Making it better for trainees

Good morning, everyone. It’s a pleasure to be here in Edinburgh for this triennial Conference – which has the theme of ‘Making it Better’.

I’d like to thank the President – who championed this work on improvement for the profession – and the Royal College for inviting me to be here today.

I’ve been asked to talk about ‘Making it Better for Trainees’. How can we improve the overall experiences of doctors in training?

In my view, medicine is the best career in the world, no matter which branch you choose – surgery, medical specialties, general practice or even ophthalmology! It is challenging, stimulating and rewarding. To be able to work with like-minded colleagues to improve the quality and extend the length of life of our fellow humans is indeed a privilege.

Being a doctor in training should, in many ways, be the most exciting part of that career. It’s a role that is designed to embody learning and practical training, while actively contributing to a very busy service. There should be enough pressure to make it energising, coupled with adequate supervision and support to reduce that stress and make it enjoyable.

And I’d like to emphasise, based on the data the GMC has collected, that many doctors report that they do have that positive experience. Overall, the picture is a very encouraging one.

But we can still do better. Not all doctors in training have that constructive and balanced experience – and remember, they are very capable people who, quite frankly, are resourceful and used to maximising the opportunities offered to them even if these are not ideal.

And things have not been ideal for anyone over the past couple of years. It would be wrong to blame Covid for the issues we need to resolve to make it better for all trainees.

But Covid has, however, shone a light on some of the pre-existing deficiencies – and it’s prompted some beneficial changes too, so we must not lose sight of what these might be.

And, during each trainee’s period of development, education and training, as trainers and role models we have a responsibility that goes beyond providing clinical experience and knowledge and setting doctors on a successful career trajectory.

We also shape their whole vision of what medical practice means, and what their life in the profession might look like. If students and trainees don’t develop in positive, safe environments, they fail to thrive. and That has a negative impact on their wellbeing, behaviours, ability to provide safe, compassionate care –and ultimately on their wish to remain in this rewarding, but demanding profession.

Making things better for trainees isn’t optional: it’s key to the medium- and long-term future of our health service and our noble profession.

National training survey

So – one excellent way of getting to the bottom of how to ‘make things better’ is to ask the doctors in question!

This is where the GMC National Training Survey can help us out - it goes to almost 47,000 trainees and 16,000 trainers every year so we can hear directly from them about their experiences.

Their responses provide us with clear data and a solid evidence base on the current position and how, as employers, education bodies – and of course the GMC - we can work together to improve things for trainees, trainers and, ultimately, patients.

On a most basic level, we want to be sure that trainees are learning what they need to learn and building the skills they need to treat patients safely. But we also ask about culture and wellbeing.

• Are they being treated with respect?
• How confident do they feel about their future in medicine?
• What’s in place to protect them from burnout?

Last year, 76% of trainees completed the survey – and in 2019, when we weren’t in the throes of a pandemic, it was 95%. This is a very high response rate and therefore provides strong, reliable data.

This year’s national training survey only closed a couple of weeks ago, so these data are still being analysed, but the 2021 results do provide some very helpful information.

Let me share a couple of relevant headlines. I’ll start on a very positive note.

To begin with, 85% of trainees had a good or very good experience in their training posts last year. There’s some variation across specialties, and that may reflect specific responses and experiences during Covid - but overall, that’s certainly an encouraging result. And, possibly surprisingly, it’s an improvement on pre-Covid years.

What can we learn from that, I wonder? What, during one of the most difficult and pressurised periods in the NHS’s history, could have been good for doctors in training?

Firstly, I’m sure you will all recognise that the skill and dedication of trainers, education bodies and the trainees themselves played a huge part in that. This reflects some of the resourcefulness I alluded to earlier. It was always there – it just needed to be released! But it also recognises how important the people involved in training are in being the key to its success.

In addition, these positive changes are also due, at least in part, to the increased flexibility that occurred during the pandemic.

That includes:

• Flexibility of - training methods and materials, especially online teaching and recognition of a wider range of training opportunities
• Flexibility to progress through the ARCP processes
• And flexibility in the various assessment methods during the pandemic.

Statutory education boards in all four nations, royal colleges and the GMC worked together with doctors in training to provide a suite of derogations and reduced bureaucracy to lighten the load – something that was very welcome.

At all levels they also managed – against all the odds – to continue to do an excellent job of maintaining access to training and assessments, both face to face and remotely, and making sure doctors progressed through their training where possible – although there have of course been situations in which disruption to training has been unavoidable, particularly in the craft specialties like surgery, where opportunities to undertake surgical and practical procedures were largely suspended by the cancelation of elective lists.

However, these changes have all been welcomed and have focused our minds on how these themes can be captured for the future – and reforming medical education is being pursued with all parties for the long term with the aim of improving the training experience going forward.

These apply certain principles – primarily that:

• patient safety is paramount
• standards must not be compromised
• competence – not numbers
• outcomes – not time
• consider the role and required learning of the doctor

These emphasise assessment of overall competency, rather than on the quantity of assessments trainees complete.

