David Oliver: Supervision and clinical autonomy for junior doctors—have we gone too far?
BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4659 (Published 14 November 2017) Cite this as: BMJ 2017;359:j4659All rapid responses
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Editor
I thank all the rapid respondents who have written so far and look forward to more and I will do my best in due course to distill and comment on the final collection - they are all thought provoking.
With specific regard to Dr White's response, he did make some constructive suggestions with specific regard to core trainee level doctors holding the bleep and effectively "acting up" with some feedback and supervision from medical registrars. Also about timing of consultant presence in the acute take, both of which I agree with. Though he and I are both in General Internal Medical specialties and it would be interesting to know what the issues are in other fields of medicine, including surgery, critical care and general practice, among others.
He did allude to some wider issues about junior doctors' working lives, concerns and morale. I wrote in this journal a few weeks back in no uncertain terms about the need to tackle these concerns in as many practical ways as possible and with some urgency or else reap the workforce whirlwind. [1] Rota gaps, in particular are a major enemy of good training experiences.
That column referenced a range of reports and surveys asking junior doctors at various grades what they themselves thought about their working lives and conditions, their training, etc. These come from a range of medical royal colleges but I have cited in this response a couple from the London Royal College of Physicians. [2,3]
Feedback from junior doctors themselves has also informed position papers such as the NHS Improvement "Eight Key Actions" paper on improving junior doctors' working conditions. [4]
Of course no-one believes that describing the problem however forcibly and making recommendations will solve the problems alone but they do show a very clear attempt to listen to what thousands of doctors in training are telling the rest of the NHS about their work and training.
Meanwhile, this very article on supervision and autonomy was written very much from the standpoint of what junior doctors said in various reports about the quality of their own training, in which the balance between independent and closely supervised practice were clearly flagged by them.
Having said all that, the last thing we need in the NHS right now, is inter-generational conflict among medics, as I also argued in these pages. [5] Most NHS doctors who become consultants or GPs are only junior doctors for a fraction of their career and so it's equally important to consider welfare, morale, recruitment and retention and working conditions at all stages of medical careers not just working in training grades. [6]
It's crucial for any service or institution to have an organisational memory - including medicine. This can help prevent us repeating mistakes by not heeding the lessons of history. Remember, current training arrangements are the result of responses to earlier circumstances and events and all such changes have unintended and unforeseen consequences, however well intentioned at the time, Consultants like me who have been in the job a while don't need anyone to remind us how much the volume or pace or acuity or complexity of medicine has altered (although so has the ratio of doctors to patients, leading to some compensation). Even in the response of Dr Verma (from what he has said, he is fairly early in his own consultant career) we can see that he has noted major changes in how services are organised and led and how training is experienced and supervised.
People who have been in the system a long time don't need to rely on some kind of imagined era of medicine because we were working in it at the time and remember the good stuff and the horrors.
It is not helpful, as I have argued before, to judge modern day medics by standards of yesteryear and using the how things used to be to attack modern day trainees, who are in my view every bit as dedicated and conscientious and professional as earlier generations but have different expectations placed on them and different expectations of their own..
But it is absolutely valid for those who remember more traditional "firm" structures, "see one do one teach one" attitudes, lack of formal pastoral supervision or assessment; the phenomenon of very junior doctors running acute take or wards or overnight surgery, with very little middle grade, let alone consultant supervision to talk about "how it used to be" so we can learn from the parts that were unsafe and should never be returned to but also try to pick out some of the features that may have improved the quality of training and doctors' confidence and preparedness to take on senior roles.
Some kind of omerta on discussing where we have come from historically would be counterproductive
Finally, I am happy to admit that I for one did discuss the use of victim narrative among the medical profession (though never in specific regard to doctors in training) in a column in this journal and I stand by it. We as a profession with high status and job security and relative privilege and power have tremendous influence over our training, our supervision of junior doctors, our curriculae and assessments, how we treat one another and how much we speak truth to power. And we absolutely should discuss how we can help tackle issues - the locus of control is often not external to the profession.
