Doctors Training in todays NHS

The compatibility of The European Working Time Directive (EWTD) , Doctors training and The NHS in 2010

There’s been a lot written recently about the future of the NHS in both national ‘lay’ press and medical press, both from the point of view of financial sustainability in these times of austerity, and also with reference to the problems being experienced with patient safety with regards to junior doctors experience. I normally read such pieces with a large pinch of salt, but recently the excellent ‘Doctor at Work’ series of articles in The Times this week and an article by Max Pemberton in The Daily Telegraph ( ) have brought me to put some of my thoughts on this subject online.

In my opinion there are several overlapping and cross referencing points on these topics.

The first thing to say is that I do feel in a somewhat privileged position to comment on doctors training. At the tender age of 44 and in the relatively early stages of my Consultant career, I am not a ‘in my day’ old dinosaur crowing about prehistoric times, but neither am I someone who has only worked in the most recent era. In my relatively short time in medicine I have witnessed (and personally experienced) endless tinkering and wholesale changes in the system of doctors training. I was one of the first ‘run through’ Registrars in a system introduced by Sir Kenneth Calman, and as such had to wait for a job while Senior Registrars in the previous system of training (who had an unending contract), hung around until the particular Consultant job they wanted came up.

I am now a College Tutor, Clinical Supervisor and Educational Supervisor responsible for overseeing the training of all the Junior ENT Surgeons in the NHS Hospital Trust at which I work. I am also the honorary Tutor in ENT Surgery to all the Medical Students passing through my Hospital on secondment from Guys, Kings and St Thomas’ Medical School.

By way of recent historical comparison with todays trainees, I started my medical career as a House Physician in 1990 working a 1 in 3 on call rota with 4 day weekends starting at 8am on Friday morning and finishing at 5pm on Monday evening. This was followed by an obligatory trip to the nightclub on Monday evening until the early hours, to celebrate the end of the weekend on call, and a bleary start to the Tuesday morning ward round!

This ‘work hard, play hard’ ethos is I’m sure familiar to most of us in the early stages of any professional career. I never counted the hours we worked per week – I realised that it was mighty busy and that it was tiring but I was 24, single and with boundless energy. In short, I loved it and often stayed late on my evenings off to catch up and help out. I never knowingly harmed or killed a patient, as I was careful and was well supervised in a well demarcated firm (or ‘team’) consisting of myself, another House Physician with whom I was paired, a Senior House Officer, a Registrar and a Consultant Physician. Having a strong background in team sport, this team spirit was immensely important to me. We worked together and socialised together and realised that if we shirked or bunked off early we would be piling the work on our team members / friends. I had not known the other junior members of my team well previously despite the fact that they had been at the same Medical School as me, but we became very close friends. When I see them now we greet each other like long lost family members or as I would imagine (in our own very small way) old military comrades with shared experiences only they can know about or understand.

At the end of 6 months (note the time period spent in the post) I was thoroughly competent and largely independent in the management of all acute medical emergencies (and many more chronic medical complaints) and all within 6 months of qualifying as a doctor.

My next House Surgeon job at St Thomas’ in London was with an old fashioned, very eminent Sir Lancelot Spratt character who was fearsome and confrontational, but if you towed the line, worked hard and did things his way he would teach you well and look after your reference for future jobs (which he did). I had to phone him every night (not just when on call) with an update on his patients and had to know all their latest results off pat. When I did a ward round with him, I was not allowed notes to refer to and had to present each patient and know all their latest details and results when asked. All this may seem rather silly now, but every ward round in the future after that seemed like childs play and I became used to knowing all the details about patients in my care as a routine. I still quote his many well practised lines of surgical wisdom to the Medical Students I teach today, and can still hear him saying them to me as I do so.

After these 2 ‘Housejobs’ and at the end of my first year as a doctor, I stayed at St Thomas’ for a 6 month period as a Senior House Officer (SHO) in Accident and Emergency (Casualty). This period in A and E was the only time in my career that I have experienced working a shift system. I hated it. I didn’t like working weeks of nights and found the odd starting and finishing times difficult to cope with. I was delighted to return to a ‘normal’ working pattern at the end of that 6 month period.

I was lucky that I decided on Ear, Nose and Throat (ENT) Surgery early on in my career (not so difficult as my father and grandfather had been ENT Surgeons before me!), but in order to pass my Fellowship of the Royal College of Surgeons (FRCS) I did a 2 year SHO surgical rotation comprising 6 months Urological Surgery, 6 months Orthopaedic Surgery and 1 year of General Surgery. During all these junior posts I had a gratis and comfortable room in the Hospital whenever I was on call and free toast, tea and coffee provided in a spacious Doctors Mess (note the use of the military terminology). Small things, but much appreciated at the time.

