Who trains our doctors? The hidden workers behind medical education

LSE Events Podcast Host

Welcome to the LSE Events Podcast by the London School of Economics and Political Science. Get ready to hear from some of the most influential international figures in the social sciences.

Lassonde Conte

By saying a warm welcome to everyone in the room and everybody online. I appreciate you have multiple, multiple demands on your time, so thank you for prioritizing this this session. I'm secretly confident that you'll think it was the right choice by the time we finish, but you can definitely give us that feedback. My name is Lassonde Conte. I'm an Associate Research Fellow here at the LSE in LSE Health. I'm a health economist working on infectious disease and more recently establishing a Wellcome Trust funded center looking at the economics of diagnostics. It is an honor and a secret long term goal to get Patricia here today on the stage. I've known Patricia for over 20 years and from the very first conversation I had with her I knew that she was the real deal. Her originality of thought, her fearlessness to pursue questions that others would just accept as the status quo, and I think also your sort of warmth and openness to hear others ideas and suggestions make you a delight to know. In terms of housekeeping, we're not scheduled to have an alarm go off today, so if we do, then we need to sort of move and convene at Pankhurst House. Also we're going to be recording this event both in terms of audio and visual, so hopefully people accept that by being in the room and can consent to that. And can I ask that people turn their mobile phones off, follow my own advice so that we don't disrupt the event. This is part of a series of events to mark the LSE Health's 30th anniversary and over the past three decades LSE Health has become globally recognised as a centre of excellence for health policy and health economics research. Shaping health systems through rigorous policy orientated research. Influencing governments and international organizations on themes such as health financing, pharmaceuticals, aging, antimicrobial resistance and health system resilience, to name but a few. So to the main event, our topic and our speaker. The topic what happens when the academic work that shapes medical training is authored by people who largely remain invisible to the system? In this lecture, Professor Patricia Kingori examines a striking phenomenon revealed through her documentary and as of last week, BAFTA long listed documentary Shadow Scholars. Patricia tries to unpack how highly educated Kenyan scholars ghostwrite medical and healthcare assignments for students worldwide. These writers possess the expertise to train the next generation of healthcare professionals, yet their intellectual contributions go unacknowledged and the students who do reap the rewards and enter the practice do so without fully gaining and developing the competencies which they are expected to do so and to build. Professor Kingori will explore how the case study illuminates broader global health inequities. Her research demonstrates how essential workers such as community health workers and research field workers enable critical interventions, yet they get marginalised within knowledge structures and knowledge production and professional recognition. As part of LSE's 30th anniversary, this lecture addresses fundamental questions around global health and equity and medical education. Who has the authority to validate medical knowledge? What determines their expertise? And who recognises it as legitimate? And what are the implications when systemic power dynamics continue to render crucial contributions invisible? This question extends beyond academia. It spills over into the realities and the quality and the equity of the health systems that serve us all. And finally to the speaker Patricia Congori is a Professor in Global Health Ethics Ethics at the University of Oxford. Her research examines ethics, power and authenticity in health and science. With an extensive network of collaborators and primary research across Africa and Southeast Asia, she leads welcome projects on fakes and fabrications, global health crises and invisible labour. Patricia advised on Sage during COVID 19, is a trustee at the Medical Research foundation and was awarded Salesforce Woman of the year 2025. I've added a couple of points to the bio that you didn't in 2021, Patricia became one of the youngest women ever in the 925 years of Ox to get full professorship and was recognized as the youngest black professor at Oxford and Cambridge. And she really is a leading light for many of us. So it's with pure joy and the utmost respect that I welcome Patricia Kingori to share her work, her ideas and her reflections with us.

