As a medical student and then as a junior doctor I was a believer in the power of evidence based medicine, and of audits projects as tools to change the world. The idea of finding evidence in the form of a journal article, presenting it to colleagues and it leading to a change our practice inspired me. The model of taking a standard, assessing our practice against it, making recommendations to improve our performance and then repeating the process to evaluate the effectiveness of the intervention made me feel that it would truly be possible for me to do my bit to change the world.

In my first year out of university I did 3 audit projects, made the recommendations and then before I could persuade the relevant advisory boards and groups to approve the changes it was time for me to move on to my next post and despite numerous visits back to the departments for meetings nothing even came of my recommendations. My second year out of university took a similar pattern, although after 18 months of pestering I understand the head injury proforma was finally introduced, shortly to be replaced by one written by another doctor who had followed my job in the department. In the years since then I've done other big audit or projects, but on the whole the response has been been similar, with people citing financial restrictions and administrative red tape as reasons for no changes being made.

Journal clubs are a similar ball game. Papers are brought every few weeks by the juniors as examples of interesting, containing key learning points, or showing new evidence, but I've so far only seen one journal club paper lead to a change in department policy. The usual cited reasons are that the paper is insufficiently powered, the study population is not quite the same as ours locally so results cannot be extrapolated, or that it would be too difficult to get changes past a local policy board.

So what changes can we hope to make as junior doctors? I've (hopefully) made a difference to the lives of many patients and their families by treating their illnesses or offering advice, I've gathered reams of audit data to demonstrate that we are not meeting targets and standards, trying to make improvements when I can along the way and I've brought some journal articles to the attention of my colleagues to broaden their knowledge, but have I really made any difference to the policies and procedures of the NHS or its local hospitals? I would love to be able to say yes, but the evidence suggests otherwise.

So for now I shall continue making my difference in the world by treating these patients, and continue striving to make my mark on the NHS. But in the mean time at least I have lots of projects (albeit unsuccessful ones) to put in my portfolio.