One bleep and you're a doctor

They call it the killing season; the first weeks of high summer when 3,500 newly minted doctors flood the wards of hospitals up and down the country. It is a nerve-wracking time for nurses, who must be extra- vigilant to protect patients and themselves from the excesses and deficiencies of the pre-registration house officers. But this is nothing compared to the fear that grips the heart of the doctors themselves when, flying solo for the first time, they are confronted with patients whose symptoms appear to elude every text-book and tutorial of five years of study.

Tim Matthews, 23, was lucky. The first patient of his medical career was a dead one and the symptoms weren't hard to miss: no pulse, heartbeat or chest movements, her pupils were fixed and dilated, and there was no response to pain stimuli. Before his hospital induction course yesterday, Dr Matthews had never seen a death certificate. Now here he was signing the first of many.

Then there were the relatives to see and sympathise with, the husband and daughters who were still in shock from the events of the past 24 hours. The patient had been an emergency admission the day before, a middle-aged woman with a brain haemorrhage. She had deteriorated quickly and died in the early hours of the morning. Dr Matthews, whose gentle West Country demeanour is at odds with his front-row physique, was not untouched by the experience: "It was a bit awkward ... you do feel awkward in that situation. It was upsetting, but on your first day I don't think it is such a bad thing to feel so upset," he said.

Of the 11 new house officers - including five Germans - who began their medical careers at the Southport and Formby District NHS Trust in Lancashire last week, Dr Matthews had drawn the shortest of all possible straws. He was the on-call medical house officer and would be working from 9am on Wednesday morning until 5pm Thursday evening. He was philosophical at the prospect. "You're going to have to do it sometime in the first week anyway and there's no guarantee it will be busy. I just want to get through and manage it OK."

"Managing it OK" is something the British Medical Association fears that many pre-reg house officers are not equipped to do. A working party report on medical education published last week highlighted outdated teaching and training techniques which, it says, are rife in some medical schools and hospitals. Learning by humiliation still persists, it claims, so that some trainees were too afraid to ask for help. Deaths caused by medical accidents often involve unsupervised juniors, and too many are still being greeted on their first day with the words: "Here's your bleep, here's your ward, off you go."

While discontent over the hours junior doctors must work rumbles on - the BMA says implementation of the Government's much vaunted "New Deal" to reduce the hours dramatically leaves a lot to be desired - the issue of quality of training is also moving up the agenda. The BMA's report makes 35 recommendations, including an overhaul of the medical curriculum; a named consultant to co-ordinate supervision of juniors in every hospital, and individual training plans for consultants.

Much of this is already in place at Southport, says Jonathan Parry, chief executive. Every new house officer signs an "educational agreement" with his or her consultant, detailing what each expects from their time with a particular medical firm. "They are expected to show clinical responsibility, but we stress as soon as they are unsure they must call someone." Dr Matthew Serlin, a consultant chest physician and the postgraduates' clinical tutor, says the consultants in the hospital expected to be called twice as often as normal over the next few weeks.

Dr Matthews's greatest fear was the crash bleep going off. This alerts the crash team that someone somewhere in the hospital is in cardiac arrest. As the on-call junior, he was part of that team, required to stop whatever he was doing and get to the arrested patient fast. He would be expected to assist nurses in providing heart massage and resuscitation until senior medical staff arrived, then prepare injections and do whatever else was demanded of him. Every junior dreads arriving first; nurses see a white coat and, in an emergency, expect it to take the lead. Tim Matthews knew the theory but ...

The bleep had, in fact, gone off at 8.30am, presenting him with his first career dilemma. Officially, he did not start until 9am; should he attend or should he stay put? He stayed put and declined to say whether fear informed his decision or a determination to stick within contracted hours. No one had reprimanded him anyway.

And so he had presented himself at 9am sharp on the admissions ward, his starched white coat marking him out among the harassed senior house officers, in sweaty shirtsleeves with stethoscopes flung casually over their shoulders. His pockets bulged with the medical equivalent of a new schoolboy's pencil case; stethoscope, pen-torch, tourniquet and tendon- hammer, because "you can never find one when you need one". But most important of all was the house officer's bible, the Oxford Handbook of Clinical Medicine, known as the "Cheese and Onion" because of its green and white cover.

