Was there ever a golden age for junior doctors?
BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3662 (Published 06 July 2016) Cite this as: BMJ 2016;354:i3662
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- Caroline White, freelance journalist, London, UK
- cwhite{at}bmj.com
Doctors who trained before 2000 remember being exhausted by working for days with almost no sleep. But they also remember feeling well supported in their “firm”—a team typically comprising a junior house officer, a senior house officer, registrar, and consultant, who always worked together and covered for each other. They describe the rewards of getting to know their patients and the camaraderie of the doctors’ mess. Then the “New Deal,” which was designed to improve working conditions for junior doctors, and the European working time directive, which was introduced to protect all kinds of workers from exploitation and tiredness, heralded a change in working patterns. With the exception of the most recent trainee, all the other doctors we have interviewed, by chance, seem to believe that, however tired they were, it was better to be a trainee doctor in the past than it is now. But many, including the BMA, would be horrified to go back to the exhaustion of the past.
1950s: Harold Ellis, part time teacher of anatomy at King’s College London, former emeritus professor of surgery, University of London
Qualified: 1948, University of Oxford
Trained: Oxford, Sheffield, London plus two years in Royal Army Medical Corps
Caseload: 20-30 patients
Ward rounds: Daily
Hours: No set hours. We didn’t count the hours
On call: One day a week and one weekend in two or three
Time off: When it was quiet. Some Sundays
Leave: Two weeks
Pay: £2/week
Perks: Free accommodation, all meals, laundry, doctors’ mess
Harold Ellis: “I used to see emergency patients in my pyjamas, underneath my white coat.”
We all knew one another and what each was capable of. The firm was like a happy band of brothers and as the most junior member of it, you felt part of a team and intense loyalty to the unit.
Lots of sacrifices had to be made, but we were just brought up to believe in that. You were expected to put work before family life. You never felt completely off duty. On Saturday nights we would dance to gramophone records in the nurses’ recreation room, which had a telephone in case we were needed on the ward. We weren’t paid much, but sometimes patients would provide jugs of beer, and we didn’t go out so I didn’t spend anything.
Then and now: We had more responsibility and much longer hours, and I am not sure that juniors now understand what hard work means. But they have a lot to complain about: they aren’t getting properly trained or the experience they need. Statistically, patients were probably more at risk but it wasn’t a noticeable factor. We did make mistakes, but you apologised, and patients didn’t expect compensation.
1960s: Eleanor Arie, retired consultant rheumatologist
Qualified: 1965, University of Oxford
Trained: Oxford, Nottingham, London
Caseload: 40 patients
Ward rounds: Daily
Hours: Officially 8 30 am to 6 pm but often longer
On call: 24 hours twice a week plus one weekend in three 8 am Friday to 5 pm Monday; rest of the time “available” as a resident
Time off: One evening per week and one weekend in three
Leave: One month (six weeks in general practice). I had to take annual leave plus two weeks of unpaid leave to have my first child
Pay: £500/year
Perks: Free accommodation, all meals, laundry; maid service in the doctors’ mess
Eleanor Arie: “Scrutiny was simply what your boss thought of you”
There was little structured training, but as a houseman you had the support of a registrar; as a registrar, you had the senior registrar at home on the end of a phone, and the consultant could always be called in. The doctors’ mess was a very mutually supportive environment. It was where you went when not haring around the wards to talk through issues and get the moral and clinical support you needed. It had a strong sense of community.
It was a constant struggle to be taken seriously as a woman and as a part timer. Men were uncomfortable around us, and I was the first female houseman the ward sisters had had to deal with. It was a new experience for them. You had to be a bit aggressive to get anywhere as a woman doctor.
Then and now: I think it was easier in my day because medicine was much less complicated and you had to know less. Procedures now are much more technical and complex and the working time directive makes it harder for juniors to learn and gain confidence. Many felt heroic to have survived the awful workload. It was almost like a badge of honour. Because of the long hours we worked without breaks, I don’t think it was safe for us and it was worse for patients. I used to fall asleep driving home and I stopped going home in the car after a weekend on call. But despite the potential for disasters, I wasn’t aware of any, and was fairly well protected by senior cover.
