CONTENTS

ABOUT THE BOOK

Doctors are the people we turn to when we fall ill. They are the people we trust with our lives, and with the lives of those we love. Yet who can doctors turn to at moments of stress, or when their own working lives break down?

What does it take to confront death, disease, distress and suffering every day? To work in a healthcare system that is stretched to breaking point? To carry the awesome responsibility of making decisions that can irrevocably change someone’s life – or possibly end it? And how do doctors cope with their own questions and fears, when they are expected to have all the answers?

Caroline Elton is a psychologist who specialises in helping doctors. For over twenty years she has listened as doctors have unburdened themselves of the pressures of their jobs: the obstetrician whose own fertility treatment failed; the trainee oncologist who found herself unable to treat patients suffering from the disease that killed her father; the brilliant neurosurgeon struggling to progress her career in an environment that was hostile to women. Drawing on extraordinary case studies and decades of work supporting clinicians, Also Human presents a provocative, perceptive and deeply humane examination of the modern medical profession.

ABOUT THE AUTHOR

Dr Caroline Elton completed her undergraduate degree at the University of Oxford, was awarded a postgraduate fellowship to the University of Pennsylvania, and completed her PhD in the Department of Academic Psychiatry, UCL Medical School. She is a chartered psychologist and has held a number of positions working with doctors. Her first role involved shadowing senior clinicians on ward rounds, in outpatient clinics and in operating theatres, as part of an initiative to challenge outdated models of medical education. Later she was appointed as Head of the Careers Unit, responsible for supporting trainee doctors across the whole of London. She has also worked as Head of the Extended Medical Degree Programme – the largest ‘widening participation’ medical degree course in the UK. Caroline has written extensively about doctors, the problems they face and how best to support them, and is a regular speaker at conferences in the UK and abroad.

AUTHOR’S NOTE

A note on client confidentiality which I have taken very seriously. I have changed names and all identifying particulars so as to preserve my clients’ anonymity. Before using any personal information in the book (even under the guise of anonymity), I showed each client the draft, invited comment and sought their permission: all were willing to share their experience. Most were willing to do so on the basis that it is this book’s aim to help doctors facing career struggles and highlight the extraordinarily difficult pressures that many doctors face.

INTRODUCTION

Medicine in the Mirror

AS THE AEROPLANE wheels touched down on the tarmac I instinctively reached for my mobile phone, like many others around me. The flight from London to Washington DC was only eight hours, so there wasn’t much to work through. And there was nothing that a breezy ‘out of office’ message wouldn’t hold at bay for the next eight days. Nothing of concern – until I reached the last email:

I froze. This was not an email to ignore. But how could I provide ‘sane input’ when I was on the wrong side of the Atlantic? In the taxi to my son’s house, I phoned a colleague in order to pass the baton to her – but I only got her answerphone. There was no option but to answer Leo’s email myself.

*

Everybody goes to the doctor from time to time. For some, visits are a frequent occurrence, whilst for others they are mercifully rare. But however often we seek medical advice, or need treatment, most of us, quite naturally, tend to be preoccupied with our own concerns, and to make all sorts of assumptions about the doctor who is listening to us, taking our medical history, or cutting into us during an operation. If we think of them at all.

We take it on trust that the doctor is up to the task, and doesn’t feel tired or overwhelmed. We rarely consider whether the doctor, like Leo, is terrified of accidentally hurting us. We simply assume that if they are relatively junior, there will be a senior clinician somewhere nearby to answer their questions and ensure that they’re doing their job correctly. We tend not to worry whether or not they are bright enough for the job – after all, they will have trained for years and will have passed countless exams to get through medical school and beyond. And when parts of our body are being examined, we don’t want to entertain the possibility that doctors may find some patients attractive. We don’t wonder if the doctor likes patients at all, finds them disgusting, or resents the responsibility inherent in patient care. Instead we imagine that doctors enjoy their work and find it satisfying to treat patients like us.

