Why are newly qualified doctors unprepared to care for patients at the end of life?

Medical Education 2011: 45 : 389–399 Context Death and dying occur in almost all areas of medicine; it is essential to equip doctors with the knowledge, skills and attitudes they need to care for patients at the end of life. Little is known about what doctors learn about end‐of‐life care while at medical school and how they learn to care for dying patients in their first year as doctors. Methods We carried out a qualitative study using face‐to‐face interviews with a purposive sample of 21 newly qualified doctors who trained in different medical schools. Results Data were analysed using a constant comparative approach. Two main groups of themes emerged. The first pertained to medical school experiences of end‐of‐life care, including: lack of exposure; a culture of ‘clerking and signs’; being kept and keeping away from dying patients; lack of examinations; variable experiences, and theoretical awareness. The second group of themes pertained to the experiences of recently qualified doctors and included: realising that patients really do die; learning by doing; the role of seniors; death and dying within the hospital culture; the role of nursing staff, and the role of the palliative care team. Conclusions Undergraduate medical education is currently failing to prepare junior doctors for their role in caring for dying patients by omitting to provide meaningful contact with these patients during medical school. This lack of exposure prevents trainee doctors from realising their own learning needs, which only become evident when they step onto the wards as doctors and are expected to care for these patients. Newly qualified doctors perceive that they receive little formal teaching about palliative or end‐of‐life care in their new role and the culture within the hospital setting does not encourage learning about this subject. They also report that they learn from ‘trial and error’ while ‘doing the job’, but that their skills and knowledge are limited and they therefore seek advice from those outside their usual medical team, mainly from nursing staff and members of palliative care teams.     

“I’d been like freaking out the whole night”: exploring emotion regulation based on junior doctors’ narratives

The importance of emotions within medical practice is well documented. Research suggests that how clinicians deal with negative emotions can affect clinical decision-making, health service delivery, clinician well-being, attentiveness to patient care and patient satisfaction. Previous research has identified the transition from student to junior doctor (intern) as a particularly challenging time. While many studies have highlighted the presence of emotions during this transition, how junior doctors manage emotions has rarely been considered. We conducted a secondary analysis of narrative data in which 34 junior doctors, within a few months of transitioning into practice, talked about situations for which they felt prepared or unprepared for practice (preparedness narratives) through audio diaries and interviews. We examined these data deductively (using Gross’ theory of emotion regulation: ER) and inductively to answer the following research questions: (RQ1) what ER strategies do junior doctors describe in their preparedness narratives? and (RQ2) at what point in the clinical situation are these strategies narrated? We identified 406 personal incident narratives: 243 (60%) contained negative emotion, with 86 (21%) also containing ER. Overall, we identified 137 ER strategies, occurring prior to (n = 29, 21%), during (n = 74, 54%) and after (n = 34, 25%) the situation. Although Gross’ theory captured many of the ER strategies used by junior doctors, we identify further ways in which this model can be adapted to fully capture the range of ER strategies participants employed. Further, from our analysis, we believe that raising medical students’ awareness of how they can handle stressful situations might help smooth the transition to becoming a doctor and be important for later practice.     

Help,I’m losing patient‐centredness! Experiences of medical students and their teachers

