Since medical school there has always been some issue related to training and junior doctors. At medical school the Moderning Medical Careers (MMC) changes led to a huge number of doctors career paths and progression. Then the coupling/uncoupling of runthrough training programmes, changes to training pathways and specialty eligibility. But it was in 2015/16 when I first saw and tasted industrial action with the junior doctors strike.
Less than 10 years later, the junior doctors are still fighting and although there is a lot of negative attention I suspect many people, in the broader context of poltical and economical turmoil, support the efforts. Listening to junior doctors now, make me consider the good, the bad and the ugly of my own career path.
I consider myself fortunate. I decided prior to medical school that I wanted to do orthopaedic surgery. There was something about it that appealed and it is the only specialty that naturally has banter built in and was quite chilled out. Getting through medical school I only had one goal and that was to become a surgeon.
Foundation Year 1
Although I was at university in the North East, I applied for and got my foundation jobs in the West Midlands . I was immensely disappointed with the jobs I got. At that time we were only told what we doing in FY1 and then based on portfolio scores could rank our FY2 jobs. In FY1 I started off on my first (and only) medical job – diabetes and endocrinology and general surgery at a small district general hospital, before moving to a larger university hospital to do urology.
The way we worked back then was interesting. The diabetes/endocrine/general medicine job was a real challenge to start with. The day started at 0900, but Found myself getting there at 0800 everyday just to get myself set up for the monster ward rounds that went from 0900 to past lunch. Every few weeks my consultant was on call so the ward rounds immediately following it were even longer. Following the ward round there were all the jobs that needed doing which meant getting out of the hospital before 1700 was rare. Them most forgotten part of the job is the evening consolidation and updating of lists, which was almost immediately followed by a call to the on-call team for jobs.
Some colleagues were really overwhelmed and you could tell by the number of jobs they would hand over. I used to get really annoyed when I got drug chart re-writes or routine tasks needed doing out of hours but not much you can do about that. These were the days when a few hospitals were still using MD-DOS based systems for lab reporting and hard copy radiology films.
I got to a handful of clinics but due to the complexity of the issues for me at that stage was of limited benefit. The on calls were hard work and the wards were like wading through treacle. The issues of social care meant we had a lot of long waiters and this in itself perpetuated the issues with the longer patients being in the hospital the more problems they developed.
In that rotation though I had an awesome consultant, Professor Vinod Patel. His enthusiasm was phenomenal and he was very encouraging. He advised me to just do the simple things well and as such I managed to get 3 audit projects completed and wrote modules for an educational project that went on to be published as a book a few years later.
Switching to General Surgery in December was a culture shock. Whereas in August I was given the FY1 bleep with a list of 20 patients, in Gen Surg I was given the bleep……there were no inpatients at that time. The start time was 0800, and I was getting in for 0730 just to be prepared but the ward round usually finished at 0830 with both the volume of work and magnitude of the issues being significantly different to the medical rounds.
I loved this rotation because I had the chance to go to theatres. I was only ever assisting but I got to immerse myself in the surgical environment which is what I wanted. The workload was different when compared to medicine because in addition to emergency inpatients, we also had a lot of elective patients rolling and out for surgery, so many more discharge summaries. At that time they were all on paper in triplicate!
The jump from Gen Surg to Urology was big as it was also a change in hospital. The workload was much bigger because of the size of the hospital, but it was still good fun with lots more opportunity to get to theatre. At least at this place the computer system was a bit better.
The thing I noticed about FY1 was that we had a doctors mess, we had the opportunity to get lunch and have a break, there were drug company sponsored dinners and lunches which I got to go to and free accommodation was available. There were some nurses with whom we had challenges but most of them were chilled and we all got on. The work seemed less complex and the volume was lower, but the fundamental challenges with technology and social care were still there.
The biggest advantage I had in my first year was no night-shifts. But the overall pay also reflected that and my work pattern had fewer days off than others.
Foundation Year 2
In November of my FY1 year an opportunity came up to apply for an academic FY2 post. I remember applying and depositing a copy of my portfolio at a building near the University of Birmingham and then a little while later getting a letter back offering me what looked like a dream set of rotations. The biggest advantage was that I was staying in the same hospital where I was doing urology (so no move needed), and I’d be starting of doing intensive care, followed by an academic orthopaedic rotation, and finishing off with orthopaedics
Intensive care as a rotation was brilliant. The nature of it demanded a more proactive consultant lead approach, and everything I did involved a registrar. ITU nurses were brilliant and always giving us gentle nudges in the right direction. There were a couple of consultants who had a certain intensity about them but the job could get stressful at times, especially dealing with patients who had not only life-threatening conditions but also seriously life-altering ones.
This was a true shift work though – and tremendously gruelling at times, especially when the emergencies were flowing in. The good things was that coming in early and staying late was never a necessity due to how well staffed it was back then.
My learning accelerated during this rotation in clinical evaluation and the same message from FY1 was emphasised, do the simple things well. The daily focus on thorough clinical evaluation, and that repetition multiple times during a shift really reinforced a practice that I still try to continue. Going through physiology in as much depth as we did meant that I got through Part A of the MRCS during this rotation. In anticipation of my upcoming academic job I managed to get ethical approval for my project so I could hit the ground running.
Moving into an academic post next was a real shift in pace. I had more autonomy to do what I wanted to but this came with pressures to actually deliver. In those four months I consented patients and collected blood and synovial fluid samples, processed and prepared the samples for analysis in the lab and then spent hours in front a computer screen analysing loads of data. I was lucky enough to get some poster presentations both national and international and even got a travel award. But once again the lack of out of hours work meant I had to do some ITU shifts just to keep things ticking along consistently. The flexible hours were a complete joy as I was able to structure my timetable to suit what I needed to do. Some days I didn’t come in, but other days i’d be doing 14 hrs in the lab…
My final rotation in orthopaedics was awesome. I did my first DHS as an FY2, as well as having hands on experience with a whole load of trauma. But there was friction. There are two types of junior doctors in orthopaedics. Those who love it and those who don’t.
Those that do look for any opportunity to get to theatre whereas those who don’t looked for any opportunity to get to the mess. It held true that those without any enthusiasm for the rotation they are in are unlikely to facilitate those who are enthusiastic. Even when the workload was evenly split, I would get everything I needed to get done sorted as efficiently as I could before going to theatre but my partner who was not orthopaedically inclined would complain. Either way I loved orthopaedics too much to be fussed. Coming in at 07.30 for a trauma meeting that started 15 minutes before your official shift meant that everyone who was there wanted to be there. Finishing late was no problem because theatres ran as they needed to. It was acknowledged and accepted and we all felt that we were investing our time into enhancing our experience.
Comparison
The real term pay cut that has been experienced has been felt at all levels and as singular issue it is significant but not the whole story. There is no more free accommodation, there is now limited team structure which allowed rotational doctors to feel involved. The move to shift work has wrecked the ‘firm’ structure which was a key part of supporting the team. Ever complex rotas mean that training opportunities suffer. My current trainees are fortunate if they get to 14 theatre lists with me in a 6 month period (and I currently have one elective operating list a week).
The lack of opportunity, the poor remuneration, the isolation that many feel has made a once phenomenal opportunity into a very unattractive one. The issue though is that many of these bright individuals are getting better opportunities elsewhere, whether it is overseas or in a different field. No one can be blamed for doing what is right for them, and if their worth is not recognised by their employer then they should take whatever opportunity that is best for them and their family. Medicine is a vocation, but we have to be in a position of some security so we can focus our energies on helping those who need it.