Aviation industry research suggests that when people are happy and satisfied with their colleagues, communication and teamwork naturally improve.1,2 In turn, the likelihood of poor communication and interpersonal interactions resulting in adverse events is reduced.3 This is vital in high-risk industries like medicine and aviation, in which errors can be catastrophic.4
Not everyone agrees that the safety lessons learned by aviation are applicable to medicine, but, if aviation’s exemplary safety record is due in part to applied research into communication and interpersonal interactions, then medicine may also expect to gain from similar research.5,6
Doctors begin their postgraduate training as interns working under supervisors, usually registrars. Given the degree of contact between registrars and interns, behavioural characteristics of registrars have the potential to affect the quality of interns’ clinical training and the intern experience as a whole. Furthermore, interns’ exposure to registrars as role models may have significant consequences for their own effectiveness as future supervisors. However, we could find no published research in medical or educational literature on interns’ perceptions of their supervisors.
We set out to examine desirable and undesirable behavioural characteristics in registrars from the intern’s perspective, in areas such as guidance and supervision, interpersonal dynamics, teamworking ability, and communication skills. We sought to discover whether these issues are currently a problem in intern training and how registrars might improve their performance as clinical supervisors, as we believe such issues have implications beyond the intern training experience to broader issues of error minimisation and patient safety.
Our study was conducted between December 2003 and February 2004 at Nepean Hospital, Penrith, NSW. This is a 420-bed suburban teaching hospital with 180 specialists who cover most major medical and surgical specialties. On average, the hospital employs 14 basic training registrars and 17 advanced training registrars in medical and surgical specialties.
Eighteen of the original 23 interns in the 2003 intake at Nepean Hospital were interviewed. Thirteen were women (age range, 25–31 years; median age, 27 years) and 5 were men (age range, 25–35 years; median age, 28 years). All were graduates from accredited Australian universities. Six of the 23 were no longer at the hospital after their first year, and only one of these could be interviewed. Interviewees had either completed a full year of rotations or were in the final month of their intern year. Each interviewee had completed at least one medical, one surgical and one emergency department term. The interviews were voluntary, with all participants giving informed consent.
We used semistructured face-to-face interviews involving both open- and closed-ended questions7 to identify registrar characteristics that interns considered either desirable or undesirable in their working relationship.8 All responses were kept confidential and de-identified.
To maintain consistency of questioning and recording, one of us (C S L) conducted all the interviews. Responses were recorded manually in an abbreviated form during interviews; interesting comments were noted verbatim. Notes were subsequently transcribed into point form, and the data analysed. Audio recordings were not used.
A content analysis method9 was used to process the data. We assembled a list of coded categories based on interns’ responses,10 then cut and pasted each excerpt from the transcribed data into one of those categories. We used sequential, or “iterative”, data collection and analysis (ie, results from early interviews influenced data collection in later interviews).11 In the categorisation process, clear recurring themes were obtained from the data using grounded theory inductive techniques.12 From these, a number of desirable and undesirable behaviours and attitudes emerged.13,14
Overall, interns’ responses were positive, most describing high levels of satisfaction with registrars’ abilities to deal with the varied demands of learning, teaching, and practising medicine.
Interns emphasised the importance of “good” registrars (Box), with comments such as, “It is the registrar that makes or breaks a term, rather than the consultants or the particular ward where one is placed”. Although a number of undesirable characteristics were elicited, many of these were thought to result from — or be much amplified by — an overstressed healthcare system that places great demands on registrars.
Many interns resented registrars who did not answer their pagers and felt that having their registrar out of contact for significant periods adversely affected their confidence and, on occasion, the quality of patient care. For interns doing surgical terms, some registrars were often out of contact in theatre, leaving their interns to cope with emerging problems alone.
“Good” registrars, on the other hand, gave warning if they were going to be out of contact, called between surgical cases, organised other registrars to cover for them, or left pagers with theatre nurses who could relay messages.
Respondents also preferred registrars who scheduled regular meetings throughout the day. The suggested ideal minimum was a full morning ward round together, then two “paper rounds” by phone, and a final check-in by the registrar before leaving for the day.
Willingness and ability to teach were considered important characteristics. Interns preferred registrars who would teach on the spur of the moment at the bedside without prompting. Other themes relating to good teaching included being willing to listen to and answer interns’ questions or suggestions; having an encouraging and supportive attitude; allowing a progressive increase in interns’ responsibilities, thereby building their confidence; and appreciating the intern as being a member of the team with a valued perspective, not just a “secretary”. (One intern was told by a registrar to “go to the cafeteria and tell me what hot foods are available today”.)