Medical Education 2010: 44 : 662–673 Objectives Despite all educational efforts, the literature shows an ongoing decline in patient‐centredness during medical education. This study explores the experiences of medical students and their teachers and supervisors in relation to patient‐centredness in order to gain a better understanding of the factors that determine its development. Methods We conducted 11 focus groups on the subject of learning and teaching about patient‐centredness. We then carried out a constant comparative analysis of prior theory and the qualitative data collected in the focus groups using the ‘sensitising concepts’ provided by the Attitude–Social Influence–Self‐Efficacy (ASE) model. Results Although students express positive attitudes towards patient‐centredness and acquire patient‐centred skills during medical education, this study indicates that these are not sufficient to attain the level of competent behaviour needed in today’s challenging hospital environment. Clinical clerkships do provide students with ample opportunity to encounter patients and practise patient‐centred skills. However, when students lack self‐efficacy, when they face barriers (time pressure, tiredness) or when they are surrounded by non‐patient‐centred role models and are overwhelmed by powerful experiences, they lose their patient‐centred focus. The study suggests that communication skills training protects students from negative social influences. Moreover, personal development, including developing the ability to deal with emotions and personal suffering, self‐awareness and self‐care are important qualities of the central phenomenon of the ‘doctor‐as‐person’, which is identified as a missing concept in the ASE model. The student–supervisor relationship is found to be key to learning patient‐centredness and has several functions: it facilitates the direct transmission of patient‐centred skills, knowledge and attitudes; it provides social support of students’ patient‐centred behaviour; it provides support of the ‘student‐as‐person’; it mirrors patient‐centredness by being student‐centred, and, lastly, it addresses supervisor vulnerability. Finally, participants recommend that student‐centred education and guidance be offered, self‐awareness be fostered and more opportunities to encounter patients be created, including more time in general practice. Conclusions Supportive student–doctor relationships, student‐centred education and guidance that addresses the needs of the doctor‐as‐person are central to the development of patient‐centredness. Medical education requires patient‐centred, self‐caring and self‐aware role models.     

‘More shades of grey in my answers’: an interview study revisiting attitude erosion during clerkships

Context Small declines in patient‐centred attitudes during medical education have caused great concern. Although some of the self‐report scales applied have solid psychometric foundations, validity evidence for the interpretation of attitude erosion during clerkships remains weak. Objectives We sought to address this gap in a qualitative study of the relationships between scores on four commonly used attitude scales and participants’ experiences and reflections. Our aim was to gain a better understanding of the score changes from the participants’ perspectives. Methods We conducted semi‐structured interviews with 15 junior doctors from a cohort (n = 37) that had previously shown a small decline in patient‐centred attitudes during clerkships, measured on four self‐report scales. In the interviews, we explored interviewees’ experiences of their development of patient‐centredness and subsequently discussed their scale scores, particularly for those items that contributed to a rise or decline in scores. We analysed the data using a process of constant comparison among personal experiences, scale scores and participants’ explanations of score changes, applying the coding techniques of grounded theory. Results The analysis revealed important response distortions that might be responsible for small declines in scores during clerkships separately from changes in attitudes. The drastic alterations to the participants’ frame of reference, attributable to the transition to clinical practice, represented the most prominent cause of distortion. More nuanced, context‐specific, patient‐centred reasoning resulted in more neutral responses after clerkships, paradoxically causing a decline in scores. In addition to response distortions, the interviews revealed shortcomings in content validity such as an ‘extreme’ construct of patient‐centredness. Conclusions This study calls into question the validity of the interpretation of attitude erosion during clerkships. The findings suggest that small declines in scores on self‐report attitude scales are related to a recalibration of trainees’ understandings of patient‐centredness as they grow more clinically experienced. The evolved construct of patient‐centredness and the way attitudes are measured require special attention in the development of future instruments.     

‘You’re judged all the time!’ Students’ views on professionalism: a multicentre study

