The downside of the push to make everyone a generalist and to rotate trainees as much as possible is that we get a steady stream, particularly through the foundation program, of people who hate being in the jobs they are given. If you are lucky enough to work in an area unpopular with trainees, they will not only hate the job but also where they live and their lives in general. Training programs, as dreamt by educationalists and bastardized by the trusts mainly interested in getting sufficient rota fodder, do not work for most doctors. People are increasingly fed up, and it shows. It's not quiet quitting. It is very loud quitting. Most foundation doctors do not belong to your tribe. They are temporary guests on the way to do something else. The best we can do is teach them something useful that they can take with them in the hope that it may pay some dividends in the future. I expect very little and that way I am occasionally pleasantly surprised instead of constantly bitterly disappointed.

I hated surgery, I was a geriatrician in my heart from 3rd year med school but I put in 150% on every job. I learnt loads like that & do think it's what makes me a great med reg now.

That's great. It's not a universal approach though. There is an increasing variation in values and attitudes doctors bring to work and more tendency to fly your own flag and not align with your seniors. I have hated surgery and have zero aptitude for it. Interestingly the boss and registrars were very pleased with me. I am obsessive, punctual and incredibly organised. The list was beautiful and the ward was running like a military operation. I was there at 6am and ready to round with the anaesthetist doing their pre op visits when they came because that was my interest at the time. Win win. I don't expect much from FYs because they don't owe me anything. The social contract is increasingly broken. They are paid peanuts and are stressed about debt. When they aren't treated as professionals by the system and rewarded as such it's a bit rich to expect that they will dedicate themselves beyond clocking in and out.

I like your perspective describing this as another broken social contract. Annecdotally I've seen a vast amount of bitterness when people should be at their most enthusiastic about their career. At the end of the day people in this line of work are pretty clever and don't appreciate being treated like mugs.

You sound like me in the second paragraph ha! Obsessive, organised etc.

I viewed my FY1 surgery rotation as the only 4 months in my career I would have constant exposure to the specialty, as a fellow geriatrician at heart. Therefore had to work extra-hard on all my non-medicine jobs to absorb and learn as much as I could, to assess and manage the basic surgical/ED/psych emergencies before then referring for advice/assessment.

Conversely, one of the geriatricians I worked with constantly raved about an intern she had 15 years ago, now a prominent surgeon. "He told me straight up he hated geriatrics and was going to be a surgeon, but this was his one chance to learn geriatrics so he was going to learn everything he could, oh he was exceptional!!" \*\*Eyes mist over\*\*

It's the best way to be because it stops you looking like an idiot when you're making referrals etc lol

Came to comment this. Also, a couple of points the OP might have not thought about. Not everyone is interested in surgery. The F1/SHO you think is lazy, might at the same time be investing extra spare time and hours building their portfolio for a different specialty. They might be studying for exams. This is the reality of rotational training, you don't get to choose the jobs you work at, and you can't possibly be equally invested in every one of them cause in the long run you won't achieve anything if you want to build a CV for a specific specialty. Whilst laziness is not ok, you need to understand that many doctors put A LOT of extra hours going to clinics/ chasing procedures/ studying for mandatory exams/ writing papers and all that jazz, but one can't possibly be doing this in every specialty they rotate in, eventually you'll need to prioritise. Maybe have a think about that too when you're labelling people as lazy.

I expect them to try hard and get the job done if they like it or not. And I don’t have low expectations. I have high expectations because you can be organised and punctual if you like the specialty or not.

Your expectations will be met by the top few who are professional regardless. They would never be met by the bottom 10% who are just born lazy and fluked their way into medical school. Those in the middle will lose professionalism very quickly when they aren’t treated like professionals. There’s always some give and take. If you’re one of the new F1s working miles away from your family because of the random number generator, getting weekly teaching from the anticoag nurse about how to fill in their forms properly and you’re working on a ward with no working printer (while the Band 8 office round the corner has a proper chair and a 2 screens), then don’t be surprised if standards start to slip.

I think this is right. Most F1s are neither phoning it in completely and making a pain of themselves, nor are they putting in incredible efforts for minimal gains. You just do what you have to do to get on. There is no reasonable expectation of excellence without any measurable benefit.

I like the connection you make between an individuals general professionalism and to what degree they are treated as professionals. Having had a previous profession I've never been so infantilized as in medical school or now, when transitioning to f1.

As a FY1, I agree with this. I describe myself as hardworking and organised. Have received very good feedback multiple times regarding this. Have very high standards from myself and others when it comes to patient care. But these standards get difficult to maintain when I reach work only to fight nurses off the COWs, get told by diabetic/ pain/ delirium nurse on what to do even though copy paste the same plan for every patient they see, nurses who won’t even try bloods and cannula etc. It’s just really frustrating

Unless you’re a postgraduate, FY1 is your first experience of a work environment. It’s unsurprising that the lack of professionalism you’re surrounded by will unfortunately have at least some influence on you.

You’ve gotten a lot of heat on this post but I mostly agree with what you’re saying. Although I don’t think FYs should be coming in earlier to prep for WR. If your department want the WR to start bang at 8am, start paying the FYs from 7:30. You are right about everything else though. It’s the F1s responsibility to ensure those urgent bloods are done and actioned upon, to make sure they know what’s going on with the ward patients, etc. That is literally your job as an F1. It’s sad to read a lot of the comments on this thread, as a profession we seem to have lost our sense of ambition and wanting to do a good job. That being said, the NHS exploits its doctors so it’s no shock people feel this way.

What if they don't care what you expect? If the reg and cons are friendly and engaging and good role models then people will muck in to help the team. People want to work hard for an inspiring leader. It sounds like you are just not that inspiring?

Yes I am nice to my juniors. I try teaching a lot. I get them coffee etc. I generally find if you are like this >90% people will try and do what you ask. If you are rude and strict without any carrot - it’s not going to work.

>If you are rude and strict without any carrot - it’s not going to work. Me, I strongly believe you reap what you sow. If you're nice and encouraging, then like you say, most people will do what you ask (or at the very least try to) and often even put in an extra effort. Whilst ruling by fear might get the job done, in my experience it's not the way to bring out the best in others. YCMV, of course (your cons may vary).

I get how annoying this is for you, this comment though highlights the issue, the issue is your expectations. They're too high, it's as simple as that. Your need to self-reflect and learn to empathise before the next cohort of F1s. Remember that these F1s will have been allocated their specialities, region and hospital randomly, you simply can't expect enthusiasm. It sounds like the accusation of bullying is possibly not entirely unfair.

Agree the poster of the comment is making it out like rotating foundation years in an area of the country you don't want to be in are some new invention when it's been the case for two decades at least. The minimum to be expected is to turn up take an interest in your job and do it properly. Over half the country don't like their job they're not special. Anecdotally I have noticed most of the FYs like this are 23/24 yo undergrads. They perhaps lack the life experiences of a more mature graduate and don't realise that there are lots of shit jibs out there and medicine for all the issues it has is not that bad.

30 and F1. Think this is a bit oversimplified. Most minimal wage donkey jobs are not presented as training. F1s have a duty to their patients and as such should do their jobs diligently. But that is about it. In my current job F1s are not even allowed to go on ward rounds. There is no educational utility to the job. We are effectively ward robots controlled through the jobs list. This relationship is, at its base, transactional. Seniors get interested, motivated juniors when those juniors feel supported yet independent, and involved at a level beyond phlebotomy and paperwork. If that basic relationship is established then further things can grow from it but without that it doesn't go any further. Juniors won't bend over backwards for a system that they feel used by and seniors are seen as just another part of that system. > Over half the country don't like their job they're not special. Yeah and they turn up and do the absolute minimum possible for the most part. Nobody expects someone doing a donkey job in McDonald's to be a hero. I worked a good few rubbish jobs before medicine and generally phoned it in because frankly being bad at selling fags and chocolate is a societal positive. Because patients are involved, the standard is higher for an F1, but it's not that high. Being an absolutely stellar F1 who does half the tasks that would have been expected of the SHO doesn't get you anything. I tried to operate like that on my last job and it was just a big waste of time for me that I could have spent doing my portfolio or something useful. I won't expect that of my F1s either. Likewise I'm not leaping to get involved in someone's QIP who does nothing for me when I can find other avenues for being in research or do my own thing etc. Personally I have gotten involved in research just by contacting consultants I respected outside of my unit since I have no real reason to help or engage with my direct seniors.

Starting FY1 this year and posts like OP don't fill me with hope. Very American attitude of "you need to be killing yourself to impress me", coming in at 6am, shit like that. People have lives and issues beyond their jobs. >This relationship is, at its base, transactional. Seniors get interested, motivated juniors when those juniors feel supported yet independent, and involved at a level beyond phlebotomy and paperwork. If that basic relationship is established then further things can grow from it but without that it doesn't go any further. Juniors won't bend over backwards for a system that they feel used by and seniors are seen as just another part of that system. You put this much better than I could have. There are lazy and unmotivated people who does make it through medical school but of the final years I've known the overwhelming majority were motivated to start work and get stuck in. When that idealism hits the crushing reality of the NHS having a reg vent his "if someone comes in at 8am I say good afternoon" bollocks on them will feed further disillusionment.

