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  *

  So what did happen to Leo?

  With the tragic cases of students and junior doctors who had committed suicide in mind, I responded to Leo’s email with considerable care. I wanted to acknowledge his obvious distress yet at the same time convey hope. I told him about other medical students and junior doctors I had encountered in the past who had expressed similar feelings. I also told him that some of them had gone on to have successful careers within medicine, whilst others had decided to build their careers outside the profession. But above all else, I emphasised that he shouldn’t attempt to soldier on without help. His first priority was to go and see his GP and tell her how he was feeling. In addition, he might find it helpful to seek support from the university counselling service, as well as pastoral staff within the medical school. And I flagged up the 24-hour crisis line operated by the British Medical Association.

  I explained that I was out of the country but would respond to any emails he sent me, and would be happy to talk on my return to the UK the following week. A couple of days later Leo wrote back. He’d already made contact with his GP and his personal tutor and he had found it helpful to know that I had supported other doctors who felt as he did. He also wanted to arrange a time to talk when I was back in the UK.

  The following week, we talked on the phone for over an hour. Leo told me that he was feeling better than when he had first emailed me; he had contacted the BMA helpline and in addition, his GP and personal tutor had been helpful. When I asked about the impending exams Leo was clear that he was well enough to sit finals and he’d done enough studying to pass. It wasn’t the exams per se that he was worried about; more what came next. When we then discussed how he felt about starting work Leo was adamant that he wanted to give it a try even if he decided a few months down the line that clinical medicine wasn’t right for him.

  After his exams Leo was due to go away on holiday for a month with his girlfriend. On his return he would be moving to a new town with her, to start his first job as a doctor. We left it that Leo would get in contact with me if he wanted to think about which specialty might work best for him, or if he wanted to consider leaving medicine entirely. But a couple of weeks before finals wasn’t the right time to discuss either of these issues.

  A month into his first job I received another email – very different from the first.

  I am happy to tell you that things got a lot better after speaking with you. I managed to pass finals and had a very relaxing holiday and have now moved in with my girlfriend. I’m working at the university hospital which is going much better than expected, and I have actually enjoyed the acute side of medicine. Anyway, I am taking things slow and steady and making sure I prioritise my own health and happiness first, and I’m trying to keep myself as balanced as I can.

  It’s probably a bit too early to tell how Leo’s medical career will pan out in the longer term. But later on in the book we’ll meet doctors who walked out within days of starting their first job; the fact that Leo is enjoying work is certainly encouraging.

  I’m still shocked, however, by how frequently medical students and junior doctors find themselves at the ‘edge’. Aren’t there better ways of training our future doctors? Ways that mean they don’t need to phone 24-hour helplines, or send desperate emails to unknown psychologists, in the hope that someone out there will listen. And couldn’t we manage the transition from medical student to junior doctor better?

  That’s the place where these stories begin.

  1

  Wednesday’s Child

  I ALWAYS ASK clients about their first job as a doctor. I don’t specifically ask about the first day of that first job – but sometimes, as with Hilary, that’s the story I am told.

  Hilary, a qualified GP, came to see me because she was thinking about leaving medicine.

  ‘I’ve reached the end of the road with general practice,’ she explained in our initial phone conversation.

  ‘The only thing that I like about it is that it provides a regular income,’ she continued.

  Like many other GP clients, Hilary told me how she felt that contemporary general practice pulls doctors in opposing directions. On the one hand, she lived in fear of incorrectly reassuring a patient that a particular symptom didn’t warrant a referral to a specialist for further investigation. On the other hand, she dreaded being singled out by her clinical managers as having an inappropriately high referral rate to specialist services. Damned if you do and damned if you don’t, with no wriggle room in between.

  It was five years since she had first qualified as a GP, but even before she finished her GP training, she had started to doubt whether it was the right career for her.

  ‘I’m not a natural doctor,’ she said. ‘I constantly feel like a square peg in a round hole.’

