Also Human Read online

  ‘Should I be worried about this student?’ asked the senior faculty member.

  I was speechless. How could one not be worried by this student’s behaviour? Isn’t it fairly obvious that anybody who decides that getting a form signed takes priority over an emergency resuscitation is going to find the day-to-day demands of clinical practice impossible? Years ago, it was left to supervising clinicians to weed such students out and there can be considerable reluctance to do so, particularly if the students are academically gifted. Nowadays this task is aided by the SJT.

  Final year students sit the SJT in December, and this score is added to the Educational Performance Measure to calculate their overall score. In March they are told which region they have been allocated to, or if they have been placed on the reserve list. In April they get told which specific hospital within the region they will be working at. However, those on the reserve list may not be told if a place has become available for them until right before the fateful first Wednesday in August. Between March and August medical students on the reserve list have to sit it out and wait.

  What this tends to mean in practice is that the weakest final year students (those who have scored poorly on either or both of the measures) are allocated to the places which other more highly ranked students have avoided. Final year medical students can easily find out which are the less desirable posts by looking at the results from the GMC trainee surveys, alongside a host of other websites. So medical students can find out how well supported foundation doctors have felt in each of the different regions or how favourably the quality of training was rated. More highly ranked students are likely to choose those programmes where students felt better supported and better trained, whilst weaker students are left to take whatever is left over.

  And there’s more. Medical students can be sent to hospitals anywhere in the country – from Cornwall up to northern Scotland or Northern Ireland. Because weaker students on the reserve list will be placed in left-over slots, they are more likely to end up working in parts of the country where they know absolutely nobody, and have no accessible systems of support. This is an educational variant of what GP Dr Julian Tudor-Hart famously termed the ‘inverse care law’4 – those who most need care, end up receiving the least. Except in this situation it isn’t vulnerable patients receiving the poorest medical care – it’s vulnerable medical students being offered the least support in their first post.

  On paper, at least, there is a system in which final year medical students can apply to be allocated to a specific foundation programme5, based on their ‘special circumstances’. So, for example, if you have a school-aged child, or if you are the primary carer for somebody with a disability you can request that you won’t be sent all over the country, but will be pre-allocated to a specific post. This is all good in theory, but in practice, given the stigma attached to mental health issues and the unwillingness to be seen to be struggling, very few students request this option for mental health or educational reasons.

  For the last few years when the allocations have been announced in March, a small number of students have been placed on the reserve list. This always generates a lot of column space in the medical press. But in 2016 it happened to the grand number of thirty-six UK students. Tiny numbers. And by the time the programme started in August, all thirty-six of these students had been allocated jobs. In the UK, if a final year medical student passes finals (and the overwhelming majority do), and doesn’t score too drastically on the SJT (which also only involves a tiny number of students) they will end up with an F1 job somewhere. It may be far from home, and it may not be one that they want – but it will be a job.

  *

  In the US, as in the UK, the overwhelming majority of final year medical students are offered a first year post – a residency. For example, in 2016, less than 7% of US medical students failed to be offered a post through the National Resident Matching Program (NRMP)6. But there are also some key differences between the US and the UK.

  First, as with so many medically related comparisons, there is the huge issue of money. UK medical students don’t pay to apply to the foundation programme, whereas in the US the application for residency is anything but free. I asked a friend’s daughter, Sophie, who successfully applied in 2016 for an obstetrics and gynaecology residency programme, to give me some idea of the costs, and this is what she told me:

  Application fees for 55 programmes – $1,900

  Transcript fees – $1,000

  Fee to the NRMP – $65

  Travel and hotel costs to attend 23 interviews – $6,000

  So in all, Sophie reckoned that she had spent around $9,000 – a huge sum on top of an already enormous medical school debt.

  Another key difference between the UK and the US is the sheer scale of the enterprise. In the US in 2016, over 30,000 residency slots were up for grabs – a figure which is more than four times greater than the number of first year posts on offer in the UK. The NRMP matches the applicants to this vast number of posts through the use of a complex mathematical algorithm which gained its two inventors – Lloyd Shapley and Alvin E. Roth – the Nobel Prize in Economics in 20127.

  Prior to using this algorithm, medical students would apply to hospitals and their preferences would be visible to the selection committees. The selectors would first look at those applicants who had ranked their hospital as their first choice. If they still had vacancies the selectors would look at applicants who had ranked them second – and so on, until all their vacancies were filled. The problem with this system was that when an applicant’s ranking was visible to the selectors, those applicants who had aimed too high would be severely punished. Frequently these poor medical students would end up with one of their last choices.

