Recent reports point to a lack of resources for, and coordination of, postgraduate medical education in Australia.1 High patient expectations, increasing public access to medical information, and the pressure for patient throughput in hospitals all create additional pressures for junior staff. There is growing recognition of the key roles played by registrars in the health sector, particularly in our public hospitals. Registrars are responsible for ensuring safe, effective, and timely delivery of health care, medical decision making, and health improvement and safety initiatives, while simultaneously performing a number of managerial, supervisory and leadership roles.2,3 The extent of these managerial responsibilities was highlighted in a recent job-shadowing exercise that revealed a large array of leadership requirements.4 The Australian Curriculum Framework for Junior Doctors that was launched in October 2006 also highlights the importance of professionalism and communication as key learning areas for prevocational doctors.5
There is general acknowledgement of the central role played by registrars supervising and training prevocational doctors. This extends beyond the context of traditional medical knowledge and skills, and includes providing leadership, fostering teamwork, and providing effective feedback. In the fields of surgery, anaesthetics, trauma and emergency medicine, increased mortality is associated with inadequate supervision of trainees.6 Registrars are expected to develop these complementary leadership and management skills by modelling them on those of their own supervisors, or intuitively. The adequacy of this traditional model is now being increasingly scrutinised.
As a background to this project, a comprehensive literature review was undertaken to examine the available existing literature on professional development in both medical and non-medical domains.7 The programs identified were very variable. They consisted of: short courses of only several hours, sometimes spread over a number of weeks or months, with specific focus on certain aspects of professional development;8-11 an undergraduate curriculum in Canada containing 30 professional development sessions;3 an academic postgraduate program over 2 years;12 and professional development programs that are self-directed and ongoing.13-15 Outside of medicine in Australia, the major Frontline Management Initiative recognised the need for employees in their first managing role to be provided with the necessary preparation.16
The following key themes emerged from the review of this literature:
In 2002, a program was developed at Dandenong Hospital (Southern Health Network in Victoria) to address the non-clinical training needs of physician trainees, based on an analysis by stakeholders (including junior doctors) of the ideal registrar. It was clear from this process that a highly functioning registrar needed core managerial competencies in addition to clinical skills. Based on the initial interest by junior medical staff in this program, a national project was set up to undertake a comprehensive evaluation of existing programs, and to develop a generic program for the professional development of registrars across all areas of practice. The project was funded by the Australian Government under the Medical Training Review Panel grants scheme.
A workshop was convened in March 2004, involving 45 nominees from all states; 22 were clinicians, representing best-practice programs. Nominees were drawn from a range of professional groups including junior medical officers (4), registrars (9), consultants (9), directors of clinical training (4), medical education officers (8), representatives of specialist colleges (4), and representatives of state and territory education councils (7). The workshop generated the design and implementation principles for a professional development program and a curriculum framework outlining the appropriate competency content, suitable for national roll-out (Box 1).
There was a significant amount of preparatory work that preceded the launch of the national Professional Development of Registrars pilot programs. Engaging senior clinicians, medical colleges, postgraduate medical councils, medical administrators, junior doctors and their representative organisations was a critical early focus. Formal consultative mechanisms included establishing a national advisory committee of stakeholders drawn from a wide cross-section of the medical education field to oversee the project. In addition, a working party comprising registrars drawn from a range of training programs was set up to establish strong communication links with the intended clients. A number of presentations to raise awareness of the need for these types of programs in national and state forums were also undertaken.
To provide coherence and content for the competency framework, an extensive review and assessment was undertaken of similar programs from domains other than medicine, as well as “off the shelf” programs offered in the medical domain. Compilation of stand-alone workbooks, learning-needs assessment forms, and a range of other supporting learning materials were part of the program development phase.
