As another batch of junior house officers ticks off the last few days to full registration and yet another brood of recently retired medical students assembles nervously to fill their places, I worry all over again about what the former have endured and what the latter are about to face.

I worry both as a current user of quite large numbers of house officers and as the survivor or the very different regime of 30 years ago. I claim no expertise, only a growing bewilderment at what we ask of our most junior colleagues.

The problem is easier to describe than to solve. The conflicting requirements of humane working hours, continuity of care, and a satisfactory breadth of early experience may be fundamentally irreconcilable.

Of course, house staff are no longer required to sleepwalk through the kind of twilit ordeals of exhaustion and risk on which we once prided ourselves. Good. Instead they spend far less time on call for far greater numbers of patients, most of them bewildering strangers.

But I worry, too, that even in daylight modern housemanship seems much more a matter of reacting or failing to react to events, crises, and reported abnormalities emerging apparently at random from a passing stream of sick strangers. Knowing the patients, in the sense of gaining a constructive experience of admitting, treating, and discharging real people with presentations, faces, worries, and families, too, may now be more or less impossible.

Yes, in their first year they will see many cases, events, and crises, but if they can assemble all that into a coherent body of clinical experience they will have done so despite rather than because of the way their work is organised.

There is fragmentation at a higher level, too, as over the years rotational attachments have grown in number and shrunk in duration. Doubtful or vulnerable trainees slide past, more likely to be handed on—perhaps with great relief—than supported. As with their patients, so with them: no overview, no sense of the shape of the case, and always the easy, risky possibility of not looking for problems.

So we begin again, welcoming the class of ’99, hoping somehow that things will be better for them, but knowing that it is all too likely that a year from now we will still go on rounds with junior staff of whom we may know little, trying to look after patients of whom they may know nothing at all.