Why is it so hard starting out as a junior doctor?
August is not an easy for the NHS. It’s changeover month for UK junior doctors. That’s around 75,000 highly skilled healthcare professionals, referred to by CEO of one NHS Trust as the “backbone of UK hospitals”. Most move into unfamiliar places of work. Many move into brand new specialties. All move on the same day.
No matter what industry you work in, you can probably imagine the impact this has on the system as a whole. If football is your thing, imagine there was a rule that every midfield player in the Premier League had to move to a new club on a random Saturday in January. Madness, you say? Well, you might be right.
Back in 2009, researchers from Imperial College London studied the outcome of over 300,000 NHS hospital admissions during the preceding few years. They found that patients admitted to hospital with a medical complaint on changeover day were 8% more likely to die than those admitted a week earlier. That’s damning enough, of course. But for every extra recorded death, you can be sure there are many other patients non-fatal forms of harm that don’t make the statistics.
Following that study, some more cynical British press outlets dubbed August “the NHS Killing Season”. Even within the profession, changeover day became known by the decidedly sinister moniker “Black Wednesday”. And while the patients who suffer as a result of this phenomenon are the real victims of this story, it’s not a lot of fun for staff either. The vast majority of medical professionals get into this line of work because they want to care for people. Starting from scratch in a new place throws up a hundred little barriers to doing that. How do I log into the labs system in this new hospital? Who do I ask for an out-of-hours CT scan? What’s the number for the community palliative care team?
But the most difficult professional shoes to fill on Black Wednesday are those of the FY1s. They’re the brand new doctors - Foundation Year 1s - fresh out of med school. Of course, you might think that five plus years at university is plenty of time to prepare for starting work. In reality, though, it’s a bit like learning to drive from the passenger seat. Sure, you pick up a thing or two. But the most important stuff can only be learned by doing.
After the Imperial study back in 2009, a solution was cooked up. There’s a small window of time around July when med students have graduated and got their medical registration, but they haven’t actually started work yet. What if, asked some bright spark, these soon-to-be FY1s spend a bit of that time working alongside their outgoing counterparts? They’ll be registered as proper doctors, so they can get some actual hands-on experience before they fly solo. Plus, if they do this “FY0” period at the same hospital they’re about to start working at, they can orient themselves and pick up some insider insights before the other junior doctors rotate on. Seems like a no brainer, right?
I qualified in 2010, the first year FY0 was being introduced. Unfortunately, some of the details were still being worked out and it turned out our overlap period was going to last just four days. And by the time mandatory corporate training had taken its pound of flesh, four actually meant two. Even so, during those two days of working with my outgoing FY1 colleague - we’ll call her Jane - I learned at least one important lesson. Namely: how much I still had to learn.
We were “post-take” on the first of those days, meaning that we were looking after all the patients admitted to hospital under internal medicine the previous day. One of those patients was an elderly chap who had a urine infection and had become dehydrated: a very common story. He also happened to have a background of heart failure, which meant that he was at risk of fluid building up on his lungs. The usual strategy here is cautious rehydration. Say, a litre of intravenous fluid over 12 hours.
Unfortunately, there was a problem with the fluid administration and this chap ended up getting a litre of saline over just a couple of minutes. If you’ve ever seen someone in acute pulmonary oedema - which is where fluid builds up on the lungs and effectively begins to drown someone from the inside - you can imagine that what happened next was not good.
If this scenario had come up in one of the exam papers in finals, it would have been an easy one. But, faced with an actual human being in acute distress, it turned out I could barely string two thoughts together.
I honestly can’t remember whether I started the initial treatment before calling Jane in a panic, or whether I just called her off the bat. What I do remember is that she was cool as a cucumber when she arrived. She checked we had started all the right treatment, had a chat with the patient and his family, and said she’d call back to see him soon. Outside the room, she told me that although his numbers weren’t great, she was pretty sure he was going to bounce back. I asked how she had come to that conclusion and she said something like, “Oh, you just get a feel for that stuff.”
By the end of my own FY1 year, I understood exactly what Jane meant. Speak to any seasoned doctor or nurse and they’ll describe a sixth sense for patients who are about to “go off”. It starts to develop pretty quickly when you qualify and start to practise in the real world, although it continues to evolve over many years afterwards. It can be really difficult to explain, as sometimes your patient looks terrible on paper but you’re not too worried about them, and sometimes the opposite is true. But it’s also incredibly important. When you’re on call overnight with a list of 20+ patients to see, the ability to judge at a glance who needs urgent attention and prioritise accordingly: that can be literally life and death. Which is one of the reasons that starting out as an FY1 is so scary.
Another major advantage conferred by real–world experience is what I’m going to call “strategic forgetting”. I don’t want to bash medical schools too much here, as they do a great job in many ways. But alongside the useful stuff, you do learn an awful lot of crap. The syllabus tends to be set by senior physicians who have become highly specialised in one area and prone to forget what it’s like to be a very junior doctor. As just one example, in the ophthalmology section of a particular written exam - and I kid you not about this - we were asked to name the wavelength of green light. Funnily enough, that turns out to be of limited use at 3am when you’ve got 15 IV lines to put in, 7 catheters to site, and one of your patients has just started vomiting blood across the room. That particular brain-space is probably better used for something more important, like the key steps on your hospital’s major haemorrhage protocol.
I'm assured by colleagues who did their FY1 year more recently than me that things have improved since. The FY0 period lasts a full 1-2 weeks in most hospitals. A study published in 2021 did not find a significant mortality increase between July and August, though there were some caveats to that result. Ultimately, though, FY1 still represents a steep curve of both experience-driven learning, and unlearning. The only way to acquire the sixth sense about unwell patients, to gain insight into what knowledge should always be at your fingertips versus what can be Googled later, to develop the muscle memory for managing the many and varied emergencies that can occur inside the walls of an acute hospital… it’s to get out there and do it.
However - and it’s a big "however" - that's not to say preparation is futile. These days, there are a ton of great resources you can arm yourself with to help you find your feet. The NICE Clinical Knowledge Summaries are one great example. The Asked To See Patient guides to managing common complaints are another. And, the Resuscitation Council UK Advanced Life Support guidelines when things really start to go wrong.
Here at Eolas, a core part of our mission is to help healthcare professionals hit the ground running whenever they switch to a new clinical setting. We do this by making sure they have everything they need, in one place. To make life a little easier for the 2023 FY1s, we’ve collected links to all of these resources - plus plenty more - and put them all into a “FY1 Survival Guide” inside the Eolas Medical app. It’s completely free to use, and over the next few weeks we’ll be inviting the 2023 outgoing FY1s to take ownership and add their own insights, teaching sessions and links to great resources. I've even recorded an "Arrhythmia Bootcamp" tutorial series to help with those tricky cardiology patients during on-calls. It’s a small contribution in the grand scheme of things, but if it helps just a couple of FY1s and their patients, mission accomplished!
If you know anyone who might benefit from the FY1 Survival Guide, don’t hesitate to share the image below that shows how to get access.
And if you’re about to start FY1 yourself, good luck!