  But leaving wasn’t easy either. Neither of her parents had been to university, and her mother’s father had worked as a gardener for the local doctor.

  ‘My mother is so proud of me, and everything that I’ve achieved. She really doesn’t want me to change career.’

  I asked Hilary to tell me about her first job as a doctor and she described how her heart sank when she saw from her rota that she’d been placed on the on-call team on her first day. What this meant was that in addition to her responsibilities on the surgical ward to which she had been attached, she also had to assess new patients as they were admitted to the hospital for surgery. It’s a bit like trying to be in two places at once; nobody wants to be on call on Day 1.

  On her first morning as she walked on to the surgical ward she was immediately informed by the senior nurse that, following surgery, one of the patients was extremely sick and urgently needed to be seen by a doctor. Naïvely, Hilary asked which other doctors were available.

  ‘Mr Baker the surgical consultant is on a course, Mr Shah the registrar is on annual leave and Dr Glover is off having worked a bunch of nights. It’s just you,’ said the nurse.

  Hurriedly, the nurse led Hilary to the patient’s bedside. The first thing that Hilary clocked was the patient’s strange, grey pallor. With extreme difficulty the patient opened her eyes and whispered, ‘Doctor, am I going to die?’ Then, a second later, a barely audible request: ‘Doctor, please call my family.’

  Hilary didn’t have a clue whether the patient was at death’s door, or whether she should urgently summon the family. More importantly, she also didn’t know whether there were medical interventions she should be making, to save the patient’s life. Moving away from the patient’s bedside in order to confer with the nurse, Hilary asked for help.

  ‘You’re going to have to get used to this,’ said the nurse. ‘Mr Baker never turns down an opportunity to operate – he’ll operate on anybody. With some of the patients on this ward it might have been better if they had escaped the knife. They’re often even sicker when they come out of theatre.’

  A junior nursing assistant called the senior nurse away. Left on her own and unsure what to do next, Hilary decided to review the patient’s notes. There were no clues there either. With mounting anxiety, she wondered whether she should call the registrar from another team, or ask the senior nurse to return to the bedside. Nothing that she had learnt in medical school had prepared her for this situation.

  By chance Fiona, a fledgling doctor attached to another ward, walked down the corridor and out of the corner of her eye caught sight of a panic-stricken Hilary. Realising that all was not well with her colleague, Fiona slipped away from her own clinical team, and walked on to Hilary’s ward:

  ‘Are you OK?’ asked Fiona.

  ‘Not really,’ Hilary replied. ‘I’m the only doctor on this ward, all the others are away today, and there’s a really sick patient who looks like she is going to die.’

  She led Fiona to the patient’s bedside; neither of them spoke as they peered down at the sickly looking patient, who had fallen asleep again.

  ‘I’ll call my mum,’ Fiona whispered.

  For a second,
Hilary thought that Fiona was joking. Even though she would love to magic her own mum on to the ward, she couldn’t see how the appearance of Fiona’s mum was going to improve the situation.

  ‘Mum’s a nurse on the Rapid Response Team,’ Fiona explained. ‘She’ll know what to do, and I am sure she will come if I ask.’

  So that’s what they did. Fiona’s mum was summoned and five minutes later appeared. She took one look at the patient, realised she was desperately unwell, and called the consultant anaesthetist. A couple of minutes later the anaesthetist appeared, agreed with his nursing colleague’s opinion and less than ten minutes after that, the patient was transferred to the High Dependency Unit, for urgent medical treatment.

  The patient survived. And Hilary’s first day continued.

  All the time that Hilary had been trying to sort out the desperately ill patient, her bleep had been going off, summoning her to the Surgical Assessment Unit (SAU). As soon as the patient was transferred, she dashed down to the SAU and encountered an extremely angry nurse.

  ‘There are nine patients waiting. Where have you been?’

