Why are UK junior doctors taking time out of training and what are their experiences? A qualitative study

Physician entrepreneurship: A study of early career physicians' founding motivations and actions

The literature on professional socialization suggests that their training and socialization lead physicians to prioritize professionally prescribed activities over entrepreneurial activity. This leaves unexplained how and why early career physicians would engage in entrepreneurship, a behavior that many healthcare organizations now seek to encourage. To address this shortcoming, we conducted an inductive study, augmented with survey data, of UK National Health Service physicians involved in entrepreneurial projects. We detail a process of physician entrepreneurship underpinned by organizational improvement motives and identification with the organization. Entrepreneurs breached constraining roles and formed ventures which originated as intrapreneurial initiatives but shifted to individual-level resourcing. Entrepreneurial behaviors coincided with physicians' commitment to remain with the NHS albeit with adjustments to their career plans. Overall, the study suggests that physicians manage the pressure exerted by professional socialization by adapting both the kind of entrepreneurial projects and career pathways they pursue.

An evaluation of clinical fellow programmes in an acute teaching hospital trust

BACKGROUND/AIMS

Clinical fellows support the hospital workforce while gaining experience in different specialities, research, leadership and teaching. The authors aimed to assess the impact of clinical fellow programmes in an acute teaching hospital trust.

METHODS

An anonymous electronic service evaluation was sent to clinical fellows to investigate their views on whether the programme had improved patient safety, doctors' clinical performance, training and wellbeing. Thematic analysis was used to analyse the free-text responses.

RESULTS

A total of 95 out of 144 clinical fellows responded to the evaluation survey. The clinical fellows believed that the programme had improved patient safety, clinical performance (time to manage acute patients), foundation and internal medicine training, undergraduate teaching and junior doctors' wellbeing. Four similar themes emerged from the free-text responses: career development, patient safety, training and doctors' wellbeing.

CONCLUSIONS

Clinical fellow programmes may improve patient safety, clinical performance, training, undergraduate education and doctors' wellbeing.

Five-Year results of a multi-specialty induction course for surgical training

Background

The Essential Surgical Skills Course (ESSC) is a multi-specialty induction "boot camp" style course that has been run successfully for five years. The aim of the current paper is to create an accurate guide for the replication of the course by other teams and assess the course's fitness for purpose, through the survey feedback provided by trainees.

Methods

The course's fitness for purpose was assessed through cumulative five-year survey feedback from trainees. This observational study describes the design and process of content adjustment according to feedback.

Results

The course its five-year span offered twelve different procedural skills in four different specialties. Feedback for each session was persistently >8/10. Key themes identified as beneficial include teacher-to-trainee ratio (often 1:1), teaching style, course structure and responsiveness.

Conclusions

The ESSC was found to be fit for purpose for the induction of trainees into surgical training. The key factors contributing to the success of the course include the structured method of curriculum design, outstanding teaching delivery methods, teacher-to-trainee ratio, the availability of appropriate faculty and infrastructure and the willingness to learn from trainee feedback and adjust the content of the course accordingly. It acts as a paradigm for courses aimed to prepare surgical trainees for a "step-up" in their careers.

How do foundation year and internship experience shape doctors' career intentions and decisions? A meta-ethnography

PURPOSE

Foundation years or internships are an important period for junior doctors to apply their knowledge and gain clinical competency. Experiences gained during the foundation years or internships are likely to inform newly qualified doctors' opinions about how they want to continue their career. We aimed to understand how medical doctors' internship experiences influence their career intention/decision.

METHODS

We conducted qualitative evidence synthesis using meta-ethnography. We searched six electronic bibliographic databases for papers published between 2000-2020 and included papers exploring how foundation years or internship experiences shape doctors' career intention/decisions, including in relation to migration, public/private/dual practice preference, rural/urban preference, and specialty choice. We used the GRADE-CERQual framework to rate confidence in review findings.

RESULTS

We examined 23 papers out of 6085 citations screened. We abstracted three high-level inter-related themes across 14 conceptual categories: (1) Deciding the personal best fit both clinically and in general (which option is 'more me'?) through hands-on and real-life experiences (2) Exploring, experiencing and witnessing workplace norms; and (3) Worrying about the future in terms of job market policies, future training and professional development opportunities. Confidence in findings varied but was rated high in 8 conceptual categories.

