Disclaimer: This article relates to Junior Clinical Fellow post that is being offered to Masaryk graduates for several years in a row. It does not relate to Foundation Programme posts although in many ways they are similar. All views are my own and they are biased.
In this post I will discuss both good and bad about working as a junior doctor in Whiston Hospital and I will comment on the education, work environment and the culture of the NHS in general. I will also try to compare this to my experience as a doctor in the Czech Republic for those of you who are considering both.
Background
As a medical student I used mainly English textbooks as part of my studies for USMLE and therefore my views and standards of practice were (and still are) inclined towards American practice of medicine and postgraduate education. I graduated in 2017 and worked as an Internal Medicine Resident at St Anne’s University Hospital and University Hospital Brno. Although the work at the latter institution was much more rewarding, I was constantly frustrated by the reality of Czech postgraduate ‘education’ and healthcare ‘system’ (quotes intended). I left my family, friends and the country with my wife Klara and 1 year old son Daniel and moved to the UK.
Klara and I started to work as Junior Clinical Fellows in August 2018. I was offered post equivalent to FY2 due to my previous experience. We have been since working full time including on calls. Not having anyone who could help us with childcare has put extra stress on us and we had to juggle between work duties and childcare. (NB that this is an important factor in my overall experience). In early 2019 I got into a three-year training post in new Internal Medicine Training program and started as IMY1 in August 2019.
Application, Interview & Job Offer
All applicants have to apply through the online system before the deadline, listing all their experience and references. Interview itself is very structured and organised and panel of the interviewers follow pre-designed application scoring system known only to them. Successful candidates are selected only after all applicants have been interviewed.
In this way it is fairly just system. In contrast, in most places in Czech Republic interviews happen on a first come-first serve basis. Interview process is non-structured, biased and often includes discriminatory and illegal questions (for example about maternity plans, family background, etc). Candidates in Czech Republic are often selected based on networking and willingness to accept ridiculous conditions (part-time money for full time job, mandatory PhD to save money for the department, illegal overtime commitment, etc).
STHK offers full time job for full time money including on call commitment (compliant with European Working Time Directive) of less than 48 hours/week (on average). This includes some protected teaching time, 28 days of annual leave (including bank holidays), dedicated study leave time with allowance. Annual gross pay varies depending on the on-call frequency and grade (postgraduate year) and I will get to that part later.
Workplace
The new Whiston Hospital opened in 2010 and it is 956 bedded modern-built well-designed district general hospital. It has one of the busiest emergency departments in the region and it’s regional burns & plastics centre. Navigation in the hospital is really easy and you will not encounter not functional doors or signpost ‘This is not the entrance’ or ‘Exit next door’ (shout out to ICRC). Wards and corridors are clean and spacious. Patients’ rooms are either 4 bedded bays or single rooms (usually reserved for infection control or dying patients). All of them are spacious with curtains around them, patient’s own TV, phone, tray, wardrobe and comfortable bedside chair. All of the beds are height- and position-adjustable. Some of the bays include lifting mechanism installed in the ceiling to mobilise and transfer heavy patients.
Please note that not all NHS hospitals look like this. However, hospitals have redevelopment plans to maintain current standards of care. Me personally, I still prefer even the oldest hospitals here in the UK to the current state of post-soviet hospitals in the Czech Republic.
I don’t have to explain to students in Czech Republic what hospitals there look like. I felt constantly frustrated by their poor designs and lack of safety precautions. During winter pressures in University Hospital Brno a new ‘standard’ emerged and from 3 bedded rooms became 4 bedded rooms. In already crowded space they put another bed and suddenly there was absolutely no space to work in. There was no such thing as bedside. You could not do any bedside ultrasound (not that there was one) or procedure. On morning rounds to get to the patient you had to move the 30-year-old rusty tray and try not to spill everything that was on it. You could not safely handle or move patient because there was simply no space for it. Imagine cardiac arrest situation. Oh, don’t forget about asbestos.
On the other hand, one thing that is poorly designed in Whiston Hospital is the lack of doctors’ offices. Yes, there are some offices on the wards, however, these are tiny and cannot accommodate all the doctors working there. Computers are scarce and in era of digital patient notes this is horrific combination. Simply put, there is not enough workspace for all the personnel. You often have to passively aggressive push someone out to do your job. I personally find this as an unforgivable sin. Some of the wards are better than others but this is still true in general.
