Lets set out some house rules.

In days gone by, FY1 doctors were called housemen, house officers, house physicians, house surgeons or similar.

Their training was mostly through a school of hard knocks. They spent unholy numbers of hours tramping the corridors of hospitals up and down the country, lived on site and essentially existed to serve their team and their patients. The deal was quite clear – live in, know everything about your patients and pick a career at some point during that year – or at least divide it into knives, potions, or GP. Further detail would come later during an SHO rotation.

The choice of jobs when leaving medical school was more about geography than subject matter. It was clear that you would spend 6 months doing surgical house jobs, and 6 months doing medical house jobs.

Over the past few years, particularly with recent changes to working hours regulations, career structures and overall philosophy in medical education, this deal is not quite so clear. Indeed, FY docs now have to spend a portion of time in the community (in the first year when not fully registered with the GMC I have always wondered what service commitments are like for these docs) and the choice of job combinations available through FPAS is bewildering.

It is quite possible to go through the majority of the first year out of medical school without being anything except supernumerary.

And therein lies a problem.

The first weeks and months in a house job are a formative experience. This was when, in the words of a brilliant registrar of mine, you learned to ‘love your patients’. You learned that attention to detail, accurate recall of clinical histories, obsessive organisational skills, and a dogged determination to acquire key investigations, opinions, or procedures where what made a difference to the outcomes of the patients, and therefore your team. In those first few weeks, late nights, self doubt, early morning wakening, and late night calls to wards to check on results and requests were the norm.

Today there can be a very different experience for some of our junior colleagues. Some are placed in jobs where they are little more than observers, an appendage to the team, rather than the tightly coiled spring turning the inner cogs of the medical machine.

What does this do for their formation into the medical workforce of the future? What impact does it have on their feelings of self-reliance, of knowing they have made vital contributions to the care of patients?

I’m not sure what the long term outcomes are, but recent experiences make me feel that there has been at least one detrimental effect.

Previously the rules of engagement were clear – you were the houseman, you fetched notes, maintained lists, knew or had to hand the bloods etc. it didn’t really matter which firm you were on, those were the rules.

With FY1 jobs in critical care, GP, and other ‘non-traditional’ house officer specialties, the role of the junior is less clear, and boundaries of knowledge and competence are more blurred.

Given that in the medical world knowledge about fancy subjects like critical care can afford a veneer of competence – this sometimes offers false confidence to trainees ( see here for some theory) and their position in other more traditional firms is less clear.

So – with the senior doctors of today ( I can’t claim to be senior, but was one of the last cohort to go through traditional house jobs) all having trained in the old model, it is understandable why they might assume the old house rules apply.

On the flip side, with new trainees not going through the same formative experiences as their seniors, it is entirely understandable why the unwritten rules are not immediately apparent to them.

This corrupted hidden compact between seniors and juniors is one reason why there is sometimes a disconnect between expectation and delivery of duties on the wards.

To point fingers, blame, shout and generally be exasperated is not the answer.

I would suggest that departmental inductions firstly need to happen, and secondly need to include a bit of explicit contracting – setting out of the house rules of engagement. And in the deal should be something of benefit to both sides – including a bit of mentoring / coaching, honest mutual feedback and real training.