The loss of continuity has repercussions on both sides of the patient–doctor relationship: reflections from the medical take

On a typically busy Sunday morning as the admitting medical registrar, I find a junior colleague somewhat reluctantly checking results from those he had seen the day before. He was keen to close a feedback loop second nature to any responsible doctor in training, which ingrains deep learning, accountability and ultimately a sense of pride over clinical decision making. With sadness, however, I could see a very real conflict here. Instead of working in a system that finds a way to nurture the instincts of a responsible trainee, it left him wracked by guilt, reluctant to desert his post on the ‘shop floor’ for just a few minutes as the strain facing the medical take mounted and the ‘to be seen’ column threatened a second page. The need for a debate about a realistic compromise between the needs of the service and those of the junior doctor working in general medicine has not been more acute. Without it, we risk turning keen aspiring medical doctors into robots who, by the end of a physically and emotionally exhausting shift, muster just enough energy to find a clerking proforma, print the ‘blood stickies’, and eventually find the patient who can now thankfully be removed from the endless ‘to be seen’ column. This is unfortunately a situation most juniors on the acute medical take are all too familiar with.

The configuration of acute medical services is evolving to accommodate a multitude of competing interests: patient flow, early consultant review and timely discharge to name a few. Optimal working patterns are clearly yet to be defined however, given that a recent Nuffield Trust survey into acute medical services in England found that in 50 hospitals, no two ran the same system. ¹ Most patients were found to be passed between up to five medical teams during a single stay with care fragmented and suffering from duplication at multiple levels. Now, this represents an opportune moment to forge a system that works for all. Solutions to improving existing acute medical services such as merging emergency department and acute medicine front door assessment, and increasing the availability and training of advanced nurse practitioners and physicians associates, are in different stages of adoption throughout the UK. ² We must not forget, however, the needs of the doctor in training, and prevent working patterns evolving that directly conflict their development. Failure to do so, and allowing solely management not professional need to dictate working patterns in acute medicine, risks turning a generation of junior doctors away from general medicine since this environment often informs the junior what a career in medicine may actually offer. This compounds the problem. To safeguard professional standards and lifelong learning, we have a responsibility to keep the medical take working for the doctor in training, not just vice versa. Hard work in medical admissions needs to be seen to pay on-call doctors a training return, instead of leaving them feeling that admissions is at best a necessary evil for progression through a medical career, and at worst desperate to get away from general medicine. This requires both the right service configuration and senior doctors who recognise their responsibility to embrace training in some form on the take no matter how busy it becomes.

Structuring medical rotas to provide adequate cover during busy periods within the limits of the European working time directive while leaving room for training is difficult. We often hear of the cost these competing pressures have on patient continuity and its importance in providing quality care is recognised at consultant level. ² Continuity is not a one way street, however, having positive repercussions for both sides of the doctor–patient relationship; contiguous patient–doctor relationships by definition impart accountability and learning. Formalising the chance for the junior doctor to see patients on both days 1 and 2 of admission by making an effort to embed continuity in medical rotas will improve patient experience, but also the training and morale of the medical workforce by keeping doctors professionally invested in the outcomes and experiences of the patients they see. We need doctors hungry to hear of the results of the handovers given the day before out of a sense of pride and in recognition of the power of that first consultation. Not just programmed to reach for the next clerking proforma day in day out, as they walk through the doors of the assessment unit.

We should be under no illusion of the damage that knee-jerk alterations to the working patterns of our junior workforce to accommodate admissions pressures may do and the huge disincentive to entering a medical specialty that such experience often represents. Finding solutions is difficult but mandatory. Securing the patient–doctor relationship through continuity must be at its core, having positive ramifications far beyond patient experience.