Medical Education 2010: 44 : 814–825 Objectives This study describes how medical students perceive professionalism and the context in which it is relevant to them. An understanding of how Phase 1 students perceive professionalism will help us to teach this subject more effectively. Phase 1 medical students are those in the first 2 years of a 5‐year medical degree. Methods Seventy‐two undergraduate students from two UK medical schools participated in 13 semi‐structured focus groups. Focus groups, carried out until thematic saturation occurred, were recorded and transcribed verbatim. Data were analysed and coded using NVivo 8, using a grounded theory approach with constant comparison. Results From the analysis, seven themes regarding professionalism emerged: the context of professionalism; role‐modelling; scrutiny of behaviour; professional identity; ‘switching on’ professionalism; leniency (for students with regard to professional standards), and sacrifice (of freedom as an individual). Students regarded professionalism as being relevant in three contexts: the clinical, the university and the virtual. Students called for leniency during their undergraduate course, opposing the guidance from Good Medical Practice. Unique findings were the impact of clothing and the online social networking site Facebook on professional behaviour and identity. Changing clothing was described as a mechanism by which students ‘switch on’ their professional identity. Students perceived society to be struggling with the distinction between doctors as individuals and professionals. This extended to the students’ online identities on Facebook. Institutions’ expectations of high standards of professionalism were associated with a feeling of sacrifice by students caused by the perception of constantly ‘being watched’; this perception was coupled with resentment of this intrusion. Students described the significant impact that role‐modelling had on their professional attitudes. Conclusions This research offers valuable insight into how Phase 1 medical students construct their personal and professional identities in both the offline and online environments. Acknowledging these learning mechanisms will enhance the development of a genuinely student‐focused professionalism curriculum.     

A system for maintaining the educational and training standards of junior doctors

The development of junior doctors' competence is complex because the hospital environment in which doctors work places many demands on them. The need for quality education and training and personal development may be in direct conflict with the service commitments required from hospitals. This paper describes the methods by which the Postgraduate Medical Council of New South Wales, Australia, addresses the needs of junior doctors in the state in order to improve the quality of their education. Key elements of the Council's function include the provision of hospital clinical supervisors who oversee junior doctor education and training, and central involvement in supplying the junior doctor workforce to all state hospitals who must meet defined accreditation standards. This paper also provides data on evaluation of those methods and some educational outcomes.     

“It’s a Balancing Act!”: Exploring School/Work/Family Interface Issues Among Bilingual,Rural Nebraska,Paraprofessional Educators

Abstract: Nebraska’s rural school districts have a rapidly growing Spanish‐speaking student body and few qualified instructors to meet their educational needs. This investigation examined factors that promote and challenge the ability of rural Nebraska paraprofessional educators to complete an online B.S. program in elementary education, with a K‐12 English as a second language endorsement. Interviews focused on the interface between school, work, and family, with special attention on family system change and adaptation. Twenty‐six bilingual paraprofessional educators enrolled (or formerly enrolled) in the education program were interviewed. Twenty were first‐ (n= 15) or second‐generation (n= 5) immigrant Latino/as. Influences of program involvement on the marital and parent‐child relationships are discussed, as are implications for future work with unique populations.     

Medical students’ professional identity development in an early nursing attachment

Medical Education 2010: 44 : 674–682 Objectives The importance of early clinical experience for medical training is well documented. However, to our knowledge there are no studies that assess the influence of very early nursing attachments on the professional development and identity construction of medical students. Working as an assistant nurse while training to be a doctor may offer valuable learning experiences, but may also present the student with difficulties with respect to identity and identification issues. The aim of the present study was to describe first‐year medical students’ perceptions of nurses, doctors and their own future roles as doctors before and after a nursing attachment. Methods A questionnaire containing open questions concerning students’ perceptions of nurses, doctors and their own future roles as doctors was administered to all Year 1 medical students (n = 347) before and directly after a 4‐week nursing attachment in hospitals and nursing homes. We carried out two confirmatory focus group interviews. We analysed the data using qualitative and quantitative content analyses. Results The questionnaire was completed by 316 students (response rate 91%). Before starting the attachment students regarded nurses as empathic, communicative and responsible. After the attachment students reported nurses had more competencies and responsibilities than they had expected. Students’ views of doctors were ambivalent. Before and after the attachment, doctors were seen as interested and reliable, but also as arrogant, detached and insensible. However, students maintained positive views of their own future roles as doctors. Students’ perceptions were influenced by age, gender and place of attachment. Conclusions An early nursing attachment engenders more respect for the nursing profession. The ambivalent view of doctors needs to be explored further in relation to students’ professional development. It would seem relevant to attune supervision to the age and gender differences revealed in this study.     

