12 September 2009

Even learners can see the problem

One of Dr Grumble's sons, Edward, is now a Foundation doctor. The system prefers to call them 'trainees'. From the start doctors are made to feel small in today's NHS. You can't help but think this is deliberate. But it is not good management. You should make your staff feel important. And you should persuade your patients that your junior doctors are important and able. Patients need to feel confident in the people looking after them. They don't need to see the L plates.

Before Dr Grumble refers a patient to a colleague he tries to build them up. He tells the patient that they are going to see a real expert. It's good to build up trust and confidence. When doctors were in charge we knew this. Our junior doctors were called House Physicians, House Surgeons, Senior House Officers, Registrars and Senior Registrars. GPs made the mistake at one stage of calling their junior doctors 'trainees'. It did not engender confidence. The fresh-faced young doctor does not have his confidence bolstered by being reminded of his lack of knowledge and it is not such a good idea to emphasise it to the patient either. It is much better to introduce yourself as a Senior House Officer than a Foundation Trainee. Not that that is allowed any more. In fact it has been expressly forbidden.

In any case we are all learning all of the time. Dr Grumble's staff might think he knows almost everything but he doesn't. We are all trainees. None of us knows everything. The differences between the junior and senior doctor are just differences of degree. The important thing for both is to know when you don't know and when to ask somebody else. The weak doctors are those who cannot recognise when something is beyond them.

Strangely the management know the importance of building people up. Look at your hospital's news letters. You will find the management are forever bolstering their own images with columns in their propaganda sheets with titles like Talk from the Top or Head Honcho Headsup (OK that one was made up). They know the importance of making themselves seem important. So why don't they realise that the same is important for their staff - especially clinical staff who interact with the public?

None of that was the purpose of this post. Dr Grumble went straight off on one of his tangents. The point of this post was to tell you that Edward Grumble has been on the phone to Mrs Grumble expressing his concerns about continuity of care. He has only just qualified and already he realises that patients are so complex you cannot easily pass on everything that needs to be known about them to the next jobbing shift worker. It is another one of those things that managers cannot grasp. They think hospital shift workers are just like factory workers. If they had their way they would be.

The problems, as we all know, have stemmed from shift working forced on the profession by various initiatives including the European Working Time Directive. Remedy is concerned. Junior doctors, some on paltry pay, are not being paid for all the work that they do. Yet there are ways around this pdf . We really do need to address these issues. It is not just about doctors. It is about patient safety pdf.


Anonymous said...

Puffing up junior doctors' egos may be good for collegial relations. However patients deserve to be made aware of the limitations of their doctors' knowledge and experience.

Everybody starts out somewhere so why cover up inexperience with fancy-sounding titles? Honesty from doctors is the best way to engender patient trust and confidence.

the a&e charge nurse said...

Anon (13:38) - nurses are not called trainees after they qualify, why should doctors?

Incidentally, inexperience is not covered up with 'fancy sounding titles', it is covered by the registrar or the consultant, or dare I say, one or two of the more experienced nurses - they used to call this sort of stuff team work?

Dr Grumble said...

Perhaps, anonymous, that is the thinking behind the changes. It is the obvious alternative point of view. Our masters are clearly of the view that everybody should be seen by the top doctor but if they speed up the process to create top doctors that too is a charade.

If the patient says to you that you look too young to be a doctor, it is clear that they know already that you do not have a wealth of experience so giving both parties a bit of confidence with a job name that does not include the word trainee does not seem to me to be unreasonable. After all we are talking about people with 5 or 6 years at medical school behind them who are well able to perform at an appropriate level competently. And the word trainee may go on being used very much longer than that. In other walks of life the people concerned would be in charge.

You could argue otherwise. You could say that when your pilot is landing a plane full of passengers for the first time everybody has a right to know though I doubt they usually do.

