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Vol. 38 No. 3 · 4 February 2016

What a Junior Doctor Does

Lana Spawls

Antidiuretic hormone​ , also known as vasopressin, is released when levels of water in the blood become too low – when you’re dehydrated. It tells the kidneys to reabsorb water back into the bloodstream. For a while this keeps you going: it was working overtime in my system when I found myself ten hours into a Saturday shift at the hospital, without a drink or a break since my breakfast cup of tea at home. It wasn’t a shift crammed with life or death emergencies: I had a clinic in A&E reviewing patients with minor injuries, two ward rounds and a never-ending list of jobs to do. Each time I crossed one off I’d receive a bleep on my pager: another sick patient to review, scans to order, bloods to take, prescriptions and discharge letters to write. At weekends, junior doctors cover care across the whole hospital. I’d been assigned three wards. I managed to make it to the canteen, and a first mouthful of beans, before the familiar jangling started again. I went to the nearest phone to dial in: a prescription of intravenous paracetamol needed changing to oral. I added it to my list and went back to eat. A few more mouthfuls and it went off again. There was no answer when I dialled back: apparently the 15 seconds it took me to reach the phone was too long and the caller had rushed off. I added the number to my list. I’d call them back.

Four days later I’m working my ninth day in a row. On normal weekdays I’m only responsible for the forty or so patients under the care of my usual team. Usually I would split this with another first year foundation (FY1) doctor, but he’s on holiday so it’s down to me. From 4 p.m. until 9 p.m. I’m on call looking after patients from four different surgical teams. About half an hour before I should finish I’m bleeped to examine a patient who has just arrived on the ward and is due to go for surgery the next day: a teenage girl with a brain tumour. Until she has surgery we won’t know if it’s cancerous or benign. She and her mum look nervous. We talk about her older brother who’s just had a baby daughter, her favourite subjects at school (art and drama) and what she wants to do when she grows up (be a dancer). Before surgery she needs blood tests so I go to find a tourniquet, needles, bottles and gauze. It’s a ward that I don’t usually work on, and every ward keeps its equipment in a different place. On top of this, the printer for the blood bottle labels isn’t working. It takes me nearly an hour, including a trip to another ward, to get everything ready. The patient tells me how difficult – and painful – it was the last time someone took her blood. I tell her how important the tests are and how quick I will be, but now I’m getting nervous too. My first attempt is fruitless and she’s not keen to let me try again, but eventually I persuade her. This time I find a better vein, a little deeper but more bouncy, and get it straightaway. She stops crying to tell me it wasn’t actually that bad. When I leave work, nearly two hours late, the lights have been stolen from my bike, which I’d left in front of the hospital, so I cycle home in the dark. At least it’s not raining. I never find out what happened to the girl.

I’m up at 6.30 a.m. the following day. My basic hours on a surgical rotation are 8 a.m. to 4 p.m., though it’s rare for me to finish on time, and there’s a rota for out of hours work – weekends, evenings, night shifts. Depending on the size of the hospital, the team (or teams) for any specialism might comprise a group of consultants, two or three registrars and a few other more junior doctors, looking after between 15 and 50 patients. Because consultants spend a lot of their time in clinics and seeing outpatients, only one is usually responsible for inpatients each month; registrars are often in clinics too, or reviewing patients on other wards or in A&E. The term ‘junior doctor’ encompasses everyone from the newly qualified doctor fresh out of medical school to the registrar one day away from becoming a consultant. Because the training path is so long, and not everyone becomes a consultant, doctors can remain junior for a long time, or for ever. The basic path to consultancy takes around 14 years. The five or six years of a medical degree are followed by two foundation years, during which you take six rotations in different specialties (usually a mixture of medical, surgical, GP and A&E). Most doctors then start a training programme to specialise in a certain area – this can take anything from three years for GP training to more than eight for neurosurgery. Some programmes are ‘run-through’, which means you start straight away, but most require two more years of core training (another four or six placements) before you apply for jobs as a registrar. You can be well into your thirties before becoming a consultant, even later if research breaks and parental leave cause delays. The junior doctor treating you in hospital may have more than ten years’ experience, across the different hospital departments, and it’s this general medical expertise that the government is relying on to enforce its ‘seven days a week’ NHS.