Improving cultural competence education: the utility of an intersectional framework

Medical Education 2012: 46: 545–551 Context Most US medical schools have instituted cultural competence education in the undergraduate curriculum. This training is intended to improve the quality of care that doctors, the majority of whom are White, deliver to ethnic and racial minority patients. Research into the outcomes of cultural competence training programmes reveals that they have been largely ineffective in improving doctors’ skills. In varied curricular formats, programmes tend to teach group‐specific cultural knowledge, despite the vast heterogeneity of racial and ethnic groups. This cultural essentialism diminishes training effectiveness. Methods This paper proposes key curriculum content changes and suggests the inclusion of an intersectional framework in the cultural competence curriculum. This framework maintains that racial and ethnic minority groups hold multiple social statuses, called social locations, which interact with one another to uniquely shape the health views, needs and experiences of the individuals within the groups. Social locations include those defined by race, ethnicity, gender, social class and sexuality, which are experienced multiplicatively, not additively, within a particular social context. Cultural competence education must go beyond simplified cultural understandings to explore these more complex meanings. Doctors’ ability to understand, communicate with and treat diverse groups can be vastly improved by applying an intersectional framework in academic research, self‐awareness exercises and clinical training. Results Integrating an intersectional framework into cultural competency education can better prepare doctors for caring for racial and ethnic minority patients. This paper recommends curriculum elements for the classroom and clinical training that can improve doctor knowledge and skills for caring for diverse groups. Medical schools can use the proposed model to facilitate the development of new educational strategies and learning experiences. These improvements can lead to more equitable care and ultimately diminish disparities in health care. Although these recommendations are designed with US schools in mind, they may improve doctor understanding and care of marginal populations across the world.     

Understanding the behaviour of newly qualified doctors in acute care contexts

Medical Education 2011: 45 : 995–1005 Context A particularly onerous aspect of the transition from medical student to practising doctor concerns the necessity to be able to rapidly identify acutely unwell patients and initiate appropriate resuscitation. These are skills in which many graduates feel poorly prepared and are considered by some to be best learned on the job. This constructivist study investigated the factors that influence the behaviour of junior doctors in this context and initiated the development of a framework that promotes understanding of this important area. Methods Focus groups involving 36 clinicians with a variety of clinical experience were conducted and analysed using a qualitative, grounded theory approach. The complex relationships between emergent themes guided the development of a framework that was refined and validated by further interviews with participants. Results Six main themes, grouped under three broad headings, emerged from the data: ‘transferring knowledge into practice’ and ‘decision making and uncertainty’ (cognitive challenges); ‘acts and omissions’ and ‘identity and expectations’ (roles and responsibilities), and, finally, ‘the medical hierarchy’ and ‘performing under stress’ (environmental factors). The framework presented within this paper illustrates the complex relationships between these factors. Conclusions Although the potential of metacognitive strategies to reduce medical error is acknowledged, the framework promotes looking beyond the individual to consider the contributions to patient safety of identity issues, role uncertainty and the hierarchical clinical environment. A more distributed approach to situation awareness may help junior doctors to better tolerate complexity and uncertainty. The efficacy of simulation as an educational strategy may be improved by finding ways to recreate the hierarchical and stressful environment in which junior doctors practise. Junior doctors should be aware of the impact of affect and emotion on behaviour, and clinical supervisors should strive to ensure that roles and responsibilities are explicitly discussed.     

