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For peer review only

“I did try and point out about his dignity”: A Qualitative Narrative Study of Patients’ and Carers’ Experiences and

Expectations of Junior Doctors

Journal: BMJ Open

Manuscript ID bmjopen-2017-017738

Article Type: Research

Date Submitted by the Author: 17-May-2017

Complete List of Authors: Kostov, Camille; Salisbury District Hospital, Salisbury, United Kingdom Rees, Charlotte; Monash University, Faculty of Medicine, Nursing & Health Sciences

Gormley, Gerard; Queens University Belfast, General Practice Monrouxe, Lynn V; Chang Gung Memorial Hospital Taoyuan Branch, Chang Gung Medical Education Research Centre

<b>Primary Subject Heading</b>:

Medical education and training

Secondary Subject Heading: Qualitative research

Keywords: MEDICAL EDUCATION & TRAINING, MENTAL HEALTH, QUALITATIVE RESEARCH

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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“I did try and point out about his dignity”: A Qualitative Narrative Study of

Patients’ and Carers’ Experiences and Expectations of Junior Doctors

Camille E. Kostov1, Charlotte E. Rees2, Gerard J. Gormley3, Lynn V. Monrouxe4

Running head: Patients’ and Carers’ experiences and expectations

Affiliations:

1. Salisbury District Hospital, Salisbury, United Kingdom.

2. Monash Centre for Scholarship in Health Education (MCSHE), Faculty of Medicine,

Nursing & Health Sciences, Monash University, Melbourne, Victoria, Australia.

3. Centre for Medical Education, Queen’s University Belfast, Belfast, Northern Ireland,

United Kingdom.

4. Chang Gung Medical Education Research Centre (CG-MERC), Linkou, Taiwan.

Contact details for corresponding author:

Lynn Monrouxe

Chang Gung Medical Education Research Centre, Chang Gung Memorial Hospital,

Guishan District, Taoyuan City, Taiwan.

Telephone: +886975367748

Email: [email protected]

Word count, excluding title page, abstract, references, figures and tables: 7,251

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Keywords

Medical Education, Junior Doctor, Patients, Caregivers, Communication

Funding Statement

The study was funded by the General Medical Council, who were kept informed of

progress with the collection, analysis, and interpretation of data but the researchers

remained independent from the funders. The GMC have given their approval for

submission of this publication.

Competing Interests Statement

We have read and understood BMJ policy on declaration of interests and declare that

we have no competing interests.

Data Sharing Statement

No additional unpublished data are available outside the research team.

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Abstract

Objectives: For many years now, the voice of patients has been understood as being a

critical element for the improvement of care quality in healthcare settings. How well

medical graduates are prepared for clinical practice is an important question, but one

that has rarely been considered from patient and public perspectives. We aimed to fill

this gap by exploring patients’ and carers’ experiences and expectations of junior

doctors.

Design: A qualitative narrative methodology comprising four individual and six group

interviews.

Participants: 25 patients and carers from three UK countries

Analysis: Data were transcribed, anonymised and analysed using framework analysis.

Main results: We identified three themes most pertinent to answering our research

question: (1) Source of knowledge; (2) Desires for student/trainee learning; and (3)

Future doctors. We also highlight metaphoric talk and humour, where relevant, in the

quotes presented as these give a deeper insight into participants’ perspectives of the

issues. Participants focused on personal and interpersonal aspects of being a doctor,

such as respect and communication. There was a strong assertion that medical

graduates needed to gain direct experience with a diverse range of patients to

encourage individualised care. Participants narrated their experiences of having

symptoms ignored and attributed to an existing diagnosis (known as ‘diagnostic

overshadowing’) and problems relating to confidentiality.

Conclusions: Our findings support the view that patients and carers have clear

expectations about junior doctors, and that patient views are important for preparing

junior doctors for practice. There is a necessity for greater dialogue between patients,

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doctors and educators to bring clarity to the expectations and confidentiality issues

around patient care.

Article Summary

Strengths and limitations of this study

1. With a plethora of research on medical students’ and doctors’ opinions, our

study uniquely gives voice to patients and carers about their views of medical training

in the UK

2. This is a multi-site study with patients representing three UK countries

3. Participants focused on issues of respect, communication and the need for

doctors to be trained for a diverse patient cohort

4. Participants were mainly part of support groups and charities and thus might be

more politicized than the general public

5. The majority of participants were female and/or mature so the views of younger

patient groups are not as well represented

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Introduction

Medical education aims to prepare graduates to work as safe, compassionate and

competent doctors.[1-3] Globally, medical education is changing in response to an

ageing population, increasing numbers of people living with chronic multiple

comorbidities, greater emphasis on cost-effectiveness, and rising public and patient

expectations.[4-8] The term ‘junior doctor’ is often used to describe doctors across a

variety of levels, but here we refer to those in their first two years of work following

graduation. Concerns have been raised that medical graduates are not fully prepared to

begin their roles as junior doctors, falling short of wider public expectations. For

example, issues regarding patient safety and effectiveness of care when medical

graduates begin work, which is exacerbated by other doctors rotating to new posts

simultaneously. This is known as ‘the August changeover’ and ‘July phenomenon’ in the

UK and United States respectively.[9, 10] Such fears are communicated to the public via

the media, with reports of increased death rates and pleas for junior doctors to work

within their limits.[11-13]

Similarly, there have been concerns relating to the lack of support for junior

doctors, especially whilst working on call.[14, 15] Healthcare-related television

programmes are popular with the general public, and it has been suggested that this

may be contributing to the rise in complaints from patients about doctors.[16] The role

of junior doctors in recent National Health Service (NHS) scandals has also been

highlighted.[17] More recently, junior doctors in the UK have received both positive and

negative press through discussions regarding the imposition of new contracts, and

subsequent industrial action (i.e. strikes) taken by them.[18-20] Such media coverage

and governmental reports influence public perceptions of the healthcare system,

including the important roles of junior doctors.

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As a response to fears that medical graduates might be unprepared, a range of

stakeholders’ views have been sought on the topic of graduates’ preparedness for work,

including that of junior doctors, supervisors, educators, other healthcare professionals,

employees and policy makers.[1, 21-25] In the largest UK study to date on the topic,

with over 11,000 participants, a third of junior doctors disagreed that their medical

school had prepared them well for practice.[26] In a more recent NHS national training

survey, 70% of junior doctors reported feeling “adequately prepared” for their first

foundation programme posts.[27] Specific clinical tasks have been identified for which

junior doctors overall feel well prepared (e.g. history taking and clinical examinations)

or underprepared (e.g. prescribing and emergency care.[28-32] Similar findings on

preparedness are mirrored internationally,[3, 33] as well as additional aspects such as

holistic and empathic patient care.[34-36]

Though it is recognised that patients should be involved in medical education

and research[2, 37], they are rarely consulted on such matters. Indeed, a recent rapid

review of the literature from 2009-2014 on UK graduates’ preparedness for practice

only identified one (of 87) manuscripts with patients as participants.[38] This was in

the setting of patient safety teaching across multiple healthcare education curricula, and

the results from the patient group are largely amalgamated with the other stakeholders’

data.[39] Thus, while a range of stakeholders have been consulted previously, patients

are rarely asked, with the majority of research comprising self-reported data on

preparedness confidence. This paper therefore aims to address critical current gaps in

the literature by giving voice to patients and carers regarding their views of medical

training. In doing so, we propose to answer the research question: What are patients’

and carers’ experiences and expectations of junior doctors?

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Method

Design

We followed a qualitative narrative interview design to explore the experiences of

patients, their representatives, and carers, across three UK countries: Wales, England

and Scotland. We used purposive sampling to identify appropriate participants. Data

were collected as part of a wider study commissioned to inform the development of the

General Medical Council (GMC)’s document Tomorrow’s Doctors.[24, 40] This included

narrative interviews with a variety of stakeholder groups: junior doctors, clinical

supervisors, other healthcare practitioners, undergraduate and postgraduate deans,

patients and carers, government officials and policy makers; along with a longitudinal

audio-diary study with junior doctors (total n=185:[24]). A narrative approach allowed

us to explore participants’ perceptions of preparedness, and focusing on their own lived

experiences rather than general attitudes and beliefs.[41]

Narrative theory proposes that people share ‘stories’ as a way of making sense of

events that occur and of the world around them, within a specific social and cultural

context.[42] Narratives come in a range of forms. Although not all aspects are present,

and the order is often recursive, narratives comprise stories of events that have

occurred in the narrator’s past, often with an opening abstract (summarising the event

in a few words), followed by an orientation (who was present, where the event

occurred), then the sequence of events (the turning point, the ‘problem’, from the

narrators’ perspective), then resolution and an evaluation of the event.[43] Narratives

can also come in the form of ‘small stories’ – in the form of narrative-as-talk-in-

interaction.[44, 45] These can be seen as comprising narrative activities that include

stories of on-going, future or hypothetical events (so, not restricted to past events),

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shared (and therefore known) events, along with allusions to (previous) stories of

events and deferrals/refusals to tell the story. These have been referred to as fleeting

moments comprising a narrative orientation to the world,[46] occurring within

conversations between people who have a shared history (including a shared culture).

Analysis of narrative data allows insights to be gained into individuals’ experiences of

events,[47] alongside their orientations to specific aspects of the world. Narrative

theory and analysis can therefore enable us to explore patients’ and carers’ experiences

and expectations of junior doctors, and the ways in which their views are formed.

We arranged focus groups wherever possible to enable comparisons to be made

between different participants’ points of view and to understand how meanings are

constructed within the group.[48] Where participants volunteered alone, an interview

was conducted. Crystallization of data by combining focus groups and interviews

allowed greater depth of inquiry and thus a more comprehensive and deeper

understanding of participants’ views.[49]

We developed an interview guide from questions set for the wider study and also

based on the feedback from an initial pilot interview with a patient involvement

representative (see Acknowledgements). Although we encouraged participants to recall

first-hand experiences with junior doctors, participants also recalled stories of

preparedness that were not directly experienced by the narrator, or experiences with

the wider healthcare system. In addition to narratives of events, participants also

revealed their attitudes towards junior doctors’ preparedness through evaluative

comments (not specifically linked to any single event). We report our analysis of data

from patient representatives separately from other stakeholder groups due to the

different (albeit slightly overlapping) set of analytical themes.[24]

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Recruitment

A purposive sampling approach was used. Following university, medical school and/or

health board ethical approval across all sites involved in the wider study, we

approached patient representatives from a variety of different backgrounds.[50] We

took particular care to involve patient representatives who reflected the changing

demographics of our ageing population and increased numbers living with chronic

disease. There were no specific selection criteria, as we wanted all members who felt

they could speak on behalf of patients about their views and experiences of junior

doctors to come forward. Patients were not recruited directly from hospitals in which

junior doctors worked, firstly for ethical reasons and secondly because we wanted

patients with stable conditions. Thus, we approached patient support groups and

charities, encouraging participants to come forward to contribute to the study as part of

a group. We also recruited a number of patients who were also involved in medical

students’ learning, during which time they acted as simulated patients (i.e. as actors for

students to practice communication and clinical skills).

Participants

We conducted ten interviews (four individual and six group) with patient

representatives (n=25) across three of the four UK country sites, comprising 9 hours

and 58 minutes of data (see Table 1 for demographic details). The main medical

conditions represented were dementia, chronic respiratory diseases and learning

disabilities. All participants, including the simulated patients (n=2), spoke to us from the

perspective of their roles as being patients and carers themselves. Of participants who

identified themselves as carers (n=9), a number also spoke of their own experiences as

patients. Some participants had backgrounds in the healthcare professions, though all

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were retired (including four nurses, a paramedic, a social worker, an occupational

psychologist and an occupational health advisor).

Data Collection

The researchers came together for a 2-day orientation and team-building exercise

during which time they practised their narrative interviewing skills under the direction

of LVM. Three researchers (CK, NK & JC; KK supported KC during initial interviews, see

Acknowledgements) then conducted the interviews in their own country location using

the same interview guide, following a semi-structured narrative approach. Most of the

interviews took place at the support groups’ usual meeting places or offices, hoping that

the familiar environment would encourage participants to share their experiences.[51]

Groups were kept relatively small (n=2-6) for practical reasons, and also for intimacy.

At the start of the interview we introduced the project and confirmed all participants

understood how medical graduates are currently trained, ensuring they were familiar

with the term ‘junior doctor’. Interviews explored participants’ understanding of the

concept of ‘preparedness for practice’ and their personal experiences relating to this

concept (e.g. when starting a new job themselves). Participants were invited to share

their experiences of junior doctors, and were prompted to expand on how prepared

junior doctors were in each instance. Finally, we asked participants to comment on how

prepared for practice they felt that junior doctors were overall.[24] All interviews were

audio-recorded, transcribed verbatim and anonymised using pseudonyms for all

participants except one carer, who explicitly asked that she and her husband be named

(see Acknowledgements).