For many of us, much of what we know about the medical profession comes from watching television. But neither the medical soap operas, nor the fly-on-the-wall documentaries paint an accurate picture. We don’t see junior doctors feeling so overwhelmed by work that they run away in fear. Neither, for ethical reasons, would we be shown doctors telling parents that their baby has died. Yet that’s just one of the many traumatic tasks that might be on a doctor’s ‘to do’ list alongside calming down a delusional patient or deciding whether to call a halt on a failing resuscitation attempt. And television, compelling though it may be, is restricted to sights and sounds; it can’t convey the smell of decaying flesh, or as one doctor described it to me ‘the feel of burnt, crispy, human skin’.

A lot of what doctors do is shielded in secrecy. ‘We cannot speak of these things to people outside medicine, because it is too traumatic, too graphic, too much,’ wrote one doctor recently, in the New York Times. But the writer then flagged up the difficulty of gaining solace through talking to colleagues, as medical culture regards these difficult tasks as ‘just the job we do, hardly worth commenting on’. A conspiracy of silence.

This book breaks the silence. Over the last twenty years, working as an occupational psychologist in two unusual roles, I have seen and heard things that are hidden from patients.

I found the first of these roles by chance; while idly flicking through the jobs section of the newspaper I spotted a vacancy on a project that aimed to make hospital consultants more effective teachers. Rather than removing doctors from their clinical duties and sending them en masse to the education department for training, faculty from the education department went into hospital to shadow the clinicians as they taught their students and junior doctors. Ward rounds, operations or outpatient clinics could continue as normal as clinicians were observed as they went about their everyday duties. What’s more, the educational feedback was more precise: tailored to the specific context in which each particular clinician worked.

I applied for the role, and ended up working on the project for the next decade. During this time I shadowed hundreds of consultants; I watched as babies were born, patients were given terminal diagnoses or took their last breaths. My job was to help these consultants become more effective teachers in the different settings across the hospital; in the process I witnessed many extraordinary things.

Alongside this hospital-based role, I also had a more typical job for an occupational psychologist: working as a careers counsellor, helping people sort out the difficulties that they were experiencing in the workplace. For many years my two jobs were separate: some days I observed doctors whilst on others I counselled people in all occupations other than medicine. Then in 2006 my two jobs merged. Postgraduate training of doctors in the UK was completely overhauled, junior doctors had to make specialty choice decisions at an earlier point in their careers, and the NHS woke up and realised that there was a need to establish careers support services for doctors.fn1

In 2008 I was employed by the NHS to set up and run the Careers Unit – a service for all trainee doctors in the seventy-plus hospitals across the capital. Although I hadn’t embarked on the observation work to prepare me for this new role, serendipitously the ten years I spent shadowing clinicians turned out to be invaluable. I had seen, for example, anaesthetists or gastroenterologists or cardiac surgeons in action, so I had a more nuanced understanding of the pleasures and challenges of each specialty than I could ever have acquired from a book.

But the doctors who came banging on my door at the Careers Unit didn’t only want to talk about choosing the right specialty. Other themes recurred again and again: coping with the transition from medical school; questioning whether they were suited to the practice of medicine; the impact of exposure to patient suffering; the seeming impossibility of reconciling family and professional demands; the emotional complexity of leaving or abandoning a medical career. These are some of the issues that I explore in this book.

As a psychologist, I saw how medical training often fails to acknowledge that doctors are people too, with their own thoughts, feelings, fantasies and desires. Their training moves them around the country, and separates them from family and friends. They can get ill, or divorced, or fail to find a partner. Some struggle to progress their careers after taking time out to care for their children or elderly parents, others struggle with passing specialty exams. The sexism or racism found in other professional spheres hasn’t been surgically excised from medical work. Some doctors feel that they have ended up in the wrong specialty. All of this takes a toll.

All of this needs to be told.

