Supporting Juniors, The good, the bad & the not so ugly
Training, mentoring & consultant support in the new world
Written by: Andrew Vincent. Published: 2nd June 2010
Twenty one years after qualifying from Medical School and after 12 years as a consultant neonatologist, I decided to retrain as a GP. What did I learn about induction, mentoring, training and support from the junior doctor perspective? What lessons can be learnt by consultants of today? How can some services do it so well and some so badly? I was privileged to do three 4 month posts, General Practice, Medicine and A&E before I decided general practice was not for me. What can these specialities learn from each other? What can we all learn?
The Good - General Practice
Doing adult medicine for the first time
in 20 years was a steep learning curve.
However, the support that I and indeed my
other colleagues received in their 1st GP
attachments as part of a GP rotation scheme
was second to none. GPs, it appears, woke
up a long time ago to the concept that GP
training is training first and service delivery
second. We only have one opportunity to
grow GPs with a strong learning ethos, an
ability to reflect, and a lust for continuous
development that they will continue to take
with them through their long careers.
So what actually happened during these 4 months? I started by sitting in with a variety of GPs, Nurses and PAM to truly understand the GP approach and role. When I started to see my first patients I had 30 minutes per appointment (compared to 10 minutes for the GPs themselves). This enabled reflection and learning with easy access to the internet and sites like NICE and GP notebook between patients to consolidate knowledge. Sitting down daily with my GP trainer to reflect and learn on all patients has reinforced rapid knowledge and skills acquisition and learning. Weekly 2 hour tutorials enabled deeper understanding of the management of key clinical areas e.g. hypertension and contraception.
I felt honoured that my GP trainer was prepared to invest so much of his time to ensure that I too would one day become a truly excellent GP.
Lessons learnt from GP
For GP trainees/trainers
- Build time into all posts • for reflection and self learning
- Supervision by a GP trainer is time consuming, but will deliver high performing GPs in the future who will hopefully be inspired to invest their time in the next generation of doctors
- The opportunity to have regular “supervision/mentoring” from a consultant or senior colleague particularly on a one to one basis should not be underestimated. In times of increasingly frenetic working where many trainees feel all training opportunities have been lost and they are only in place to be menial dogs bodies, this is essential for building commitment and enthusiasm for your speciality. Consultants should consider how they can deliver more hands on support and training of juniors whilst also delivering service provision e.g. opportunities for FY2s to sit in on OP consultations.
Medicine
It would be fair to say I do not look back
on my medicine attachment with fond
memories. I think there are many lessons to
be learnt that would not only improve the
junior doctor experience, but also patient
safety and experience, efficiency and
effective delivery of care.
The usual corporate induction took 1 hour. I learnt nothing new. A few words were said about the medical rota but these were only relevant if you were working in the Trust’s other hospital. No one from my hospital was present.
The FY1 (who had spent 4 months in Psychiatry as her first medical post) and I arrived on the ward to the following scenario:
Our consultant was on annual leave. The extremely competent registrar needed to leave quickly as she was starting a week’s study leave. The registrar for the other firm was not working that day. We were quickly told the weekly timetable, were reassured that everything would be self apparent and we did not need to worry.
Things rapidly went down hill…from not knowing what blood bottles to use, not being allowed to use sticky labels for any bottle in this hospital, to having no computer access for x-rays and results.
One hour after first arriving on the ward I was called to say I had three patients waiting all requiring the same procedure. Neither I nor the FY1 had either seen the procedure nor mind done one. Neither did it appear had anyone we tried to ask. An hour and a half later, we managed to find an SHO in another area to help us. Having watched one “procedure” I was subsequently deemed the expert and had responsibility for teaching a further three junior colleagues.
The saga continued for the next 4 months. An induction interview which did not occur for 6 weeks, three appointments for my appraisal where the consultant did not turn up nor send a message to say he needed to cancel.
Memorable highlights included four of us being told we were not organised enough and needed to leave work at 5pm each night. This was so the trust could meet its hours monitoring even though this was clearly not possible with the workload and would have put patient’s safety at risk. Secondly, being told on the last day of the job we had turned out alright in the end after an extremely shaky start!
Lessons I learnt or had reinforced:
Consultants need to:
- Review hospital inductions • to ensure they meet your needs of delivering safe patient care (especially in the first few days on the job). E.g. what do you do in a specific shift, how do bleeps work, the cardiac arrest system etc. As a consultant if you are not sure what needs to be included ask your juniors. Even better, inspire them to write an induction handbook. Remember they can put it on their CV to demonstrate leadership.
- Ensure someone senior and competent is always available when new doctors start. This may mean cancelling clinics and not agreeing to annual leave and study leave for all senior team members. Remember many juniors are now on 4 month rotations. Ensure the change over dates are clearly marked in both your own and the department’s calendars.
- Recognise that not all juniors are the same. Take time at the very start of the job to understand your junior’s needs and the support they will need. Remember patient safety and experience and effective, efficient treatment is ultimately your responsibility.
- Take time out to support and nurture your team throughout their attachment. Remember to praise and support improves morale and personal and organisational performance.
- Consider how insignificant a junior feels, if you are late, don’t turn up or cancel their assessments and appraisal. Make sure you do not set yourself up to fail.
- Does the trainee know the goals and standards expected of them?
- Does the trainee know the timescales for achieving tasks
- Has the trainee received the appropriate training
- Have I provided the trainee with the support and resources necessary to achieve their role?
The not so ugly A and E
Many I know would dread the idea of
4 months in A and E especially after 12
years in a consultant post. Yet despite the
frenetic nature of the post and the un-ideal
shift patterns for work life balance, A and
E managed to get Junior Doctor support
and training so very right that they had a
committed, high performing junior
doctor team.
What lessons can consultants learn?:
- A well thought out departmental induction which is practically relevant with time to ask all those “silly questions” which people always assume you know is worth its weight in gold.
- Adequate senior supervision at all times, especially in the early stages of the post ensures safe, effective and efficient delivery of care.
- Consultants who even though they are busy always have time to answer your questions and teach you so you do not need to keep asking the same questions again recognise this is a high quality investment in their time, which ultimately saves time, resources and complaints.
- A well thought out teaching programme makes individual trainees feel valued. Summarising each training session and sending the notes to all trainees means that those on nights etc, never miss out on a training experience.
- Having knowledge of available support from a variety of named individuals is vital for trainees. Do not assume their educational supervisor is someone they would naturally turn to or indeed feel able to turn to.
- Regular thanks, praise and reassurance that you are doing a good job results in high morale and high performance.
- Juniors need to take breaks if they are to perform effectively. We need to lead by example.
I look back to my own consultant career and think I did a pretty good job in supporting my juniors. Some of you may be reading this now and I hope you agree. As consultants we need to recognise that our juniors need strong clinical leadership with support and guidance to deliver safe, effective care. We cannot do this from arms length. Life is frenetic for us too but training and support of our juniors is a high quality investment of our time. One day these individuals may be our consultant colleagues or GP colleagues referring our patients, would we want them to be untrained, demotivated and poor performers?