Data Analysis

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Using Ritchie & Spencer’s (1994)[52] five-step Framework Analysis (involving data

familiarisation, thematic framework identification, indexing, charting, mapping and

interpretation), ten researchers from four UK countries involved in the wider study met

over two days. Following familiarisation with the data from all stakeholders, a thematic

framework for the wider study was developed both deductively (using outcomes for

graduates from Tomorrow’s Doctors: GMC 2015 and inductively from the data). As data

from patient representatives were less clinically focused than other groups, further

development of the thematic analysis for this data was undertaken by LVM, KK and CK

to capture the range of themes. CK indexed and charted the data using ATLAS.ti with

cross-checking by the wider team. We established credibility and confirmability by

describing our analytic methods, involving multiple data analysts and using illustrative

quotes. Transferability was established through our inclusion of a diverse group of

patients and carers from three UK countries.[53]

Results

Through thematic framework analysis of the data from patient representatives we

identified nine themes in total, of which there were seven content-related themes (i.e.

what people said) and two process-related themes (i.e. how they said it): In this paper

we concentrate on the three themes (summarized in table 2) that were most pertinent

to answering our research question: (1) Source of knowledge (to contextualise the

data); (2) Desires for student/trainee learning (experiences and expectations of medical

training); and (3) Future doctors (experiences and expectations of junior doctors). We

also draw the reader’s attention to metaphoric talk and humour where relevant in the

quotes presented. The themes discussed in this paper go beyond the main themes

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discussed by Monrouxe and colleagues, which concentrated mainly on junior doctors’

preparedness in relation to the outcomes listed in Tomorrow’s Doctors.[24, 40]

Few differences were identified in the data regarding different patient groups.

Carers were more likely to talk about certain difficulties, for example, communication

barriers related to confidentiality and the issue of diagnostic overshadowing (i.e.

dismissing underlying ‘other’ symptoms as part of an existing diagnosis). Although

some of our patients and carers had previously worked within the health system (as

mentioned above), it was difficult to ascertain whether or not this produced differences

in the data.

Remarks on how to interpret the transcription notations in the quotes that

follow include: Bold was used to emphasize content (added by authors); Underline for

accentuated speech; ‘-’ for sudden break in speech; [ ] for additional information to add

contextual clarity; ( ) for information anonymised, e.g. (name of hospital) and (( )) for

additional information regarding non-verbal language, e.g. ((laughter)).

Theme 1: Source of knowledge

This theme is concerned with how the various sources of information contributing to

patients’ and carers’ perceptions of junior doctors’ preparedness for practice appeared

to impact on their expectations of them. The data coded to this theme includes (1.1)

patients’ first-hand narratives of personal experiences with junior doctors and the

wider healthcare system; (1.2) their ‘second-hand’ narratives of experiences from

friends and family members, and (1.3) patients’ personal views of junior doctors as

influenced by popular culture and the media (often narrated as impersonal “they”).

1.1. First-hand narratives: ‘It happened to me…’: Patients’ first-hand narratives

included communication problems such as being spoken about rather than with (as a

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patient) and lack of support and involvement (as a carer). Despite this, these first-hand

narratives were generally more positive in comparison with their second-hand

narratives of others’ experiences and media-influenced personal views. For example,

participants’ positive experiences regarding the care received by junior doctors were

sometimes framed in contrast to the behaviour displayed by seniors:

“On one occasion we had to go to A&E when my husband was quite ill. He has heart

failure but he has other problems as well. Now, as we went in the doctor

[consultant] said straight away, “Now do you want to be resuscitated?” The other

thing, I think he’d had a really bad day this doctor; he turned around and said to my

husband, “You know you’re taking up a bed, and somebody might be really ill and they

might need it more than you?” And this is actual fact. It’s actually what he said. And

yet, one of the junior doctors came up to us and she said, “Don’t worry about

that, we’re not sending him home”.” (Shirley, Focus Group 6, Site 1).1

1.2. Second-hand narratives: ‘It happened to them…’: Participants’ narratives tended

to be more negative when sourced from second-hand knowledge (i.e. the experience of

a friend, family member or colleague) and focussed on problematic role models from

which junior doctors were learning:

John: I was speaking to somebody else about the culture in organizations. Within

hospitals you have subcultures, and some wards can be very good, and it depends

on whose running them, you know, do they listen to patients or whatever.

Liz: Yeah, yeah. In a certain hospital, there are two wards. You go into the one ward

and everything is fine. You go into the other ward and it’s terrible. But it does go

down to who is in charge and what specialists are on that ward. But if that’s your

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first ward as a junior doctor that is what you’ll learn. And if it’s the bad ward,

you’re learning the bad practice.

John: Yes, definitely.

Liz: It’s terrible really.

(John and Liz, Focus Group 2, Site 1).

1.3. Knowledge from the media: ‘Did you see the news?’: Participants also tended to be

more negative when influenced by the popular press, constructing future hypothetical

conversational narratives as they oriented to the world through sensationalised media

reports. For example, participants in one focus group joked about the dangers of going

into hospital in August during graduates’ first days of work, evidently based upon

information sourced from the media: “they do say”:

Liz: They [the media] do say, “Don't go into hospital in August because you’ll die”

John: That’s right, don’t.

Liz: No, they do say that.

((General laughter))

Stephanie: Or at the weekends.

Liz: You know, it’s quite frightening. Don’t get ill. Feed yourself in the house like,

you know, but don’t go into hospital.

(Liz, John and Stephanie from Focus group 2, Site 1).

In contrast, participants constructed positive images of junior doctors when they talked

about watching television programmes, leading to them developing a compassionate,

understanding and sympathetic notion of junior doctors in comparison to those from

previous generations:

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Holly: I think the students- doctors today- I think they’ve got a bit more-

understanding than the older doctors, you know, they do ask. With older doctors,

I suppose it's the way they were trained, I don't know, but the students I think have

more care-

William: Sympathetic.

Holly: -I've been watching them doctors on the telly.

Tom: Compassion.

Megan: Eager to please.

(Holly, William, Tom and Megan from Focus Group 5, Site 1)

Theme 2: Desires for student/trainee learning and support

This theme concerns patient representatives’ perceptions of the aspects of

student/trainee learning that they highlight as being important. These comprise (2.1)

experiences across patient diversity (including various diseases, ages, socioeconomic

and cultural backgrounds); (2.2) experiences across a broad range of clinical specialties;

(2.3) lifelong development of knowledge and skills; (2.4) in-depth clinical reasoning (i.e.

not limiting conclusions to a single diagnosis, and not letting an existing diagnosis

overshadow new comorbidities); and (2.5) the need for academic, clinical and pastoral

support.

2.1 Patient diversity: Patients and carers expected junior doctors to be trained across

a diverse range of patients, preparing them to be responsive to the needs of the

population. Patient representatives thought that trainees should gain direct experience

caring for patients from various socioeconomic and cultural backgrounds, learning to

consider how such backgrounds affect disease presentation and patients’ abilities to

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cope. Seeing patients in their own environments, whether at home or in community

care, was suggested as a way to expose students to this. One participant illustrates this

in his narrative by using metaphoric talk, which along with his use of “they” for junior

doctors reveals how he sees the doctor-patient relationship as somewhat adversarial:

“They’d have a better idea if they saw what life is like on the other side of

the fence.” (Tom, Focus Group 5, Site 1).

Additionally, participants thought that junior doctors needed to learn how to care for

vulnerable groups, such as those with learning disabilities or mental health problems,

understanding their specific health and social care needs. Beyond this, participants

explained that doctors’ individual attributes affected their abilities to care for diverse

patients, suggesting that some of these skills could not be taught. One carer illustrated

this point when narrating a series of events around his mother’s carers in a nursing

home. He talked about how qualities such as understanding and empathy are innate,

although he also employed a powerful metaphor of education as a journey (“going down

a road”), to illustrate that some of these things could be developed:

“We’re [patients and doctors] not all equal. So the people [doctors] who are

successful with patients at risk or more demanding patients, that’s a special kind of

person and although it’s possible to train individual doctors to become more

understanding, unless they’ve really got it within them, I think they’re only going to

go so far down that road of having full understanding, full empathy, full

willingness to spend time- I’ve seen some care staff dealing with my mother who

was very aged and in a care home. Some care staff were exceptionally good, and

other staff were OK. And I put that down not to their training, not to their age, not to

their experience, but to themselves. They just have a better understanding, a better

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willingness, a better desire to undertake that kind of work. And some doctors will fit

that bill but not all.” (Jack, Interview 1, Site 2)

2.2. Broad training base: Patient representatives also felt that students must be taught

broadly about all medical specialties, regardless of their future career plans. For

example, Harry narrated the hypothetical thoughts[54] of a medical student that he

considered appropriate for approaching their learning:

Harry: Well I think any student going into medicine at the moment has got to

look at the broader spectrum, and once they've got an idea of everything that's

going on, then they can decide in their mind, “This is the way I want to go, or that's

the way I want to go”.

Nick: Yeah.

Harry: It's the benefit obviously of going into the general practices and following

your consultants around and everything else. It's the correct and right way to do it.

(Harry and Nick, Focus Group 5, Site 1)

2.3. Lifelong development: Participants also highlighted that all doctors should

continue to develop their knowledge and skills throughout their careers, not just in

terms of technical clinical knowledge, but also by growing as a person.

2.4. In-depth clinical reasoning: A number of patient representatives described the

issue of, what one participant referred to directly as: “diagnostic overshadowing”

(Elaine, Focus Group 3, Site 1). Diagnostic overshadowing occurs when once a main

diagnosis is made, all other symptoms and issues are associated with that diagnosis,

thereby overlooking co-existing conditions. Another participant expressed the need for

junior doctors to learn how to listen to carers as a way of preventing such diagnostic

overshadowing as she narrated an event involving her husband and the physical pain he

was experiencing. In doing so, she revealed two different, but both oppositional, ways

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in which she understood the doctor-patient relationship: as a game (“playing the

system”) and as war (“fighting your corner”):

“I think too often people are dismissed with one diagnosis, when in fact they’ve got

an underlying urinary tract infection, or chest infection, or a pain, which they can’t

express anyway. But we know, as their loved ones and their next of kin living with

them 24/7, that he is in pain somewhere. And I think that’s probably one of the

biggest frustrations that I found. And because I know how to play the system, we

got a lot quicker response than many of the thousands of carers out there that don’t

know how to do it. And that makes me angry, but you’re going to fight your corner

first and foremost. It’s just those sorts of things that make caring so impossible, or

so very challenging- so very difficult, and why people collapse under the strain”

(Rosie, Focus Group 6, Site 1).

Additionally, carers narrated events suggesting that once a simple diagnosis has been

reached, how doctors can be reluctant to look for additional complexities:

“Yeah, you know when you said about the junior doctor- I'm talking about in the

hospital setting when my children finally got to (name of hospital) and we all had to

say what- and the junior doctor was taking notes, and so on… and I just feel that

they've got somewhere there’s an algorithm which they say, “Yeah, yeah, yeah,

yeah, diagnosis. Full-stop. Don't want to know anymore”.” (Kate, Focus Group 6,

Site 1).

2.5. The need for support: Finally, participants narrated events that made them

conclude that junior doctors needed support: both clinical support on busy wards, as

well as pastoral support. It was identified that support from peers and from seniors may

both be important in different ways. For example, Liz narrated her in-depth knowledge

of junior doctors’ experiences when she told the group about how little she had

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experienced junior doctors being supported during ward rounds. Interestingly, she

demonstrated her empathy with the junior doctors and narrated a future hypothetical

event, based on past experiences, by placing herself in the role of the junior doctor:

Stephanie: I think junior doctors need support beyond the firm they’re working

with.

Liz: Because it must get frustrating. I mean if you go around the ward and you count

to twenty and they’re [patients] all awkward.

Stephanie: ((laughter))

Liz: At the end of the ward you think, “Ah I’m going to kill them all.”

Stephanie: But you can’t say that to your consultant. Whereas if you had a little

group where you could go to where it was acceptable to say that and have a

laugh about it that would make a lot of difference. But also you need superiority

in there to give you permission, to feel that, you know.

(Stephanie and Liz, Focus Group 2, Site 1)

Theme 3: Future doctors

This theme concerns the key skills and qualities that patient representatives desired

from future doctors, and included: (3.1) Patient-centred communication; and (3.2)

Greater respect (i.e. listening to patients and carers, treating them as individuals and

addressing their needs and concerns).

3.1. Patient-centred communication: Participants narrated situations in which they

felt disempowered and vulnerable when entering hospital. Ultimately, they felt that

junior doctors should be well prepared to communicate effectively with patients on all

levels: rapport building with patients who are often nervous in the clinical setting,

treating them with respect, dignity and working in partnership with them. For example,

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Gavin shared his story about how he felt when he arrived at hospital leading him to

assert that all doctors should understand and react to patients’ vulnerabilities:

“… you come into a strange building, you’re sort of in a state of shock, you don’t

know the building, the professionals do, and there’s this, actual almost basic need to

be looked after in terms of, being welcome, being reassured. And I think as a

junior doctor, or any doctor, you should actually be aware of what their

immediate needs are, and get into a relationship.” (Gavin, Focus Group 1, Site 3).