Of course the NHS already operates 24 hours a day, seven days a week. But the hospital day is designed to wind down: patients need to rest and non-essential procedures often aren’t carried out the day they’re ordered. There are always doctors on duty: all hospital doctors work night and weekend shifts, junior doctors in the hospital and consultants on call at home. The night team works from 9 p.m. to 9 a.m. (or 8 p.m. to 8 a.m. in surgery). The doctors’ workload is managed by the nurse practitioner, who screens all the jobs and assigns them based on doctors’ seniority and availability. A night shift can see you dashing from one ward to another across the hospital. If anything serious comes up you can call the medical registrar, but the nurse practitioners are invaluable for a new doctor, struggling to put in a cannula in the middle of the night. Common blood tests are run by lab technicians through the night, but to get a scan or a more unusual blood test often requires a phone call to convince someone (whom you may have woken up at home) that it can’t wait until the morning.

On a normal day, week or weekend, we start with a handover from the night team. We each have a list of the patients under our care. Every patient is seen every day, but the team often splits into smaller groups and runs simultaneous ward rounds; each of these can still take three or four hours. My first patient is J, a 76-year-old man with a bad infection (cellulitis) in his foot. He came in the day before, and has a history of diabetes, ulcers, heart disease. He’s still able to look after himself, but only just: the short daily visit by his carers is no longer enough. I take his notes from the trolley by the nurses’ bay and we look them over. He’s on intravenous antibiotics and fluids as well as his regular medication. Blood forms I left out yesterday were taken by the phlebotomists early this morning but we won’t get the results for another hour or so. The tests will tell us whether the infection is responding to the antibiotics, and we check the observation chart kept by the nurses: his blood pressure is good, oxygen saturation normal, temperature has settled but his heart rate is high. Each observation has a score (zero is normal) which, added together, give an indication of how sick a patient is. J gets a not too worrying two.

But results and notes only tell a small part of the story: we treat the patient, not the results, and diagnosis doesn’t end with the first treatment plan. The antibiotics have started to work – but J is complaining of pain in his chest as well as his feet. He hasn’t seen a physio yet – I’ll have to chase that up – and a diabetes nurse needs to be scheduled to review him too. We’ll have to think about his home care and what antibiotics he’ll need when he comes off the IV. He may need stronger painkillers too. But the first concern is his chest and we need to take more blood and get an ECG to rule out a heart attack. Few patients, especially elderly ones, have only one problem. I quickly note down the jobs that need doing – physio, nurse, prescription, bloods, – and request an ECG, before we move onto the next patient. On a good day there will be three or four of us on the ward round and we can break off to do jobs along the way, but if I’m the only junior doctor I have to finish the ward round before I can do anything else.

The hospital canteen stops serving lunch at 2.30. If my ward round goes on too long I’ll miss it. But most doctors don’t eat there anyway: the sandwiches are better at the branch of Costa in the hospital, or at the Subway over the road, and we take them down to the basement mess to eat. The mess is shared between all the junior doctors (though registrars might eat in one of their communal offices). It’s here I would take a nap if I got the chance on a night shift – though that never happens – and in the daytime it’s where we have a break (that doesn’t happen much either). There are sofas, kitchen stuff, toilets, lockers, a ping-pong table. In the afternoon I work through the jobs accrued during the ward round and anything else that has come up.

Some of my patients are ready to go home but have remained on the ward for weeks, or even months, because the necessary social care isn’t in place for them: rehabilitation or more equipment, a bed in a nursing home. Meanwhile they stay in hospital, at risk of infection and taking up a bed that could be used for someone else. With the hospital always on red alert, with an acute shortage of available beds, there is constant pressure to discharge patients in order to be able to admit new ones. But over the last five years local councils, their budgets slashed by central government, have made billions of pounds of cuts to social care budgets, making it harder for hospitals to discharge people safely. It costs between £200 and £300 per night to keep a patient in a hospital bed, money that would be better spent on helping medically fit patients be cared for at home.

