Reasons not to be cheerful

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You might easily have missed the news, published this week, that half of UK doctors finishing foundation training (the first 2 years after qualifying) are not continuing their medical training. It’s a big and troubling statistic, and one that makes government promises of more home-trained doctors look like wishful thinking.

A year ago, during the heat of the junior contract crises, Jeremy Hunt announced an “urgent” review of junior doctors’ morale. It made for good headlines, but nothing has been heard of it since. So, to save the government the trouble and expense, here are ten reasons why doctors are not cheerful.

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  1. Lack of respect

At no point in my medical career have I felt a lack of respect from my patients.

But junior doctors, and NHS staff in general, are aware of a lack of respect from other places. There are the crass comments about the medical profession coming out of the mouth of Jeremy Hunt, and his minions, blaming doctors for a crisis that we did not create. And there are the misleading stories in the media about doctors in the UK. And then there is the forced imposition of a contract we didn’t sign up for.

  1. Lack of support

Sometimes, things go wrong. This happens in any job. And sometimes, it might be your fault. This happens to everyone. It certainly happens to all doctors. And, in medicine, the stakes are high.

In those circumstances, what all of us would hope for would be to identify the mistake, learn from it, apologise, and move on. What you need from those around you is helpful advice about how to avoid similar mistakes in the future, and reassurance that you are still good at your job.

Without support, mistakes can fester, confidence can be lost, and it is difficult to move on.

  1. Lack of a team mentality

Being a junior doctor can feel quite isolating. Every one of us has experienced that panicky moment when a patient deteriorates in front of you, and you don’t know what to do. The good news is that you’re always one of a team, and there are always others to help.

Team mentality is what gets you through that night shift from hell, that endless ward round, or that lengthy operation. You are in it together. You don’t want to let your colleagues and friends down, and they don’t want to let you down.

The increase in shift-working means that we are increasingly working with people we don’t know. We get less support from them, and we offer them less support in return. It’s a lose-lose situation.

  1. Lack of a team

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Even if you can hang on to the team mentality, it’s not much help if you’re missing your team. Understaffing has been a big issue for junior doctors for years (and has even developed its own twitter hashtag, #mindtherotagap).

We’re used to teams shrinking, working alongside “unfilled posts”, working overtime to cover our imaginary colleagues.  We’re used to receiving last-minute emails and phone calls asking us to fill weekend or night shifts because colleagues are ill and there is no slack in the system. We’re used to our employers making minimal efforts to fill these holes, because it’s cheaper for them if the skeleton crew just suck it up.

  1. Lack of a safety net

In the aviation industry, like in medicine, small mistakes can be very costly. Pilots work within a very comprehensive safety net of checklists and controls.

Medicine ought to work in this way too. A patient coming into an emergency department will be triaged and assessed by a nurse, then a junior doctor, then perhaps a more senior doctor, before a consultant makes a final management plan. If they are admitted they will be assessed by a ward nurse who will carry out regular observations, and a pharmacist will screen their medication. This should all happen with 24 hours. If one person makes an error, there should be multiple opportunities for this to be corrected.

But what if this safety net isn’t there? What if other members of the team are missing, and steps have to be skipped? If something goes wrong, it’s hard to accuse the empty posts, the colleagues who didn’t show up, the managers who didn’t fill the rota gaps, or the people who designed an inadequate system in the first place.

The finger of blame points squarely at the people who did see the patient, and who were trying to do their job under difficult circumstances. Working without a safety net is nerve-wracking.

  1. Lack of sensible assessments

If you try to define a good doctor, you’ll probably focus on their interactions with patients. And looking after patients can be a very full time job.

But quite apart from patient care, a junior doctor is meant to be jumping through a number of hoops. They are expected to compile a portfolio of their experience, complete numerous on-the-job assessments, collect proof that they are competent to perform many procedures and document their “reflections” on meaningful events.

In addition to this extensive portfolio, they also have to complete a number of professional exams, for which they study in their own time, and for which they pay exorbitant fees out of their own pocket.

And every few years, for no obvious reason, the hoops are shifted and the rules are changed. It doesn’t make us happy. Doctors need to be assessed. But there must be a better way than this.

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  1. Lack of control

In the past, a junior doctor finishing their first year after qualifying had choices. Some might apply straight for a training program, and head off into the sunset in their chosen specialty. Some might not be sure which specialty they wanted to pursue, and they could apply for stand-alone posts in various specialties until they made up their minds. For some, particularly those with families, geography might be more important than specialty – they could apply for any job they liked that was local. There was no time limit on training.

A decade ago, medical training in the UK was dramatically changed. Doctors are now forced to choose a specialty just two years after qualifying. Many programs have national applications, meaning a London trainee with a family might apply for neurosurgery, be accepted, but be sent to Cardiff or Leeds to train. It’s not surprising that he or she might decide to take a break from their career instead.

  1. Lack of money

You don’t see doctors begging on street corners, and no-one would claim that they aren’t paid enough to get by. But the cost of studying to be a doctor is shooting upwards, leaving many junior doctors with massive debts before they have wielded a stethoscope in anger.

NHS salaries are lower than those paid in the private sector, pay-rises are slower, and working conditions are often worse. It’s easy to look at your peers, who work predictable hours in shiny offices, who never work on weekends or nights, who aren’t likely to be dispatched to work hours away from friends and family, and wonder why they are earning more than you are.

The freeze on NHS salaries (a real terms pay-cut) while private sector pay rises, and the increase in tuition fees, make that equation more and more lopsided. It’s not surprising that some people are pulling the rip-cord and bailing out.

  1. Lack of long-term vision

Medical training is a marathon, not a sprint. GCSEs and A-Levels. Five or six years at medical school. Two years as a foundation trainee. Seven or eight years as a specialist trainee. Give or take a PhD.

It’s a long-haul. As tough working conditions at the bottom of the pyramid take their toll, it’s not easy to see the end of the long road ahead. And, as working conditions from the top to the bottom deteriorate, it’s not clear whether running this marathon is worth it.

  1. Lack of optimism

It’s hard to find happy people in the NHS at the moment. As waiting times spiral and targets are missed, while the Government demands more and more for less, not many people are optimistic about the future. It’s not only junior doctors – everyone is feeling squeezed.

You’ve spent years studying hard in medical school, paying for the privilege, and when you arrive at your destination everyone is miserable. When your role models are muttering about leaving medicine themselves, what are you going to do?

DISCLAIMER: It’s not all doom and gloom. If you are depressed by reading this post, for balance please also read Abrainia’s earlier post “Reasons to be cheerful”.

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