How can we make changing rotations easier?BMJ 2023; 381 doi: https://doi.org/10.1136/bmj.p1093 (Published 30 May 2023) Cite this as: BMJ 2023;381:p1093
Provide key information ahead of time
Eleanor Morris, academic foundation year 2 doctor, says, “As a foundation doctor, I change rotations every four months. It generates stress and anxiety for me, a lot of which stems from lacking key information. What will my shifts be like? Is there a changing room? Am I expected to arrive early for my shifts?
“I’ve been lucky to have most of my rotations in one hospital. I can imagine that these feelings would be even worse if I had to contend with new computer systems, parking permits, and finding a new department.
“We could make changing rotations easier by providing junior doctors with clear expectations of the rotation well in advance. We know that doctors rotate—it’s not a surprise. We should, therefore, routinely send key details four to six weeks before the start of the rotation.
“It’s also useful to have a list of the key people to contact if there are questions or concerns, and some responses to frequently asked questions covering things like what to wear (scrubs or professional attire), facilities, and how to arrange leave. My current rotation on cardiothoracic surgery is a good example of this. We were given a handbook of information before starting, in addition to a virtual induction on the first day.
“Clinical supervisors can show their support for trainees by asking some broad questions during an initial meeting, such as, ‘Do you have all the information that you need?’ or ‘Have you settled in with the team?’
“Some departments staff the ward with more senior doctors on the first day of a rotation to enable juniors an opportunity to look around without the pressure of fulfilling a clinical role. This is great—where practical—for building confidence and helping trainees to feel valued. It’s much easier to focus on looking after patients once you know where the toilet is.”
Make us feel welcome
Nuthana Bhayankaram, paediatric specialist trainee year 4, says, “I’ve only recently started to appreciate how much of an impact changing hospitals every six months can have on physical and mental wellbeing.
“There are logistical things that come with every new job—like working out how to get to your new workplace, where to park, and where you need to go on your first day. And there are practical things—like getting used to unfamiliar computer systems. It also takes time to get used to how the department is run and who everybody is.
“I’ve been reflecting on what can be done to improve this experience for junior doctors.
“For a start, employers should make sure that trainees are sent all the information they need on where to park and where to go on their first day ahead of time. They should also make sure that trainees’ ID badges are ready and working when they start and ensure that training in the IT system is included in induction.
“It’s also helpful when departments make sure trainees do not finish their time with them on a night shift—causing them to miss the induction for their next rotation. Nor should trainees start a new rota by working a night shift as that is very daunting.
“In the last two departments I’ve worked, the rota co-ordinator or consultant made a sheet with all the new trainees’ names and photos on, so that the multidisciplinary team could start learning who we were as soon as we started. This made us feel very welcome.
“As trainees, we need to acknowledge that rotating into a new job is stressful and we should manage it in the way we manage other stressful events—by giving ourselves time to adjust, rest, and replenish. It does take time to settle into a new department and learn the system and everyone’s names—be kind to yourself.”
Have comprehensive information about the day-to-day
Monica Ivan, consultant in infectious diseases, Hull University Teaching Hospitals, says, “There are a few ways that we have tried to make life easier for the doctors rotating into our department.
“We do their induction during our weekly multidisciplinary team meeting so that everyone is there for introductions. My clinical lead produced a comprehensive document about our day-to-day work, clinics, and ward rounds which included telephone numbers and everything else our trainees needed to know.
“We have a ‘team infection’ WhatsApp group. Every person that has ever rotated through our department is in there, so it’s easy for trainees to share information (although no patient information is shared), ask questions, and contact seniors. It’s good for sharing fun stuff too.
“We ensure that annual leave for significant events, such as weddings, honeymoons, and religious celebrations, is always approved. For the rest, we have the following rules: study leave takes priority, and is always approved; leave for training days and teaching sessions is always granted; personal development time is granted although this is more flexible and each trainee will need to decide when they can have it; and annual leave is granted if the ward has sufficient cover—this is rarely a problem and all consultants are happy to step down and cover if needed.
“Quite often, unfortunately, our trainees start their rotation with us with a night on-call. If they do, I send them an email with some brief guidance, mobile numbers of the senior team who are covering, and clear instructions that they should call us if they are in doubt. Everyone is welcome to drop by before the on-call day so we can show them around.”
It’s an outdated training model
Sonya Bushell, foundation year 2 trainee and BMA local negotiating committee representative, Yorkshire, says, “In the past two years I’ve worked six different jobs in three different towns and four different organisations. It’s been incredibly difficult moving jobs every four months. Just as I began to form professional relationships, develop skills, and better understand the specialty it would be time to move on again. Because of annual leave and cross-cover arrangements I sometimes spent less than forty days on my base ward before changeover.
“Rotational training is stressful, frustrating, and tiring. Doctors must either commit to long commutes or to moving home frequently. Either choice contributes to financial pressures and difficulties making or maintaining relationships. This makes life particularly hard for junior doctors with children, caring responsibilities, or disabilities.
“Rotational training also adds stress at work, as junior doctors must adapt to working with new teams, processes, IT software, and equipment (often without adequate inductions). Those working without ‘lead employer’ arrangements must redo disclosure and barring service and occupational health checks whenever they rotate.
“There is little incentive for departments to teach or welcome rotational doctors. Rotational doctors often feel undervalued by permanent members of staff, particularly when those permanent members of staff can more easily access training and professional development opportunities. Additionally, it is often difficult for rotational doctors to know how to escalate concerns or access support within their new department or organisation. This presents risks to doctor wellbeing and patient safety.
“Rotations are sometimes described as essential for training, but there is little evidence to support this. Many countries operate training schemes whereby doctors are based in one hospital but occasionally work in other hospitals to meet specific training needs. It is time for the NHS to listen to doctors and move away from an outdated model of training. I am delighted that our motion on rotational training was passed at the BMA Junior Doctors Conference and I look forward to positive changes in the future.”