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Abstract
Aim To measure new consultants' perceptions of their preparedness for different clinical and non-clinical aspects of the role of consultant.
Design A cross-specialty questionnaire was developed and validated, containing items asking how well specialty training had prepared respondents for the role of consultant in a number of clinical and non-clinical areas. Responses were on a five-point Likert scale with a ‘Not relevant/no opinion’ box, and one free text section. Analysis was carried out on 10 scales derived from the questionnaire items through exploratory factor analysis.
Participants Consultants who had completed their specialty training in the north of England between 2004 and 2009 and had held a substantive consultant post in the region for <5 years were sent questionnaires in late 2009.
Results The effective response rate was 70.6% (211/299). Ten factors reflecting areas including clinical skills, communication skills, team and resource management were identified. Overall, higher scores were observed on factors relating to ‘providing care for individual patients’ rather than ‘having responsibility for the system of care’. The lowest scoring factors related to resource management and supervision, with mean scores falling below the scale midpoint. There were no significant differences between specialty groups, or on any demographic variables.
Conclusions A questionnaire to measure new consultants' perceptions of how well their specialty training had prepared them for practice was developed and validated. Findings were similar across specialties, suggesting that training programmes in all areas need to integrate higher-level management skills into their curricula, alongside the development of clinical expertise.
- Medical education and training
- specialty training
- consultants
- leadership and management
- registrars
- hospital
- attending physicians
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- Medical education and training
- specialty training
- consultants
- leadership and management
- registrars
- hospital
- attending physicians
Introduction
The transition from trainee to senior grade doctor (specialist registrar to consultant, or resident to attending) is a challenging and stressful stage in a doctor's career.1–5 The consultant role in a modern healthcare setting involves greater responsibility in areas such as service planning, staff management, managing resources and healthcare governance, and doctors have reported feeling less prepared for these non-clinical aspects of the role than for the clinical aspects.4–10 Recognition that doctors have roles beyond clinical care, for which they may not be prepared by curricula, is not new,11 ,12 but is an area of concern which has still not been fully resolved.
The involvement of doctors in the organisation of services is seen as important if progress is to be made in providing high-quality care.13 ,14 A stronger leadership role for doctors in key management practices has been linked to better healthcare and higher productivity,15 and lack of involvement of doctors in the management and leadership of an organisation can be linked to failures in care.16 Key factors identified in these failures include inadequate medical leadership, poor communication, disempowerment of staff and patients and a disconnection between staff and managers.17 The complex nature of healthcare organisations as professional bureaucracies requires leadership at different levels, not just at the top.18
Internationally, it is recognised that the responsibilities of doctors are changing, with increased team-working and accountability for a system that delivers healthcare to the population, as well as for care of the individual patient.18 ,19 For example, in the UK, since the early 1980s doctors have been required to become more accountable for making decisions on resource allocation. These changes run counter to the cultural values usually ascribed to doctors, that is, a strong sense of clinical autonomy and accountability to individual patients,20 and may have created tensions between doctors and managers.18 ,21 The experiences of clinicians who have made the transition to management roles indicate an essential difference in professional identity,22 and the professional status of physicians comprises values and norms different to the economic goals of hospitals.23
The first qualitative phase of the current study found that trainers, specialist trainees and curricula do not seem to fully acknowledge the diversity and complexity of the role of the modern medical consultant.6 This earlier work is outlined in box 1.
Summary of qualitative study
The aim of the qualitative study was to determine the extent to which specialty training provides doctors with the skills they require when they become consultants.
Face-to-face interviews with 32 final year specialty trainees and 20 telephone interviews with newly appointed consultants explored expectations of the consultant role and their own preparedness. Issues were triangulated with telephone interviews with 12 medical managers who had an overview of new consultants' performance.
