Dave Caesar column: Unravelling medical staffing

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COLLEAGUES and I have spent the last two months meeting members of the public in West Lothian to explain how we are hoping to provide their services, including the Emergency Department at St John’s Hospital, Livingston, and what the staffing of these services will be.

There is no doubt that the way medical staffing is structured in hospitals is pretty complicated, and I will attempt to explain it a little here.

It may surprise you to learn firstly that, as the clinical director of a service, such as the emergency department, I actually have very limited influence over who works in the departments I have responsibility for.

This is because our medical staff fall into two main groups – those that are doctors in training, and those who are in posts having completed, or stepped out of medical training ­programmes.

Doctors in training come through a variety of routes to the ED. They are termed a variety of things – junior doctors, core trainees, foundation doctors, clinical development fellows, higher specialist trainees and many others that are unprintable.

These members of staff could be training for a career in a medical or surgical specialty, anaesthesia, intensive care medicine, or to be a GP.

Only a minority are actually training in Emergency Medicine. Many will not have decided which career path they intend to follow. Some will spend four months in our ED, some six months, some a year.

No matter where they are in their training, or which route they are following, they are usually collectively termed “junior doctors”. This sometimes throws up images of spotty 17-year-old trembling kids on a work placement, but these doctors are all incredibly bright, have all completed at least five years at medical school, obtained a hard-fought for degree, and then will have at least one year of post-graduate work in hospital under their belts.

The higher specialist trainees could have been working for six, seven, sometimes ten years post-graduation, and are highly-skilled doctors.

Despite their undoubted experience it is still vital that our junior doctors are supported by senior consultant staff. This helps to ensure that they develop their skills and constantly achieve the quality and patient safety standards we expect.

But really, the term “junior” only reflects the fact that they remain in training posts. They, in fact, are the engine of many services, including emergency medicine – the guys and girls at the sharp end – and also the innovators, the fresh eyes and minds that challenge us to improve and lead the way to a better future for patients.

Sometimes, the potential that lies within this group is obscured by the pressure we all feel to provide our service in the face of high demand and intensity of practice.

This group of junior doctors are employed by the post-graduate deanery which covers south-east Scotland. The deanery decides on the number of trainees and rotations these doctors have through services.

I, as a service provider, have very little say in who or how many junior doctors may come our way. What I am more able to influence is the number of doctors in the other group – those that have completed training (consultants /senior doctors), or those that have stepped out of training schemes (specialty doctors).

This group of staff can be employed by service leads, but to do so requires two essential ingredients. It has to have the backing of our organisation to commit to the financial implications and there also have to be appropriately trained doctors who are able to function at that level of specialism, as well as want to work in our ED.

The first condition has traditionally been a difficult one, but, I am pleased to say, the importance of having senior medical staff in the ED in recognising acute illness, improving patient outcomes and experience, and managing patients more satisfactorily, whether admitted to or discharged from hospital, has been well recognised by both NHS Lothian and the Scottish Government, and we have been extremely well-supported to recruit senior doctors to all three emergency departments in Lothian.

The second condition has had an extraordinary amount of coverage in the media in the last year or so. What we lack in the whole of the UK is enough doctors who are choosing emergency medicine as a career path, and therefore the demand for these specialists is currently outstripping the supply by some margin. I still passionately believe that our specialty offers unrivalled variety, excitement, and clinical gratification, whilst our working environment, though occasionally oppressive, is unbeatable for team-working, camaraderie, and enjoyment.

So, in summary, don’t be disheartened if you are seen by a “junior” – they are likely to be an extraordinary individual – and there is more likely than ever to be a consultant right behind them to coach them towards the best management.

Dave Caesar is clinical director of emergency medicine, Edinburgh Royal Infirmary and St John’s Hospital, Livingston