Dear Sir
Over the years the hospital working system has changed from the traditional firm-based apprenticeship system to working in changing teams, new multidisciplinary roles, and increased emphasis on clinical governance. There was concern about trainee learning and patient safety, linked to long working hours, hence contributing to the introduction of the European Working Time Directive (EWTD) and the hours of work being reduced to an average 48 hours a week. It is perceived by senior doctors that junior doctors, especially FY1s, are seeing fewer acute admissions when on-call, even during the day, compared to their pre-EWTD predecessors.
Alas, EWTD is often blamed as to why FY1s maybe clerking fewer patients when on-call, however a study performed at a large London Teaching hospital found that the introduction of reduced hours was not the only reason why the opportunity to clerk ill patients had declined.
The FY1s understand the importance of seeing acutely ill patients to help develop their clinical skills and they want to be on-call, but there seems to be few opportunities to be on-call and even when on-call FY1s seem to have few opportunities to clerk acute patients. Several factors combine to reduce the likelihood of the FY1 being first to assess an acutely ill patient, especially the increasing number of posts with no on-calls. The need to assess rapidly to avoid breaching A&E 4-hour targets, and an increasing focus on patient safety have led to more senior doctors being the first contact in acute patient care. More senior trainees may not trust an FY1 to see sicker patients, either because they do not work together regularly, or because with fewer previous opportunities to do so, the FY1s have less confidence or ability.
It is important to emphasize that the FY1 year is a learning year, but concerning that the FY1s feel that they have ‘to ask permission’ to clerk cases, suggesting that FY1s see themselves more as a learner than part of the team – more akin to medical students.
Finally, FY1s value being on-call as this leads to managing acutely ill patients and helps them to gain confidence. However, rota constraints, changing on-call team composition, a reduced sense of acute medicine as “their role”, and the introduction of posts without acute components, combine to reduce FY1s’ opportunities to experience acute medicine.
Shital Amin, Kings College London, London, UK. E-Mail: [email protected]
Jonathan Cartledge, University College London (UCL), London, UK