Pre-FY1 Shadowing in the North Western Deanery a 2010 Review Recommendations for the 2011 Shadowing Period North Western Deanery Foundation Forum Melissa Bouchard, Foundation Doctor, North Western Deanery Paul Baker, Foundation School Director, North Western Deanery 1
Background In 2009, Manchester Medical School (MMS) reorganised its final year and introduced finals exemption examinations in January, meaning many may not need to take traditional finals in May. A previous month-long consolidation period in May (where much shadowing would have taken place) was dropped. Students still required shadowing (which is also a GMC requirement), but this could occur after graduation. This meant drastic changes to Trusts usual arrangements. Shadowing was organised in the two weeks prior to starting work in August. Included in this shorter timescale would be 60 hours of shadowing time, which entails observational sessions with the FY1 that the joiner will be replacing whilst based on the ward they are due to start on. Set teaching sessions, e-learning and other related shadowing activities would also take place during those two weeks to ensure the new FY1s would start their new job knowledgable, prepared and confident. The generally accepted minimum, and GMC expectation nationally, appears to be one week of shadowing activity. The 2009 review by the Juniors forum scrutinised programmes within the North Western Deanery, their individual timetables and how they used the shadowing time. New recommendations were created from the results and these were communicated to all hospitals. This 2010 re-audit investigated if the previous recommendations were taken on board and if this lead to any changes in the shadowing period in all hospitals in the Deanery. The same methodology was used with the addition that this year we felt it would be beneficial to obtain the joiner s opinions on their shadowing period. Methods All programmes provided the timetables for their shadowing period along with their policy on attendance. We looked at the time spent in each of the following areas shadowing, teaching, e-learning, Trust and courses provided. This data was collated and analysed for whether all items were successfully delivered and 2
how. We also created a questionnaire asking the new FY1s how useful they felt the teaching and the shadowing were during those allocated weeks and if they felt better prepared after this for their new job. Results As in 2009, we found considerable variability amongst the 17 sites (Table 1). Shadowing time ranged from 20 hours (30 hours in 2009) to 64 hours (no change from 2009). The mean was 45 hours (2 hours less compared to 2009), however 3 sites did not indicate in their timetable when or if shadowing took place. One hospital achieved the recommended 60 hours of shadowing compared to five hospitals in 2009. One site actively encouraged completing an on-call night shift during the shadowing period. Compared to 2009, set teaching increased on average by 5hrs, the minimum in one program being 5hrs and the maximum 29hrs. However a majority of teaching sessions were based around topics. Some Trusts provided peer led teaching at lunchtimes; others had an afternoon led teaching session run by FY2s. 7 sites scheduled time for e-learning modules and one provided an e-learning session. The minimum amount of time given for e-learning was 30 minutes and the maximum 17hrs. Two hospitals were found to have used the shadowing period for the pre-employment screen, which goes against the previous recommendations. Preemployment screen should be used as a tool to detect any weaknesses in pre-fy1, encourage them to work and improve in order to be fit for practice on their first day as a junior doctor. Most sites offered ILS & AIMS during the shadowing period and one site had ALS booked for all joiners. Most hospitals used the Monday and Tuesday prior to the FY1 s official first day, for trust. The feedback highlighted how useful the shadowing period was to pre-fy1s. Most felt it enabled them to gently be introduced to their future work environment and team. 3
However most were unhappy with the signing out system as it transpired that not all afternoons on the ward were useful and some found it frustrating to stay on hospital grounds for the sake of it. The majority preferred shadowing in the mornings and lectures to be held in the afternoons. The soon-to-become-fy2-led teaching sessions received the most praise as they appeared to be the most relevant lectures. The IT training lectures were described as being unhelpful as students were unable to retain such information whilst sat in a lecture theatre. Certain hospitals used a log book of mandatory skills to have signed off by peers, this received positive feedback. The majority of the students did express their confusion regarding the shadowing period being compulsory but not receiving pay. Discussion Embarking on life as an FY1 doctor is an extremely daunting prospect. There are moves afoot nationally to align better the content of final year medical degree courses to preparation for professional practice. Essentially much of final year may become shadowing a job. This review looks at shadowing the job, specifically in the Trust (and ideally the very same post) which will be joined in the following August. The shadowing period is mandatory for graduates of the Manchester Medical School. It should be offered to all other joiners and if possible recommended in their preparation for starting work. It could not, however, be made mandatory for non-manchester UK or overseas graduates unless the period became contracted paid work time. The reason why this period is unpaid should be made clear to all joiners. The pre-work shadowing period provides the opportunity to settle into the job with no responsibilities for patient care. Manchester graduates however are allowed to practise procedures (and use their log book of clinical skills to be signed off by ward doctors) as they are indemnified by the MMS. All other joiners may not be adequately covered until their first day of employment so programmes should consider issuing an honorary 4