I then did a total of 2 ½ years as an SHO in ENT before becoming a Registrar in my chosen surgical speciality – I felt well prepared, and the transition to becoming a Registrar was largely seamless, as I had had similar responsibilities in my previous post and was experienced enough to cope with the clinical workload.

Note the total time in ENT junior training alone before I became a Registrar – 30 months.

I thought a 6 month period in a new speciality about the perfect time for general training in a particular surgical discipline. For the first 4 months (note the time period !) in a new post the learning curve was very steep and one often felt supernumerary and not useful to ones colleagues as you learnt the intricacies of a new surgical speciality. Suddenly however, (and it always seemed to be at the end of 4 months!) things seemed to click and you ‘got it’. You were off and running and were able to be useful to both your patients and your seniors, and as your senior colleagues realised this they lengthened the leash – you were now a real Urologist/Orthopaedic surgeon/ENT Surgeon etc etc…..

After 6 years as a Registrar, I became a Consultant ENT Surgeon at the age of 37, 13 years after qualification as a Doctor. This was bang on the average age of a newly appointed ENT Consultant at that time.

When I contrast my own experiences with what newly qualified junior doctors experience now, it makes me want to weep for them. In no way would I say that I am in any way more intelligent or in many cases more motivated to be a ‘good doctor’ than they are. I am just a product of the system in which I trained, in which a doctor put his or her patient first and hours worked were seen as good experience rather than a danger to the patient. These days, from the way you read about the ‘outdated’ method of training that I experienced , I am seemingly portrayed as some sort of zombie-like psycho working ‘more than 100 hours a week’ (always the magic round figure quoted) wandering the wards in a catatonic state slaughtering patients left, right and centre due to my exhausted state of mind– not my recollection of my time in training, I have to say.

Junior Doctors training is now undertaken through the Foundation Years system. Instead of the system where in their first year after qualification everybody did a 6 month period of Surgery and a 6 month period of Medicine as the core aspects of their training, newly qualified graduates now do a Foundation year 1 (FY1) which consists of 4 month placements in any number of unrelated surgical and medical disciplines and then at this extremely early stage of their career have to decide which discipline they want to pursue. They then apply for a ‘themed’ FY2 year (equivalent to a junior SHO in the past.) Again there are 3 posts of 4 months each during this year, and may be in diverse surgical disciplines. All job applications are on generic ‘forms’ rather than carefully honed CVs, which although I’m sure are extremely politically correct give the reader / shortlister (i.e me !) very little information on the true ‘aptitude’ or feel for medicine that the person has. Note the 4 month periods – just as a doctor (and their senior colleagues) may feel themselves becoming useful, they move on and are not allowed the luxury of the last 2 months of increasingly useful training where the pressure is comparatively off.

While I understand that such generic experience of differing training posts may be of benefit to those doctors wishing to pursue a career in General Practice, for Surgeons in training it’s a disaster. What they need is more time in surgical training posts learning how and when (and when not) to operate.

After these 2 Foundation years, doctors apply to be admitted to Core Training for 2 years (equivalent to a Senior SHO in the past.) These years are meant to more reflect the discipline that the doctor has decided to go in to, and generally (finally!) are for 6 or 12 month periods. For instance, in ENT Surgery the person may have a year in ENT Surgery, 6 months in Neurosurgery and 6 months in Plastic Surgery. At the end of this period, doctors apply to be admitted to a Specialist Training post (StR), equivalent to a registrar in the past. This lasts for 4 to 6 years at which stage the doctor is eligible to apply for Consultant posts. These latter stages of training are the ‘least different’ part of training from what I experienced , although now, on average, 10 rather than 13 years are spent in training after qualifying as a doctor before becoming a Consultant, and there is now the very large caveat / black cloud of the EWTD hanging over the whole length of current doctors training period.

