Matthew Roycroft: Medicine’s generation gap—let’s stop comparing

The modern trainee wants exactly what doctors have always wanted: to see patients regularly, to diagnose, to treat, and to learn from those experiences

I recently heard a group of consultants talking about the junior doctors of today. I didn’t mean to overhear their conversation, but a few key words (“juniors” . . . “not the same” . . . ) caught my attention and I couldn’t help but listen. They were comparing modern day trainees to themselves at the same stage of training. They discussed how trainees often aren’t present for interesting cases, how competency progression is slower than it used to be, and how trainees spend less time on site than they have in the past.

Factually, I think much of what they said was accurate, but their language was highly critical. They also completely overlooked the systemic changes that have led to the differences in how junior doctors work now compared to previous decades—a common problem in discussions of medicine’s generation gap.

It’s become a truism to say that significant intergenerational differences have evolved over the past 50 years. Nowhere is this more obvious than within healthcare systems, where we have three distinct generations (the baby boomers, generation X, and generation Y), who are soon to be joined by a fourth (generation Z, the “digital natives”), all working closely together. It’s been pointed out that recent generations, although remaining career motivated, are far more demanding of flexibility and a work-life balance than previous generations, who are broadly seen as being hard working but possibly to the point of excess. Yet to understand the modern trainee, we need to not only appreciate the emerging cultural differences between generations, but also the changes that have happened to both medicine itself and our training over the same timeframe.

It’s true that training grade doctors now, for better or worse, work shorter hours than their predecessors, but those hours are incredibly psychologically demanding. The treatment options for most conditions have evolved massively and, consequently, so too has the potential for doctors to get it wrong. Rightly or wrongly, trainees worry about things like which combination of antiplatelets to give to patients after a myocardial infarction and stress about whether a troponin release is a type 1, 2, 3, or 4 myocardial infarction (and that’s just within cardiology). It really wasn’t all that many years ago that managing a heart attack was simple: aspirin and bedrest. The huge growth in treatment options for almost every condition means that decision making is more complex now than it’s ever been—simultaneously requiring greater knowledge and increasing the chance of errors, both of omission and commission. The stress of long hours has simply been replaced by a different kind of stress: that of shorter but more intense working.

And what of the changes to training itself? For good reasons, we moved nationally towards having a training system that is highly regulated and closely assessed, but this places heavy demands on doctors. Trainees are struggling to meet curriculum requirements due to the lack of time and opportunities set aside for this learning. I continually hear colleagues lament that time that could be spent on training and face to face patient contact is instead filled up with simple repetitive tasks that have less educational value.

It may be great for patients that their discharge letters are completed quickly and in great detail by an experienced trainee, but it has to be acknowledged that there’s a point (very early on in training) when the educational benefit of writing large numbers of letters every day significantly reduces. Similarly, there are only so many cannulas and catheters one has to insert to become highly competent. Finally, the shift towards “senior decision maker led care,” which again has fantastic potential benefits for patients in the here and now, is stopping juniors from seeing patients themselves. There’s only so much that can be learnt from observing. I can’t help but wonder if the reported increase in trainees taking time out of training is at least partly contributed to by trainees simply not feeling ready for the next stage of their career.

Of course, it’s not just junior doctors who are feeling the burden of increased bureaucracy. Senior clinicians are also overloaded with ever increasing demands, and without the time for all of them, they have to prioritise patients above everything else. While this is the right decision, it unfortunately means that there is less time for training, placing a strain on the trainee-trainer relationship. Where once it used to be a common occurrence to sit down over a cup of coffee after a ward round or clinic to discuss interesting cases or career plans, now this has to be timetabled in at the last minute—if it’s even possible at all.

Complicated and detailed reports have been written about how we could improve training, such as the Royal College of Physician’s (RCP) Keeping Medicine Brilliant. Yet, fundamentally, the modern training grade doctor wants exactly what doctors at their stage have always wanted: to see patients regularly, to diagnose, to treat, and to learn from those experiences.

If trainees can appreciate that their abilities genuinely are different to equivalently experienced doctors a decade or two before, and if their supervisors can appreciate that trainees themselves aren’t to blame for that, then hopefully we can finally move the discussion on to something useful. Rather than lamenting how modern juniors are not what they used to be, let’s start thinking about what we can do to improve things now within the constraints of the present system.

Matthew Roycroft is a leadership fellow working for the School of Medicine in Yorkshire and the Humber and an ST6 in geriatric medicine/GIM on the RCP’s Trainees’ Committee. All opinions are the author’s alone and don’t necessarily reflect the viewpoint of any other organisation.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.