There was agreement that clinical work was the area with the highest perception and observation of preparedness, with some adjustment needed to increasing responsibility, including for decision making, prioritisation and delegation. Understanding of, and adjustment to, a more organisational and managerial role was needed, in particular, with regard to designing, developing and changing services. There was anticipation of poor preparedness for people management, for example, addressing poor performance, and new consultants felt poorly prepared for providing feedback to trainees. Other areas of concern included dealing with complaints, time management and job planning. Some specialty trainees lacked full appreciation of all aspects of the consultant role, and exposure to the full role varied, for example, opportunities to attend management meetings and exposure to complaints procedures.
The second phase of the work sought to further explore whether UK specialty training prepares consultants fully for the new roles they will play in a modern healthcare setting. The study was carried out in one region of the UK—the Northern Deanery (deaneries are organisations within the structure of the UK National Health Service (NHS) responsible for postgraduate medical and dental training at regional level. The Northern Deanery covers the northeast of England and parts of Cumbria to the west). Specialty curricula are set at a national level, although delivery may vary at a local level.
The aim was to establish the perceived preparedness, for a number of aspects of practice, of a larger group of new consultants working in a range of specialties. A questionnaire was used as it allows data to be gathered from a larger sample. The objectives of this phase of the study were:
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To develop and validate a measure of new consultants' perceptions of their preparedness for practice.
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To compare preparedness for different aspects of the role.
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To compare the preparedness of different subgroups through implementation of this tool.
Method
Questionnaire development
A cross-specialty questionnaire was developed from themes generated from the qualitative work, from earlier literature and through consultation with experts. The items were designed to cover six areas which were identified as important: clinical skills, communication, teaching and supervision, management and team-working, healthcare governance and general professional aspects of the role of consultant. The aim of the questionnaire was to produce aggregated scales to measure preparedness for different areas of practice.
The questionnaire was pre-tested with an opportunistic sample of 12 newly appointed consultants from a range of specialties working in the Northern Deanery. This resulted in changes to the wording of five questions and the addition of three more questions. A revised version of the questionnaire was then piloted by post with a larger sample of 30 newly appointed consultants selected randomly from the full sample. As this resulted in no further changes to the questionnaire these responses were included in the final analysis.
The final version of the questionnaire comprised 68 items which asked respondents how well their specialty training had prepared them for the role of consultant in each of the six areas. Response to all items was on a five-point Likert scale with anchors at each end only—from 1 (‘not at all well’) to 5 (‘extremely well’). A not relevant/no opinion box was also included. A free text section enabled respondents to provide additional comments about their specialty training or recommendations for improvement.
Participants
The questionnaire was distributed by post to 323 consultants who had completed their specialty training in the Northern Deanery between 2004 and 2009, and had been working in a substantive consultant post in the region for less than five years. Participants were recruited from a consultant lists matched against Northern Deanery databases for date of completion of training. Two screening questions were included in the questionnaire to ensure that the responses came from the target sample (ie, location of specialty training and length of time in post). The questionnaire was distributed in late 2009 and was followed up by two reminders, two weeks and four weeks after the initial distribution. The questionnaires were returned directly to the researchers and had no identification code, thus ensuring anonymity of responses.
Data analysis
Validation analysis
To ensure the construct validity of the questionnaire, the proportions of missing data per items were examined (high levels of missing data suggesting that an item is inappropriate or unclear), and an exploratory factor analysis conducted to establish how items associated with different components of practice relate to each other. Reliability statistics (Cronbach's α) were calculated for the resultant scales. Because the questionnaire is measuring subjective preparedness, and there are no adequate indicators of actual preparedness to indicate actual preparedness, no analysis of predictive or concurrent validity is possible.
Exploratory analysis
Descriptive statistics for the different factors were examined to identify areas of high and low perceived preparedness. Comparisons between specialty groups, male and female doctors, and those qualified in the UK and elsewhere were conducted using nonparametric significance tests.
Results
Of the 323 questionnaires distributed, 24 were returned undelivered due to incorrect addresses. Two hundred and eleven questionnaires were completed (65.3% of the total), giving an effective response rate of 70.6%.