Some participants narrated being more active as recipients of poor communication

practices by senior clinicians. For example, Suzan narrated an event in which she was

treated like an object by a senior doctor with a junior doctor and medical student

present, she talked about how she tried to redress the situation by speaking directly to

the medical student:

“There was no introduction to anybody. She just wafted into my room with two

other gentlemen. She [senior doctor] just said to them both [junior doctor and

medical student], “Have any of you looked at this scar?” And she just ripped the top of

a sixteen-inch piece of plaster off. She said, “Why has nobody examined this before?”

and she left it like that and walked out of the room. And I said to the year five

student, I said, “Can you just come back a minute? Please will you remember never

to treat patients, or junior doctors, like that?” It was appalling.” (Suzan, Focus

Group 1, Site 3)

Participants talked about the need for junior doctors to understand how and when to

involve carers in consultations, and to understand that issues such as confidentiality

should be addressed with both the patient and carer. Specifically, carers narrated

situations when they felt exasperated when information was denied. For example, using

more metaphoric talk for exclusion, Kate (Focus Group 6, Site 1) narrated how she felt

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she came “across a brick wall all the time” in her encounters with receptionists, nurses

and doctors. Appropriate carer involvement was associated with more positive

narratives of care from carers and patients. In addition, patient representatives

emphasised through their stories how it was essential for junior doctors to be prepared

to give full and clear information, empowering patients to be involved in making

decisions. Further, through their narratives participants emphasised the need for all

healthcare professionals to tailor their approach appropriately to individual patient

needs and capabilities. For example, Grace narrated a situation involving her sister who

was assisted in using her inhaler by a healthcare professional following a junior doctor’s

assumption that she understood their instructions. Grace sues sarcasm as the person

explaining clearly thought the task was simple and could not see that actually, for a

patient with Dementia, following those instructions was going to be very difficult:

“My sister has Alzheimer’s, I don’t think she would have the concept of “hold this

thing [Meter dosed inhaler], put the thing at the end, press it in, inhale it”. So she

[healthcare professional, not junior doctor] said, “Well, it’s very simple” [said

sarcastically].” (Grace, Focus Group 4, Site 1).

3.2. Greater respect: Patient representatives shared several narratives illustrating a

lack of respect towards vulnerable patients. The narratives portrayed unacceptable

care, causing high levels of stress for patients and carers. Concerns regarding

undignified care were expressed with regards to junior doctors, nurses and nursing

home staff. One carer narrated a future hypothetical situation in which she described

that she feared how hospital staff would treat their loved one more than the

consequences of her illness, dementia:

Grace: …It should not be like that. That I'm not fearing the illness [dementia] itself,

that I'm afraid of how she's going to be treated.

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Catherine: But she will have support.

Grace: Yes, and that's the big difference for me. I'm not frightened of the illness, I

can deal with that. We as a family can deal with it, we're all very close. But all of us

are terrified of how she's going to be treated.

(Catherine and Grace, Focus Group 4, Site 1).

Participants narrated the importance of respect and for newly qualified doctors to be

aware of this. They also spoke of the importance of senior doctors as role models for

developing respectful attitudes, emphasising how critical their input is, especially

within the first few months of junior doctors’ careers. For example, Liz drew on her

experience of the healthcare setting [using the term ‘the firm’, which no longer exists

now, instead of ‘the team’] as she narrated a generalised situation in which junior

doctors begin to learn how to become a doctor:

“…when you become a junior doctor, you work within one firm, and really your role

models are very limited. And you're attitudes will actually be formed by the

attitudes of those senior doctors. And I think during that year or first two years,

housemen [junior doctors] really need the opportunity to discuss what they're

learning, and what they're experiencing, with a wider group of people than the firm

they're working for, so that they can actually stand back from what's going on and

say, “Well you know, that's not quite so good, you don't need to do it that way”.

Because as I say, you're [junior doctor] the lost one. Because you're in the rough-

and-tumble and everything's new. You form your attitudes very early on really.” (Liz,

Focus Group 2, Site 1).

Finally, participants described how a lack of consideration for individual patient needs

could cause significant stress and emotional burden for patients and carers, as well as

for junior doctors and other professionals involved in their care. This is illustrated by a

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carer’s narrative, in which she describes an event when her husband broke the nose of a

junior doctor who ignored her advice regarding the best way to approach her husband:

“I can certainly share from a personal perspective, feeling a great deal of empathy

for the junior doctor, who obviously didn't have a clue what they were doing, as

didn't have any idea how to speak with my husband- did not say to me- this was in a

hospital setting, in an acute setting, when I had obviously said- he was in the earlier

stages of dementia looked a very fit healthy specimen, but I did kind of say I needed

to be with him whilst he was examined- that was all fine, but I did kind of say, “Can I

just advise you how to do this?” The answer basically was “no”, so I sat back and

thought, “Now, wait for it”. So, it was the same speak as you would speak to any

other adult, but no chance to assimilate, to even test to see if there was any

level of understanding. But I looked at my husband's eyes and thought, “There's a

belt coming, I can see it.” He was smiling. So with that, he broke the nose of- bang-

and I did say, “Actually, I did try and point out about his dignity da-dee-da-da-da”

because what he did, this guy, was go straight to my husband's stomach.”


Discussion

Patient representatives narrated their experiences of events involving junior doctors

and the wider healthcare system, alongside sharing conversational narratives

comprising hypothetical events based on past experiences, illustrating what they expect

of tomorrow’s doctors. Findings were similar across all patient groups, regardless of

their condition or background. Patients’ and carers’ narratives primarily focussed on

problematic events concerning personal and interpersonal skills. This contrasts with

existing preparedness for practice literature, which represents clinical perspectives and

focuses mainly on knowledge and practical clinical skills.[24, 38] In comparison to

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stakeholders from our wider study, patient representatives were the only group to

highlight the importance of including patients in their own care, which included helping

them to understand their conditions and make decisions regarding treatment options,

and acknowledging their important role.[24] Shared decision-making is known to

positively influence health outcomes, and good interpersonal skills and information

sharing enable patients’ preferences to guide care.[55] Despite this, patients and

relatives still expect guidance and involvement from doctors, especially in decisions

such as end-of-life care.[56]

Patient representatives in our study recognised that medical training is generally

of high quality, and proposed that junior doctors today are better prepared than

previously. However, they expressed some concern, particularly regarding junior

doctors’ communication skills and abilities to provide individualised patient care.

Instances relating to direct encounters with junior doctors were limited, and thus

narratives often were in the form of more conversational narrative activities comprising

stories of future or hypothetical events based on their prior experiences with healthcare

professionals and students at all levels – including senior doctors – alongside second-

hand narratives and stories from the popular press. Thus through a range of narrative

practices, participants highlighted the consequences of doctors’ ignorance towards the

needs of vulnerable patients, such as diagnostic overshadowing, which has been

discussed in previous literature.[27, 57] According to our participants, the

preparedness of medical graduates could be improved by their having: more experience

in the community and across patient diversity, greater emphasis on personal skills and

communication, and more realistic experiences of the responsibilities that they will

have as junior doctors. It is recognised that patient involvement in medical education

contributes to students’ development of a ‘patient-centred professional identity’.[58]

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Furthermore, it may increase students’ understanding of professionalism in terms of

appropriate communication skills, listening and empathy.[59, 60] Passi et al. add that

role modelling is an important contributor to professional development, and that senior

doctors’ personal qualities will influence trainees, as well as their clinical

competence.[61]

Our findings concur with current issues in healthcare provision and what is

already known about the relationship between medical education and patient

outcomes: life experience influences preparedness for practice;[1] communication skills

are a fundamental part of medical education;[62] understanding patients’ backgrounds

is important for patient-doctor relationships and health outcomes;[59, 63]

professionals have a lot to learn from patients and their families;[64] excluding patients

and carers can negatively affect patient outcomes;[65] and respect should be explicitly

taught to medical trainees.[66] Changes in medical education prompted by the evolving

needs of our society have encouraged a greater emphasis to be placed on patient

safety,[3] as well as recognising the importance of components such as role modelling,

respect and responsibility in the training of new doctors[67].

As supported by our findings, the popular press can significantly influence

patient and public perspectives, in particular they appeared to find their way into the

conversational narratives of our participants. Media coverage and governmental

reports therefore have the ability to undermine patients’ trust in doctors’ abilities to

care for vulnerable patient groups, as emphasised in the NHS Inquiry into Mid

Staffordshire,[17] and latterly reinforced in the recent Shape of Training Review in the

UK.[68] Such reports appear to contribute towards feelings of anxiety amongst patients

and the general public with regards to safe and effective health care delivery thereby

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feeding into societal master narratives. By contrast, longitudinal (and possibly

voyeuristic) insights into the lives of junior doctors as they progress through the highs

and lows of their training appears to provide a much needed humanistic antidote to

media and governmental reports.

Our paper adds new weight to existing evidence on preparedness for practice,

which has contributed to current medical education curricula. Patient representatives’

actual experiences of junior doctors’ preparedness for practice (rather than merely

their views on this) have been explored for the first time. Importantly, these first-hand

experiences and personal views of junior doctors were mainly positive, seeing them as

being better prepared in ‘human’ factors than previous generations. Participants felt

that doctors’ personal attributes were very important, and that in some cases no

amount of educational intervention would be able to change a person if they had the

wrong attributes for being a doctor. Despite their positivity, participants also shared

first-hand narratives of very poor communication from junior doctors and the

consequences that this can have.

A key take home message provided to us by patients and carers is that they feel a

separation between themselves and doctors and other healthcare professionals, for

example: “we’re not all equal” and “on the other side of the fence”. They narrated this as a

barrier to doctors being able to understand patients, and thus meet their individual

needs. It is not possible from our data to elicit the consequences that this may have, but

it does suggest we have some way to go in empowering patients to see themselves as

equal partners in healthcare provision.

Strengths and challenges

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There are several caveats to our study. Participants were mainly part of support groups

and charities and thus might be more politicized than the general public.[37] Almost a

quarter of our participants were ex-healthcare professionals, which is likely to have

affected their views as they drew on their own previous understandings and

experiences as professionals within the NHS. However, these candidates spoke to us in

the context of their current role as patients and/or carers, and it is possible that past

experiences contributed to their willingness to participate in the study. The majority of

participants were female, and due to our purposive sampling our groups poorly

represented younger patients. Therefore our findings need to be read with these issues

in mind, and they are unlikely to be transferable to all UK patients, especially younger

patients and their carers. Finally, although we draw the reader’s attention to important

features of language within the results section, it was not feasible to explore fully here

how participants narrated their experiences and the implications of the language used

in this study [69, 70]. Metaphors were used extensively within our data and resonated

with several categories previously identified by Rees et al.,[69] for example: hierarchy

(e.g. “you’re at the bottom of the heap”); machinery (e.g. “I’ve fixed that hip”); and war

(e.g. “I’ll fight my corner”). Likewise, humour was also used (e.g. “Make sure they’ve got

the right side for the heart, like”) as a method of building relationships and coping within

focus groups.[70]

Our findings also have strengths. Participants represent perspectives of patients

and carers from three sites across the UK, with a range of backgrounds and experiences

and so are likely to be reasonably representative of UK patients and carers with similar

demographic profiles. Qualitative ‘information power’ was applied to guide the size of

our sample[71]. Narrative interview methodology was used to collate participants’

views, encouraging personal incidents to be shared where possible. Focus groups

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enabled the additional narration of conversational narratives that highlighted

participants’ orientation to the world of healthcare and of how junior doctors should be

prepared for practice. Crystallization of data between focus groups and individual

interviews led to a broader and deeper understanding of the issues discussed,[49] with

themes within the data being consistent irrespective of whether the data was collected

using interview or focus group methods. Finally, the collaboration of numerous analysts

from different professional backgrounds (clinical and social sciences) encouraged

multiple ways of seeing the data, avoiding selectivity in our analysis.

Implications for educational practice and research

Despite our study limitations, our findings have a number of implications for

educational practice and further research. In terms of educational practice, patient

representatives had clear expectations of junior doctors and were passionate that their

voices be heard and considered in the shaping of medical education. The data therefore

highlight the necessity of patient involvement in medical education teaching: the views

and experiences of patients and the public are important in creating junior doctors who

will be adequately prepared to look after them. Indeed, participants provided us with

clear messages about what they expect from junior doctors, often presenting a different

picture to other “clinical” participants from the wider study, such as clinicians, other

healthcare professionals, educators and policy-makers.[24]

While patients and carers seemed confident that medical graduates had the

necessary knowledge and practical clinical skills for effective and safe patient care, they

demonstrated concerns about the extent to which junior doctors are prepared for the

personal and interpersonal skills essential for promoting individualised patient care

and shared decision-making. They emphasised the importance of communicating

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effectively with patients and carers, being attentive and respectful to individual needs,

and the value of experiencing a wide variety of patients and environments.

As a result, we suggest three things for medical education: greater clarity and

training is needed regarding the practicalities of sharing information with carers, there

should be more opportunities for students to experience first-hand the impact of illness

on patients and carers (for example, by attending patient support groups), and senior

clinicians should be encouraged to consider their responsibilities as role models and the

influence they have on the development of junior doctors’ personal and interpersonal

skills. In order for clinical practice to meet our public’s rising expectations for health

care delivery, greater involvement and empowerment of patients and carers is

advocated.

