Personal Views: Hospital doctors need a new career structure
Authors: Graham Read
Journal: BMJ (2005)

Change may occur by diktat, evolution, or default. So how did we move from a “consultant led” to a “consultant provided” service? Has anybody thought through the consequences? When I first entered medicine hospital doctors often did not become consultants, particularly in surgical specialties, until they were well into their 40s. In true Lancelot Spratt style consultants then had an impressive retinue: senior and junior registrars, senior house officers, and—in one instance I can remember—a “first assistant.”

Doctors often preferred treatment by senior registrars for themselves or their families because they were usually the most up to date and had the most immediate hands-on experience. They were certainly experienced practitioners with a great deal of independence. Unfortunately they were still called “junior” doctors.

The system ensured that the burden of on-call work finally passed, so that when a doctor finally became a consultant he (it usually was a he in those days) could be consulted about difficult cases, which he then had the time to deal with because he did not have the burden of dealing with every patient himself. The consultant had time to teach, be a politician, and, in some cases, practise privately.


In few other professions does career progression end at the age of 30


It went without saying that everybody in the hierarchy had a service role, for learning was by apprenticeship. As a preregistration houseman my job was to ensure that every patient was properly clerked and that all the relevant investigations were ordered and the results known by the time of the weekly consultant ward round. If I didn't do it the job was not done.

Of course, this system had many unsatisfactory elements, and much discrimination existed. I knew many surgical aspirants who went into general practice or some other branch of medicine because in the end they failed to achieve the glittering prize of becoming a consultant.

How everything has changed. First registrars (no longer a distinction between senior and junior) and then house officers and senior house officers were designated as “training posts” and therefore above being required to do mere service work. As a clinical director I was once castigated because the senior house officers on our ward were doing too many tasks that were deemed “educationally unproductive.” I never received a reply to my question as to which tasks this referred to. Was it clerking a patient with a condition they had seen before, writing a prescription for a “take home” drug, or perhaps seeing patients at all? Now I am no longer permitted to have a separate clinic list for a registrar, because he or she must be supernumerary, being there only to be taught and not to have any service “commitment.” If the registrar is away the service does not suffer, but when I am away no one does my clinic.

I once asked an applicant for a surgical consultant post how many operations of a particular type he had performed on his own. The answer was zero: he had never operated without his chief. What kind of doctors are we training who have never had to undertake a clinic unaided or cope alone with an unexpected event during surgery?

In few other professions does career progression end at the age of 30. Consultants are being trained in increasingly narrow spheres, because that is all they can achieve by that age with the limited hours now available to them. I have seen advertisements for a cleft lip surgeon; but who will want to spend 35 years doing only one type of operation?

Surely most consultants will become bored after working for 10 years in a narrow field, especially one with little development? A bored consultant will not perform to the highest standard. Ageing affects us all, but under the new pension scheme we will still be expected to continue to be on call and perform with the same dexterity until the age of 65. I suspect that in a few years consultants will be expected to look after their own ward patients when the last of the senior house officers become “educational.” My own general medical skills have suffered considerable attrition over the years; how will consultants of the future maintain these skills—if they ever have them—as well as their specialist ones?

At present the intention seems to be to train consultants in the shortest possible time so as to churn out work to fulfil government targets. The consultant is the only “approved” permanent career post in hospitals, although of course there are many people in staff or associate grades who are somehow not part of the system and lack both recognition and the opportunity to progress. Other professions do not have only one grade. Can you imagine a bank that has only branch managers?

Is it not time to devise a new career structure for hospital doctors that will allow varying degrees of specialisation, responsibility, and hours of working? We need much more flexibility than exists at present for hospital doctors to be able to move to other specialties, seek new challenges, or work in different ways so they can have sustained, fulfilled working lives.