Professor Patricia Kingori

Thank you so much. Thanks for coming out. On a Monday evening in January when I was invited to come, I thought there won't be many people, I could just be a handful. So I can just kind of go under the radar a bit. So this is actually way more people here than I thought. So I'm going to speak for about half an hour, not very long because I actually really want to have a dialogue. Every single time I present my work I always learn new things and gain new perspectives. So I think the conversation is just as important as my presentation. So I'm hoping that my presentation would be thought provoking and stimulate debate and further conversation. So I am going to talk about so this is the title who trains your doctors? The Hidden workers behind Medical Education. And I'm going to initially introduce you to this concepts of shadow scholars. So shadow scholars is actually one of the many names that's given to the people who write essays, sit exams. They're also known as academic writers, online workers who write intellectual surrogates. They also like to call themselves, which is my actual favorite term for them. And basically they produce knowledge on behalf of students all around the world, but predominantly in the global north, mostly America, the uk, Australia, are the three top places. And this form of knowledge is considered fake. This form of knowledge production is considered considered fake because they write for other people. And essentially, what's really interesting about them, which I found really fascinating, is that most of the work they do is bespoke. So they will write for a complete essay from scratch for everybody that they work, they write for. And the reason why they do that is that they get paid not to plagiarize. So every single piece of work in general tends to be bespoke. So this is listed as some of the things that they do. And I'm going to focus mostly on students, but they do also work for academics. I could get. That's a whole nother lecture. We'll just stick to the students for today because that's what's asked to talk about. So in 2019, I went to a lecture in Oxford at the Oxford Internet Institute. And I kind of like sometimes just to go along to things I don't really know that much about. So I went along to this lecture at the Oxford Internet Institute, which was about online labor and looking at how people across the world use the Internet to earn essentially a living. And they produced this graph. And one of the things that really drew my attention was Kenya, because it was a place where I've done lots of research. My father's Kenyan as well. So, you know, it's like you see a map and your eyes just go to places that you recognize are familiar. And I noticed that Kenya was in green. And so I asked them, what. What's this writing on translation? Because I'd done research in Kenya. I didn't know it was a place that was. Did a lot of writing and translation. And it turned out that actually this is a euphemism for shadow scholarship and academic writing for hire. So I became really fascinated in what was going on in Kenya, why this was kind of happening, and why was it Kenyans in particular? So that was something I really started to focus on. What became clear was that they had a sense of the numbers of people in Kenya who were taking part, but there had been little or no qualitative work, to actually go and to talk to the writers to find out who they were, what their backgrounds were. And so I became really interested in going and actually speaking to them. And initially I thought, well, none of these writers are going to really talk to me because this is really clandestine and, you know, maybe they'll. I won't be able to get that many people and. But when I went to Kenya, I realized actually that they were like chomping at the bit to talk to me. They wanted everybody to know about them. They wanted people to know how smart they were, how much work they did. And the fact that they were invisible was a real source, a very sore point. And so I'm going to talk a little bit more about that as well. So just to also give some context to this is that I hadn't appreciated until I started asking how many people in Kenya knew somebody who also did this. So I was kind of talking about it and they were like, oh yeah, my cousin used to do that and oh yeah, my brother did that for a while. And I funded my degree doing that. And it was interesting to me to meet some Kenyan students in Oxford who had funded their degree by doing this in order to get to Oxford. So it's actually really interesting and very much part of a kind of a legacy labor option for many young Kenyans. So here are some stats that have been produced just to give us some context. Right? So 72% of this kind of industry is found in Kenya. And it's really interesting to think about why this has happened. So it's kind of a kind of combination of seemingly really random things. So firstly, you've got a very high unemployment rate for young people, which I will speak to a little bit. Secondly, the Kenyan government, I think it was in 2020, around 2010, decided that all university students would get a free laptop. And then in 2012, the UAE made a massive investment in fiber optic Internet technology for Kenya. So Kenya has amazing Internet. So you start to see how these three really random things kind of come together to produce this in a way that makes it the global leader. So you've got really amazing Internet to the point where most of the time when I'm speaking to, like, people in Kenya, I'm having to make apologies for my Internet cutting out, or they're just. And really, really, really bright, highly educated young people without job, formal job prospects, and then a laptop that you can use pretty much anywhere. So the industry, it's concentrated in Nairobi and Kisumu and Mombasa. These are very close to academic institutions and research centers and they write for people all over the world, as I've said. And recent statistics have shown that actually this form of employment actually surpassing many of the traditional sectors such as tourism and remittances from all over the world. And we start to see actually becoming now increasingly one of the sort of largest generators of income in Kenya. So the market's estimated to be worth around $1 billion. And you'll start to see why quite soon. So just to give you a sense of how much they earn, these academic writers, they earn roughly about 7,000 pounds a year, which doesn't seem a lot, but I'll put that into context in a minute in relation to just what other people in Kenya are ear learning. So just to give you some of the scale of the, of the industry. Right, so we've understand a little bit about what's going on in Kenya, but to also understand this in relation to where is the demand coming from? The demand is coming from around the world and we have rough estimates that are saying in 2014 that was saying around 30 million students were paying somebody to complete their work. And we really get a sense that 72% of this is happening in Kenya. So you start to see where this is happening from. This is 2014, so some time ago now. And what's interesting about the figures that we have is that these are all student self reports. So you can imagine the people who haven't reported might bump that up quite considerably. So in terms of the numbers, we know that I've already said that most of this is concentrated in Mombasa, Kisumi, Nairobi. If we just look at Nairobi alone in 2015, it was estimated to be around 40,000 of these writers. By 2018, this has gone up to roughly about 80,000 writers in Nairobi alone. So just to give you a sense of the scale, so we get a sense of the demand and a little bit of the supply as well. Just to come back to just some information about Kenya, so I've mentioned already the youth unemployment which is about 40%. And this again is just very difficult to get an actual pinpoint because you're looking at people who are maybe moving in and out of employment. And even with the academic writers for hire, we know that they often the market shrinks and expands according to what's happening in the global north. So for example, when I was doing my. Sorry, that was when I was doing my research, I couldn't get anybody to talk to me around the end of term in the UK or America, because that's their busy time. Because students know that they need to get their assignments in by the end of term. So that's when the market tends to. The supply expands in Nairobi. So no one's. No one's kind of talking to me in, in December, right? Because that's when all that's their busy time. So they have certain times that often reflect what's happening in the. In the global north academic year. And so you'll often find people who are doing other work and they would have shift to those busy times to get the work, and then they might go back to do something else. The reason why this is important is because it gives. It makes it hard to necessarily give a very strong figure, but we can give like estimates, roughly, we know how many. So just to give you a sense as well, about sort of the focus of today's talk, which is around medical education, to give you a sense of what's happening in Kenya around medical education, we know that there are far fewer doctors per people, not only than the UK, but actually what the WHO argues it should be 2.5 per thousand people. And Kenya's way under that. In addition to that, doctors on average are paid around $5,000, £5,000 a year. So it's really disincentivized in many ways to remain being a doctor in Kenya. And I've just got some images here of some of the strikes, what have been ongoing strikes in Kenya. And the sign, I don't know how many of you speak Swahili, but the sign that's held up by the DOCT is saying, I am not an online writer. Right? So it's this idea that actually, you know, this is. I'm so badly paid that actually online writers are getting paid more than I am. So this is giving you a kind of a sense of the kind of context from the Kenyan perspective. Okay, so I've already given you some sense of how. What's been happening with the market, but really what we've seen over the last 10 years, it's just the numbers have just gone completely through the roof. So already in about 2018, you can see from some of these articles, people were complaining that, you know, undergraduates were cheating. These were the ones who were admitting 16% were saying that they were cheating, and they were using these essay meals. So essay meals are essentially the. Another euphemism that's used to describe the industry. So we've got these things that's happening at the moment that's kind of all converging We've got people working really, really hard in Kenya, high unemployment rates at the end of it and hardly any jobs. Really poor pay when they do get jobs. And then in the global north, we've got more and more and more and greater, greater numbers of students are cheating. And this is 2018. So what we've noticed is that across all of the industries, so engineers, doctors, midwives, lawyers, nurses, pilots and dentists, the numbers have grown. So 4% of medical students in 2014 said that they had paid somebody to complete their work for them. But by 2018 this was already 16%. So you start to see just how much it has grown in just four years. But that was really nothing compared to when Covid happened. And I remember speaking to writers who had never ever dreamt that they would ever write. They were never in Kenya, they were never, ever, this was never something they'd thought about. But the demand was so high that they were working like 16, 18 hour days just to meet the demand from students in the UK and the US on Australia