Writing for the General Medical Council's bulletin, Dr Bryan Burford and Dr Gillian Vance, from Newcastle University's School of Medical Education, reflect on their research into the experiences of junior doctors.
‘What do Foundation Programme doctors actually do?’
This was the question addressed in new research from Newcastle University School of Medical Education, commissioned by the GMC. It was commissioned as part of ongoing work to review the outcomes we set for medical education in the UK.
It’s essential that our requirements produce doctors with the right skills and our review will help us make sure our outcomes for medical school graduates and Foundation Year 1 (F1) doctors continue to be appropriate. It also complements previous work on how well graduates are prepared for practice.
A major focus of our research at Newcastle University School of Medical Education is to consider the experiences of medical students and trainees at all levels of medical education, from school-leaver to exit exams, including the crucial change from senior medical student to junior doctor. This transition from undergraduate studies to graduate practice is one of the most important, and challenging experiences that a doctor will go through during his or her career.
A notable gap exists in the knowledge of many people involved - students, nurses and even doctors themselves - as to what actually makes up the work of today’s Foundation Programme doctors.
With the support of the GMC and Foundation Schools around the UK, we undertook the largest direct consultation of Foundation Programme doctors and nurses to date to assess what roles, responsibilities and tasks make up the routine work of a Foundation Year 1 (F1) and Year 2 (F2) doctor, and to evaluate how these reflect the outcomes set by the GMC. (The GMC sets the standards and outcomes that all medical students must meet if they are to graduate and work as a doctor in the UK.)
Curriculum outcomes: Theory and practice
Our initial aim was to find out which of the activities specified in GMC outcomes are routine, or rare, in trainees’ work. We found many activities that were common, such as prescribing, cannulation and note-writing, but there were also outcomes which were rarely performed in practice, such as giving injections, setting up infusions or treatment of transfusion-related problems. The scarcity of some of these activities was due to opportunity – after all, transfusion reactions are thankfully uncommon – or due to an overlap with the jobs carried out day-to-day by nursing staff.
Despite this, it is important to recognise that many of these rare activities are still essential at certain times – such as in emergency settings, out-of-hours care and in particular specialities.
The relationship with nurses: division of labour
There was clear evidence of how important the relationship between nurses and Foundation doctors is:
The approach of senior nurses can determine how responsibility is distributed, and the division of labour, although medical leadership is the main influence on the doctors’ role.
Many nurses can, and do, perform activities that historically were solely part of the medical role. However, this division of labour is inconsistent and can leave trainees uncertain where their responsibilities start and end. Doctors’ and nurses’ misunderstanding of each other’s responsibilities, capabilities and training may add to this uncertainty.
Variable roles: Where do F1s fit in?
We found that the sense of being prepared – that is being able to do the job – was not in question. Trainees are generally clinically capable of the activities they are expected to undertake. What we were more struck by was how trainees talked about their work and how the activities or tasks they undertake relate to the roles they fulfil.
We found that Foundation doctors described three main roles:
• Supporter - the most common role described, but also the least rewarding in the eyes of foundation doctors. This role involves supporting the ward or medical teams to deliver patient care.
• Independent practitioner – here the F1 has more explicit patient care and decision-making responsibilities. It is less common than the support role, but is felt to be much more rewarding, albeit more challenging.
• Learner – a vital component of the Foundation Programme, but this role was felt to be less apparent in much of an F1’s day-to-day work.
Our findings - through establishing how, why, and to what extent Foundation Programme doctors take on these roles in practice - can help educators identify how to help individuals to flourish in their training.
Managing expectations of work: ‘It’s work, Jim…'
One of the lessons for undergraduate education is to focus on managing expectations – making our medical students more aware of the reality of what will be expected of them in their first professional post.
The realisation that work may often involve a role and activities not associated with ‘being a doctor’ – working under instruction, performing administrative tasks – can be demoralising for trainees. This realisation is in spite of specific clinical placements - the student assistantship and shadowing programmes - designed to give students and new graduates experience of the F1 role.
The value of some of these activities for direct patient care is not always recognised by newly-qualified doctors and by taking this finding on board, educators may also be able to explore ways in which the important place of the F1 in the patient care journey can be emphasised.
Capitalising on expertise: The frontline
We heard from senior NHS managers that the expertise gained by junior doctors on the frontline is rarely, if ever, capitalised upon by organisations to help improve healthcare delivery. As well as impact on medical education, there are also potential lessons from our findings for organisational policy, and how Foundation Doctors may be more fully integrated into the workforce.
The bigger picture
We found that Foundation Programme doctors routinely do many of the activities for which undergraduate curricula equip them. Those that are rare may still be important in certain circumstances.
All in all we suggest that undergraduate medical education may benefit from a wider focus on how these activities fit within the roles expected for F1s.
While specific outcomes are necessary for designing robust curricula, guidance for undergraduate students also needs to clearly address how new Foundation Doctors work. This will help us to produce graduates who are able to adapt to the varying roles of a Foundation Programme doctor and fit into a multi-professional healthcare organisation, which they themselves have the opportunity to shape.
Picture caption: Dr Gillian Vance
published on: 8 October 2015