Finally, in terms of further research, we think more detailed analyses of the

needs and concerns of carers is needed, alongside further exploration of patients’ first-

hand experiences with junior doctors, and consideration of how patients and the public

form their views on healthcare, including the influence of the media. In addition, further

linguistic analyses would yield a greater understanding of patients’ perceptions of

newly qualified doctors and how those perceptions were formed.

Conclusions

This study explores how well junior doctors (i.e. medical graduates in their first two

years after graduation) are prepared for clinical practice, according to patients, their

representatives, and carers’ personal experiences and expectations. We decided to

collect their voices because the topic of graduates’ preparedness for work has been

mostly investigated in terms of medical knowledge and practical skills from the

perspectives of junior doctors and their supervisors, with little concern about patients’

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and carers’ views and evaluative comments of medical training. Our findings support

the view that patients and carers hold a set of clear expectations around junior doctors’

roles and practices, and that patients’ views are important for preparing junior doctors

for practice. Our findings highlight the necessity for greater dialogue between patients,

doctors and educators in order to bring clarity and alignment of the expectations and

confidentiality issues around patient care. This study adds evidence to existing research

on preparedness for practice, which have contributed to the development of current

medical educational curricula.

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TABLE 1: PARTICIPANT DEMOGRAPHICS FOR A QUALITATIVE NARRATIVE INTERVIEW STUDY OF

PATIENTS’ AND CARERS’ EXPERIENCES AND EXPECTATIONS OF JUNIOR DOCTORS

Characteristic Frequency

Age Range (years)

25-45 1

46-65 8

66-85 14

No information 2

Gender

Female 17

Male 8

Self-identified Nationality

British 12

English 2

Scottish 2

Welsh 8

No information 1

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TABLE 2: OUTLINE OF THE THREE STUDY THEMES

1. Source of knowledge: This theme aims to identify and contextualize patient

representatives’ experiences and personal views on junior doctors’ preparedness

for work. It includes:

1.1. Patient representatives’ first-hand experiences with junior doctors and the

healthcare system in general (’it happened to me’).

1.2. Patient representatives’ second-hand experiences (’it happened to them’).

1.3. Their views as influenced by media and popular culture.

2. Desires for student/trainee learning: This theme collects patient

representatives’ perceptions and expectations for junior doctors in terms of medical

training. It includes:

2.1 Patient diversity: Patients from different socioeconomic and cultural settings

will help junior doctors in their preparedness for practice. Junior doctors should

also work with vulnerable patients (e.g. patients with learning disabilities; mental

health issues) to practice innate human skills (i.e. respect, understanding, empathy).

2.2 Broad training base: Junior doctors should broaden their knowledge and

perspectives on more than one medical specialty.

2.3 Lifelong learning and development: They should constantly strive to develop

both professionally and personally.

2.4 In-depth clinical reasoning: They should shun “diagnostic overshadowing” (i.e.

avoiding or only reluctantly drawing conclusions on a disease and its symptoms that

move away from the original diagnosis).

2.5 The need for support: Junior doctors should be provided with both clinical and

pastoral support (including support from peers and seniors).

3. Future doctors: This topic deals with patient representatives’ expectations and

experiences for junior doctors as human beings. The theme comprises:

3.1 Patient-centered communication: Desired communication skills in junior

doctors include empathy, dignity and willingness to work with patients as partners.

3.2 Greater respect: Junior doctors (but also seniors, nurses and nursing staff)

should develop respectful attitudes toward patients. Lack of respect is a source of

stress and emotional burnout for both care providers and recipients.

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Author Contribution

LVM and CER contributed to the conception of the study; LVM, CER and GJG designed the work;

CEK contributed to the acquisition of the data; all authors contributed to the analysis and interpretation of data; CEK, CER and LVM drafted the manuscript, all authors revised the

manuscript critically for important intellectual content; All authors gave their final approval of

the version to be published; all authors agree to be accountable for all aspects of the manuscript

and will ensure that any questions relating to the accuracy or integrity of any part of the manuscript are appropriately investigated and resolved.

Acknowledgements

The authors wish to thank the wider research team for their involvement in the study design,

helping to secure funding, ethics approvals and analysis (Dr Karen Mattick and Professor Alison

Bullock) and the data collection (alongside Dr Camille Kostov were Dr Judith Cole, Dr Narcie

Kelly), with an additional thank you to Dr Kathrin Kaufhold who was involved in all of the above

and was an important source of support for the paper. They thank Dr Philip Bell, the Patient and

Public Representative (PPR) associated with the wider study for his assistance in developing

the interview protocol for the PPR groups. In addition, the authors thank Professor Alexander

Anstey for his comments and suggestions on an earlier draft of this paper. They thank all of the

participants for taking part in this research and sharing their narratives, with special thanks to Dr Rosie Tope (PhD), one of the carers who participated in the study and who explicitly asked

for her and her husband, Dr Roy Nolan, to be acknowledged.

Ethical Approval

Central University Research Ethics committee (CUREC) reference number 13/44.

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Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist

Developed from: Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research

(COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health

Care. 2007. Volume 19, Number 6: pp. 349 – 357

No. Item Guide questions/description Response / Reported on Page #

Domain 1: Research

team and reflexivity

Personal Characteristics

1. Interviewer/facilitator Which author/s conducted the

interview or focus group?

See ‘data collection’ in Methods (page 10)

Four researchers (CK [Author], GS, NK, JC, see

Acknowledgements)

2. Credentials What were the researcher’s

credentials? E.g. PhD, MD

Professor Lynn V. Monrouxe (LVM): PHD

Professor Charlotte Rees (CER): PHD

Dr Camille Kostov (CK): MBBCh

Dr Gerry Gormley: MBBCh

3. Occupation What was their occupation at the

time of the study?

See title page (page 1)

CK: Medical Student

LVM: Director of Medical Education Research,

Cardiff University School

CER: Director of the Centre for Medical

Education, University of Dundee

GG: Senior Lecturer in the Centre for Medical

Education, Queen’s University Belfast

4. Gender Was the researcher male or female? GG: Male

CK, CR, LVM: Female

5. Experience and

training

What experience or training did the

researcher have?

LVM and CER have vast experience of

conducting qualitative research and analysis

(over 15 years each).

GG has previous experience in qualitative

research and analysis.

CK received narrative interview and thematic

analysis training prior to conducting the

research and were supervised and supported

by LVM, CER and GG throughout the study.

Relationship with

participants

6. Relationship

established

Was a relationship established prior

to study commencement?

See ‘Design’ in Methods (page 6)

Participants were recruited through patient

groups and in collaboration with our patient

advisor, Mr Philip Bell. Researchers had no

relationship with participants prior to this

point.

7. Participant knowledge

of the interviewer

What did the participants know

about the researcher? e.g. personal

goals, reasons for doing the

research

See Data Collection section in Methods (page

7)

Participants were aware who the interviewers

were. Participants were informed of all

researchers that were part of the research

team and that would have access to the data

via information sheets.

8. Interviewer What characteristics were reported Information reported about interviewers

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characteristics about the inter viewer/facilitator?

e.g. Bias, assumptions, reasons and

interests in the research topic

included position during the study and

reasons for the study.

Domain 2: study design

Theoretical framework

9. Methodological

orientation and Theory

What methodological orientation

was stated to underpin the study?

e.g. grounded theory, discourse

analysis, ethnography,

phenomenology, content analysis

See ‘Design’ in Methods (pages 7-8).

We used a qualitative narrative interview

design, we explain the theory behind this.

Participant selection

10. Sampling How were participants selected?

e.g. purposive, convenience,

consecutive, snowball

See ‘recruitment’ in Methods (page 9).

Participants were self-selected using

purposive sampling. “We took particular care

to involve patient representatives who

reflected the changing demographics of our

ageing population and increased numbers

living with chronic disease”. All participation

was voluntary.

11. Method of approach How were participants approached?

e.g. face-to-face, telephone, mail,

email


“Patients were not recruited directly from

hospitals in which junior doctors worked,

firstly for ethical reasons and secondly

because we wanted patients with stable

conditions. Thus, we approached patient

support groups and charities, encouraging

participants to come forward to contribute to

the study as part of a group. We also recruited

a number of patients who were also involved

in medical students’ learning, during which

time they acted as simulated patients (i.e. as

actors for students to practice communication

and clinical skills).”

12. Sample size How many participants were in the

study?

See ‘Participants’ in Methods (page 9)

“We conducted ten interviews (four individual

and six group) with patient representatives

(n=25) across three of the four UK country

sites, comprising 9 hours and 58 minutes of

data (see Table 1 for demographic details).”

13. Non-participation How many people refused to

participate or dropped out?

Reasons?

Participation was voluntary and participants

were not considered to take part until they

participated in the interviews. No participants

withdrew from the study after participating in

interviews.

Setting

14. Setting of data

collection

Where was the data collected? e.g.

home, clinic, workplace

See ‘Data collection’ in Methods (page 10)

“Most of the interviews took place at the

support groups’ usual meeting places or

offices, hoping that the familiar environment

would encourage participants to share their

experiences.[51] Groups were kept relatively

small (n=2-6) for practical reasons, and also

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for intimacy.”

15. Presence of non-

participants

Was anyone else present besides

the participants and researchers?


The participants and one (or two) interviewers

were mainly present. One participant had her

carer with her, who remained silent during the

interview.

16. Description of

sample

What are the important

characteristics of the sample? e.g.

demographic data, date

See Table 1 (page 31)

The gender and age proportion of each

participant group has been reported.

Data collection

17. Interview guide Were questions, prompts, guides

provided by the authors? Was it

pilot tested?


Semi-structured narrative interviews were

conducted using a discussion guide as a

memory aid for interviewers. All interviews

were trained in narrative interviewing.

18. Repeat interviews Were repeat inter views carried

out? If yes, how many?

No repeat interviews were carried out with

the same participants.

19. Audio/visual

recording

Did the research use audio or visual

recording to collect the data?


With participants’ consent, all narrative

interviews were audio-recorded.

20. Field notes Were field notes made during

and/or after the inter view or focus

group?

None made. Although discussions with the

supervisory team occurred quickly following

the interviews by way of a researcher debrief.

21. Duration What was the duration of the

interviews or focus group?

Group interviews took between 1-1.5 hours

and individual interviews were between 30-60

minutes. We do not report this as we do not

consider this to be a measure of quality

(Varpio L, Ajjawi R, Monrouxe LV, O’Brien B,

Rees CE (2017) Shedding the cobra effect:

problematising thematic emergence,

triangulation, saturation and member

checking. Medical Education. 51(1)40-50.)

22. Data saturation Was data saturation discussed? We do not report this as we do not consider

this to appropriate for our research position






23. Transcripts returned Were transcripts returned to

participants for comment and/or

correction?

We do not report this as we do not consider







Domain 3: analysis and

findings

Data analysis

24. Number of data

coders

How many data coders coded the

data?

See ‘Data analysis’ in Methods (page 11)

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25. Description of the

coding tree

Did authors provide a description of

the coding tree?


26. Derivation of themes Were themes identified in advance

or derived from the data?


Themes were derived from the data by

framework analysis.

27. Software What software, if applicable, was

used to manage the data?


Data were coded using ATLAS-ti qualitative

analysis software.

28. Participant checking Did participants provide feedback

on the findings?








Reporting

29. Quotations

presented

Were participant quotations

presented to illustrate the

themes/findings? Was each

quotation identified? e.g.

participant number

Yes.

30. Data and findings

consistent

Was there consistency between the

data presented and the findings?

We have ensured consistency between the

data presented and the findings of the study

through thoroughly reviewing the manuscript.

31. Clarity of major

themes

Were major themes clearly

presented in the findings?

See ‘Results’ (page 11-23)

The results section is organized around the

major themes of the study, which are

described under specific headings.

32. Clarity of minor

themes

Is there a description of diverse

cases or discussion of minor

themes?


The results section includes discussion of both

major themes, minor themes and diverse

cases under relevant themes and sub-themes.

An attempt is made to give an idea of the

relative prominence of each sub-theme

described.

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Journal: BMJ Open

Manuscript ID bmjopen-2017-017738.R1


Date Submitted by the Author: 04-Aug-2017


Gormley, Gerard; Queens University Belfast, General Practice Monrouxe, Lynn V; Chang Gung Memorial Hospital Linkou Branch




Keywords: MEDICAL EDUCATION & TRAINING, MENTAL HEALTH, QUALITATIVE RESEARCH


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Affiliations:


2. Monash Centre for Scholarship in Health Education (MCSHE), Faculty of

Medicine, Nursing & Health Sciences, Monash University, Melbourne, Victoria,

Australia.

3. Centre for Medical Education, Queen’s University Belfast, Belfast, Northern

Ireland, United Kingdom.



Lynn Monrouxe



Telephone: +886975367748


Word count, excluding title page, abstract, references, figures and tables:

8,681

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Keywords


Funding Statement

The study was funded by the General Medical Council, who were kept informed

of progress with the collection, analysis, and interpretation of data but the

researchers remained independent from the funders. The GMC have given their

approval for the publication of this paper.


