Next Wednesday, the NHS welcomes another intake of junior doctors on to hospital wards. If clinical standards slide, they'll be blamed, but will it really be their fault?
For thousands of young people in Britain, next Wednesday is the biggest day of their life so far. They have waited at least five, perhaps six, years for this moment. On 3 August a new intake of junior doctors take their first cautious steps on to hospital wards. Should you be concerned?
This annual changeover hit the headlines in September 2009 - the usually muted Guardian described it as the NHS's "very own black Wednesday" - when researchers at Imperial College published a study showing mortality rates amongst patients admitted to emergency units rising by 6% compared to the previous Wednesday (i.e. yesterday). The research was based on data from nearly 300,000 patients between 2000 and 2008. Apart from top line indicators, the study actually tells us very little. Further research, for instance analysing the nature of individual deaths, would be needed to draw firm conclusions. Dr Paul Aylin, who led the study, said they had unearthed "an interesting pattern" but emphasised that it is "a relatively small difference" (a discrepancy of forty-five extra deaths over the nine years). Even so, it is apparently sizeable and consistent enough to be more than mere chance at play.
Might it be a case of new employees learning the ropes and mixing their bowsprit with their bowline, as suggested? Actual practice suggests it shouldn't be. All hospitals run thorough inductions for their new intakes - whether this week and/or this coming Monday and Tuesday. The training sessions range from clinical functions such as intermediate life support, common emergency calls, and infection control, to the more everyday concerns in any new workplace, like your weekly rota or where the coffee machine is. Familiarity ought not to be an issue.
Furthermore, in order to get this far, medics have had to pass as many as three dozen exams. The suggestion that junior doctors might not be properly prepared demonstrates ignorance of the highest order. The vast majority of them now have to undergo at least one week of work experience (often salaried) prior to starting on wards for real. In the Severn Deanery, which includes Bristol, Gloucester and Swindon, a week's 'shadowing' is mandatory for newly qualified doctors. Shrewsbury makes them do it for a fortnight. Some research suggests that higher rates of shadowing have lessened morbidity.
On top of having to absorb thousands of new doctors, there is a logistical challenge in reallocating those junior doctors finishing their first year and progressing to F2 (foundation year two), typically in a totally different hospital. So to blame mishaps and confusion on wet behind the ears trainees alone is narrow minded, when hospitals face this bigger administrative challenge. One doctor in the south-east, about to start their second year in a new hospital, bemoans the lack of support that F2's receive in comparison to F1's. "There's usually no handover so the first few days are guaranteed to be a shambles as you work out how things are done in the new hospital and new specialty." Saying that, there is an "excitement" at learning new things and meeting new people. And patients should be unaffected: "the nurses and more senior doctors remain the same so it's not the end of the world."
Two years ago, the Daily Mail suggested that the slight rise in hospital deaths could be blamed on novices fending for themselves because senior doctors are likely to be on holiday. "Nonsense", says another junior doctor. Seniors were "less likely" to head to the beach at this critical time, not more.
Surely these youngsters are nervous though? "Something that scares me most is the sound of a cardiac arrest bleep going off. If you're the first person to the scene, you've got to act. It's unlikely and the seniors will be there in seconds but you never know how you'll react until you're put into that position."
And there is the nub of it - if there is a slide in clinical standards next Wednesday, it can be blamed as much on poor supervision as inexperience. When the Imperial College study was released two years ago Patricia Hamilton, the Department of Health's director of medical education, said, "junior doctors are closely supervised by a senior doctor and this ratio is often 1:1." One doctor coming to the end of his first year told me that they were "so supervised nothing could possibly go wrong". Of course, things can, do and always will go wrong, even at the hands of the most experienced doctors; but if you go to hospital next week, don't think your life teeters on the brink in the hands of young bundles of nerves.
So God speed and good luck. Just don't break a leg, that sort of thing really isn't good for you on any day of the year.
This article first appeared in Total Politics on 28th July 2011.