Stepping Up: Advice to Junior Doctors [and their teachers]

The best part of my job involves acting as a trainer, assessor and guide to a band of junior doctors.  This is fun!  After 10 years of “nose to the grindstone” ED work it is great to be in the role of supervisor – nothing freshens and keeps one honest in practice like acting as a supervisor in the clinical setting.

So first of all – thanks to all you super-keen, young Docs out there.

Now every few months I sit down with the JMOs individually and we have a chat – career guidance counselling, specific clinical scenarios or a global feedback session.  On average our juniors are very keen to get feedback and being the ‘over-achievers’ that most Docs are – they crave criticism!  But here is the thing – 97% of them are doing just fine.  They do great work, get along with the staff, are nice to the patients and have appropriate knowledge and skills for their relative gestation.  So feedback can be a dry task….

Sitting down with enthusiastic learners and saying “your are doing great!” is easy.  And I think positive encouragement goes a long way… but… there is always a but.  We know a lot about behaviour and change as GPs and what I have learned is that too much support, and not enough pressure leads to entrenchment.  I have seen many great young doctors get to a point in their development – usually around  the second or third year postgrad – where they get “stuck”.  And this is frustrating for them. So here are my thoughts on helping junior Docs “Step Up” and make the most of their training.

Why is this so?  Well partly it is a symptom of the culture of medicine.  We like to be smart, thorough, get it “right all the time” and are probably introspective and harsh on ourselves on average.  These are the type of characteristics we admire in an intern – we want them to do the basics well and not miss important stuff (…was the K+ a bit low on the old lady with Dig toxicity?).  However, being super-good at your job tends to go along with being conservative in one’s thinking.  Staying safe is good, but there is a tension between being safe and learning – taking responsibility, accepting risks and learning through experience.  Does that make sense?  Here’s an example:

John is a third year JMO.  He has down his intern year and spent a year as an RMO in all the subspecialty areas, even a short stint in ICU.  He is a smart guy (aren’t we all?) and is seriously considering a career in Cardiology or maybe ICU.  As a typical Aussie trainee he has been exposed to a spattering of procedural work, put in a couple of CVCs and a handful of invasive procedures like ascitic taps and joint injections.

John has been working with me for 6 months and has learned a lot about general ED and GP stuff.  He tends towards the crit care end of the ED.

We get a call – the ambos are on their way in with a “chest pain”.  It is not too busy in the department so I ask John: “You want to run this one?”  He certainly does.  So from the flight deck I observe him take handover from the Ambos, get the history, put in some lines and give empirical aspirin and GTN.  He does a thorough exam then wanders over to me with the initial ECG in hand.

John asks: “Do you mind if I run this patient past you?”  The ECG looks benign, normal.

OK, lets hit the pause button and dissect the situation a bit.  Typically at this point most JMOs will layout the history and exam findings in great detail, textbook presentation.  We discuss differential diagnosis and the standard protocol for this scenario.  And usually at that point there is a subtle shift – they are seeking a nod, reassurance that they have done it right – which is fine.  So you say: “Great, well done.” Backs are slapped.  So what next?

I find that it is at the stage of planning management and disposition that most of our JMOs lose confidence and play it safe by seeking approval from their senior colleagues.  This is all appropriate – as it should be.  However, I see many senior doctors (especially when rushed for time) take over at this point.  Instead of challenging the young Docs plans they tend to assume responsibility and make the critical calls.  Admit / Discharge, Antibiotics / no ABs, get the CT / watch and wait etc….

This is a problem.  Although we tend to think in binary terms – medicine is really very grey – lots of uncertainties.  The toughest calls usually do not involve the super-sick patients where a pathway is determined by the disease.  The tougher calls are the 50% calls – the ones where there is no clear, logical choice.  The moments where you just have to suck it up and make a decision (hopefully with some basis in evidence, but often not!)

I was lucky (or unlucky)  to train as a GP – and this is very different to many hospital-based specialties in that you are left alone in a room, with the patient and just a few minutes to get the information and formulate a plan.  Ok – granted most of the decisions in GP-land are not life-and-death.  However, the cognitive task is the same – you need to make a call!  Should you prescribe an ACE-I or a B-blocker for the hypertension? The clock is ticking!

I think that my GP training was really very useful for my subsequent ED work.  We learn to carry on in the face of uncertainty, the value of strategic follow-up and we  develop a healthy “disregard” for the type of diagnostic paranoia that tends to haunt some of the “high powered specialties”.  How does one get to that point?  Well in GP it is really a matter of being thrown in the deep end with a life-line  from a supervisor who is rarely “in the room”.

In contrast – in most Emergency care training the junior doctor and the teacher are usually geographically in the same place and have the option to share the decisions.  This is potentially a problem for the development of the JMOs inner consultant.

So here is my advice to junior docs and their supervisors:

TRAINEES

– don’t stop at collecting the Hx and Exam.

– Take time to make a plan (diagnostic strategy, discharge or treatment ), then be prepared to argue your position – preferably with evidence, guidelines etc  to back you up and ensure it is appropriate for the context of your patient

– Imagine your supervisor is not there!  What would you do?  Or pretend you would be waking your boss up at 3 AM. to ask the question you are actually asking at 3 PM – you’d better have all the thinking done before you wake ’em!

– Accept that you may be wrong from time to time.  Any other belief system is delusional and will likely lead to plenty of unnecessary anxiety!

TRAINERS

–  You need to create a “safe space” for your trainees to stretch their wings and fledge.  This is tough – it is about creating an atmosphere of trust with clear boundaries around communication and risk.  You need to have clear lines of communication and understanding around when you will “step in” or how they can “wave the white flag” for a rescue.

–  Sometimes it is about containing one’s own ego – you may know the answer, you might be the world expert on say… Marchiafava-Bignami syndrome – but you need to allow the JMOs to find the answers for themselves.  Learning is often about discovery, making synaptic connections requires actual “doing”.  Telling a JMO ‘how’ or ‘what’ is like giving a man a fish.  We need to teach them how to fish, they need to work out the ‘where’ and ‘why’ for themselves.

– Sit on your hands.  Sometimes actually, literally sit on them.  I call this “masterful inaction” – the ability to sit and watch your trainee flail, struggle, proceed in a half-arsed manner and then….. SUCCEED.   The classic example that comes to mind for me is teaching epidural insertion.  It is a technical skill that requires a “feel” – the chalkiness of the ligamentum flavum, pop – you are in!  You cannot teach this without allowing the trainee to feel the pop, yet the temptation is to find the spot, push it through and hand it over to complete – it is nerve-racking!  Sometimes you just have to have a bit of faith and allow them fly on their own!

I am expecting a new “class of RMOs” in January – they will all be in this middle of this phase of their training – finding their feet and growing their own wings.  I think it is a great idea to sit down with them and have a chat about this process – early in the year.  For example, “here are the stairs, up there is the door to independent practice, there’s the fire alarm over there, feel free to linger on the second floor landing if you like, there is a “NO RUNNING” policy, we prefer if you use the hand rails on the tricky turns.  Most importantly enjoy the view out the windows!”

How do you get the best out of your trainees – or if you are a trainee, what do you look for in the bosses to allow you to transition to independence?

Casey