It also means that we assess whether outcomes were achieved, rather than the amount of time a doctor has been working on a specific area.

Additionally, reducing the burden of the training process is something that has been known for a long time. Changes to the ACRP process were introduced during the pandemic – making ACRP less of a box-ticking exercise, focusing more on the quality of a doctor’s practice and looking at their competence in a more holistic way.

Hardly surprisingly, the results of our training survey suggest that trainees felt it was a change for the better. It helped them to progress more flexibly, to be more reflective about their practice, and to put more thought into how they might continue to learn and improve.

We can’t, and don’t want to, lose these changes post-pandemic, and we need to recognise the positive effects these have had by professionalising the process of education and accountability.

Trainees’ desire for constructive feedback from their trainers – with an ongoing dialogue about their progress and assessments and appraisals that are a useful learning experience, rather than a list of achievements to tick off – is clear. Trainees want a clear picture of what they can expect from their trainer, and they want to be able to challenge that if they aren’t getting the best value from their placements.

Different aspirations

It is important to recognise the different aspirations that trainees have.

In general, they aren’t necessarily looking for linear career path anymore – much as people in other professions do, they want to use their transferrable skills and explore different areas of expertise and different working environments as they accumulate experience.

In other words, they want more flexibility.

They’re looking for a more personalised, flexible approach, but for many years they have felt ever more constrained within rigid training programmes and curricula. This means they’ve lost autonomy over many aspects of their lives. For example,

which region they train in

where their next placement is

inability to change specialties – and with no ability to recognise training taken place in a different programme

compulsory full time working training, unless there is a ‘good reason’.

Many of these have been, or are being, addressed with a less restrictive approach. Less-than-full-time training has been reported as having increased from 11 – 15%, and recognition of previous training and placements has become easier to navigate.

Giving trainees more control and reasonable flexibility over aspects of their training, and their lives in general – is so important to make trainees feel less likely to be ‘done to’ and more likely to feel valued.

Team working and environments

That brings us nicely to the more human element of the NTS survey results.

During the pandemic, doctors across the board reported that they felt teamwork improved, and that there was a real sense of colleagues pulling together at every level to support each other through a difficult time. This involved both single and multiprofessional teams, suggesting that more supportive interactions with the healthcare professions they work with, across all disciplines, were in play.

The value of being part of a functioning team cannot be underestimated, as was emphasised in the work of Michael West and Denise Coia in the Caring for doctors, caring for patients report, where the ABC concept of Autonomy, Belonging and Competence highlights that need for Belonging. Being part of a group that you can identify with, and one that provides feedback and support, is essential for the wellbeing of all doctors.

Those who were not part of a supportive network reported significantly higher levels of burnout than those who worked in a supportive environment – which had a negative correlation with the pressure of work that they were under.

So, we know that workplace cultures of respect, support and inclusion are vital for all doctors to deliver the best care they can.

And key to this positive environment is strong leadership.

All doctors thrive best in supportive, caring environments, at every level. But it’s particularly important for trainees, right from their very first day of clinical practice.

For me personally, this is a must - we owe it to our trainees to make they feel supported, included and respected.

• They must feel able to ask questions, to admit to their mistakes and seek help when they need it.
• They must have a safe route for raising concerns in confidence and be reassured that there will be no reprisals.
• Leaders in medicine can help to instil that culture in their teams simply by role modelling and championing those behaviours.
• We need to be open and transparent when things go wrong, and to discuss what we’ve learned from it.
• We need to be constructive with our feedback.

And we need to be honest about those times when we’re struggling under pressure or finding it hard to cope. These are conversations we need to normalise.
For decades, the notion of leadership was all about maintaining control and appearing invincible. But times have changed, and so have the expectations of our trainees. Their psychological safety is essential.

Understanding our trainees

Which brings me to another aspect of ‘how to make things better for trainees’, and that is for us to try to understand them better – generational differences have always been a challenge!

For those of you who still picture someone barely out of their teens when you hear the word ‘millennial’, it might come as a shock to you to learn that you are in fact a millennial now at the age of 40. We’ve probably seen our last cohort of millennial trainees now – they’ve handed the baton to Generation Z.

There’s evidence to suggest that Generation Z tends towards the progressive in terms of social and political views.

They’re more ethnically diverse than previous generations and they’re more likely to be open about their sexuality. Today’s doctors in training have been educated in a time where open conversations about mental health and wellbeing support have become normal, even encouraged. Frankly, that’s something we can learn from them.

And so, following on from this and quite rightly, they have high expectations of their colleagues and their working environments. Perhaps more than any other generation, they value wellbeing, respect, and inclusion.

In 2021, 81% of trainees agreed that their working environment was fully supportive, and that staff treated each other with respect – and, a reassuring, 89% agreed that their own department, unit or practice provided a support environment for everyone, regardless of background, beliefs or identity.

