Unravelling Medical Staffing

Colleagues and I have spent the last 2 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 like with the well-publicised difficulties in recruiting some tiers of medical staff.  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 2 main groups - those that are doctors in training, and those who are in posts having completed or stepped out of medical training programmes.

Those doctors who are 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, muggins, and many others that are unprintable - and, in the Emergency Department, 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 4 months in our ED, some 6 months, some 1 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 17yr old trembling kids on a work placement, but these doctors are all incredibly bright, have all completed at least 5 years at medical school and obtained a hard-fought for degree, and then will have at least 1 year of post-graduate work in hospital.  The higher specialist trainees could have been working for 6, 7, sometimes 10 years post-graduation, and are highly-skilled doctors. 

The "junior" term 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, and their numbers and rotations through services, by the post-graduate Deanery (which covers South East Scotland).  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 2 essential ingredients.  It has to have the backing of our organisation to commit to the financial burden of employing Consultants in Emergency Medicine, or Specialty Doctors in EM, 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 EDs. 

The first condition has traditionally been a difficult one for us, but, I am pleased to say, the importance of having senior medical staff in the Emergency Department 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 our NHS organisation and the Scottish Government, and we have been extremely well-supported to recruit senior doctors to all 3 EDs in NHS 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 an extraordinary individual - and there is more likely than ever to be a consultant right behind them to coach them towards the best management.