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16 May 2018

Why it’s a bad idea to fall ill in August


By Zara Aziz

The first Wednesday in August is often referred to as “Black Wednesday”: it is the day when final-year medical students qualify and other junior doctors change between wards, specialties or hospitals. A study of 300,000 NHS patients showed that mortality rates rise by 6 per cent in emergency specialties in August. Nor is it the full story: this is also a time when doctors can make many more mistakes that don’t lead to death.

New doctors face a steep learning curve. Emergency and surgical specialisations can be particularly challenging. No amount of schooling prepares for the hands-on experience of looking after very ill patients. Someone can be admitted with a heart attack, or a post-operative surgical patient can suddenly deteriorate on the ward in the middle of the night. There is a big attitudinal shift, too: hours become longer and the workload increases, with doctors experiencing their first night duties and time “on call”.

When I qualified as a doctor, I secured my first job in the children’s department of a small district general hospital. I had “shadowed” the outgoing house officer diligently the previous week, but I remember feeling terrified. It was sobering to think I was the first port of call for emergencies. Yet I quickly learned that we had more supervision in paediatrics than almost anywhere else in the hospital. In the four months I spent in the post, I lost count of the number of times my consultant came in at night to see a sick child.

Usually, most other hospital specialties have relied on “middle grades” or registrars (the pre-consultant stage) to supervise juniors. Nowadays many wards have a first-year doctor and a consultant only: “middle grades” are few and far between. Due to funding shortfalls, few consultant posts are being advertised, which in turn has led to a fall in the number of new registrars.

Although consultants often encourage newly qualified doctors to contact them if there are any problems, this is not easy if the consultant surgeon is “scrubbed up” in theatre or seeing patients. Most junior doctors would think twice before ringing their consultant at 2am for something that may or may not be significant. Nor does it help that August is a popular time for senior doctors to take leave.

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In recent years there have been national initiatives to ease the transition of newly qualified doctors starting in August: paid shadowing and targeted teaching have been introduced to limit mistakes. In 2010, one such initiative at University Hospitals Bristol led to a 52 per cent reduction in mistakes made by first-year doctors during their first four months. It may also make more sense for new doctors to start their first post in September, when there is better staffing.

The shortage of “middle-grade” doctors is more difficult to tackle, as it is hard to create more registrars when there are no consultant posts to fill at the end of training. We might be moving closer to a consultant-led model of care, which could be good for patients – provided there are enough consultants to go around. 

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