1970s: Charles Easmon, emeritus professor of health policy, University of West London
Qualified: 1969, St Mary’s Hospital Medical School, London
Trained: Windsor and London
Caseload: 40 patients
Ward rounds: Daily
Hours: 8 30 am to 5 30 pm, but variable
On call: One night in two and one weekend (9 am Friday to 5 pm Monday) in two
Time off: What the weekly rota allowed; one in two weekends
Annual leave: Four weeks
Pay: £1000/year
Perks: Free accommodation, all meals, laundry
Charles Easmon: “It was a bit of sink or swim and a matter of pride not to ask for help if you could possibly manage it”
During the day you worked as part of your firm; at night you linked up with the registrar from the other [surgical or medical] team so between the two of you, you knew all the patients you had to look after. The opportunities to learn were considerable. You learnt as much from the nurses as from your senior colleagues, if not more.
The weekends could be very tough. By Monday afternoon you didn’t know whether you were coming or going. But you knew what you were getting into and you just got on with it.
When you were on call, you could have your calls put through to you in the pub across the road. It never caused problems as we were responsible. It was very much a social thing and reinforced the ability to keep going through the long hours.
There was a lot of wasted talent—mostly doctors from overseas—who didn’t quite fit into the system despite their skills, knowledge, and passion, and who never got the chance to climb to the top of it. They were going nowhere fast because of unfairness, a lack of any structure, and the corresponding degrees of patronage and power in the hierarchy.
Then and now: Difficult to judge, but I think it was probably a different type of hard back then. Patients fared well, given the state of medicine then, but the long working hours were a risk for them. Patient safety would have been a factor, but the attitude was that you were being treated in hospital and sometimes things went wrong. Society wasn’t litigious, but I don’t think serious mistakes were admitted to. Audit was almost non-existent.
1980s: Lynne Turner-Stokes, director of Regional Rehabilitation Unit, Northwick Park Hospital, London
Qualified: 1979, University College Hospital London
Trained: London
Caseload: 25-30 patients
Ward rounds: Most days
Hours: 14 hour days usually
On call: One in two nights and every other weekend (9 am Friday to 5 pm Monday)
Time off: What the weekly rota allowed
Annual leave: Two weeks at the end of every six month rotation plus two weeks study leave if you could get it. Maternity leave of three months was just about tolerated
Pay: £12 000-15 000/year
Perks: Free accommodation, all meals, laundry, doctors’ mess
Lynne Turner-Stokes: “You were woken in the morning by a maid with a newspaper and a cup of tea, and if you left your shoes outside the door they would be cleaned for you”
The expectation was that as a houseman you would live in and essentially be on the job the whole time, and even on your nights off you would only leave if you were comfortable that it was reasonably quiet. But there was a great sense of camaraderie. At one hospital, the closed bleep system was wired up to the pub across the road. It sounds bizarre, but if you left work slightly worried about a patient, you could socialise with your mates and be bleeped when the results came in and go back to the ward.
In two hospitals, patient bequests ensured you had a free bottle of beer or cider with the evening meal. A nurse would sit outside and take your bleeps for you while you ate.
You were very supported in the firm, senior back-up was always available in person or on the end of a phone. At the same time, we were given a lot of freedom: in my first house job I did 46 appendicectomies because I was keen on surgery and the senior house officer wasn’t a good cutter.
Women had to work harder to convince peers that we could step up to the mark and be as good as men. People would have lost faith if I had taken more than three months off for each of my children.
Then and now: It’s much harder now because of the fragmentation and competing pressures youngsters have. They work fewer hours but are often unsupported and more thinly spread. And those hours are crammed so they feel they can never do their job properly no matter how much they run around. We were very tired, but we were able to provide continuity of care, and a tired doctor who knows their patients is probably better than a fresh one who has to make decisions about someone they don’t know.
1990s: Adrian Stanley, senior clinical teaching fellow and honorary consultant physician in cardiovascular medicine, University of Leicester
Qualified: 1992, University of Southampton
Trained: Southampton, Bournemouth, Leicester
Caseload: 25-30 patients
Ward rounds: Daily. Juniors had to do all the procedures as there were no technicians or nurses to do them
Hours: 9 am to 5 pm but usually 7 pm.
On call: One in three/four nights (usually only half an hour to two hours’ sleep) and one weekend in three (9 am Friday to 5-6 pm Monday)
Time off: What the weekly rota allowed; two in every three weekends off, except that one of those weekends I would work the Friday night until Saturday mid-morning
Annual leave: At least 10 days every six months
Pay: Around £19 000/year (£11 000-£12 000 for 40 hour week plus on-call nights and weekends paid at 50% of normal working rate)
Perks: Free accommodation, all meals, laundry, doctors’ mess
Adrian Stanley: “There was no robust system of reporting errors and no culture of reporting”
The senior house officer and the registrar were always available, enabling the consultant to provide less supervision. There was a strong camaraderie among a small network of individuals who knew each other really well.