Rotas vary considerably between specialties, but it’s common to work one long day a week (12 to 13 hours) and one weekend in five, as well as weeks of night and twilight shifts. Some rotas give you a day off the following week if you work a weekend, but many expect you to work 12 days in a row. The European Working Time Directive limits the number of hours that junior doctors can work in a week to 48, averaged out over 26 weeks. Doctors, like all workers, are required to have minimum rest periods: 11 hours in every 24, and one period of 24 continuous hours a week (or 48 a fortnight). Under the current contract, the Health and Safety Executive can challenge hospitals with unfair rotas and fine them up to £5000 for each breach. The government initially proposed to remove this provision in the new contract for junior doctors; they have now agreed to penalties for hospitals where doctors work more than 72 hours in a week, but not when that limit is breached by doctors who’ve had to work beyond their contracted hours.

An FY1 doctor earns a basic salary of £22,636 a year (it increases each year). In addition, each rotation is ‘banded’ depending on how many hours you’re scheduled to work each week and how many of them are unsocial – outside 7 a.m. to 7 p.m., Monday to Friday. If, for one four-month rotation, you worked 48 hours a week, most of which were unsocial, you would get a 1A banding, earning you 1.5 times your basic salary. But if in your next rotation you worked only 40 hours per week, none of which was out of hours, you would earn just the basic salary. Under the new contract, it would increase by 11 per cent, but the hours that are considered normal (‘plain’ hours) would also be extended: 7 a.m. to 10 p.m. Monday to Friday and 7 a.m. to 7 p.m. on Saturday. Most doctors would have their banding decreased and their overall pay cut as a result of this change. The government has offered a transitional pay premium to ensure no doctor has a pay cut when the new contract is introduced, but this is time-limited and merely delays the inevitable. The current system of pay increases means that doctors are not financially disadvantaged if they take time out for research or to have children, or if they change their training programme. Under the new contract, pay would correlate to training level, regardless of previous experience. It would also mean a fundamental shift in working patterns, to a system closer to the unsociable and more complicated rotas of A&E. The government has announced no plans to hire more doctors or increase the student intake, so the seven-day NHS will be staffed using only the doctors currently working in hospitals, inevitably lowering the levels of care on weekdays. The proposed locum pay cap will make covering absences even more difficult.

The British Medical Association has been in talks with NHS Employers since October 2013. The talks lasted a year before the Review Body on Doctors’ and Dentists’ Remuneration was asked to investigate and make recommendations on a new contract. It published its final report in July 2015. Its general recommendations included cancelling the supplement for trainee GPs, which would lead to some being paid up to a third less than their hospital counterparts, and removing the clause which allows consultants to opt out of providing non-emergency care at weekends (only 11 out of 20,000 surveyed last year currently did so).

The government returned with a new contract. After polling its members, the BMA decided not to re-enter negotiations. The contract proposed by the government offered doctors a worse deal than the one it had rejected almost nine months earlier. The main points of contention included the extension of plain hours, the tying of pay rises to training level rather than experience, the overall reduction in pay, the removal of penalties for hospitals imposing unsafe working hours and the fact that the government was prepared to force the contract on doctors regardless of whether the BMA agreed to it. David Cameron said last month that junior doctors could not be allowed to ‘block progress in our NHS’. Whose NHS?

The government has done everything it can to make it seem as if its main concern is with reducing weekend mortality rates, but even if that were the issue it isn’t nearly as simple as Jeremy Hunt would have us believe. His claim that 11,000 lives could be saved every year is misleading. The research paper it was based on found that while support services are more limited over the weekend (this includes porters, phlebotomists, radiologists as well as doctors), this was not necessarily the cause of the relative increase in deaths among those admitted over the weekend who died within the next thirty days. For one thing, it’s important to note that patients admitted to hospital at the weekend are sicker than those admitted during the week. It was not possible, the researchers said, to determine ‘the extent to which these excess deaths may be preventable’ and it would be ‘rash and misleading’ to assume they were. One statistic given to the media – that babies delivered at the weekend have a higher mortality rate – is not surprising, given that all the predictably difficult births are scheduled for Caesarean sections during the week. Hunt’s discredited claim that patients were 20 per cent more likely to die if they suffered a stroke at the weekend overshadowed an achievement – the creation of acute stroke units that have greatly improved outcomes on all days – which should be the model for weekend services: improved and well-supported emergency provision.