Some people think that the demeaning titles, and they are demeaning, are deliberate and nothing to do with being honest with patients. For example, some young doctors have been prevented from calling themselves Dr on their name badges. Now what do you think that is all about?

Nurse Anne said...

Junior doctors are the best. They are the most "with it". Maybe all the knowledge and experience isn't 100% of the way there yet. But they know how to think and they are well grounded on earth. The consultants do not even know how to prescribe imodium during the few occasions when they are down on this planet.

Nurse Anne said...

Charge nurse makes a could point.

Once I got my degree and then took and passed board exams a few months I had the initials RN behind my name and was able to call myself "Nurse".

Sam said...

Do graduate lawyers, engineers, architects, economists, bankers ... etc .. are called trainees on graduation? .. and, they all spend between 2-3 years at uni!

I think the term 'junior doctor' which was once used in an affable to describe what used to be a strong relationship between a senior doctor and his/apprentice has now become a way to abuse fully qualified and highly acclaimed professional young' doctors .. you only need to look at how they are expected to go against their code of ethics and lie about the 'real' number of hours they work because of the EWTD .. and work upto 50% more hours for free too to confirm this!

It seems that the crazy notion now is to make believe that

Junior = Kid

And that has to change because it it continues, then say goodbye to loyalty ... and what that means to patient care!

Respect when respect is due if you want the same back .. and that means reward to suit endeavour too!

Sam said...

I meant 2-3 years less at uni ... pardon me :-)

No One said...

I will tell you something about "factory workers"

In a factory continuity counts too

In one of the biggest most complex manufacturing sites there are essential 3 similar sets of machines (I will dumb this down for doctors), three similar immensely large and complex sets of machines.

Each shift is split into 3 and each of those 3 has a machine each (superset of a lot of smaller machines). With me so far?

There are many interesting phenomenon. One is that the team running the machine is much more directly relevant to the quantity and quality of production than the state of their machine. I have seen machines with many worn and almost broken parts kept running sweetly by one of the best teams. The opposite extreme of course is that a perfect machine with a poor team tends to produce poor results. You can observe the 3 machines running side by side and their relative success (a bit of competition between the 3 teams helps).

Another point of note to you is that teams often get to develop a preference for "their" machine, and a team which knows the particular quirks of one of the machines will tend to be able to keep production running much more sweetly. Lots of little seemingly unimportant bits of knowledge about how and when parts of the machine have been repaired can often be used to keep production running smoothly even when faced with lots of component failures.

So in essence you as usual are assuming docs are some superior animal. I can tell you for free continuity counts in factories too, a team that knows each other and knows "their" machine inside out will always produce the best results.

Hope this helps you understand the real world etc. Good factories do not randomly assign staff.

Dr Grumble said...

One is that the team running the machine is much more directly relevant to the quantity and quality of production than the state of their machine. I have seen machines with many worn and almost broken parts kept running sweetly by one of the best teams.
***** ******
There are very clear parallels with teams that look after patients. A good team can make up for a poor infrastructure. The staff and how they work together are much more important than the hospital.

The importance of the team is one of the reasons that some of us are so dismayed that we now have to work in teams of people that are constantly changing. You need to have the same people in a team for a reasonable period of time for it to work well.

And, Nurse Anne, you are of course right. Junior doctors do the job they are supposed to do better than consultants. That's another thing managers don't always grasp.

Anonymous said...

From a patient's point of view, I've found that junior doctors who are still brushing up on their consulting skills spend longer taking a history and listen better than their consultant colleagues. Often these juniors pick up on important details that their 'seen-it-all-before' consultant colleagues overlook.

I don't see what the embarrassment factor is over being called a 'trainee specialist' or 'trainee GP' as in effect that is what the junior doctor still is.

Out of interest, why are doctors so concerned with status, hierarchy and ego?

Whether it's doctors vs. nurses or specialists vs. GPs or Juniors vs. Seniors or clinicians vs. managers. Ego, status and hierarchy seem to be prevalent themes among NHS doctors' posts.