  Nowadays applicants interview at the hospitals without the hospitals knowing how high up the list the applicants had rated them. Then the preferences of all the applicants and all of the hospitals are fed into the computer at the same time and the algorithm is used to create a simultaneous match between thousands of applicants and thousands of jobs that, in theory, is less influenced by the gaming strategies inherent in the old matching method. Having said that, many applicants resent the system because each individual still ends up with only one job offer. And they hate the feeling that their future depends upon the working of a complex mathematical algorithm – even if it did win somebody a Nobel Prize.

  This was certainly Sophie’s experience. She recognised that with the NRMP process, applicants can’t (as can happen in the UK) wind up somewhere completely out of their control as they will only be considered by the specific programmes that they ranked. But she still expressed some regret.

  ‘Do I wish we could have the opportunity for more than one programme to ultimately make us an offer and then be allowed to choose like normal adults? Yes.’

  The money side of things and the sheer scale of the operation may be different in the UK and the US. But in both countries, final year medical students end up with only one offer. They look around them and see that other professions (law, business, accountancy) don’t assign people to jobs this way. And, like Sophie, they resent the lack of choice. Isn’t it paradoxical, considering the burden of responsibility junior doctors are expected to bear as soon as they start working, that the application system in both countries manages to infantilise final year medical students?

  *

  For T.S. Eliot in his epic poem, The Waste Land, April is the cruellest month of the year8. But April is not so bad in ‘Wardland’ – in that realm, the calendar shifts on a couple of months and you have to worry about July and August. These are the months when medical students metamorphose into junior doctors and take up their first jobs. The jobs that they had spent the best part of the previous year applying for.

  ‘Why July matters’ is the title of a recent commentary in the American journal Academic Medicine9. The author quotes a systematic review of thirty-nine separate studies that reached the following conclusion: ‘Len
gth of hospital stay, duration of procedures and hospital charges peaked during the month of July. Of note, rates of patient mortality also increased in this period.’

  But it’s not just in the US. The authors of the Academic Medicine paper go on to describe an international study which found that ‘rates of fatal medication errors increased by 10% during the month of July in countries with teaching hospitals … the greater the proportion of teaching hospitals in a region, the greater the mortality rate from medication errors.’

  The UK isn’t immune to this effect either, but as changeover is the following month, the peak occurs in August rather than July. In 2009 a group of researchers at Imperial College in London published a retrospective study using hospitals admissions data over an eight-year period across the whole of England10. The key question they looked at was whether in-hospital mortality was higher in the week following the first Wednesday in August than in the previous week. Only hospitals that took on trainee doctors on the first Wednesday in August each year were included.

  As national data were gathered from across the whole of England, there was a sufficient sample size to adjust the calculations for confounding patient factors that may have affected the risk of death, including age, gender, socioeconomic status and the presence of other serious illnesses. Just under 300,000 patients were admitted on these two days in the years from 2000 to 2008. Of those, 151,844 were admitted on the last Wednesday in July and 147,897 on the first Wednesday in August. In total, there were 4,409 deaths in the two groups, 2,182 among those patients admitted on the last Wednesday in July and 2,227 among those patients admitted the week after. When the researchers adjusted for potential confounding factors, they found that the odds of death in the group admitted in August was 6% higher than the group admitted in July.

  Two years later, in 2011, an online survey in the UK reported that 90% of physicians felt that the August transition had a significant negative impact on patient care and patient safety. Respondents highlighted the inadequacy of measures at the local level to support junior staff in their induction, and to ensure patient safety. The title of the paper was ‘August is always a nightmare’11 – taken from a comment by one of the physicians in the survey. August is the cruellest month, it seems. At least for patients in teaching hospitals in the UK.

  *

  I didn’t warm to Bella when I first met her. As I described how I worked with clients, I gained the distinct impression that she was somewhat contemptuous of what I was saying. By the end of the first session I realised that my initial impression was fundamentally incorrect. What I had initially taken to be disdain was actually a potent combination of shyness and wariness.

  I had been asked to see Bella by her psychiatrist, who was treating her for depression. A couple of months earlier Bella had become so unwell that she was unable to continue in her first post as a junior doctor. Following a period of treatment (both psychotherapy and medication), her psychiatrist felt that she was now well enough to consider whether she wanted to resume her medical career. And that is why he had contacted me, and asked me whether I would be able to have some sessions with Bella.

  Her psychiatrist told me that Bella was exceptionally able, winning prizes in both medicine and surgery at medical school. On paper, there were few indicators that she would be totally overwhelmed by the transition from medical student to F1 doctor; she wasn’t one of the medical students who had needed to repeat years in medical school because of recurrent exam failure or ill health. But as I talked to Bella in the first session, it became clear that she had experienced mounting dread as the first Wednesday in August approached. She knew she lacked the confidence to assume responsibility for treating patients.

