Newly qualified doctors are underprepared, study suggests
Authors: Matthew Limb
Publication date: 07 Feb 2017
Matthew Limb reports on new research that suggests that many newly qualified doctors lack some of the basic clinical skills they need to practise medicine in the UK
When junior doctors first start working on the wards they are generally underprepared for many aspects of clinical practice, an analysis bringing together previous studies has found.
The researchers behind the study think that many newly qualified doctors are not initially ready to undertake safe and legal prescribing, make diagnoses, or manage emergencies. Many are also unprepared when it comes to reporting errors and safety incidents, and understanding ethical and legal issues and how the clinical environment works, the researchers said.
The findings come as the GMC revealed its plans for a single standardised test that all doctors wishing to practise in the UK must sit.
The GMC said that the teaching of practical clinical skills is not good enough at some universities, and that almost half of new doctors from some medical schools say that they do not have the skills necessary to prescribe drugs. 
The researchers’ review identified a number of other problem areas in communication, including multidisciplinary team working, handovers, and breaking bad news to patients. They said that there was strong evidence to suggest that graduates were unprepared in their understanding of the issues around prescribing and emergency care, including their clinical reasoning skills.
However, the study did find that graduates were reasonably well prepared for history taking, performing full physical examinations, and some clinical skills such as venipuncture.
The GMC graduate outcomes list 32 procedures that graduates should be prepared to perform. The authors said that, to date, no research had examined all 32. Only 14 studies identified graduates’ preparedness when mapped across the outcomes. Such mapping suggests that graduates were prepared for around one third of the procedures (11 out of 32). For some skills, such as central venous line insertion, all the available evidence said that they were unprepared, although this particular skill is not one of the GMC outcomes.
There was reasonably strong evidence that graduates had problems of preparedness around ethical and legal issues, including for complex ethical situations such as caring for dying patients and understanding mental health law. Studies also showed that graduates were ill prepared for understanding how the clinical environment worked.
The researchers examined whether transitional interventions—such as assistantships, shadowing, and induction—were effective in easing undergraduates’ move into the workplace. They said that there were too few data to draw firm conclusions on the efficacy of assistantships but that trainees shadowing their first post could develop preparedness as long as appropriate teaching was in place.
Mandatory induction periods were also effective, but insufficient induction could leave junior doctors feeling underprepared, frustrated, disorganised, and anxious.
The researchers said that there could be a potential role for the revalidation process in supporting doctors who feel underprepared. The GMC recently proposed beginning the revalidation cycle as soon as doctors completed the foundation scheme. “If revalidation is perceived by junior doctors as a supportive process that endorses or reinforces strong performance and provides developmental feedback for weaker areas, then it could contribute towards those doctors feeling more prepared for their next stage of training,” the researchers said.
Looking at the evidence
The analysis, which was published in BMJ Open, was carried out to plug a perceived gap in the evidence on preparedness.
It highlights where further research and interventions are needed in both medical schools and the clinical environment.
The study was carried out by a team that included Karen Mattick, professor of medical education at Exeter University, and Alison Bullock, who leads the Cardiff unit for research and evaluation in medical and dental education. Their work examined research published between 2009—when the GMC launched Tomorrow’s Doctors, the outcomes and standards’ document on undergraduate medical education—and 2014.
Most of the 87 studies (75%) comprised junior doctors’ self reporting on preparedness, while some involved clinical educators, patients, or other NHS employers.
Few studies defined the concept.
Many studies collected data immediately after graduation and focused on preparedness for graduates’ first days as a junior doctor. Data are sometimes inconclusive and can contain contradictions, the researchers said. For example, graduates may give themselves higher ratings than in their assessments by senior colleagues.
The researchers looked for areas where the evidence was strong and where conclusions could be drawn with some confidence. Their analysis identified six themes: individual skills and knowledge, interactional competence, systematic/technological competence, personal preparedness, demographic factors, and transitional interventions.
Have standards deteriorated?
The researchers said that it was difficult to say if doctors were less prepared than their predecessors. This was because of the way medicine has changed, situational and contextual factors, issues around research quality, and how the concept of preparedness was defined.
Mattick and Bullock said: “We shouldn’t be asking if graduates are more prepared than before. Rather, attention should be given to better understanding what they’re being prepared for, and whether that preparation is appropriate and sufficient.
“We found that doctors were well prepared in some areas and less so in others. Our research shows areas where it might be beneficial to focus greater attention and resources.”
There are currently plans to change the point at which doctors become fully registered with the GMC. At the moment, doctors are only fully registered after they have successfully completed the first year of the postgraduate foundation training programme. But the GMC plans to have full registration at the point at which medical graduates graduate. Could this make medical students feel more prepared for clinical practice?
Mattick and Bullock said that their findings from an earlier study—part of the same programme of research—showed that stakeholders saw foundation year one as an “important safety net,” protecting patients by close trainee supervision and protecting trainees with a safe environment for “learning on the job.”
“Even though the daily practice of newly qualified doctors might not change, there is a risk that full registration at the point of graduation might imply higher expectations from the outset, making the transition from medical school into practice feel more,” they told BMJ Careers.
“Understanding the areas for which medical graduates are especially unprepared—such as prescribing—should flag up to policy makers and curricula developers what needs to be done for the sake of patient safety,” they add. “Taken together, our research findings should enable those planning any such policy change to ensure that these risks are taken into account.”
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Matthew Limb freelance journalist BMJ Careers