The patient as office file

Observations on junior doctors' hours

There is a modern superstition that all things desirable must be mutually compatible. Thus it must be possible, in our present circumstances, that junior doctors should not work excessively long hours, in accordance with the European Working Time Directive, and that patients should receive good medical care. In fact, we have to choose one or the other: and it seems we have chosen the supposed welfare of junior doctors, rather than that of patients.

For many years, the medical care in hospitals was based upon the "firm" - teams of junior doctors, in various stages of training, under the direction of a consultant, for the care of whose patients they were responsible. They were expected to know (and did know) all his cases in detail, and to attend to the medical needs of his patients until they were met, irrespective of the time it took to meet them.

It was an exhausting system, but it ensured continuity of care, a fundamental principle of good medical practice. Hospitals recognised the sacrifices made by junior doctors, who were not well-paid, by granting them small privileges such as being served meals at unsocial hours. Contrary to George Bernard Shaw and his chief disciple on this matter, Margaret Thatcher, a profession is not a conspiracy against the laity: it is a vocation to maintain standards for the benefit of others.

In the name of the efficient use of resources, and a reduction of exhaustion among junior doctors, the system that served for many years has been ditched. Junior doctors now operate a shift system, and leave hospital as promptly as any bureaucrat leaves his office, in mid-crisis if the clock so dictates. The aim of each shift is now to keep the patient alive until the next shift takes over, when he ceases to be the departing doctor's responsi- bility. The result is that when, as a consultant, I ask a junior doctor about a patient for whom he or she is allegedly responsible, he or she rarely knows him well. Under the new dispensation, junior doctors and patients are increasingly ships that pass in the night.

All this was foreseen many years ago by an extremely distinguished physician who died recently, Dr D M Davies. Seeing far into the future, when the problem was only a cloud on the horizon, he wrote to the Lancet in 1972: "Someone ought to have explained to those responsible . . . that patients are a little different from files, ledgers and efficiency reports and cannot be put away tidily at 5pm and picked up again at 9.30am; and that a doctor who is acquainted with a patient and his case is usually in a better position than someone without such acquaintance to deal with, or advise on, some sudden or unexpected change in that patient's condition."

With the intellectual honesty and clarity that it has been the aim of all recent British governments to extinguish, preferably for ever, Dr Davies went on: "Let it not be pretended that schemes intended to improve efficiency in the use of manpower (some would call it papering over the cracks) are of benefit to patients, because they are not."

The only thing that Dr Davies did not foresee was successive governments' animus towards the independence of professions: an animus that derives from the simultaneous desire to control and to be able to lay the blame elsewhere when the need arises.