Demographics
The demographic breakdown of the sample is given in table 1. The majority of responses were from men (62.6%, n=132; 37.4%, n=79 from women), and most were in the 35–44 age group (81.5%, n=172). The majority described themselves as white (65.8%, n=139, of whom 123 described themselves as ‘white British’). Only one reported that they had a disability.
Sample demographics
Respondents had completed their basic medical education in 14 countries, most in the UK (68.7%, n=145), followed by India (19%, n=40). To consider any effects of place of undergraduate study, the reported countries were re-coded to compare UK (n=145), European Economic Area (n=13) and other international graduates (n=47).
While respondents were selected on the basis of training in the Northern Deanery, 14.7% (n=31) reported they had also undertaken some training in another deanery. Several had completed at least some of their specialty training in part-time hours (15.7%, n=33), and 29.3% (n=60) had completed a doctorate (MD or PhD) during their training. Respondents had been in a substantive consultant post for between one month and five years (mean=30.6 months).
Representation of different specialties
The questionnaire asked respondents to provide their clinical specialty as a free text response. Responses ranged from the general (eg, medicine, surgery) to specific subspecialties (eg, neonatology, hepatology, neuroradiology). To allow comparisons between groups, these were re-coded into broad specialty groups providing sufficient numbers for statistical comparison. These groupings should meaningfully aggregate different training experiences. Frequencies of different specialty groups, and their gender profiles, are given in table 2.
Frequencies of specialty groups, and gender profiles
Validation analysis
Use of scale and missing data
There were no missing data arising from items not being completed, and low numbers of ‘not relevant’ responses (across all items, for all respondents, there were 396 ‘not relevant’ responses, <2% of the total). Table 3 lists those items for which more than 5% of responses were ‘not relevant’. Together, these account for 61% of all such responses. Within these, there is over-representation of lab medicine (15% of responses compared with 4% of sample), and radiology (19% compared with 7%), and under-representation of medicine and surgery (respectively, 18% of responses and 33% of sample, and 3% of responses and 16% of sample). This suggests that the items are less likely to be relevant to those doctors who do not have constant patient contact.
Items which had more than 5% of responses ‘not relevant’
These figures indicate content validity, as items are felt to be relevant to the majority of respondents. The majority of the 68 items showed use of both ends of the scale, indicating discriminant validity. While there was a negative skew with some items having few ratings at 1 or 2 (indicating preparedness), this is not considered a problem in a sample who have completed training.
Factor analysis
Principal components analysis (PCA) was carried out in SPSS V.17. ‘Not applicable’ responses were treated as missing data in this analysis.
An initial analysis identified a low Kaiser-Mayer-Olkin statistics of sampling adequacy (KMO) of 0.677. Examination of KMOs for individual items identified one (for ‘Clin_constructing procedures’) as particularly low at 0.366. Repeating the analysis with this item omitted increased the overall KMO to 0.846, defined as ‘good’ according to Field,24 but there were multiple cross-loadings and spurious factors consisting of just one item.
Elimination of cross-loading items resulted in a 10 factor solution (eigenvalues >1), with a KMO of 0.867, and communalities ranging from 0.607 to 0.888, meaning that between 61% and 89% of the variance in these items is explained by the retained factors. No cross-loadings with differences of <0.3 were present in the final factor structure. The KMO and communality statistics are taken to be indicative of a dataset appropriate for factor analysis, and are preferred as an indicator of appropriateness, rather than the ratio of participants to items.25
The solution is summarised in table 4, which gives the items with a loading >0.40 (ie, accounting for more than 16% of variance of the factor), and the variance explained for each factor. The solution explains 79.7% of the total variance.
Factor labels, items loading >0.40 and variance explained
Descriptive statistics
Table 5 presents the descriptive statistics for the factors as calculated from the simple aggregation of the items shown in table 4. Each aggregated scale shows internal consistency, with Cronbach's α for each factor >0.8. As eight of the 10 factors were scored at or above the midpoint, the results tended towards preparedness, although several were nearer the neutral midpoint than the upper end of the scale. Two factors had means (and 95% CIs) below the midpoint. While not at the bottom of the scale, these factors indicate relatively low preparedness.
