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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