Dr Who? - Continuity of Care at a Junior Level Is Non-Existent

15/02/2013 17:03 GMT | Updated 16/04/2013 10:12 BST

Concerns regarding the hours over or under worked by junior doctors presumed indolent are frequently highlighted in today's media and of course by seniors who view any form of hedonism a sin serving to voice their opinions through the classic, 'Back in my day,' paradigm.

From a personal level I would be hard pushed to agree with comments concerning a '9 to 5' culture in the NHS. It just doesn't exist. Of course the aim to limit working beyond contractual hours has been cemented courtesy of the EWTD. But as most hospital juniors would agree departing often two hours post duty is a frequent occurrence. It is all too common for example that at thirty minutes past four, when most of the necessary undertakings have been performed for inpatients reviewed that morning, to engage in updating patient handover lists for the on call team and review investigation results, acting in accordance. This is also the ideal time to finally get a moment to speak to relatives about on-going care, something we always feel needs addressing earlier but is just physically impossible to do. Add to this the often expected bleep from a ward nurse informing you that one of the patients you saw earlier that day who essentially was just waiting for social input has now suddenly become less responsive and needs urgent input. To all the juniors out there let's unite on this point.

During a period totalling 10 months of my training, governed as a 6 and 4 monthly rotation at separate hospitals I had the experience of simply being, as I would put it, non existent, not only to the world at large but more importantly to my patients. And such a pattern of labour in the NHS is becoming ever so prevalent. The rotas at the time consisted of working 12 hour shifts in series, either 3 or 4 days at a time, with an exit away from the hospital in a mostly house bound state for a maximum of 2 to 3 days to then return to say for example a stretch of night shifts for up to 4 days. The pattern would then recycle with an inclusion of annual leave as appropriate, usually a 9 day lieu period every 4 months. The time spent during these rotations were not typical work environments of a morning ward round with your team members, but more of an independent factory worker admitting patients as they arrive, presenting your findings sporadically later that day or early in the morning if working a night shift for example. Some readers may feel this shift system is not workable, but the reality is the body can adapt fairly easily and so it is not such a grave concern. Maybe these comments won't bode well with advocates of patient safety but to revisit the 'back in my day' police the current hours expected to be worked are much more tolerable than was the case previously. My concern however festers in essentially not being able to finish what you have started.

With this pattern of working, juniors are continually bombarded with a fresh set of faces and the patients cared for the day before are simply a distant memory, thrusted into the hands of others. Often as juniors we tend to look up any investigations ordered for the patients we previously admitted and may even go in person to see the atypical cases not really fitting a diagnosis at the time of presentation. But it is not always possible to remain in close watch. One can only question therefore the ramifications this poses from a teaching and learning perspective? And add to this, a point which I feel ranks higher in priority, is from the patient's perspective; what must they be thinking? Do they think we now no longer work there? Or are not suitable to manage them any further? Or simply don't care about their progress? And what's worse still is for them having to explain their symptoms and concerns repeatedly to an array of different medical workers. After a while you would surely choose to give up if the personal touch just isn't there right? As a consequence, if patients then don't narrate fully what they may have told a previous doctor this could have implications on their further care and conclusions about the cause of their symptoms.

Simon Sinek, synonymous with the concept of the Golden Circle (Why? How? What?) refers to the fact that people invest into 'Why' we do what we do as it is closely related to our brain's limbic system which is responsible for our feelings and behaviour. By 'Why' he expands by questioning what is our purpose, our cause and our belief, why does our organisation exist, why do we get out of bed in the morning and why should anyone care?

Transferring this ideology to the health system, if the NHS continues blithely to enact such poor continuity of care, we risk losing our patient's investment in 'Why' for example doctors became doctors in the first place. It certainly wasn't to deliver second rate fragmented care that is forced upon us from operational panjandrums.