contract to the new comers 2 weeks earlier if we feel practical procedures are important in shadowing. We leave this to an open discussion. The shadowing period allows the new doctors to receive training in essential IT (ordering investigations, checking results) and hospital-specific tasks such as forms and documentation but also in dealing with their first on-calls. We also feel that joiners should be introduced to their e-portfolio early in order to focus their interest on attaining the required competencies but also on their future careers. Teaching sessions and courses should also be designed to refresh memories on how to deal with acutely unwell patients and who to call for help. These 2 weeks should allow joiners to familiarise themselves with their ward team and work environment in order to promote a smooth transition into their first Foundation year. However, large amounts of mandatory trust such as fire safety can impact significantly on how useful this time is to the new doctors. An addition to the program which we feel could enlighten junior doctors on the functioning of their hospital would be a session where the clinical and non-clinical managers introduce themselves to the new doctors. A recurrent theme in recent feedback is the lack of involvement that doctors have in the management of their ward and hospitals. An earlier introduction to the management team would allow breakdown of the barriers between doctors and managers and encourage regular team work throughout their training with a unified objective: patient safety. This review highlighted much good practice but also areas where improvements could be made. In the absence of a clear definition of what shadowing actually is, it was not surprising to find again this year differences between all the programmes. Clarification is needed on what constitutes good and useful shadowing and how many hours of teaching and e-learning is reasonable. 5
Conclusions Shadowing and the terms around it need to be defined and agreed by all programmes before July 2011. In discussions, MMS recommend 60 hours should be given to shadowing over the 2 week period (using the remaining 20 hours for -type activities) whilst the GMC recommend 40hrs. We have defined the shadowing period such that it includes time spent observing the FY1 whom the students will replace in August as well as peer led teaching, e-learning, IT, ANTT and ILS. We have suggested a timetable (see table 2). True shadowing, i.e. observational time ideally with the FY1 that students are due to replace and on the ward they are due to work on, should be minimum of 40 hours as per GMC expectations. Shadowing should be supported with useful teaching, including peer-led teaching. This should be preferably during the lunchtime hour as these sessions seem to receive the best feedback. ATSP re: is a new teaching session that was successfully implemented in the Pennine Acute Hospitals NHS Trust in 2010. Those sessions were found to be very useful by the students. The FY2s involved in the project are currently training FY1s on all sites to deliver those sessions. Joiners should be introduced early to their e-portfolio and all IT based lectures should take place in a computer lab. We suggest that all sites put in place a signing in and out system in order to monitor that all future trainees receive the same standard of preparation to FY1. All lectures should have a register to verify attendance. 6
2010 Recommendations 1. 60 hours over the two weeks should be allocated to shadowing. 2. 20 hours should be allocated to e- and other -type activities 3. True shadowing i. Should be a minimum of 40 hours. ii. Where possible, whole days or half days should be allocated, preferably mornings 4. Teaching sessions i. Shadowing should be supported with useful teaching ii. Should be peer-led where possible iii. Should be preferably during the lunchtime hour. iv. Should include ATSP Re, portfolio training and Meet your managers sessions. 5. Joiners should be timetabled for on-call or Medical Emergency Unit sessions. 6. IT, e- and e-portfolio sessions should preferably occur in computer labs. 7. Records of attendance should be kept. i. lectures should be registered ii. daily signing in and out system 8. The reason why this period is unpaid should be made clear to all joiners. 9. e- i. should be timetabled in the 2 weeks but outside of the 60 hours shadowing. ii. should be supported with an introductory lecture and drop-in sessions iii. excessive repetition should be avoided in other processes. 10. Mandatory Trust Induction i. Should build upon and not excessively overlap with e- ii. Should be attended but the program should be prepared so there is as little impact on shadowing time as possible iii. Best suited to the paid days in the first week of August 7
Table 1: Results Hrs marked on the shadowing schedules of 17 sites 2009 2010 min max average min max average shadowing 30 64 47 20 64 45 teaching 2 25 11 5 29 16 e -learning 1 20 8 0.5 17 9.5 register use of first Monday use of first Tuesday courses 4 sites signed in daily other sites: Elearning, shadowing, ILS other sites: on-calls or shadowing (4), admin, Elearning 1 site had ALS, 2 had ALERT 7 sites only at teaching 9 sites had 5 sties had 14 sites had ILS and 10 had AIMS register at teaching trust trust ILS & AIMS 4 sites signed in, 2 signed in & out, 1 signed in weekly, 3 had log books. other sites: teaching, shadowing, ILS 1 site had clinical skills 1 site had ALS, 2 had ALERT 7 sites only at teaching (only 5 sites register at teaching AND daily sign in) 7 sites had 4 sites had 4 sites had shadowing 11 sites had ILS and 9 had AIMS register at teaching only trust trust or shadowing ILS & AIMS 8
Table 2: Suggested Time Table. Week 1 Monday Tuesday Wednesday Thursday Friday 9h - 12h Shadow FY1 Shadow FY1 ANTT 12h - 13h F1 teaching F1 teaching Portfolio training Shadow FY1 Shadow FY1 F1 teaching e- learning 13h - 17h IT intro Shadow FY1 Shadow FY1 Shadow FY1 e-learning Week 2 Mon Tues Wed Thur Frid 9h - 12h Shadow FY1 Shadow FY1 Shadow FY1 ILS Flexible/ Other teaching 12h - 13h ATSP Re; F1 teaching Meet your managers F1 teaching 13h - 17h Shadow FY1 Shadow FY1 Shadow FY1 Flexible/ Other teaching Overall: Shadowing 60 hours True shadowing 40 e-induction 12 Any two of the Shadow FY1 or Flexible/Other teaching sessions be scheduled for On Call or Acute Medical Admissions shifts 9