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Trainee Jobs: Pot Luck or Picking Teams in Gym Class?

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Fardod O Kelly FI“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is most adaptable to change…” (C. Darwin; ca.1857)

 

On Friday 18th March 2016, U.S. medical school students and graduates participated in the National Resident Matching Program (NRMP) with 42,370 registered applicants attempting to match into 30,750 PGY-1 and PGY-2 positions. This was preceded the same day by the Irish Higher Surgical Training (HST) Urology interview held in the RCSI in Dublin for a smaller number, but just as eager candidates endeavoring to secure their future in their own field. Thousands of candidates, in the pursuit of a career that they have so far, only dreamed about. Thousands of candidates, all with one thing in common: Not one of them knew where they were going to end up if they were somehow successful.

The British Medical Journal (BMJ) on their careers website explaining to core trainees how they might perform better in interviews, outline a roadmap of 12 key components from extra courses to leadership skills, but not once mention visiting the various deanery sites in order to assess whether the place represents a good fit for your own ambitions, learning objectives and style of management.

Prof. Adrian Joyce provided an editorial on the BJUI blogs site in 2013, highlighting the need to devise a better means of training “The UK conundrum shared with many other healthcare systems is how to provide effective training within the demands of service commitment and the EWTD… The challenge therefore is to devise innovative ways of training within the limit of fewer hours and training, not service, must become the priority for trainees and for those surgeons, departments and hospitals that train them…”

Therefore, we have two health systems on these islands, with the UK National Health Service (NHS), and the Irish Health Service Executive (HSE), both acknowledging the mandatory requirements of the European Working Time Directive (EWTD) to shorten working hours, and the need to fulfill service commitments within the health sector, and the need to allow for postgraduate training to ensure a steady workforce into the future, but also to balance the requirements of the Specialist Advisory Committee (SAC) and the Joint Commission on Surgical Training (JCST) as well as the Royal Colleges to ensure that training is to a satisfactory level. In order to achieve this, hospitals and trusts are allocated a number of trainees who have gone through the above selection process and have accumulated years of experience, qualifications and debts to fill a very complex role within a volatile system.

However, when did a “one-size-fits-all” approach become acceptable to trainers and trainees who need to work alongside each other within these environments filled with stress, litigation, and variable relationships with managerial types within the system? We all see patients, break bad news, manage expectations, provide treatment options, and above all know that each patient is different. They handle information, make choices, adhere and respond to treatment in a myriad of ways depending on a huge number of variables and confounders (not to mention the relatives). We have developed nomograms to try to communicate outcomes and risks to patients for disease like prostate cancer, such that entering the keywords “prostate cancer” and “nomogram” into PubMed will in excess of 900 hits. So, the hospital environment is complicated, and patients are complicated, but what about the lowly figure of the surgical trainee who has successfully demonstrated the aptitude and the background to progress to higher training?

Sullivan et al. demonstrated in 2013 that despite the reduction in trainee hours in the USA, resident attitudes, and program location were most frequently associated with voluntary attrition, with “the personal cost of training” (p<0.001; HR2.89) playing a major role in leaving a program. Bell et al. elegantly demonstrated in 2012 that despite the abundance of information on particular candidates, many of the fundamental qualities that are associated with success for the surgical trainee cannot be identified by review of the applicants’ grades, scores, letters of recommendation, personal statement, or even from the interview process. Therefor only by meeting trainees, in order to identify unique behavioral, motivational and personal talents that applicants bring to the program, allowed the authors to determine applicants who were a good match for the structure and culture of that particular program.

The standard interview process, whilst objective, does not allow trainers and institutions the luxury of getting a feel for the candidate, and applying instinct and acumen as to whether and how the trainee will fit into the overall scheme of things. The exact statement can be played in reverse.

All the innate instinctual abilities and skills that we prize in being able to quickly assess measure patients have been denied to us in choosing some of our closest junior colleagues on whom we rely on so heavily.

From a trainee urologist’s perspective, and one that would apply to nearly any other profession, one of the greatest predictors of your happiness and productivity at work is your relationship with your senior colleague. This is therefore intuitively important when considering new post, on order to know how you’ll get along with your new boss. This can be hard to assess in an interview when one is attempting to masquerade an unbridled sympathetic response and trying to demonstrate one’s one appointability, but it’s crucial to evaluate the panel as well. What sorts of questions should you ask to understand their management style? Should one try to talk with other people who have previously rotated through the post? Are there red flags you should watch out for? Will it even matter?