*

It might be tempting to think that the doctors I encountered were atypical. But this would be false. In August 2016, a final year student at a New York medical school climbed out of her window and jumped to her death. The Dean of the University wrote an impassioned opinion piece in the New England Journal of Medicine¹. Referring to research from the Mayo Clinic², he described ‘a national epidemic of burnout, depression and suicide amongst medical students’. And he went on to say that the ‘root causes’ of this epidemic stemmed from

A few months before the New York medical student committed suicide, Rose Polge, a junior doctor in the UK, walked into the sea and drowned. This tragedy received widespread newspaper coverage – at least in part because it occurred when junior doctors had taken the unprecedented step of going on strike – the first in forty years – in protest against the imposition of a new working contract.

‘Long hours, work-related anxiety and despair at her future in medicine were definite contributors to this awful and final decision,’ wrote Rose’s parents on the web page of a charity set up to raise money in her memory³.

Except it isn’t final. The following year another junior doctor disappeared⁴. As with Rose, her car was found abandoned by the sea. What happened next is not known.

Rose’s parents were not alone in pointing the finger at the working conditions doctors face in the UK. A 2016 study published in The Lancet concluded that GPs’ clinical workload was reaching ‘saturation point’⁵. Similarly, the quarterly monitoring report from the King’s Fund published at the beginning of 2017 noted sustained increases in patient demand⁶, particularly from elderly patients with complex health needs, rising delays in transferring patients out of hospital into social care and severe financial pressures leading to cuts in staffing. These findings were echoed in a survey of nearly 500 junior doctors conducted by the Royal College of Physicians which reported that⁷:

But ultimately it’s not just doctors who are suffering. It’s all of us. The Royal College of Physicians’ survey found that nearly a half of doctors felt that poor morale had a serious, or extremely serious, impact on patient safety. Similarly the 2016 General Medical Council survey of junior doctors⁸ reported that one in five emergency medicine trainees were concerned about the impact of their workload on patient safety. And another study carried out by researchers at Harvard Medical School reported that paediatric trainees who were suffering from depression made six times more medication errors than their non-depressed colleagues⁹. These researchers also found that the rate of depression amongst these trainees was twice that expected in the general population. Despite these high rates of mental distress, nearly half of the depressed trainees seemed unaware that they were unwell and only a small number were receiving treatment.

*

It’s extremely rare for a psychologist to gain such intimate exposure to the day-to-day reality of medical work. In many ways I have been granted an insider’s vantage point on the profession. Yet crucially, in both of my roles I was working as an outsider, as a psychologist rather than as a medic. I haven’t been socialised into the world of medicine through a long and arduous training process, so things that medical colleagues might take for granted, I have questioned. My training has also given me a psychological lens to interpret what I have seen or been told; I’m often interested in the unconscious reasons that lie beneath some of the decisions doctors make.

But the significance of being a psychologist rather than a doctor goes further. I suspect it’s a bit easier for doctors to admit to me that they are struggling at work, than to have the same conversation with another doctor. When their jobs are making them unhappy, doctors often imagine that they are the only ones who feel as they do, and they are wary of voicing their concerns to the senior clinicians who supervise them. And stigma – particularly around mental health issues – is still a very real problem in the medical profession.

There are, of course, a number of books written by exceptional physicians, which provide readers with an extraordinary glimpse into the world of medicine. I have read many of them, and they have enormously enriched my understanding of the profession. But this book is different; it’s not describing the personal experience of one doctor, but instead draws on observations and conversations with hundreds of doctors over a twenty-year period. And whilst other books involve doctors writing about their patients, in this book the mirror is reversed: doctors like Leo come to see me, a psychologist, and I am writing about them.

*

So what did happen to Leo?

With the tragic cases of students and junior doctors who had committed suicide in mind, I responded to Leo’s email with considerable care. I wanted to acknowledge his obvious distress yet at the same time convey hope. I told him about other medical students and junior doctors I had encountered in the past who had expressed similar feelings. I also told him that some of them had gone on to have successful careers within medicine, whilst others had decided to build their careers outside the profession. But above all else, I emphasised that he shouldn’t attempt to soldier on without help. His first priority was to go and see his GP and tell her how he was feeling. In addition, he might find it helpful to seek support from the university counselling service, as well as pastoral staff within the medical school. And I flagged up the 24-hour crisis line operated by the British Medical Association.

