Stairway to…


Medical education is an interesting topic – and almost everyone in the profession has an opinion on it.

If you believe one of the most recent papers looking at the subject – or, in fact, the media coverage (Telegraph and Daily Mail) of the paper, all junior doctors are unprepared ( and more to the point – feel unprepared) for their role on the frontline of medicine, looking after acutely unwell patients.

There are a number of responses from medical bodies which do well to illustrate their current gripes – with the RCS blaming the EWTD, and others raising the emphasis put on communication skills and not hard medical pracitce as a reason for this unpreparedness.

So, as a medical registrar, do I believe that juniors nowadays are somehow less well prepared to cope with acutely ill patients as when I emerged from the medical school?  Well, no, probably not.  I don’t think that I was miles ahead of the current cohort when I joined the ranks of junior doctors, but I do believe that I probably had to rely on myself a little more as I made my way through my early jobs.  These days juniors tend to be better supported, and have help nearer to hand than “when I was a lad”

And is this a bad thing?  I am not convinced that having the most junior members of a workforce, who are often the ones who first have to detect when patients are acutely unwell, being able to ask for help more readily is a bad thing – in fact, it is probably a good thing for patients.  The unintended consequence may be that the junior staff are less self reliant, and may cope less well at the next jump up the ladder of medical training.

Which brings me to my next thought – the step-wise progression in medical training.

Some people view te ideal medical training as a smooth progression through grades, with a constant acquisition of competencies as one progresses. There are even phrases like “the spiral curriculum” to highlight how this should be a slick process, rather than a bumpy ride.

The reality is very different.  It is more like a staircase, with huge steps up a learning curve at every transition.  The doctor in training who advances up this ladder is confronted with a sudden change in role – often stepping into the shoes of someone many years their senior, and being expected to fill the gap left behind.  This is a very stressful time for people going through the system, and can lead to huge anxiety at changeover time – leading to underperformance.

This has been noticed by our regulator – but solutions are not exactly pouring out of the sky. (The First 5 scheme from the RCGP recognises this issue in the GP world)

And my solution? – it is about self awareness, and awareness of the needs of the team.  At present, it feels like I am a very good SHO (ST1-2 in new money) when I was an SHO I felt like I was being a very good House Officer (FY1) – I have always felt like I am achieving comfortably the standards required of the grade I have most recently been through.

As I get nearer and nearer to a consultant role, I hope that those training me – my clinical and educational supervisors, will be able to recognise that I need to start making the transition to a consultant role not on the day I move to a new job, but starting now – a couple of years out.  Often the culture of the workplace keeps you in a grade – and unable to act beyond it (the variety of standard of members of a particular grade make the judging of this very difficult for clinical supervisors I know)

However – it is too easy to blame the culture of the places where I work, the people supervising me, and ‘the system’ for keeping me down, or holding me back – I think that I, and all the trainees taking this staircase to a career in medicine, need to get slightly more real about how we are going to progress.

We need to shake ourselves out of the habit of fulfilling the minimum required to get to the next step, and start to act up where safe and possible, and learn from those above us, or more experienced than us, to enable us to start practising the skills they need every day – be that interacting with other colleagues, managing certain medical decisions, or unerstanding how to manage patients through juniors rather than doing it ourselves.

It is only when doctors in training notice at half way through their current grade that in the near future they are going to be taking more responsibility soon, and proactively start to behave in a manner appropriate for that step up, that we will start to smoothe out the jumps in the training ladder, and reduce this perceived unpreparedness.

That said, one can never fully prepare for the unknown – but forewarned is forearmed – I fully intend to enter the consultant grade with my eyes open, and not sleepwalk into another learning curve which feels more like Everest than the smooth or spiral transition that some educators believe it should be.


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