David Oliver
References
[1] Oliver D. Junior doctors’ working conditions are an urgent priority. BMJ 26th September 2017. http://www.bmj.com/content/358/bmj.j4407
[2] RCP London “Being a junior doctor”. 2016 at https://www.rcplondon.ac.uk/guidelines-policy/being-junior-doctor
[3] RCP London “Keeping medicine brilliant” 2016 at https://www.rcplondon.ac.uk/guidelines-policy/keeping-medicine-brilliant
[4] NHS Improvement 2017 Eight High Impact Actions to improve the lives of junior doctors. At https://improvement.nhs.uk/resources/eight-high-impact-actions-to-improv...
[5] Oliver D. Doctors need intergenerational solidarity Feb 2016 BMJ http://www.bmj.com/content/352/bmj.i724
[6] Oliver D Keeping older doctors in the job http://www.bmj.com/content/355/bmj.i6260
[7] Oliver D Challenging the victim narrative about NHS doctors. BMJ 17th October 2017 http://www.bmj.com/content/359/bmj.j4304
Competing interests: No competing interests
The push to a more senior led service was a laudable aim and obvious ambition with increased supervision leading to improved safety and more bedside teaching. However, like many things, it has become a victim of the law of unintended consequences.
I don’t believe the juniors coming through these days are any less capable or intelligent than in days gone by. Far from it. Rather the system that has been created leaves them no opportunity to learn to make their own decisions. The resultant lack of confidence manifests itself in a decision making palsy.
Rising workloads also make having the time to “teach” as opposed to “dictate” a plan increasingly difficult as you know there are more people to discuss & review. Work placed based assessments are in danger of becoming “tick boxes” (many may argue they already have) and increasingly rigid protocols become supervision by proxy.
Voltaire was correct when he warned us that perfection can itself be a problem. I don’t for one minute advocate that we return to the old culture of “See one, do one”. Rather we need to find a middle ground whereby trainees are allowed to flex their wings in a graduated manner with senior support where necessary.
Let us not forget that these trainees will be the senior doctors of the future. We owe it to both our patients and our profession to ensure that they are adequately prepared for that role.
Moving towards this though in an increasing litigious environment where mistakes are punished rather than used as learning events will not be simple. As David said, there are no easy answers. How do we square the circle when our patient today not unreasonably expects the best care possible??
Competing interests: No competing interests
Great article! The handling of competing risks is what Doctors do, increasingly with the increasing multi-morbidity of patients . Doctors in training learn this by experience (but need the confidence). It is better if the 'senior decision-maker' may sometimes discuss and ratify the Registrar's management plan. To do this, we need to free up the Doctors.
May I suggest we train a cadre of 'Doctors' Assistants' to do the work that does requires neither a medical degree, nor Practitioner/Registered status?
At East Sussex, we ran an award-winning pilot of 'Doctors' Assistants' at Band 3 (£18,000pa mid-point). We selected from HeatlhCare Assistants, ran a a two-week induction and weekly tutorials. They work till 8pm, covering 7 days/week. They find results, do dementia screenings, take forms, scribe in notes, locate patients, cannulate, draft discharge summaries, etc. We put a job description and tips to implement this on: http://www.bit.do/dr-assistants Doctors in training loved them. The business case needs to be built on: fewer exception reports [from excess hours of doctors in training], fewer day-time doctor locums, better discharge processes and patient flow.
We should be proud of and develop staff who do not need or want to be autonomous decision-making Practitioners, to free up time for the Doctors for whom this management experience is essential.