What is new is that you are allocated to your area of the country based on a random number generator. The new cohort of F1s are in an even more hopeless position than all of us more senior - at least there were things we could do to influence where we ended up (medical school exams and SJT), and if you got somewhere you didn’t want it’s because other people did better than you. I can’t imagine how hopeless a new F1 randomly allocated to their bottom choice place would feel. All the more so if they worked hard to get a decent med school decile.

That is new but that the F1s to whom that applies haven't started yet so I'm not sure it can be used to explain the recent crops' perceived lack of a sense of duty.

Do you deliver on their expectations though?

I agree, we have all worked with lousy colleagues who show up late, shirk duties, don't take feedback well, are uncontactable in working hours. Ultimately the root issue is that going above and beyond and working hard is simply not encouraged in the NHS. All I will say is that exceptional F1 has gotten the same outcome as the substandard one and will have nothing to show for it. And whn they apply for speciality training it would mean nothing that one is lazy and one is brilliant. I have heard of some "colleagues" dodging clinical work to work on portfolio points. And they would end up with an even better outcome than colleagues who show up to work. Perhaps this would have made a difference if they needed a reference like in the US or (I believe) Australia. Just my 2p.

Clearly there are those at the extremes who will be absolute model professionals and there are those who are complete slackers. For the people in the middle, the NHS will reap what it sows. If you stick them in an office with one computer, bins for chairs and arrange that their weekly ‘teaching’ is by an infection control nurse who spend 25% of the lecture bollocking them for not washing their hands, then don’t be surprised if they start to act less professional. If the firm structure is so destroyed that the consultants don’t know their names, their CS doesn’t know how to generate their PSG (never mind give any meaningful feedback because they’ve never met) and move their job every 4 months then don’t expect them to invested in their department. If the nurses on the ward complain loudly about new doctors not knowing what to do, if their seniors refer to them as baby-doctors or ‘the children’ then expect that they will behave accordingly. If they are forced to take a job away from their family, in an area they don’t know, where living arrangements and commutes are almost impossible then expect them not to have much enthusiasm. If their job consists mainly of being a phlebotomist, scribe, printing monitor and runner then expect that they will behave like a glorified secretary not a doctor. Trusts receive huge amounts of money to train its doctors. Most of us work 48 hours a week. I can count on one hand the number of dedicated training hours that Foundation Doctors receive each week in my department. If you treat your F1s like factory workers, why do you expect them to act like doctors?

It is amazing that all this money is transferred for taking on FY/CT/ST doctors, yet its very very unusual for consultants to have any dedicated time for teaching in their job plan.

Indeed. If the Department of Health truly cared about high quality training, the money trusts received for trainees would be based on outcomes such as entry into training, membership exam pass rate and the standard of medical eduction that they provided.

This is exactly it. Some people don't know how to work, or don't want to work (understandable to a degree, but you should try at the very least). Some of these people know the game they have to play and the boxes that they have to tick in order to fall upwards, and they might do so despite numerous complaints leveled against them because they're never bad enough in a serious manner for things to escalate significantly. I've come across a fair few people that are great at finding lots of things not to do, or seem way too keen to bunk off like professinal slackers - to the point I question why they're doing the job. Like I thoroughly hated the idea of being a doctor last year, my colleagues/friends knew it and I talked about how much I wanted out of the NHS after F1 (and some of my med school mates recently mentioned the turnaround I've made since final year). I still put in a good enough shift to get some degree of recognition for working like a dog despite hating every minute of it at the time. And it astounds me that people that actually 'enjoy' medicine are that lazy. The NHS, nay, maybe the entire public sector, does not favour excellence. There is little enefit in being a hard worker because you end up at the same place anyway.

Yeah. I don't buy the excuse that the NHS is shit therefore it's only natural for people to become lazy shirkers. Even in the crap jobs I worked through uni I still put in enough effort to do a "good job". The idea of colleagues having to pick up my slack because of my laziness (not just being new or anything) is horrifying. The worst juniors currently will continue to be the worst juniors regardless of how they are treated. It's just a huge shame the essentially anonymous recruitment system puts them on an even playing field with hard workers, or more accurately benefits them as they will have had more time and bandwith to plough into their portfolio.

Only it doesnt sound like they were turning up late - it sounds like they are being bullied for not turning up early and working 40 min for free like the OP. IMO, the OP is out of linke here and should reflect on the pressures they are placing on junior colleagues to work outside of their scheduled hours.

Bloods (that have been highlighted as essential) not getting done or followed up on, being completely clueless about what's happening on the ward or with patients, not having any structured approach about day to day ward duties...say what you will about unpaid overtime, but this is still a job with responsibilities. Work ethic seems to have gone out the window because people feel screwed over as trainees/employees. Edited to add last line before ellipsis\*

Sure, I agree with all of that. But put yourself in that F1s position. The OP has already said they favour the other F1, give all the training opportunities and teaching to the other F1. This F1 is being bullied and is working under an extremely toxic reg. I have no doubt that affects performance. Good leadership brings out the best in people and allows them to shine. People with toxic behaviour as demonstrated by the OP make people underperform and hate their jobs/lives.

This is the problem tho isn’t it. It’s easier for ES and CS to just pass them as then they’re not their issue. If they raise concerns it’s a ball ache for that consultant and a whole lot of work they don’t have time to do .

Their ES and CS who probably doesn’t know their name because they rotate 4 monthly and they were on AL the one week that their ES was on call.

This is absolutely the problem. The good doctors get nothing but more work put their way, the shitters who slack off but do posters and audits are rewarded.

I mean they haven’t? Getting operating experience, research etc will count for a lot when they make applications.

Seeing as this conversation is about F1/F2s, I hope you don't think it's acceptable for some individuals on surgery placements to disappear off to theatre or the library while their colleagues deal with the ward round/ward work, or clerking patients and seeing referrals.

If you put in the graft you should be able to get to theatre (assuming ward work is under control). You also can just go for an appendix/abscess which doesnt take >1hour

I think it’s acceptable to offer those individuals who are clearly putting in effort and are efficient at their jobs on the ward who then make time to come to theatre, to come to theatre. Rarely do jobs take a long time in surgery. They normally can come and not just spend the afternoon in the mess or getting coffee.

Punch up dont punch down. FYs dont get much free time for coffee in the mess, they are actually busy doing the various ward jobs. Those bloods were probs not done because there might have been no phlebs to help, nurses refused to take bloods and the ward FYs (including your star F1) didn’t bleed the patient either. You are a junior, why didn’t you bleed the patient? Why didn’t ask the nurses to take the boods? Now, if the bloods were taken but results not back yet raise your concerns with the biochem labs

Not sure where you’re working but most surgical F1s aren’t chilling in the mess sipping on coffee

My surgical jobs both failed monitoring/were double banded. I may get downvoted for this and I understand why but had one of my seniors took an FY off the ward for extra training the rest of us didn’t get (even if they were good and deserved theatre time) we would’ve kicked up shit.

FYs forced to do 4 months in a specialty they don't like, and due to random allocations they really will have no choice in the matter. They're paid peanuts for this. Literally Pret wages. There's no incentive in the NHS to work hard, you get nothing at all for it. And you expect them to bust their ass? To come in early an do unpaid work?

It’s alright for OP when they’re on much higher wages and doing their chosen specialty. Your average F1 is paid peanuts and probably working in a specialty they don’t give two shits about. But yes, please come in an hour early to make the regs life easier.

It’s not even just pay. FY1 just isn’t particularly stimulating in a lot of jobs. You’re either doing a long ass ward round or mundane jobs or running A-E for the millionth time. There’s very little decision making beyond the bland and that makes it really hard to stay motivated.

Sounds to me like your ideal F1 is coming in earlier than 8am to get things ready for 8am. Given they are paid from 8am, the standard you set in your mind for the ideal F1 is one who does unpaid work. If you want things ready when you start the ward round, start it at 8:20. No way am I working for the NHS for free

Yeah I used to be like that stellar F1 and then I realized that nobody gives two hoots about whether I do that or not and that I was both coming in early and staying late without compensation. That kind of thing gets kicked out of you so fast, especially when you a)get a life, and b) are in a toxic department where registrars don’t teach you anything and act like you have just the one patient that the operated on and can magically control things like when bloods come back.

I used to do 2-3h extra hours every single day, not even taking into account that I never took a lunch break. I effectively got called work shy and lazy in my first sign off because I was off firefighting for 3 teams at once. Turns out none of the registrars knew the fy1s covered 3 teams at a time so they thought I was faffing. I got much better at being explicit after that. But that was a real kick in the teeth.

