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The Last Junior Doctor

Posted by Dr No on 11 December 2015

frankly.jpgAs the post nuclear option Heremy Junt/BMA contract row rumbles on behind the scenes – the top hit on google news today for junior doctor contract is a three day old blog post on Conservative Home by a psychiatrist sorely in need of Photoshop if ever there was one, and the BMA’s ‘latest update’ is weeks old, a thoughtful post by JT reminds us that the opposing comedy duo of Junt and the BMA Junta are not the only threats to junior doctors. The SPECTRE known for the time being as NICE, the National Institute for Clinician Evisceration, has produced yet more guidelines on statins. Commendably dense with the rhetoric of patient choice, the general thrust is nonetheless on upping the uptake. JT’s gripe is three fold. The first is that clinical guidelines, statistical tools, algorithms, call them what you will, become wet paper bags when they attempt to contain the complexity of real life. The second is that guidelines alongside variations of payment by result tends to get, well, results, ie more people on statins, without care for whether they want them or need them. The third, touched on more briefly, but just as important, is that, up against the hour glass of surgery time, thoughtful deliberation never stood a chance. It is the dead duck floating feet defiantly up, but head drowned in the time-hoopered barrel of clinical complexity.

The first comment to JT’s post is a feisty essay by a proper PhD doctor, a spirited woman with many arrows in her quiver. Blasting off with an Apprentice-speak/NHS-speak hybrid – “Informed shared decision making restored my dignity, increased my autonomy, empowered choice and prepared me for change” – well, that’s alright then, all rockets fuelled and ready to fly, the comment quickly becomes a wild-card polemic against a hapless JT, and in so doing a classic case of an author saying more about herself than her target. JT’s post was a lament for the near impossibility of achieving shared decision making in today’s time constrained, guideline driven and target incentivised general practice, however laudable the aim. Not only is this bad for the patient, but it also harms the doctor, who is reduced to being a cogwheel in the patient’s pathway, the rubber stamper of state sponsored prescription protocols, the statinator.

A few months back, Dr No had the pleasure of meeting a statinator. The doctor, a pleasant young man fresh from completing his GP training, was an expert in putting round pegs in round holes, and square blocks in square holes. Oval pegs were rounded off, and triangular sticks were squared off, but at a cost: at each rounding and squaring off, data, important clinical information, was lost, and with that loss, the doctor’s ability to doctor was lowered. When the best tool in your box is the pathway protocol – and boy did this GP have pathways and protocols – then all patients becomes circles and squares, to be plugged into their matching holes. Instead of doctoring, the doctor works like an old time telephone operator, plugging patients into pathway sockets. You don’t need years at medical school followed by years of junior doctor training to plug plugs into sockets. Perhaps the last junior doctor has already finished her – increasingly it is her – training, and in her place we now have junior operatives, doing operator training.

Worse still, it seems that today’s junior doctors early in their training have seen the future, and are increasingly deciding that further training – ie continuing as a junior doctor - is not for them. Every year for the last few years junior doctors ending their first two years (Foundation years) of training after qualifying are given the option – on pain of not getting signed off if they don’t take up the option, which does wonders for the response rate – of completing a career destination survey. Four years ago, in August 2011, almost three quarters (71.3%) said they were progressing directly in some shape or form into specialty training. Every year since, that proportion has dropped, until this August (2015), when it only just over half (52%). That’s a staggering one third fall in just four short years. The main gainers from those who turned their backs on specialty training are service posts (mostly get-rich-quick never mind the training locum posts) – up from 2.3% in 2011 to 9.2% in 2015 and what we may conveniently call FU doctors – ‘Not practising medicine – career break’, up from 4.6% in 2011 to 13.1% - that’s over one in eight - this year. The survey failed to collect data on why the FU doctors wanted out; instead it dryly notes that a ‘targeted study would be required’ to find out WTF made these doctors become FU doctors.

Nor should the implications of a ‘career break’ be underestimated. Like livestock escaped from an impoverished field into brighter meadows, many career escapees will find that the grass really is greener on the other side of the fence, and returning to medicine will lose its appeal. Those who do decide to return will find Absolutely Stilton will absolutely put huge obstacles in their way once the break runs to more than a few months. What Stilton and his goons charmingly call ‘skills fade’, and even more charmingly ‘skills decay’, sets in, and the more junior the doctor, who has by nature paid less into his or her professional skills bank, the faster the lights go out. No firm current GMC rules exist, at least that Dr No has been able to find, but he suspects that once the career breaks goes over six to twelve months (the National Clinical Assessment Service defines a significant period of absence as ‘usually over six months’), career break doctors will increasing be seen as sunset doctors, doomed like sunset software to end their days unloved and unsupported by those who helped bring them into existence.

If these rates of decline in junior doctors going into specialty training (which here includes general practice training) continue, in a few short years there won’t be many junior doctors entering specialty training, let alone completing it. The day of the last junior doctor, at least as we know him or her today, may be nearer than we think: and where will we be then?


its great to see this article on web.

Of the perils which await those young fresh faced junior doctors ...... When they are forced to confront our NHS. I am hoping & hoping my daughter won't go into medicine ! I'd much prefer her to be a banker or lawyer = they are paid properly and the general public never gets the opportunity to routinely abuse them !!
Junior doctors - think again !! The Government just wants to privatise your skills !!! Good Luck

Better a career break than a nervous breakdown I say .

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I think the medical system should provide many improvement resources to the juniors. I wouldn't study a domain where there are very little opportunities, either.

Just to ask - have our Junior docs now given in to Hunt ??
I.e. No strike - they just accept the contract ??
Does anybody know what the current situation is please ??

I'm a new medical student and i really liked the way as you've explained al aspects..
I just loved it
Here's my research about the same, please have a look on that.

The junior doctors should be supported so as to grow in their carrer

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