Having dealt with the dead patient and her relatives, the more mundane tasks took over. It was his job to admit new non-emergency patients, to take a careful record of their medical histories and carry out a basic examination. He had to "work them up" and order the X-rays, blood and urine tests and other diagnostic tests that the on-call consultant, Dr Serlin, would expect for the following morning's ward round.

This was not too demanding. But as the morning wore on, Dr Matthews's stress level rose. The patients were less of a problem than the paperwork: choosing the right form from the multitude available, filling it in correctly and leaving it in the right place to be collected. Meanwhile, the number of patients he had to see was growing. And this was the quiet bit of the morning, before local GPs went out on home-visits and identified people who needed to be in hospital.

The nurses were helpful when asked but appeared uninterested in their new member of staff. "We've seen too many go through to get over-excited," said one. "It's great when they start, they're all really keen and they'll do anything you ask. Stick a form in front of them and they'll sign it. In six months, when they have a bit of confidence, it is different."

If Dr Matthews was nervous, his patients wouldn't have guessed. By mid- morning he'd dispensed with his white coat and slung his stethoscope over his shoulder. He had an easy bedside manner that encouraged people to talk. Hilda, 52, who had got up that morning and blacked out with "thumping great chest pains", couldn't be stopped as she detailed 35 years of her medical history. Dr Matthews was mid-examination when, at 11.27am, his bleep went off: two patients to be admitted. At 11.28pm, it went again: a GP referral of a 71-year-old woman with chest pains. The day had really begun.

Shehzada Nazir, 23, had an equally macabre start to the day. A woman with lung cancer on one of his wards had died during the night, and he was required to certify her death. "It's very unusual," he said. "I don't think anyone else will have had to do this on their first day."

Dr Nazir's confident manner was in sharp contrast to Dr Matthews's low- key approach. He was a pint-sized Raj - a character from the television programme Cardiac Arrest - but without the sleaze. From his carefully gelled locks to the multi-coloured "What's up, doc?" tie, Dr Nazir breezed around the wards, introducing himself to nursing staff and the patients he would be caring for. The reception was good, apart from one nurse who said tartly: "Hi. If you bite, you'll find we bite back."

An academic high-flyer from Liverpool University, Dr Nazir had opted for Southport and Formby District General for his house job because he believed it would mean a better all-round training. Medical schools, he says, do not prepare you for real life in a hospital. Teaching hospitals are more prestigious to train in but are also more competitive, and juniors there really are the lowest of the low. They can spend a year doing little more than clerking patients or collecting blood. "There are advantages and disadvantages to both, but I want to learn as much as possible," says Dr Nazir.

Perhaps one reason Dr Nazir remained so cool was that unlike Dr Matthews, he had a senior house officer, Dr Harry Bardgett, with him for most of his first day. A year ago Dr Bardgett, too, was facing the same ordeal of being a novice on the wards and wanted to ease Dr Nazir into the job.

In most cases, junior staff can turn to another doctor, but they know they are busy, too, and they fear the irritation their call may cause, especially when the task is a menial one. Dr Matthews's first real problem came late in the afternoon. He needed to take blood from a patient he had admitted, but four attempts had failed to raise a vein. "She's really dehydrated," he told the SHO, Dr Peter Moncur, by way of an apology. "Yes, I have done one before, but it's been six months."

Dr Matthews believes medical school prepares doctors-to-be "as best it can" but admits that the transition from a student to a doctor who, however junior, must take responsibility for a patient, is a hard one. He says more medical schools should introduce a system that allows final-year students to "shadow" house officers to initiate them into what the job really involves. This has been implemented successfully by Manchester University, and is now being copied by some other medical schools, including Bristol, where Dr Matthews studied.

By 5pm at the end of his first day, Dr Nazir and another junior were laughing and joking over a pot of sputum they had just collected from a patient. Why was it the colour of squashed tomatoes? Did they have enough to send for testing? And how much sputum was enough anyway?

For Dr Matthews, however, the adrenaline was still pumping. He'd drunk several Cokes and admitted eight patients. But his baptism of fire was far from over. He faced another 24 hours at the sharp end. He was, he admitted, "absolutely shattered" but quietly triumphant that so far he'd "managed OK". What he wanted most was a hot bath.