CONCLUSIONS

Our meta-ethnographic review revealed a range of ways in which internship experience shapes medical doctors' career intentions/decisions allowing us to produce a broad conceptual model of this phenomenon. The results highlight the importance of ensuring sufficient, positive and inspiring clinical exposure, improving workplace environment, relationship and culture, refraining from undermining specific specialities and communicating contractual and job market policies early on to young doctors, in order to attract doctors to less popular specialties or work locations where they are most needed. We propose our conceptual model should be further tested in new research across a range of contexts.

Recommendations for improving the working conditions and cultures of distressed junior doctors, based on a qualitative study and stakeholder perspectives

Background

Doctors, including junior doctors, are vulnerable to greater levels of distress and mental health difficulties than the public. This is exacerbated by their working conditions and cultures. While this vulnerability has been known for many years, little action has been taken to protect and support junior doctors working in the NHS. As such, we present a series of recommendations from the perspective of junior doctors and other relevant stakeholders, designed to improve junior doctors’ working conditions and, thus, their mental health.

Methods

We interviewed 36 junior doctors, asking them for recommendations for improving their working conditions and culture. Additionally, we held an online stakeholder meeting with a variety of healthcare professionals (including junior doctors), undergraduate medical school leads, postgraduate speciality school leads and NHS policymakers where we asked what could be done to improve junior doctors’ working conditions. We combined interview data with notes from the stakeholder discussions to produce this set of recommendations.

Results

Junior doctor participants and stakeholders made organisational and interpersonal recommendations. Organisational recommendations include the need for more environmental, staff and educational resources as well as changes to rotas. Interpersonal recommendations include changes to communication and recommendations for better support and teamwork.

Conclusion

We suggest that NHS policymakers, employers and managers consider and hopefully implement the recommendations set out by the study participants and stakeholders as reported in this paper and that the gold standards of practice which are reported here (such as examples of positive learning environments and supportive supervision) are showcased so that others can learn from them.

Returning to clinical work and doctors' personal, social and organisational needs: a systematic review

OBJECTIVE

This systematic review aims to synthesise existing evidence on doctors' personal, social and organisational needs when returning to clinical work after an absence.

DESIGN

Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

AMED, BNI, CINAHL, EMBASE, EMCARE, HMIC, Medline, PsycINFO and PubMed were searched up to 4 June 2020. Non-database searches included references and citations of identified articles and pages 1-10 of Google and Google Scholar.

ELIGIBILITY CRITERIA

Included studies presented quantitative or qualitative data collected from doctors returning to work, with findings relating to personal, social or organisational needs.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using a piloted template. Risk of bias assessment used the Medical Education Research Study Quality Instrument or Critical Appraisal Skills Programme Qualitative Checklist. Data were not suitable for meta-analyses and underwent narrative synthesis due to varied study designs and mixed methods.

RESULTS

Twenty-four included studies (14 quantitative, 10 qualitative) presented data from 92 692 doctors in the UK (n=13), US (n=4), Norway (n=3), Japan (n=2), Spain (n=1), Canada (n=1). All studies identified personal needs, categorised as work-life balance, emotional regulation, self-perception and identity, and engagement with return process. Seventeen studies highlighted social needs relating to professional culture, personal and professional relationships, and illness stigma. Organisational needs found in 22 studies were flexibility and job control, work design, Occupational Health services and organisational culture. Emerging resources and recommendations were highlighted. Variable quality and high risk of biases in data collection and analysis suggest cautious interpretation.

CONCLUSIONS

This review posits a foundational framework of returning doctors' needs, requiring further developed through methodologically robust studies that assess the impact of length and reason for absence, before developing and evaluating tailored interventions. Organisations, training programmes and professional bodies should refine support for returning doctors based on evidence.

Factors affecting the UK junior doctor workforce retention crisis: an integrative review

OBJECTIVES

To determine the factors contributing to the junior doctor workforce retention crisis in the UK using evidence collected directly from junior doctors, and to develop recommendations for changes to address the issue.

