Junior doctors in an acute care setting

The General Medical Council’s Tomorrow’s Doctors lists 16 outcomes, all of which medical students must achieve by the time they graduate “in order to be properly prepared for clinical practice and the Foundation Programme.”1 One of these is the provision of immediate care in medical emergencies—that is, acute care, which includes the ability to assess and recognise a patient’s severity of illness, diagnose and manage acute medical emergencies, and provide life support. A separate outcome is the ability to prescribe drugs safely, effectively, and economically.

It is worrying that the authors of a review of 10 studies describing the educational impact of UK medical school training on graduates’ preparedness to begin clinical practice have reported that graduates perceive themselves to be less well prepared in acute care and prescribing than in the other 14 outcomes.2

All 10 studies used questionnaires, face to face interviews, or focus groups. Four studies could not be included in the quantitative analysis of graduates’ self perceptions or those of their professional colleagues.2 The remaining six provided quantitative assessments of preparedness from 12 groups of graduates and eight groups of the graduates’ professional colleagues. The validity of data provided in these is uncertain, as only 17 of 20 assessments provided questionnaire response rates, and almost half of these had rates below 50%.2 Data from one of the included studies pre-date 19903 and their relevance could be questioned, given changes in medical education, patient case mix, and clinical working environments since then. Excluding this study, the total numbers of graduates and their professional colleagues providing opinions on which the review authors’ conclusions are based are 1051 and 705, respectively, over seven years.2 The opinions of such small groups may not necessarily represent those of the wider graduate population or their professional colleagues.

Nevertheless, there is a common theme of perceived poor preparation in acute care running through all 10 studies. So why should newly qualified doctors feel this way? The management of acutely ill or deteriorating patients is complex and stressful.4 Clinical scenarios often develop rapidly, and fears of poor patient outcome, error, complaint, and litigation are common. Doctors are often required to integrate a varied and large amount of information while concurrently treating a patient who has no diagnosis. Many newly qualified doctors report difficulty in transferring their considerable theoretical knowledge to practice.5 Although they feel confident that they can describe what they should do to treat a given condition, they often freeze in emergency situations because they have never been taught how to do it. For some, their expectations and the perceived expectations of their senior colleagues create a tension between the desire to ask for help and the worry that this will be seen as a mark of failure.6 Similarly, tension can exist between the desire to help an acutely ill patient and the fear that doing the wrong thing could worsen the patient’s condition and outcome.5

Perceptions do not always reflect reality; but is there evidence that newly qualified doctors really aren’t equipped to manage acutely ill patients? Most is circumstantial. More than half of patients admitted to intensive care units from wards receive suboptimal care which, at least in part, has been delivered by newly qualified staff.7 Junior doctors often provide emergency care that “would be improved by greater consultant input and supervision.”8 The early death rate for patients increases in the week immediately after the changeover of junior doctors.9 Patients are also less likely to be treated promptly and are more likely to die if they are admitted to hospital at the weekend, with the chances of survival being better where more senior doctors are on site.10 Studies have shown that some trainee doctors possess poor knowledge of aspects of acute care,11 and in the latest review2 the healthcare staff working alongside newly qualified doctors appear to judge them as less well prepared in acute care than in the other Tomorrow’s Doctors outcomes.

It is easy to suggest that research is required to evaluate if, how, and to what extent under-preparation in acute care influences new graduates’ performance and patient outcomes. Whatever the results, is it acceptable for the least experienced clinician still to be the first responder to a sick or deteriorating patient? The concept of patients being attended by the “right person . . . first time” is accepted for medical admission units,12 so why not apply this principle to general hospital wards? The GMC is explicit that students who are unable to provide immediate care in medical emergencies “must not be allowed to graduate with a medical degree.”1 Ensuring that every medical student is taught the practical aspects of how to manage the most common medical emergencies, and is assessed to be competent at the bedside, is not only time consuming but perhaps unachievable at least before graduation in the current educational model. Perhaps we should accept that graduation from medical school does not currently equip newly qualified staff to deal with medical emergencies. Doing this would lead hospitals to face the fact that, for patient safety reasons alone, urgent care should be provided by staff that have been properly and appropriately trained to provide it.