There are a number of healthy checklists in the business world which lend themselves to translation in surgery:

  • Trust your instincts: Ask yourself whether this is the training post you want and the consultant you want to work for. Did you get a good feeling from the person? Is she someone you can imagine going to with problems? Or someone you could have a difficult conversation with? This is especially important when the stakes are high
  • Do your homework: One of the greatest faux pas one can make is to incompletely prepare. You should try to gather as much information on the unit/post as possible including the history of the department, publishing record of the consultants, theatre logbooks from other trainees, inter-personal relationships, red flags. Google each consultant and check out the social media presence of the unit (#SoMe) as a proxy of their willingness to engage with social technology and communication
  • Meet your colleagues: Spend time with future colleagues in the unit independent of the interview. Take some time to chat to nursing and clerical staff as well as other trainees. More information can be acquired about a unit over a cup of coffee with future colleagues than any other approach

In this time of flux within health service systems, trust, collegiality and communication as key. Things that sound apt are not always what they seem. The quotation attributed above to Darwin, is often one that is misquoted, and although seems appropriate, there is no evidence that he ever made that statement. In the same way, trainees can no longer be seen to be but from the same cloth. Their own lives and careers are unpredictable and multi-faceted, and the answers and applications relied on at interview do not guarantee a good correlation coefficient when plotted on a graph belonging to a particular unit i.e. not a “good fit”. Perhaps it is time to trust our own instincts when appointing a trainee to a particular unit by taking the time to meet candidates and assessing – in addition to applications and CVs – how they might slot into a department – so that when it comes to tackling overcrowding, waiting lists, theatre slots, emergencies, call, research, audit, management and teaching, at least they can be met with the strongest team possible.

 

“…it’s better in fact to be guilty of manslaughter than of fraud about what is fair and just…”  (Plato, The Republic and Other Works)

 

Fardod O’Kelly is a Specialist Registrar in Urology at AMNCH, Tallaght, Dublin 24, Ireland. Twitter @FardodOKelly

 

Consultant on call: incorporating lean thinking or Chaos theory?

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The RCS report on ‘the implementation of the working time (EWTD) directive’ has recently been submitted. Recommendations include the need to rethink teams and services working patterns.

In urology a combination of the EWTD, depleted middle grade numbers and political will, have necessitated that consultants increasingly deliver out of hours service. There are theoretical advantages to a consultant being first point of call: the most experienced clinician physically present on the ‘shop floor’, delivering expertise at the point of contact with the patient, identifying and treating conditions more quickly than a more junior doctor. These views were supported by a major impact paper published in the BMJ that highlighted increased death rates for elective cases operated on Fridays and at the weekend. The conclusion from this paper and popularised in the press was that patients are more susceptible when senior doctors are not on the ‘shop-floor’. However there are recognised confounding variables to the papers findings. Friday operating lists have often been allocated to the most junior surgeons and post-operative complications are primarily related to co-morbidities and what occurs on the operating table, rather than the variability and quality of decisions made in post-operative care. Incomplete data was excluded and there may be a weekend effect for routine coding. The study itself highlighted the weaknesses of using administrative data and selection biases that exist for elective procedures scheduled on weekends.

The downside of frontline consultants is underutilization. The need to maximize utilization of staff-skills is not unique to healthcare and whole support industries have developed to optimise this most precious of resources. One of the most successful approaches has been lean thinking, which originated in the Japanese car industry. Lean methodology has been successfully replicated in multiple industries including healthcare improving costs and quality in parallel. A commonly quoted example, which highlights advantages over the ‘old way’ of thinking, was the understanding in how to optimise the factory conveyor belt, resulting in numerous correlations with other industry workflows, many of which use Mitrefinch US to optimize such processes. The conveyor belt was introduced by Ford in 1913, revolutionizing the car industry. It dictated the productivity of ‘the line’ with any interruption having significant implications to workflow. With this in mind Ford had a policy that only the most experienced person in the factory, the foreman, could stop the line, believing this to be safest and most cost-efficient. However this assumption was proved incorrect by Toyota in the 1960’s. Coming from a culture of respect and valuing the contribution of co-workers, they ruled anyone could stop the conveyor belt and that sections of the line work in teams. When the line was stopped all the team rallied to solve the problem and later performed root-cause analysis. In the Toyota model problems were identified and quickly fixed, but more importantly all the team were demonstrating continuous improvement, reflected in minimal rework required for completed cars. In the Ford model the primary aim was to keep the line moving, as a result many cars were completed with problems built in, several panels often needing removal to access mistakes and rework contributing 20–25% of total workload. Effects compounded by lack of feedback so that the same problems/issues were repeatedly not identified nor understood how to correct or prevent. In the Toyota model the line that could be stopped by anyone was on average stopped four times a month approaching 100% efficiencies, compared to 90% efficiency at Ford with the line being stopped four times a day on average. Disempowering the workforce resulted in reduced quality. Toyota thinking highlighted the key element for improvement was access to expertise when needed and that root-cause analysis resulted in continuous incremental improvement (kaizen in Japanese).