You might imagine, then, that we can be confident that most training environments are supportive and inclusive for all trainees. But unfortunately, when we look at the responses of doctors with different protected characteristics, we do see a small difference.

There is a 7% difference between the responses of white doctors and minority ethnic doctors. 91% of white trainees felt their working environment was inclusive, compared with 84% for trainees from minority ethnic backgrounds. Both these figures are improvements on previous results, but the difference, although small, is still concerning.

But where we see a more notable difference is in progression in training for different groups.

The concept of differential attainment in medical education is well recognised. We know there is a clear attainment gap between white doctors and doctors from ethnic minority backgrounds. Progression through the ARCP process is not at the same rate. For ethnic minority doctors with a UK PMQ, there is a gap of 12%, and for those with an overseas PMQ, that gap jumps to 30% in post graduate medical exams.

This is a complex issue – but at the GMC we’ve set, and are committed to, an ambitious target to completely close that attainment gap. If we’re going to achieve it, we need to work together to make sure that all trainees’ needs are met in a fair and equitable fashion.

If we’re going to make things better for everyone, we clearly need to look more closely at addressing the problems faced by specific groups, and not treat trainees as homogenous.

We already know many of the answers to these issues.

• Providing good induction that is tailored to the needs of the doctor. Those new to the NHS practice cannot be expected to understand the complexities of how health care is delivered in the UK.
• Treating each trainee as an individual - having proper conversations with our trainees to hear what they have to say and to get to know them as individuals. That coffee cup chat that reduces the power gradient.
• Developing the strong compassionate leadership that creates a culture of inclusion – encouraging that open and honest training environment.

The GMC proposes to embed those positive behaviours, and intolerance of negative behaviours, into the updated version of Good medical practice – the overarching guidance that outlines the standards expected from doctors.

It is currently out to consultation, being nearly 10 years since it was last revised and, although the main principles won’t change, it needs to be brought up to date to mirror changes in society.

From the moment a student enrols in medical school, Good medical practice sums up everything they are working to become. It is the basis of sound, ethical medicine and those principles form the backbone of good practice, right up until the day they retire, but it’s during their education and training that they’re really entrenched.

That’s why it’s essential that Good medical practice sets out the behaviours we expect of trainees, but also what they can expect of their colleagues.

For example, the proposed updates to Good medical practice make it explicitly clear that doctors have a duty not to harass, bully or discriminate against anyone.

And just as importantly, doctors must act if they become aware of such behaviours from colleagues – or support others to act.

If we don’t do all we can to instil fairness and the right to speak up from the very start, we run the risk of losing some of our most promising and talented physicians from UK practice – almost before their careers have begun – if they are unable to progress.

And what can we learn from other professions?

As I said at the beginning, medicine as a career offers incredible rewards and unique opportunities. But that doesn’t mean we can be complacent. We know from the GMC’s The state of medical education and practice in the UK report that 23% of doctors in the UK are considering leaving the profession.

There are, clearly, other career options out there, and considering what they might offer that training as a doctor doesn’t is something we tend to give much thought to, despite the fact that those alternative careers might be very rewarding.

At the GMC conference earlier this month, one of the speakers was a GP who runs a very busy inner London practice. She mentioned that her son has just started medical school – but he’d told her that, having seen the pressure she was under and the long hours she put in, he’d rather work at Google than the NHS.

Not for the salary, or even for the smart offices or the free tech gadgets, but for the company’s commitment to their staff and their wellbeing. It seems that free meals, an on-site wellness centre and gym, mental health support, flexible and hybrid working patterns and even free massages are quite a draw.

I can’t see the NHS offering free massages for trainee doctors any time soon – many hospitals do not even provide hot food in the evening or weekends, adequate IT to do the job efficiently or safe overnight parking. Offering some of those basic comforts – what are referred to as the ‘little things’ – would improve the experiences of trainees immensely.

Conclusion

To sum up, then, it’s my view that the key ingredients required to make things better for trainees are:

• a relevant curriculum, delivered through a variety of experiential and taught ways
• a fair and open training environment
• support and a feeling of belonging – a psychological safety.

Considering the needs of trainees is perhaps more important now than it’s ever been.

As we emerge from the worst of the pandemic, our health services are facing challenging years ahead, and we will not get through those years and beyond without a sustainable, highly skilled medical workforce – and not just doctors, but the wider health and social care workforce.

We have an excellent chance here to set expectations at the training stage for how doctors and all healthcare professionals work and train together in the years ahead, for their own mutual benefit and for the benefit of patients.

The more we can improve their training experience:

• the better we can provide nurturing conditions
• the more likely we are to see them stay in the profession – delivering the best possible care for their patients and securing a supportive, compassionate environment for themselves and their colleagues.

As I said earlier, trainees are the future of our profession. It’s by making things better for them that we can safeguard that future, and that’s an opportunity we can’t afford to ignore.

Thank you for your attention, and I look forward to being in a position to discuss these issues with you, and more, in the months ahead.