Un-weighted mean scores for items in table 3 (factors sorted in order of descending mean score)
Overall, the factors with means at the upper end of the scale were those which may be seen as related to ‘being a clinician’ rather than ‘being a manager’; that is, the skills which are part of the standard course of practice as a trainee, compared with those which are only part of a consultant's role.
At the lower end of the scale, the factors relating to resource management and supervision had mean scores below the midpoint. Time management and ‘supporting activities’ were also quite low. Interestingly, teaching is rated relatively high compared with supervision, suggesting it is the management, and dealing with concerns about poor performance, rather than strictly the educational component, for which the respondents feel under-prepared.
Differences between subgroups
Further analysis compared the factor scores (calculated by the regression method, so taking account of the weighted contribution of each item) between different subgroups: specialty group, gender, age, country of primary medical qualification, whether trainees had trained full or part-time, or whether they had completed a doctorate. Nonparametric methods were used because of the differences in sample sizes. The Bonferroni correction for multiple comparisons was applied to reduce the likelihood of a type I error (false positive)—this moves the threshold for statistical significance to reflect the ‘family’ of tests being carried out, in this case, the 10 factors. Results were, therefore, considered to be statistically significant if p<0.005 (rather than 0.05). No results were significant at this level, and the conclusion, therefore, is that the factor scores are consistent across the sample subgroups.
Respondents had been in a substantive consultant post for between one month and five years (mean=30.6 months). A negative correlation between this variable and the ‘Teaching’ factor was statistically significant, albeit with a small effect size (ρ=−0.259, p<0.01). This suggests that the respondents felt less prepared for teaching the longer they had been in their consultant post. No other correlations were statistically significant (all other ρ<0.2).
Free text responses
The free text responses in box 2 illustrate how preparedness for some of these factors is described by some respondents, provide some suggested improvements to training, and give an indication of some trainee attitudes towards training.
Illustrative free text responses
Experiences of training
I think my clinical training in diagnostic and clinical management, both of patients and the resources of the NHS, has been excellent. I have felt that education in managing complaints/difficult patients and particularly problematic colleagues has been poor. In addition, the managerial aspects of putting together business plans, and the organisation of the NHS, are poorly covered. I had to attend extra courses to gain some knowledge in these areas. (CQ10)
Training was good in day-to-day work management in (specialty) with good on-call experience. I feel training was lacking in some areas, such as dealing with complaints, setting up new services, business plans, etc. Apart from supervising junior trainees when I was a final year SpR, I did not feel that I was treated any different, and would have benefited from more involvement in managerial areas as far as possible. (CQ185)
The system of rotating around hospitals generally provided good and varied clinical training. However, it made it difficult to become involved in some of the non-clinical aspects of the job, particularly, designing new services, initiating/managing change, etc. (CQ77)
Suggested improvements to training
A major weakness of the otherwise good training was the poor involvement in the business management side. Even in my final year, I was never invited or involved in any business meetings, it was more important for the SpR to keep up the service. I would suggest that SpRs should learn the business side of the NHS organisation as they go along, like they do with their teaching skills. I also suggest that SpRs should have more formal teaching in education, whether it is as a teacher or clinical supervisor. Also, the risk management issues and implications could be better taught. However, I had an excellent clinical training. (CQ120)
As my consultant role evolves, I realise that my understanding of how the 'system' really works, and who I need to speak to, to make things happen, is not as good as I thought it was. The 'non' clinical managerial roles now seem to outweigh the clinical tasks on which I focused during training. These aspects of the role should be an earlier part of specialty training. (CQ74)
Clear guidance on SPA/job planning would have been very helpful (eg, from BMA rep). Managing complaints: training needed. Managing poor performing juniors: need advice/training (CQ93)
I think more specific time on day-to-day management of a service would help, that is, prioritising OP (outpatient) referrals, how to change/set up a service, tying in service with targets, responding to complaints. Need more on NHS structure (national and local) earlier on rather than just in final year management course, which is good, but almost too new to take in at each stage (CQ190)
Encourage greater exposure to management meetings in the final 12 months of training (CQ42)
All final and pre-final registrars need training in follow up of their own patients for a year with consultant supervision/support in outpatient setting. (CQ26).
