Trainee Issues

Healthcare must extend to provide the needs of the population it serves. Despite major initiatives on both side of the Atlantic, there is evidence to suggest that the gaps in medical care between socio-economic and ethnically diverse groups are increasing rather than diminishing.

There is also evidence to suggest that many students of medicine do not complete training or leave the service due to disillusionment either lifestyle and opportunities. There are others who become ill or dysfunctional.

Appropriate selection of trainees, either at undergraduate or postgraduate level is crucial to ensure appropriate placement to serve the needs of the individual and the service. There has been discussion (and some evidence) about the potential benefits of personality profiling before admission to Medical school.

Accessibility to structured and well informed career advice and counselling limits the likelihood of the trainee/placement mismatch and the consequent difficulties incurred. Mentorship (qv) and appropriate educational supervision are essential components of a good residency programme providing a supportive and developmental learning environment.

As training programmes become more restrictive requiring earlier commitment to training programmes (UK) and extended training within a narrow specialty band, it is essential to select appropriately or facilitate transfer between specialties if appropriate. In order to limit the risk of trainees becoming disenchanted with their specialty choice, support must be offered at an early stage and consideration must be given to the expectation of both trainee and the role adopted.

Comparability of trainee experiences

Many projects in the past have been focused on the difference been medical education responsibilities and activities for clinical teachers. However, it could be argued that to gain the most in terms of change of practice, a survey of trainees' experiences within the different systems would effectively point up the strengths and weaknesses of each. Such a project could include contact with trainees in all areas of North Carolina as well as their trainers.

Trainees and difficulties in professional life

There is little doubt that training for a career in medicine exposes the individual to a unique set of stressful experiences. The issues of life and death, sharing of patient confidences, the long hours and the burden of increasing clinical responsibility carry a heavy price. Historically, peer support and infamous camaraderie have allowed the burden to be shared and black humour (on both sides of the Atlantic) has served to defuse potentially traumatic situations. Changes in working practices have led to greater clinical isolation for trainees and loss of the traditional team structure has lessened the ability to share experiences and seek support from colleagues.

For trainees to survive intact from the pressures exerted upon them they need to be made aware of the risks from an early stage. They also need to have support from peers and seniors and offered counselling and career guidance whenever needed. Should their particular chosen career path prove inappropriate for any reason (emotionally, academically or lack of dexterity) alternative career pathways need to be explored and ease of transition needs to be facilitated.

Competencies

The pressure in the United Kingdom at the current time is to produce more "fully-trained" doctors within the shortest space of time. This may have more political than clinical imperative, but the need to achieve shorter working hours for all medical staff (see Working Time Directive) is at least partly the driver. There is a perception that shorter training can be achieved if there is a consistent and robust means of assessing the competence of a doctor to take on a defined role. This has led to the concept of "Competency-based curricula" suggesting that doctors training needs to be focused to achieve a pre-determined standard. All Medical Royal Colleges within the UK have been asked to develop their own curriculum and appropriate methods of assessment to assure completion of training.

The aphorism widely held in educational circles that "good assessment drives good training" has had a major influence on medical training in the UK. Formative appraisal and summative assessment is now an essential part of every training programme and contributes not only to the quality assurance of the training programme, but is critical to identify completion of training and later revalidation for medical practice.

All trained medical staff participate in a yearly cycle of Appraisal which is designed to confirm adherence to the standards set by the General Medical Council (regulatory body in the UK) defined as Good Medical Practice (http://www.gmc-uk.org/standards/).

The Accreditation Council for Graduate Medical Education is responsible for the Accreditation of post-MD medical training programs within the United States. Accreditation is accomplished through a peer review process and is based upon established standards and guidelines. As part of its Outcomes Project the ACGME has defined six competencies that residents are expected to demonstrate to the level of a new practitioner. (http://www.acgme.org/outcome/comp/compFull.asp). Toward this end, programs must define the specific knowledge, skills, and attitudes required and provide educational experiences as needed in order for their residents to demonstrate the competencies. A number of instruments have been developed to facilitate assessment of these defined competencies.

Mentoring

A mentor is someone who takes a special interest in helping another person develop into a successful professional.

The perceived need for a mentor varies from individual to individual and with progression through the training grades. Newly qualified doctors value peer support and may be presented with a range of senior colleagues who can each adopt part of the mentoring role eg Preceptor, Educational Supervisor, Clinical Tutor. While any of these might offer support for a brief period, such contact is necessarily time limited and there is, by necessity, a trainer/trainee relationship.

As doctors progress through the career grades they identify the need, on occasions, for advice and support from colleagues who have no direct responsibility for their clinical work. They may seek advice on career and professional progression, but also may need help with issues relating to personal problems and issues relating to working environment. They are also concerned during this period with passing examinations and fearful of prejudicing professional references.

With a tendency, especially in the UK, to shorten training time, doctors who have completed their training (eg Consultants) may find they have a wider range of responsibility and clinical exposure than that for which they have been prepared. At this time they may value the support of a mentor, within or without their specialty or place of work to offer wise counsel and a different viewpoint. This may help in preventing unnecessary stress and doctors over-extending their capability.