Senior house ocer perspectives on the educational benets of a local teaching programme at a specialist orthopaedic hospital

Delivering local teaching programmes equally relevant to all senior house ocer (SHO) equivalent junior doctors within a tertiary level specialist hospital is challenging. This study aimed to establish the views of SHOs within a specialist orthopaedic hospital on the value of the current local teaching programme to their educational needs how it may potentially be improved? Data was collected via questionnaires of SHOs selected through a combination of convenience and purposive sampling. Responses underwent thematic analysis which utilised a hybrid model of a priori and emergent coding.


Background
The Royal National Orthopaedic Hospital is the largest specialist tertiary referral Orthopaedic hospital within the United Kingdom. The senior house o cers (SHOs) within the Trust are from varied clinical backgrounds with differing levels of experience, career aspirations and training needs.
There is a weekly on-site 2-hour formal teaching programme intended solely for the SHOs within the Trust. This is aimed at providing generalised orthopaedic education catering to the learning needs of this group and is delivered by Trust Consultants and specialist registrar doctors. It is protected 'bleep free' educational time. Despite this, attendance at the teaching programme has previously been noted as being variable.

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The Committee of Postgraduate Medical Deans (COPMED) previously recommended a minimum set of standards for training SHOs, which included 'four hours of bleep free post-graduate education per week' (1). Despite these recommendations, previous studies have demonstrated this is not always provided to trainees. 47% of SHOs across a range of specialties and 69% of surgical trainees were found to not receive protected teaching in the study conducted by Cooke and Hurlock (1999) based on the questionnaire responses for 439 junior doctors. Although this study does highlight shortcomings in the provision of protected teaching time, it does not explore the potential reasons behind this.
Flett et al (2) compared the attendance rates of 285 SHOs among three different specialties at postgraduate teaching within the same Deanery. The attendance rate was found to be as low as 40.8% with only 55.1% of responders stating they had protected teaching time. The study reported 'service commitments' were a major obstacle to attendance but the study did not include any surgical trainees and was based solely on quantitative questionnaires and therefore lacked rich, qualitative data. (4) similarly identi ed service commitments and staff shortages as barriers to attending teaching. These di culties may potentially be addressed however by 'Trusts that accept responsibility to educate and train their SHOs' although such 'in-house' teaching is challenging to implement (5,6).

Tasker et al. (3) and Anyiam et al
There are currently no published studies reporting upon the effectiveness of a local teaching programme at a specialist orthopaedic hospital, or indeed any other specialist hospital. Many of the SHOs within the hospital Trust at whom this teaching is aimed are not in formal training programmes. For them it therefore may represent their only regular formal teaching opportunity, placing an even greater signi cance upon it.
Given the importance of this teaching programme to SHOs within the Trust and the current absence of any published reports of comparable programmes, the aim of this study is to elicit SHO perspectives on the educational bene ts of a local teaching programme at a specialist orthopaedic hospital. Through this process, the relevance and value of the current teaching programme can be assessed as well as identifying means by which it may potentially be improved?

Methods
Questionnaires were chosen as the method of data collection as it was felt by the authors a well-designed questionnaire compiled predominantly to extract rich qualitative data would provide the information needed to address the research questions and provide an opportunity for all SHOs within the Trust to participate within the study.
Focus groups and structured interviews were considered but deemed not appropriate for the purposes of this study predominately for pragmatic reasons. The relatively limited number of SHOs within the hospital and their busy clinical work load leads to a very pressured working environment making more time consuming methods of data collection unfeasible.
Participants were selected by a combination of both convenience and purposive sampling. An email was sent to all the SHOs within the Trust containing an information sheet informing them of the nature of the study. A copy of the questionnaire was also attached to the email for reference.
Multiple printed copies of the questionnaire were provided to the current 'SHO lead' for the teaching programme to circulate at teaching sessions and return to the study author completed anonymously. The 'SHO lead' for the teaching programme attends virtually every teaching session, thereby giving multiple opportunities for the other SHOs who may attend the teaching programme more sporadically to complete the questionnaire. The option of returning the emailed questionnaire completed anonymously to the author's hospital 'pigeon hole' was also offered, thereby giving even the SHOs who may never attend teaching the opportunity to express their opinions.
Questions were included to determine duration of post-graduate experience, current career grade and career aspirations to help establish the heterogeneity of the group the teaching programme was being delivered to.
The study was conducted between January-April 2019. Formal ethics approval was not required as no randomisation or group comparison was to be performed. The surveys were anonymised.
Responses written within completed questionnaires underwent thematic analysis. A hybrid model of a priori coding based on assumed responses and emergent coding to re ect any unexpected responses was utilised.
The initial aim was to receive a response from at least 12 (50%) of the SHOs within the Trust. This number was to be re-evaluated during the study period to determine if theme saturation was apparent on attainment of the provisional target of participants.

Results
Completed questionnaires were returned from a total of 12 SHOs. There was a broad spectrum of postgraduate medical experience amongst responders, ranging from 1.5-10.0 years (mean 4.1 years). Only 4 responders were in a 'Core' surgical training programme and 8 responders were 'Trust grade' service SHOs with the length of time of all responders being employed within the Trust ranging from 3 months -2 years (mean 9.8 months). In terms of frequency of attendance, 6 responders attended 'nearly always', 5 'sometimes' and 1 'rarely'. A diverse range of career aspirations were expressed amongst responders as follows; 4 orthopaedic surgeons, 3 general practitioners, 2 radiologists, 1 medical director, 1 sports & exercise medicine physician and 1 'undecided'.
After thematic analysis of the 12 completed questionnaires, theme saturation was reached and therefore additional participants were not required.
A total of 12 codes were identi ed which led to the formation of 4 themes: 1. Quality/utility of teaching 2. Content of teaching 3. Accessibility of teaching 4. Non-educational bene ts of teaching programme Table 1 provides full details of thematic analysis, coding and quotes from questionnaires upon which these codes were formulated.