who wanted their work written for them. And that shift to online work really just propelled this into a whole nother level. I mean, the writers in Kenya were buying cars, buying land for their family members. They were absolutely minted. And they have, it's never really, I mean, things have gone back a little bit, but that really, that expansion in the market really catapulted this whole industry into a whole nother kind of stratosphere. So during this time, you know, lots of academics and lecturers and teachers were complaining and saying, you know, we've got a problem here in Australia. They were saying 70% of academics were saying that they were really worried about this. So they had students who they thought were using these writers in the US, according to this book, Cheating Academic Integrity, 37 of the 50 million students were paying somebody during the pandemic to do their work for them. And most of this, as we've already established, was happening in Kenya. So what was really interesting was that this just was just kind of happening at pace where everybody was like, this is nothing I've ever experienced before. And yet what was fascinating because as I mentioned before, this work was bespoke. It wasn't really being detected by plagiarism software. So one of the main ways in which most academics can get a sense that students are not doing their own work is that they run it through plagiarism software. And if it isn't plagiarized, it's really, really then difficult to say that someone has cheated. But in some universities, even to run it through plagiarism software, you can't just do that randomly. You have to justify why this student or you run all of them through plagiarism software. And some universities don't do that. Many universities are completely ignored the problem and don't want to ignore the problems. They'll want to admit that there is a problem. So, for example, I know that the Guardian ran a survey in around this time, 2021, and I think it was something only like 10% of universities admitted that they had a cheating problem, even though the figures just weren't adding up. I was speaking to the writers who were telling me they were working in universities and doing exams for 60% of students in one class. And when I spoke to people in that university teaching, they were saying, no, we've never had any issue here at all. So the discrepancy between what we were knowing, hearing from students that they were cheating and the writers in Kenya versus what institutions were saying was completely different. And I think that was also really a really interesting feature of this. So I'm just going to talk a little bit about how you go about this. This isn't advertising, this isn't to advertise any of the platforms, but just to tell you how it works in relation to Kenya. So if any of you are ever desperate, I'm not saying you should do this, but this is one way that you can find out a little bit more about the industry. So it's 10 o' clock at night, you've got an essay to stewing, 9am the next day, and you really have got to get this piece of work done. It's, you know, you're really in trouble. You can go to any of the major search engines and you can type in, I need help with essay on whatever subject it is, cardiology. And one of these websites will pop up. Right now, they're supposed to be legal, but actually they've rebranded themselves as revision tools. So they're there and you can get them. So this will come up. And what's interesting about this is that you, when you look at it, you don't really get any sense of. There's nothing particularly Kenyan about it. Just looks like a platform that could be from anywhere, really. And there are loads of them, there are hundreds of them. And this platform looks like it's wherever this one's called, do my assignments, but there are others. So you go log onto the platform, you tell it what he wants to do, somebody pops up that says, that looks a Little bot there says get in touch. You say what you want, you say when you want it by, and you hand over your. They normally give you a discount for the first one. You hand over your. Your credit card details and you should get the something, your essay that you just bought in the time that you want it. It's really that as transactional. So students who I've spoken to have described it as like a deliveroo or, you know, it's just like getting something in. Right. It's very easy, straightforward process. But what's interesting about all of these is that you get no sense that this is in any way involved in anything to do with Kenya. What they often do is that they make it seem as if the person you're talking to is actually in the uk. If you're a UK student, if you're an American student, you get the sense. You'll get the sense that the person is in the us. So you'd be assigned to me. I'm your academic writer in Kenya. And you. I will be communicating backwards and forwards. I will change my vpn. So we think you think that you communicated to somebody in the uk. Often they'll use voice disguising software if you want to talk to me, so you'll get the impression you're talking to a British person. Same if you're in America or if you're in Australia, and often can use avatars, so they never give the impression that you're talking to a black Kenyan. If you want to see them, you'll see an avatar picture of a white person and they'll give you a white name and they'll use a voice disguising software so that you feel that you're talking to a British person. And the reason for that is that it's money that most people, if they know they're talking to somebody in Kenya, firstly, they'll draw on all sorts of racial stereotypes that the work will be inferior and secondly, they'll want to pay them less. Whereas if you think that you're talking to somebody in the UK or the us, you will pay more for that service. So here is another company called Peachy SA, which is really interesting. So they've been going since 2007, registered in London, Wyoming, with Israeli, Russian and British directors. But what's really interesting about them is two things. One, they claim that they're the most ethical business in the world. And the reason why they claim that they're ethical is because they're seeking to liberate students from unethical universities, which they describe as debt machines that shackle 18 year olds with loads of debts, right? So basically the way that they, they market themselves is you've got this really boring assignments to do, don't worry about them, send that to us and you can go out and earn, you can earn money, you can have your part time job, you can do that free internship if. And we can help you. Right? So this kind of marketing is really, is really popular and when you speak to students they say yeah, they're right because how am I supposed to do all of these things I need to do in order to be competitive? I know sometimes I'm looking at CVs of people in their early 20s and I'm like why these people not won Nobel prizes? Like they've done so much, you know, like the internships, the part time jobs. You can't just do your degree, you've got to get first and it's so much pressure and so much competition and you've got this debt, right? So they're saying we can help you because we can take one of these things that you've got to do away. That frees you up to do all the other things that you've got to do. What's really interesting is at the bottom of the website you'll see all of these universities that they work with and most importantly that they used either have students come from or that they use tutors from so academics from to do the essays for students. So I'm not having anything, you know, this is their claims. I don't know what's going on inside these universities but what's really fascinating is that there's absolutely no Kenyan university listed here at all. So you get the front of shop. It's always global north institutions, white tutors, white writers and depending where you are in the world, different genders. So if you're an American student, American students like their academic writers and their shadow scholars to be young women from Wisconsin, we go into that another time and preferably with brown hair and if you are from, from the uk, well the UK and Europe tend to prefer older men of retirement age. And this level of specificity is really important in terms of thinking about who from who in the mind's eye of a student is the most trustworthy and the person least likely to tell anybody else that they're using their service. So but the point of this is that none of this looks especially global, right? It looks very regional, very local and a lot of work goes into presenting these industries as very, very far away from Kenya and Africa. So here's another example for medical assignments, medical education. So you go onto one of these and you. One of the things that's really important is you have. They offer, nearly all of them offer the same thing, 100% plagiaris free. So the writers in Kenya run their essays or all their assignments through plagiarism software first before sending it back to the students. So they know it's 100% plagiarism free. They've got thousands of PhD students and other people who they use to write these essays. They can guarantee that safe and secure online payment and free unlimited revisions. So if the student isn't happy with any of the work, they can send it back. Now, what I find really interesting with the writers is for a special fee, they can offer you a service which they call to curate your profile, right? So imagine that you come to me, you've been getting D's and C's, and you know you're really in trouble, and you've got a term to kind of turn things around. What you don't want to do is go from a sort of C and D to an A or an A star, right? Because that will flag all sorts of things. So for an extra fee, you pay them to curate your profile. So you send them all your information, all your course outlines and what the marking scheme looks like. And they bring you from A, from a C, D up to a B. Right? But in addition to that, they'll make sure that they message your tutor, you know, I'm really interested in this. Oh, I saw this. They'll do a certain times of the day or night, especially at nighttime, so that you look like you're really working very hard at night. And then you have this. They'll communicate with your tutor on your behalf and you pay for that. And then from the B, then you go up to the A, and everybody feels happy. The tutor thinks they're doing a really good job and the students get the grade without flagging any, without any red flags. And so this is another additional service that you can get from the writers in Kenya. So this here is specifically looking at medical work, medical assignments, but really it's the same whether this is engineering, whether this is, you know, they do a lot of work for pilots because they have to have lots of exams. So they'll sit a lot of exams for pilots as well. But, you know, cheating isn't anything new. And what's. But what. The only thing that's interesting now, I think is the kind of scale of the Problem. So here we've got really recently. So this is Oxford in 2023. All the medical students had to reset their exams because there was some kind of cheating that was going on there. Same in Glasgow. Had similar issues in many, many, many, many medical schools. Every now and again this gets uncovered and it's usually kind of because either, well, it's very rare because somebody admits it. It's nearly always because there's kind of collusion. So you'll have too many students in one class who are doing this right. And then it just becomes like, how is this possible that all of these students could be