Attitude towards training
The most important aspect of specialty training in my view remains clinical, especially for specialties like surgery. If you can't operate you can't do the job! (CQ111).
In some areas, my negative choices may reflect a lack of personal motivation in seeking knowledge/experiences. I think these areas MUST be part of the trainee's curriculum. (CQ79).
Discussion
This paper has presented the development and validation of a questionnaire to assess new consultants' perceptions of the degree to which their specialty training prepared them for work as a consultant. Ten areas of practice were derived from a factor analysis, with a trend towards greater preparedness for more obviously clinical tasks, and less preparedness for management tasks. No differences were found between specialty or demographic groups.
These findings support those of earlier research in individual specialties, regarding perceptions of higher preparedness for clinical than non-clinical aspects of the consultant role.4–10 In this study, the areas in which respondents felt more prepared may be seen as those relating to ‘providing care for individual patients' rather than ‘having responsibility for the system of care’.
Lack of preparedness for some aspects of a senior management role (such as resource management—related to finance and service development) may be expected to an extent as there will be fewer opportunities to practise those aspects in training. However, even in some elements of practice that have traditionally been part of the consultant role (eg, time management and supervision), new consultants did not rate their preparedness highly. The results do not necessarily mean that the new consultants are unprepared or lack competence, and the midpoint of the scale around which the lower means clustered was neutral. However, if trainees complete their training even feeling underprepared for some, even minor, aspects of the job they have been trained for, there may be concerns about elements of their training.
The strength of the current study is its cross-specialty scope, large sample size and a high response rate. Most other studies on the transition from specialist trainee to medical specialist have been limited by the fact that they report on transitions in highly specialised medical disciplines, which hampers their transferability to a broader range of disciplines.26 A limitation of this study is that it provides only the perspective of newly appointed consultants themselves. However, while perception of preparedness may not be indicative of actual ability, it does have a potential effect on the doctors' confidence to take on, or even avoid, certain aspects of the role. A further possible limitation is that the study was conducted in one area of the UK only. In the UK, curricula are nationally set through Royal Colleges and the GMC; while there may be national differences, there is no reason to suggest these may be greater than local differences. However, generalisation to other countries and other healthcare systems cannot be assumed. Since these respondents started their medical training, changes have been made to curricula at undergraduate and postgraduate levels, and it may be that repeating this study in a few years would find greater preparedness for managerial responsibility.
Internationally, many organisations and governments have recognised that doctors need a set of skills greater than those required to look after the health of individual patients. It has been identified that involving doctors in management and leadership is a crucial factor contributing to improvement in healthcare organisations, and there is a need to develop these skills.13–16 ,18 ,20 ,27 This study, however, demonstrates that doctors in the UK's NHS, in all specialties, feel less prepared by their training for these broader aspects of the role. At the same time, policy changes28 and budgetary restrictions require clinicians to be involved in decision-making processes far more centrally.
While free text responses suggest that there are implications for trainees themselves, in terms of their prioritisation and proactiveness, the capacity to gain non-clinical skills needs to be seen as core by trainees and trainers alike, and the findings of this study clearly have implications for those responsible for medical training.