Changes in residents’ opportunities for experiential learning over time

Medical Education 2012: 46 : 1189–1193 Context Learning in the clinical environment is believed to be a crucial component of residency training. However, it remains unclear whether recent changes to postgraduate medical education, including the implementation of work hour limitations, have significantly impacted opportunities for experiential learning. Therefore, we sought to quantify opportunities to gain clinical experience within medical‐surgical intensive care units (ICUs) over time. Methods Data on the numbers of patients admitted and invasive procedures performed per day between 1 July 2001 and 30 June 2010 within three academic medical‐surgical ICUs in Calgary, Alberta, Canada were obtained from electronic medical records. These data were matched to resident doctor on‐call schedules and residents’ opportunities to admit patients and participate in procedures were calculated and compared over time using Spearman’s rho. Results We found that over a 9‐year period, the opportunities afforded to residents (n = 1156) to admit patients (n = 17 189) and perform procedures (n = 52 827) during ICU rotations decreased by 32% (p < 0.001) and 34% (p < 0.001), respectively. Conclusions Our results suggest that there has been a significant decrease in residents’ clinical experiences in the ICU over time. Further investigations to better understand these changes and how they may impact on performance as residents become independent practising doctors are warranted.     

Pilot study comparing patients’ valuation of health‐care services with Medicare’s relative value units

Background and aims Physician reimbursement for services and thus income are largely determined by the Medicare Resource‐Based Relative Value Scale. Patients’ assessment of the value of physician services has never been considered in the calculation. This study sought to compare patients’ valuation of health‐care services to Medicare’s relative value unit (RVU) assessments and to discover patients’ perceptions about the relative differences in incomes across physician specialties. Design Cross‐sectional survey. Participants and setting Individuals in select outpatient waiting areas at Johns Hopkins Bayview Medical Center. Methods Data collection included the use of a visual analog ‘value scale’ wherein participants assigned value to 10 specific physician‐dependent health‐care services. Informants were also asked to estimate the annualized incomes of physicians in specialties related to the abovementioned services. Comparisons of (i) the ‘patient valuation RVUs’ with actual Medicare RVUs, and (ii) patients’ estimations of physician income with actual income were explored using t‐tests. Outcomes Of the 206 eligible individuals, 186 (90%) agreed to participate. Participants assigned a significantly higher mean value to 7 of the 10 services compared with Medicare RVUs (P < 0.001) and the range in values assigned by participants was much smaller than Medicare’s (a factor of 2 vs. 22). With the exception of primary care, respondents estimated that physicians earn significantly less than their actual income (all P < 0.001) and the differential across specialties was thought to be much smaller (estimate: $88 225, actual: $146 769). Conclusion In this pilot study, patients’ estimations of the value health‐care services were markedly different from the Medicare RVU system. Mechanisms for incorporating patients’ valuation of services rendered by physicians may be warranted.     

Contextual dynamics in clinical workplaces: learning from doctor–doctor consultations

Medical Education 2013: 47 : 463–475 CONTEXT Some studies have explored the role of learning context in clerkships and in clinical teams. Very little is known, however, about the relationship between context and competence development in more loosely framed, day‐to‐day practices such as doctor–doctor consultations, although such interactions are frequent and typical in clinical work. METHODS To address this gap in the literature, a study was conducted using semi‐structured interviews in four different hospitals and participant observation at one site. Inductive content analysis was used to develop a framework. Special reference was made to the principles of situated cognition. RESULTS The framework illustrates how different situational, personal and organisational factors interact in every learning situation. The interplay manifests in three different roles that doctors assume in highly dynamic ways: doctors learn as ‘actors’ (being responsible), as ‘participants’ (being involved) and as ‘students’ (being taught); contextual influences also impact on the quality of learning within these roles. CONCLUSIONS The findings add to the current literature on clinical workplace learning and to the conceptualisation of context in the field of education. The practical contribution of the research lies in disentangling the complex dynamics of learning in clinical environments and in helping doctors and medical educators to increase their responsiveness to contextual factors.     