getting a stars and somebody goes back and has a look at the grades. So my work, I, as I mentioned, I went out to Kenya and I spoke to some of the writers there are specifically interested in those who did medical and general healthcare papers. So this is exams, but also theses and all sorts of other things. And just from their perspective, what did they think about doing this work and how did they find it was really interesting. So this is one of them speaking about nursing, but also got others that spoke about writing for doctors and doing medical exams and stuff for them. So this one is saying, you know, I do a lot of nursing, which means I do all the research, all the writing, and I've got to understand all the concepts. And is what's interesting about the medical academic writers was their kind of sense of what is right and wrong. So you'll meet some writers who say, yeah, I would just never, ever, ever write for a medical student or for a nurse. That to me is a no, I don't mind doing it for the pilot. And I'm like, what? That's quite. I've got issues with that. So I'm interested in where they kind of draw the line themselves. Like, you know, I mean, an engineer is okay, but I'm not thinking about that bridge, you know, but they're like, no, I won't do it for doctors, I won't do it for nurses, but I don't mind doing it for some of these other things. But this particular writer was saying that she had real issues because of obviously thinking about the patients. And, you know, these are real issues. And in the, in the documentary, we speak to Kath Ellis, Professor Kath Ellis, who's also done lots of work looking at academic writers for hire and in particular the information that's uploaded onto these platforms. Okay. Which aren't, despite their claims, very secure. So one of the things we found when we looked in the folders of the things that are uploaded from students, medical students is often really severe data breaches. So for example, they would upload patient notes because the writers will have to give their assignments will be based on certain information that they need to have, which would be inpatient notes. So I mean, there's all sorts of ethical issues which are the kind of things that I'm very interested in, involved in this. It's not only is this right and fair on other students, is this right and fair to patients, but then the amount of information that's often given on these platforms is enormous. So the students themselves give huge amounts of information. Often the platforms will demand all sorts of things. You know, you've got your credit card statements, but some of them will ask for passport details, driving license, parents information, all that kind of thing. So there's that. In addition to that, you have, if you want to have additional services, they will ask you for, you know, your password so that they can communicate with your tutors. They want all sorts of your single sign on details. So you end up giving quite a lot of information. And that's been a source of worry for so many people. I know Thomas Lancaster, Imperial College has spoken a lot about how susceptible students and vulnerable students make themselves when they use these services. But the vulnerability isn't just theirs, because one of the things we realize when they use patient notes and they upload those so that the writers can do, can make case studies for their assignments, is that they divulge incredible amounts of personal information about other people as well. But going back to this particular thing, this particular quote, so there were multiple ethical issues involved in this quote. So one, she's saying, look, you know, I'm dealing with patients. These are real life patients. I have a problem with that, although it pays my bills. But there's also the other ethical issues. And she's saying, this is my brain. You know, it's just like, this is my work, this is my effort, and this is my knowledge. And you're dealing with the patient. So she understands really clearly that this is something that's wrong for her, but she needs the money. And we've already given you some context as to the kind of circumstance in Kenya. Again, there was this sense that one of the things that was really interesting why the writers really disliked the term shadow scholars and referred to prefer to call themselves intellectual surrogates was because they were. They thought that the idea of the shadow was the wrong way around. They thought that they were the real thing and the sheens in the global north were the shadows. Because because they're the ones that have the brain. So if you're paying somebody to write you a PhD in two years, that is as far as they're concerned, they're not the shadow, you're the shadow. And so this, this particular academic writers saying, you know, from here in Kenya, we're having a big impact. We're helping thousands of people every year to get degrees, to get tenure, to get their research funding, because we write their grants, we help them to keep their jobs, to get promoted. And many people are sitting there in your office because of our efforts, and that's a fact. And they're there because of our contribution. And in fact, they're the shadows of us. And so this idea was really fascinating to me when you're thinking about who's in the light and who's in the shadow. Because what they're forcing us to think about is who are these people, right? Who are these people that's walking around as doctors, as nurses, with qualifications obtained from other people who are meeting and dealing with patients? The shift then becomes thinking about what's going on in the global north, and then the ethical questions are then shifted to the north about what is going on up here with students in teaching and what's going on in institutions. And what's interesting as well, I think, is that while we are. This quote here really sums it up, which is that even though we're really asking for medicine's becoming more diverse, what we're seeing is that really there is still this band of mostly white men who are dominating the top echelons of medicine. And more than just about race and gender, it's also about class as well, which is that when you have any profession that has a certain number of people who are able to gain an advantage by outsourcing assignments, which then allows them to do all sorts of other things, the people who aren't doing that cannot compete. You just cannot compete. And so those people end up really not being able to stay or to be kept on. And, you know, recent reports about what's going on at the moment in medicine, about the number of people who. Number of people finishing medical education and find themselves unemployed, I think really, really lends to these kind of concerns about the looping effect. We're just not getting people who are kind of being able to come through and really change things because of what's happening in terms of cheating in this field. So the future. I'm just going to speak briefly and I know that you wanted to ask some questions about AI as well. So I'm not going to talk too much about this, but we know that, like, recently AI has completely changed the whole kind of education system. And really trying to understand what's happening is really interesting from the perspective of the writers in Kenya. So the Guardian did a survey seven months ago now and found something like, you know, the vast majority of 7,000 proven cases of cheating. And this was just random, a really random kind of survey. And so cheating is on the rise. Lots of teachers are concerned about it, lots of institutions are concerned about it. And there's a sense that with, you know, platforms like ChatGPT, students are just pounding out all of these essays and assignments. And so the issue is, well, what does this mean for this whole industry in Kenya? Because does this not put them out of work? I think that's one of the many questions that people will ask. But I found it really interesting just to speak to the writers and find out how they're dealing with this. Right. Because actually, one of the things that they've been able to do is to pivot their skills to what they describe as humanizing AI. So imagine, and most of us have used ChatGPT, who know our field quite well, will see that often people conflate, and students do this, conflate fluency with intellect. So because something reads well doesn't make it intelligent. And if you know your field while you're reading something and you're like, yeah, it's words and it kind of sounds, but this is wrong, and that reference is also wrong. And that's rubbish. And so we know this when we are marking it. And so. And one of the things in particular that a lot of the kind of large language models do in this kind of confabulations is around references. So you have to know me very well to know that I've never written in the Health Economics Journal, but if you're a student, you would never know that. You won't be able to spot that reference in there. And so often this is the ways in which students get caught out. Not to mention that actually AI detection software is getting much better. So many students will use ChatGPT to generate a first draft and then they will send it to the writers in Kenya who will then pick out all of the things that are wrong and all the problems and then send it back to the student who then submits it. And so they've been able to make money from this. And every single time a student gets caught or there's some scandal around student getting caught using ChatGPT, it really helps the writers in Kenya because they're able to. To say, you see, you can't trust it, but send it to us. And also, I think at the moment, the universities are themselves not entirely clear about what they're going to do. So some people don't want to 100% put all their trust in these large language models because they think one day I'm going to get caught out. So, for example, some institutions have said that they are going to almost adopt like a kind of the way that the Olympics do with athletes, which is that we'll retrospectively test and see whether you've used it, and if you have, then you're disqualified. Some institutions have said, well, we can't manage this right now, but one day in the future we will be able to. And we are going to be able to just run all these assignments through. And if you haven't written it yourself, you're going to. Your qualifications are going to be removed. And so because of that, lots of students are still using these writers, and so they are able to sell their services as humanizing AI. In addition to that, one of the things, the big slights of hands in AI is to make it look as if it isn't actually humans involved in training these models. And a lot of this work takes place in Kenya. So another way in which kind of Kenyans are kind of these intellectual surrogates for tech. So at the moment, we've got kind of a real issue here, which is that we need more doctors and more doctors are promised. And we've been told that by 2031, 32, there's going to be a doubling of numbers of doctors in the uk. And one of the big claims is that this is going to be doctors from the uk, so a reduction in doctors coming from other parts of the world. The question is, who are these people? Who are they? How are we suddenly going to get double what we've got when so much of what we've got relies on international doctors and work coming here and working here? And what's going to be happening in the medical schools to be training these doctors? Is there capacity to train this many? Is there capacity to also make sure that the quality and the standards are met? So I'm just going to mention quickly the Shadow Scholars documentary. And thank you.