Don't you get enough satisfaction from just doing your jobs?

Betty M said...

Other than knowing consultants are the top of the tree most patients couldn't tell you how many year's experience a SHO would have - calling them junior at least indicaes something.

Lawyers don't have a problem calling the eqivalent of a house officer (3 years degree, plus 1 or or 2 year's law school depending on the degree) a trainee so I'm not sure why Drs should be quite so precious.

Sam said...

"Out of interest, why are doctors so concerned with status, hierarchy and ego?"

You make them sound arrogant by mixing those three consepts up in this particular way, and that's not fair! Anyone, in any walk of life, in any profession aspires to higher their status if they are moderately ambitious and that's how hierarchy forms .. anywhere .. and it's a good thing too, for the individual .. and the establishment.

"Don't you get enough satisfaction from just doing your jobs?"

What, regardless of unreasonable working conditions?!.. that's a bit intimidating! Would you?

Cockroach Catcher said...

The Cockroach Catcher

Cockroach Catcher said...


One old lady pressed the bell and asked after being examined by a teenage looking bright young doctor: Nurse, can I see a real doctor now.

There was a time when consultants wear a bow tie and no white coat.
Scrubs changed all of that although in the States they used colour to distinguish doctors from other staff.

I have a suspicion that the current dress code is more than just MRSA.

Perhaps doctors should pay for what they do in order to get the respect or be like Mayor Bloomberg, be paid $1.

The Cockroach Catcher

Anonymous said...

They have dispersed with the use of SHO and are now using Foundation or F1, my new Doctor recently was referred to as an F1 which tells me she’d just graduated in July when I looked at the GMC website – despite her newly qualified status she was lovely! So what’s an F2? I’m confused?

Dr Grumble said...

As you say, Alison, these things don't help the patients if they don't know what they mean. And quite a few of the medical staff haven't yet grasped all the new titles.

As you have clearly discovered the Foundation Trainees have already become abbreviated to F1 and F2. It used to be that you had a pre-registration year when you worked under supervision and then at the end of your first year you became fully registered. Now there are two years. Foundation Year 1 (hence F1) and Foundation Year 2 (hence F2) but, curiously, you still get fully registered after year 1.

There are some good features to the subsequent nomenclature (which gets more complicated) in that it is possible to determine just how senior any individual doctor is. This is not of very much use to patients but it is quite useful to other doctors especially now we so often have to work with people we do not know.

There is talk above about hierarchies. The reality is that medicine is more difficult than some are prepared to believe and just how much mileage you have is part of what determines how competent you are likely to be. It's not just about seniority or hierarchy it is about what sort of doctor you are. I am quite prepared and do take advice from more senior 'junior' doctors in another specialty.

Despite the comments above I still don't think it very helpful to patients or doctors to refer to fully registered doctors who may have entered medical school well over ten years ago as trainees. The term junior doctor which has been around for much longer is little better. In the old days when training was longer 'junior doctor' could refer to highly trained and experienced doctors of up to around 40 years of age.

As I pointed out it was never my intention to go down this route. The point about calling so many of our doctors trainees just slipped out. I don't feel that strongly about it and it is interesting to see how many comments the post has spawned. I can't help but wonder why.

Anonymous said...

When the system was working properly, the houseman - and yes, he should be allowed to call himself "Dr", he has bloody well earned it - was by far and away the most important member off the team. Far more important than the consultant. The houseman was the continuity expert; the co-ordinator; the only member of the team who know where all the patients were, the only member of the team who had personally seen, talked to and examined every patient that had been admitted by the firm for which he worked. He was the one who had all the facts at hand. When the consultant came round, and wanted to know the results of the CXR and the most recent potassium, the houseman knew.

Of course the houseman was inexperienced but, because he was highly intelligent and because he had had a firm grounding in medical sciences (did you weep when you read Stephen Brearly's recent letter?), he learned exponentially and at a speed that no "intermediate practitioner" could achieve. He was also, by and large, support by the team of experienced nurses who of course had far more knowledge than he of day to day ward management of in patients.