I explained that I was out of the country but would respond to any emails he sent me, and would be happy to talk on my return to the UK the following week. A couple of days later Leo wrote back. He’d already made contact with his GP and his personal tutor and he had found it helpful to know that I had supported other doctors who felt as he did. He also wanted to arrange a time to talk when I was back in the UK.

The following week, we talked on the phone for over an hour. Leo told me that he was feeling better than when he had first emailed me; he had contacted the BMA helpline and in addition, his GP and personal tutor had been helpful. When I asked about the impending exams Leo was clear that he was well enough to sit finals and he’d done enough studying to pass. It wasn’t the exams per se that he was worried about; more what came next. When we then discussed how he felt about starting work Leo was adamant that he wanted to give it a try even if he decided a few months down the line that clinical medicine wasn’t right for him.

After his exams Leo was due to go away on holiday for a month with his girlfriend. On his return he would be moving to a new town with her, to start his first job as a doctor. We left it that Leo would get in contact with me if he wanted to think about which specialty might work best for him, or if he wanted to consider leaving medicine entirely. But a couple of weeks before finals wasn’t the right time to discuss either of these issues.

A month into his first job I received another email – very different from the first.

It’s probably a bit too early to tell how Leo’s medical career will pan out in the longer term. But later on in the book we’ll meet doctors who walked out within days of starting their first job; the fact that Leo is enjoying work is certainly encouraging.

I’m still shocked, however, by how frequently medical students and junior doctors find themselves at the ‘edge’. Aren’t there better ways of training our future doctors? Ways that mean they don’t need to phone 24-hour helplines, or send desperate emails to unknown psychologists, in the hope that someone out there will listen. And couldn’t we manage the transition from medical student to junior doctor better?

That’s the place where these stories begin.

1

Wednesday’s Child

I ALWAYS ASK clients about their first job as a doctor. I don’t specifically ask about the first day of that first job – but sometimes, as with Hilary, that’s the story I am told.

Hilary, a qualified GP, came to see me because she was thinking about leaving medicine.

‘I’ve reached the end of the road with general practice,’ she explained in our initial phone conversation.

‘The only thing that I like about it is that it provides a regular income,’ she continued.

Like many other GP clients, Hilary told me how she felt that contemporary general practice pulls doctors in opposing directions. On the one hand, she lived in fear of incorrectly reassuring a patient that a particular symptom didn’t warrant a referral to a specialist for further investigation. On the other hand, she dreaded being singled out by her clinical managers as having an inappropriately high referral rate to specialist services. Damned if you do and damned if you don’t, with no wriggle room in between.

It was five years since she had first qualified as a GP, but even before she finished her GP training, she had started to doubt whether it was the right career for her.

‘I’m not a natural doctor,’ she said. ‘I constantly feel like a square peg in a round hole.’

But leaving wasn’t easy either. Neither of her parents had been to university, and her mother’s father had worked as a gardener for the local doctor.

‘My mother is so proud of me, and everything that I’ve achieved. She really doesn’t want me to change career.’

I asked Hilary to tell me about her first job as a doctor and she described how her heart sank when she saw from her rota that she’d been placed on the on-call team on her first day. What this meant was that in addition to her responsibilities on the surgical ward to which she had been attached, she also had to assess new patients as they were admitted to the hospital for surgery. It’s a bit like trying to be in two places at once; nobody wants to be on call on Day 1.

On her first morning as she walked on to the surgical ward she was immediately informed by the senior nurse that, following surgery, one of the patients was extremely sick and urgently needed to be seen by a doctor. Naïvely, Hilary asked which other doctors were available.

‘Mr Baker the surgical consultant is on a course, Mr Shah the registrar is on annual leave and Dr Glover is off having worked a bunch of nights. It’s just you,’ said the nurse.

Hurriedly, the nurse led Hilary to the patient’s bedside. The first thing that Hilary clocked was the patient’s strange, grey pallor. With extreme difficulty the patient opened her eyes and whispered, ‘Doctor, am I going to die?’ Then, a second later, a barely audible request: ‘Doctor, please call my family.’

