Tuesday 13 September 2016

Medical Trainee Designation: Staff Confusion and Potential Impact on Patients & Training

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Since 2007 in the UK an increased number of terms have been used by General Medical Council (GMC) in the UK to classify grades of doctors in psychiatry training to reflect the international shift toward competency based medical education. Terms such as Specialist Registrar/Higher Trainee (ST4-6), Specialty Registrar/Core Trainee (CT1-3), Foundation Doctor (FY1- 2) have replaced the older and well established terms such as Registrar (SpR), General Practice Vocational Training Scheme (GPVTS), Senior House Officer (SHO) and House Officer (HO). Faced with such complexity the default term “junior doctor” has been used widely instead. However a default term (e.g. “Resident”) may cause confusion too as US studies report. As far as we are aware the situation has not changed as yet. Educationally and independent of any impact on the trainee’sself-efficacy, a default (generic) term is likely to limit training opportunities and patient care - through mismatching of clinical tasks and trainee competency levels. The aims of this study, undertaken within a single specialty (psychiatry), were to explore other healthcare professionals’: (i) understanding of the different terms by which doctors in training are designated; (ii) how well they could match clinical tasks to a specific (i.e. core training) grade; and (iii) their attitude to the term “junior”. 

The survey was conducted by interviews of staff (non-medical) from two health providers providing psychiatry training posts in Oxford. The design included a simple stratified sample of staff working with trainees at randomly selected wards or community teams. The interview tool consisted of closed and open questions (appendix1). Staff were asked to select from seven medical categories (lowest training grade to consultant) and one “Other Professional” category, the person they would ask to undertake specified clinical tasks. These tasks were expected learning outcomes from the core training programme curriculum chosen as its competency requirements are intermediate between Foundation, General Practice, and Higher Training grades. The tasks included the overall performance expected of a trainee at the end of the programme and seven items related to less complex curricular outcomes. To minimise bias interviewees were not informed about the links to the core curriculum. Two additional items explored interviewees responses to the term “junior” using a vignette-based approach and finally their agreement along a Likert scale with the statement: “I am clear about the role and competency of different doctors”. 

They were asked for any linked recommendations arising from this item. The interviews were conducted between February – July 2013 by FS and MG following a small pilot study to match their interview style. The survey was registered with the relevant audit office and approval obtained from the medical education leads at hospital and training authority level. Formal ethics committee approval was not required as per National Research and Ethics Service guidelines and no patients were interviewed. Consent to the face-to-face interview was obtained from each staff member prior to any rating of the survey items. There was no time limit for respondents’ replies which were recorded on an anonymised basis. Staff were asked to identify the category of doctors they considered “Safe to make decisions in all but the most complex clinical situations; competent” - the core training programme end outcome. The results are presented in Table 1 (with some categories collapsed into an “Other Doctors” category due to small numbers). 

This group contains doctors who are in training grades below that of Core trainees and non-training grades below or equivalent in competency with Core trainees). Only 20% chose the Core trainee grade; the majority (68%) chose more senior grades while 10% chose the category for whom the task is outside their curricular requirements or clinical experience. In response to the vignette-based item “Your car will be tested and repaired by our “Junior technician” only 30% chose the “I do not mind” option; the remainder chose either to seek clarification about the competency of the junior technician or a more qualified technician /second opinion (Figure 1). When asked to expand on their response they referred to the term “junior” as indicating: “Incompetency”, “Lack of experience” and “Inadequacy”. One staff member interpreted it as a “Baby professional” who “should be looked after”. In response to the vignette-based item “Your car will be tested and repaired by our “Junior technician” only 30% chose the “I do not mind” option; the remainder chose either to seek clarification about the competency of the junior technician or a more qualified technician /second opinion (Figure 1). When asked to expand on their response they referred to the term “junior” as indicating: “Incompetency”, “Lack of experience” and “Inadequacy”. One staff member interpreted it as a “Baby professional” who “should be looked after”. 

Within health teams, reciprocal understanding of the roles of all health professionals enhances team working and patient care. Training opportunities within teams motivate trainees’ learning through promotion of clinical expertise and professional identity; facilitation of any healthcare professional’s training therefore requires knowledge of their competency levels by other team members. In practice such knowledge is usually understood in terms of training grade terminology. Our findings show that 14% of respondents self-rated as having a partial or full understanding of medical training grade terminology, supporting a similar finding (22% of 55 nurses) in a surgical setting. Together the reports tend towards a generalisation of findings across specialties and show that lack of clarity may persist for several years (six in the current report). Findings from the US show that poor clarity extends to patients even without any changes in complexity to the medical grade designations. An original feature of this study is the confirmation of the earlier report’s implication of how poor understanding of medical grade terminology could cause harm to patients. 

In up to 10% of instances the more complex tasks were signposted to training grades where such complexity was above their expected curricular requirements. Such mismatching if repeated in the workplace may be a contributing factor to actual errors by doctors transitioning across training grades. In addition to the patient safety aspects, the findings show how poor understanding of training grade terminology could result in reduced opportunities for training – either through referral to more senior grades (as in the more complex tasks) or to Other Doctors or Professionals for less complex tasks. The former, in addition to reducing training opportunities, is likely to compound the workload of more senior doctors already working to new legal working directives and increased service demand. Additionally It is possible that signposting of curricular inappropriate tasks to higher grades may lie in respondents’ beliefs in the term “junior” – which the findings show, even in a non-medical context, was linked by respondents to a perceived lack of competence. The situation is compounded if more curricular appropriate tasks are directed The limitations of the study include the choice of a single specialty and only two healthcare providers, thus limiting generalisation; and the relative delay in reporting these results. However the changes in training grade terminology in the UK are not confined to psychiatry, and there is similarity of results with a very disparate specialty (surgery) as noted above. Furthermore the issues arising from changes to trainee terminology remain current given the shift internationally towards competency based medical education and linked trainee designation.  











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