LSE Events Podcast Host

Hi.

Lassonde Conte

Hi.

LSE Events Podcast Host

I'm interrupting this event to tell you about another awesome LSE podcast that we think you'd enjoy. Lseiq asks social scientists and other experts to answer one intelligent question, like why do people believe in conspiracy theories or can we afford the super rich? Come check us out. Just search for lseiq wherever you get your podcasts. Now, back to the event.

Lassonde Conte

Thank you. Wow. Wow. And to time.

Professor Patricia Kingori

Oh, brilliant.

Lassonde Conte

So we've got time for plenty of questions. I'm going to take chair's privileges. One is just the question of how do you get a research idea and then suddenly you have a film about it? Most of us are happy with the publication, but how did you manage to. What was a thought and then what was the practicalities of turning this information into a film?

Professor Patricia Kingori

To be honest, I had no intention of making a film at all. I mean, I went out with the idea of speaking to the writers first, because I didn't even know if they were gonna speak to me. And then a kind of friend, Eloise King, who's one of the directors I've known for a long time, talking to her about it. And I told her I was going out to Kenya and she said, okay, well, why don't I. Can I just maybe just come along and just maybe meet some of them? And the idea wasn't really ever to make a documentary, it was just to see. But what we found when we were there were that they were so very charismatic and extremely bright. Like some of the brightest people I've ever met. You know, it took me like, well, you know. Cause I shared an office with you four years to do my PhD, and these guys are pounding them out in like two years, you know, and you're meeting people who are like doing sort of three essays on completely different subjects in like a 16 hour period. I could barely do one essay that was my own in like a week. So I just became really interested. I felt like I was meeting like elite athletes, you know, Like, I had like a peep through the Olympic Village and I could see people warming up and I was like, you know, I felt like somebody that goes for a run, like on a Sunday, and then all of a sudden you're like transported into the Olympic Village and you're like, okay, so this is like really the big league now. So their enthusiasm to be part of the film, to be filmed, and really to have the world know that they were there was a thing that really kind of propelled the story. And plus it really, for me, raised this question about why didn't we know about them? Like, if you're talking about this many number of people, what is the work that it's involved in? Us just not knowing about them? Because I didn't want to use any of kind of those kind of archaeological terms. Like I discovered them because you don't discover 8,000 people. They're there. Right. It's just. What is it that's made you not be able to see them? So I was also really interested in that as well. Like how. Yeah. What was all that about? And then they were, they were happy to be involved in it in the film. So.

Lassonde Conte

Yeah, I mean, I've got other questions, but I won't hold. I won't hold. Okay, so I'm going to take a. I've got a couple online, but I'm going to start with some. A couple of questions in the room. Take two at a time.

Professor Patricia Kingori

Yeah, that's cool.

Lassonde Conte

Yeah. If you've got memory like mine, it wouldn't work. Two at a time. And then we can then go on. Yes, two. Yeah, I've got. I actually know both names, but it's not a setup, I promise. Every plant, Milen Legard and then Rob Yates, if I take it in that order.

Audience Member 1

Hi.

Audience Member 2

Thank you, Patricia. It was fascinating and I'm not surprised that you're still doing fascinating work. I have a very basic question, I suppose. I mean, can you tell us more about who. I mean, the demographics. Are there more women than men? Are they young?

Audience Member 3

Are there.

Audience Member 2

I mean, what do they, what do they aspire to as well? I mean, are they, you know, is it a short career? Is it a never ending career? I mean, can you tell us a bit more about. And are there. So I know you focused on medicine, but did you find that this was. Is medicine a bigger market or is marketing actually the big market? Or do we know anything about this industry? Because, I mean, I knew nothing about that industry and so I'm just shell shocked.

Lassonde Conte

Should I get Rob or do you want to answer that?

Professor Patricia Kingori

Let's get Rob.

Lassonde Conte

And then we just take the second question.

Rob Yates

Thank you.

Audience Member 4

So I'm Rob Yates. Thank you so much. My mind is absolutely blown. You're dead right. So glad I came out on a Monday night and to discover a whole new field like this. Mine's a similar question really about the impact potentially on the Kenyan health system and the labor market in Kenya and sort of trying to get an idea of these doctors doing this work. I mean, are most of them working as doctors and do this in part time or are they doing it absolutely full time? And do you think they sort of enjoy what they're doing and would really prefer to go back to doctoring and were those medical salaries to go up, they'd sort of of pat this in or. I'M just sort of trying to sort of understand the sort of dynamics of sort of whether changes in health financing, changes in salary levels would necessarily mean that they'd stop doing this and going back to being doctors or, you know, is this likely to continue forevermore, do you think?

