Rethinking the objectives and practicalities of shadowing
Authors: Mark Jenkins, Elisaveta Sokolov, Sophie Rintoul-Hoad, Mark Kinirons, Adrian Hopper,
Publication date: 28 Feb 2013
With pre-work shadowing now mandatory for newly qualified doctors, Mark Jenkins and colleagues consider why we need to reconsider the current format of shadowing
Patients have a right to be treated by competent, safe, and confident doctors. However, if incoming foundation year 1 doctors (FY1s) are unfamiliar with the clinical teams, equipment, and their environment, errors and preventable adverse events are more likely to occur.
Every summer, 7000 new doctors in the United Kingdom start their first job. This extensive “cohort turnover” leads to a reduction in productivity because it disrupts day to day operations and results in a loss of tacit knowledge held by the more experienced departing workers.
This effect was first considered a potential cause of patient harm in 1990 in a US article hypothesising a “July effect.”  A 2011 systematic review of mostly US data found a trend towards increased mortality and decreased efficiency at end of year changeovers.
The effect acquired a more emotive name when it was later recognised in the UK: the “August killing season.” Emergency hospital admissions on the first Wednesday in August had an average 6% higher mortality than admissions on the previous Wednesday. A 2005 survey of all medical graduates found only a third felt “prepared” to start work.  Figures from Medical Education England show that 35% of entrants to the foundation programme move to a different geographical area, which means that about 2500 new doctors start work in an unfamiliar hospital.
Shadowing should result in a safe transition of care, allowing new graduates to benchmark their abilities against the required standard of care so that problems can be identified before there is any risk to patient safety. However, in the UK there has never been a formalised arrangement to prepare medical graduates for work and a fragmented system of informal shadowing has been in place.
The General Medical Council’s guidance documents Tomorrow’s Doctors and The New Doctor recommend “at least a week of ‘protected time’ of shadowing,”  but they provide no clear objectives. This conflicts with the General Medical Council’s own analysis in 2008 of the readiness of FY1s to begin work, which recommended that “[shadowing] guidelines should be more explicit and prescriptive.”
In 2008, University Hospitals Bristol NHS Foundation Trust undertook a structured shadowing programme with a mandatory paid week of “ward based shadowing,” formal teaching on patient safety and handovers, and social events to develop a peer network. This resulted in a 52% reduction in the number of mistakes made by new doctors in their first four months. However, Bristol’s example has not been reproduced nationally.
In an article on shadowing in 2011, Christine Outram, managing director for Medical Education England, argued for a cohesive national approach. She said there was “enormous variation in the timing, quality and delivery of shadowing opportunities.”
To tackle the lack of a national system of shadowing and to improve patient safety and quality of care, NHS medical director Sir Bruce Keogh announced in June 2012 that all newly qualified doctors must spend at least four days shadowing their new job.
Since 2010 we have undertaken an investigation of shadowing at Guy’s and St Thomas’ NHS Foundation Trust, one of the largest teaching hospitals in the UK. The 60 FY1 doctors joining the trust each August gave us a large sample to examine the key aspects that make shadowing an effective experience.
Working with the trust’s patient safety lead, we defined objectives using standards from the General Medical Council, Medical Education England, and the BMA. We then created metrics to reflect these objectives and converted them into a survey. Results of the survey showed that most FY1s felt “more prepared” for their new role after shadowing. However, during the shadowing period only half had covered areas that we believed were crucially relevant to patient safety.
We therefore developed a set of objectives so that incoming and outgoing FY1s had clear expectations of the key safety points that should be covered during shadowing.
Building on Atul Gawande’s work on using checklists to support more reliable systems, we developed and implemented a simple checklist to ensure the objectives of shadowing were systematically covered. These included orientation to clinical teams, environment and information technology systems, patient safety issues (such as falls, delirium, prescribing, and venous thromboembolism), and core aspects of the rotation (such as rotas, on-call responsibilities, and who to contact for advice during working hours and out of hours).
To allow a more systematic handover of tacit knowledge from outgoing FY1s, we also put together a guide to the trust. Written in conjunction with consultants, the electronic guide included information on all the core rotations and patient safety issues.
The August 2011 cohort of doctors received the checklist and guide two weeks before the start of the informal shadowing period. A survey of 11 responders afterwards found that only one had used the checklist, though nine had used the guide and thought it was useful. Although eight FY1s felt more prepared by shadowing, they had not achieved our key objectives as only one had covered critical areas of relevance to patient safety.
