A Novel Remote Induction Programme for New Junior Doctors during the COVID-19 Pandemic

Sean Lobo, Department of General Surgery, Ninewells Hospital, United Kingdom, Email: seanlobo95@outlook.com

Received: 18-Aug-2021 Published: 08-Sep-2021

Introduction

Starting a new job as a junior doctor is often challenging, particularly on surgical wards, as patients are often acutely unwell. The 2020 intake of junior doctors faced an additional challenge they had started work during the COVID-19 pandemic, which affected these new clinicians in a multitude of detrimental ways [1].

It has been previously suggested that there is an increase in mortality when there is a junior doctor changeover, with figures of 4%-12% being quoted. This has led to terms such as the ‘August Effect’ or ‘Black Wednesday’ [2]. It has been suggested that an effective induction programme can help improve patient safety and the confidence of new clinicians [3].

The COVID-19 pandemic has challenged how a traditional induction programme can be effectively delivered. Issues have included social distancing requirements and the potential for doctors to miss a conventional face to face session if they were unwell with COVID-19 or required to self-isolate. This problem is further compounded when one considers that these new doctors will have had no experience of COVID related practice and an induction event is the ideal forum to explain protocols relating to patient management, infection control and workplace behaviour.

We set out to develop and implement an effective remote induction programme to improve junior doctors’ confidence by equipping them with the requisite skillset to thrive in the clinical environment. It was intended that this additional programme would be complementary to the mandatory hospital induction. In addition, it was desired that these additional sessions would be trainee led and delivered by trainee doctors of varying grades.

When developing this programme, we considered the challenges medical students face when transitioning to the role of a doctor. These included a steep learning curve relating to clinical practice, the need to develop team working skills and the requirement to be able to ask for clinical or pastoral help [4]. Bearing in mind these themes, we developed a virtual induction programme utilising a range of educational modalities and with contributions from a multidisciplinary professional team.

Methods

The induction programme consisted of a series of online interactive tutorials. These sessions were offered to a cohort of new foundation doctors who were starting work in a large surgical department in a UK teaching hospital. These new doctors were commencing placements in General Surgery, Urology, and Vascular Surgery (with an expectation they would cross cover between these specialties).

Each educational session was tailored to allow development and learning in a specific area of clinical practice. The programme was delivered between August 2020 and November 2020. Surgical foundation doctors, who had recently commenced their training, were invited through emails, word of mouth and social media.

Prior to each session, a survey was circulated to all potential participants to determine their confidence and knowledge regarding the upcoming topic (Table 1). These surveys were circulated utilizing Survey Monkey (an online platform designed to deliver surveys and obtain anonymous feedback). At the time of completing this initial survey participants were given the opportunity to raise specific questions that they wished answered during the online tutorial.

All online induction sessions were provided via Zoom video conferencing technology. Permission was sought to record each session so doctors not present could review the material later.

The first session focused on prescribing and was led by a specialist surgical pharmacist, who provided an interactive lecture. During the session, the pharmacist demonstrated real life anonymised medical prescription errors. At the end of the session, resources were circulated which provided guidance about common prescribing scenarios that the participants had highlighted, or that the pharmacist felt were particularly relevant to foundation doctors.

The second module was led by a senior surgical registrar and concentrated on the management of acutely unwell patients. The doctor gave description of clinical situations they had encountered during their clinical practice and facilitated group discussion of these scenarios. This session was intended to ensure that doctors could develop a set framework to systemically assess each patient and ensure clinically safe and appropriate actions. To help ensure the session was interactive and immersive real life observation charts and drug charts were utilized (Figure 1). This session was intended to demonstrate that an emergency generic management is often more important than determining an exact diagnosis. Foundation doctors were able to make suggestions and subsequently reflect on their ideas in a supervised environment whilst also being able to critically analyze the alternative strategies suggested by other participants.

Figure 1. An example of a drug chart we utilised during an acute case simulation

The third session covered working as junior doctor on night shift, as it was identified that the new cohort of junior doctors felt unprepared for night shifts. This was expressed through informal feedback to seniors prior to the programme and was also noted during collection of the surveys initially.

The fourth and final session focused on personal organization and task prioritization. The aim of this session was to assist these new doctors develop into an effective and organized clinician. This tutorial was led by a senior surgical registrar who utilized real life clinical scenarios to demonstrate efficient working practices. In addition, a clinical development fellow offered generic advice regarding time management during periods of ward work.