Education
Before I can comment on postgraduate education in Whiston Hospital you should familiarize yourself with general structure of medical training in the UK. Bear in mind that this subject could deserve an article on its own and that education was the number one thing I left Czech Republic for and therefore it is a very sensitive subject to me.
In the UK non-GP training is 9-10 years long on average, compared to 5 years in Czech Republic. This is a big consideration as achieved competences and certificates are not much transferable (that means they might ask you to re-do your training if you decide to come back to Czech Republic). However, I have limited knowledge about this and I advise you to seek more information.
To stay focused on 2 year post offered by STHK I will try and limit Education section only to the 2 years as a ‘Foundation’ Doctor (Junior Clinical Fellow).
E-Portfolio & Supervision
As a Junior Clinical Fellow you will be appointed into non-training post and you will not be supported or supervised by the North West Deanery. However, STHK will offer you almost all the educational opportunities as for trainee doctors and will treat you as almost equal. As I mentioned earlier you will have study leave allowance in Year 2. Most importantly, you will have named Educational supervisor and named Clinical supervisor who will oversee your training and clinical competencies. At the beginning of each post you will have to meet with your supervisors face to face and go through some basics. You will also have to develop your own Personal Development Plan and liaise with your supervisors how to achieve it. Supervisors will support you throughout and if you encounter any difficulties, they are the number one people to go to.
In a way this is unparalleled to situation in Czech Republic where you still need to have named supervisor, however, this is only hypothetical person. From my experience in two posts sponsored by Ministry of Health (Internal Medicine Residency) I spoke to each of the supervisors only once and very briefly over the phone. This was of course unrelated to my education and was about a clinical case. There never was any educational agreement and surely no support. Yet, a significant portion of the budget sponsored for my training was dedicated for their salary.
In the UK as a proof of clinical competencies you will have to maintain your portfolio. This should go in line with curriculum of the training post and the curriculum is clearly defined by Health Education England. (E-)Portfolio is more than just a logbook and consists of assessments, observed procedures, cases encountered, reflections, courses and lectures attended and many more. You may find it overly bureaucratic and pointless, however, when done well it is more than just a tick-box exercise and it will help you achieve things and prove your qualities. Most importantly, you will need to satisfy HEE requirements to advance into specialty training. More on that later.
Learning on the job
As in Czech Republic only very little time is spent on didactic teaching either on the wards, in skills lab or in lecture theater. Therefore you will have to learn on the job. However, the day job and the on call job is so different in nature and in learning opportunities that I have to discuss them separately. Majority of points discussed later are related to medicine only. I do not want to and due to little experience should not comment on surgical education.
Day job learning
See The job section below.
On-call learning
This is my (sadly) favourite part of the job. On calls are different to medicine and surgery and are different to FY1 and FY2 (or SHO).
Medical FY1 out of hours covers on 4-5 wards, each of around 32 patients. FY1s are first doctor-contacts for the nurses and if they need you to prescribe something or are concerned about the patient, they call FY1. Some say FY1s are just nurse-filters so other more senior doctors can do their jobs and honestly, it’s (sadly) true. FY1 on call deals with prescribing, discharge letters, reviews and management of unwell patients and (difficult) cannulation and bloods. They attend emergencies in form of Tier 1 calls and MET calls.
Medical SHO is much more interesting job. They review and clerk-in (admit) patients identified by A&E staff for admission to medical bed. They also support FY1s and troubleshoot on wards if needed. In Whiston Medical SHOs lead most of the MET calls.
To me acute take (medical admissions) is the most educational part of the job overall (mainly because I make it that way). This is the time with the most autonomy. During 12 hour on call shift I on average admit ~10 patients. The list is constantly busy and there are always patients waiting to be seen by the medical team. Therefore, there is never a time to rest and you work continuously (except obligatory breaks). Having said that, you will encounter a wide spectrum of medical problems. On average shift you will review and manage 2 acute coronary syndromes, 4 respiratory patients (COPD or asthma exacerbation, pneumonia), 2 frail patients and rest is a mixture of sepsis, meningitis, atrial fibrillation with rapid ventricular response, diabetic ketoacidosis, decompensated heart failure, acute kidney injury, decompensated cirrhosis and so on.
