Junior doctors: providing care today, training for tomorrow

13 January 2012

We welcome Goddard and Lees timely editorial and its recognition of the importance of the Registrar role [1]. The authors highlight that the Dr Foster Hospital Guide [2] did not report any association between the numbers of junior doctors (ST2 and below) and the differences seen in weekend mortality rates. Given the high volume of clinical care delivered by junior doctors on weekends we find Dr Foster’s result surprising, and are not alone in this [3].

Although Dr Foster Intelligence notes that “junior doctors work around the clock” the overall numbers available out of hours tend to be much smaller than during the weekday. With Hospital at Night and the rota systems implemented under the EU Working Time Directive, this smaller cohort of junior doctors is often looking after patients that they have never met before, whilst cross-covering specialities they are unfamiliar with.

Although senior input is often available, this is similarly stretched with higher ST grades being burdened with clerking new admissions and patient reviews. Furthermore, in an ageing population with a high prevalence of co-morbidities, the patients occupying hospital beds are more complex than ever. To digest weighty volumes of notes in the short period that an on-call doctor can spend with a patient is increasingly difficult, compounded by night nursing staff that are often unfamiliar with the patient’s pre-morbid state.

Whilst increasing the numbers of ST3+ doctors available out of hours is clearly important [4], it is only one piece of a complex healthcare puzzle. The number of junior doctors needed out of hours for the delivery of quality care, and to meet training needs, should be further investigated. Medical needs, rapid deterioration in patient status, and acute emergencies do not obey the 9–5 working week - nor should a medical system that prides itself on equity of access to care.

[1] Goddard A, Lees P. Higher senior staffing levels at weekends and reduced mortality. BMJ 2012;344:e67.

[2] Dr Foster Health. Reducing mortality at nights and weekends. In: Inside your hospital 2011. http://drfosterintelligence.co.uk/wp-content/uploads/2011/11/Hospital_Gu... (accessed 12 Jan 2012)

[3] Macdonald H. Dangerous weekends - more complicated than just a lack of consultants. BMJ Group Blogs 2011. http://blogs.bmj.com/bmj/2011/11/29/helen-macdonald-dangerous-weekends-m... (accessed 12 Jan 2012)

[4] RCP Council. RCP position statement on the care of medical patients out of hours. Royal College of Physicians 2010. http://old.rcplondon.ac.uk/professional-Issues/Pages/RCP-on-care-of-medi... (accessed 12 Jan 2012)

Competing interests: Competing interests: ZA, VK, CJR and ANT are junior doctors as defined by the report. All authors are fellows in the NHS Medical Director Clinical Fellows Scheme hosted by the Faculty of Medical Leadership and Management.

Grant A Hill-Cawthorne, ST3 in Medical Virology

Zeinab Abdi, Academic F2, Leicester University Hospitals; Eamonn Breslin, ST6 in O&G, North London Rotation; Colin Brown, Academic Clinical Fellow in Infectious Diseases & Microbiology, King’s College London; Nick Ibery, Neurosurgery, North London Rotation; Varo Kirthi, Academic FY2, The Royal Marsden NHS Foundation Trust; Anna Moore, CT3 Psychiatry, Berkshire NHS Foundation Trust; Carl J Reynolds, CT1, Chelsea and Westminster Hospital; Aniket N Tavare, CT1, Oxford University Hospitals NHS Trust; Wai Keong Wong, ST5 in Haematology, North Central London Rotation

Norfolk and Norwich University Hospitals NHS Foundation Trust, Specialist Virology Centre, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY

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