Professor Patricia Kingori

Okay, so who are they? I think it's really interesting that question because when you first, when I first went to Nairobi, they kind of often work in hubs initially to get the training, the kind of entry level. So when you go to the hubs, you see mostly young men there. And I think it'd be really easy to make the assumption that it's mostly men that do this work. But actually what you find is that actually a lot of women do this work, especially women with children, because it offers a lot of flexibility. They also don't have to deal with any of the negative things that come with being in an institution. And so there's also quite a number of women that do this work, but they're themselves are kind of the shadow shadows, right. Because they're not often the most visible, because they're often working in the home context, take their kids to school and things like that, and then come back and do this and work around the family. So in terms of the very present versions of them, you tend to see mostly men. So the other question was who are they? And then what did you else did you ask? Career aspirations? Yes, I think that many of them would like to have their own career and have their own CV and be themselves in the world. And that part of the motivation for being part of the documentary was precisely to let people know that they were there, even though we, we used AI veils to disguise them. And I'm really fascinated by some of the stories sometimes when they really fed up because it's actually really. Must be a really strange phenomena to help somebody get promoted and be in Nairobi with your life the same. But you're watching somebody else virtually online get another promotion and another promotion and that person has got, you know, this job and then you're seeing them, but you're. And you know, and they're writing all this sort of social media posts about how well they've done and you know, how hard it was and. But you know that it's you, right? And so one of the writers was saying to me that they got really fed up actually one time and there was a job that came up her Ivy League university and they had, they thought, you know what, I'm just going to apply, I'm not going to get it. But I'm just going to put. So they put in their application and they were really surprised when they got a letter back. I mean, it was a rejection letter, but they at least got a reply. And they replied back to this letter saying, I didn't expect to get in. But just so you know, I have actually been working for you and I have written for all of these people that's been in your institution. So don't just discount me because of where I'm from, because I'm actually capable. So every now and again they will just. They don't necessarily expect anything from it, but they just kind of want the world to know that they're there and to give them a chance. And so in terms of career prospects, in ideal world, I think they would love to be able to be themselves in the world, but this is what they're able to do. And as far as long as they can do it, they often will try to keep doing it. It's really demanding. And one of the things I've realized is over time with the writers, I've noticed how their health is deteriorating. So initially it's really interesting because when we first meet them, they're not wearing glasses. They're very kind of. And then you start, they start to have really the glasses, the eyesight starts deteriorating. Then they start complaining about migraines. Then, you know, it's all of these health issues that come from sitting, being sedentary for like 18, 16, 18 hours a day. Also because they work to the time zones of the US and the UK and Kenya, they're up in the middle of the night to get the work. Because what happens is, as I've shown you with the platform, a student will come in and ask for something and then they bid. So it's first come, first serve. So whichever writer is up and able to unrespond straight away to that, shouldn't they get the job? So they often really messes up their sort of circadian rhythm and all of the health things that come. So having been in contact with them over sort of a number of years now, it's interesting to see how the health's been affected. So this in relation to your question about how long they can do it for, it's really often determined by all sorts of other things like how the health bears up. And often they're trying to get other kind of work as well, or set the foundation for their own businesses so they don't have to do this long term, because even if they want to, I mean they can't. And so, I mean, if you think about, like, elite runners, these are not things that they can do for the rest of their lives. You know, you can't put that level of stress on your body all the time. And if thinking about that in terms of mental health and just being inside, in the computer, often very asocial, like, I'm antisocial, you know, you're not getting exercise, so it's not. It's not great from that perspective. And you were talking about the. What impact of this is on the Kenyan healthcare health system. I think I haven't measured that, but I think that, I mean, given the rates, the numbers of doctors in Kenya at the moment, we know that Kenya needs more doctors. So if those doctors are helping other people in the global north become doctors, then of course, that's a problem. I find it really interesting when I speak to the writers about doctors from the global north coming to Kenya. This is kind of weird looping effect. And one of the writers was telling me that her child was really sick and she had to go to the hospital with her child. And there was this really young American doctor there, and she's just like, I just felt like I couldn't really have him look at my child because I was one in second and third opinions, because this guy, I mean, he could be anybody, you know, And I thought that was really interesting. One of the really interesting thing about the writers is that they're absolutely, absolutely not deferential to positions or titles. So when I'd first met them.

Lassonde Conte

I.

Professor Patricia Kingori

When I first met them, I came into the room and I was really struck by how much they knew about my work. They had read everything. They were asking me questions about papers I wrote in 2012. I was really flattered by this because, like, I'm lucky if some of my colleagues read my stuff, you know, so I'm like, God, this is great. You know, academics were just like, like, you know, it's fantastic. And then I realized actually that what they were doing was testing me to see if I was who I said I was, because I don't trust anybody that comes with a title, you know. So I also thought that was quite interesting as well. And they. And as often for us, this kind of, from their position, a perspective, a kind of naivety, that we're just like, so you just trust somebody because they're saying they're a pilot? It's like, yeah, you know, but they don't have any of those illusions, you know. So I found that to be also quite Interesting. But yeah, in relation to the health system, I think it's like an obvious problem. I don't know any. I think the solutions are much more complicated. Right. But I think it's one of those things that's like, if you could just fix it by having those writers be doctors in Kenya, then that would be really amazing. But you can see already the pain conditions for anybody in the healthcare system in Kenya is so poor that they're just disincentivized from doing that just on an individual level. It just doesn't often make sense. Okay.

Lassonde Conte

I'm a nervous flyer, even though I have to fly.

Professor Patricia Kingori

Oh, listen, I'm sure be fine.

Lassonde Conte

You added a new dimension above turbulence. Can the pilot actually fly the plane?

Professor Patricia Kingori

Well, that's what autopilots and stuff. You don't have to worry.

Lassonde Conte

Anyway, not helping. We'll move on to an online question here. We have a question from Chiamela Cosmos. I hope I've pronounced your name correctly. To what extent does the shadow scholar industry in Kenya represent a breakdown of medical, Global medical health education system rather than just an individual failure of ethics by individual medical students?

Professor Patricia Kingori

So to what extent does it represent a breakdown of the global medical systems.

Lassonde Conte

Rather than the individual.

Professor Patricia Kingori

I think to varying extents. Right. I mean, I can't necessarily speak about the whole global medical education systems, but it's clear from the presentation that there definitely are issues in relation to how it operates. And I think just this work is just kind of shining at one small light, one variable in a much bigger, bigger issue, I think.

