ESRC seminar Leeds 2011

Preparedness, induction and performance

Trudie Roberts

University of Leeds

“You come out of medical school knowing bugger all—no wonder August is the killing season. We all kill a few patients while we're learning”

Cardiac Arrest TV series 1994

The killing season—fact or fiction?

Paul Aylin and Azeem Majeed BMJ 1994

Early In-Hospital Mortality following Trainee Doctors' First Day at Work

Jen, Bottle, Majeed, Bell and Aylin

www.plosone.org/article/info:doi/10.1371/journal.pone.0007103

Accessed Sept 2011 published August 2009

Published evidence

Current Expectations of transitions

Students – ‘it will be awful’

Medical schools – ‘employers will moan they always do’

Employers –’ what have the medical schools been doing for 5 years’

Regulator –’ why isn’t it working?’

Current prevailing thinking

• Doctors can be prepared for new levels of responsibility/transitions

• They need first to learn (acquire) knowledge, skills, values

• Knowledge, skills, values are transferred to new situations

• Knowledge, skills, values are then applied to those new situations, being modified through experience

Transitions are stressful

For

• Students

• Teachers

• Employers

• Regulators

• Patients

Students

The Nietzsche approach

‘that which does not kill me makes me stronger’

Students

Followed by the prayer approach:

“Please don’t let me kill anyone”

The Medical Schools

The poor us approach:

Despite no recognition for teaching, no proper funding for teaching and NHS clinicians who will not teach we have managed to graduate these new doctors so that ungrateful hospitals can continue to function

The Medical Schools

Not our fault approach:

“We, the unwilling, led by the unknowing, are doing the impossible for the ungrateful. We have done so much, for so long, with so little, we are now qualified to do anything with nothing.”

Ps ‘Mistakes might be made but not by us’

The Employers

The blame others approach:

‘What have these doctors done in 5 years at medical school?’

And the ‘we’ll sort these people out approach:

‘We’ll provide an induction so they don’t kill anyone’

The Regulator

The flexing muscles approach:

‘We want the students, medical schools and employers to do as they are told, so we’ll insist on an induction’

And the fingers crossed approach:

‘We hope no patients are harmed in the training of these doctors’

Some facts

Doctors experience multiple transitions during training and subsequent careers

Generally, transitions are known to be associated with increased risk of untoward and adverse events

Doctors with lots of transitions (locums) make up a sizable proportion of FtP referrals

The Team

• Trudie Roberts,

• Sue Kilminster,

• Naomi Quinton,

• Miriam Zukas

ESRC Public Services Programme

Sub-theme on medical regulation

ESRC RES-153-25-0084

Four levels to consider when thinking about links between transitions, responsibility and performance:

Individual

Teams and sites

Employers

Regulation

Conclusion 1

Conclusion 2

For the individual local knowledge is key in many cases to (perceptions of) good performance

Conclusion 3

Local relationships are key to good and safe performance so tribalism needs to be replaced by collegiality

Conclusion 4

The effect of local culture is enormous should not be under estimated and is the key to safe transitions

Conclusion 5

Regulation needs to acknowledge and support transitions more specifically

So what does it all mean?

Performance

Performance tends to be understood as skill (possessed or acquired) but our work argues it is better understood as practice (doing or being)

So…..

Preparation is important but both the person and the place needs to be involved

Induction - the current watch word

April is the cruellist monthAugust is the cruellist month

Thank you

Questions or comments?