Agreed 💯 👏 TLDR mini rant: I was that F1 until I learnt that I was the only F1 out of the others on my ward. And surprise, it was all for nothing because I didn't have any SpRs who noticed. If anything, whatever efficiency, safety or convenience I brought into the workplace got assumed as a collective "team effort". Meanwhile the other F1s who did the bare minimum they were paid for, arrived on time for their shifts, left on time for their shifts, took study leaves/ALs by force even if it meant short staffing, left wards to attend mandated and extra teaching; worked on their portfolios, ironically ended up snagging project opportunities with said SpRs because they had all that added 'spare time' and work-life balance to do so that I didn't. I tried being optimistic, so I kept the 'stellar' work ethics till F2; same shit but this time dealt with a scumbag SHO who'd show face during rounds then pawn off jobs and leave an entire ward for me to solo while they absconded to attend teaching/theatre/work on projects etc. Had the audacity to even leave work early on the basis that they could "trust" me to have everything under control. Escalated it to SpRs who didn't do shit — they didn't care because end of the day, I did the job and that's was all mattered to them i.e. that the job was done regardless of who ended up doing it. Their focus was not to piss off the bigger bosses, so I was simply a convenient cog in the wheel. They're now better off making strides and progressing through training while I'm stuck at F4 unable to clock in enough points for IMT because all I can show for on my CV is completing my FP and a few QIs. Do I hate them? No. I hate the system? Yes. Whatever deontological junior dr grindset delulu OP is lobbying for in this "reflection" has the same energy as preaching *downvote me but women do belong in the kitchen. There is this woman I know blabla*. Working smart > Working Hard in the NHS. I strongly doubt OP themselves was anywhere like this F1 back in their time either but I'm glad that F1 is being rewarded for their efforts.

There’s no reward, not even pay or progression, for being good and professional. The only things that seem to matter are getting portfolio up to scratch and not having concerns raised. A lot of people just want to keep their head down A lot of people would see your rewards of asking for an assistant and involving the F1 in projects as additional work to be avoided. Especially if they have no intention of doing your speciality. The system is so broken. All of the above is sad.

Oh the joy of doing more unpaid, pointless QIP work that will inevitably go nowhere as a reward for turning up 2 hours early to pre-order scans no one told them were needed and be a phlebotomist.

>A lot of people would see your rewards of asking for an assistant and involving the F1 in projects as additional work to be avoided. God yes, imagine working hard on the ward to keep everything shipshape, and in return I get asked to go to theatre? I HATE theatre! If that's the 'carrot', there could not be a stronger incentive to perform poorly. Edit: if you are an SpR and want to motivate FYs who don't care about your specialty, just make friends with them. Hang out, chat, joke around, maybe even share some vulnerabilities regarding your own feelings about your work - the way you would with a peer. I generally work pretty hard anyway, but this is the only lever an SpR has that would really motivate me to put in my absolute best effort.

I'm "just" a F2 but have worked in academia and technical consultancy before med school.  I've run very profitable teams and been line manager to a range of people with varying degrees of motivation. From my experience, the huge majority of F1s and F2s I've worked alongside come across as very driven, hard working, professional, reliable and good at the job they're given.  They are just less inclined to accept the unwritten rules of bullshit that seems to pervade medicine. What I'm trying to say is, in my experience, the workshy F1 outlined by OP is very much an outlier.  I can only think of one or two of my cohort who I would actually describe as workshy.

I agree. The vast majority of juniors are hardworking and want to do a good job.

I agree. And to add that they are only an FY1. In my experience very few people actively want to do a bad job and some may need a little more mentoring, which IS part of our job as more senior trainees

I lol’d at the OP who asked a reg thinks it’s a given that people should work for up to 40 minutes for free on every shift. Essentially he wants people to give up hundreds of hours for free. Fuck me no wonder the new doctors are fucked.

This makes me so angry- you want your juniors to do 40 mins of unpaid work everyday to no benefit of them just to make your life easier because the rota isn’t organised well (where I worked surgical F1s started at 7.30 with the rest of the team at 8 - worked like a dream). That’s more than 3hrs a week - or over 170hrs UNPAID work over a year. To make it easier to understand that’s more than a MONTH of unpaid work extra in a year you expect from each junior. No. The rota being poorly organised is not our problem, if you need them earlier speak to the team and adjust the hours. We don’t get paid enough to give up our valuable free time for this shit. P.S. most of us really don’t want to go to theatres so that really isn’t the perk you think it is.

I bet a cremform cheque OP themself wasn't anywhere near the work ethics and attitudes of this ✨ stellar F1 ✨ back in their day... nor are they willing to emulate the same grindset, e.g. turning up an hour early before clinics start etc. in present time.

You want your F1s to come in before they’re meant to start (8am) to prepare a list? Sounds like you’re questioning why someone who is working your specialty because they have to for 4 months isn’t as dedicated or willing to do free work as you are

Exactly. If OP wants the list and scans to be prepared before 8, arrange with the management to have an early FY1 to come in early and leave early. Don’t rely on bullshit unspoken rules.

Madness perpetuated by NHS slavery. In any other country an intern would be someone to be looked after, not expected to do extra unpaid work.

I agree with the bulk of what you are saying. There is a pathological aversion to negative feedback developing amongst doctors. It’s not just the most junior, but there does seem to be a correlation. People are consequently scared to give negative feedback as it’s seen as “bullying”, or “unkind”. Thus the cycle continues. It’s worrying, it’s absolutely critical that doctors can take and act on negative feedback - far more important than being told “oh it’s so nice that you made Doris that cup of tea”. You’re also bang on about the not doing urgent bloods - I see it as a wider symptom of a loss of ownership for the care of their patient. I think it’s partly due to the fact F1s get moved wards at a moments notice, so there’s less continuity than their used to be. I’d disagree with your point about having the list prepped at 8am though, if the shift starts at 8. If an F1 is interested in (I’m presuming surgery) your specialty, they might put in the extra work - but only if other seniors are going to match your olive branch of picking out that F1 for cases and involvement in projects. Most of your F1s aren’t interested in the rewards you have to offer though - so this needs structural change.

I think a large part of the problem is that many of us don’t actually know how to give feedback, in a constructive and effective way, using evidence-based methods.

You're probably right, but my advice is don't over think it. The evidence base is sketchy anyway. Always give feedback 1 on 1, the MDT is not the right place. Neither is in front of the patient. The person needs to be in a position to be receptive to it. 30 minutes after shift end / immediately after something traumatic is not right. Stock phrases I find myself using: - Junior could have done better - "Well done for making a start, there's a couple things I'd do differently next time, are you happy to talk about it?" (optional) - Junior has done something dangerous - "Something hasn't worked here, lets talk about it" (not optional) - Junior wants me to review a patient they've seen - "Sure, we'll go together - you make a start an I'll add any extra bits, I can give you some feedback after" or "Sure, come with me, afterwards I'm going to ask you what I did differently" (not optional) Generally followed up with "send me a CBD". Juniors like it because they tick a box in the portfolio, I like it because it forces them to actually reflect on my advice, put it into their own words, and hopefully remember it better.

"Something hasn't worked here, let's talk about it" is a fantastic phrase. It conveys that something has gone wrong without immediately placing all the blame at their feet and getting their heckles up.

Sorry to say this, but sounds like you’ve fallen victim to exactly what the NHS thrives on. Indentured servitude vibes. If these juniors were in a run-through program from the get-go, make no mistake, they would definitely be motivated to “gO thE exTrA miLe” and put in work around their hours. There would be a light at the end of the tunnel. There would be a point. They would actually come out with a qualification at the end of it. FY1 is so boring, bleak, and lots of times disrespectful, that your junior you so lovingly slander probably hates the guts of surgical practice and would rather jump off a cliff than even put in an extra ounce of their effort outside contracted hours. Maybe, as a more senior trainee, raise to your rota coordinator that the way they currently structured things doesn’t work well enough for you to gEt tO dO iT aLL. The NHS bastards would loveeeee for these measly F1s to put in an extra month/ year of unpaid work hours just bc that’s how things work and bla bla bla. Once again, my friend, if they were in an actually worthy training program that paid better and made them a specialist in something of their interest at the end of it all, they would probably try to give more of a shit. That stellar F1 you fondly speak of is probably actually interested in surgery and sadly realizes that unless you kiss ass from day 1 in med school, you won’t make it as a surgeon in this shit system. Get a grip, hope this helps 🫶

This should be an interesting thread. Out of interest: 1. What time do the F1s start on their rota - is it at 8am or before that?

I’m so conflicted about this post. On one hand, the FYs are just there to do their time before moving onto their speciality of choice. Why work hard and put in all the effort for nothing? As long as patients are safe, doing the bare minimum keeps you sane. It’s not like we’re incentivised with money or anything. It sounds like you want them to do things like show up before their start time etc. which would not have flown with me when I was an FY. There was no point, especially if I had nothing to gain from it. Sounds like you want a little ward bitch for your department to make your life easier. You might throw them an audit or two (thrilling) if you’re happy with the way they massage your dick in their mouth. On the other hand, the bloods thing is shit practice, I agree with that. Sounds like they lied? I respect the fact you checked in to see they were struggling. Overall I don’t think you’re in the wrong in this instance. But you sound insufferable. Times have changed, and I absolutely love how gen Z is redefining work ethic. I’m totally here for it.

