In praise of young doctors
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e4549 (Published 11 July 2012) Cite this as: BMJ 2012;345:e4549All rapid responses
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What would be in a student's dream training curriculum? Surely those who are currently doing the training belong to a cohort which were not put through the same kind of mill so many students are finding intolerable? Of course they are not responsible for drawing up the current curriculum or the numerous forms and check boxes...but why aren't more trainers speaking out against the present system? Seems there is still in some areas anyway the remains of a culture where somebody in a relatively vulnerable situation could be referred to as 'boy' and get away with it. This is hopefully fairly rare but there isn's a sense of students being able to engage in much dialogue either with trainers or individuals they meet in clinics or on wards.
As medical students still in the main come from privileged backgrounds, often with help from ambitious as well as caring medical parents, and do perceive a lack of engagement with other people, it might be useful to do be able to do a 'gap year' after qualifying, for example shadowing a social worker, working in a drugs rehabilitation centre, a home for elderly people, time out to attend conferences and groups led by people with different conditions, social and medical - real life encounters and less role play or tick boxes where student responses are geared to getting marks in the same way as they have been processed all the way through previous education. Once qualified and started in any job it is much more difficult to get time out to reflect and gain wider experience outside a particular field.
Competing interests: No competing interests
We read with great interest the article by Iona Heath on the state of junior doctors around the country[1].
As people that are crossing the student-doctor boundary very soon we echo the sentiment that she has expressed. Reflecting on the past 5 years, we cannot help but see how our performance was determined by exercises and assignments that had reduced us to tick-boxes.
We were given formulas to perform examinations, take histories and break bad news. We were even assessed on our abilities to reflect and there was a formula for that too. As we look forward to our time on the wards in a few weeks time we anticipate discovering a strategy for success on the wards as this is also prevalent outside the classroom. It was to one of the author’s chagrin when on a surgical ward round a junior doctor questioned the consultant about a patient’s management. The latter retorted, “You’re not here to think boy!”.
Recently, JAMA published the graduation speech that addressed Harvard Medical School’s class of 2012 reminding them of how the wonders of modern medicine may be futile in the face of social inequality and that it was their voices that needed to be expressed for change in the health care system[2].
We understand the burden on medical schools and training programs to produce competent doctors but this does not amount to creating mere minions. They must not strip individuals of their identities. The consequences may be that the doctors at the end of a production line are too detached from the society they serve to cater for their needs appropriately.
1. Heath, I. In praise of young doctors. BMJ. 2012 Jul 10;345:e4549.
2. Berwick, DM. A piece of my mind. To Isaiah. JAMA. 2012 Jun 27;307(24):2597-9.
Competing interests: No competing interests
As a recent graduate (2008), the changes I have seen in working patterns of juniors are heart sinking.
At medical school, we students were attached to a firm who all worked together on the medical take and then looked after those patients until they were discharged. Juniors were supported by regular ward rounds with their team and continuity of patient care ensured a wealth of learning opportunities.
The system had started to erode as I became a houseman though in my surgical job we did still keep our take patients until discharge and I was thus able to learn from the patient journey.
It's about more than learning from our patients, however. As a houseman, these men and women on the wards were "my" patients and I worked hard to make sure they got the best care. I got to know them and their relatives during their inpatient stays and that investment was rewarded with job satisfaction on seeing them through their treament.
Just 4 years on, the team structure of working seems an almost distant memory. On calls are spent frantically reading patient notes to try and get up to speed on a patient I've been asked to review. I've often never met them before and may never meet them again. It makes me feel inefficent and disengaged.
On those rare occasions I get continuity with patients, I remember everything it is I love about my job. The satisfaction of being able to explain things to patients, following through on plans of care and supporting them through their treatment.
How can we get more continuity back into our workplace?
Competing interests: No competing interests
I agree with Dr. Heath, something does seem to have gone very wrong with medical training. I have just completed six years at medical school and am pretty sure I have had to tick (quite literally) more boxes than any previous medical generation. Certainly my parents, both recently retired after 35 years of medical practice, never had as many skills, or competencies, certified during their training.
During my clinical years at medical school I spent an inordinate amount of time in pursuit of the registrar on the ward, desperately trying to get a CEX signed, loitering in A&E with fingers crossed for a DOPS opportunity, or following the FY2 in the hope of presenting a patient for a CBD. I am doubtful as to whether these work-based-assessments (or ‘supervised-learning-events’ as my new e-learning portfolio jubilantly announces they are now called) really improve clinical skills. Most doctors signing assessment forms do so with little interest, whilst these forms simply detract from the teaching itself. Time spent searching for opportunities to get forms signed reduces time spent with patients.