We have read and understood BMJ policy on declaration of interests and declare

that we have no competing interests.



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Abstract

Objectives: For many years, the voice of patients has been understood as a

critical element for the improvement of care quality in healthcare settings. How

well medical graduates are prepared for clinical practice is an important

question, but one that has rarely been considered from patient and public

perspectives. We aimed to fill this gap by exploring patients’ and carers’

experiences and expectations of junior doctors.

Design: This comprises part of a wider study on UK medical graduates’

preparedness for practice. A qualitative narrative methodology was used,

comprising four individual and six group interviews.


Analysis: Data were transcribed, anonymised and analysed using framework

analysis.

Main results: We identified three themes pertinent to answering our research

question: (1) Sources of knowledge (sources of information contributing to

patients’ and carers’ perceptions of junior doctors’ impacting on expectations);

(2) Desires for student/trainee learning (experiences and expectations of

medical training); and (3) Future doctors (experiences and expectations of

junior doctors). We also highlight metaphoric talk and humour, where relevant,

in the quotes presented to give deeper insights into participants’ perspectives of

the issues. Participants focused on personal and interpersonal aspects of being a

doctor, such as respect and communication. There was a strong assertion that

medical graduates needed to gain direct experience with a diverse range of

patients to encourage individualised care. Participants narrated their

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experiences of having symptoms ignored and attributed to an existing diagnosis

(‘diagnostic overshadowing’) and problems relating to confidentiality.


expectations about junior doctors, and that patient views are important for

preparing junior doctors for practice. There is a necessity for greater dialogue

between patients, doctors and educators to clarify expectations and

confidentiality issues around patient care.

Article Summary


1. With a plethora of research on medical students’ and doctors’ opinions,

our study uniquely gives voice to patients and carers about their views of

medical training in the UK




4. Participants were mainly part of support groups and charities and thus

might be more politicized than the general public

5. The majority of participants were female and/or mature so the views of

male and younger patient groups are not as well represented

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Introduction


competent doctors.[1-3] Globally, medical education is changing in response to

an ageing population, increasing numbers of people living with chronic multiple

comorbidities, greater emphasis on cost-effectiveness, and rising public and

patient expectations.[4-8] The term ‘junior doctor’ is often used to describe

doctors across a variety of levels, but here we refer to those in their first two

years of work following graduation. Concerns have been raised that medical

graduates are not fully prepared to begin their roles as junior doctors, falling

short of wider public expectations. For example, issues have been raised

regarding patient safety and effectiveness of care when medical graduates begin

work, which is exacerbated by other doctors rotating to new posts

simultaneously. This is known as ‘the August changeover’, ‘black Wednesday’

and the ‘July phenomenon’ in the UK and United States respectively.[9, 10] Such

fears are communicated to the public via the media, with reports of increased

death rates and pleas for junior doctors to work within their limits.[11-13]

Similarly, there have been concerns relating to the lack of support for

junior doctors, especially whilst working on call.[14, 15] Healthcare-related

television programmes are popular with the general public, and it has been

suggested that this may be contributing to the rise in complaints from patients

about doctors.[16-18] The role of junior doctors in recent National Health

Service (NHS) scandals has also been highlighted.[19] More recently, junior

doctors in the UK have received both positive and negative press through

discussions regarding the imposition of new contracts, and subsequent

industrial action (i.e. strikes) taken by them.[20-22] Such media coverage and

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governmental reports influence public perceptions of the healthcare system,


As a response to fears that medical graduates might be unprepared, a

range of stakeholders’ views have been sought on the topic of graduates’

preparedness for work, including that of junior doctors, supervisors, educators,

other healthcare professionals, employees and policy makers.[1, 23-27] In the

largest UK study to date on the topic, with over 11,000 participants, a third of

junior doctors disagreed that their medical school had prepared them well for

practice.[28] In a more recent national training survey, 70% of junior doctors

reported being “adequately prepared” for their first foundation programme

posts.[29] Specific clinical tasks have been identified for which junior doctors

overall report being well prepared (e.g. history taking and clinical examination)

or underprepared (e.g. prescribing of medicine and emergency care).[30-34]

Similar findings on preparedness are mirrored internationally,[3, 35] as well as

additional aspects such as holistic and empathic patient care.[36-38]

For many years now, since the physician-patient relationship has become

more of a partnership, patients have been valued in terms of their potential

contribution to the development of tomorrow’s doctors, including: medical

student selection, direct teaching and assessment, curriculum development and

quality assurance.[39, 40] Furthermore, patients’ experiences have been

conveyed to doctors and students both face-to-face and via valuable learning

resources (e.g. http://www.healthtalk.org and http://www.youthtalk.org.uk). But

despite the recognition that patients should be involved in medical education

and research,[2, 41] they are rarely consulted on matters such as medical

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graduates’ preparedness for practice. Indeed, a recent rapid review of the

literature from 2009-2014 on UK graduates’ preparedness for practice only

identified one (of 87) manuscripts with patients as participants.[42] The study

identified was in the setting of patient safety teaching across multiple healthcare

education curricula, and the results from the patient group are largely

amalgamated with the other stakeholders’ data.[43] Thus, while a range of

stakeholders have been consulted previously, patients are rarely asked, with the

majority of research comprising self-reported data on preparedness confidence.

This paper therefore aims to address critical current gaps in the literature by

giving voice to patients and carers regarding their views of medical training. In

doing so, we propose to answer the research question: What are patients’ and

carers’ experiences and expectations of junior doctors? Note that experiences

are occasions lived by our participants, whereas expectations are their opinions

that something might occur or a presumption that someone might behave in a

particular way. These two aspects can be related, for example, current

experiences of junior doctors might influence future expectations of junior

doctors and likewise, current expectations about junior doctors might affect

future experiences of junior doctors. However, there might also be a gap

between expectations and experiences, for example, a patient might expect a

junior doctor to lack communicative competence but then be pleasantly

surprised by the interpersonal skills of a junior doctor they experience (thus

their experience exceeds their expectation). Therefore, we draw both on patient

representatives’ experiences and expectations in the current paper.

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Method

Design

We followed a qualitative narrative interview design to explore patients’, their

representatives’ and carers’ experiences of junior doctors across three UK

countries: Wales, England and Scotland. We used purposive sampling to identify

appropriate participants. Data were collected as part of a wider UK study on

graduates’ preparedness for practice commissioned to inform the development

of the General Medical Council’s (GMC’s) outcomes for graduates document.[44]

This included narrative interviews with a variety of stakeholder groups: junior

doctors, clinical supervisors, other healthcare practitioners, undergraduate and

postgraduate deans, patients and carers, government officials and policy makers;

along with a longitudinal audio-diary (LAD) study with junior doctors (total

number of LAD entries=185:[26]). A narrative approach allowed us to explore

participants’ perceptions of preparedness, and focusing on their own lived


Narrative theory proposes that people share ‘stories’ as a way of making

sense of events that occur and of the world around them, within a specific social

and cultural context and as such are co-constructed within that cultural

context.[46] Narratives come in a range of forms. Although not all aspects are

present, and the order is often recursive, narratives comprise stories of events

that have occurred in the narrator’s past, often with an opening abstract

(summarising the event in a few words), followed by an orientation (who was

present, where the event occurred), then the sequence of events (the turning

point, the ‘problem’, from the narrators’ perspective), then the resolution and an

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evaluation of the event.[47] Narratives can also come in the form of ‘small

stories’ – in the form of narrative-as-talk-in-interaction.[48, 49] These can be

seen as comprising narrative activities that include stories of on-going, future or

hypothetical events (so, not restricted to past events), shared (and therefore

known) events, along with allusions to (previous) stories of events and

deferrals/refusals to tell the story. These have been referred to as fleeting


conversations between people who have a shared history (including a shared

culture). Analysis of narrative data allows insights to be gained into individuals’

experiences of events,[51] alongside their orientations to specific aspects of the

world. Narrative theory and analysis can therefore enable us to explore patients’

and carers’ experiences and expectations of junior doctors, and the ways in

which their views are formed.

We arranged focus groups wherever possible to enable comparisons to be

made between different participants’ points of view and to understand how

meanings are constructed within the group.[52] While we preferred to conduct

focus groups wherever possible because of the benefits of group interviews (e.g.

stimulation, snowballing, safety etc.), we also offered individual interviews to

those who preferred that method and for those participants who volunteered

alone (i.e. no one else from their location volunteered to participate).

Crystallization of data by combining focus groups and interviews allowed greater

depth of inquiry and thus a more comprehensive and deeper understanding of

participants’ views.[53]

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We developed an interview guide from questions set for the wider study

and also based on the feedback from an initial pilot interview with a patient

involvement representative (see Acknowledgements section). Although we

encouraged participants to recall first-hand experiences with junior doctors,

participants also recalled stories of preparedness that were not directly

experienced by the narrator, or experiences with the wider healthcare system. In

addition to narratives of events, participants also revealed their attitudes

towards and expectations of junior doctors’ preparedness through evaluative

comments (not specifically linked to any single event). Although we report our

analysis of data from patient representatives separately from other stakeholder

groups due to the different (albeit slightly overlapping) set of analytical themes,

we compare our patient-related findings with those of other stakeholders later in

our discussion.[26]

Recruitment

A purposive sampling approach was used. Following university, medical school

and/or health board ethical approval across all sites involved in the wider study,

we approached patient representatives from a variety of different

backgrounds.[54] We took particular care to involve patient representatives who

reflected the changing demographics of our ageing population and increased

numbers living with chronic disease. There were no specific selection criteria, as

we wanted all members who felt they could speak on behalf of patients about

their experiences and expectations of junior doctors to come forward. Only

patients with stable conditions (and their carers) were recruited to this study,

for two ethics-related reasons. Firstly, we thought that patients with stable

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conditions would be less vulnerable than those currently experiencing acute

phases illness and would therefore find interview participation less challenging

and arduous. Second, our University-based ethics approval was sufficient for

patients (and carers) recruited via non-clinical sites but was not sufficient for

patients with active illnesses recruited directly from hospitals where junior

doctors worked. Thus, we approached patient support groups and charities,

encouraging participants to come forward to contribute to the study as part of a

group. We also recruited a number of patients who were involved in medical

students’ learning, during which time they acted as simulated patients (i.e. as

actors for students to practice communication and clinical skills).[55]

Participants


representatives (n=25) across three of the four UK country sites, comprising 9

hours and 58 minutes of data (see Table 1 for demographic details). The main

medical conditions represented by participants were dementia, chronic

respiratory diseases and learning disabilities. All participants, including the

simulated patients (n=2), spoke to us from the perspective of their roles as

patients and carers. Of those who identified themselves as carers (n=9), a

number also spoke of their own experiences as patients. Some participants had

backgrounds in the healthcare professions, though all were retired (including

four nurses, a paramedic, a social worker, an occupational psychologist and an

occupational health advisor).

Data Collection

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The researchers came together for a 2-day orientation and team-building

exercise during which time they practised their narrative interviewing skills

under the direction of LVM. Three researchers (CK, NK & GS; KK supported CK

during initial interviews, see Acknowledgements) then conducted the interviews

in their own country location using the same interview guide, following a semi-

structured narrative approach. Most of the interviews took place at the support

groups’ usual meeting places or offices, hoping that the familiar environment

would encourage participants to share their experiences.[56] Groups were kept

relatively small (n=2-6) for practical reasons, and also for intimacy. At the start

of the interview we introduced the project and confirmed all participants

understood how medical graduates are currently trained, ensuring they were

familiar with the term ‘junior doctor’. Interviews explored participants’

understandings of the concept of ‘preparedness for practice’ and their personal

experiences relating to this concept (e.g. when starting a new job themselves).

Participants were invited to share their experiences of junior doctors, and were

prompted to expand on how prepared junior doctors were in each instance.

Finally, we asked participants to comment on how prepared for practice they felt

that junior doctors were overall.[26] All interviews were audio-recorded,

transcribed verbatim and anonymised using pseudonyms for all participants

except one carer, who explicitly asked that she and her husband be named (see

Acknowledgements).