In the UK, the GMC has already responded to the changing nature of the role of doctors in healthcare in its regulatory standards, for example, by making explicit the role of ‘Doctor as Leader’ within its core statement of Good Medical Practice,29 setting out the wider responsibilities of doctors in draft guidance on Good Management Practice 30 and issuing a new guidance document on leadership and management for all doctors.31 Elsewhere in the world, doctors are being encouraged to take on broader leadership roles. Denmark has been noted for its explicit aim to engage doctors in leadership roles and its efforts to provide training and support at postgraduate and consultant levels.32 In Canada, the physician manager role has been identified as one of the seven core competencies for specialist physicians (http://rcpsc.medical.org/canmeds/index.php). In the USA, it has been suggested that time away from direct clinical responsibilities is needed to allow for substantial engagement in other physician activities, such as management of the delivery of healthcare services, quality improvement initiatives, community work and advocacy.33 Leadership training at undergraduate level, however, seems to be less common internationally.32
In the UK, a five-domain Medical Leadership Competency Framework, along with a Medical Engagement Scale, has been designed to ensure that all medical students and doctors (hospital doctors and general practitioners) acquire competence in management and leadership and understand that this is integral to their role.34 The Medical Leadership Competency Framework has now been incorporated into undergraduate and postgraduate training.
Within the UK, Medical Royal Colleges are addressing this in different ways. For example, the Royal College of Psychiatrists is just about to produce a study Guide for Higher Trainees which uses the findings from this research to address deficits in training, by setting out opportunities for on-the-job learning in the hope that future consultants will be more prepared for the demands of their job.
Future research may be needed to ensure these educational interventions make a difference for future medical leaders.
Conclusion
This paper moves away from using the term management and/or leadership, as these terms can have many definitions and lack specificity. Instead, it is suggested that one set of skills is required to look after individual patients and another set of skills and knowledge is required by doctors to ensure a healthcare organisation provides high-quality healthcare to all patients. While recognising these skills can overlap and be complementary, it is this second category in which doctors feel less confident and less well trained. There are, possibly, many reasons for this, which may include relatively low representation in the curriculum, timing or methods of assessment, and trainee attention and engagement. The similarity of findings across specialties suggests that training programmes in all areas need to integrate management skills into their curricula alongside the development of the clinical expertise that is core to their consultant role. Particular attention may need to be given to the resource management and service development aspects of training, and also to supervision and handling poor performance. Further work will be required to explore the best methods of developing these skills and competencies for doctors.
Main messages
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New consultants feel less prepared by their training for elements of their work relating to the organisation of healthcare, rather than delivery of care to the individual patient.
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Findings were similar across specialties, suggesting that training programmes in all areas need to integrate higher-level management skills into their curricula alongside the development of clinical expertise.
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Specialty training programmes should review their coverage of areas including resource management, service development, supervision and dealing with poor performance.
Current research questions
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How can training programmes improve management skills without compromising clinical skills?
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To what extent do the medical profession, including specialty trainees, value management skills in training?
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How can training programmes reflect and respond to policy developments, such as changes in commissioning services?
Key references
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Brown J, Ryland I, Shaw N, et al. Working as a newly appointed consultant: a study into the transition from specialist registrar. Br J Hosp Med 2009;70:410–14.
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Westerman M, Teunissen PW, van der Vleuten CPM, et al. Understanding the transition from resident to attending physician: a transdisciplinary, qualitative study. Acad Med 2010;85:1914–19.
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Morrow G, Illing J, Burford B, et al. Are specialist registrars fully prepared for the role of consultant? Clin Teach 2009;6:87–90.
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Busari JO, Berkenbosch L, Brouns JW. Physicians as managers of health care delivery and the implications for postgraduate medical training: a literature review. Teach Learn Med 2011;23:186–96.
Acknowledgments
We would like to thank all the consultants who completed this questionnaire. We also thank Paul Crampton, Research Assistant, for support with data entry.
References
Footnotes
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Funding The work was carried out while GM, BB, JI and NR were employed by the Northern Deanery. GM, BB and JI were employed to carry out independent research on behalf of the Deanery and NR acted as adviser to this piece of research.
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Competing interests This work was carried out while GM, BB and JI and NR were employed by the Northern Deanery. GM, BB and JI were funded to carry out independent research on behalf of the Deanery; NR acted as adviser to this piece of research; they declare no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work. RB declares no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.
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Ethics approval This study received ethical approval from the NHS National Research Ethics Service (Sunderland Research Ethics Committee).
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Provenance and peer review Not commissioned; externally peer reviewed.