  Before Hilary had the opportunity to explain that she had been dealing with an emergency on the ward, the nurse gave a rushed account of each of the nine patients whose names were on the whiteboard by the nursing station. Hilary absorbed almost nothing of this informational deluge.

  ‘Is there another doctor here?’ she asked, finding it hard to believe that she had been expected to fly solo on the SAU as well as on the ward.

  ‘Triple A emergency admission.fn1 Everyone’s in theatre,’ was the unwelcome response.

  By this stage in the day, the nine names on the whiteboard were swimming in front of Hilary’s eyes. And having already dealt with a clinical emergency (albeit by calling Fiona’s mum), she was desperate to know if any of the names were higher priority than the others.

  ‘Could you possibly help me work out who I should see first?’ asked Hilary.

  ‘Figure it out yourself, blue eyes,’ was the nurse’s response. And with that, she walked off – probably to get on with her own enormous list of tasks.

  Over a decade had passed when Hilary told me about her Day 1, but she could still remember the face of the desperately ill patient, and her name. She could still recall that sense of panic and fear. I asked if she thought there was any relationship between her horrendous first day and her current feelings about her work; she told me that she couldn’t see a link. The following day Hilary emailed me:

  I was thinking yesterday about your question as to whether that first day set up any future feelings about my job and I said I didn’t think so. On reflection, I think that it was just the beginning of a huge number of experiences (of myself and others) that brought me to my current belief on working within NHS medicine:

  That it just doesn’t care. That it chews people up, spits them out and then gets another well-meaning chump to replace them. Sorry if that sounds harsh and I do have some sadness in writing it but I also think it’s 100% true.

  So for Hilary at least, that first day may have paved the way for extreme job dissatisfaction, ten years down the line. What strikes me most forcefully about Hilary’s story is that the whole set-up seems so precarious. In the UK all first year doctors start work on the same day – the first Wednesday in August. Given that Day 1 is a national fixture across the whole country, why was the supervising consultant away on a course? Why had the registrar been allowed to go on annual leave at the same time? What if the patient had died, and Hilary had been held responsible? Why hadn’t back-up provision been made on the Surgical Assessment Unit in case all the experienced staff had to rush into theatre to deal with an emergency?

  Do we really want a system where a patient’s life depends upon someone’s mum arriving in time?

  *

  It would be reassuring to think that Hilary’s experience was exceptional. Sadly, this is not the case. I was shocked by Hilary’s conclusion that her experience was in fact commonplace. ‘Lots of my F1 colleagues had similar experiences,’ she told me. ‘And the following year in a completely different hospital, the same thing happened to the F1 on my new team. That day I had induction in the morning into my new role as an F2 and only got to the wards in the early afternoon. But the new F1 in the team had been left to fire-fight all morning. It happens all the time.’

  This conclusion of Hilary’s is borne out by studies of first year foundation doctors. In fact a 2014 programme of research commissioned by the GMC reached the following conclusions1:

  The August transition was highlighted in our interview and audio-diary data where F1s felt unprepared, particularly for the step-change in responsibility, workload, degree of multitasking and understanding where to go for help … trainees were reasonably well prepared for history taking and full physical examinations, but mostly unprepared for adopting an holistic understanding of the patient, involving patients in their care, safe and legal prescribing, diagnosing and managing complex clinical conditions and providing immediate care in medical emergencies.

  The study also emphasised how pressures on the healthcare system can impact on a recent medical graduate:

  Trainees may feel prepared for situations when all goes to plan, but unprepared when exposed to high volumes of work which demand prioritization and multitasking; or uncertain thresholds (not knowing when to refer to seniors); inadequate team-working; or when seniors are not easily accessible.

  This isn’t only a pretty accurate description of Hilary’s first day. Given the current pressures in the NHS, a high volume of work requiring prioritisation and multitasking has become the norm.