Data Analysis

Using Ritchie & Spencer’s (1994)[57] five-step Framework Analysis (involving

data familiarisation, thematic framework identification, indexing, charting,

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mapping and interpretation), ten researchers from four UK countries involved in

the wider study met over two days. Following familiarisation with the data from

all stakeholders, a thematic framework for the wider study was developed both

deductively (using outcomes for graduates from Tomorrow’s Doctors: GMC

2009/2015 and inductively from the data).[44] As data from patient

representatives were less clinically focused than other groups and contained

fewer preparedness/unpreparedness judgements, further development of the

thematic analysis for this data was undertaken by LVM, KK and CK to capture the

range of themes. CK indexed and charted the data using ATLAS.ti with cross-

checking by the wider team. We established credibility and confirmability by

describing our analytic methods, involving multiple data analysts and using

illustrative quotes. Transferability was established through our inclusion of a

diverse group of patients and carers from three UK countries.[58]

Results

Through thematic framework analysis of the data from patient representatives

we identified nine themes in total, of which there were seven content-related

themes (i.e. what people said) and two process-related themes (i.e. how they said

it): In this paper we concentrate on the three themes (summarized in table 2)

that were most pertinent to answering our research question: (1) Sources of

knowledge (sources of information that contribute to patients’ and carers’

perceptions of junior doctors’ impacting on their expectations (2) Desires for

student/trainee learning (experiences and expectations of medical training); and

(3) Future doctors (experiences and expectations of junior doctors). We also

draw the reader’s attention to metaphoric talk and humour where relevant in

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the quotes presented. The themes discussed in this paper go beyond the main

themes discussed by earlier Monrouxe and colleagues, which concentrated

mainly on junior doctors’ preparedness in relation to the outcomes listed for

graduates.[44]

Few differences were identified in the data regarding different patient

groups. Carers were more likely to talk about certain difficulties, for example,

communication barriers related to confidentiality and the issue of diagnostic

overshadowing (i.e. dismissing underlying ‘other’ symptoms as part of an

existing diagnosis). Although some of our patients and carers had previously

worked within the health system (as mentioned above), it was not possible to

ascertain whether or not this produced differences in the data given our

qualitative approach.

We present our themes and sub-themes below with representative

excerpts from the data. These excerpts are reproduced within their interactional

context where appropriate (rather than cleaned up to look like solo narratives)

to enable the reader to see how they were co-constructed (as narrative activities)

within the social interaction of the group and individual interviews. Remarks on

how to interpret the transcription notations in the quotes that follow include:

Bold was used to emphasize content (added by authors); Underline for

accentuated speech; ‘-’ for sudden break in speech; [ ] for additional information

to add contextual clarity; ( ) for anonymised information e.g. (name of hospital)

and (( )) for additional information regarding non-verbal language e.g.

((laughter)).

Theme 1: Sources of knowledge

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This theme is concerned with how the various sources of information

contributing to patients’ and carers’ perceptions of junior doctors’ preparedness

for practice appeared to impact on their expectations of them. The data coded to

this theme includes (1.1) patients’ first-hand narratives of personal experiences

with junior doctors and the wider healthcare system; (1.2) their ‘second-hand’

narratives of experiences from friends and family members, and (1.3) patients’

personal views of junior doctors as influenced by popular culture and the media

(often narrated as impersonal “they”).

1.1. First-hand narratives: ‘It happened to me…’: Although patients’ first-hand

narratives included communication problems such as being spoken about rather

than with (as a patient) and lack of support and involvement (as a carer),

participants also narrated positive experiences regarding the care they received

by junior doctors, and this was sometimes framed in contrast to the behaviour

displayed by seniors:

“On one occasion we had to go to A&E when my husband was quite ill. He

has heart failure but he has other problems as well. Now, as we went in the

doctor [consultant] said straight away, “Now do you want to be

resuscitated?” The other thing, I think he’d had a really bad day this doctor;

he turned around and said to my husband, “You know you’re taking up a bed,

and somebody might be really ill and they might need it more than you?” And

this is actual fact. It’s actually what he said. And yet, one of the junior

doctors came up to us and she said, “Don’t worry about that, we’re not

sending him home”.” (Shirley, Focus Group 6, Site 1).1

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Interestingly, participants’ first-hand narratives were generally more

positive than second-hand narratives recounted of others’ experiences and

media-influenced personal views. Indeed, when drawing on these latter

two sources of knowledge the narratives were predominately negative, as

will be illustrated next.

1.2. Second-hand narratives: ‘It happened to them…’: Participants’ narratives

tended to be more negative when sourced from second-hand knowledge (i.e. the

experiences of friends, family members or colleagues) and focussed on

problematic role models from which junior doctors were learning:

John: I was speaking to somebody else about the culture in organizations.

Within hospitals you have subcultures, and some wards can be very good,

and it depends on whose running them, you know, do they listen to patients

or whatever.

Liz: Yeah, yeah. In a certain hospital, there are two wards. You go into the

one ward and everything is fine. You go into the other ward and it’s terrible.

But it does go down to who is in charge and what specialists are on that

ward. But if that’s your first ward as a junior doctor that is what you’ll

learn. And if it’s the bad ward, you’re learning the bad practice.




1.3. Knowledge from the media: ‘Did you see the news?’: Participants also

tended to be more negative when influenced by the popular press, constructing

future hypothetical conversational narratives as they oriented to the world

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through sensationalised media reports. For example, participants in one focus

group joked about the dangers of going into hospital in August during graduates’

first days of work, evidently based upon information sourced from the media:

Liz: They [the media] do say, “Don't go into hospital in August because

you’ll die”


Liz: No, they do say that ((General laughter))


Liz: You know, it’s quite frightening. Don’t get ill. Feed yourself in the

house like, you know, but don’t go into hospital.


In contrast, participants constructed positive images of junior doctors when they

talked about watching television programmes, leading to them developing a

compassionate, understanding and sympathetic notion of junior doctors in

comparison to those from previous generations:


understanding than the older doctors, you know, they do ask. With older

doctors, I suppose it's the way they were trained, I don't know, but the

students I think have more care-



Tom: Compassion.


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To summarise this theme ‘sources of knowledge’, patients and carers drew on

first-hand and second-hand experiences, plus their knowledge of the media

when articulating their perceptions of and expectations for junior doctors’

preparedness. While they experienced communication problems and a lack of

involvement first hand, they perceived junior doctors’ communication to be

superior to those of senior doctors, with their first-hand narratives being more

positive than second-hand ones. Indeed, second-hand narratives typically

problematized junior doctors’ senior role models, while media representations

gave patients’ and carers’ mixed views of junior doctors’ preparedness, ranging

from print media fear-mongering about general junior doctor incompetence to

more positive personalized and human representations of junior doctors in TV

documentaries. Such patient and carer perceptions based on these sources of

knowledge and intertwined with their perceptions about student/trainee

learning, which we discuss next.



student/trainee learning that they highlight as being important. These comprise

(2.1) experiences across patient diversity (including various diseases, ages,

socioeconomic and cultural backgrounds); (2.2) experiences across a broad

range of clinical specialties; (2.3) lifelong development of knowledge and skills;

(2.4) in-depth clinical reasoning (i.e. not limiting conclusions to a single

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diagnosis, and not letting an existing diagnosis overshadow new comorbidities);

and (2.5) the need for academic, clinical and pastoral support.

2.1 Patient diversity: Patients and carers expected junior doctors to be trained

across a diverse range of patients, preparing them to be responsive to the needs

of the population. Patient representatives thought that trainees should gain

direct experience caring for patients from various socioeconomic and cultural

backgrounds, learning to consider how such backgrounds affect disease

presentation and patients’ abilities to cope. Seeing patients in their own

environments, whether at home or in community settings, was suggested as a

way to expose students such diversity. One participant illustrates this in his

narrative by using metaphoric talk, which along with his use of “they” for junior

doctors reveals how he sees the doctor-patient relationship as somewhat

adversarial:

“… you know, GPs practice for a few months to see the type of patients that will

eventually end up in hospital, because… I think a lot of the junior doctors come

from middle class backgrounds therefore they might… not know what life is like

on the other side of the fence, you see in the poorer quarters, the estates or the

ghettos as they call them in America… and there are plenty in this country and in

[city]… if they went in a GP practice in certain areas and saw the people and how

they live perhaps they'd have a better idea…”

Tom, Focus Group 5, Site 1

Additionally, participants thought that junior doctors needed to learn how to

care for vulnerable groups, such as those with learning disabilities or mental

health problems, understanding their specific health and social care needs.

Beyond this, participants explained that doctors’ individual attributes affected

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their abilities to care for diverse patients, suggesting that some of these skills

could not be taught. One carer illustrated this point when narrating a series of

events around his mother’s carers in a nursing home. He talked about how

qualities such as understanding and empathy are innate, although he also

employed a powerful metaphor of education as a journey (“going down a road”),

to illustrate that some of these things could be developed:


successful with patients at risk or more demanding patients, that’s a special

kind of person and although it’s possible to train individual doctors to

become more understanding, unless they’ve really got it within them, I think

they’re only going to go so far down that road of having full understanding,

full empathy, full willingness to spend time- I’ve seen some care staff dealing

with my mother who was very aged and in a care home. Some care staff

were exceptionally good, and other staff were okay. And I put that down not

to their training, not to their age, not to their experience, but to themselves.

They just have a better understanding, a better willingness, a better desire

to undertake that kind of work. And some doctors will fit that bill but not

all.” (Jack, Interview 1, Site 2)

2.2. Broad training base: As well as diversity in patient background,

participants also thought students must be taught broadly about all conditions

and medical specialties, regardless of their future career plans. For example,

Harry narrated the hypothetical thoughts[59] of a medical student that he

considered appropriate for approaching their learning:

Harry: Well I think any student going into medicine at the moment has

got to look at the broader spectrum, and once they've got an idea of

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everything that's going on, then they can decide in their mind, “This is the

way I want to go, or that's the way I want to go”.

Nick: Yeah.

Harry: It's the benefit obviously of going into the general practices and

following your consultants around and everything else. It's the correct and

right way to do it.



continue to develop their knowledge and skills throughout their careers, not just

in terms of technical clinical knowledge, but also by growing as a person

However, their own experiences of this were not always positive as the following

narrative suggests:

Jessie: when we are delivering the 15- 20 minute presentation to them, they're

not- sort of they are taking it on board- but then we've got to go back again,

but this time- cause they get passed- we've got to do it to the medical students

again- and to the nurses and doctors which are on the ward, ‘cause we deliver

um- this for the awareness training…to hospital staff, but at the moment- some

of them are taking it on board but the hierarchy people- the very hierarchy

people- the professional people are not…the doctors who are very high

up…’cause they're not taking no hand outs no nothing at all…

Danna: they didn't really take it that good did they?

Jessie: they didn't take it that good at all…that's the worst side we saw- so far

(Jessie and Danna, Focus Group 3, Site 2)

2.4. In-depth clinical reasoning: A number of patient representatives described

the issue of, what one participant referred to directly as: “diagnostic

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overshadowing” (Elaine, Focus Group 3, Site 1). Diagnostic overshadowing occurs

when once a main diagnosis is made, all other symptoms and issues are

associated with that diagnosis, thereby overlooking co-existing conditions.

Another participant expressed the need for junior doctors to learn how to listen

to carers as a way of preventing such diagnostic overshadowing as she narrated

an event involving her husband and the physical pain he was experiencing. In

doing so, she revealed two different, but both oppositional, ways in which she

understood the doctor-patient relationship: as a game (“playing the system”) and

as war (“fighting your corner”):

“I think too often people are dismissed with one diagnosis, when in fact

they’ve got an underlying urinary tract infection, or chest infection, or a

pain, which they can’t express anyway. But we know, as their loved ones

and their next of kin living with them 24/7, that he is in pain somewhere.

And I think that’s probably one of the biggest frustrations that I found. And

because I know how to play the system, we got a lot quicker response than

many of the thousands of carers out there that don’t know how to do it. And

that makes me angry, but you’re going to fight your corner first and

foremost. It’s just those sorts of things that make caring so impossible, or so

very challenging- so very difficult, and why people collapse under the

strain” (Rosie, Focus Group 6, Site 1).

Additionally, carers narrated events suggesting that once a simple diagnosis has

been reached, doctors can be reluctant to look for additional complexities:

“Yeah, you know when you said about the junior doctor- I'm talking about

in the hospital setting when my children finally got to (name of hospital)

and we all had to say what- and the junior doctor was taking notes, and so

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on… and I just feel that they've got somewhere there’s an algorithm which

they say, “Yeah, yeah, yeah, yeah, diagnosis. Full-stop. Don't want to

know anymore”.” (Kate, Focus Group 6, Site 1).


conclude that junior doctors needed support: both clinical support on busy

wards, as well as pastoral support. It was identified that support from peers and

from seniors may both be important in different ways. For example, Liz narrated

her in-depth knowledge of junior doctors’ experiences when she told the group

about how little she had experienced junior doctors being supported during ward

rounds. Interestingly, she demonstrated her empathy with the junior doctors and

narrated a future hypothetical event, based on past experiences, by placing

herself in the role of the junior doctor [note, Stephanie uses the term ‘the firm’,

which no longer exists now, instead of ‘the team’]:

Stephanie: I think junior doctors need support beyond the firm they’re

working with.

Liz: Because it must get frustrating. I mean if you go around the ward and

you count to twenty and they’re [patients] all awkward.



Stephanie: But you can’t say that to your consultant. Whereas if you had a

little group where you could go to where it was acceptable to say that

and have a laugh about it that would make a lot of difference. But also you

need superiority in there to give you permission, to feel that, you know.


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To summarise this theme ‘desires for student/trainee learning and

support’, patients and carers’ talked about their expectations for student

learning so that graduates were properly prepared for practice.

Participants had expectations that students were educated to work with

diverse patients and vulnerable groups, that they were taught about a

diverse range of conditions and specialties, that they were committed to

lifelong learning, that they had good clinical reasoning and were open to

involving patients and carers in clinical reasoning, and finally, that they

were well supported. Such participant desires for students learning and

support were related to the key capabilities they wanted from future

doctors, which we turn to next.