You will also have the opportunity to learn many of the procedures. Most of them should be learnt and performed during daytime but for some of them on calls are an excellent opportunity to practice. Common procedures are lumbar puncture, ascitic tap and drain, diagnostic and therapeutic pleural aspiration, chest drain using Seldinger’s technique, central lines or intraosseous access in emergencies. Blood cultures, peripheral cannulation, arterial blood gasses or urinary catheters are FY1 competencies.
In contrast to medical on calls in Czech Republic depending on where you work shifts are either 12 or 24+ hours long. Nights are usually not busy and you are allowed to sleep at night and admissions are mostly occasional. What I missed there is exposure to unwell patients with various presentations. What I admitted on call in Czech Republic in one month I see here in one night. While in Whiston you will appreciate autonomy while on call, in Czech Republic you will lack support. Seniors sleep and case discussion is considered as lack of competency and failure (see later in Support section). There were supportive seniors and I will always remember them. Common procedural skills were underdeveloped for multiple reasons: (1) there was no interest in performing procedures that could be done by a specialist in their department (for example chest drains); (2) supervision was limited and shortcuts were taught due to budget, staff or equipment limitations; (3) speciality specific patients.
On the other hand, in Czech Republic you could get early exposure to specialty skills. For example, there is inappropriate overuse of central lines for venous access. However, this is an excellent opportunity for doctors to develop these advanced skills. Similarly, you could learn how to implant pacemaker, perform echo, aspirate bone marrow, do lumbar puncture or chest drain depending on where you worked. This applies to any speciality and any procedure. They are taught early and performed non-lex artis because of lack of standards, staff and equipment. Ultrasound is underused because it is not available and because of old-school habits (use of US guidance is considered as lack of skill). While this is appreciated in specialists even abroad (they are very skillful with their bare hands) it is not safe practice in modern medicine.
Being more than just a Medic
As part of postgraduate training (in Foundation program or later on) you will have to continuously develop skills other than medical ones. The doctor is more than just a textbook and golden hands. Remember that you will become leaders of health organisations and therefore you will need to develop leadership skills. This will happen formally and informally. You will lead with or without authority – junior doctors, nurses, non-medical staff, department or the whole hospital. You will also teach constantly, improve service, design systems and develop safety mechanisms, reflect on your practice and review practice of others. You will use and do research.
Many of these skills you will develop naturally or just with time and some energy. That is because training in the UK is built around service provision and they want you to have these skills. It might sound silly but there is absolutely no focus on this in Czech Republic in general (big applause to workplaces who focus on these skills).
Conclusion
Czech postgraduate training lacks meaningful (and well defined) curriculum requirements. Supervision is only on paper. However, it is less bureaucratic and easier to achieve. It is more speciality focused and you will become a specialist.
Training in in Whiston (and UK general) is more supervised and more structured, well defined but can be too much of tickbox exercise and is incredibly long. There is not much of a didactic teaching and more of reflecting. To do well in career you have to do loads of expensive courses that no study leave allowance can help you fully with.
The job
During the day in medicine you will do the same job as FY1, FY2, CT1 or CT2. It is only a matter of how well.
On average, one junior doctor looks after 12 patients (8-16). Every day starts at 9am usually with some form of board round with an update on the overnight events. This is very dependent on how well the ward is functioning. Then all of the patients will get seen and that usually takes 3-4 hours. This is very time consuming because everything needs documenting. Notes are over inflated with useless, repetitive and often incorrect information. Important information is often lost. There are no such things as brief summary sheets (ICU is an exception to the rule).
There is consultant-led ward round at least twice a week on most medical wards (sometimes three times a week). That means that consultant is reviewing patients him/her-self. Junior doctor assists consultant during the review most of the time only with administrative and computer stuff. I personally hate this aspect of the job as I feel like overqualified personal assistant. I do not get to examine the patients and at the end of the ward round you are left with clerical jobs – send referrals (oh, and we use fax machines), request investigations, discuss with other specialities, take bloods, do cannulas and all the non-doctor things. Sometimes people get unwell later and you need to step up and review them.