Discussion
In terms of quality of the current teaching programme, the feedback was largely positive, being described as as 'generally good', 'often useful' and 'up to date'. It was clear from the responses the teaching was well received, especially by the Trust grade SHOs for whom this teaching programme represents their only formal regular teaching, epitomised by the comment 'please continue! It is the only regular formal teaching we receive'.
Not unexpectedly given the diverse range of educational needs of this heterogeneous learning group, opinions on the utility and content of the teaching programme were somewhat more varied. The majority of Trust grade SHOs felt the 'teaching programme relevant' to their educational needs and contained an appropriate content which 'helped improve knowledge', covered 'relevant topics' and found it 'useful to be taught concepts which have clinical applications'. This was not universal however and in particular the 'Core' surgical trainees and some of the more experienced Trust SHOs suggested the teaching is 'at times a little basic' and does not always cover 'orthopaedic/surgical topics' making them feel it was not always 'directly relevant to my educational needs' and would therefore prefer 'more orthopaedic subjects'.
There was an appreciation demonstrated by the more senior trainees however regarding the reasons for this, commenting on the di culty in 'juggling ortho core trainees and general practice trainees' meaning that inevitably 'it's di cult to gain enough speci c teaching matching my needs' and although 'orthopaedic trainees would prefer orthopaedic teaching aimed at a higher level', this would be 'di cult to arrange' and is 'impossible for teachers to keep the topic relevant for everyone'.
In terms of the learner perspectives on the person delivering the teaching, it was generally felt the programme 'bene ts from teaching being delivered by senior clinicians' and there was a preference towards 'consultant lead teaching'. Sessions delivered by non-Consultants were also well received however, with a suggestion being made to 'encourage registrars to give more teaching sessions' and indeed the potential of near-peer teaching to enhance the training of junior doctors is widely described in medical education literature (7).
There was also a demand for more 'hands on' teaching sessions and it was expressed 'more interactive media', 'slide shows' and 'videos demonstrating surgical procedures' would be well received. This demonstrates a variety of preferred learner styles within the group, as described in Flemming's VARK model (8).
In order to enhance the teaching programme, the general theme was compromise is required to make it relevant to all and that 'topics should be interesting for most the SHOs' and 'not focused on speci c areas'. In keeping with this, suggestions were made for a greater emphasis on 'learning in related elds like pathology and haematology' and for 'more radiology teaching' to be included as part of the programme.
Barriers to attending post-graduate medical education programmes are well recognised (9)(10)(11). Workplace related barriers such as clinical commitments were the most frequently cited barriers to attendance in this study. Reasons for not being able to attend included 'teaching falls on theatre days', 'on-call', 'busy doing ward jobs' and 'sometimes it's my clinic day and I am therefore unable to attend'. There was an appreciation expressed by those who did make it to the teaching sessions however that the 'teaching is bleep protected' and it is 'good that it is bleep free'.
Physical barriers to attendance were not frequently cited to be an issue within this study as the 'teaching is on-site, therefore generally convenient to attend'. Despite this, attendance at the teaching programme has anecdotally been described as being 'quite variable' with a suggestion therefore made to 'make teaching compulsory as will improve attendance'. Although the current teaching programme is bleep protected and provided for the bene t of all SHOs within the Trust, individual attendance is not currently closely scrutinised.
The non-educational bene ts of the teaching programme were identi ed by numerous trainees. The social bene ts of what is 'often the only chance' to 'get to know other SHOs in the hospital' was cited by many as a positive aspect of the teaching programme and 'lunch being provided' was described as a 'nice gesture'. Its value in terms of peer support was also noted as it 'provides an opportunity to discuss work and training related issues with colleagues'.
Given half the SHO within the Trust completed the survey, we feel this study does provide a realistic insight into their perspectives of the current teaching programme and aspects of it they would like to enhance. There may inevitably be an element of volunteer bias affecting the outcome, as the views expressed by the trainees who took the time to complete the questionnaire may not necessarily re ect the views of those who did not complete the questionnaire. In order to minimise this bias, the option of participating in the study remotely was conveyed to all SHOs and the questionnaires were circulated at multiple teaching sessions to allow even infrequent attenders an opportunity to submit as response. Despite these measures however, it is unlikely that all bias was completed eliminated.
It is unfortunately not possible to draw a like for like comparison between this and any other study due to the absence of any other published studies which address the exact same question. It does however illustrate the teaching programme in question is generally well received and is felt to provide multiple bene ts, both educational and non-educational to those that attend. It also highlights the di culties in delivering a teaching programme to a learner group with such diverse educational needs and has demonstrated that barriers to attendance do still exist which are similar in nature to those described in previous studies.

Conclusion
This study highlights the di culties in delivering a teaching programme to a clinical learner group with varied educational needs within a specialist hospital setting. Despite these di culties, we have demonstrated such a teaching programme can be of signi cant educational and non-educational bene t. Issues regarding making teaching equally relevant to all within a diverse clinical learner group may potentially be minimised by learner survey to identify educational topics of equivalent utility. Such topics can subsequently be incorporated into future teaching sessions.