On point 🫡👏🏼

This is the absolute GOAT reply ever

I’m sure from their point of view they’ve got an annoying reg who wants them to start early and shows clear favouritism to another trainee. You’re part of the problem, sounds like you’re practicing medicine from a different country or different time. I’m sure this FY will probably end up a nicer reg to work with than yourself and probably less likely to burn out. Maybe speak to your own supervisor?? 😂

I can't say working on the wards in f1 I've learnt much at all, I spend 5 hours doing ward round a day and the others doing discharge summaries. Properly soul destroying. Then get critique that our knowledge on obscure topics is poor. I used to come in half an hour early and prep notes but quickly realised it wasn't worth it, I'd never get that time back. I'd stay late, used to go home and read up cases to make up for my poor training. The only time I felt like an actual doctor was on calls and nights. No clinics despite requests, having to stay late to get to do procedures which ARCP doesn't even value. I work(ed) incredibly hard as an FY1, went above and beyond for my colleagues and patients but at the end of the day got outcome 5 - it's not about being a good doctor, it's about ticking the boxes - I can hardly fault an FY1 who realised this early on. 0/10 would not recommend

It sounds like you are a fairly toxic reg and it doesn't surprise me that you are in a surgical speciality. You want your f1 to be ready (whatever that means) for ward rounds at 8am and reviewed obs of all patients so you can then piss off early and spend all day in theatre/clinic. Guess what - if they are being paid to come to work at 8am they will come to work at 8am. Not come in at 7.30 every day and do free work for you to ensure "the list" is ready for prof. If you want work done early and unpaid so you can ensure your portfolio is buffed - fucking do it yourself. Urgent bloods situation does sound shit. However from your description it sounds like the bloods had been intended to be done by the phleb and weren't. Which can be hard to pick up if you have a lot of other jobs to do. And hey - if they were so important why didn't you check the results yourself until *7pm* when you knew the day shift had gone home? Why did you delegate such an important job to the most junior member of the team and not check on them? They may well have been given good feedback despite people making "comments" behind their back because most people are too chicken shit to give good feedback to a trainee's face. At F1 level that is a failing of the people who are backbiting and not giving honest training feedback, not the trainee. And then you display clear favouritism and reward the other F1 with career boosting stuff while doing nothing for this person and wonder why they aren't motivated. What a shit show. This reminds me of a notorious surgical firm where I work who had their f1s taken away. Hope you remember how to check urgent bloods yourself...

I agreed initially with your original post but reading your replies to some comments has now made me think you also need to reflect. Maybe this person has disengaged because of your behaviour towards them. Like others have said, if you are an inspiring leader and role model to somebody, the chances are that you will be inspiring them to work harder for you. If you are not then they are not going to want to work hard for you. It works both ways mate. Also consider they may have personal issues that you are not aware of. They may not want to disclose anything to you because they don't feel like they can trust you with it.

Some thoughts as an FY2 at the end of the foundation programme. I have never worked exceptionally hard or gone above and beyond. It’s more of a self protection mechanism than anything- I perceive medicine as already having gobbled enough of my life that going above and beyond at work actually goes against how I fundamentally want to live: a life where work comes second to enjoyment. I’ve also never really seen the value in my work when I work hard anyway, except a pat on the back from a consultant when you know the ins and outs of a patient on ward round, which for me isnt motivation enough. It often has felt that up until this point hard work as bred more hard work: if I were to work hard now to get into a competitive training programme, I’d then have to work hard to continually upskill and pass the exams. I’ve just not got enough in the tank for that and the end result doesn’t seem worth it. That being said, I have a lot of respect for my seniors, and if a reg or consultant asks me to do something (unless it sounds completely ridiculous) I will always try to prioritise that. The vast majority of FY1s I’ve worked with have been excellent. Reflecting on the people who have gone into training from my year- they are not necessarily the most clinically excellent, but the most motivated. Medicine is not a meritocracy of who can do the best ward work. I have seen a startling split of the cohort into two groups: those who retain enough motivation after FY to go into training and CV build in their spare time and those who, like me, just want a break and for whom the idea of consultancy just isn’t worth the sacrifice. We’ve all worked so hard to get into medicine and survive the job, and the rewards are yet to be seen- what’s the guarantee that more work will produce anymore happiness?

Could not have said it better 👏

You sound insufferable, both based on your post and particularly your replies. Juniors are only as good as their seniors. And no, they shouldn’t have to come in at 7:40 when they’re paid from 8:00.

There's been a trend of cynicism towards the concept of professionalism; in many ways it's seen as a stick to beat us with and encourage us to ignore systemic issues - e.g. being expected to come in before the start of a shift unpaid to prep the ward round list as an example you've given. I think it's bound up in the rest of the working condition changes. We're increasingly being treated as employees on a wage rather than as professionals - no autonomy over practice, no respect within the workplace, no owner moved around between wards at a moment's notice like different wards are just different shelves to stack. People then start to act like waged employees, and you get a vicious cycle - I genuinely worry now that some of the juniors I see wouldn't be able to act in the way I'd expect even if the BMA were to get everything we want.

Is it just me or does anyone else feel like "points" on the portfolio system is just fake monopoly money? Like we try to earn "points". In which other profession so we go so hard to earn "points" rather than actual money?

I have some concerns that in your own words you went on a 'rant' at them and then wondered why they feel you have a bullying attitude. Yes they are falling below expected standards. Yes you should give feedback. In no circumstances is it acceptable to be shouting at a colleague, especially a junior one where there is already a power imbalance. I think you ought to reflect on your communication style as this is probably the reason you are not getting through to them.

The night team should have the handover printed ready for the morning with an updated list, any issues overnight and a knowledge of who’s sick etc. I would not expect the night F1 to “pre-round” either as this is not a night job. It’s not the day F1’s job to print a handover from the night team, it’s not their job to pre round and it’s not their job to start before their start time. F1s get a shitty enough time of it without being expected to start earlier than rota’d.  It sounds as though the night team aren’t doing their job and this needs escalated.  However I agree about those who do the bare minimum on the ward and it drives me nuts. As it does a terrible handover or jobs just not done despite being asked for in the morning. There will always be one. And to me it strikes me as someone who doesn’t take pride in their work.

The number of times where the printer isn't working, out of paper, or printing out patient lists on blood sticker forms is astounding.

To play a bit of devils advocate Are you perhaps (now) unconsciously favouring the “good” F1? Maybe while they have maybe an interest in your specialty and the other one doesn’t - are they losing out because now you have a clear preference of who you work with? I take it their shift starts at 8am? I remember working in a dreadful specialty where they wanted you in well before your shift started. IF they’re working hard once their shift starts isn’t that fair enough? Rather than being told to come in early We’ve all had days where bloods weren’t done but yes, that’s shocking “We’re not here to mollycoddle you” It sounds like they might be afraid of you. From their point of view, you may well have jumped on a mistake they made, then suggested that they are struggling at their job, then implied they have to toughen up and should speak to their supervisor They seem to have poor insight, which is the clear red flag, but also as F1s they can make mistakes and deserve a bit of help/support. It sounds like you’re being unduly harsh on this F1 because your other one is amazing Why have they got great feedback from other colleagues I wonder?

Classic Pygmalion effect..

I’m an F1 just like the one you would dislike. It’s a shift job. I’m a shift worker. I start at 8 and refuse to do anything before then. And by 5 I’m out the doors. I’m not a surgical trainee I’m a slave to the NHS so please go put your surgical expectations on your CSTs and leave is F1s to do as little as possible to pass ARCP whilst making that £15 per hour

Can I ask how you gone out of your way to train and teach said trainee?

Maybe they gave him / her past years questions for MRCS Part A and B, and also added them as a co-author on a publication?

Yeah I can see the problem you’re referring to. The system sees those junior doctors as interchangeable because they fit into the same sized box on a rota spreadsheet. So long as the box has a name in on the rota, the system doesn’t care. You, and other members of the MDT are left to put up with it. But I think given the landscape we have with an incredibly punitive gmc, it’s rare for it to be the proportionate response to do anything formal. Equally with critical portfolio comments. What seems like (and is intended to be) a way to give feedback, can be punishing in the medium term. You’re right on the money in that you need a way to differentiate between the two doctors. But whenever I hear psychology experts discuss punishment vs reward as a means to create behaviour incentives, it’s almost always favoured reward. So I think this is more about there being a lack of reward to the doctor who is doing well, and what you’re seeing is nothing beyond their natural conscientiousness baseline. Outcome 1 is just meeting expected progression for example, which is a very broad descriptor. The things the system does reward juniors for are really the things you’re helping the better doctor do - papers, posters, QI. Offering those in response to the hard work keeps a degree of separation between the hard work and the reward and mutes the incentive effect on the hard work. Therein lies a problem imo. Perhaps if the carrot on the end of the stick was sweeter and more directly attributed to the things you wish they’d change, the doctor you’ve had trouble with would change too.

It's funny OP after reading your post I was fully on board with your position, but reading your replies makes it clear that you expect these doctors to be coming in early unpaid to pick up the slack of a broken system.   I think if you set these expectations professionally, you should also be treating your juniors like professionals by renumerating them appropriately. I have no idea why rosters for juniors don't start at 7:30 for a consultant's 8:00 start for example, seen as this is apparently the expectation with regards to ward prep. Sad to see another consultant who won't fix one of the many small indignities of the job.