Because I have some background in IT, I find computer systems in Whiston very bad (although since my time here there have been improvements). Feeling unsupported by IT with quite often non-functioning systems, printers and faxes, your job takes much more time to do.
Nurses are frequently not trained to do (or really bad with) things like cannulation, taking bloods, do urinary catheters. And at the end of the day, it is a junior doctor’s shared responsibility to do it.
Due to on-call commitment junior doctors are frequently off the ward and cross-cover each other. Therefore, there is not much of the continuity of the care and often no one has a clue what is going on with the patient.
When you are left with all the clerical staff on the ward where you cannot rely on the nurses you are set up for a bad day. Unfortunately, this happens more often than I would like it to. Lot of junior doctors stay frequently overtime to finish all the jobs and have no time to rest. This will happen anywhere in the world in the field of medicine and is not something specific to Whiston. I often had no time to have a break. It was only with experience I learned to decide what is important and what not, what can wait and what needs sorting straight away.
However, things like these should not happen and there is a system for Exception reporting in place. It has been there for a while. Yet, here we are…
Support
As mentioned in the Education section, all working doctors have clear grades and chain of command is established. If FY1 should encounter a problem that he or she not resolve independently, it should be escalated to SHO grade (FY2-CT2). Similarly, SHO escalates to Registrar (ST3+) and in theory, Registrar to Consultant. Everyone except consultants carries a bleep (pager) and is, in theory, immediately contactable.
The level of support you will appreciate mostly out of hours. Nights are busy and you are constantly in between 3-4 things. You can contact your senior doctor any time as no one is sleeping. In the beginning of your training as F1, they expect you to discuss most of the things and they expect getting bleeps about all the trivial things. This is normal and when provided with support, fresh doctors are getting more and more confident. When they lack confidence, knowledge or ability to do certain tasks, senior will take over (when appropriate and needed).
Now, you might have heard stories about what on calls and working on wards look like in Czech Republic. I worked in tertiary centre that was well staffed and well supported. I always had a senior doctor in the house to discuss case with. However, they were sleeping most of the time and depending on personality, they might have not wanted to be disturbed. Sometimes, discussing clinical problems was considered as a sign of professional weakness. This really depends on the individual department you might work in. As for me, I certainly feel one hundred percent more supported in Whiston Hospital that I ever felt in Czech Republic. Day or night.
It should be noted that poor Clinical supervision out of hours at STHK was identified in National Training Survey in three consecutive years (newer results are not available to me).
Pay
The topic of pay is very sensitive and I will share my opinion and my perception. Just remember that I have caring responsibilities and hence my needs go in line with that.
As a Junior Clinical Fellow, we were getting net pay (after taxes, pension and insurance deductions) around £2000 and £2500 monthly in Year 1 and Year 2, respectively. Salary is made of basic salary and additional on call commitment. How does it compare to formal FY1 and FY2 I do not know. However, as IMT1 I am getting only slightly more than I was as JCF Year 2. This goes with rumour that I heard, that Junior Clinical Fellows earn slightly more than their Foundation counterparts.
The downside is that as Junior Clinical Fellow your pensionable income is made only of the basic salary and that is significantly less to the Foundation trainees. In formal training post your on-call commitment is, from the most part, included in your basic salary and is therefore pensionable.
If the pay is adequate your responsibilities and work, one can argue. I certainly feel that doctors in NHS should earn more and be taxed less.
Culture
Culture as a shared goals, values, beliefs, expectations and practices is something that, in my honest opinion, is STHK most noticeable for. And it is fundamentally different to anything you can experience in Czech Republic.
Trust set its vision to provide high quality care focused on the 5 pillars of patient care that they smartly market as 5 star patient care. The trust in 2019 received overall Outstanding rating by CQC which is something they should and are rightfully proud of. And you can tell that when you talk to the staff in the hospital. Every now and then there are campaigns promoting new improvement projects. Overall, this spirals in even more funds, more improvements and healthier culture. Trust was awarded many prizes in providing patient care and as an employer.
Video above is one of the many examples that Trust is really proud of what they are doing. That positive environment is really something that you need to experience for yourself to appreciate it.