For those unaware of it, The European Working Time Directive now states that a worker cannot be at work for more than 48 hours per week. The SIMAP judgement by the European Court of Justice in 2000 defined all the time that the worker is required to be present on site as actual working hours for the purposes of work and rest calculations. Therefore even if a doctor is on site (and not working / receiving valuable hands on training) the hours are counted. What’s more, if any of the junior doctors ‘breach’ their 48 hour limit, stringent financial penalties are introduced for the Hospital – not good news for them in the present climate. This has led to a culture of the Hospitals ‘getting their moneys worth’ from the juniors rather that recognising and valuing their contribution to patient care. On call rooms have been taken away so that the temptation to grab some sleep while in the Hospital if things are quiet is not an option – in order to comply to the EWTD doctors have to cross cover multiple specialities (particularly at night) meaning that often they are covering so many patients that rest while at work has, in any case, become another thing of the past.

Cross cover and such a fragmented system is not good news for patients… see . Senior doctors in all surgical disciplines have repeatedly warned of this fact, the latest being on the day I write this piece – see .

My thankfully short experience of working shift systems (which all junior doctors have to work these days throughout their training to be ‘hours compliant’) made me realise that this way of working is far from ideal either professionally or socially. Because of this, the concept of ‘team working’ and ‘team ethic’ have largely disappeared and patient care and safety depends on ‘handovers’ to colleagues you have never worked with on a day to day basis and often only see at these handover times. One Times article last week likened the rotas that have to be drawn up today to ensure hours compliance as a pile of Jenga bricks, with the immediate problem being that if 1 brick comes out (due to leave or illness) the whole system comes crashing to the ground. I have experienced such meltdowns on several occasions, and have been scrabbling around late in the day with members of the ENT Department management team to find locum or internal cover for the affected shifts.

As well as the general day to day aspects of life as a junior doctor these days, the fact that they do so many fewer hours than we did means that their pay is in real terms far less than mine was at a similar stage. Remember that we’re talking about the crème de la crème of school graduates here, and although medicine is a vocation, why put up with all this hassle for small beans when there’s a job in the City for such motivated and bright people. I’m not surprised to see that in a recent survey, up to 25% of junior doctors are leaving medicine or going abroad to work in systems more approaching that in which I trained – what a waste of talent. My Consultant colleagues son has left medicine in his Foundation years and recently came top of the pile in his recent MBA business exams – a lucrative and fulfilling career in business beckons for him.

Would I encourage my children to go into medicine ? No way, Jose! Shame, as I don’t know of another family with three generations of ENT Surgeons in it and four would have been nice.

So it looks like the patient is facing a ‘perfect storm’ in todays NHS – inexperienced and demotivated Junior Doctors and a system facing unprecedented financial pressures, all with the background of random targets introduced by the last Government to including the one that all patients are seen and treated within 18 weeks of referral from their General Practitioner.

Why don’t the Consultants do more emergency work and train the doctors better, I hear you cry!? The reason is that we are snowed under with clinical work already, with ever increasing amounts of patients in our outpatient clinics and on our operating lists (far beyond accepted limits set by our speciality bodies) to keep up with the time targets that Mr Blair kindly introduced. The concept of a ‘training’ operating list or outpatient clinic where less patients are listed to allow a surgeon in training to have unflustered supervised time with their Consultant to perfect technique are long gone, and a lot of their training is done by osmosis watching their Consultant as he or she performs the surgery themselves to get through the long list of patients in time. If the operating list overruns, the theatre manager will be quite within their rights to (and often does) cancel the patients at the end of the list.

If we Consultants are to do the emergency work as well, we inevitably would be drawn away from the politically very important elective work, and as well as this (as is often overlooked !) remember that we are subject to the EWTD as well, and would require time off in lieu of this to compensate. Consultants are very expensive commodities to waste on emergency work when much cheaper juniors can perform this task ‘adequately’…..

We are reaching a watershed in terms of our junior doctor colleagues at the moment, as the last pre-Foundation Training Registrars are emerging through the upper echelons of the senior tier of training.

I fear that the contrast with their colleagues now entering the senior tier from the new Foundation system of junior training is going to be marked. I must emphasize that this will not be their fault, but how can someone who has done on average 10 months of ENT Surgery in a Foundation post be compared to the person that has done up to 30 months in the old system as I did ? Excellent trainees continue to come through the system now and probably will continue to do so, but this will be despite the system training them.

Educationalists may say a lot of that time in the old system was wasted, but if I’m flying on an aeroplane I’m reassured to hear that the Captain has plenty of hours of flying under his belt even if some of that time may be perceived as fairly mundane and routine.