Competing interests: No competing interests
David is right: there are no easy answers. However, I see the e portfolio and the endless sign offs have meant people constantly need to be supervised so the sign off can be done
My feeling is this disempowerment from qualification
This is compounded by shift patterns and the lack of a firm structure over some months where you can agree on a level of autonomy
A moderately experienced dr with appropriate support can manage most things to an acceptable level
It’s a bit like a parenting circle of Trust - it’s got smaller over the years
I think it’s time to widen again, knowing you can what’s app a friend
Competing interests: No competing interests
I’m a CMT2 feeling underprepared for Med Reg. FY+CMT didnt cover many specialities incl neuro/renal/resp/rheum/gastro. Have never done A&E/ITU. I’ll have done 4 AMU jobs by time I’m finished. I’m great at blds/chasing scans/dc summaries. Feel totally under prepared for emergencies.
The curriculum feels like a tick box exercise. Many of us are not competent with procedures we have “ticked off”. We have no training in accepting/refusing medical referrals in A&E.
CMT is changing so perhaps those coming through will have a different experience.
Competing interests: No competing interests
David Oliver asks an important question that our profession needs to address. Thinking about my own experiences as a Pre-Registration House Officer in 2003-4, I was frequently on-call and left to clerk, bleed and manage unwell medical patients. Challenging and nerve-wracking at times, within a few weeks I became competent at managing poorly patients with conditions including pulmonary oedema, renal failure, sepsis and seizures. As a Senior House Officer, I was tasked with running a ward as well as attending out-patient clinics, we used to support the House Officers and leave them to run the ward as we attended clinic.
The weeks of nights I did were dangerous - having to do 7 consecutive nights each shift 14-15 hours long. On call weekends were also torrid, covering 40+ hours over 3 days after a busy working week, often being one of two Doctors covering all the medical wards (250+ patients). The levels of supervision were adequate in hours, but woefully inadequate out of hours.
This needed to be addressed - and was. The European Working Time Directive and record levels of NHS funding by the Labour government of the day saw marked changes in staffing levels and shift patterns. However, was the baby thrown out with the bath water?
A decade ago, I remember that Foundation year 1 Doctors were removed from many on-call rotas, and the old Senior House Officer grade of Doctors were stopped from going to Out-Patient clinics and theatre, so that they could support the Foundation Year 1 Doctors on the wards. At the time, I was a SpR "lead" in my hospital - a role in which I worked with management as a representative of trainee Doctors (akin to a modern day Chief Registrar), I remember fighting hard to reinstate on-calls for foundation year 1 Doctors, arguing that it would leave them experience poor for on-calls as a FY2 or CMT trainee. I managed to win that particular battle but overall the war was being lost.
I generalise but we now have trainee Doctors who are ill equipped to run a ward, struggle to deal with a poorly patient and are reticent to take responsibility. Core Medical trainees at the end of their training with MRCP are deterred from acting up as the Medical Registrar on-call during the day for experience. Core trainees do not attend out-patient clinics to enrich their experiences.
The sad truth is that we have infantilised our trainees over a decade or so, and as their capabilities have diminished, this has increased the clamour for Consultant led services in many aspects of care. Whilst I am all for improved care and experience for our patients, what about training for trainees?
We must remember that our trainees are an elite group who are incredibly intelligent and have a track record of academic success. Getting into medical school is still statistically one of the hardest things to achieve during one’s medical career. They have then undergone a rigorous 4-5-year undergraduate academic and clinical training programme, passing innumerous assessments at great financial cost to them and their families, as well as to taxpayers. They are professionals of high calibre and we need to treat them as such, balancing supervision with real life experience, whilst maintaining patient safety. A difficult balance to perfect, but something our profession has failed miserably to do for the current generations of trainees.
Competing interests: No competing interests
A tone of recognising changing pressures in acuity, turnover, patient safety and service provision is welcome.
