We recognise and acknowledge the issues raised by Dr Levine in his letter (13th July 2012). Newly qualified doctors can expect to be as prepared as their undergraduate training allows and their level of clinical supervision facilitates. These are important additional factors when considering preparedness of medical graduates commencing work at foundation year 1 (F1) level. F1 doctors must be able to increase their level of competence in relation to the assessment of critically ill patients, by working in functional teams both during the day and also at night.

NHS hospitals have traditionally relied on multiple tiers of postgraduate doctors in-training to provide immediate patient care at night, with consultants being non-resident but available on-call from home. This model was and still is the subject of continuing debate. Particular concerns were raised about the impact of working excessive hours on the mental and physical health of newly qualified doctors and the quality of care they provided to patients. The European Working Time Directive (EWTD) acted as a major catalyst for changing the working pattern of these F1 doctors and the Hospital at Night concept was rolled out across a number of NHS trusts in response. This scheme proposes that the way to achieve effective clinical care in the hospital at night is to have one or more multi-professional teams working who, between them, have the full range of skills and competences to meet patients' immediate needs. There is now huge variation across NHS trusts with some hospitals employing no F1 doctors at night. Provided the supervision is appropriate, significant training opportunities exist at night, which are additional to those experienced in the day [1] and we, like Dr Levine, have concerns about this reduction in training opportunities at night for undergraduates and F1 doctors. Over 90% of F1 doctors (n = 1,084) recently surveyed reported that night shifts improved their prioritisation, decision making and planning [1]. In conclusion, when considering preparedness of medical students for medical practice we must consider the environment in which they are asked to work, as well as the training they have received.

[1] London Deanery Foundation Conference 2012 - submitted for publication. http://www.londondeanery.ac.uk/foundation- schools/conferences/2012-foundation-programme-conference

Conflict of Interest:

None declared

Newly qualified doctors can expect to be as prepared as their undergraduate training allows. For the initial management of acutely ill patients, perhaps involving practical procedures, we have to ensure that training and assessment of both students and doctors occur, as far as possible, under similar conditions to those in which doctors will work. 4 days of shadowing help but are not enough. The reality for many newly qualified doctors may be dealing with very sick patients at night in unfamiliar surroundings, in poor light and without much immediate assistance from even nurses, let alone more experienced doctors. Many new doctors report that they are at their most anxious and feel least prepared under these conditions. It would be interesting to review how much acute work medical students are now made to experience at night. I suspect that the results of such a survey might make uncomfortable reading.

Few formative or summative assessments are carried out at these times by colleagues who are properly trained both in assessment and discussion of the factors that can impair performance (as opposed to competence under controlled conditions). Feedback capable of boosting confidence or generating insight into unhelpful behaviour is best carried out as soon as possible after the event; criticism the next day often misses the point. Effective decision-making, particularly for novices, involves clinical reasoning techniques that are not on the curricula of enough medical schools. Being able to talk through these thought processes at the time is invaluable for both senior and junior doctors but is too often denied to the latter by circumstances. Tackling this sort of unpreparedness certainly benefits from simulation, particularly in teams, but, where real life conditions can be so chaotic and unsupported by anything resembling a team, we may have to do much more to improve the working conditions themselves. Assessing ill patients is difficult enough for experienced doctors who are supported by other staff and not being constantly interrupted by pagers. It should cause no surprise that performance and perception of acute work by very junior doctors is inadequate when working without such benefits. Competence and performance can be very different things.

Conflict of Interest:

None declared