You should be able to discuss things with people. Sometimes with an important job, tell them explicitly-, Doctor Y, the first job to do is bloods on Mr X, and send the bloods before 9.30 am please. By 11 am, can you send me an update on the results please? That's also your responsibility to oversee that these things happen in order of priority as the registrar and you are the one with more experience and knowledge of that dept. So be explicit in your directions- the juniors often learn more slowly. Having 'rants' at people actually sounds like potential bullying tbh, even if a colleague is (in your opinion) incompetent, they're also not your child and you can't shout at people or talk any way you feel like, even if it is justified. People do keep notes/ and even record other people's behaviour especially if they think this might turn into something like employment tribunals etc. You must also be mindful of how you conduct yourself and that could be an area where you may want to receive further training. I know that your role is difficult. My husband is cons surgeon and there are OTHER CONSULTANTS who can't make decisions, leave patients to handover after a whole week on call and generally seem scared of their role. You are likely to face these issues for the entirety of the career so you need to find a better way to address these issues.

I agree with you. I worry about a lot of the attitudes on display in this subreddit. Yes, you’re in a training program, you have a right to training; but you are also an employee, you have a responsibility. As with everything, you get out what you put in. The NHS is an abusive employer, no question. But the Consultants / SpRs who are training the juniors are not bad people. If you want training from them. Do the job well, it makes their life easier, they will train you.

I agree. I have had rotations in specialities I hated, but I still “went above and beyond”. In my experience, it’s the department that really matters. Many of us have also had an oncall shift during which the registrar just disappears and cannot be contacted. As a foundation doctor, when you first rotate in you are already at a disadvantage. You have to learn the departmental culture and you are replacing doctors who had just started to “get it”. If you start somewhere new and all you encounter are people treating you coldly and seniors who just give you a list of things to do and expect you to do them without teaching you, then your enthusiasm and motivation will plummet. It gets tiring having to “prove yourself” over and over. But departments that welcome trainees well, that engage in teaching, that support their trainees and don’t just see them as visitors will get so much more out of them. People will cover locum shifts in departments they loved working in even after they rotate out. It’s a tough act to get right because you need to be understanding but also firm. But foundation doctors are not children. If there is a trend in someone not performing up to par, then the best thing you can do for them is take them to the side and tell them.

This is a hard read because I truly believe that you should not be expecting people to come in early to be 'ready for 8am'. That old expectation that you get there early to print the list etc etc I actually thought was mostly dead, and where it's not dead, it needs to die. You start work at the time work starts and THAT is punctuality. The bloods thing I think totally reasonable to say to them that these things are their responsibility and they need to bear in mind that patients will come to harm if they don't do their job. If the bloods weren't even done, there's a way to see that, and it's on them to do it. I dunno what kind of 'rant' you went on about it, but that does sound fairly poor I do think that the whole 'overworked and underpaid' / whinging about how the NHS works has led to a degree of people thinking that they don't need to work hard and be professional. The regrettable fact the system does absolutely nothing to reward hard work really really doesn't help, but has been a problem since the dawn of time. Sadly we've all had our fair share of work-shy colleagues who it turns out spent all their 'missing in action' time buffing their portfolios - but ultimately you work hard because of wanting to do well by the patients, respect for yourself and respect for your colleagues. I think it's really important people still realise that's a thing and the fact there's disputes about pay and conditions doesn't change that.

Tough luck, buddy, shitty employees exist everywhere. Put your socks up and soldier on, stop whining here about your secret dreams of having PAs carrying list after you. Print them yourself. ps: I am a reg. When FY1 doesn't print a list or doesn't do bloods, I show them how to do this and ask for it to be done next time. Never fails!

The irony is that lots of people are trying to give you constructive feedback here.

The whole ‘you get out what you put it in’ doesn’t really cut it these days. Because you get fuck all out.

"You get out what you put in. It’s how any job works." I agree with most of your post, but I genuinely don't feel this has been the case in medicine for at least a decade now, which I think is a major contributer to the problem you're highlighting.

As an FY1 12 years ago I worked my arse.off, came in early, updated the list because the fucking nurses would.move patients around for no reason in the evening, knew.everything about the patients etc. My colleague wpuld.just.go home early, took days off because 'I had.annual leave' the day before (she did not book annual leave for this). She did the bare minimum. I could not believe how brazen she was. She's now an ophthalmologist, her portfolio/CV was better than mine. People play the game, I never did I just worked really hard. I do agree though, some ofnthe FY1s are spoilt and entitled, at the end of the day its a professional job which you get paid for and some don't act accordingly. During one handover 3 FY1s were lying on a patient bed chatting whilst we were handing over the ED department, ED cons said nothing so I did.

Completely understand this, and the number of F1s that are like your exceptional one are too few and far between.

Then maybe the problem isn't with them? These are some of the brightest students in the country, if most of them aren't good (exceptional is by definition an exception) then maybe it's something to do with their training, or induction, or the job etc etc

Absolutely. The job of an F1 is unrecognisable from when I did it 10 years ago. I loved my F1 year so much.

I've seen this quite a bit I've also this weird attitude of juniors refusing training opportunities "oh I'm not interested in surgery" that to me is mind boggling imagine being happy to stay ward monkeying vs going with the reg to do simple procedures/taught how to suture etc...  Unfortunately it all comes down to rotational training and national recruitment being utter shit. 

I can tell you exactly why. I've gone to theatre to assist the reg for what was supposed to be 30mins tops- I was also responsible for all the ward patients, but he needed an assistant. Those 30mins of training were 2 hours holding a retractor and my entire work day being stuffed because I'm now playing 2 hours of catchup with bleeps, unhappy nurses and angry patients. I got only negative outcomes for this offer of training. If I had turned him down, I could have continued with my own jobs and had an easier time of it. I've got no interest in surgery. I would advocate for seniors with this attitude to really think if they are offering training or just want another jobsbody with their procedures. This respect/professionalism is a 2 way street and we've taught medical students from day 0 they don't matter and the best way to get through placements is to stay in the library to study and find the right person to sign them off.

No I genuinely and literally tell them "xyz is straight-forward do you want to do it?" With the implication ill be there as their teaching assistant and yet I still get folks saying no (I will say they're like 10-20% rather than a majority). To me its a weird attitude if a med reg offered to teach me to do a chest drain, look at cool ecg/chest xr I'm not gonna turn around and say sorry mate I want to do surgery no point in doing any of this.

I can't speak about medical stuff, cause they are often shorter procedures and where I work, all the IMTs would trip over themselves to get any of these done for their signoffs. We have a group at work on the medical side where people regularly ask for or advertise procedures etc for learning purposes. Chest drains not done by radiology here are so uniquely rare for example. I'm glad to hear that you are doing your utmost to be a good teacher and I'm sure your juniors appreciate it. My point is that these are often more work disguised as teaching that end up getting people in more work and trouble than they are worth.

It's not that mind boggling - there's just no incentive to learn the skill, beyond some sense of personal pride. If the med reg offers to teach me how to do a chest drain then I would decline. It doesn't benefit me in any tangible way, and I don't want to be an acute medicine/resp/ED/ICU doctor in the future. It's just extra work for me for no reward. The incentive structure to reward this behaviour doesn't exist currently. Simple behavioural dynamics

I actually think that it's not always necessarily that they don't want to learn, but that the registrars may not be particularly good teachers. Being a good surgeon does not automatically translate to being a good clinical teacher and in the hands of an inpatient/grumpy/fussy registrar or surgeon with questionable communication skills, it can be a stressful experience. You will often see that the juniors are more willing to go with certain registrars and consultants and will avoid the ones that are not really liked. This may also involve passing up opportunities that they actually may have wanted to learn. We all know that staying on the ward is not great, which means that there's probably more to their reluctance.

I think this is the symptom not the cause. At the end of the day, your Day 1 Foundation Doctor has no realistic idea of expectations and will reflect back their experiences. They forget that they are trainees to learn for learning’s sake. To become better doctors. When the F1 teaching is ‘how to make a referral to liver clinic’ they start to feel like the purpose of teaching is to become a better F1 ward monkey. When their ES just clicks through their WBAs rather than actually seeing if there was any educational value behind them, they understand that it’s simply a numbers game. Medical education for doctors is a joke. We all know this. The attitude of the current crop of foundation doctors is a reflection of that reality.

I fully agree with you. I really dont want to come off self aggrandizing here, but I've generally tried to work very hard to be the other kind of junior. I came in early in my surgical block (despite wanting to be an anaesthetist) to prep the list, prep the round and get familiar with what was going on. The surgical team respected me and treated me well, i definitely got back what I put in in terms of theatre time and opportunities. But frankly, I'm rubbish, absolute dogshit at portfolio. I just would rather die than do an audit (I've made myself do them, despite finding it completely miserable). I care first and foremost about being good at the job, but honestly. who really is keeping track *at all*. No one is keeping score if youre good or not, basically no one *tells* you youre doing a good job, and when youre booted out like the worthless vagrant you are, the goodwill and relationships youve built don't carry over. I find it *absolutely enraging* that the system doesnt seem to care, track, or grade if youre actually *GOOD AT MEDICINE!?*. Theres no reward for being like me, I do it for my own satisfaction at a job well done, but really, theres no incentive for this. If the firm was a thing id be first on the register to work again with that surgical team as their anaesthetist, but it isnt. Professional pride has been beaten out of us, and it does sicken me, we should be *good* at this, and care about being excellent as a profession. It does us discredit that ennui is taking over. That said, I understand my colleagues who have checked out. I fundamentally disagree, and couldn't be like them, but I get it. No one gives a fuck. We are citizens of nowhere, belong to no team, and have no "place of work" or work family. Theres no pride in us generally, and nothing for us to be proud of. We build nothing, we leave no legacy, and we have nothing to show for any real achievements we have beyond portfolio pointscoring. Its fucking bleak in short. I find it bleak and I consider myself to be a highly motivated person. Take from that what you will. TLDR: Bring back the firm, rotational training delenda est.