This theme concerns the key skills and qualities that patient representatives

desired from future doctors, and included: (3.1) Patient-centred communication;

and (3.2) Greater respect (i.e. listening to patients and carers, treating them as

individuals and addressing their needs and concerns).

3.1. Patient-centred communication: Participants narrated situations in which

they felt disempowered and vulnerable when entering hospital. Ultimately, they

felt that junior doctors should be well prepared to communicate effectively with

patients on all levels: rapport building with patients who are often nervous in the

clinical setting, treating them with respect, dignity and working in partnership

with them. For example, Gavin shared his story about how he felt when he

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arrived at hospital leading him to assert that all doctors should understand and

react to patients’ vulnerabilities:

“… you come into a strange building, you’re sort of in a state of shock, you

don’t know the building, the professionals do, and there’s this, actual almost

basic need to be looked after in terms of, being welcome, being reassured.

And I think as a junior doctor, or any doctor, you should actually be

aware of what their immediate needs are, and get into a relationship.”

(Gavin, Focus Group 1, Site 3).

Some participants narrated being more active as recipients of poor

communication practices by senior clinicians. For example, Suzanne narrated an

event in which a senior doctor treated her like an object, with a junior doctor and

medical student present. She talked about how she tried to redress the situation

by speaking directly to the medical student:

“There was no introduction to anybody. She just wafted into my room with

two other gentlemen. She [senior doctor] just said to them both [junior

doctor and medical student], “Have any of you looked at this scar?” And she

just ripped the top of a sixteen-inch piece of plaster off. She said, “Why has

nobody examined this before?” and she left it like that and walked out of the

room. And I said to the year five student, I said, “Can you just come back a

minute? Please will you remember never to treat patients, or junior

doctors, like that?” It was appalling.” (Suzanne, Focus Group 1, Site 3)

Participants talked about the need for junior doctors to understand how and

when to involve carers in consultations, and to understand that issues such as

confidentiality should be addressed with both the patient and carer. Specifically,

carers narrated situations when they felt exasperated when information was

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denied. For example, using more metaphoric talk for exclusion, Kate (Focus

Group 6, Site 1) narrated how she felt she came “across a brick wall all the time”

in her encounters with receptionists, nurses and doctors. Appropriate carer

involvement was associated with more positive narratives of care from carers

and patients. In addition, patient representatives emphasised through their

stories how it was essential for junior doctors to be prepared to give full and

clear information, empowering patients to be involved in making decisions.

Further, through their narratives participants emphasised the need for all

healthcare professionals to tailor their approach appropriately to individual

patient needs and capabilities. For example, Grace narrated a situation involving

her sister who was assisted in using her inhaler by a healthcare professional

following a junior doctor’s assumption that she understood their instructions.

Grace uses sarcasm as the person explaining clearly thought the task was simple

and could not see that actually, for a patient with Dementia, following those

instructions was going to be very difficult:

“My sister has Alzheimer’s, I don’t think she would have the concept of

“hold this thing [Meter dosed inhaler], put the thing at the end, press it in,

inhale it”. So she [healthcare professional, not junior doctor] said, “Well, it’s

very simple” [said sarcastically].” (Grace, Focus Group 4, Site 1).

3.2. Greater respect: Patient representatives shared several narratives

illustrating a lack of respect towards vulnerable patients. The narratives

portrayed unacceptable care, causing high levels of stress for patients and carers.

Concerns regarding undignified care were expressed with regards to junior

doctors, nurses and nursing home staff. One carer narrated a future hypothetical

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situation in which she described that she feared how hospital staff would treat

her loved one more than the consequences of her illness, dementia:

Grace: … It should not be like that. That I'm not fearing the illness

[dementia] itself, that I'm afraid of how she's going to be treated.


Grace: Yes, and that's the big difference for me. I'm not frightened of the

illness, I can deal with that. We as a family can deal with it, we're all very

close. But all of us are terrified of how she's going to be treated.


Participants narrated the importance of respect and for newly qualified doctors

to be aware of this. They also spoke of the importance of senior doctors as role

models for developing respectful attitudes, emphasising how critical their input

is, especially within the first few months of junior doctors’ careers. For example,

Liz drew on her experience of the healthcare setting as she narrated a

generalised situation in which junior doctors begin to learn how to become

doctors:

“… when you become a junior doctor, you work within one firm, and really

your role models are very limited. And your attitudes will actually be

formed by the attitudes of those senior doctors. And I think during that

year or first two years, housemen [junior doctors] really need the

opportunity to discuss what they're learning, and what they're experiencing,

with a wider group of people than the firm they're working for, so that they

can actually stand back from what's going on and say, “Well you know, that's

not quite so good, you don't need to do it that way”. Because as I say, you're

[junior doctor] the lost one. Because you're in the rough-and-tumble and

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everything's new. You form your attitudes very early on really.” (Liz, Focus

Group 2, Site 1).

Finally, participants described how a lack of consideration for individual patient

needs could cause significant stress and emotional burden for patients and

carers, as well as for junior doctors and other professionals involved in their

care. This is illustrated by a carer’s narrative, in which she describes an event

when her husband broke the nose of a junior doctor who ignored her advice

regarding the best way to approach her husband:

“I can certainly share from a personal perspective, feeling a great deal of

empathy for the junior doctor, who obviously didn't have a clue what they

were doing, as didn't have any idea how to speak with my husband- did not

say to me- this was in a hospital setting, in an acute setting, when I had

obviously said- he was in the earlier stages of dementia looked a very fit

healthy specimen, but I did kind of say I needed to be with him whilst he

was examined- that was all fine, but I did kind of say, “Can I just advise you

how to do this?” The answer basically was “no”, so I sat back and thought,

“Now, wait for it”. So, it was the same speak as you would speak to any other

adult, but no chance to assimilate, to even test to see if there was any

level of understanding. But I looked at my husband's eyes and thought,

“There's a belt coming, I can see it.” He was smiling. So with that, he broke

the nose of- bang- and I did say, “Actually, I did try and point out about his

dignity da-dee-da-da-da” because what he did, this guy, was go straight to

my husband's stomach.”


To summarise this theme ‘future doctors’, participants talked about the key

skills/qualities they wanted in their doctors specifically around patient-

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centred communication and respect. While they commonly narrated

patient experiences (themselves or their loved ones) of feeling vulnerable,

disempowered and disrespected in the healthcare setting, they instead

wanted effective communication, respect, dignity, partnership working,

clear information, empowerment and involvement, and they expected that

senior doctors should role model those behaviours to their junior

colleagues.

Discussion

We asked patient representatives to share narratives of their experiences of

junior doctors’ preparedness for practice. Participants narrated a range of events

involving junior doctors and the wider healthcare system, alongside sharing

conversational narratives comprising hypothetical events based on past

experiences, illustrating what they expect of tomorrow’s doctors. Findings were

similar across all patient groups, regardless of their conditions or educational

backgrounds. Patients’ and carers’ narratives primarily focussed on problematic

events rather than positive events, mainly concerning personal and

interpersonal skills. This contrasts with existing preparedness for practice

literature, which represents clinical perspectives and focuses mainly on

knowledge and practical clinical skills.[26, 42] In comparison to stakeholders

from our wider study, patient representatives were the only group to highlight

the importance of including patients in their own care, which included helping

them to understand their conditions and make decisions regarding treatment

options, and acknowledging their important role.[26] Shared decision-making is

known to positively influence health outcomes, and good interpersonal skills and

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information sharing enable patients’ preferences to guide care.[60] Despite this,

patients and relatives still expect guidance and involvement from doctors,

especially in decisions such as end-of-life care.[61]

Patient representatives in our study recognised that medical training is

generally of high quality, and proposed that junior doctors today are better

prepared than previously. However, they expressed some concern, particularly

regarding junior doctors’ communication skills and abilities to provide

individualised patient care. Instances relating to direct encounters with junior

doctors were limited, and thus narratives often were in the form of more

conversational narrative activities comprising stories of future or hypothetical

events based on their prior experiences with healthcare professionals and

students at all levels – including senior doctors – alongside second-hand

narratives and stories from the popular press. Thus through a range of narrative

practices, participants highlighted the consequences of doctors’ ignorance

towards the needs of vulnerable patients, such as diagnostic overshadowing,

which has been discussed in previous literature.[29, 62] According to our

participants, the preparedness of medical graduates could be improved by their

having: more experience in the community and across patient diversity, greater

emphasis on personal skills and communication, more realistic experiences of

the responsibilities that they will have as junior doctors and being exposed to

senior clinical role models displaying appropriate professional attitudes and

behaviours. As such, these aspects focus quite heavily on the issue of patient-

centred professionalism.[63] Indeed, current literature recognises the

importance of patient involvement in medical students’ development of their

‘patient-centred professional identity’.[64] Furthermore, it may increase

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students’ understanding of professionalism in terms of appropriate

communication skills, listening and empathy, all of which feature strongly as

aspects of patient-centred professionalism worldwide.[65, 66] Aligned with our

participants’ narratives, a number of researchers have highlighted the

importance of role modelling as a key aspect for medical students’ professional

development, stressing that senior doctors’ personal qualities will influence

trainees’ patient-centred professionalism development, as well as their clinical

competence.[67-70]

Our findings concur with current issues in healthcare provision and what

is already known about the relationship between medical education and patient

outcomes: life experience influences preparedness for practice;[1]

communication skills are a fundamental part of medical education;[71]

understanding patients’ backgrounds is important for patient-doctor

relationships and health outcomes;[65, 72] professionals have a lot to learn from

patients and their families;[40] excluding patients and carers can negatively

affect patient outcomes;[73] and respect should be explicitly taught to medical

trainees.[74] Changes in medical education prompted by the evolving needs of

our society have also encouraged a greater emphasis to be placed on patient

safety.[3]

Our findings also concur with other research that suggests public opinion

of doctors can be influenced by what they see on the television.[17, 18] Indeed,

we noticed that the popular press significantly influenced patient and public

perspectives; in particular they appeared to find their way into the

conversational narratives of our participants. Although to our knowledge there

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were no significant news stories regarding junior doctors being covered at the

time of data collection, media coverage and governmental reports do appear to

undermine patients’ trust in doctors’ abilities to care for vulnerable patient

groups, as emphasised in the NHS Inquiry into Mid Staffordshire,[19] and latterly

reinforced in the recent Shape of Training Review in the UK.[63] Such reports

appear to contribute towards feelings of anxiety amongst patients and the

general public with regards to safe and effective health care delivery thereby

feeding into societal master narratives (e.g. ‘the good doctor’ narrative turns into

a ‘doctor death’ one).[75] By contrast, longitudinal (and possibly voyeuristic)

insights into the lives of junior doctors as they progress through the highs and

lows of their training via television documentaries appear to provide a much

needed humanistic antidote to media and governmental reports.

What was largely absent in our data was patient and carers’ views of

structural factors impacting on junior doctors’ abilities to carry out their work.

Although patients talked a lot about doctors’ lack of time and the ‘busy ward’

conditions, for the most part individual or interactional factors were cited as

being responsible for junior doctors’ development (e.g. poor role models,

willingness to learn, self-awareness). This contrasts starkly with the

perspectives of others working in the healthcare environment, who also

commonly point to issues such as staffing levels, ward culture and supervisors as

facilitating or inhibiting factors to junior doctors’ preparedness.[26]

Our paper adds new weight to existing evidence on preparedness for

practice, which has contributed to current medical education curricula. Patient

representatives’ actual experiences of junior doctors’ preparedness for practice

(rather than merely their views on this) have been explored for the first time.

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Importantly, these first-hand experiences and personal views of junior doctors

were mainly positive, seeing them as being better prepared in ‘human’ factors

than previous generations. Participants felt that doctors’ personal attributes

were very important, and that in some cases no amount of educational

intervention would be able to change a person if they had the wrong attributes

for being a doctor. Despite their positivity, however, participants also shared


negative consequences.

A key take home message provided to us by patients and carers was that

they narrated a separation between themselves and doctors and other

healthcare professionals, for example: “we’re not all equal” and “on the other side

of the fence”. They narrated this as a barrier to doctors being able to understand

patients, and thus meet their individual needs. It was not possible from our data

to elicit the consequences that this might have had, but it does suggest that we

have some way to go in terms of empowering patients to see themselves as equal

partners in healthcare provision.


There are several caveats to our study. Participants were mainly part of support

groups and charities and thus might be more politicized than the general

public.[41] Almost a quarter of our participants were ex-healthcare

professionals, which is likely to have affected their views as they drew on their

own previous understandings and experiences as professionals within the NHS.

As such, this subset of participants are likely to have narrated events quite

differently compared to infrequent users of healthcare services due to their

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greater understanding of the healthcare workplace. Nevertheless, they provide

insights that are informative in ways that only frequent users of the system could

provide. They also spoke to us in the context of their current role as patients

and/or carers, and it is possible that past experiences contributed to their

willingness to participate in the study. The majority of participants were female,

and due to our purposive sampling our groups poorly represented younger

patients. Furthermore, participants narrated far more negative than positive

events, despite being asked about what junior doctors appeared to be prepared

for i.e. what were they doing that made patients feel comfortable and safe.

