A Chocolate Bar A Day Keeps Your Hypo At Bay

This is not a joke nor an advertising slogan extolling the virtues of a new chocolate bar. It is in fact one of the Top Tips given to new junior doctors about to take the first steps in their chosen profession.

It appears in the Scottish Medical Careers Handbook published in 2009 by NHS Education for Scotland and still available on the internet. The Handbook offers Top Tips to new Foundation Year 1 doctors, recently graduated from medical school and now in their first job. Some advice is reassuring and practical, such as not to “try to do more than you can. Know your limitations. Any problems/questions – ASK. It’s safer to ask before making a decision if you are unsure. That way, next time you will know what to do.”

Other Tips relate to teamwork and the need to maintain good relationships with the nurses – “if you annoy them, they can make your life exceptionally more stressful” – and other colleagues – “don’t slate other colleagues; you don’t know what will be being said about your skills as a doctor!”

FY1s are also advised to tap into the experience of more senior doctors and to “always show respect even if they may not be the most friendly/approachable/understanding. They have years of experience and you can learn a lot from them if you are willing to listen.”

So far so good, practical advice offering new junior doctors insights into the medical professional world and how they should cope with its challenges. However, the Top Tips also presented a harsher view of this world, based on the realities of working long hours and under intense pressures.

New junior doctors are advised to “be prepared to be exhausted for your first month working. You will work, eat (little) and sleep. That’s it. Your body will eventually switch up a gear and you will be able to cope with long hours on your feet. It’s exhausting at first, but you’ll get used to it.”

Also, “you will not always get away on time/get lunch/dinner – be prepared for dehydration and hunger. Keep a bottle of water/bar of food nearby so you can avoid your own hypo when dealing with a patient’s!”  

If junior doctors were discouraged by these truths, they shouldn’t be – “Remember this is only for one year! You will often feel maltreated, unjustly accused, everyone’s dogsbody. The year flies by though, and soon you will have your own FY1 to boss around. But be kind – remember how you felt as a FY1 and be considerate to the new docs.”

Here was the NHS predicting that new junior doctors would become exhausted by the working conditions it was responsible for and that they would be too busy to have a proper break to eat lunch or dinner. Far from living up to its duty of care towards its employees, the NHS trivialised the exhaustion and lack of sleep junior doctors would suffer from and then offered only ineffectual solutions. It is too easy to over-react to the use of the word “dogsbody” when referring to FY1s. I don’t believe the NHS meant it literally. However, after reading the Top Tips, it is difficult to argue against the NHS displaying a disrespectful attitude towards the youngest and most inexperienced members of the medical profession. I have no doubt that the FY1s behaved more professionally in their work than the NHS has done in producing and publishing this Handbook.

I was very angry when I first read the Handbook and the Top Tips several months after my daughter Lauren died on 17^th September 2011, after only 7 weeks as an FY1 doctor. I resolved to find out more about the working conditions of junior doctors, the hours they worked and the effect they have on them and their patients.

I discovered that large numbers of junior doctors have been routinely working beyond their rostered hours, that they work under intense pressures and are left feeling short of sleep. As a result, too many junior doctors suffer from chronic fatigue from working long hours over extended numbers of days and under great intensity. Of particular interest was the experience of FY1s as this was Lauren’s level. Many of her Lauren’s friends who had graduated with her had similar experiences – a cycle of work, eat and sleep, with little time or energy for anything else. It was clear that Lauren’s experiences were not unique but were common among her peer group.

When I met Alex Salmond, First Minister of Scotland, in January 2014, I presented evidence contained in previous years’ GMC surveys of junior doctors which showed that FY1s in Scotland fared less well than the general population of junior doctors. A greater percentage worked beyond their rostered hours on a daily and weekly basis and felt short of sleep when at work as a result. Although ten per cent of all junior doctors reported that they had been asked or felt pressured to submit a record of hours worked which were compliant with the Working Time Directive when their actual hours were NOT compliant, twice as many FY1s stated they had come under such pressure to falsify the hours they worked.

In summary, a significant majority of FY1s in Scotland were working in excess of their rostered hours, and a significant minority of FY1s were being pressured to submit an incorrect record of hours they actually worked.  

It is curious that the questions regarding WTD compliance did not appear in the 2013 survey nor in subsequent years. Does the GMC believe that if they no longer ask a question which produces embarrassing answers then the problem disappears? Junior doctors have provided ample evidence to the contrary and have documented a number of techniques the NHS has used to ensure compliance, including the refusal to sign-off non-compliant but accurate submissions and threats to career progression if non-compliant returns are submitted.

The problems caused by junior doctors in the early stages of their careers working under intense pressure for too many hours has not gone away.  According to the 2018 GMC Survey, a larger proportion of doctors at the end of their Foundation Years training reported feeling burnt out. The Survey noted that this proportion then gradually decreases as junior doctors pass through specialist training. Similarly, a larger proportion of doctors in foundation training find their work emotionally exhausting, which decreases as specialist training progresses.

In response, many junior doctors decide to take a training break after completing their two Foundation Years training, for example to undertake further study, to continue to work as a junior doctor while assessing career direction, or to work abroad. One of the most common themes for doing so comes under the heading of health and wellbeing. Taking a break to prevent or to recover from burnout is the fastest rising reason within this broad heading. Others cite the need to get control over their lives and to achieve a different work life balance. In the words of one junior doctor to the GMC, “We’re undervalued and treated badly. I think people just want a break from that.” That view has become more prevalent as increasing numbers of junior doctors taking a training break after FY2 testifies.

Some junior doctors are voting with their feet after completing their two Foundation Years training. In the 2018 survey, more than 1 in 20 (5.2%) thought of leaving the profession completely. Many have translated this thought into action. The GMC analysis shows that of the doctors who completed the Foundation Programme in 2012, 7% did not return to UK training within five years.

It is surely a matter of great concern to the NHS, the medical profession, and the general public that the newest doctor recruits, the least experienced members of the medical profession, are particularly adversely impacted by the working conditions they face when entering the profession and the years which follow. Also, that so many are so exhausted at the end of their first two years that they have to take a break to recover. Of further concern is the numbers who never return to medicine, who after two years are disillusioned and have lost their enthusiasm for the profession they studied and worked so hard to enter.

We cannot allow so much talent to be lost to the NHS. We need to ensure that junior doctors are properly supported, not with the offensive and frivolous Top Tips of the Handbook, but with substantive measures which will improve their working lives and ensure that they can deliver to the best of their abilities the health care we all want to receive without them being exhausted and burnt-out.

One of these measures is to significantly reduce the hours which junior doctors are required to work. This has been the central element of my campaign for the past 7 years. I ask you to support it by writing to your political representatives in the Westminster and Scottish Parliaments and Welsh and Northern Irish Assemblies. Please use the template letter I have provided in an earlier post.

Junior doctors deserve better than to be told to “keep a bottle of water/bar of food nearby so you can avoid your own hypo when dealing with a patient’s!” We must not reward their commitment and dedication with exhaustion and burnout and disillusionment. We must take better care of those who work so hard to take care of us. Well rested doctors deliver safer care for patients!