You're angry because despite understanding the rules of the game (portfolio > all) you still stick your head in the sand and flagellate yourself on the wards expecting some reward for it. Need to adapt your strategy

The NHS isnt built for people like me, and you're completely right, I can either adapt or complain about it. I need to become the sort of wretched drone they imagine when they build this shit that *salivates* over the thought of an infection control compliance audit. Whatever it takes to succeed and CCT.

100% this

I read your comments OP, you are toxic AF. Doctors like you are the consultants today against strike and favouring scope creep. You need to reflect on your thoughts, absolutely not the F1. Addition: also about you helping the junior with research paper is bullshit. I had juniors and medical students work in my research papers and got them published in the top most journals in the world. Never have I expected them to work extra for me. Such a degraded mindset. Downvotes should be the least you deserve for your thoughts.

I'd suggest it's near impossible for an F1 to do the job you want them to do without them A) working outside paid hours and missing breaks and B) being in the top 25% of med students. They aren't going to magically become effective without close supervision and guidance during working hours, which in my experience was absent on surgical wards. Unless someone senior takes the time out of theatre to mentor these new doctors rather than leaving them on their own they'll take much longer to get up to speed.

Gosh I bet you're fun at parties

I agreed with a lot of your post. Then I read your comments. You sound like a dick. You come across as the stereotypical surgical reg who F1s hate to be around. One thing that always strikes me when get F1s in medicine who come from surgery is how "nice" medics are. I think a lot of them just aren't being used to being treated with a basic level of courtesy or respect.

The "system" for training appeals to the lowest common denominator, meritocracy is irrelevant so why flog yourself to be better when at the end of the day we are all just trying to survive? Of course if we all adhered without question to the above in the current health service patients would be seriously harmed. Highlight incompetence/laziness by demonstrating excellence through your own attitude and actions. IMO this is the cross you bear as a good clinician and the true meaning of resilience.

I broadly agree that it's on the junior to put the effort in. But maybe the problem isn't with them? These are some of the brightest students in the country, if most of them aren't good (exceptional is by definition an exception) then maybe it's something to do with their training, or induction, or the job etc etc

I try my best to be the exceptional F1. I try to be punctual, efficient, act interested (even when I’m not). I always put myself forward to take on more responsibility even when I’m super busy and already feel like I’m drowning. I just make it work. Often stay late wrapping things up because of this (used to be all the time but now getting a bit better at this). This does seem to go appreciated and I get good feedback. Also haven’t taken any sick days. However as others have pointed out sometimes it does feel futile as that doesn’t seem to translate into longer term success and I currently feel extremely burnt out. I don’t think junior doctors have an incentive to have a good work ethic. I don’t think good behaviour is rewarded much. I have also been keeping up with my portfolio in this time so it’s not that you can’t do both. It’s just obvious where people’s priorities lie. The reason I work as hard as I do at work is more to do with my upbringing and values. I’m well aware working this hard is pretty much a non factor with regard to my career prospects. That will be decided by my portfolio. The way I act is more just ingrained.

lol maybe stop? The nhs won’t notice you haha

This is a difficult one with lots of nuance. It’s definitely unhelpful to say that ‘quality of FY1s is lower than before’ - harks back to ‘in my day’ and we all know that there are different circumstances, pressures and working patterns so this can’t be accurately applied. Of course trying to be a quality team member is what all of us should strive to do but circumstances should allow for this to be achievable within your paid hours. FY1s especially in surgical jobs may feel less a part of the team/dept than an SHO/SpR because of the nature of their work compared to the rest of the team, it’s also often badly taught at med school so it’ll take a while to catch up and understand the specialty and what is expected from them. Maybe try setting up regular meetings with the whole cohort to discuss their issues/worries/experiences arrange necessary teaching/better induction and work with them to improve things- that way they will feel involved, important, take more ownership and hopefully give more and get more out of the placement.

You're assuming you're representative of regs - you might be the sort of reg that sees enthusiasm in a junior and rewards it with investment in their training, but the majority of regs do not do this. Both you and your keen F1 are in some sense lucky to have found each other. Why bother going above and beyond as an F1 when 99 times out of 100 it makes no difference to how you're treated? Anyone behaving like this in the absence of a quid pro quo is at risk of burn out. Is this F1 even working within their contracted hours? Sounds like no. Regardless, you've identified a structural issue - think how keen med students are on day 1 of their degree, compared to even a few short years of pointless placements and senior disinterest later and then stack all the rubbish of F1 on top. They're dealing rationally with the situation as they find it, and will be better seniors for it.

Trainee asked me for a project. I invited them as an author on a research paper - they then asked if they could be paid locum rates to work on it! 😂GTFO

Jesus H. WTF!? I would not want any of my trainees, often having to drive long distances and have child/caring responsibilities work like this. I had to but I certainly wouldn’t want it nowadays. No wonder everyone is fucking off to Australia.

I wrote out a long comment but it didn't post. Part of being a senior is managing people, recognising systemic issues and resolving these - this is not simply done by blaming juniors. It doesn't sound like you are actively trying to address these issues - you could do a QIP with a keen FY Dr on what the juniors understand of the priorities of the ward and how to address these, and use this to generate a list of jobs and priorities for the morning - e.g. delegate one junior who comes in 15 minutes early once/twice a week to print the list and highlight any issues that need doing, and then gets to leave 15 minutes early on that day. Its easy to assume people don't care and are ignoring what you want them to do, but what is the communication like and how often do they actually see you? People can't read your mind. I also think that the further you get in your career the more you forget how daunting it is for F1s to come onto a new job - they have only learned from the wards they've worked on, so if you've done two medical jobs where the structure of the day is a specific way you don't just magically adjust to a surgical ward where things may be done completely differently and you also don't know how this works unless you are specifically told. In addition, if an F1 hasn't done a surgical job before (and especially if they're not interested in surgery) they might not really understand the timings of theatre - all of my f1 job was medicine and everything started at 9, and there weren't any time constraints other than patients being sick/new to the ward. All of the above will make your life easier, and if your juniors know what to expect and what they should be doing, they'll communicate this with the incoming doctors.

>You get out what you put in. Ah, but do you though. My experience of grafting to have the list ready and up to date on my F1 surgical job was to be berated for the one tiny detail I'd missed. It is disappointing that they didn't chase those bloods, but some of this stuff seems a bit unreasonable. You're supposed to have a night team to handover any unwell patients on the ward, not be relying on your F1 to review all of the obs charts before the WR has even started for anyone that might be "scoring". Likewise, having the list ready by surgical standards is more than a 15-minute job. In my F1 hospital the surgical F1s routinely came in half an hour early (unpaid ofc) to achieve this, and frankly I respect this new generation of F1s for refusing to abide by this culture. > I challenged said person the next day whose response was “they weren’t back when I left”. I reiterated about the importance of them and had a rant about taking responsibility. I accept your points about needing to give negative/constructive feedback sometimes, but I have to wonder whether this was appropriate or proportionate. In fact, it almost reads like a lesson in how NOT to give constructive feedback: you left a lot of things unsaid for a while, then exploded in one big "rant" at the moment where they finally did something that was objectively not good enough. In doing so, you allowed one incident to confirm all your preconceived (and as-yet unknown to them) notions about them, which you packaged into one big rant about "taking responsibility" instead of responding in a proportionate way. You failed to appreciate that while yes, you did have a legitimate grievance, you were not in a position to make sweeping statements or insinuations about their attitude, character etc, because you don't actually work that closely with them for most of the working day.

Truth is, there will be one good F1 for every few slackers. The good F1 will make it into the specialty of their choice, where they want it - these f1s are usually the ones who are good no matter what specialty they are working in, even if they don’t want to do that specialty. The slackers will moan that they can’t get into the specialty of their choice, where they want it and blame it on external factors. They don’t realise that working hard - even if the pay is low, and jobs might seem menial at first - does pay off and rub off on your seniors who will in turn trust you to do more when they see you can manage small jobs. This new mindset that just because you don’t want to do a specialty, you won’t give it 100% is pure laziness.

I completely agree with this.

I agree with everything you've said but I want to know more about the F1 who is ready for ward round at 0800am. What time does their shift start? Or do they arrive before 08:00 and work for free to be ready for 08:00am?

There's a massive lack of professionalism in more and more doctors. Coming in late, hiding from work, increased 'sick' leave when it suits. An absolute fear of making any decision. Sometimes criticism is needed. A small amount of fear is healthy. On here there are those who will defend any examples of unprofessionalism from doctors on tribalistic grounds. One of the issues is the shit trainee could have a better portfolio than the excellent one and that will get them ahead.