The culture you will face in Czech Republic is unfortunately quite the opposite. If you will work in hospital or department with positive attitude and motivation to make changes and improve, hold onto that. From my experiences, every challenge and opportunity is dismissed due to financial situation, poor staffing, training curriculum problems, finance or just political reasons. Honestly, culture in Czech Republic on average is so sad and so backward thinking that the less of it you will experience the better.
Friendliness & Professionalism
Staff in Whiston Hospital is extremely friendly that to some degree it took me time to adjust. Everyone will smile at you naturally and you will develop this subconscious habit yourself. When communicating with other healthcare professionals in the hospital you will very rarely encounter someone rude or unprofessional. Even with very stupid questions, maybe as part of British culture, they will be nice to you and try to be helpful as much as they can.
It goes without saying that harassment, abuse, violence and racism have zero tolerance.
Learning from errors
As mentioned above, one of the pillars that STHK is focused on is patient safety and systems. This is a topic that I am more and more interested in (and you should too). If you have not realised it by now but healthcare is a high-risk industry but with low reliability. Methods that turned aviation industry into much safer and reliable industry are now being implemented into medicine as well. Checklists, guidelines and safety checks are being used more than ever and are here to stay.
In the UK, USA and other high-income countries they do realise this and implement these systems in practice. In Whiston Hospital they have reporting system in place that will investigate errors from as simple as mislabeling patient note to as severe as intentional negligence. Lessons are learned and if systematic error is identified, system is replaced by a new one.
You might have already noticed some systematic errors in Czech Republic or might have witnessed unintentional error. I witnessed severe harms that I do not want to speak of. But for example, of minor ones, prescription errors happen all the time. Unfortunately, the problem is even if you work in the system you will not realise it as there is no preventive measure to alert you or stop you.
Defensive medicine
One of the things that I really hate about working in the NHS and is not necessarily Whiston-specific, is the culture of defensive medicine. Due to fear of litigation, every single concern and complaint needs to be addressed. Patients are overinvestigated and overtreated. Almost every infection is considered sepsis. You need to be signed off and trained for everything. On paper it looks like a high standard but in practice it is just another bureaucracy or barrier to delivery of care.
Sometimes I miss simple days in Czech Republic when training is not needed (nor existent) and complaints are addressed by showing the doors. Medical negligence is not such a great deal. On the other hand, is this the care that you would want for your parents?
Moving forward
At the end of the two-year Junior Clinical Fellow programme, you might decide to continue with and apply for the training. Nowadays because of the rota inflexibility increasing number of Foundation trainees choose to take an extra year – F3 year and do locum shifts, earn money, travel, work on portfolio and apply for training afterwards.
If you decide to go into training you would have to obtain the Certificate of Readiness to enter Specialty Training. This is an important and across specialties standardised paper that proves that your competencies are equivalent to those of Foundation trainees. As default, in Whiston you will get this certificate at the end of the second year (July). This will delay your progress into the training as applications open in November every year and you need to have the letter. Therefore, under standard circumstances, you still would have to take an extra year out to progress into training (ST1/CT1/IMT1 grade).
However, Certificate of Readiness to enter Specialty Training can be issued by any consultant or GP that you have worked with for consecutive 3 months or more. Therefore, if you know what to do, you can get the certificate as early as November of your F2 year and apply straight away. Czech graduates often do not know that.
Watch my talk on MUDr Talks briefly explaining how to enter speciality training if you are international (Masaryk University) medical graduate.
The great question
So, should you leave Czech Republic for Whiston Hospital? It depends on many factors and only you can decide for yourself.
If you are a Czech cohort Masaryk graduate, I can recommend the two-year Junior Clinical Fellow post in Whiston. It is a good taste of what certain standard of practice should look like. You will have some educational opportunities and it will be up to you how will you use them. Even if you decide to go back to Czech Republic you will have experience that should be appreciated and no one will take away from you.
However, if you are a UK national and know your way around, I would look out for official Foundation Training programme posts or standalone FY2 posts in hospitals with better staffing ratio, more flexible rota and ability to choose posts in line with your desired specialty and career goals.
Having said everything above, bear in mind that it is still a job. No matter what, it is still a job that you will love and hate. You are recruited to provide service with the opportunity to develop yourself along the way. Not the other way around. The trick is to know about it from the beginning and know how to play with the system. Otherwise, the system will play with you.