Personal views: One pilot son, one medical son
Authors: Ewan Macdonald
Journal: BMJ (2002)

Some time ago two of our sons went “off the payroll”—for the last time, I hope. The nature of lifelong learning is such that our eldest, at the age of 28, is now pursuing his third career post-university, and is a commercial airline pilot. Our second son started work as a preregistration house officer eight years after leaving school. He had the obligatory year out to see the world and did a two year intercalated BSc in sports medicine.


On starting work my pilot son's first 18 flights were always with a third, safety pilot, and for the next 20 flights he was always with a training captain. He was finally allowed full operational work after having acquired and demonstrated the appropriate competencies. He works in a profession where there is a planned programme of professional development and has regular evaluation. On overnight stops he gets accommodation in four or five star hotels. He regularly undergoes a health assessment to ensure his fitness. He is allowed to fly a maximum of 100 hours per four-week period. 


My medical son will continue to work in an environment that is demonstrably psychotoxic



My medical son, meanwhile, started his career with a shift lasting 26 hours during which he had no sleep, rest, or food. During this first night he had some dealings with a sick drug misuser, who subsequently died from overwhelming infection. Because of a cluster of such deaths in the region the local public health department, the police, and the procurator fiscal showed considerable interest in the case. The police interviewed my son's colleagues aggressively. This was my son's initiation to the stresses of working in the NHS as a junior doctor.

The intensity of work as a PRHO was high. Shifts of up to 32 hours were a regular feature. While my pilot son's job has continually enthused and inspired him, my medical son's experience has been different. After the first three months I thought he was depressed—certainly he was alienated and worn down. Since then he has adapted and coped, but one of his contemporaries resigned. There was no locum cover for two months. My son then developed an acute soft tissue infection that required treatment with intravenous antibiotics and subsequent surgery. During the two weeks he was off, there was again no locum. Colleagues had to cover his rota and as a result he felt under considerable pressure to return to work against medical advice.

In the light of my sons' career development, I have been reflecting on the current interest in doctors' performance, clinical governance, and revalidation. My impression is that government spin doctors have orchestrated some of the public concern to feed the media in the hope of distracting the public from political failures to deliver improvements in health care. I have no doubt that the General Medical Council processes to deal with poorly performing doctors are highly developed, sophisticated, evidence based, fair, and thorough. I have no doubt that doctors, like pilots, should be periodically evaluated to ensure that they are still competent. However, the NHS approach to clinical errors is way behind the system in the airline industry.

I welcome the recent reductions in junior doctors' hours, but these come at the expense of more senior doctors, especially consultants. As a stressed senior consultant said to me recently of junior doctors, “They are less confident, less competent, and at five o'clock they go home.” Over the past 10 years there has been a 50% increase in NHS activity, without a concomitant increase in resources. Increasingly I see stressed, burnt out, and alienated consultants and senior general practitioners. When I was a medical registrar, 12 acute admissions in 24 hours was normal. Now 30 or 40 are routine.

The culture of medicine is to respond heroically to patients' needs and the demands of the service. Ultimately, however, this seems to be resulting in more and more doctors leaving as soon as their pension benefits allow, which exacerbates the manpower problem. The BMA, the royal colleges, and the GMC have tended to focus too much on the easy target of the performance and competence of doctors, but fail to deal with the context in which doctors are working. They are not putting enough effort into defining what is an acceptable workload and what are the parameters of a safe, healthy working environment.

And what of my sons' futures? My pilot son will continue to have regular health checks, strictly regulated working hours, and rest periods. He will receive planned retraining and routine evaluation of performance, and will work in a supportive psychosocial environment. My medical son will continue to work in an environment that is demonstrably psychotoxic, and for a system that strives to meet political rather than health targets, where there is limitless demand, and where the concept of a safe working environment is poorly developed.

Surely it is time we depoliticise the health service so that we can have some coherent long term planning to improve the public's health and maintain the wellbeing of all healthcare workers.