Reconsidering our measures
Our shadowing scheme had three barriers to success. Firstly, not all doctors did a period of shadowing; secondly, it was often undertaken before July; and, thirdly, there was no clear strategy for implementing the checklist and the guide. The coincidental introduction of mandatory shadowing in July 2012 dealt with the first two issues. To tackle the third, we took a two pronged approach.
Gawande showed that, to be successful, checklists need to be mandatory. We believe that the low uptake of our checklist was the result of insufficient support and training in its use by both incoming and outgoing FY1 cohorts.
With support from the patient safety lead at Guy’s and St Thomas’s NHS Foundation Trust, we therefore made our checklist mandatory. In July 2012, on the first day of induction, we gave a 30 minute presentation on the importance and use of a checklist to all incoming FY1 doctors. Outgoing FY1s were also informed of its role and that completion would be audited.
Building on the positive reaction to the guide, we wanted to develop it further and therefore transferred our current data to the Doctors Advancing Patient Safety (DAPS) toolbox.
The toolbox is a password protected online resource that provides free user generated content that is specific to hospitals and is written by and for junior doctors. It includes key sections covering patient safety and the exact details of junior doctors’ new roles. We asked outgoing FY1 doctors to write a short summary of their jobs using a proforma to standardise the information included and so facilitate transfer of tacit knowledge.
A repeat audit of 17 FY1s in September 2012 showed that, after shadowing, the proportion who felt more prepared for life as an FY1 was similar to that in 2011. However, the proportion covering core patient safety objectives improved substantially to nine of 16 responders.
We also made it compulsory to hand in a copy of the checklist to ensure completion and to audit what was being covered. The completion rate was 90%, yet only around half of responders reported that the checklist was useful. Criticisms included a lack of applicability to their clinical role and to their hospital site (the trust is split across two locations).
Should we all be adopting this solution?
We know that cohort turnover poses a considerable risk to patient safety. The fact that shadowing is now mandatory emphasises its role in ensuring that new doctors are safe and well prepared to start work.
However, national guidelines on what shadowing should entail do not exist, and there are no national systems to ensure tacit knowledge is transferred. The checklist and the DAPS toolbox offer clear and auditable methods to provide structures that are easily transferable and have been shown to increase dissemination of key information.
The checklist is not specific to individual specialties as its objectives are integral to every foundation year role. Its simple two sided format helps tackle the problem of “information overload,” allowing clear prioritisation of the knowledge that needs to be transferred. This builds on the growing understanding of the role checklists have across healthcare and helps new graduates become familiar with their use at an early stage.
The DAPS toolbox enabled us to cover any gaps from shadowing, facilitate the transfer of tacit knowledge, and provide a more robust guide to our large foundation trust. We recognise that hospital specific guides are not new, but internet platforms allow quick and widespread access and this matches how junior doctors now access clinical information.
To deal with concerns about inappropriate or erroneous content, editing is restricted to nominated junior doctors with senior supervision at each hospital, and these senior supervisors facilitate contributions. This is an improvement on trust intranet systems, where information is often difficult to find, quickly becomes out of date, and may not contain practical tips on carrying out jobs efficiently. Requiring junior doctors to be responsible for this information can engage them early on in process improvement and patient safety.
A key advantage of this project, like the World Health Organization surgical checklist, is that it is sustainable, scalable, and reproducible and can improve quality and safety without requiring appreciable financial resources.
Pressures on junior doctors grow from the first day of work, as the Collins report has outlined. A systematic UK-wide shadowing process therefore needs to be in place. There should also be a national assessment of whether patient safety issues are being dealt with among incoming FY1s, and we should all be striving to ensure there is complete coverage of these areas.
Although shadowing makes graduates feel “more prepared,” the process can miss crucial patient safety issues. With a system of metrics, a checklist, and an online guide we have produced a clearly auditable and easily transferrable system to improve patient safety.
Contributors: MJ, SRH, and ES were all FY1s at Guy’s and St Thomas’ NHS Foundation Trust between 2010 and 2012 and contributed with data collection and analysis. MJ wrote the article with senior review by MK and AH. For copies of the authors’ checklist, contact MJ ( firstname.lastname@example.org).
Competing interests: None declared.
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Mark Jenkins academic foundation programme year 2 doctor
Elisaveta Sokolov academic foundation programme year 1 doctor
Sophie Rintoul-Hoad former foundation year 1 doctor
Mark Kinirons elderly care consultant and clinical lead patient safety
Adrian Hopper, elderly care consultant and associate medical director Guy’s and St Thomas’ NHS Foundation Trust, London, UK