Hilary didn’t have a clue whether the patient was at death’s door, or whether she should urgently summon the family. More importantly, she also didn’t know whether there were medical interventions she should be making, to save the patient’s life. Moving away from the patient’s bedside in order to confer with the nurse, Hilary asked for help.

‘You’re going to have to get used to this,’ said the nurse. ‘Mr Baker never turns down an opportunity to operate – he’ll operate on anybody. With some of the patients on this ward it might have been better if they had escaped the knife. They’re often even sicker when they come out of theatre.’

A junior nursing assistant called the senior nurse away. Left on her own and unsure what to do next, Hilary decided to review the patient’s notes. There were no clues there either. With mounting anxiety, she wondered whether she should call the registrar from another team, or ask the senior nurse to return to the bedside. Nothing that she had learnt in medical school had prepared her for this situation.

By chance Fiona, a fledgling doctor attached to another ward, walked down the corridor and out of the corner of her eye caught sight of a panic-stricken Hilary. Realising that all was not well with her colleague, Fiona slipped away from her own clinical team, and walked on to Hilary’s ward:

‘Are you OK?’ asked Fiona.

‘Not really,’ Hilary replied. ‘I’m the only doctor on this ward, all the others are away today, and there’s a really sick patient who looks like she is going to die.’

She led Fiona to the patient’s bedside; neither of them spoke as they peered down at the sickly looking patient, who had fallen asleep again.

‘I’ll call my mum,’ Fiona whispered.

For a second, Hilary thought that Fiona was joking. Even though she would love to magic her own mum on to the ward, she couldn’t see how the appearance of Fiona’s mum was going to improve the situation.

‘Mum’s a nurse on the Rapid Response Team,’ Fiona explained. ‘She’ll know what to do, and I am sure she will come if I ask.’

So that’s what they did. Fiona’s mum was summoned and five minutes later appeared. She took one look at the patient, realised she was desperately unwell, and called the consultant anaesthetist. A couple of minutes later the anaesthetist appeared, agreed with his nursing colleague’s opinion and less than ten minutes after that, the patient was transferred to the High Dependency Unit, for urgent medical treatment.

The patient survived. And Hilary’s first day continued.

All the time that Hilary had been trying to sort out the desperately ill patient, her bleep had been going off, summoning her to the Surgical Assessment Unit (SAU). As soon as the patient was transferred, she dashed down to the SAU and encountered an extremely angry nurse.

‘There are nine patients waiting. Where have you been?’

Before Hilary had the opportunity to explain that she had been dealing with an emergency on the ward, the nurse gave a rushed account of each of the nine patients whose names were on the whiteboard by the nursing station. Hilary absorbed almost nothing of this informational deluge.

‘Is there another doctor here?’ she asked, finding it hard to believe that she had been expected to fly solo on the SAU as well as on the ward.

‘Triple A emergency admission.fn1 Everyone’s in theatre,’ was the unwelcome response.

By this stage in the day, the nine names on the whiteboard were swimming in front of Hilary’s eyes. And having already dealt with a clinical emergency (albeit by calling Fiona’s mum), she was desperate to know if any of the names were higher priority than the others.

‘Could you possibly help me work out who I should see first?’ asked Hilary.

‘Figure it out yourself, blue eyes,’ was the nurse’s response. And with that, she walked off – probably to get on with her own enormous list of tasks.

Over a decade had passed when Hilary told me about her Day 1, but she could still remember the face of the desperately ill patient, and her name. She could still recall that sense of panic and fear. I asked if she thought there was any relationship between her horrendous first day and her current feelings about her work; she told me that she couldn’t see a link. The following day Hilary emailed me:

So for Hilary at least, that first day may have paved the way for extreme job dissatisfaction, ten years down the line. What strikes me most forcefully about Hilary’s story is that the whole set-up seems so precarious. In the UK all first year doctors start work on the same day – the first Wednesday in August. Given that Day 1 is a national fixture across the whole country, why was the supervising consultant away on a course? Why had the registrar been allowed to go on annual leave at the same time? What if the patient had died, and Hilary had been held responsible? Why hadn’t back-up provision been made on the Surgical Assessment Unit in case all the experienced staff had to rush into theatre to deal with an emergency?

