If you want to improve your chances of surviving a visit to hospital, best wait until September.
That’s the implicit message from the Royal College of Physicians of Edinburgh (RCPE), which is today warning that patient safety is “compromised” in August when the latest intake of medical trainees comes into post.
The UK’s newest doctors – most of whom were medical students until a few weeks ago – started work on the first Wednesday in August, coinciding with the date when other doctors in training rotate into other positions.
Although there is already research evidence to show that patients admitted at this time have a higher early death rate than at other times, today’s announcement from the RCPE is among the strongest criticisms yet (they call it a “nightmare” in the press release title) of a system which not only ensures that hundreds of doctors are starting a new job on the same day, but that they are doing so at a time when many of their senior colleagues are on holiday.
This might make sense in some ways – for example, if a consultant surgeon is away, then operating lists will have been cancelled – but emergencies do not tend to wait until Professor So-and-So gets back from holiday or until new doctors get up to speed.
To back its criticism of what tends to be known as “Black Wednesday”, the college, along with the Society of Acute Medicine, conducted a survey of doctors’ experiences throughout Scotland and the UK. The findings, published in the journal Clinical Medicine, are clear. More than nine in ten (93 per cent) of respondents believed the August changeover had a negative impact on patient care, 90 per cent thought it had a negative impact on patient safety and 58 per cent thought it had a negative impact on doctors’ training. The negative effects were found to last for up to one month.
Eight in ten of the 763 respondents thought the situation could be greatly improved by moving away from the current national changeover on a single day to a staggered transition by grade, taking place over a period of a month. Those who made comments also supported moving changeover to a different time of year to eliminate conflict with the holiday period.
Dr Louella Vaughan, honorary consultant physician in acute medicine at the Chelsea and Westminster Hospital in London, and lead author of the study, said the survey results added to the emerging evidence base indicating that the current August changeover system increases a number of risks for patients, including an increased early death rate.
“Over 90 per cent of doctors who responded to the survey believe that patient safety is compromised every year in August by this outdated system,” she said. “When considered along with other related evidence it is clear that the current system is in urgent need of reform. The doctors surveyed have indicated that not only is there an appetite for change, but the desire to enthusiastically lead and support it. All that is lacking now is the political will.”
RCPE president Dr Neil Dewhurst said that patient safety and the quality of patient care should not be knowingly compromised. “For many years doctors have been aware of practical problems caused by this annual changeover. Formal evidence in support of our concerns has, however, been limited, but is now increasing and has reached the level where it should not be ignored.
“Other changes to established systems within healthcare have been shown to deliver real improvements for patients and similar consideration must be given to making the changeover in training safer. We would urge the Scottish and UK governments to review this matter as a matter of urgency.”
The authors of the paper want to see stronger and more consistent clinical leadership for junior doctors at the start of training – and say that consultants should not be used to fill rota gaps or to save on locum costs, but should be providing direct support to trainees.
They also say there is evidence in favour of longer periods of “shadowing” – where medical students are prepared for the world of work by effectively functioning as junior doctors, rather than just clerking in patients – ideally where they will later be working. “Despite the General Medical Council making shadowing a requirement of the final year of medical school, only a minority do so in their place of later employment,” they write. “The GMC also recommends that shadowing students should be ‘protected’ from the ‘business’ of being a junior doctor, which the evidence suggests may be counterproductive.”
The British Medical Association gave a neutral response to the college’s survey and press release – and said that health boards and trusts had a responsibility to make sure staff were prepared. Dr Alan Robertson, of the union’s Scottish Junior Doctors Committee, said: ‘It is well recognised that the August change-over can be chaotic for junior doctors and the services where they are working. Having said that, the fixed change-over date in August does give the NHS a clear date for which to plan services and to ensure that sufficient supervision is in place to provide support to those new in the job. However there could be scope for some of the suggestions posed by the RCPE in their report. It is vital that employers provide comprehensive induction for staff.”