Bias against foreign-born or foreign-trained doctors: experimental evidence

Medical Education 2010: 44 : 1241–1247 Objectives Bias against foreign‐born or ‐trained medical students and doctors is not well understood, despite its documented impact on recruitment, integration and retention. This research experimentally examines the interaction of location of medical education and nationality in evaluations of doctors’ competence and trustworthiness. Methods A convenience sample of prospective patients evaluated fictitious candidates for a position as a doctor in community practice at a new local health clinic. All applicants were described as having the same personality profile, legal qualifications to practise, a multi‐degree education and relevant work experience. The location of medical education (the candidate’s home country or the UK) and national background (Australia or Pakistan) of the applicants were independently experimentally manipulated. Results Consistent with previous research on skills discounting and bias, foreign‐born candidates were evaluated less favourably than native‐born candidates, despite their comparable education level, work experience and personality. However, overseas medical education obtained in the First World both boosted evaluations (of competence and trustworthiness) and attenuated bias based on nationality. Conclusions The present findings demonstrate the selective discounting of foreign‐born doctors’ credentials. The data show an interaction of location of medical education and birth nationality in bias against foreign doctors. On an applied level, the data document that the benefits of medical education obtained in the First World can extend beyond its direct outcomes (high‐quality training and institutional recognition) to the indirect benefit of the attenuation of patient bias based on nationality.     

Career satisfaction and professional accomplishments

Medical Education 2010: 44 : 969–976 Context Research on doctor career satisfaction has often focused on factors such as income, specialty, gender, work hours, autonomy, patient load, lifestyle preferences, work environment, and insurance regulations. Other educational, personal and professional factors have not received sufficient empirical attention. Objective This study was designed to test the following five hypotheses that doctors’ career satisfaction is associated with: (i) Higher satisfaction with their undergraduate medical education; (ii) Greater academic and clinical competence; (iii) More involvement in teaching and research activities; (iv) Higher orientation toward lifelong learning; and (v) Increased professional accomplishments. Methods A survey was mailed in 2006 to a national sample of 5349 doctors in the United States who graduated from Jefferson Medical College between 1975 and 2000; 3170 (59%) returned completed surveys. Based on responses to a career satisfaction question, doctors were classified into three groups: Highly satisfied (top third, n = 1078); moderately satisfied (middle third, n = 1031); and least satisfied (bottom third, n = 1061). These groups were compared on a number of variables. Results All five research hypotheses were confirmed. Additionally, no significant association was observed between career satisfaction, age, years in practice, gender, or ethnicity; however, career satisfaction was associated with doctors’ specialties. Conclusions The findings suggest that factors such as satisfaction with medical education, medical school class rank, assessments of clinical competence, teaching, and research activities, orientation toward lifelong learning, and professional accomplishments should be considered for a more comprehensive understanding of doctors’ career satisfaction.     

Postgraduate training and career choices: an analysis of the National Physicians Survey in Japan

Medical Education 2010: 44 : 289–297 Objectives This study analyses and discusses recent changes in young Japanese doctors’ career paths, in terms of their distribution in different types of facilities and specialties, following changes to the postgraduate clinical training system in 2004. Methods Data from the National Survey of Physicians, Dentists and Pharmacists conducted by Japan’s Ministry of Health, Labour and Welfare were used for this study. Results After the introduction of the new postgraduate training system, 2 years of clinical training became mandatory and a doctor‐to‐facility matching system was introduced. Since then, more young doctors have migrated from academic hospitals to non‐academic hospitals. The number of first‐year doctors at non‐academic hospitals increased, whereas the number at academic hospitals decreased. In terms of the distribution of doctors per specialty, the decreasing tendency of doctors to choose internal medicine and surgery has accelerated. These results illustrate the significant changes that have affected young doctors’ career paths since the new system was introduced. Conclusions Designing and providing desirable postgraduate clinical training and achieving appropriate doctor distribution are important policy issues. Appropriate policy interventions regarding a mechanism to ensure the appropriate distribution of doctors should be established and attention should be paid to expanding doctors’ choices and increasing patient satisfaction and general cost‐effectiveness.     

