Given that a considerable proportion of a junior doctor’s life was spent at work, interactions with other staff and patients were of marked significance to experiences of the workplace and as such featured strongly in doctors’ accounts.
106 Socialisation and support
Graham chose junior posts at District General Hospitals (DGHs) and smaller units, in teams with which he became familiar as a medical student or of which he had heard good reports and where he expected to work happily. His narrative was dominated by social interactions, by camaraderie between colleagues who readily supported each other and enjoyed spending time on ward-based activities. Since on-site doctors’ accommodation units at both hospitals functioned as an off-duty venue for socialising, he regularly spent time there with colleagues who he regarded as friends. Learning was exciting. He was able to get to know all the patients under his care. When needed, support and expertise were available. Working 100 hours in the week was perfectly acceptable;
‘You really did feel a valued member and it was kind of, not quite a holiday, but an experience, an expedition that you all did together…it was good fun, and you learned a lot and … because it wasn’t a teaching hospital and you were a bit more independent, you could go and do things like insert chest drains and things like that, rather than have the middle grade doctors do it all, you could do it as a junior.’ Graham
With forward planning, Graham’s choices facilitated higher levels of socialisation and autonomy and he was able to practice technical skills which proved useful later in his career.
Inspirational teachers
Exposure to the influence of a single inspirational teacher can steer entire careers; which for John was to immerse him in quite different specialist arena. His story was somewhat animated and clearly he expected everyone to remember a pathology teacher whose colourful demonstrations of knowledge had inspired him;
‘BG was a very, very fantastic teacher, people used to sit there in awe… it was like wallpaper, you had all these stains…blue, red, pink, yellow… meetings where he would take the piss out of the clinicians for being crap you know, he put up all these things, ‘Oh, [a clinician] got it wrong, I mean look at this you know, ha, ha’ ..
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and everyone was ‘Oh fantastic B’...he would put together a whole case about …all the organs that were going wrong. Fantastic.’ John
Others stated their inspiration more mutely; for Jennie it was her GP trainer whose practice of spending time getting close to patients matched her own preferences and to which she attributed her career-long habit of getting ‘very involved’ with patients. Stewart’s trainer influenced him in several ways;
‘I did a joint surgery with him on about my second day in and this girl made a big fuss …she wanted to see Dr S and wouldn’t see anyone else. And she came in with a sore throat and went out with the pill … I had no idea that that happened…And generally his whole attitude… he was knowledgeable but very self-effacing … was interested in detail and that was one of the things that inspired me.’ Stewart
Impressive clinical knowledge, an attitude towards patients which resonated with a young doctor, or a package of skills and attitudes, the various attributes of these inspirational teachers had proved durable.
Competitive strategies
Contrasting stories emerged from workplaces with more hierarchical structures; Alice found the academic competition there was ‘just ruthless’ while George who was pushed to his limits trying to keep pace with work demands, recalled attitudes of colleagues only slightly more experienced than himself;
‘..within that machine … were a couple of people in the middle of it who I just disliked because I thought they were snakey, challenging, hierarchical people who wanted to prove me wrong, who wanted to say to the consultant ‘He’s admitted [the patient], then he has done this and he has forgot to do that and thank goodness I rescued it and can I now get a foot on the ladder please?’’.’ George
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Here George sensed no patient-centred care; emphasis was on formulating a clever diagnosis and making your mark as a clinician worthy of recognition and promotion. He described those doctors as;
‘a hideous group of people who were climbing up each other’s backs…the hierarchy, the pecking order, the stress [of professional exams]… and all those things made them not nice people.’ George
His adopted mental attitude was to ‘take the battering of it for that short lived period …and soldier on’, but he felt that in doing so, in behaving as a ‘tool in a machine’, a sense of compassion was lost and he had encountered working practices which did not foster positive development of his clinical mentality; pressure and criticism forced him to adopt survival strategies.
Bullying
More serious for those who encountered it was bullying behaviour which had longer term consequences. Having chosen to work on the team of a consultant she had idolised as a medical student, Alice became ‘the butt of his slagging and it was the job from hell’. Not only was she expected to underpin the team by staying late to complete the most mundane duties, she found his attitude sarcastic and damaging to the extent that she declared herself almost broken by it and was driven to confronting him about how her opinion of him had changed because of his unreasonable (and unprofessional) behaviour.
A slight improvement appeared to follow this difficult conversation (and her tears) but she was later informed by other consultants that he was ‘blocking references; and so he tried very hard ….to make sure I didn’t get a job’. Only after Alice removed him from her list of referees was she invited to interviews and able to progress – fortunate that other consultants had not closed ranks to support his actions. This entire episode came as quite a shock;
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‘...it really upset me that somebody could get such joy out of somebody working hard and picking holes in it, I think that was a revelation to me that people would behave like [that].’ Alice
Expectations of fair and ethical behaviour were clearly breached leaving Alice in shocked disappointment with this senior consultant.
Unfairness also affected Helen who despite total commitment felt little support and regularly experienced overt and public criticism from her consultant. She felt humiliated by criticism if was she was not promptly present for a ward round and perceived senior nurses unresponsive when asked for support in caring for severely ill patients.
Table 2 Transcript extract, Helen
The data extract above picks out a long-remembered moment when a peripheral team colleague witnessed her exhausted distress and with the smallest of gestures supported her determined but very real struggle to survive (and is shown in raw form for comparison with a later poem).
Oh it was terrible, it was a 2 in 3. [laughs] I didn’t get, I don’t think I actually sniffed fresh air for 3 months , absolutely dreadful in terms of bullying from nursing staff , bullying from consultants , no rest, exhaustion just shat on really it was horrible. Awful. Awful. And [I] remember one moment one day where I was crying in the treatment room , because I was making up the IVs and I was so tired and the pharmacist who was the only friendly person on the ward , saw I was upset , gave me a cuddle and came and bought me a box of jelly babies . [laughs].
110 Relationships with patients
Although Jennie’s narrative skated lightly over pre-registration hospital posts she returned to reflect on how she developed in her ability and preference for establishing close, longer-term relationships with patients and recalled how they expressed appreciation. She recalled chatting and making jokes with inpatients and being touched by their responses;
‘...there was a lung cancer patient and I remember, in fact, I have still got it; he wrote poems about me’ Jennie
Not only did she spend time getting close to patients and their problems as a junior doctor, but the same pattern of empathic concern which was established then continued throughout her career.
Graham recalled how he and his colleagues used to divide their time between assisting in operating theatres and closer working with patients;
‘You would go in and help them do the surgery bit, which was fun, but after a while the novelty wears off and you would rather be back on the wards, thinking and doing things, you know, for patients.’ Graham
Clearly Graham and his colleagues were less curtailed than some in how they organised their work, able to choose when to return to tasks which affected smooth running of patient care – and they made certain to enjoy both learning together and socialising in the on-site Doctor’s Residence.