In researching how to produce sporting greats out of my children (as parents do!), I recently read a very interesting book called ‘Bounce’ by Matthew Syed (a Times Journalist as well as ex- European Table Tennis Champion) who makes the assertion that ‘natural talent’ is overrated with all sporting and other pursuits of excellence. He quotes the ’10 year rule’ as what you have to devote to being any good at anything, or put another way, the ’10,000 hour’ rule. In other words, hard work and perseverance at the coal face. I’m sure you can do the maths at how long a junior doctor should spend training in the context of a 48 hour week when most of those hours are spent alone and not in useful supervised training activities ?

There was another revealing article on this topic written in The Daily Telegraph recently by a Surgical Registrar about to become a Consultant – therefore one of the very last ‘old style’ trainees – . He writes a diary of his final few days as a Registrar and says ‘If I stick to my official rota this week, I’ll miss out on 18 operations. If I’d worked like that for the past seven years, I would not be anywhere near ready to complete my training. The Royal College of Surgeons and the Association of Surgeons in Training recommend surgical trainees work a 65-hour week to gain the necessary skills.’ He concludes, ‘So my advice is to check who is doing your surgery, and whether they began their specialist training after 2007. I would want any doctor operating on me to have carried out the procedure 80 to 100 times. If they haven’t, ask for a surgeon who has. It could just save your life.’

So if you’re a patient reading this what would I recommend you to do.

First of all I must say that I have some sympathy, as with the passage of years I now see myself, my family, friends and colleagues as potential patients rather than just providers of healthcare. It is no longer the case that we medics get some sort of prefential treatment on the NHS. There was another article written by a senior medical academic in The Times recently who was admitted to Hospital acutely and therefore experienced the NHS for herself. She bemoaned the lack of continuity of care and never seeing the same doctor twice, but also the fact that when her chest was examined the perfunctory and haphazard nature of the examination was such that she wouldn’t personally have allowed the doctor who performed it to pass finals if she’d have been their examiner. I also remember a previous Consultant Surgical Trainer forced to retire after a shoulder injury prevented him operating – he had been refused physiotherapy in his own Hospital due to fact that he was ‘out of their area’.

Despite the fact that I’m thankfully in good health, I have therefore taken the easy option by just renewing my Private Medical Insurance (PMI), something which allows some autonomy and ability to choose one’s doctor in the comfort of a Private Hospital. If this is an option open to you, I would thoroughly recommend it and if you already have PMI, for goodness sake don’t cancel it. If you have PMI through a company perk, value it highly. Don’t give it up easily, and think carefully before surrendering it for another benefit that may seem more valuable on the face of it. There is always the option to ‘pay as you go’ in Private Healthcare, and this may be preferable if you believe that your good health is likely to last long term or, if you do need treatment, you would like a particular surgeon to perform your surgery, on a certain date and in a particular Hospital (none of which the NHS will ever be able to guarantee.)

If this is not an option, at least be an active participant in your NHS care.

· Ask your surgeon when he / she qualified and where did they do their training – be especially pleased if they finished their training more than 5 years ago!

· How many of these operations do they do? What are their outcomes and complication rates ?

· Are they a subspecialist in your operation or an occasional ‘dabbler’ who specialises in other operations usually ?

· Ask other people that may have been treated by them and your GP what your surgeon is like and whether they would let Mr / Ms X operate on their family (or in some cases, on their dog…).

· Don’t be afraid to ask for a second opinion from another local or national expert in the field and who has been recommended to you.

· Read testimonials (such as on this website) or look your surgeon up on the General Medical Council and British Medical Association websites.

· Research them on their Surgical Speciality websites (www.ent.org and www.fpsuk.org in my case.)

This is no more than you would do before engaging a builder to build an extension or a new nanny to look after your children, and has potentially very important consequences! In particular, it is no more than any discerning Private Patient would do…..

Regrettably this degree of research is not possible when one is rushed to Hospital in the middle of the night in an emergency. In tribute to my Colleagues in Emergency Care Medicine (and to allow my reader to relax somewhat !) I would say that my experience these days of the degree of expertise and senior input into the immediate resuscitation and treatment of seriously ill patients has led me to believe that this area of medicine is considerably better than in my time as a trainee. It’s when you’re rushed out of Accident and Emergency within 4 hours (to meet another of Mr Blairs targets – thanks again) and get to the ward that your concern may start…..

What is the answer to all these issues – well, that’s a difficult one and despite a long time to think about it I am still pondering and I suspect may be for some considerable time longer!

Hopefully, however, this diatribe will allow you to have some insight into optimising your own and your familys medical experiences, as well as allowing me to vent my spleen on what I find such a vexing subject.

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