Preparedness, induction and performance

1. Preparedness, induction and performance Trudie Roberts University of Leeds

3. “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

4. Published evidence The killing season—fact or fiction? Paul Aylin and AzeemMajeed 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

5. 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?’

6. 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

7. Transitions are stressful • For • Students • Teachers • Employers • Regulators • Patients

8. Students • The Nietzsche approach • ‘that which does not kill me makes me stronger’

9. Students • Followed by the prayer approach: • “Please don’t let me kill anyone”

10. 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

11. 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’

12. 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’

13. 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’

14. 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

15. The Team • Trudie Roberts, • Sue Kilminster, • Naomi Quinton, • Miriam Zukas ESRC Public Services Programme Sub-theme on medical regulation ESRC RES-153-25-0084

16. Conclusion 1 • Four levels to consider when thinking about links between transitions, responsibility and performance: • Individual • Teams and sites • Employers • Regulation

17. Conclusion 2 • For the individual local knowledge is key in many cases to (perceptions of) good performance

18. Conclusion 3 • Local relationships are key to good and safe performance so tribalism needs to be replaced by collegiality

19. Conclusion 4 • The effect of local culture is enormous should not be under estimated and is the key to safe transitions

20. Conclusion 5 • Regulation needs to acknowledge and support transitions more specifically

21. So what does it all mean?

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

23. So….. • Preparation is important but both the person and the place needs to be involved

24. Induction - the current watch word

25. April is the cruellist month August is the cruellist month

26. Thank you • Questions or comments?