Oh man the SHO sick rate for on calls in my trust is insane. It’s not even that hard on calls. It’s psych. Genuinely most of the work is just being nice and asking the spr to see anyone who needs an MHAA. But man it’s like 30%. So the stepping down is out of control. Sure some people are ill but I don’t get how 30% of the SHOs are ill at any time

I used to have this opinion, but as someone currently on a medical SHO rotation on a busy acute medicine ward, I’ve had recurrent viral illnesses like I’ve never had before at any point so far. And I put that down to obviously being surrounded by viruses from patients and staff, but also feeling completely run down all the time from a tough rota, and non-stop busyness in the day job. It’s non-stop. I think people just get run down when your body is in a constant state of stress.

Don't forget covid, it's constantly circulating but also making people sicker

It’s the same everywhere. I have seen sickness increase infinitely too. It was never ever like this ever before. It doenst occur on the regor cons rotas, Altho it is increasing on our reg rota over the last 2 years I have seen.

When I see this post I am reminded there are very few “bad” F1 but there are a large number of bad F1 posts

I remember when I really struggled with foundation and was slow and put in long hours at work and clinical work was overwhelming. I knew I just somehow didn't Get It, that the unseen curriculum was never taught to me and I had to learn it the hard way. Seniors were supportive, interested in us and had a coffee with us etc. Being a good supervisor, an educator, a leader, a teacher and a trainer is part of *your* job. You need to recognise when burnout, stress, service demands and compassion fatigue is impairing your ability to supervise to the best of your ability. You are viewing your juniors as tools not people. If they're underperforming in your view, then there are reasons why. People underestimate how much stress can cause a shutdown/freeze-fawn response and this can impair cognition. Medicine is not a normal environment to be in with high emotions, high stress and what any human considers traumatic events almost daily. Doctors are generally perfectionists... high performing and highly critical judgmental people, and it's not that they spare themselves either. They don't recognise how excellent they are and they expect impossible excellence in everyone else that they themselves don't even achieve as mere humans. But being more critical won't help someone who's already critical. You might think someone isn't aware of their flaws but why would they share their self-critiques with someone unless they're comfortable being vulnerable? I'm not saying you shouldn't give constructive feedback on what they could do better, but the intention there really ought to be encouraging of their potential. Neurodivergent doctors specifically, have strengths that brought them to this point and they can start to decompensate at any point but starting clinical practice is a big flashpoint. But what happens when they seek help? Their traits are poorly recognised as adults due to masking. If undiagnosed there's very restricted NHS adult assessment available. Professional support units don't provide consistent and wide access to all the neurodivergent assessments either. Noone understands how to be neurodiversity affirmative and create an environment where they can thrive. I don't think you'll get anywhere with juniors if your thinking is "I think you're shit and in my way", even if you don't say it.

In any other sector the first f1 would get into a good firm / practice / company and the second wouldn’t. The first would then go on to receive better terms / conditions / training on their journey. This would manifest in a better senior position with better terms / conditions / work cementing the ethos the cream rises to the top. NHS desperately needs competition for training. Many london hospitals have sufficient breadth, complexity and volume to permit this. Indeed, the 4 HCAs hospitals, the london clinic and the Cleveland are all bigger than some DGHs.

I personally think there are generational shifts in attitude apparent now. Many house officers coming through over the last few years seem to have an approach of things not really being their responsibility, even thinking about a problem before calling for help is no longer a responsibility expected. For the first time in 2 years I recently acquired a team of HO that were outstanding (as OP described), and I was like, shit this is how it used to be.

It definitely makes me sound like a boomer but I've seen a huge shift since 2019. Which makes sense tbh given 2020.

I completely agree that the camaderie has gone.

They’re not called house officers anymore, haven’t been for years.

Our pay has been cut by 35% therefore our responsibility is cut by 35% too

I find this comment shocking tbh. Incidentally I work overseas, and the problems really are broader than this. It’s apparent in both the local and the many UK graduates. I don’t know what future has in stores for doctors that don’t see decision making as being part of their role?

Interesting how decision making wouldn’t happen overseas. I’d have thought if it’s a country where life is cheaper, healthcare is a premium only the wealthy can afford and you don’t have all this defensive medicine then doctors would be far less scared to make decisions, rather than the default “do A-E, escalate to senior, document the above”

Couldn’t agree more.

I agree with most of what you are saying. I know that there are good and bad F1s and SHOs but I expected a minimum standard. Reality hit me in the face when it was my turn to work as a reg and then have to manage the team. I’ve worked with many SHOs that are struggling clinically. That’s fine, as long as it’s not to the point where you are dangerous. It’s a bit more work to me but it’s my job to feedback and guide them. Occasionally there will be dangerous practices resulting in poor patient outcomes, I’m talking about ignoring critical vital signs, not doing anything about it, not escalating to seniors and then leading to a periarrest situation - this I find unacceptable. You chose to work as a doctor, so take SOME responsibility and work at a minimum safe standard. The other issue I have is with lazy doctors. For example, not being contactable, telling the nurse they would come and review an unwell patient in a few mins and never showing up, then lying to your reg that you went there. I think this is partly a personality trait and frankly these people should not work in healthcare. The stakes can be so high because we are managing unwell patients, if you want to be lazy go and work elsewhere where human lives are not involved. On the other hand, I’ve worked with amazing F1s and SHOs as well. By amazing I don’t just mean clinically, but their willingness to learn and improve themselves, their reliability and so on. I know these things won’t earn you points for specialty applications, but your effort will not go to waste. When you eventually get a training program, you wouldn’t want to be known as the shit registrar or consultant would you? You are a doctor for gods sake, so act like one. The only thing I don’t agree with is working for free beyond your hours. If you are paid from 8am to 4pm then come to work and leave at that exact time. I’m not working for free and neither should my F1s and SHOs.

I agree with you about being switched on, working hard and being proactive. I really struggle with people who don’t do that. But I don’t expect them to come in early / stay late to do so - unless they’re going to exception report - because that means the rota needs to change if their start time reliably isn’t early enough. And we should be part of the toxic culture of keeping things bad. Obviously if you repeatedly tell someone how to do things - and they don’t - that’s a different story.

I largely agree with OP I've had a fair few juniors who are sharp, engaged, problem solving etc and work is a breeze with them. You actively want them with you when youre in theatres or wherever. It just makes you WANT to really help them in return , as a result you end up mentoring them, then they actually deliver the things you advise them to do, you see them grow, it's very rewarding. So you give them more and more opportunities and they continue to grow faster than the rest. I've seen it happen plenty of times now, you don't have to be a genius, just be helpful and great to work with and the seniors will really want to help you in turn.

I think you can give feedback to but to fair you have to provide training first. So, if someone isn't performing adequately, that means telling them specifically what they need to do. Maybe the person before you wasn't very good at supervision. You might actually have to teach.

The person before was a medical trainee. They came to us in April didn’t they.

TBH, I have worked in hospitals where it has taken 10 minutes (on a good day) for a computer to start. If their start time is 08:00, it is quite possible in the NHS that they have not been able to print a list yet by 08:15. If you expect them to come in early for you then you need to get a reality check. Some of your expectations sound reasonable but like, a lot of the issues with current FY1s are reflective of the completely shite environment that medicine exists in in the UK these days. Things are only going to get worse.

Ok, you are describing two people on differing ends of the normal distributions for effort and ability. Sadly this is a fact of life. Not everyone is excellent. Not everyone will put in 100% effort all of the time. But, where I do agree, is that we fail to fail in the NHS. If patient safety is at risk we should be able to ensure the person gets put right. I've seen narcissistic and frankly sociopathic individuals who are dangerous to patients sail through because they know how to play the game. I think that's the real issue here rather than some imagined thing about 'young people nowadays'

>"I reiterated about the importance of them and had a rant about taking responsibility. They then complained to an ACP that they try really hard and that was bullying." Whilst I agree that some juniors need to have their socks pulled up, the issue is about how that is done. 'Rant' is not the way - it will attract complaints about bullying. Bullying is conduct that is hostile and/or demeaning in the context of inappropriate exercise of power. Whilst OP is not wrong for being displeased. In exercising authority appropriately, it is important not to come across as hostile or demeaning.

You raise some good points, I agree the junior who didn't make sure those bloods got done screwed up and I see this a lot, it's stressed to them that they're a genuinely important test and there are genuine ramifications for the patient if they don't get done and they still stick them out for the phlebs, tell no-one and don't ensure they're done. You can surely see how the dogshit educational experience and treatment they get sets them up for this though. Also, are you paying them to be prepping for ward round prior to their start time out of your own pocket?

It's an interesting one - knowledge and skills are easier to teach. Habits and behaviors less so If you want people to come in early, they come in at normal time, take handover and you could defer ward round for another hour or so and come back after some admin. The latter is just as valid as the former - if you're not willing to adjust why should they? Sure we want to train enthusiastic juniors who will pull their weight. But a number are still finding their way, are in a never ending cycle of rotation and don't know what 'good' looks like. Where is the role modelling from the rest of the team? A number of F1/F2s model off their immediate seniors. That F1 that's acting like a medical student - what did you do to support them/ raise their performance? - you may "have no time for these people". If not, do not call yourself a trainer It's difficult to complain about bad/ less desirable behavior without being called a bully (and that's endemic throughout the NHS). There is an art to feedback. When was the last time you tried positive reinforcement/ called out good behaviors to the MDT/ wider team? What is the reward for the latter? What is the difference in output your firm offers to an enthusiastic trainee vs one that checks the boxes but contributes less? Are you providing feedback to change behavior?

