The Generational Divide: Are We Really So Different?

From 85-hour workweeks in 1962 to Chaotic treatments in 2026

They say that every generation has its own troubles, troubles they naively believe are entirely unique to their time. Medicine is no exception. But to truly understand the struggles of yesteryear, we need to hear directly from the people who lived through them.

So, dear On-Call reader, you have two options. You can either put down this newsletter right now, track down your Consultant, and fire some questions at them, or we can step into the online time capsule that is the BMJ archives.

If you’re still reading, I’m guessing your Consultant isn’t the chatty type, or you’ve still got another half-hour before you're due back on the ward.

BMJ Archives

Let’s look at the words of Dr David Tweedie, a retired Consultant Anaesthetist who qualified in 1962. Writing to the BMJ in 2016, he reflected on his days as a House Officer. His schedule consisted of one half-day off a week and alternating weekends, rotating through Orthopaedics, Paediatrics, and A&E. His weekly hours averaged a crazy 85.6 hours (43.2 on normal duty and 42.4 on-call).

While the European Working Time Directive eventually put an end to those hours in the interest of doctors’ wellbeing, the sheer magnitude of the shift drop length is worth contemplating. We have to ask: Have appropriate changes been made to ensure the NHS can still function effectively when its doctors now work 48 hours instead of 86?

Sadly, the answer is a resounding no.

Different Eras and Different Battles

Let’s be clear: even when we consider the increased training opportunities it may have provided, there is nothing noble about working an 86-hour week, even with the historical perks of free meals and accommodation.

The most striking distinction for us, however, was how Dr Tweedie’s memories painted a picture of a close-knit team in which House Officers lived on-site. Doctors learned from their colleagues; they got to know them, hospital mess culture was alive and post-shift drinks were commonplace. Reading through these archives, it really seemed like there was a sense of kinship in medicine. We know from literature that strong workplace relationships and a sense of meaning in your job are strong factors in job satisfaction. We all need a long think on how we can cultivate this environment in our profession again?

So you’d be able to share a pint with your Consultant after the shift, but how has the medicine changed? Dr Tweedie remembers what doctors could actually do at the time. Therapies were basic with few antibiotics, no modern "wonder drugs" like beta-blockers or PPIs (peptic ulcers were treated with a milk drip), and the MRI machine was still a thing of the future.

Ultimately, doctors of every era have been deeply committed to providing the best possible care for their patients, while navigating unique struggles both inside and outside the workplace. We gain absolutely nothing from engaging in a generational slanging match.

Power and the BMA’s 7% Problem

The Employment Rights Act is being lauded by some resident doctors as a triumphant success. Headlines will frame it as removing the requirement for half the workforce to support a strike before it can go ahead. In practice, it shifts decision-making away from individual members and towards union structures and higher committees, leading to a more centralised kind of control.

Democracy still technically exists, as we elect BMA representatives when elections come around, but this is representative democracy in the same fashion as local government, with the same familiar weakness: low participation.

In the last set of BMA council elections, what was the name of the doctor you voted for? Chances are most readers have no idea as they didn’t vote. Doctors don’t engage with these elections, so outcomes are shaped by a small, self-selecting minority.

The 2022 BMA council elections saw a turnout of just 7.1%, meaning 92.9% of members didn’t vote. Whatever the reason, time pressure, indifference, or the assumption that someone else will sort it out, the effect is the same: a very small active base ends up doing most of the deciding.

So, while the legislation may make strike mechanics easier, the system only really works if more doctors engage in local and national union elections. Otherwise, power will end up sitting in a smaller and smaller room.

Friend or Foe: The Great “Service-Provision” Debate

What is it that separates “Service-Provision” from necessary experience?

Let’s play a game. I say a phrase, and you decide whether it is a positive or negative descriptor.

“Character Building” - On the surface it suggests a challenging but ultimately beneficial experience. In NHS reality, though, it often slides into the negative category. So rather than meaning a “growth opportunity”, it’s more of a euphemism for being placed in a chaotic, understaffed department and told to get on with it.

What about “Service Provision”? Almost universally used as a negative descriptor. If a placement is heavy on “service provision”, it usually means your day is dominated by telling the sister in charge that bed 10’s discharge letters will have to wait whilst you do bed 27’s. In other words: “We need you to keep the system running, not necessarily to train you”.

But the more you read, the more tasks and jobs seem to become consumed under this broad ‘service provision’ umbrella. Can it be possible that seeing and clerking patients could also be a form of service provision? And if so, why do we use the phrase in a negative way?

The Great Service Provision Debate

It’s worth being honest about why we think that phrase exists. Hospitals do not accidentally generate service provision; it’s the default state of a system under pressure. If demand exceeds the workforce's capacity, we doctors inevitably become the buffer that keeps things moving.