However, we cannot conclude from this that patients consider junior doctors to

be unprepared on the whole and/or they predominately have negative

experiences of the healthcare profession. It might be that patients expect and/or

experience predominately positive interactions with their doctors, but it is their

negative experiences that they remember most of all due to these having a

greater impact on them. Furthermore, in the focus group setting where

participants are sharing their narratives, it might be that the negative ‘shocking’

stories are more ‘newsworthy’ and ‘tellable’.[49] Finally, previous research has

shown a strong link between negative events and memory, with negative events

being more memorable than positive ones as they tend to involve more intense

information processing to understand and deal with them.[76, 77]

Therefore our findings need to be read with these issues in mind, and they are

unlikely to be transferable to all UK patients, especially male and younger

patients and their carers. For example, based on current research on health

trends in younger patients, such a group might have discussed junior doctors’

preparedness for issues such as mental health care, diabetes prevention,

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sexual/reproductive health, transitioning from child to adult care and the role of

online media as a health information source for joint decision-making.[78-80]

Finally, although we draw the reader’s attention to important features of

language within the results section, it was not feasible to explore fully here how

participants narrated their experiences and the implications of the language

used in this study [81, 82]. Metaphors were used extensively within our data and

resonated with several categories previously identified by Rees et al.,[81] for

example: hierarchy (e.g. “you’re at the bottom of the heap”); machinery (e.g. “I’ve

fixed that hip”); and war (e.g. “I’ll fight my corner”). Likewise, humour was also

used (e.g. “Make sure they’ve got the right side for the heart, like”) as a method of

building relationships and coping within focus groups.[82]

Our findings also have strengths. Participants represent perspectives of

patients and carers from three sites across the UK, with a range of backgrounds

and experiences and so are likely to be reasonably representative of UK patients

and carers with similar demographic profiles. Qualitative ‘information power’

was applied to guide the size of our sample[83]. Narrative interview

methodology was used to collate participants’ views, encouraging personal

incidents to be shared where possible. Focus groups enabled the additional

narration of conversational narratives that highlighted participants’ orientation

to the world of healthcare and of how junior doctors should be prepared for

practice. Crystallization of data between focus groups and individual interviews

led to a broader and deeper understanding of the issues discussed,[53] with

themes within the data being consistent irrespective of whether the data were

collected using interview or focus group methods. Finally, the collaboration of

numerous analysts from different professional backgrounds (clinical and social

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sciences) encouraged multiple ways of seeing the data, avoiding selectivity in our

analysis.



educational practice and further research. In terms of educational practice,

patient representatives had clear expectations of junior doctors and were

passionate that their voices be heard and considered in the shaping of medical

education. The data therefore highlight the necessity of patient involvement in

medical education teaching: the views and experiences of patients and the public

are important in creating junior doctors who will be adequately prepared to look

after them. Indeed, participants provided us with clear messages about what

they expect from junior doctors, often presenting a different picture to other

“clinical” participants from the wider study, such as clinicians, other healthcare

professionals, educators and policy-makers.[26]

While patients and carers seemed confident that medical graduates had

the necessary knowledge and practical clinical skills for effective and safe patient

care, they demonstrated concerns about the extent to which junior doctors are

prepared for the personal and interpersonal skills essential for promoting

individualised patient care and shared decision-making. They emphasised the

importance of communicating effectively with patients and carers, being

attentive and respectful to individual needs, and the value of experiencing a wide

variety of patients and environments.

As a result, we suggest three things for medical education: greater clarity

and training is needed regarding the practicalities of sharing information with

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carers, there should be more opportunities for students to experience first-hand

the impact of illness on patients and carers (for example, by attending patient

support groups), and senior clinicians should be encouraged to consider their

responsibilities as role models and the influence they have on the development

of junior doctors’ personal and interpersonal skills. In order for clinical practice

to meet our public’s rising expectations for health care delivery, greater

involvement and empowerment of patients and carers is advocated.

Finally, in terms of further research, we think more detailed analyses of

the needs and concerns of carers is needed, alongside further exploration of

patients’ first-hand experiences with junior doctors, and consideration of how

patients and the public form their views on healthcare, including the influence of

the media. Furthermore, future research with larger samples of patient

representatives would benefit from an exploration of the differences in

experiences and expectations by educational background of patient

representatives and perhaps different disease states (e.g. chronic illness,

palliative care, acute illness). Finally, further linguistic analyses would yield a

greater understanding of patients’ perceptions of newly qualified doctors and

how those perceptions were formed.

Conclusions

This study explores how well junior doctors (i.e. medical graduates in their first

two years after graduation) are prepared for clinical practice, according to

patients, their representatives, and carers’ personal experiences and

expectations. We decided to collect their voices because the topic of graduates’

preparedness for work has been mostly investigated in terms of medical

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knowledge and practical skills from the perspectives of junior doctors and their

supervisors, with little concern about patients’ and carers’ views and evaluative

comments of medical training. Our findings support the view that patients and

carers hold a set of clear expectations around junior doctors’ roles and practices,

and that patients’ views are important for preparing junior doctors for practice.

Our findings highlight the necessity for greater dialogue between patients,

doctors and educators in order to bring forth greater clarity and alignment of

expectations for patient care. This study adds evidence to existing research on

preparedness for practice, which have contributed to the development of current


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TABLE 1: PARTICIPANT DEMOGRAPHICS


Age Range (years)

25-45 1

46-65 8

66-85 14

No information 2

Gender

Female 17

Male 8


British 12

English 2

Scottish 2

Welsh 8

No information 1

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1. Sources of knowledge: This theme aims to identify and contextualize patient

representatives’ experiences and personal views on junior doctors’

preparedness for work. It includes:

1.1. Patient representatives’ first-hand experiences with junior doctors and

the healthcare system in general (’it happened to me’).

1.2. Patient representatives’ second-hand experiences (’it happened to

them’).



representatives’ perceptions and expectations for junior doctors in terms of

medical training. It includes:

2.1 Patient diversity: Patients from different socioeconomic and cultural

settings will help junior doctors in their preparedness for practice. Junior

doctors should also work with vulnerable patients (e.g. patients with learning

disabilities; mental health issues) to practice interpersonal skills (i.e. respect,

understanding, empathy).



2.3 Lifelong learning and development: They should constantly strive to

develop both professionally and personally.

2.4 In-depth clinical reasoning: They should shun “diagnostic overshadowing”

(i.e. avoiding or only reluctantly drawing conclusions on a disease and its

symptoms that move away from the original diagnosis).

2.5 The need for support: Junior doctors should be provided with both clinical

and pastoral support (including support from peers and seniors).

3. Future doctors: This topic deals with patient representatives’ expectations

and experiences for junior doctors as human beings. The theme comprises:


doctors include empathy, dignity and willingness to work with patients as

partners.


should develop respectful attitudes toward patients. Lack of respect is a source

of stress and emotional burnout for both care providers and recipients.

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Author Contribution

LVM and CER contributed to the conception of the study; LVM, CER and GJG designed

the work; CEK contributed to the acquisition of the data; all authors contributed to the

analysis and interpretation of data; CEK, CER and LVM drafted the manuscript, all

authors revised the manuscript critically for important intellectual content; All authors

gave their final approval of the version to be published; all authors agree to be

accountable for all aspects of the manuscript and will ensure that any questions relating

to the accuracy or integrity of any part of the manuscript are appropriately investigated

and resolved.

Acknowledgements

We wish to thank the wider research team for their involvement in the study design,

helping to secure funding, ethics approvals and analysis (Dr Karen Mattick and

Professor Alison Bullock) and the data collection (alongside Dr Camille Kostov were Dr

Grit Scheffler, Dr Narcie Kelly), with an additional thank you to Dr Kathrin Kaufhold who was involved in all of the above (except securing funding) and was an important source

of support for the paper. We thank Dr Philip Bell, the Patient and Public Representative (PPR) associated with the wider study for his assistance in developing the interview

protocol for the PPR groups. In addition, we thank Professor Alexander Anstey for his comments and suggestions on an earlier draft of this paper. We thank all of the

participants for taking part in this research and sharing their narratives, with special thanks to Dr Rosie Tope (PhD), one of the carers who participated in the study and who

explicitly asked for her and her husband, Dr Roy Nolan, to be acknowledged.

Ethical Approval


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Domain 1: Research







Acknowledgements)








time of the study?


CK: Medical Student








CK, CR, LVM: Female

5. Experience and

training


researcher have?










Relationship with

participants

6. Relationship

established








point.


of the interviewer




research


7)







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9. Methodological





















was voluntary.



email
















study?









Reasons?





interviews.

Setting

14. Setting of data

collection










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for intimacy.”


participants







interview.

16. Description of

sample







Data collection



pilot tested?










19. Audio/visual

recording








group?
























correction?









findings

Data analysis

24. Number of data

coders


data?


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coding tree


the coding tree?






framework analysis.





analysis software.


on the findings?








Reporting

29. Quotations

presented





participant number

Yes.


consistent







themes








themes



themes?







described.

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Journal: BMJ Open



Date Submitted by the Author: 24-Sep-2017






Keywords: MEDICAL EDUCATION & TRAINING, QUALITATIVE RESEARCH, Dementia < NEUROLOGY


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1





Affiliations:




Australia.





Lynn Monrouxe



Telephone: +886975367748



8,681

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Keywords


Funding Statement










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Abstract












analysis.












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Article Summary












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Introduction

























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Method

Design























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our discussion.[26]

Recruitment











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phases illness and would therefore find the interview participation less

challenging and arduous. Second, our University-based ethics approval was

sufficient to enable us to recruit patients (and carers) via non-clinical sites but

was not sufficient for patients with active illnesses to be recruited directly from

hospitals where junior doctors worked. Thus, we approached patient support

groups and charities, encouraging participants to come forward to contribute to

the study as part of a group. We also recruited a number of patients who were

involved in medical students’ learning, during which time they acted as

simulated patients (i.e. as actors for students to practice communication and

clinical skills).[55]

Participants












Data Collection

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under the direction of LVM. Three researchers (CK, NK and GS; KK supported CK


















Acknowledgements).

Data Analysis



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Results











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graduates.[44]















Bold was used to emphasize appropriate content for the theme (added by

authors); Underline for accentuated speech; ‘-’ for sudden break in speech; [ ] for

additional information to add contextual clarity; ( ) for anonymised information

e.g. (name of hospital) and (( )) for additional information regarding non-verbal

language e.g. ((laughter)).


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or whatever.











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you’ll die”

















Tom: Compassion.


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of the population. Patient representatives narrated that trainees should gain








adversarial:









Additionally, participants narrated that junior doctors needed to learn how to




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participants also narrated that students must be taught broadly about all

conditions and medical specialties, regardless of their future career plans. For

example, Harry narrated the hypothetical thoughts[59] of a medical student that

he considered appropriate for approaching their learning:



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Nick: Yeah.



right way to do it.






narrative suggests:














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working with.










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doctors:










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Group 2, Site 1).

























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colleagues.

Discussion

















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competence.[67-70]











safety.[3]






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analysis.























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Conclusions






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Age Range (years)

25-45 1

46-65 8

66-85 14

No information 2

Gender

Female 17

Male 8


British 12

English 2

Scottish 2

Welsh 8

No information 1

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them’).























partners.




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Author Contribution








and resolved.

Acknowledgements









Ethical Approval


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42

References



Education 2011, 16:627-642.


Education 2011, 16:495-504.









Teacher 2004, 26:403-408.





2007, 41:295-301.



25:774-779.







August 2017].













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47(2):197-215.



Quarterly 2012, 29(1):66-81.





4th August 2017].








4th August 2017].








74(108).














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34:123-135.





Teacher 2009, 31:e345-350.
























August 2017].

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History 1997, 7:395-415.


2001.












750.




2017, 2(1):10.











2008, 118:169-171.


care. 2013.






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Teacher 2014, 26:1-9.



35:e1422-1436.
















Journal 2010, 10:38-43.





47(1):80-96.



2015, 15:255.









26(13):1753-1760.

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Domain 1: Research







Acknowledgements)








time of the study?


CK: Medical Student








CK, CR, LVM: Female

5. Experience and

training


researcher have?










Relationship with

participants

6. Relationship

established








point.


of the interviewer




research


7)







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9. Methodological





















was voluntary.



email
















study?









Reasons?





interviews.

Setting

14. Setting of data

collection










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for intimacy.”


participants







interview.

16. Description of

sample







Data collection



pilot tested?










19. Audio/visual

recording








group?
























correction?









findings

Data analysis

24. Number of data

coders


data?


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coding tree


the coding tree?






framework analysis.





analysis software.


on the findings?








Reporting

29. Quotations

presented





participant number

Yes.


consistent







themes








themes



themes?







described.

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Journal: BMJ Open



Date Submitted by the Author: 19-Nov-2017






Keywords: MEDICAL EDUCATION & TRAINING, QUALITATIVE RESEARCH, Dementia < NEUROLOGY


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