Lassonde Conte

Okay, thank you for that question online. But anybody else in the room with a question? If I start in the front row here and then.

Audience Member 3

Thank you so much for this. I'm just sitting here because I'm from Kenya.

Professor Patricia Kingori

Okay.

Audience Member 3

I'm just, you know, feeling happy and feeling sad as well, because this is young people who are 70% unemployed and going beyond what they want to do because they are doing these out of, of desperation. But my question is, is there any policy, like recommendation to Kenyan government? Because this is a generation that is supposed to be working in the sector that is, you know, if it's education, if it's health, but they are doing this out of desperation, working for other people, like doing essay shadowing. So is there anything that the Kenyan government like, any recommendation for Kenyan government to like, pick up? And if the circle continues, then, you know, the generation will keep doing this and the government is missing on their, their, their, their expertise and many other things.

Lassonde Conte

Thank you.

Audience Member 5

Thank you very much. Thinking about Your comment about the bespoke service that some people offer, when you were speaking to the writers, were there any instances where they had developed the personal investment in the people where they were writing for, where they'd followed them through from maybe writing as students to then writing as academics and you know, really living out the being the shadow writer where they had the real kind of investment in someone who'd made it high up in the field and then I, I made that person and whether they felt positive or negative about that person reaching that level of their field.

Professor Patricia Kingori

Thank you for those questions. So I think in terms of policy recommendations, and I'm just taking my cue from the writers themselves who really want this to be legitimate. They think that they could become a place in the world where people go for this and be known for it. So they don't really feel that they in the short term can do anything to change the actual demand for their work, but they think that there's actually the Kenyan government could be more supportive in terms of actually seeing this as legitimate work. So you can imagine for a lot of these writers they just have massive gaps in their CVs. Right. So what have you been doing for the past 10 years or 5 years or working for other people? You can't really put that you're kind of an academic writer for hire or shadow scholar on your cv. So they would really like to see a bigger conversation about them being given credit. And so this requires kind of policies and guidelines that actually recognize them and I see that as the trade offs involved in that. But if I'm taking my cue from what they say really is important to them, I think in Kenya they want to be seen as this is actually legitimate work that requires a lot of resources that we're able to invest. So I hope that's answered your question and the other one about personal investment. Yes. So in the ideal scenario what happens is that they try to get GCC A level students and keep them all the way through. So help you with your gcc, then I'll help you with the A level, then I'll help you for your degree, then I'll help you all the way through. And for most of the writers, the aim is to get people off the platforms as soon as possible. So you're often trying to undercut the platform. So it's, you know, if you have to charge, I don't know, £200 per medical paper essay that I do for you on the platform, if I've, if you come off the platform and we just do it privately then I'll maybe, you know, it could be like 120 or 130 or something. So they very quickly try to have those offline relationships and then there is definitely often personal investments. I'm laughing as you said that because somebody online when the documentary came out, came out and said that they were my shadow scholar and that they had helped me get to which took me by surprise. So they're sort of taking personal investment in me even though. But he was using it as a sort of marketing tool to get. Drum up more business. But yeah, they do. They're often very personally invested in, in who they work with and sometimes people can be. Their clients can be very, very grateful to them actually and, and demonstrate gratitude because obviously they know. But what is really interesting is it's a really interesting dynamic when the clients start to lose confidence in their ability. So the writers almost become a little bit like a kind of comfort blanket for them, you know, and it, you know, you can actually do this essay yourself. But they're like, well no, because, you know, I've had this person with me for the past five years doing all my work. I'm not sure I can do it on my own anymore. So it's quite interesting when they become quite. Yeah, they're hooked on having, having this service done for them. They can't, the clients can't really work without the writers, which I also also find quite interesting.

Lassonde Conte

So that's all codependency.

Professor Patricia Kingori

Yeah.

Lassonde Conte

And we've got a couple of questions online and I'm going to come back in into the room and it's actually a different perspective. I'm going to take that this question first. So someone online said, I'm interested about why the shadow scholars keep it a secret in some instances. If they're so proud and perhaps get frustrated watching the success of other clients, could they not expose them more often?

Professor Patricia Kingori

No, because then that would be the end of their business. I mean that's one of the, you know, that's, that's one of the things that they are able to do is to guarantee that they are going to be private and confidential. That's their number one kind of business drop line. And you see it on all of their, all the websites and everything. But one of the things I think is really interesting is what happens when a student either defaults on a payment or is really rude to one of the writers. And they will often, for example, keep a plagiarized bit of the essay in and send it back to the student. And so when we hear about plagiarized work, sometimes it's by design and it's because the writers are just like, they're just so fed up with the way that students behaving that they will make sure that they get caught if they know they're not going to pay up. So sometimes it's. But that is very rare. Nine times out of 10, they will do absolutely every single thing they can to keep the student happy, as you've seen with the multiple revisions and all those things, because that's their kind of breadline. So no, I mean it wouldn't expose the student usually. I mean, I've not heard of, I've not met any of the writers who've done that.

Lassonde Conte

Okay, thank you. And another question online from Julie Davis and maybe it's within scope or the next stage of your research, but her question is how are medical schools finding more immediate and creative ways to examine doctors so that they can't cheat?

Professor Patricia Kingori

I think that's probably a bit beyond my kind of remit to understand, to explain, but I think lots of people are trying different things. So we've just had, I think, yeah, three days ago, the kind of professional examinations for accountants announced are no longer online. Everybody has to do it in a room. So they're stopping online precisely for this reason. Right. So it might be that we see a return to very, what we would consider old fashioned means of testing much more face to face. The problem with that is how does that, how do we reconcile that with this pledge to double the number of students going through medical school? Because is part of the reason why it's so common in America and so easy to get away with is because there's so many students, you know, so for example, the writers will say, you know, they'll be writing for 30 students in one class and none of those students know each other because the class has like 600 medical students in it, you know, so it's so huge. So the bigger we make this and the more industrialized we make education, it's often the harder it is for people to spot the students who are not necessarily producing their own work. So I think that's probably, I don't know, the two things seem to be in conflict somehow.

Audience Member 1

Please. Yeah. First and foremost, thank you so much for that very insightful presentation. And also all the questions, I have two small questions. One would be whether you see the market also evolving into the direction, for example of having like earbuds or anything to assist people in physical examinations or face to face. If universities decided to revert back to that. And the second one would be more on non English speaking markets. So do you also see the Kenyan scholars using translation software or other means to also be able to access markets that are not the uk, the US or Australia?

Professor Patricia Kingori

Yeah.

Lassonde Conte

Is your super short as well then?

Audience Member 4

Yeah, super short. Rich, I've some sort of black man.