  *

  In UK hospitals it might be ‘all change’ on the first Wednesday in August, but the process of applying for one’s first job as a doctor takes the best part of a year. Nine months earlier, in October, final year medical students fill in an online application form in which they have to rank their preference for each of the twenty-one different health regions across the whole of the UK. Jobs are allocated in score order, so the higher your score, the more likely you are to be allocated to your first or second preference region.

  Each applicant’s overall score comes from two separate sources. First, there is an Educational Performance Measure derived from a student’s academic scores in medical school together with extra points for additional degrees and academic publications. Secondly, and given equal weight, is their score on the so-called ‘Situational Judgement Test’ (SJT)2. This is a pencil and paper test lasting over two hours during which students have to answer seventy questions. The questions are not testing clinical knowledge (that’s assessed by medical school finals) but instead assess whether the applicant possesses the professional attributes needed to manage the everyday situations they may encounter in their first year of practice. For example, applicants might be given the following brief scenario:

  Mr Farmer has been a patient on the ward for six months; he breathes with the aid of a ventilator following a traumatic brain injury. As you make your rounds, you notice Mr Farmer appears to be experiencing breathing problems. Both the consultant and the registrar (more senior trainee) from your team are dealing with a patient on the neighbouring ward. This is your first week and you have not yet attended a potentially critically unwell patient by yourself.

  Applicants would then have to rank-order the appropriateness of the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate).

  A. Call the crash team to attend to Mr Farmer as a matter of urgency.

  B. Seek advice from the physiotherapy team who are on the ward and have experience in managing Mr Farmer’s case.

  C. Contact another registrar to discuss Mr Farmer’s symptoms.

  D. Ask the ward nurse to fully assess Mr Farmer’s status with you immediately.

  E. Ask the consultant to return to your ward straight away to attend to Mr Farmer.

  The worked examples on the UK Foundation Programme Office website
gives the answer as DCBEA, using this rationale3:

  This question is assessing your ability to make appropriate decisions in a pressurised situation. It is important to assess Mr Farmer’s status immediately. The ward nurse is most likely to be the health professional available to help and have the skills, knowledge and ability to access help if needed. It is important not to ‘go it alone’ if possible as help is likely to be required (D). Assessing the status of the patient should be your immediate priority and discussion with a senior colleague (C) could help reach an outcome for the patient. It can be important to have wider team involvement and informing them of patient progress is important (B). However, this would not be an immediate action and is less direct than Options D and C. Consultant return may not be appropriate until the patient is properly assessed (E). Crash teams should only be called in the case of arrest or emergency, doing otherwise could put other patients’ lives at risk and is therefore the least appropriate option (A).

  (Isn’t it ironic that the model answer stresses the importance of asking the nurse? This is exactly what Hilary did on the Surgical Assessment Unit, only to be told that she needed to ‘figure out’ the answer herself. The nurse was too busy to help Hilary.)

  Applicants with extremely low SJT scores have to attend a face-to-face interview, to assess whether they are competent to start working as a junior doctor. In 2016 this happened to twenty-two UK medical students and fourteen from outside the UK – only three of whom were later reinstated and offered an F1 post.

  I might have struggled to believe that anybody could get to the end of a five- or six-year medical degree, pass finals, but lack the professional understanding to get an adequate mark on the SJT. Once one has grasped a few basic principles (patient safety always takes precedence; respect the expertise of other healthcare professionals; honesty is of the utmost importance) it seems possible to work one’s way through the questions and get a reasonable score. However, when running a workshop for senior medical school faculty in one of the most academic universities in the country, an experienced clinician told me about a final year medical student who was academically brilliant, but seemed to lack sound professional judgement. On one occasion, while on an A & E placement, this particular student had needed to get his attendance form signed by the supervising consultant, but the consultant was otherwise engaged – dealing with an emergency patient resuscitation, in fact. Undeterred, the student attempted to interrupt the resuscitation, waving the form under the consultant’s nose in order to get it signed.