  Over the years I have seen a number of junior doctors who have become so distressed in their first posts that they have had to stop work – at least for a period of time. When you explore their medical school history you find that almost without exception these doctors have had previous episodes of depression and anxiety. But these episodes may not have resulted in a psychiatric referral and been managed by a GP, or in sessions with a counsellor at the university counselling service. And this is what happened to Bella; a couple of years earlier, while doing her undergraduate research project, she had lost a considerable amount of weight, and started to have problems sleeping. Although Bella wasn’t referred to a psychiatrist at this point, she had been to see her GP, who prescribed a brief course of antidepressants.

  Bella told me that her undergraduate research supervisor found her annoying, and she ended up being poorly supported. Working on the research project was the first period in Bella’s life when she didn’t know what she needed to do in order to excel academically. Unfortunately Bella’s supervisor had never before supervised a medical student’s project and she was more interested in using Bella as free labour in the laboratory than helping her write up her research. Faced with an unresponsive supervisor, Bella felt desperately unsure about what to do. ‘I felt on the precipice of failure,’ she told me.

  To be uncertain about how to write up a laboratory project is one thing; to be uncertain about what to do when faced with a sick patient quite another. If you make a mistake in your write-up, at worst, your project won’t be awarded the top grade. If you make a mistake when looking after a sick patient, the worst thing that can happen is that a patient can die. A medical student who has become significantly depressed when faced with the uncertainty of writing up her research should have been identified as somebody who might be overwhelmed by the uncertainty inherent in treating patients. However, as Bella was so strong academically, her vulnerability remained undetected. (In the end she was awarded a first-class grade for her dissertation.)

  Final year medical students have to complete a health declaration form which is forwarded to the hospital where they will be working in their first year. Bella told me that she remembers being uneasy when faced with the form; as the depression she experienced when working on her research project had never been formally diagnosed by a psychiatrist (although she had been prescribed antidepressants by her GP), she persuaded herself that she was under no obligation to mention it. She didn’t want to be singled out as different – as vulnerable and weaker than her peers. At the same time, she knew that she was being less than truthful on the form and it added to her sense of foreboding as the first Wednesday in August approached.

  An additional blow to Bella’s confidence, prior to starting the foundation programme, was that she scored far lower than predicted on her SJT. ‘If the questions assess a candidate’s professional competence to handle the everyday situations that F1 doctors typically encounter, what does it say about my competence, that I didn’t do that well?’ Bella asked herself. Her lower than expected (although still average) results added to her sense of mounting dread. A more responsive (and responsible) medical school system might have picked up on the marked difference between her academic performance (where she excelled) and her SJT scores. The latter test maps more closely on to the complexity of day-to-day clinical practice. But nobody other than Bella herself foresaw a difficulty. And on a practical level, her SJT results meant that she didn’t get placed in her first choice foundation programme, but instead was allocated to another part of the country where she knew nobody. The inverse care law in action.

  Of course, final year medical students aren’t expected to morph into first year doctors without any formal support. Over the last few years all medical students in the UK have been paid to shadow the doctor whose job they are going to be taking over, for a couple of days prior to the August start. Many medical schools also run ‘transition to practice’ courses. Bella’s medical school ran such a course, but the manager in charge of the scheme told me that attendance was appalling. Bella, being conscientious, did attend this course, but she found that there was a ‘disconnect’ between the primarily lecture-based sessions, and the reality of what she was gearing up to face as a working doctor.

  In addition, hospitals run induct
ion courses for new starters. But a 2014 study carried out by the GMC found that the quality of induction was highly variable12. Bella felt that the induction process at her hospital spent too much time dealing with practical issues such as fire alarms and manual handling of patients; at the end she wasn’t in any way reassured that she was sufficiently competent to look after patients. And the one and a half days when she was supposed to shadow the F1 doctor whose role she was about to assume were cut short because the doctor was away from work on sick leave.

  In a way, Bella was a victim of her previous success. ‘I was somebody who had never really struggled academically, and my academic achievements and career were a big part of my identity,’ she told me. And, she continued, ‘It was particularly difficult for me to feel that I was struggling.’

  Bella talked movingly about how difficult she found it to trust other people, or herself, and she linked this to some traumatic experiences in her childhood. Before she even started her first job, she knew that she would find the psychological demands of clinical work challenging. Whilst she understood what she described as the ‘mantra’ from medical school that one should always ask for help when one isn’t sure, in practice, despite the fact that her clinical knowledge and skills were excellent, even minor clinical decisions caused her considerable anxiety. In her second week at work she was on call at night and had to cover all the medical patients in the hospital; she struggled to know when exactly she should be bleeping her senior (who was in a different part of the hospital), and when she should manage on her own.