Do we really want a system where a patient’s life depends upon someone’s mum arriving in time?

*

It would be reassuring to think that Hilary’s experience was exceptional. Sadly, this is not the case. I was shocked by Hilary’s conclusion that her experience was in fact commonplace. ‘Lots of my F1 colleagues had similar experiences,’ she told me. ‘And the following year in a completely different hospital, the same thing happened to the F1 on my new team. That day I had induction in the morning into my new role as an F2 and only got to the wards in the early afternoon. But the new F1 in the team had been left to fire-fight all morning. It happens all the time.’

This conclusion of Hilary’s is borne out by studies of first year foundation doctors. In fact a 2014 programme of research commissioned by the GMC reached the following conclusions¹:

The study also emphasised how pressures on the healthcare system can impact on a recent medical graduate:

This isn’t only a pretty accurate description of Hilary’s first day. Given the current pressures in the NHS, a high volume of work requiring prioritisation and multitasking has become the norm.

*

In UK hospitals it might be ‘all change’ on the first Wednesday in August, but the process of applying for one’s first job as a doctor takes the best part of a year. Nine months earlier, in October, final year medical students fill in an online application form in which they have to rank their preference for each of the twenty-one different health regions across the whole of the UK. Jobs are allocated in score order, so the higher your score, the more likely you are to be allocated to your first or second preference region.

Each applicant’s overall score comes from two separate sources. First, there is an Educational Performance Measure derived from a student’s academic scores in medical school together with extra points for additional degrees and academic publications. Secondly, and given equal weight, is their score on the so-called ‘Situational Judgement Test’ (SJT)². This is a pencil and paper test lasting over two hours during which students have to answer seventy questions. The questions are not testing clinical knowledge (that’s assessed by medical school finals) but instead assess whether the applicant possesses the professional attributes needed to manage the everyday situations they may encounter in their first year of practice. For example, applicants might be given the following brief scenario:

Applicants would then have to rank-order the appropriateness of the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate).

The worked examples on the UK Foundation Programme Office website gives the answer as DCBEA, using this rationale³:

(Isn’t it ironic that the model answer stresses the importance of asking the nurse? This is exactly what Hilary did on the Surgical Assessment Unit, only to be told that she needed to ‘figure out’ the answer herself. The nurse was too busy to help Hilary.)

Applicants with extremely low SJT scores have to attend a face-to-face interview, to assess whether they are competent to start working as a junior doctor. In 2016 this happened to twenty-two UK medical students and fourteen from outside the UK – only three of whom were later reinstated and offered an F1 post.

I might have struggled to believe that anybody could get to the end of a five- or six-year medical degree, pass finals, but lack the professional understanding to get an adequate mark on the SJT. Once one has grasped a few basic principles (patient safety always takes precedence; respect the expertise of other healthcare professionals; honesty is of the utmost importance) it seems possible to work one’s way through the questions and get a reasonable score. However, when running a workshop for senior medical school faculty in one of the most academic universities in the country, an experienced clinician told me about a final year medical student who was academically brilliant, but seemed to lack sound professional judgement. On one occasion, while on an A & E placement, this particular student had needed to get his attendance form signed by the supervising consultant, but the consultant was otherwise engaged – dealing with an emergency patient resuscitation, in fact. Undeterred, the student attempted to interrupt the resuscitation, waving the form under the consultant’s nose in order to get it signed.

‘Should I be worried about this student?’ asked the senior faculty member.

I was speechless. How could one not be worried by this student’s behaviour? Isn’t it fairly obvious that anybody who decides that getting a form signed takes priority over an emergency resuscitation is going to find the day-to-day demands of clinical practice impossible? Years ago, it was left to supervising clinicians to weed such students out and there can be considerable reluctance to do so, particularly if the students are academically gifted. Nowadays this task is aided by the SJT.