Calling these young men and women "trainees" (and I agree with you about the mistake of GP trainees) serves only to humiliate them. A newly qualified young solicitor at Freshfields is called a solicitor, he is trusted and valued and he is paid twice what a junior hospital doctor is paid.

It is all so sad. Is it any wonder that a significant number of newly qualified doctors are leaving the country or even leaving the profession?


Anonymous said...

Did you mean learners?

Dr Grumble said...

Thanks anonymous. I did. Will rectify that bad typo.

Dr Aust said...

...and of course then there are all the staff grades (...as was? ...or still are?).

Apropos of which, we were told some time back that Mrs Dr Aust's title would be changing from "clinical assistant" to "specialty doctor", but apparently this is all still on hold as there is an argument over some aspects of the new deal.

In the meantime we should probably be relieved that at least she can still call herself "doctor".

I can see Dr G's point about "trainee" being a bit undermining, but I think one has to accept that from the patients' POV the old medical hierarchy was very confusing. Despite teaching medical students and working with various clinician scientists I never could grasp the set-up until I actually started dating a doctor.

One can't help thinking that some variant on "junior doctor", "middle grade doctor" and "senior doctor" (perhaps with word "specialist" / "specialty" inserted in there somewhere) might offer a workable compromise.

Re. Mrs Dr Aust's job, I guess on the whole we prefer "specialty doctor" rather than the others, as it is a bit more descriptive of what she is/does.

Anonymous said...

Dr John Crippen said:
A newly qualified young solicitor at Freshfields is called a solicitor, he is trusted and valued and he is paid twice what a junior hospital doctor is paid.

Poor old Crippen just can't resist comparing apples and oranges when comparing pay in the legal and
medical professions. The vast majority of bright law graduates work in small practices in the provinces, not for large international firms in the City of London like Freshfields.


It is all so sad. Is it any wonder that a significant number of newly qualified doctors are leaving the country or even leaving the profession?

Well, according to an anonymous poster elsewhere, German doctors are flocking to the UK, so it can't be that bad, can it? And what other professions are doctors going to? Life sciences, perhaps?

Dr Aust said...

Anon 20.24 (or was that no-one?)

I've never seen a single (UK) medically-qualified person in life sciences - the dismal wages are a complete no-no. I would guess a considerable number of junior doctors leaving the profession will be going - as trainees - into law, management, or (management) consultancy.

Re. the German doctors, our impression was that the junior ones are now mostly heading back to Germany having despaired of the UK training system, plus feeling that the UK is pretty much stuffed in general. Back in Mrs Dr Aust's younger days, some dozen yrs ago, German medical graduates often came to Britain to train because the reputation of the early years UK clinical training (House Officer and SHO yrs in the old system) was extremely high, plus you got a lot of patient exposure (and experience) very quickly. But I wonder whether the same is true now, as all these things might be argued to have changed drastically.

I rather suspect any talk about "German doctors flocking to the UK" would relate to newly-minted consultants or salaried GPs, that is, people who have completed training and are looking for their first "permanent" post. But even so, whether such folk will really stay in the UK long-term is a moot point. Even if German medical salaries are sometimes less than in the UK, the cost of living there is so much less that the standard of living is typically higher.

Anonymous said...

Dr John Crippen said:
A newly qualified young solicitor at Freshfields is called a solicitor, he is trusted and valued and he is paid twice what a junior hospital doctor is paid.

My London solicitor mates were called 'trainee solicitors' until they finished their training contracts.

They earned their money by getting to work at 8am and staying at work until 2 in the morning.

A said...

"(did you weep when you read Stephen Brearly's recent letter?)"

I have just read it, and I agree 100%...I am an FY2!

Dr Grumble said...

Is this the letter you mean A?