The first year of doctoring: still a survival exercise

We make no apologies for starting the New Year with an issue that will challenge and test even the most experienced medical teacher. In this issue a number of papers describing aspects of the intern or pre-registration year have been brought together to highlight some of the profound problems that doctors face in the very first year of their professional careers. Whilst much has been done in recent years to improve working conditions in what can be a very hard job, the results presented in some of these papers show that further improvement is needed. Three papers reporting work on a cohort of over 2000 young doctors in the UK form the core of the issue and are supported by others reporting on aspects of the learning and working environment of Pre-registration House Officers (PRHOs). The overall tone of the reports is good, with over half of PRHO posts being rated as very good or excellent. Sadly, nearly a third of respondents showed symptoms of psychological morbidity on the GHQ, and many individual accounts of experiences with disease, with death, and with medical teachers and supervisors are causes for concern. Junior doctors in any public health service cannot expect their work to be easy, but they do have a right to be treated with respect, courtesy and concern; to work in a supervised environment that recognises and supports them through a period of their lives where stress is inevitable; and to use their experience as the basis for continuing to learn. As Elisabeth Paice and her colleagues write, `House officers should be learning from experience under supervision, not from their mistakes'. So why are the matters raised in this issue of the journal a challenge to all medical teachers? Medical education is concerned with the education and training of doctors at all stages of their careers, and is no less a challenge in the first few years of professional life than it is at the undergraduate stage or in the continuing professional development of established clinicians. Arguably, these first years may be the most difficult challenge faced by teachers. Limited resources and growing demand, political pressures, and historical work practices all influence the culture and nature of the learning experience. McManus and colleagues show in their paper that there is considerable, and consistent, local variation in working practices, and in the treatment of doctors in training. They suggest that both the performance of hospitals/Trusts and the behaviour of consultants should be susceptible to change and improvement. Alan Bleakley in his Discussion Paper draws our attention to the cultural and socialising effects of the PRHO year. He describes an `extended curriculum' model of learning that calls into question the utility of the current passive learning mode so often used in hospital teaching. He characterises the ward team as a `community of practice'. Such communities work and learn together creating a style of practice, and in some cases this style can become stagnant and repetitive. Effective communities use the arrival of new members to question practice and learn new ways of working. The PRHO in such a team is encouraged to question ways of working rather than passively adopt existing ones, and is valued for this contribution rather than belittled, bullied or ignored. Alison Jones and the team from Manchester, UK, show that graduates from their new curriculum (based largely on integrated problem-based clinical and community experiences) are more effective communicators and team workers than graduates from the older traditional course. It will be interesting to see what effect such graduates have in shaping the communities of practice in which they will work in coming years. In coping with their distress some young doctors use avoidance (`refusing to believe something is happening'), or wishful thinking (`wishing the situation would somehow go away'). Medical educators should not fall into the same trap when thinking about this difficult period in the lives of clinicians. Paice and her team conclude their papers with some positive and practical suggestions for improvement. These include organisational matters such as ensuring close supervision and adequate cover for junior doctors during the early weeks and when colleagues are in theatre, and not forcing junior doctors to cope with difficult situations without easily accessible senior support. Educational strategies should include providing positive feedback, teaching, career advice and social interaction. Amongst these recommendations, the most important is the need for clinical colleagues and senior doctors to demonstrate good role models in relations with patients and with other clinical team members.1