Final year students sit the SJT in December, and this score is added to the Educational Performance Measure to calculate their overall score. In March they are told which region they have been allocated to, or if they have been placed on the reserve list. In April they get told which specific hospital within the region they will be working at. However, those on the reserve list may not be told if a place has become available for them until right before the fateful first Wednesday in August. Between March and August medical students on the reserve list have to sit it out and wait.

What this tends to mean in practice is that the weakest final year students (those who have scored poorly on either or both of the measures) are allocated to the places which other more highly ranked students have avoided. Final year medical students can easily find out which are the less desirable posts by looking at the results from the GMC trainee surveys, alongside a host of other websites. So medical students can find out how well supported foundation doctors have felt in each of the different regions or how favourably the quality of training was rated. More highly ranked students are likely to choose those programmes where students felt better supported and better trained, whilst weaker students are left to take whatever is left over.

And there’s more. Medical students can be sent to hospitals anywhere in the country – from Cornwall up to northern Scotland or Northern Ireland. Because weaker students on the reserve list will be placed in left-over slots, they are more likely to end up working in parts of the country where they know absolutely nobody, and have no accessible systems of support. This is an educational variant of what GP Dr Julian Tudor-Hart famously termed the ‘inverse care law’⁴ – those who most need care, end up receiving the least. Except in this situation it isn’t vulnerable patients receiving the poorest medical care – it’s vulnerable medical students being offered the least support in their first post.

On paper, at least, there is a system in which final year medical students can apply to be allocated to a specific foundation programme⁵, based on their ‘special circumstances’. So, for example, if you have a school-aged child, or if you are the primary carer for somebody with a disability you can request that you won’t be sent all over the country, but will be pre-allocated to a specific post. This is all good in theory, but in practice, given the stigma attached to mental health issues and the unwillingness to be seen to be struggling, very few students request this option for mental health or educational reasons.

For the last few years when the allocations have been announced in March, a small number of students have been placed on the reserve list. This always generates a lot of column space in the medical press. But in 2016 it happened to the grand number of thirty-six UK students. Tiny numbers. And by the time the programme started in August, all thirty-six of these students had been allocated jobs. In the UK, if a final year medical student passes finals (and the overwhelming majority do), and doesn’t score too drastically on the SJT (which also only involves a tiny number of students) they will end up with an F1 job somewhere. It may be far from home, and it may not be one that they want – but it will be a job.

*

In the US, as in the UK, the overwhelming majority of final year medical students are offered a first year post – a residency. For example, in 2016, less than 7% of US medical students failed to be offered a post through the National Resident Matching Program (NRMP)⁶. But there are also some key differences between the US and the UK.

First, as with so many medically related comparisons, there is the huge issue of money. UK medical students don’t pay to apply to the foundation programme, whereas in the US the application for residency is anything but free. I asked a friend’s daughter, Sophie, who successfully applied in 2016 for an obstetrics and gynaecology residency programme, to give me some idea of the costs, and this is what she told me:

So in all, Sophie reckoned that she had spent around $9,000 – a huge sum on top of an already enormous medical school debt.

Another key difference between the UK and the US is the sheer scale of the enterprise. In the US in 2016, over 30,000 residency slots were up for grabs – a figure which is more than four times greater than the number of first year posts on offer in the UK. The NRMP matches the applicants to this vast number of posts through the use of a complex mathematical algorithm which gained its two inventors – Lloyd Shapley and Alvin E. Roth – the Nobel Prize in Economics in 2012⁷.

Prior to using this algorithm, medical students would apply to hospitals and their preferences would be visible to the selection committees. The selectors would first look at those applicants who had ranked their hospital as their first choice. If they still had vacancies the selectors would look at applicants who had ranked them second – and so on, until all their vacancies were filled. The problem with this system was that when an applicant’s ranking was visible to the selectors, those applicants who had aimed too high would be severely punished. Frequently these poor medical students would end up with one of their last choices.