I am glad that Dr. Heath acknowledges the commitment and dedication of the vast majority of junior doctors. However, our conscientious nature makes clambering through these endless hoops burdensome and demoralising. Add to this the huge amounts of debt we face having spent five or six years at university, and it becomes easy to see why some junior doctors feel despondent at the start of our careers.
I recognise that regular appraisal of medical students and junior doctors is necessary, I just don’t think that furious box ticking is the best way to go about it. What about things that can’t be quantified with a CEX or CBD? Clinical thinking, complex decision-making, and professional judgement, these are the skills that are hard to measure and take years of clinical experience to gain.
Unfortunately, I suspect it won’t be long before young doctors have their commitment and dedication ‘snuffed out’ (1). If Dr. Heath wants a doctor who ‘thinks and questions, not one who feels obliged to blindly follow protocols’ (1), I believe she and the Royal Colleges need to act to change clinical education with urgency.
(1) Heath, I. In praise of young doctors. BMJ 2012;345:e4549
Competing interests: No competing interests
Thank you to the BMJ for running an article entitled 'In Praise of Junior Doctors' and to Dr Heath for the second to last sentence in her final paragraph offering a conclusion of hope.
I was however saddened to find an article highlighting once again the inadequacies of our training system. I was equally saddened on turning the page and reading a Personal View BMJ2012;345:e4511 which repeatedly highlighted the mistakes of Junior Doctors.
At a time of turmoil within our healthcare system, and daily battles with demoralised staff and patients, would the BMJ not be better suited to publish offered solutions or praise of training systems' that are working?
I too find the tick box training system in failure and feel it offers little or no distinction between an acceptable and exceptional doctor but, it does offer a process in continual development. In a system with increasing demands for accountability, evidence of competence may well provide us some security. Engaging in the system allows us to spot our own weaknesses and an opportunity for development, a clinically engaged doctor will have no difficulty ticking the boxes which offer just a glimpse at our daily tasks.
The European working time directive is repeatedly citied as being responsible for the lack of continuity in care and I strongly agree it has negatively impacted on patient care. Its impact on the professionalism of doctors is rarely addressed. It is most difficult for a young doctor who is actively encouraged to leave at '5', told they are inefficient if they do not to deal with the increased demands of our ageing demographic who innately require more time. When combined with the loss of on site accommodation, lengthy commute times, affective reduction in pay and increased contributions, where is the reward for working the hours to provide the service we signed up for? The EWTD does however provide scope to work (and therefore train) up to 56 hours a week in a contacted 48-hour week, with pay as a locum, in areas of our choosing.
Real praise and thanks are deserved for all those junior doctors who continue to work hard, without complaining, within a suboptimal system, without losing their desire for what is right for our patients; even if this leads to conflict for acting in best interest but against guidelines. We are fortunate for we work in a profession that gives us the independence to act for what is right. This independence will be lost if our profession does not stand behind and alongside those whose actions care for those for whom we are responsible. Perhaps the BMJ should take a pivotal role in uniting its readership not to complain but to act for what is right.
Competing interests: Nil
I read this paper by Iona Heath with considerable interest and I feel she makes a number of very valid points in relation to the current state of medical training.
In my view, part of the problem would seem to be the belief that hands-on experience, preferably lots of it, can somehow be replaced by a series of 'tick-box' exercises. Has the old 'seen one, done one, teach one' approach simply been replaced by 'seen one, done one, ticked one'? Whilst the former method did have clear disadvantages, it was, on the other hand, supplemented by extensive, on-going clinical experience.
It is this type of clinical experience that I suspect many of us feel is being compromised as changes in training take effect. Heath mentions, in relation to the European Working Time Directive, 'the vital opportunities for trainees to learn from the results of their own actions are severely undermined'. Surely, this is at the very centre of the way we learn, gain experience and as a result become better at what we do. I believe this applies to virtually the whole range of clinical skills, from practical surgical procedures to inter-personal skills such as the delivery of bad news.
An evidence base for medicine is, without question, essential. The best available scientific evidence needs to be major factor in medical decision-making. However, it is indeed unfortunate that clinical guidelines seem to 'have been transmogrified into tablets of law'. Surely, guidelines should actually be guidelines and subject to intelligent and appropriate interpretation by the practitioner. Perhaps this type of judgement is very experience-dependent and perhaps this type of skill is achieved not by a 'tick-box' exercise but by extensive exposure to real patients, taking real responsibility for actions and outcome.
Competing interests: Previous training programme director. About to undertake Master's degree in evidence-based healthcare.