DESIGN

Integrative review.

DATA SOURCES

Searches were conducted on Ovid Medline and HMIC to locate evidence published between January 2016 and April 2021. This was supplemented by publications from relevant national organisations.

ELIGIBILITY CRITERIA

English-language papers relating to UK junior doctor retention, well-being or satisfaction which contained data collected directly from junior doctors were included. Papers focusing solely on the pandemic, factors specific to one medical specialty, evaluation of interventions, or numerical data with no evidence relating to causation were excluded. Review papers were excluded.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and coded on NVivo by FKL, then thematic analysis was conducted.

RESULTS

47 papers were included, consisting of academic (qualitative, quantitative, mixed and commentary) and grey literature. Key themes identified were working conditions, support and relationships, and learning and development, with an overarching theme of lack of flexibility. The outcomes of these factors are doctors not feeling valued, lacking autonomy, having a poor work-life balance, and providing compromised patient care. This results in need for a break from medical training.

CONCLUSION

This review builds on findings of related literature regarding working environments, isolation, stigma, and desire for autonomy, and highlights additional issues around learning and training, flexibility, feeling valued, and patient care. It goes on to present recommendations for tackling poor retention of UK junior doctors, highlighting that the complex problem requires evidence-based solutions and a bottom-up approach in which junior doctors are regarded as core stakeholders during the planning of interventions.

British doctors' work-life balance and home-life satisfaction: a cross-sectional study

PURPOSE

To assess British doctors' work-life balance, home-life satisfaction and associated barriers.

STUDY DESIGN

We designed an online survey using Google Forms and distributed this via a closed social media group with 7031 members, exclusively run for British doctors. No identifiable data were collected and all respondents provided consent for their responses to be used anonymously. The questions covered demographic data followed by exploration of work-life balance and home-life satisfaction across a broad range of domains, including barriers thereto. Thematic analysis was performed for free-text responses.

RESULTS

417 doctors completed the survey (response rate: 6%, typical for online surveys). Only 26% reported a satisfactory work-life balance; 70% of all respondents reported their work negatively affected their relationships and 87% reported their work negatively affected their hobbies. A significant proportion of respondents reported delaying major life events due to their working patterns: 52% delaying buying a home, 40% delaying marriage and 64% delaying having children. Female doctors were most likely to enter less-than-full-time working or leave their specialty. Thematic analysis revealed seven key themes from free-text responses: unsocial working, rota issues, training issues, less-than-full-time working, location, leave and childcare.

CONCLUSIONS

This study highlights the barriers to work-life balance and home-life satisfaction among British doctors, including strains on relationships and hobbies, leading to many doctors delaying certain milestones or opting to leave their training position altogether. It is imperative to address these issues to improve the well-being of British doctors and improve retention of the current workforce.

Reinventing Undergraduate Clinical Placements with a Switch to Delivery by Clinical Teaching Fellows

PURPOSE

Undergraduate clinical placements have the potential for significant improvement. Previous research has shown the growing value of clinical teaching fellows (CTFs) within medical education. Changing traditional placements to a model whereby CTFs have defined roles and lead the majority of teaching can positively reinvent undergraduate clinical teaching. We wanted to see how a structured teaching programme delivered by CTFs could affect student experience and personal development within a large associate teaching hospital. We consider how such a model could be implemented and explore the opportunities for CTFs to develop in personal and professional capacities.

METHODS

A mixed methods study was organised to assess student experience of a CTF-led placement. A novel structured teaching programme was delivered by 14 CTFs, who provided or were involved with the majority of teaching for all medical students. Thematic analysis was conducted on focus groups with 48 final year medical students from Queen Mary University of London following completion of their clinical placements. The same students were asked to complete an anonymous survey from which results were analysed using modified 5-point Likert scales.

RESULTS

Eight themes were identified from the focus groups. Students appreciated the increased individualisation, relevance and variety of teaching and the ability to record progress. Other perceived effects were higher teacher to student ratios, more learning opportunities and increased familiarity and reliability with CTFs. Of the students surveyed, 96% felt their overall placement experience was very good in comparison to previous placements elsewhere. Survey results supported focus group themes and demonstrated perceived growth in students' personal development.