Nowadays applicants interview at the hospitals without the hospitals knowing how high up the list the applicants had rated them. Then the preferences of all the applicants and all of the hospitals are fed into the computer at the same time and the algorithm is used to create a simultaneous match between thousands of applicants and thousands of jobs that, in theory, is less influenced by the gaming strategies inherent in the old matching method. Having said that, many applicants resent the system because each individual still ends up with only one job offer. And they hate the feeling that their future depends upon the working of a complex mathematical algorithm – even if it did win somebody a Nobel Prize.

This was certainly Sophie’s experience. She recognised that with the NRMP process, applicants can’t (as can happen in the UK) wind up somewhere completely out of their control as they will only be considered by the specific programmes that they ranked. But she still expressed some regret.

‘Do I wish we could have the opportunity for more than one programme to ultimately make us an offer and then be allowed to choose like normal adults? Yes.’

The money side of things and the sheer scale of the operation may be different in the UK and the US. But in both countries, final year medical students end up with only one offer. They look around them and see that other professions (law, business, accountancy) don’t assign people to jobs this way. And, like Sophie, they resent the lack of choice. Isn’t it paradoxical, considering the burden of responsibility junior doctors are expected to bear as soon as they start working, that the application system in both countries manages to infantilise final year medical students?

*

For T.S. Eliot in his epic poem, The Waste Land, April is the cruellest month of the year⁸. But April is not so bad in ‘Wardland’ – in that realm, the calendar shifts on a couple of months and you have to worry about July and August. These are the months when medical students metamorphose into junior doctors and take up their first jobs. The jobs that they had spent the best part of the previous year applying for.

‘Why July matters’ is the title of a recent commentary in the American journal Academic Medicine⁹. The author quotes a systematic review of thirty-nine separate studies that reached the following conclusion: ‘Length of hospital stay, duration of procedures and hospital charges peaked during the month of July. Of note, rates of patient mortality also increased in this period.’

But it’s not just in the US. The authors of the Academic Medicine paper go on to describe an international study which found that ‘rates of fatal medication errors increased by 10% during the month of July in countries with teaching hospitals … the greater the proportion of teaching hospitals in a region, the greater the mortality rate from medication errors.’

The UK isn’t immune to this effect either, but as changeover is the following month, the peak occurs in August rather than July. In 2009 a group of researchers at Imperial College in London published a retrospective study using hospitals admissions data over an eight-year period across the whole of England¹⁰. The key question they looked at was whether in-hospital mortality was higher in the week following the first Wednesday in August than in the previous week. Only hospitals that took on trainee doctors on the first Wednesday in August each year were included.

As national data were gathered from across the whole of England, there was a sufficient sample size to adjust the calculations for confounding patient factors that may have affected the risk of death, including age, gender, socioeconomic status and the presence of other serious illnesses. Just under 300,000 patients were admitted on these two days in the years from 2000 to 2008. Of those, 151,844 were admitted on the last Wednesday in July and 147,897 on the first Wednesday in August. In total, there were 4,409 deaths in the two groups, 2,182 among those patients admitted on the last Wednesday in July and 2,227 among those patients admitted the week after. When the researchers adjusted for potential confounding factors, they found that the odds of death in the group admitted in August was 6% higher than the group admitted in July.

Two years later, in 2011, an online survey in the UK reported that 90% of physicians felt that the August transition had a significant negative impact on patient care and patient safety. Respondents highlighted the inadequacy of measures at the local level to support junior staff in their induction, and to ensure patient safety. The title of the paper was ‘August is always a nightmare’¹¹ – taken from a comment by one of the physicians in the survey. August is the cruellest month, it seems. At least for patients in teaching hospitals in the UK.

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I didn’t warm to Bella when I first met her. As I described how I worked with clients, I gained the distinct impression that she was somewhat contemptuous of what I was saying. By the end of the first session I realised that my initial impression was fundamentally incorrect. What I had initially taken to be disdain was actually a potent combination of shyness and wariness.