Being a ‘young doctor’ myself, I agree with much of Iona Heath’s ideas. In my experience, the type of person I was expected to be at medical school is quite different from that expected of me as a doctor. Although the transition from student to doctor is now aided by the introduction of shadowing days, this only explored the practical aspects of the job rather than character attributes that will see you through the coming years. Kindness, diligence, not taking work home with you, picking yourself up after your first mistake, knowing when you need help and who to call are all things I wish I had been taught about before I graduated. Yes, many attributes cannot be taught and one hopes that the entry system to medical school picks the right people, but many of these issues could be explored.
I would recommend reading the “See One Do One” article in this week’s BMA news (Saturday 14th July) from a CT2 trainee. The author describes an encounter with a patient where she held his hand as he struggled to breathe. She then had to let go, but the junior who took over the hand holding did so reluctantly and quickly let go. She went on to encourage these small acts of comfort and kindness, which are not taught at medical school, but which can make such a difference to the patients we meet. I look forward to the day when we are taught about who we need to be as much as what we need to know.
Competing interests: No competing interests
Today's trainees right from FY1 to ST7 are focussed on workplace-based assessments - direct observation of procedural skills (DOPS), mini-clinical evaluation exercise (mini-CEX), multi-source feedback (MSF), case based discussion (CbD), acute care assessment tool (ACAT), teaching observation, audit observation, reflective practice, etc. Sorry, the list may seem long and tedious, but imagine the plight of the trainees who have to go through multiple episodes of these during their 7-8 years of their training!
Trainees have to organise electronic requests, seek consultants/senior trainees to fill them out and then send reminders if they fail to complete them. And once completed, they have to be linked to respective parts of their curriculum topics - this is a mind-numbing procedure, given the non-intuitive design of the ePortfolio. And the crucial fact that is conveniently overlooked is that assessors are cherry-picked by the trainees, which makes this process innately flawed.
In all this palaver, the real ability of the trainees has somehow become difficult to judge. Does the trainee - with greater number of DOPS have better hands-on skills, greater number of teaching observations a better teacher or more CbDs have better clinical acumen? And with the European working time directive, training and work have become synonymous and trainees spend much lesser time "on the ground". And the reduced working/training hours have to accommodate these tedious ePortfolio exercises.
The focus for trainees, I'm afraid has shifted to a "tick box" race rather than the hunger to gain real skills and knowledge.
Competing interests: No competing interests
I greatly valued Iona Heath's cogent description of the implications of our profession's obsession with knowing (epistemology) over meaning (ontology). The piece provoked me to reflect upon a recent experience at a GP trainers' workshop at which delegates were unwilling to contemplate public debate of the realities of NHS rationing but subsequently discussed the potential merits of assisted dying on economic grounds.Our profession is, in my opinion, at a crossroads in terms of its response to a sustained attack on a 'free at the point of access' healthcare system that in all probability enjoys a cross party political consensus. Tragically in this context, doctors have become so busy delivering healthcare to our ageing population and addressing the progressively de-stabilising agendas of politicians, that we are failing in our duty of care as advocates for our patients.
Whether we choose to admit it or not, Evidence Based Medicine (EBM) is an artefact that has played a pivotal role in this failure. The reductivist philosophy underpinning EBM has stripped bare medical decision making allowing the profession and policy makers to make impersonal decisions at an emotional distance from our patients. Whilst EBM has undoubtedly produced remarkable improvements in morbidity and mortality, like all medical interventions it is associated with adverse outcomes and these have been neglected. In creating policy making within the vacuum of reductivism, EBM dehumanises and rather than representing the pinnacle of intellectual enterprise, it has fostered decision making with stark political naivety open to exploitation and opportunism.
The article highlights the impact of competency based medical education and how this fosters a focus on knowledge. The author has amassed enough deviance credits in Brookfield terms, to challenge the established agenda but it is my experience that promoting meaning in association with knowledge provokes significant homeostatic defence within our own profession. I fear that as a profession we are not passive victims of progress but rather more active architects of our own intellectual demise.If we are to address these fundamental deficiencies, we require a paradigm shift in how we manage the interface between medical education and its sociopolitical context that is able to embrace intellectual dissent.
S. Brookfield (2006). The Skilful Teacher: On technique, trust and responsiveness in the classroom. Second Edition. Jossey-Bass.
Competing interests: No competing interests
Re: In praise of young doctors
As medical practitioners in the 21st Century, we are bombarded with guidelines from colleges and specialist societies. Dr Heath suggests that guidelines " are fuelling overdiagnosis and overtreatment and are destroying the confidence of many young doctors".
Part of the solution to this dilemma may lie with recent guidelines issued by the Difficult Airway Society. At the end of the guideline they state, "The technique described for awake extubation is a suggested approach. Practice may vary in experienced hands."[1]
Surely it is time that this caveat accompanied all guidelines.
Reference
1. Mitchell V, Dravid R, Swampillai C, and Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012; 67: 318-340.
Competing interests: No competing interests