In November the BMA balloted its members. Turnout was 76 per cent, with 98 per cent in favour of strike action. The three strikes, planned for early December, were delayed when the government agreed to talks mediated by Acas. The government gave some ground – no one would be forced to work two Saturdays in a row, for instance – but wouldn’t backtrack on increased plain hours and pay changes, and so on 12 January junior doctors went on strike for the first time in forty years. I joined the picket line outside my hospital. Only six people are legally allowed to be official picketers but anyone else is welcome to visit, and there were around a hundred people there – mostly doctors but also local pensioners’ groups, other unions’ reps and supporters. The strike started at 8 a.m. and we stood in the freezing cold, talking to the press and passers-by, occasionally singing and chanting, and holding banners: ‘Not safe, not fair’; ‘Tired doctors make mistakes’; ‘Honk if you support junior doctors.’ Passing drivers honked all day. The media reported that 38 per cent of junior doctors went into work, trying to suggest at the same time that the strike wasn’t well supported and that the junior doctors were wilfully negligent. In fact, almost all of the doctors who went to work were scheduled as emergency cover – the same level of cover as on Christmas Day, or the day of the royal wedding in 2011.

Although the second strike has been suspended for more talks to take place, the mood among doctors is pessimistic. The first round of negotiations gave us some hope, but the government has proved belligerent. Why is it so determined to impose this contract? The desire to remove pay progression across the public sector – it has already done so for teachers – is one motive. The UK already spends a smaller proportion of GDP on public healthcare than many countries, although it has a much bigger workforce, and it’s hard not to see this as yet another move towards a part-privatised NHS. If the next government is Tory, I expect we will see a system of insurance plans and charges before I become a consultant.

Back on the ward there isn’t much time to think about the future. A six-year-old who’s just been operated on for appendicitis won’t stop screaming, or let us near her. A boy who came in with constipation is about to go into surgery for a twisted bowel: he’s on a school trip to the UK, and his parents won’t get here before they begin. Doctors come to prep him while I hold his hand. In a few days’ time he’ll be sitting in bed ringing the nurses to bring him hot chocolate and pass the TV remote, but I don’t know that yet.

22 January

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Vol. 38 No. 5 · 3 March 2016

Lana Spawls writes that ‘only six people are legally allowed to be official picketers’ (LRB, 4 February). In fact, there is no legal limit on the number of pickets allowed on a line: the figure of six comes from the Code of Practice for Picketing, issued in 1966. It says that ‘pickets and their organisers should ensure that in general the number of pickets does not exceed six at any entrance to, or exit from, a workplace,’ but there is no limit in law on the number of people who may lawfully picket.

Michael Carley

Vol. 38 No. 4 · 18 February 2016

I congratulate Lana Spawls on finding the time so vividly to portray her daily (and nightly) life as a junior doctor (LRB, 4 February). Fifty years ago, I was a first-year doctor at St Bartholomew’s Hospital. My experience was much the same as hers. The hours were even more ridiculous: on alternate nights we wouldn’t get to the end of our list of tasks until 3 a.m., after which we would be called out of our beds at least once before getting back to the wards at eight. We then worked another 12 hours before our ‘night off’. We rarely sat down to eat until the small hours, when we feasted on cornflakes pilfered from the nurses’ kitchen.

We knew then, as Spawls does now, that we were most of the time too exhausted to be good doctors, and that as a result patients were suffering – sometimes dying – unnecessarily. We felt powerless to change things, conditioned as students to be sycophants, giving ourselves up as burnt offerings to our consultants, the gods whom we aspired to join.

For the last fifty years the NHS has been consistently underfunded. This particular government’s attempt to argue that weekend services can be improved without additional resources is farcical. Its attempt to discredit junior doctors is a cynical and devious excuse to undertake further privatisation. But now there is one big difference. The mass of junior doctors has learned and organised, and for the first time in history they are identifying themselves as workers, rather than gods.

Mike Downham

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