second language).
The Medical Association of Malta has proposed a three point plan to the government in order to encourage local doctors to remain and practice: an increase in basic salary in order to offset loss of income due to the introduction of the European working time directive,6 the implementation of structured postgraduate training programmes in as many specialties as can be supported by the local infrastructure and a gradual expansion in the consultant grade in order to improve junior doctors’ long term career prospects.
Middlemarch’s Lydgate died when he was only fifty, leaving his wife and children provided for by a heavy life insurance. He had gained an excellent practice, alternating, between London and a Continental bathing-place by season and wrote a treatise on gout, a disease of the wealthy. And while he regarded himself as a failure as he failed to do what he had set out to do, Lydgate, ironically, was considered a successful man.
There is no easy solution to the problem of good doctors leaving state and academic service in poorer countries in favour of better renumerated employment with more favourable career prospects in both European and non-European countries.9 The problem must be adequately, competently and urgently addressed by the local health authorities, by schemes such as the consolidation of the current Foundation program along with other encouragements and inducements that will persuade Maltese doctors who go abroad to train to return to their homeland.
Drs. Ivan Callus and Claire Thake for their help and support in my ongoing work in English Literature in general.
- George Eliot. Middlemarch, a Study of Provincial Life, London: William Blackwood and Sons, 1871.
- K.T. Fu. The healing hand in literature: Shakespeare and surgery, Hong Kong Med J; 1998; 4:77-88.
- A.T. Westwood. Lifestyle, Lydgate and the late twentieth century. J R Soc Med. 1997; 90:42-3.
- D. Daiches. George Eliot’s Dr Lydgate. Proc R Soc Med. 1971; 64:723-4.
- F. Galea-Debono. Time for major investment in cancer equipment, Times of Malta; 2007.
- D. P. Sandhu. Current dilemmas in overseas doctors’ training. Postgrad Med J. 2005; 81:79-82.
- A. Cilia-Vincenti. Medical brain drain (Talking Point). Times of Malta; 2006.
- J. Ameen. Half of graduate doctors leave to work abroad – MAM study, Malta Independent; 2007.
- I. Vlad. European views about accession. BMJ Career Focus. 2004; 328:99.