The training of junior doctors requires a delicate balance between "on the job" experience and quality training. . . . The preregistration year is a time in which training, skills and working role are consolidated under supervision, and it has been suggested that it may be the most stressful period in medical practice.1
In South Australian teaching hospitals, the education and training of doctors in their prevocational years is currently the domain of a team comprising a Director of Clinical Training (DCT) and a Medical Education Officer (MEO), in conjunction with a general clinical training committee. The overarching aim of the DCT–MEO team is to ensure high-quality patient care by guiding and supporting the developing junior doctor. To achieve this, the team works both in and on the system of the public teaching hospital.
The DCT and the MEO have different, but complementary, roles. The DCT is a senior practising clinician and mentor, whose involvement is of necessity part-time, because of clinical responsibilities within and outside the teaching hospital (Box).2 The MEO, on the other hand, can be more focused on prevocational medical education and, especially if full-time, can provide a consistent presence in the hospital for junior medical officers (JMOs) during their training. The MEO has a range of skills in healthcare education, evaluation and counselling, and gives educational credibility to the team (Box). This team is more effective than each individual acting alone.
The complementary skills and roles of members of the
early postgraduate medical education and training team
Director of Clinical Training |
Medical Education Officer |
Multifaceted role |
Focused role |
Part-time |
Full-time |
Clinical insights |
Educational insights |
Patient care expertise |
Evaluation expertise |
Clinical teaching |
Quality monitoring |
Career advice |
Counselling skills |
In mid-1999, MEO positions were established at each teaching hospital by the South Australian Council for Early Postgraduate Training. This model was adapted from one previously developed in Queensland by the Queensland Medical Education Centre with Queensland Health. At this time, the five foundation South Australian MEOs undertook informal needs analyses at the hospitals to gain objective insights into the local system. We asked the questions "What is happening now for JMO education and training?" and "What needs to be done?". From the results of these analyses, we could tailor appropriate strategies for quality improvement of education and training in response to the particular and current needs of the JMOs at individual hospitals.
Quality-monitoring and improvement systems are vital in a structure which is responsible for staff development, as the teaching hospitals are for JMO education and training. Quality management is an important role for the MEO with educational evaluation experience.
MEOs adopt a wide range of evaluation strategies, including questionnaires, interviews and participant observation, resulting in both quantitative and qualitative data. The MEO encourages and coordinates assessment and feedback from supervisory staff on, for example, JMOs' clinical competence, but also vice versa from JMOs about their supervisors on individual term rotations. The gathering of evaluative data about the individual terms, and on the hospital's education and training program as a whole, is essential for quality improvement.
Evaluation must be part of a continuously cycling process that can be managed by an MEO to ensure rapid responses to needs as they arise in a changing environment. All aspects of JMO education and training programs, and the context in which they operate, need to be monitored. De-identified data are then fed back to the program coordinators, and used to inform the process of implementing change, which, in turn, must also be evaluated. The continual gathering of data can provide evidence of systemic problems which could cause excessive workloads, dissatisfaction with rosters, and reduced training opportunities, all of which may affect JMO development and performance.3
Evaluation undertaken because it seems to be "the thing to do" is doomed to failure. People will not engage in evaluations if they never see any results, and failure to demonstrate outcomes will lead to lack of trust in the evaluators.
It is difficult for a busy DCT to undertake comprehensive, continuous and confidential evaluation processes unassisted. By definition, an MEO in South Australia is not medically qualified and is thus perceived to be outside the "medical establishment". This is an advantage, enhancing his or her capacity to obtain free and frank responses to questionnaires and interviews, and increasing response rates and the usefulness of the data. An MEO is well placed to demonstrate and maintain confidentiality in evaluative processes and objectivity in reporting evaluation results to the DCT and the hospital management.
While formal administrative structures can be designed to facilitate the successful progress of JMOs through their service and training commitments, additional, less formal systems are also necessary. Another role for the MEO is to advocate for, initiate and organise professional, personal and educational support for JMOs. This can include:
Weekly intern meetings, providing a collegial atmosphere, peer support and debriefing opportunities in a private, relaxed and caring environment;4
A program of intern tutorials specifically for and responsive to the needs of JMOs; and
A JMO lounge, which is a private space for relaxation, recuperation and meetings with colleagues away from the ward environment.
Provision of a supportive system and atmosphere within the teaching hospital can be facilitated by the DCT–MEO team, giving junior doctors opportunities and encouragement to support each other and themselves.4
A background in education and training means the MEO can help support not only doctors in training, but also their supervisors. This can be achieved through the quality improvement process described above, and by offering practical support and advice, providing, for example, skills in "Teaching-on-the-run" or "How to give constructive feedback". In South Australia, the MEOs as a group offer a wide range of skills, including expertise in education, counselling, management, project development and research. They are a resource that can be called on across campuses and along the continuum from medical school through to specialty training programs.
Employment of an experienced postgraduate medical educator by a teaching hospital demonstrates a commitment to medical education and training of JMOs. The DCT and MEO can enhance the profile of JMO education and training within the hospital by active engagement in the work of hospital committees, encouraging mutual feedback between management and junior medical staff, advocating for education and training within the hospital environment, and helping to maintain the "delicate balance between 'on-the-job' experience and quality training" to reduce the potential for distress in junior doctors.1
- Anne A Martin1
- Flinders Medical Centre, Bedford Park, SA.
- 1. Bogg J, Gibbs T, Bundred P. Training, job demands and mental health of pre-registration house officers. Med Educ 2001; 35: 590-595.
- 2. Schofield K, Saunders NA. Education and training in the early postgraduate years: the NSW experience. Ann Community-Oriented Educ 1993; 6: 173-179.
- 3. Firth-Cozens J. Emotional distress in junior house officers. BMJ 1987; 295: 533-536.
- 4. Davis M. Intern discussion group: a supportive education experience for junior doctors. Hosp Med 1999; 60: 435-439.