When we use the term pejoratively, we are usually not criticising the act of seeing patients or making decisions. We are criticising the lack of structure around it: the absence of supervision, feedback, and protected learning time. That’s the key. Even in those tasks that are essential for doctors to gain experience (e.g. clerking patients), when there is no bridge back to reflection, education or progression, we begin to enter ‘service provision’ territory.

None of this is to suggest that exposure doesn’t matter. Medicine is fundamentally pattern-based and statistical, so familiarity improves judgement. A doctor who has accumulated 3000 hours in a speciality will, on average, be more capable than one with 1000. Repetition matters.

But repetition alone is not enough. Ten thousand hours of discharge summaries might make you exceptional at discharge summaries and the matron’s best friend, but not necessarily a well-rounded doctor. You need breadth to build judgment.

Is The Firm The Answer?

The apprenticeship model has value precisely because it sits closest to reality.

There was something about the apprenticeship/firm model that went hand in hand with good training. The keyword is ‘continuity’. You saw the consequences of your decisions days later. It was there right in front of you; you couldn’t miss it. And actually doctors felt a sense of ‘ownership’ over their patients for similar reasons, and we know that ownership increased cognitive investment. You’d have stronger neural links to these cases and more impetus to go home and read around conditions.

Right, so let’s make a thesis: expertise develops faster when learners (doctors in this case) can observe their decisions playing out in their outcomes. Add together a tight-knit environment with seniors present to offer guidance and reflection, and it is easy to see why many believe the firm system provided the best learning experience for doctors.

But for those nostalgic about the apprenticeship model, they perhaps need to understand that it belonged to a time long past. Safe hours legislation isn’t going anywhere; shift staffing is the only way we can man the ward without mass burnout, and significant consultant-delivered care is popular.

We shouldn't romanticise the apprenticeship model any more than we should dismiss service provision. The lesson isn't that we need to recreate the firm system of the 1980s; it's that we need to recreate the educational conditions that made it effective.

How do we recreate continuity, feedback, and ownership within a fragmented, shift-based system? If we fail to answer that question, service provision will remain labour with incidental learning rather than work that systematically produces expertise.

“The Great NHS Teaching Paradox: Complain that teaching doesn’t take place on the job, when the consultant decides to take extra time to teach, complain that the ward round is dragging on too long.”

“Less than full-time working is essential in our career, especially when 45-hour-plus weeks are normalised in our profession. However, given how important experiential learning is in medicine, is it right that LTFT trainees should progress at the same rate as full-time trainees, and how will such a policy affect the number of trainees who choose to drop their hours?”

“Is it weird that after one year of being a doctor, I am already dreading the day when my five years of discounted GMC membership come to an end? £516!!!”

“Paediatric milestones and Vaccine schedules battling it out for the biggest soul destroyer of medical exams.”

“A doctor who is part of the On-Call community was recently stung by an AI-assisted scam attack that led to him losing thousands of pounds in fees he believed he was paying to his solicitor for a house purchase. If sending a large amount over the phone, you can always send £1 first and check with the payee the next day to confirm receipt of the payment.”

What’s on your mind? Email us!

Some things to review when you’re off the ward…

Consultant Physician at Guys and Tommy’s David Barlow recalls a time when he was a medical student and the failure rate in finals was 15-20%, compared to the reported 0.3% failure rate at King’s College London today. Read the full article over on the BMJ.

Routine recordings of surgeries have been shared with AI developers to create models that could be sold back to the NHS and used to replace doctors. Doctors are understandably worried, but is this just a sign of the times? Should we be holding back technology that could potentially lead to the betterment of society’s health for this reason? Here’s the full piece in the BMJ.

Weekly Poll

Last week’s poll:

What do you think best explains the result of the resident doctor referendum?

…and whilst you’re here, can we please take a quick history from you?

Something you’d like to know in our next poll? Let us know!

The Doctor’s Mortgage Advantage

Wouldn’t it be nice to inherit the housing market our parents walked into? Instead, just as we reach a semblance of career stability and consider buying our first home, we’re met with sky-high deposits, stamp duty, and a growing list of hidden costs.

But there is one advantage many doctors underestimate: lenders don't just assess what you earn today; they assess how predictable your earnings are likely to be tomorrow. In fact, in most professions, lenders have to estimate the future earnings of the individual in front of them because of boring things such as economic cycles, company performance or individual negotiation. In medicine, they can open their search engine and look it up.

NHS salaries follow a defined pay scale, career progression is relatively transparent, and employment is generally secure. That makes doctors an unusually low-risk group in the eyes of many lenders. While you've probably heard of the 4.5× salary rule, some lenders offer enhanced income multiples for healthcare professionals where affordability supports it. Regular locum income that can push up annual earnings may also strengthen your application and allow for greater borrowing.

Now obviously, your credit history still matters and missed repayments and persistent debt will raise eyebrows of the mortgage broker.

So the takeaway is to not assume home ownership is years away. If you are in a stable part of your career, with some degree of geographical security, speak to a mortgage broker familiar with NHS careers before assuming you can't afford to buy.