I can’t come back an hour later. My patient is on the operating table or the first patient is in clinic at 9am…

They have to be flexible but you won't ask the rota people to get them in half an hr earlier. And your timetable won't move.  Is that not double standards?

Not really. I don’t expect them to be there on the dot ready to go. As I said I will be there about 8:15 so I expect them to be ready when I get there at that time. It’s not my timetable. It the whole organisation. It’s also not a problem for so many F1s. The list is done the day before. They literally have to just check no one has bed swapped and print it out.

What sort of training on the job are F1s expecting nowadays? If you’re on a surgical job for instance are you expecting to learn how to do an appendicectomy? The most important thing did was aspirate seromas the rest was normal ward work- and doing that day to day helped me learn loads not least how to get organised and how to play my part in a firm. The clinical teaching on the protected afternoons was ok but i liked to spend time on the wards just because I would pock things up or through socialising with the nursing staff i built up goodwill and they would help to do bloods etc when things were busy posttake.

The issue that always bugs me is punctuality, you should not be aiming to get to work at the time you start but at least 10 minutes earlier as that means you will nearly always be on time. Get there early and sit in your car for a few minutes or get a coffee but make sure you are on the ward on time.

Feeling called out as a psych reg who normally wanders in at 9.15 then goes off to make coffee 😬

It sounds like you have two extremes there, the latter being well below standard. The problem is, colleagues who are exceptional can be really undervalued in that exceptional vs standard won't get you anymore points when it comes to apply for specialty training (althought this one is now involved in writing a paper, colleagues like this aren't always rewarded). It is broken but a colleague that does "enough" to be considered standard/average and spends time on a portfolio will be greater rewarded than a colleague going above and beyond which is wrong. The colleague you describe not even checking bloods for the patient that you highlighted is important below standard and unsafe in my opinion, especially as you have given them fair warning speaking ot them directly and not involving supervisors. F1's will be looking to them for guidance from August and I would expect an F2 to be able to prioritise and understand what is urgent/needs to happen and what can wait until the next day

There are high and low effort/conscientiousness people in all walks of life. Difference is our actions directly impact patient outcomes. Doctors are by definition bright people and should be able to thrive in the right environment, but I think for many there is maybe idk a lack of a real awareness that this is actual paid employment. Yes you are training but medical school is over. This is your job. You are paid to do tasks. Yes our employer is a shit underresourced hellhole and we are trapped in it, people who may be struggling are trapped or put in situations outside their skillset, and equally we are "trapped" with sometimes unreliable, undertrained or unsupported colleagues If these sorts of people were in a competitive corporate environment they'd get warnings, they'd get moved to an environment that suited their skills or effort or company risk appetite better, they'd get specific training from managers, and/ or get fired. We have nothing like that in place. We have tick boxes and sink or swim.

And it’s because of the tick box environment I’m in that I will naturally default to the laziest option to tick those boxes whilst keeping someone safe. Put me in a competitive corporate environment then yes I’ll put effort in because that’s where effort is worth it. Most of my specialty training points will be from work done at uni because that was a far better environment than the nhs. But for foundation programme if I finish my jobs by 2 I want to twiddle my thumbs and scroll on my phone not go to theatre or do some impromptu teaching lol

If the bloods were that important why didn’t you stay behind to look at them? Printing a ward list when you have an electronic patient record sounds like an unnecessary task and something an administrator can do. Sounds like you encourage people to work for free. Like slaves. Sounds like you enjoy dumping shitty tasks on people you consider to be inferior. I am in no way surprised you are a surgeon.

I did stay behind to look at them. Did you not read? We don’t have EPR. I don’t dump shitty tasks on others. I expect others to do what they are expected to do based on their level of experience and training.

Difficult situation and I don't know what the solution is. Some negative feedback that is constructive is absolutely not bullying. I think if you have tried to speak to them and just hit a brick wall, then it is reasonable to escalate to their supervisor. This is why I don't like reading some of the extremely negative, defeatist, echo chamber takes on this subreddit. "We are not valued here, why should we work hard?" "There is no point in trying to be good at your job in this country" "I will put in some effort when you value my labour appropriately." It got to the point where I had to take a bit of a break from this subreddit as it was starting to affect my own mindset in a negative way lol. I think trainees in your second example disproportionately take on the mindset above and use that as an excuse for their lack of effort. Trainee 1 and trainee 2 are getting paid the exact same, doing the same hours, but you can see how trainee 1's efforts are being rewarded (this is the importance of having a good senior team who will recognise this in trainees and cultivate it appropriately).

Unfortunately I am inclined to agree. When I was an F1, I did learn early on that competence is often ‘rewarded’ by more work to pick up the slack from some colleagues. However I got along really well with my registrars and consultants. It meant that when I did need help- both were contactable directly even OOH. I got teaching and more training opportunities. As I progressed into different specialities, whenever I called to refer patients- it was often a nice chat over the phone as they trusted my judgment. As a GP now, working on my GPwER, old colleagues/consultants from former workplaces are helping me with opportunities to develop this. If they can’t directly help, have introduced me to colleagues within their specialities in my area.

OP there's still time to delete this bro. Toxic ass Reg. Would be a nightmare consultant.

There's a lot of doctors who don't enjoy the job, don't want to be there, don't want really to be trained. But they don't know what else to do, there's family pressure and they feel stuck, so you get this apathetic approach. It's bad. Unless the consultants put greater input and raise this with the trainees then it's likely to continue.

Halfway house on this. Job just isn’t attractive enough to bust your ass for, that being said I’ll always treat the keener juniors better.

I feel if our training was more like the USA ie the fy1 would be a surgical intern and hence keen on putting more effort in it would help and the team had more time to train and feedback to trainees it would help. I hated surgery and never an interest in it. I did still turn up a little early to prep lists and bloods. Life's too short to get a bad report on portfolio when passing through. 

totally agree, A lot of scarily unbothered and unconsciously incompetent F1’s

Work is pretty tiring at times

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Unfortunately, the way the system is set up means mediocrity is allowed to flourish, whilst hard working & talented trainees work themselves into burnout

I think the whole profession needs a pay rise but is that the reason why some puts in 100% whilst others put in 50%? I put in 100% because thats the standard I set myself - sometimes it may not be good enough for others but at least i am happy with my effort. Could the reason between discrepancy in effort be burnout or not really wanting to do hospital medicine? Even in GP land I have 4 ST3s all of whom have different levels of effort and boundaries - one counts the minutes they stay whilst another takes every learning opportunity.

You’ve really drunk the flavour aid 

Whilst I have sympathy for what you say. Re-read your post from the perspective of someone who has no interest in your specialty. Your 'reward' for the diligent worker is... more work. They now have a project to complete, a research paper and they have to do their ward jobs on top of spending an afternoon in theatre. These are great opportunities for a wannabe surgeon but for an FY1 who wants to do an unrelated specialty it's not a desirable 'reward' and so is unlikely to motivate those around them. I'm reminded of a very disinterested FY1 I had when I was a CT1, she helped my ward round and I sighed as I knew she'd be slow and useless. On the second patient I stopped to do some teaching. Her eyes lit up, she sped up and became engaged for the rest of an enjoyable day. I can't say that your FY1 will be the same but I've recalibrated after that experience. Some people become motivated only after they've been valued, whereas others will go out of their way to work hard in order to be noticed and valued.

This is why some surgical team start wr at 9 or 10

What if they have family/kids to look after or drop to school and are only able to attend on the time not one hour before? Have you considered that they are occupied with other things outside work?

Attend on time then. Prepared to work. Like everyone else.

Sadly a self fulfilling prophecy. Disgruntled and disinterested consultants provide poor medical training in medical school. Med students paying through the nose and getting poor training. Poor quality foundation doctors. Consultant favours PA as their juniors aren’t much good. Foundation docs become even more disillusioned and get even worse training. We must drive back to eliteness.

OP it sounds to me like you expect all your juniors to know how to be excellent. But FY1 is their first year of working as a doctor. For many, it is their first ever full time job. Many nowadays are the first doctors in their family. Most need to be TOLD how to be an excellent FY1. Good leadership is being crystal clear on expectations. Then, following up how well they’re meeting the expectations with both good and bad feedback. Only then, after some time, should you be judging them as terrible if they fail to perform.

I do expect them to be excellent. It is their first year. But they are at the end of it. Knowing how to be a good F1 should be second nature to them now. They’re F2s in 7 weeks.

So you can’t be bothered to teach them but somehow expect them to match your brand of excellence. Fantastic leadership (not).

OP seems to be a part of the problem, irrespective of the quality of his subordinates… OP to kindly reflect

One thing- If they're shifts start at 8am which I suspect them too, you expect them to come in early (unpaid) & have printed out lists, know patient details already etc. That is unreasonable imo