After trialling the Professional Development of Registrars program in various formats, a 2-day program (outlined in Box 2) was agreed on. This format took into account registrar feedback at the end of each of the sessions. The program itself involves experiential small-group work, individual exercises, self-analysis questionnaires, videos, and simulations, as well as some didactic content. Clinical and non-clinical presenters were involved in facilitation. There is precourse work completed before the sessions.
Ultimately, the real effectiveness of registrar development programs will lie in their ability to enhance the performance of participating doctors as clinical managers. To ascertain this in a robust way will require systematic postprogram follow-up. The limited evidence obtained from a focus group with one of the pilot cohorts and presentations at the 11th National Prevocational Medical Education Forum do provide positive indicators of the value and relevance of the Professional Development of Registrars program. This is further supported by increasing requests for delivery of the program.
An 8-month follow-up focus group meeting with one of the pilot groups indicated that the participants had derived significant value from the sessions on self-awareness, effective time management and delegation, communication and learning styles, team-building skills, registrar as teacher, giving and receiving feedback, and conflict resolution. Participants also emphasised the value of having follow-up meetings to allow for reflection on improvements made and for consideration of further areas for development. Other postprogram feedback included awareness of the recognition by hospital administration of the role of the registrar, the opportunity to network with other registrars, awareness that the transition to being a registrar was more multifaceted than it may seem, and a desire to explore leadership and management in greater depth.
The postprogram feedback supports very positive reaction ratings to the pilot programs by the participants, despite often being scheduled on weekends. In addition to overall program ratings, each session has been evaluated for content in terms of achievement of the program’s objectives, as well as the quality of presentation, as shown in Box 3. Eleven pilot programs have been conducted in workshop and modular formats; two of these have been weekend residential programs. The overall reaction to the programs by the 146 participants (134 registrars and 12 resident medical officers) has been extremely positive, with a very satisfactory average rating of 6.2 (SD, 0.6) out of 7.0.
As Box 3 shows, while all the sessions rated highly, those on building self-awareness, registrar as teacher, team-building skills, different styles of leadership, effective time management and delegation, conflict resolution, and giving and receiving feedback all averaged higher on both content and presentation. Participants also commented very favourably on the program materials provided, including workbooks.
The Professional Development of Registrars program has attracted the interest of other stakeholders in medical education and training throughout Australia, with an increasing number of requests for involvement in the program. We propose this as a model program for all medical graduates before they move into front-line manager positions in the Australian medical workforce.
As acknowledged earlier, there needs to be further follow-up on the perceived impact of the program on actual improvments in medical management. This will pose a challenge, given the confounding variables. In relation to the project itself, one of the key developments this year will be to establish a website dedicated to making resources developed under the auspices of the project available to registrars and other medical educators.
The long-term sustainability of this program will depend on getting jurisdictions to promote this type of professional development as part of the requirements for anyone making the transition to being a registrar. It is pleasing to note that the Professional Development of Registrars pilot program is being used to help in the roll-out of registrar programs. A national advisory committee has been put in place once again to provide oversight and guidance in the promulgation of the outcomes of the pilot program.
The Professional Development of Registrars program is a significant contribution to supporting the professional development of doctors. It has the potential to provide supporting resources to the Australian Curriculum Framework for Junior Doctors, especially in the areas of learning communication and professionalism. It also comes at a time when medical colleges have been expanding their curricula to reflect Australian Medical Council guidelines for the training of medical specialists.
3 Ratings of the quality of content and presentation of Professional Development of Registrars pilot programs*
Different styles of leadership |
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Effective time management and delegation |
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Action planning and goal setting |
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* Source: Course ratings forms of 146 program participants. |
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Abstract
When prevocational medical trainees become registrars, they have increasing responsibilities for ensuring safe, effective, and timely delivery of health care, while simultaneously performing a number of managerial and leadership roles.
Registrars do not currently receive training for their roles as front-line managers, despite this being an identified need by trainees and the health care workers with whom they interact.
The national program for the Professional Development of Registrars is a soundly based, well developed and successful generic program that could be applied in a wide variety of postgraduate arenas.