I never felt unsupported. And there was continuity of care for patients throughout their hospital stay. At 3 in the morning things usually quietened down on the medical admissions unit and you could catch up with your notes. The fatigue was overwhelming. Once I worked for 50 hours non-stop and fell asleep clerking a patient in.
But it never crossed my mind that we would be putting patients at risk because of the hours we worked. It was what had gone before and what we were expected to do. There was no robust system of reporting errors and no culture of reporting.
There were frequent drug company invitations to meals. I can't recall ever discussing the ethics of [this]. But the rules were different: the reps were expected to discuss the drugs and most of them did ... I was never taken anywhere that I would not or could not have paid for if going independently with friends.
Then and now: It was easier then. Having to sit at a computer for a third of the day [as juniors do now], not engaging so much with patients, and the lack of continuity of care and support would drive me to distraction. There were more characters and we had more fun.
2000s: Tom Fardon, consultant in respiratory and general medicine, Ninewells Hospital, Dundee
Qualified: 1999, University of Cambridge
Trained: Huntingdon, Bedford, Edinburgh, Falkirk, Dundee
Caseload: 15-20 initially; then 30 plus 30 others scattered around the hospital
Ward rounds: Daily
Hours: 80-120/week
On call: One day (8 am to 5 pm next day) plus one weekend (8 am Friday to 5 pm Monday) in three
Leave/time off: 30 days;extra 10 days’ study leave as senior house officer
Pay: £22 000plus additional duty hours paid at 30-50% of basic rate (before the New Deal)
Perks: Doctors’ mess with snooker table, refreshments all day, and breakfast
Tom Fardon: “As a house officer you had to make decisions and you up-skilled quickly, although it was a steep learning curve”
In 2001 when the New Deal came in, additional duty hours changed to banding, which depended on the number of out of hours worked. But health boards weren’t prepared for the change because it happened so quickly, and all the rotas were non-compliant, so we had to be paid for the extra hours. Our pay doubled and we all went out and bought cars. It took two to three years before the rotas were compliant.
The European Working Time Directive also effected a big change. As a senior house officer in Edinburgh I went from a normal working day with on-call at home after 8 to shift work from 8 to 8 or 9 to 9. Ward work changed from firms to ward based teams with a consultant on a ward for a week. Many of us mourn that loss because the start of my training was an apprenticeship, learning from those above you, and inspired by the consultant who led the firm. That’s gone.
Then and now: It’s not harder or easier, just different. But it was better then. Today juniors are asked to do a huge amount of menial tasks and are swamped with paperwork, which ties up a massive amount of time. The intensity was less than it is now.
2010: Deborah Kirkham, national medical director’s clinical fellow to NHS England and The BMJ, specialist trainee in genitourinary and HIV medicine
Qualified: 2009, University of Manchester
Trained: Salford, Stockport, Manchester, Blackpool
Caseload: 40 patients
Ward rounds: Daily
Hours: 9-6; one 13 hour shift/week
On call: 2-3 nights/month (9 pm often to midday), plus two weekends a month (9 am Saturday to 4 pm Monday)
Leave/time off: 27 days plus up to 15 days’ study leave
Pay: Starting salary £30 000/year including banding, minus £1000s for compulsory courses and exams
Perks: Living over 11 miles away for on-call qualifies for mileage allowance
Deborah Kirkham: “Shift patterns mean that it’s quite common for your boss not to get to know you”
During my first four years I moved jobs every four months. During that time you are viewed with suspicion by the other team members because they don’t know if you are going to be any good. But as soon as they get to know you, you move on again: it’s exhausting.
Senior cover is variable. As a registrar it’s good, but at more junior levels it’s more hit and miss, and during the day it depends on which members of the team are around, so you could be on your own. I almost never worked clinically with my supervisor.
The team I am on now is very clear that junior doctors are valued, but that is quite novel. It’s not the over-riding culture of the NHS, not just in terms of doctor colleagues but other health professionals as well. As a junior you are at the bottom of the pile.
Then and now: The worst part of being a junior is having to battle the system constantly, but I think a lot of doctors like their jobs despite the system. I don’t think it’s harder now. Our lives are easier in some ways, although we don’t have the same support as colleagues had in the past, and that makes the difficult things more difficult to deal with.
Footnotes
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.