CONCLUSION

Placement models where CTFs lead most teaching can improve medical undergraduate experience and training. A move towards CTF-delivered teaching can be of financial benefit to hospital trusts whilst allowing time for junior doctors to explore different clinical specialities and hone their teaching skills.

Barriers to getting into postgraduate specialty training for junior Australian doctors: An interview-based study

BACKGROUND

Medical training is a long process that is not complete until doctors finish specialty training. Getting into specialty training is challenging because of strong competition for limited places, depending on doctors' chosen field. This may have a negative impact on doctor well-being and reduce the efficiency of the medical training system. This study explored the barriers of pre-registrar (junior) doctors getting into specialty training programs to inform tailored support and re-design of speciality entry systems.

METHODS

From March to October 2019, we conducted 32 semi-structured interviews with early-career doctors in Australia, who had chosen their specialty field, and were either seeking entry, currently undertaking or had recently completed various fields of specialty training. We sought reflections about barriers and major influences to getting into specialty training. In comparing and contrasting generated themes, different patterns emerged from doctors targeting traditionally non-competitive specialty fields like General Practice (GP) and other specialties (typically more competitive fields). As a result we explored the data in this dichotomy.

RESULTS

Doctors targeting entry to GP specialties had relatively seamless training entry and few specific barriers. In contrast, those pursuing other specialties, regardless of which ones, relayed multiple barriers of: Navigating an unpredictable and complex system with informal support/guidance; Connecting to the right people/networks for relevant experience; Pro-actively planning and differentiating skills with recurrent failure of applications.

CONCLUSIONS

Our exploratory study suggests that doctors wanting to get into non-GP specialty training may experience strong barriers, potentially over multiple years, with the capacity to threaten their morale and resilience. These could be addressed by a clearinghouse of information about different speciality programs, broader selection criteria, feedback on applications and more formal guidance and professional supports. The absence of challenges identified for doctors seeking entry to GP could be used to promote increased uptake of GP careers.

The F3 phenomenon: Early-career training breaks in medical training. A scoping review

BACKGROUND

Since 2017, more than 50% of UK doctors have undertaken a 'Foundation 3 (F3) Year' training break after completing their foundation programme (the first two years following graduation), rather than immediately enter specialty training. The reasons for, and consequences of, the growing F3 trend are largely unknown. This scoping review presents the current evidence and identifies future research in this field.

METHODS

Following Arksey and O'Malley's guidelines, 12 databases and three UK-based national postgraduate organisation websites were searched for articles published in English (final searches January 2020). Multiple search terms were used to capture articles relating to the 'F3' time-period, including 'post-foundation' or 'pre-specialty' training. Title, abstract and full-paper screening selected articles reporting any aspect of F3, including within a wider context (eg postgraduate training breaks), and then underwent mixed-methods analysis.

RESULTS

Of 4766 articles identified, 45 were included. All articles were published after 2009; 14/45 (31.1%) were published in 2019. 27 articles reported research, and the remainder were opinion/commentaries. Specific personal (including demographic), professional and organisational factors, particularly the UK postgraduate training structure, are associated with undertaking an F3. The majority of F3 training breaks last 1 year and involve working (clinically or non-clinically) and/or travel. The decision to undertake an F3 is made either prior to or during foundation training. Evidence regarding the impact of F3 on health care service provision was limited but evenly balanced.

CONCLUSIONS

In summarising the existing F3 evidence, this review has highlighted important issues including health care workforce equality and diversity, training pathway inflexibility and the effect of negative early-career experiences on subsequent career decisions. More research is needed to understand the financial impact of training breaks on health care service provision, how training programmes must adapt to retain more trainees and the long-term effects of training breaks, such as F3, on subsequent career progression.

Understanding the impact of professional motivation on the workforce crisis in medicine: a rapid review

Background

The NHS is facing a workforce crisis. Responses to date have focused on improving recruitment of staff, but less attention has been paid to retention.

Aim

To conduct a rapid review using Rosabeth Moss Kanter’s three Ms model of workforce motivation as a sensitising framework to examine the current medical workforce crisis. The work considers how insights from research in other professions offers new thinking for understanding what motivates doctors to continue working.