On the ground the most successful method for increasing preparedness of seniority is the senior house officer or core medical trainee holding a referrals bleep (with the registrar able to support). This is of far greater learning opportunity than a brief post take. Whilst at times this can decrease the quality of accepted referrals for the team, it is key to the development of doctors at pre registrar level. Additionally, Consultants on the acute take need to be active and present in post-taking before, not just during, the most busy hours of the day in order that the day runs smoothly. Facilitating a smoothly running team is in my view the single biggest factor in making people feel like there is time to learn and reflect during the take.
It is is important those who assume senior leadership roles do not reinforce the portrayal of a victim narrative amongst junior doctors who speak about feelings of deprofessionalization, disempowerment, lack of agency and autonomy. Concerns are concerns. Contentedness is not an argument. We should therefore not ignore or invalidate concerns because they do not fit with a constructed idea of how medicine might have been. If one is truly concerned about autonomy of junior doctors this is a priority.
Competing interests: No competing interests
I completely agree with Dr Oliver’s conclusion that with regards to the supervision of junior doctors there is no easy answer.
During my F2 year I worked in one of the busiest accident and emergency departments in the country over the one of the worst Christmas periods in memory. We were assigned to the resuscitation (resus) area overnight (with a senior available for advice but not directly supervising us) and were responsible for taking handover from ambulance crews for all the unwell patients arriving into the resus bay.
I remember the first time I took the handover for a patient with flash pulmonary oedema as one of the most nerve-wracking experiences of my medical career thus far, however as the weeks progressed I became more confident in the management of the acutely unwell patient. I learnt new skills such as setting up NIV and placing arterial lines, so that by the end of my placement I relished the opportunity to work in the resus bay.
Many of my colleagues working in other accident and emergency departments did not get this experience and were envious of the confidence and skills I had acquired. I look back on this as a period of great learning, but I was also very anxious, having sleepless nights worrying that I had done something wrong, and I know as a cohort of doctors for the majority it was not an enjoyable time.
So what is the solution to this conundrum? How do we balance allowing doctors to learn whilst ensuring patient safety? I would hark back to the point Dr Oliver made about volume of workload. Staffing shortages mean that at busy district generals where juniors are having to ‘act up’, they are doing this in a situation where the team is already strained, short staffed and time pressured. In these situations making decisions on your own becomes daunting, and doctors are not given the time they need to think and plan.
We all know an SHO will take longer to assess an unwell patient than an experienced registrar. If the government invested more in increasing numbers of juniors, instead of focussing on having more consultant presence on the shop floor, then we could have the time to learn these skills and develop the medical leaders of the future.
Competing interests: No competing interests
Societal expectations as well as the current medico legal environment is driving the NHS towards a ' risk aversion' model of clinical care.
In the near future, artificial intelligence led algorithms are likely to make people (falsely) believe in 'perfect health care'.
So 'clinical autonomy for junior doctors' is likely to erode further and there aren't any easy answers.
Competing interests: No competing interests
We need to embrace our inner Fat Man.
I completely agree with the issues raised by David Oliver. The cult American medical satire "The House of God" by Samuel Shem, was written nearly 40 years ago, yet seems ever more prescient in this post MMC and EWTD world, in which junior doctors are being ‘trained’ over fewer hours, with more supervision and yet less decision making than ever before. The newly qualified doctors at the House of God hospital suffered a similar plight, being supervised by either The Fat Man or Jo, both senior residents, with wildly differing styles of leadership and management. The Fat Man’s laissez-faire approach was insightful, iconoclastic but not to otherwise interfere unless strictly necessary. Jo on the other hand micro-managed her juniors (and patients) to the point of destruction, trusting them no more to make their own decisions than she does herself. Jo detested The Fat Man, yet it was he who was considered approachable, available and always asked for advice. Jo remains omnipresent, overbearing and unsurprisingly her juniors are forced to lie to her to protect themselves and their patients. Junior doctors are adults; intelligent and highly capable individuals and we need to treat them as such. In short, we need to embrace our inner Fat Man.
Competing interests: The author cycles for fitness and bakes for calm.