Interns appreciated registrars who were articulate, gave clear and specific instructions, and explained their thoughts and actions. This was especially important early in the intern year, when such habits minimised misunderstandings and consequent errors. Moreover, these behaviours helped interns explain management plans to patients and learn how more experienced clinicians solve problems and make decisions.
Interns were frustrated with registrars who gave vague or unspecific instructions, such as “Keep close tabs on that patient”, which left the intern unsure exactly what was required. One intern commended a registrar who, at the end of ward rounds, would briefly run through all the tasks to ensure the intern had understood everything correctly and not missed anything.
Interns valued coffee breaks with registrars, and described them as useful times for asking questions, discussing problems, receiving informal teaching, and fostering the social relationships that many interns listed as important for good registrar–intern interaction.
Most interns felt they received abundant feedback on their own performance, but had few opportunities to offer their own opinions about the quality of their supervision. When opportunities did arise, they usually involved informal feedback given directly to supervisors, which created difficulties if the feedback was negative. Several interns thought that this situation could be improved, and one stated, “[Usually] something horrible has to happen before someone feels the incentive to come forward in this way. It would be better if there were a regular periodic opportunity when people are encouraged to give feedback”.
Registrars are evaluated only by their consultants, and, as one intern noted, “This sometimes paints a skewed picture, because registrars put on a very different face for interns to the one they use with consultants”. Interns spend at least as much time with registrars as consultants do, and feel that their feedback should be valued too.
Our results suggest that interactions between interns and registrars play a large role in determining interns’ work satisfaction and learning opportunities. Although interns in our study identified certain negative characteristics of registrars, indicating that there is room for improvement in registrars’ communication and teamwork skills, they believed most registrars performed admirably under difficult conditions.
The limitations of our study include a relatively small sample size, with all participants working in a single hospital. Ideally, future similar studies will be conducted at other hospitals, but we have no reason to believe that the opinions expressed in our study are unrepresentative of the NSW intern experience generally. We looked exclusively at Australian-trained interns, and did not correlate individual factors such as sex, ethnicity, or rotations undertaken. However, using this project as a basis, a future, bidirectional study could conduct multivariate analysis on such factors. A larger study would also ideally include a wider variety of medical staff, such as medical students, residents, registrars and specialists, and would assess how interpersonal dynamics, tutoring and communication skills might be improved.
We recommend that an instrument be designed to facilitate regular feedback from interns on the performance of their registrars, covering the themes indicated by our study. Such an instrument would allow interns to give a more objective and constructive evaluation of their satisfaction level with registrars and help registrars function more effectively as clinical mentors.
These would be logical steps towards hospitals achieving not only a higher quality of care, but also the added safety benefits that the aviation industry attributes to its commitment to researching team behaviours and using the results to guide professional training.
Characteristics of a “good” registrar, as perceived by interns at Nepean Hospital*
Personal attributes and attitude
Approachable
Polite, good tempered, patient, and easy to get along with
Independent and confident (eg, makes decisions without relying on a consultant)
Organised, punctual, and thorough
Not arrogant, condescending, apathetic, or lazy
Teaching and supervising skills
Available, staying in contact with intern throughout the day
Arranges for coverage when he or she will be out of contact
Makes time to review patients with intern
Encourages, supports and has realistic expectations of intern
Values intern’s time, suggestions, and contribution
Effective and willing teacher
Explains decisions and plans to intern
Looks out for and “protects” intern; remembers what it was like to be an intern
Communication, teamworking, and interpersonal skills
Expresses self clearly and explains things effectively
Good listener
Good team worker
Makes time for social interaction with intern
Establishes ground rules and protocols at start of term
* Characteristics of registrars that interns perceived as undesirable have been incorporated into this list by describing the opposite of those characteristics.
Received 18 June 2004, accepted 25 October 2004
Abstract
Objective: To identify and explore behavioural characteristics of registrars that interns find helpful in their working relationships and workplace learning.
Design, setting and participants: Semistructured interviews with 18 interns at Nepean Hospital, Penrith, NSW, at the end of their first working year as doctors. The survey was conducted between December 2003 and February 2004.
Main outcome measure: Desirable and undesirable behavioural characteristics in registrars, as reported by interns.
Results: Overall, interns’ opinions of registrars were positive. Desirable characteristics in registrars included approachability, availability, good communication skills, and a willingness to teach. Undesirable characteristics included an unwillingness to listen, unreasonably high expectations, a condescending attitude, apathy and rudeness.
Conclusion: The behavioural characteristics of registrars that interns find helpful are identifiable, and there is significant room for improvement in the quality of clinical mentoring by registrars. The next step is to facilitate regular feedback from interns on registrars’ performance, and to develop ways to encourage desirable behaviours in registrars while actively discouraging undesirable behaviours.