Lean Methodology was popularized by Toyota

If accessibility is the key it seems illogical in a time when technology gives us increasing options for audiovisual communication, we as a profession are choosing to regress to an approach outdated in the car industry half a century ago. An alternative approach could be a smart-phone or tablet linked to 3G and hospital wifi with an allocated Skype and mobile number. As a ‘baton’ tablet it would also necessitate face-to-face handover between consultants, whilst delivering a mobile consultant on-call service. Guidelines could be on websites and forwarded direct from the tablet to GPs and other doctors.

Downloaded apps would aid patient communication and local treatment guidelines/pathways that are evolved with contributions from all members of the team would enable ‘kaizen’.

Another key element of lean thinking is the necessity to reflect on decisions made. Make decisions slowly by consensus, thoroughly considering all options and then implementing decisions rapidly.

Reflection (Hansei): what would I do differently next time?

 

The Chaos theory states that complex dynamical systems have outcomes sensitive to minor changes, so that small alterations can give rise to strikingly greater unpredictable consequences. However, some affects are predictable, others probable. Changing a consultants’ working patterns to on-call services reduces the proportion of elective work and is likely to result in more ‘shared-care’ and reduced ‘ownership’ of patients. These effects are especially likely in smaller hospitals where the consultants’ on-call responsibilities will be more frequent. Sub-specialist clinics and surgery will be reduced and in some cases become non-viable. Shift patterns are by definition a less professional working environment. The true resultant effects are likely to be a down regulation in services with decreased consultant responsibility for long-term personalised patient care. The effects on individual trainees and the profession as a whole are harder to predict.

The changes to consultant working patterns supports the current political needs; however, they have been instigated without level 1 evidence. Only time will tell whether a consultant delivered service corrects the identified short-comings in out of hours service. Let us hope it doesn’t result in Chaos!

 

Justin Collins is a Urologist at Karolinska University Hospital. @4urology

 

EWTD: Quantity or Quality?

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The European Working Time Directive (EWTD) was due to be in full implementation from August 2009 limiting junior doctors to a 48-hour week averaged over a 6-month period. The reality of this is somewhat different from the legislation. In truth, the questions needed to be asked were – was it ever feasible? What was the training impact in a craft-based speciality going to be? Where are we now?

The detrimental effects to training in a reduced working environment has been documented in both hemispheres. Canter, in a review of the EWTD in the United Kingdom and Ireland reported ~90% non-compliance of the restricted working week. ‘Time for Training’ reviewed the implications of the EWTD and Professor Temple felt ‘high quality training can be delivered in 48 hours’; however, this is precluded where trainees have a ‘major role in out of hours services’. As most trainees, in all health systems, will attest to junior doctors do play a ‘major role’ in on-call services.

As a current urological trainee, the pressures to develop skills to operate in an ever-changing and exciting field are evident. A limited working week, twinned with health service cut backs and limited hospitals beds is without doubt a concern when filling in our logbooks. ‘Could a passage to India be the way to get more surgical experience?’, a feature in the BMJ in 2012, Elliot sends trainees abroad to gain the invaluable exposure to numbers we are limited by here.

There are two sides to the impact that a limited working week will have to an aspiring surgeon’s experience, the quantity and quality of time spent in the hospital. The debate remains regarding the length of surgical training the current structures are changing in Ireland, led by the RCSI, in an effort to shorten the length of surgical training in line with other jurisdictions. We need to strive to efficiently and effectively train surgeons within an appropriate timeframe within the restraints of legislation without a drop in the standard of skills required.

As time has passed, it remains to be seen if the EWTD will ever be implementable in keeping with the continuity of patient care to the highest standard they deserve and that we aspire to offer them. The EWTD is currently being debated at a European Commission level in order to negotiate a revised directive more in line with the challenges of healthcare professionals in a 21st century health service. Revisions to the directive may allow for longer hours in certain disciplines such as the skill based surgical specialities.

Gregory J. Nason, MRCSI, is currently Registrar in Urology, St Vincent’s University Hospital, Dublin.

 

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