Design & setting

Rapid literature review with secondary analysis of existing research examining reasons for leaving medicine.

Method

A systematic search strategy was developed with the aid of an information specialist. The search terms used were: medical professionals, retention, and NHS. The exclusions were: commentaries, non-medical professionals, non-English language, and it was limited to post-1990. The search was applied to three electronic databases, MEDLINE, Embase, and Healthcare Management Information Consortium (HMIC). This produced a dataset describing study design, and factors related to motivation for leaving the medical profession. Comparative thematic analysis distilled core themes explaining the reasons for leaving and their relation to the three Ms model.

Results

Of 3389 abstracts identified, screening and assessment produced 82 articles included in the final analysis. Thematic analysis identified four key themes: low morale, disconnect, unmanageable change, and lack of personal and professional support. The themes of mastery, membership, and meaning were substantially present within the dataset.

Conclusion

Kanter's three Ms model of motivation can be applied to the medical workforce to understand retention issues. This work supports the development of targeted solutions to tackle the worsening workforce crisis.

Developing a ‘Doctors’ Assistant’ role to ease pressure on doctors and improve patient flow in acute NHS hospitals

Introduction

The UK is short of doctors, whose workloads have increased. The new role of Doctors’ Assistant has been evaluated with the aim of addressing workload and patient-flow issues.

Methods

Five Doctors’ Assistants were introduced at two busy acute hospitals, recruited from the healthcare assistant workforce. We devised a 2-week induction, ongoing supervision and communication exercise. The evaluation used a mixed-method design. Doctors and Doctors’ Assistants completed self-reported diary entries and timings of tasks and ward rounds. Qualitative feedback was sought from other hospital staff and analysed by theme.

Results

Diary cards showed 44% of doctors’ time spent on administrative tasks. Doctors’ Assistants’ shifts documented tasks undertaken (including venepuncture, updating patient lists and drafting discharge summaries) with 84% resulting in earlier decision/diagnosis or care. Feedback reported key messages: Doctors’ Assistants provide considerable practical help, their attitude enhances the team and they improve patient flow.

Discussion

The project proved safe, successful and well liked. Unexpectedly, the project had to collect financial data to justify its continuation. Acute hospitals have few clinical roles at this level. Role transition requires training, supervision and line management.

Conclusion

The role of Doctors’ Assistant should be developed more widely, with attention to detail and economic benefits.

Are there differences between those doctors who apply for a training post in Foundation Year 2 and those who take time out of the training pathway? A UK multicohort study

INTRODUCTION

Knowledge about the career decisions of doctors in relation to specialty (residency) training is essential in terms of UK workforce planning. However, little is known about which doctors elect to progress directly from Foundation Year 2 (F2) into core/specialty/general practice training and those who instead opt for an alternative next career step.

OBJECTIVE

To identify if there were any individual differences between these two groups of doctors.

DESIGN

This was a longitudinal, cohort study of 'home' students who graduated from UK medical schools between 2010 and 2015 and completed the Foundation Programme (FP) between 2012 and 2017.We used the UK Medical Education Database (UKMED) to access linked data from different sources, including medical school performance, specialty training applications and career preferences. Multivariable regression analyses were used to predict the odds of taking time out of training based on various sociodemographic factors.

RESULTS

18 380/38 905 (47.2%) of F2 doctors applied for, and accepted, a training post offer immediately after completing F2. The most common pattern for doctors taking time out of the training pathway after FP was to have a 1-year (7155: 38.8%) or a 2-year break (2605: 14.0%) from training. The odds of not proceeding directly into core or specialty training were higher for those who were male, white, entered medical school as (high) school leavers and whose parents were educated to degree level. Doctors from areas of low participation in higher education were significantly (0.001) more likely to proceed directly into core or specialty training.

CONCLUSION

The results show that UK doctors from higher socioeconomic groups are less likely to choose to progress directly from the FP into specialty training. The data suggest that widening access and encouraging more socioeconomic diversity in our medical students may be helpful in terms of attracting F2s into core/specialty training posts.