Making sense of differences between medical schools through Bourdieu’s concept of ‘field’

Medical Education 2010: 44 : 645–652 Objectives Most basic medical education studies focus on one medical school, and the social and educational significance of differences between schools remains poorly understood. Sociologists have called for more comparative studies and for research on the institutional context of medical education. This paper introduces Bourdieu’s concept of ‘field’ as a tool for conducting such analyses. Context A ‘field’ is any arena in which there is a struggle over resources (capital), akin to a ‘game’ between players who occupy different positions depending on the resources they have. Prior studies show that higher education institutions compete in a field for various forms of capital which are reflected in their curricula and the students they attract. Methods This paper argues that medical education can be conceptualised as a field within which medical schools compete for different forms of capital, such as students, funding and prestige. The structure of the UK medical education field is analysed as a specific example of how Bourdieu’s framework can be applied. It is argued that UK medical schools’ varying curricula and admissions criteria serve to distinguish them from their competitors and to facilitate access to different forms of capital. Competition within the field helps to maintain inter‐school differences, with implications for both curriculum reform and students’ beliefs and aspirations. Conclusions Medical schools have varying curricula, reputations, and types and levels of resources. They compete with one another on all these fronts and attract different types of students and staff. Research and practice in basic medical education must take account of the position of any given medical school in relation to its competitors and to external agencies in order to critically consider the ethos of its curriculum and the perspectives of its students and staff. Bourdieu’s concept of field offers one useful way of accomplishing this.     

Medical training and the hospital at night: an oxymoron?

Context Attempts to reduce doctors’ working hours and streamline postgraduate medical training may mean junior doctors’ out‐of‐hours experience is reduced. It is also proposed that, in the UK, compulsory clinical (Foundation Programme) competencies are to be accomplished in 1 year rather than 2 years as they are at present. This observational study was performed to examine the scope of opportunity available to junior doctors to achieve such competencies while working on a ‘Hospital at Night’ (H@N) team. Methods A database of electronic requests made to the H@N team was used to tabulate the number and type of tasks requested and to define differences between specialties, using local hospital admissions rates to contextualise the data. These requests were then compared with a list of compulsory clinical competencies to assess the scope of opportunity available to trainees to achieve these competencies when working on the H@N team. Results A total of 8268 referrals were made to our H@N team between 1 October 2007 and 31 January 2008 using the electronic Hospital Information System^® (HIS^®). The predefined, online HIS^® request list included eight of the 20 tasks that represent compulsory competencies and showed that on average there were 247 opportunities per week of night shifts to perform them. Medical wards generated more requests than surgical wards (4767 versus 3170) and afforded greater opportunity to attain compulsory competencies (139 opportunities/week versus 96 opportunities/week; extra requests could not be attributed to either medical or surgical wards as original request did not include ward number). Conclusions The H@N initiative provides adequate opportunities for junior doctors to attain important clinical (Foundation) competencies. There appears to be sufficient opportunity to achieve these competencies within 1 year rather than the 2 years currently allowed in the UK Foundation Programme.     

A second open letter to the General Medical Council

In an open letter to the General Medical Council this independent group, drawn from several branches of the profession, expressed the belief that undergraduate medical education was failing in two respects; first, in the extent to which it equips doctors with the capacity to think critically for themselves; and secondly, in the degree to which it inculcates a broad and sensitive outlook towards the health of both individuals and communities. A remedy for both lies, in our opinion, in the better co-ordination of the different stages of medical education. Particularly important in this context is the period immediately after graduation. We therefore welcome the attention which the General Medical Council's Education Committee is now paying to this second stage. We welcome also the view which it has expressed that it is necessary to continue a broad education into the period when the qualified doctor is assuming responsibility for patient care. In this second letter we propose and discuss six aims for this period; and changes in educational organization needed if these aims are to be fulfilled.