Professor Patricia Kingori

I mean, you people really exposed. There's some evidence chain.

Rob Yates

I just wonder if.

Lassonde Conte

Okay, I've acknowledged that question, but I think. Can you take four?

Professor Patricia Kingori

Yeah. Yes, please.

Rob Yates

I just want to say thank you very much for this knowledge. My thoughts is I just want to get your thinking on the impact on the services that will be delivered with the doctors, I mean with the consumer of the services when they qualify. What is your thinking around the future impact on the quality of services that will be delivered to the service users? Because already I think there's some anxiety with the quality of services provided by clinicians. So I just want to get your thinking around that.

Lassonde Conte

Thank you. That was our final round and then we have one online. So sorry to throw four questions at you.

Professor Patricia Kingori

Okay. I'm going to do my best. Okay. So I think it might be easy to start with how long this has been going on for, because I think then that kind of provides some kind of context. This has been going on for decades, hundreds of years. Some people might even argue. Initially it was predominantly women who were the shadow scholars, people who were excluded from institutions, who wrote on behalf of men. And this was until very recently. So for example, in my college, Somerville College, I met a woman who was 97, an alumni of the college, and she wrote for medical students. She wrote one thesis for somebody who went on to be very, very famous. But we were able to campaign and get her thesis in her name. And 98, she was given the thesis back in her name, which was something she thought would never happen. This was something, a thesis that she wrote in 1953, I think. So it's important to put this into some kind of context. So we had women predominantly, and then we had lots of immigrants, so lots of Jewish people, Irish people, people, people from the Caribbean and different parts of Africa and India who couldn't get jobs but had all the qualifications, who were then propping up people here in institutions here. And so I think that historical context is really important. The difference now is the globalization of it through technology and the scale of it. So the work that technology has done to allow this to be much more globalized and then now the numbers of people because we've got many, many more students than we've ever had. And we've also got now many, many more of these academic writers for hire. So I think understanding this historically probably allows us to see this as not something that's particularly new, but something that's shifted and changed. So as it's become harder to treat women and minoritized groups in this country as shadow scholars, and I'm not saying it's impossible because of course it still happens. And I've spoken to women and minoritized groups in this country who are shadow scholars. The predominant number now is in Kenya for the reasons that I kind of pointed out before. And I think there's a question around non English markets. Of course there are non English markets, but the predominant markets are in English speaking countries. And I think one of the things that I'm really interested in with the writers, as you see, with the humanizing AI is their resilience and the capacity to always be flexible and bend around all the rules. So as long as the demand is there, then it'd be interesting to see what, what things like Airbod and all those other things might do to if it would dent the market in any way. I think like many people, I thought that AI would completely finish them off. And what I've seen is actually kind of sort of subversions and all sorts of other things to keep them going. So I can't really speak to that. The consumer perspective is really interesting in the quality of service. I think it's. I, I can't speak to that because I don't really know. But I think we have to resist the temptation to think that some. It's only through qualifications that people can be good doctors. I say that, I say that because it's obviously having a qualification. Being a good doctor is more than having a qualification, right? You need to be able to obviously be qualified. But we've all met, met qualified doctors who probably are not very good. And one of the things that we've learned from things like the alternative therapy movement is actually that what lots of patients want is people who are personable and have got bedside manner and all those other things. So sometimes those things could actually be as important as somebody going to medical school for eight years from the perspective of bedside manner. And I mean, your skill sets are completely different things. So what you measure quality on is also, I think, quite interesting. Right, because there was a case in Kenya actually of this guy who, Dr. Meli, who was in Western Kenya and was so good at treating patients, saved all these women's lives. Was fantastic. They're about to offer him a prize because he had saved so many people's lives and they found out he wasn't qualified at all. He was just operating as a doctor for years and years and years. And so of course he could be, you know, he could be an outlier. But I do think that maybe we have to think about, you know, what, what is quality as well. On the last question around blackmail. Yes. Is your answer. My answer, yes. But the blackmail isn't coming from the Kenyan writers. They are. There's an intermediary. So, you know, more work needs to be done to understand what's going on in terms of who owns these platforms. But certain in the UK there have been people who have been blackmailed.

Lassonde Conte

On that note, well, we'll take one question online, the final question, and this being lse, it's got tax written in the question.

Professor Patricia Kingori

Okay.

Lassonde Conte

And this is from Simi Doskin, and I hope I said your name correctly, from lse. You gave an indication of how large the sector is economically in Kenya, as well as the writer's desire to be seen as legitimate. I wonder if the work is in any way taxed or otherwise tracked by the state and if so, how.

Professor Patricia Kingori

Yeah, that's a really, really sensitive question because it's a real tension, right? They want to be visible, want people to know they're there, but they absolutely do not want to be taxed. And they feel very aggrieved at the thought of it because they feel like they are often operating against the state who is taking so much and giving so little, that the idea of operating, of paying tax on top of it is not an easy pill to swallow. So there's also that tension as well.

Lassonde Conte

Well, I think. Oh, there's a question here at the front. Are you right, sneaking out the question? And we have got.

Audience Member 1

Really interesting talk, just a kind of point to add to what you just said and maybe a potential counterpoint to the impact this is having on the medical professionals coming out.

Rob Yates

Out.

Audience Member 1

I do question how much of the way. So I'm a medical student, how much we're being assessed not only at the medical school I go to, but at other medical schools isn't really through essays. It's rather, it's. It's a competency based system and I imagine, you know, becoming a pilot is a lot like that and other vocational degrees are like that. And the way that we're assessing, you know, things like bedside manner are assessed through practical exams. Workplace based assessments were assessed on the war in real time. So I do question how much of an impact this is really having on the medical professionals coming out. Just potentially something.

Professor Patricia Kingori

I think it's worth definitely always thinking about that. I mean, we've got, I think something like 40% of medical students have said that they cheat on the osce. So I think there's quite a lot of cheating that's happening in lots of different ways. And I often think it's quite interesting because if you don't cheat, then you find it really strange that other people do or wonder how they do. But I think if you do cheat, then people are there to help you cheat. I mean, I'm not here to advertise all the different ways in which someone can help you cheat with your medical qualifications, but I think even the competency based assessments can be subverted in many, many ways if you're so inclined to.

Lassonde Conte

Okay, we're gonna have to, have to end it there. I'm sorry. But thank you all for coming out on a Monday evening.

Professor Patricia Kingori

Yeah.

Lassonde Conte

And we really appreciate your time. And to those online, again, thank you. Also, this will be available online on the LSE website and the LSE Health website. And our last thank you is to Professor Patricia Kingleray for just such an insightful, fresh, important topic. Thank you.

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