HOW CONFIDENT AND PREPARED ARE CORE MEDICAL TRAINEES IN THE UK TO PROCEED TO THE REGISTRAR LEVEL: THE TRAINEES' PERSPECTIVES.

Editor,

The journey through medical training is full of significant transitions and changes in the responsibilities and seniority levels of trainees. Many articles examine the early transition from a medical student to a newly qualified doctor. Nonetheless, few studies were designed to investigate the impact of on-going transitions following the completion of the first year as a postgraduate doctor and transitions at higher levels of training. We aimed to explore the extent to which core medical trainees in their second (final) year (CMT2) feel prepared and confident about starting their higher medical training.

METHODS

In 2013, a pretested questionnaire was sent to all CMT2 in the sector covered by University College London (UCL) partners. The total number of eligible trainees was 88. Thematic analysis was applied to qualitative data.

RESULTS

The survey was completed by 53 trainees (60.2%). While the vast majority of the CMT2s (88.7%) completed the Membership of the Royal College of Physicians (MRCP) exam, 25 (28%) revealed that they had insufficient confidence to become registrars. This confirms the previously reported finding that a positive relationship between competence and self-perceived confidence is often absent.

The trainees expressed concerns across a wide range of clinical and non-clinical domains. It appeared, however, that practical procedures constituted the major area of lack of confidence, followed by managing cardiac arrest calls, running outpatient clinics and responding to referrals from other specialties. The trainees primarily blamed the low volume of exposure to these activities during the training programme. This resembles the association of the lack of confidence with ‘low volume/high impact’ clinical activities described by Kneeborn.

The majority agreed that their job was more of a ‘service provision’, as opposed to being a training one reflecting that the CMT2s are rather distracted by jobs which are less suited for them. The lack of flexibility of placements and inadequate exposure to certain specialties was considered by many trainees as another important reason behind their insufficient confidence.

The recommendations made by the CMT2s are summarised in . The primary suggestion was a period of shadowing or ‘acting up’ as medical registrars and greater opportunity to take referrals during the acute take. This suggestion remains plausible particularly as the concept of shadowing of near peers has been successfully used at lower-level transitions (such as students shadowing foundation doctors) and was proved to enhance preparedness levels. Alternatively, the trainees felt that simulation teaching could be a good compromise. In addition, the trainees expected to have more opportunities to improve their confidence in specific areas by taking ‘time out’ through fixed leave or allocated slots. Others suggested full rearrangement of the service and the CMT rotations by having more juniors (foundation doctors) to which tasks could be delegated. They believed that this should be combined with clearly defined roles of the CMT2s, as well as separation from the roles of foundation doctors and GP trainees, who are less committed to medicine. Although a few CMT2s indicated that they would be more satisfied with an extension of the CMT, this was challenged by the majority of the trainees.

CONCLUSION

This survey highlighted a number of areas of insufficient confidence and generated relevant solutions. However, further in-depth studies are required to explore the methods of implementing these recommendations.

Table 1

The different suggestions proposed by the core medical trainees to improve their overall confidence.

Suggestion Themes
A period of ‘acting up’ as a Medical Registrar:
○ Opportunities to shadow registrars. ○ Encouragement to step up to fill registrar on-call shifts towards the end of CMT once full MRCP is obtained.
More opportunities to achieve confidence in specific areas:
○ More free courses aimed at practical skills. ○ Fixed Leave/time out of work to improve confidence in certain skills. ○ Protected, allocated and compulsory clinic time across all rotations.
Improving and reforming CMT teaching:
○ Incorporating simulation training. ○ More practical teaching in protected teaching sessions.
Service and placement rearrangement:
○ Incorporating specific mandatory placements into the CMT programme that would allow building up confidence in generic skills (ITU, Acute Medicine, Renal). ○ CMT2s to have more junior doctors doing the basic ward jobs.
Others
○ Regular consultant and registrar feedback during the medical take. ○ CMT2s to be recognized as preparing to become registrars and not as junior doctors. ○ More clear definition of roles on the ward (CMT trainees versus Foundation doctors).