Following completion of the programme feedback surveys were issued to all participants to assess subjective self-reported improvement in confidence in dealing with the issues covered in the teaching sessions.

Results

This induction programme was offered to 21 of the foundation doctors. Out of these doctors, 14 successfully attended each of the four sessions and completed both the initial and final survey.

Prior and after to the commencement of the project new medical graduates were asked to rate their confidence (on a scale of 1-10) in dealing with the 4 themes covered in the programme. In addition, using a combination of ratings scales and free text responses they were asked to provide other information regarding their concerns about starting work. Following successful completion of the programme participants were asked to re-evaluate their confidence in dealing with these themes.

The results of the pre and post programme questionnaires are demonstrated in Table 2. In addition, review of the free text responses revealed some common concerns.

Following completion of the online induction programme we noticed a trend that suggested that new foundation doctors were increasingly confident with the 4 themes covered in our induction programme (Figure 2).

Figure 2. An All confidence parameters displayed in a graph, demonstrating the values before and after the teaching programme. It is demonstrated that there was a global improvement in confidence. Each value contains its confidence interval.

Discussion

The aim of this project was to utilize a number of different modalities to provide an induction programme that equipped FY1 junior doctors to manage common medical issues appropriately on a surgical ward.

We found that the two lowest scoring parameters at the start of the project were confidence in seeing patients alone, and the management of the acutely unwell patients. We identified that these are issues that are often reported to be particularly challenging for junior doctors [5]. Within our team, we sought to equip the new foundation doctors with a generic framework that may be utilized in a variety of acute clinical settings. In an ideal setting, a suitable adjunct would be the utilization of high fidelity simulations, to replicate unwell patients, as simulations have been proven to improve safety and reliability in high stress settings [6]. However, this was limited due to social distancing guidelines. We partially counteracted this by utilizing adjuncts that the junior doctors will encounter in the clinical setting, such as observation charts and prescription charts. At the end of the programme, confidence in management of the acutely unwell patient, reported the highest increase in score following delivery of the programme.

We note that we saw the most minimal increases in the self-reported scores in organization and prioritization of tasks, though these parameters did also have the highest baseline scores. These are skills that some may argue are inherent, or may be developed through active immersion, rather than remote teaching programmes [7]. Nonetheless, an improvement in confidence was still noted in this score, and we believe that this was due to the provision of methods to prioritize tasks and develop organisational skills. Demonstrating frameworks and successful tools to an audience, encourages them to employ it in their future practice to remain organised [8].

To maximize engagement with participants in a teaching programme, a variety of modalities should be employed to hold interest and present information clearly [9]. Therefore, we sought to maximize the variety of topics and presentation techniques utilized. For instance, when undertaking the prescribing teaching session, we used a PowerPoint presentation to highlight local guidelines. To demonstrate correct prescribing methods; we utilized the same paper drug charts encountered in the clinical environment. Furthermore when discussing acute clinical scenarios, we utilized clinical accessories such as observation charts and images of paraphernalia associated with the discussed clinical scenarios. This ensured that we developed familiarity of the clinical environment, enabling the junior doctors to be prepared to encounter these scenarios during their clinical work [10].\

We were also aware of the challenges faced, both in terms of mental and physical fatigue. We ensured to complete these sessions in the early evening to ensure maximum attendance, but we also aimed to ensure that each session was limited to a maximum of one and a half hours to minimize fatigue, and we also ensured that each session had at least one break [11].

The programme took place over a 3 month period. Whilst we may attribute the global improvement in confidence across parameters due to our teaching sessions, there may also be other factors influencing this improvement. The most obvious factor, being that this was the first placement for study participants hence one would expect their baseline confidence to be low, and increase after 3 months of clinical practice [12]. Although this was undoubtedly a confounding factor we believe the programme accelerated the acquisition of skills and confidence [13].

Conclusion

A successful induction programme should address the new doctor’s concerns and expectations, whilst providing with the appropriate framework to develop clinically in a new role or setting. With the advent of the COVID-19 pandemic, this was a challenge to ensure we fulfilled these aims, whilst adhering to national policy on social distancing and other preventative measures. Therefore, we worked with a multidisciplinary team to develop and implement a novel remote induction/teaching programme aimed at new and inexperienced surgical doctors. Following the programme, we noted an improvement in confidence across all parameters. Whilst there may be other factors at play, we suggest some of these improvements were due to the successful delivery of this programme. We noted the success of certain techniques which we will seek to continually employ in induction programmes, whether indicated by a pandemic or not.

Conflict of Interest

The authors declare no conflicts.

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