Working and learning in hospitals: junior doctors adrift in fragmented communities

Abstract

This paper is based upon an ethnographic study of senior house officers (SHOs; second and third year residents) intending to become general practitioners (GPs; family doctors who practise in the community). GPs/SHOs in four very different hospitals and their associated training schemes were case‐studied. The methods included structured and semi‐structured interviews, observations of training events and occupational experience, shadow studies and focus groups. Major changes in hospitals have transformed the experience of working and learning for both GPs/SHOs and consultants. Continuity of care and the stability of medical teams appears to have given way to episodic care provided by frequently changing teams, led by consultants who are subspecialists within their own field. Does hospital training still provide the breadth of clinical experience appropriate for general practice? In hospital‐based training, GPs/SHOs who are doing a ‘real’ job make ‘real’ mistakes. They do so in a climate that is increasingly intolerant of error. They receive very different messages about the acceptability of mistakes and their place in the learning process. What appears to be missing is an educational framework for recognizing and understanding both the nature of a mistake and its clinical and educational implications. The persistent message from those involved in hospital training was that it could be improved. It seems that what is needed is a radical reconsideration and reconceptualization of how to address the learning and teaching issues of providing training that prepares GPs/SHOs for the real demands practice.

Do trainees feel that they belong to a team?

“…It was predominantly the ‘medical’ team that was reported to provide both teaching and support for these trainees. The concept that shift‐working patterns often disrupted the ‘team’ structure reflects other literature suggesting that fragmentation of the team may restrict the development of an educational interpersonal relationship between consultants and trainees . This relationship can enable consultants to determine trainees’ strengths and weaknesses, facilitating the identification of the struggling trainee.…”

“…Postgraduate medical education in the UK has undergone significant changes in recent decades . Structural changes and policy shifts have substantially influenced clinical working patterns, and the traditional apprenticeship model has been affected from both a practical and an educational perspective . Working patterns are increasingly reliant on shift systems, with a move away from clinical ‘Firms’ (whereby doctors often worked in specific uniprofessional groups led by a named consultant) .…”

A New Curriculum for Surgical Training within the United Kingdom: Context and Model

“…These reduced hours result in reduced experience and impact very significantly on training. 6 Figure 2 illustrates the effects of current time constraints within the National Health Service (NHS). Positioned at the apex of the triangle are the consultant trainers who embody the professional knowledge base.…”

Editorial

“…Three papers from the UK studied the learning of Senior House Officers, junior doctors 2–3 years after leaving medical school. Both McKee (2002) researching prospective GPs and Brigley (2005a,b) researching surgeons encountered major constraints on learning arising from supervisors being overworked, access to appropriate practice being difficult, and interpersonal communication ranging from the excellent through the tolerable to the non‐existent.…”

“…Two papers came from midwifery, Blaaka (2006) focusing on learning in a community of practice and Sookhoo & Biott (2002) on learning to cope with uncertainty in reporting the progress of labour when others are expecting definite advice. McKee (2002) describes a range of factors making hospitals a poor environment for the learning of junior doctors, especially those intending to become GPs; while the Stewart, Bregazzi & O’Halloran (2003) study of specialist registrars in Accident and Emergency medicine notes how they focus on formal learning and fail to recognize how much their progress depends on informal learning and attributes this to the assessment system. Fessey (2002b) describes the preponderance of informal learning by newly qualified nurses and how their commitment to the job affects their access to help from their seniors.…”