Twenty-six clinical teaching fellows and junior doctors were invited to take part, of which 12 did not respond or declined to participate. The fourteen doctors who took part ranged from FY2 to ST3 (equivalent) level currently worked in a broad range of inpatient specialties across medicine, surgery, paediatrics, emergency and critical care (Figure 1). Ten were working in a split clinical and educational role.
Three focus groups were carried out, each with between 4-6 participants lasting around 20 minutes in total.
Most junior doctors (85.7%, n=12) reported ‘often’ or ‘sometimes’ having medical students attached to them for clerking shifts. Participants reported that students typically spent between 1-2 and 2-4 hours (92.9%, n=13) with them per shift, though they were reportedly only engaged in ‘active teaching’ for around half this time.
Only a quarter of participants felt they taught a lot on the acute take (28.6%, n=4), with many reporting difficulties finding time to teach (76.6%, n=11) and few felt their teaching was effective (35.7%, n=5). Teaching on the acute take is rarely or never planned (78.6%, n=11) and participants found accessing relevant resources difficult (85.7%, n=12); most favouring online resources over paper resources (50.0% vs. 21.4% respectively reported using them ‘sometimes’ or ‘often’). Despite these challenges, most participants still felt they delivered relevant teaching (57.1%, n=8), though fewer (28.6%, n=4) report receiving feedback for their teaching on a regular basis.
Key themes were identified and organised within six key areas. Firstly, issues relating to how junior doctors perceived themselves, described as ‘clinical teacher factors’; how they perceived medical students described as ‘medical student factors’; and factors relating to interactions between themselves, students and the wider clinical team termed ‘team factors’. In addition, junior doctors described issues affecting their teaching relating to delivery of clinical care (‘clinical service factors’), educational provision (‘educational service factors’) and availability of resources for teaching, termed ‘resource factors’.
Clinical teacher factors
Junior doctors often questioned their own ability in managing acutely unwell patient (1.1a), with some citing their lack of exposure an important contributing factor. They perceived pressures to clerk enough patients and deliver timely patient care (1.1b).
“…when there's quite a lot of complex things going on usually and sometimes half of them I might not know myself if it's a really complex patient, and want to discuss it with someone else and that also creates a bit of a barrier to teaching as well if you're not sure yourself.“ – P8 (FG2)
“Time pressures, guilt. […] it slows you down a lot if you have a student with you for a whole clerking and you're having to explain your work” – P2 (FG1)
Many participants lacked confidence in their ability as competent clinical teachers (1.2a). In addition to clinical demand, they perceived competing pressures from students to deliver relevant and engaging learning activities (1.2b).
“…you're taking responsibility and if you're going to say to your med student 'right, go off and spend an hour clerking […] without necessarily having done a bit of pre-work yourself and just sussed it out a little bit, sometimes I feel a bit nervous sending them away.” – P6 (FG1)
“In terms of workload, so being really busy, it was like an extra pressure to try and make sure that the students were getting what they wanted” – P7 (FG2)
They recognised that delivery of student-focused teaching required an understanding of students’ ability and learning needs (1.2c).
“I think knowing their learning objectives and kind of knowing exactly what they want to get out of the day right at the start would probably be quite good because that could then, you could direct them to where they're going to learn the most.” – P9 (FG2)
Medical student factors
Participants reported students’ presence within the acute medical team was highly variable and attributed this to lack of student engagement (2.1). They felt students’ perceptions of the educational value of time on the acute take was varied, because of their diverse experiences (2.2).
"the other limit that I sort of, you know, no one really talks about is the students just don't turn up”- P10 (FG2)
“I think as a med student previously I felt like I wasn't learning that much and I could get so much more if I sat down reading a book in the same amount of time versus that amount of time in a hospital” – P8 (FG2)
"…there's other specialties that they can't find their consultant or there's nothing going on so like, [the] acute take's their first port of call.” – P13 (FG3)
Many junior doctors recognised the need for students to be aware of their own learning needs goals (2.3).
“I did a gynae rotation and they seemed to have a specific idea of what exactly they wanted to achieve which as better when they came to you, so you could facilitate that.” – P7 (FG2)
Key themes relating to the wider clinical team included a perception that senior clinicians were a source of pressure to deliver timely patient care (3.1).
“I am aware that sometimes people are less keen for you and they do kind of, hound a bit and be like, not 'stop teaching', but 'you need to prioritise a bit differently'.” – P4 (FG1)
Participants felt that student integration into the clinical team, for example by attending the morning handover, was important for their experiences of participation (3.2).
"It's easier to find the students, so if you're enthusiastic about teaching, they'll be at the surgical handover and the on call SHO will be in the handover.“ – P10 (FG2)
Junior doctors felt that senior colleagues determined the acceptability of teaching and shaped the culture within the team (3.3a); many were role-models for junior doctors
“I think the general principle is when the consultants have more involvement in the academies or more involvement in teaching in general, they're going to be more engaging and they're going to promote it more.” – P11 (FG3)
Though some junior doctors perceived the physical presence of seniors whilst teaching intimidating.
“it's also a bit intimidating as an F1 to be teaching a medical student in front of your registrar” - P7 (FG2)
They recognized that delivery of teaching was a shared responsibility and a professional requirement for doctors (3.3b), though participants reported that junior doctors tended to be more involved with teaching students than senior colleagues (3.4).
“[the student has] been basically taking it in turns with me or doing a clerking at the same time as me and then presenting it back to me and sometimes even presenting it to the post take consultant because they've been quite engaging as well” – P11 (FG3)
“the med students tend to gravitate towards the F1s” – P8 (FG2)
Clinical service factors
Doctors prioritized their time to provide clinical care, teaching students was often seen as a secondary activity (4.1). They described this perception as more intense when workload increased and there was increased pressure to provide patient care (4.2), though they workload varied throughout the day and between specialties (4.3).
“I guess because teaching is a...[pause]...it's a nicety isn't it, but I guess your job at that point in time is not to spend two hours with a case and getting someone beautifully educated on it, your job is to get through the work isn't it? And that's your priority.” – P2 (FG1)
"if your staffing levels are low and waiting times are high then you don't want to slow“ - P14 (FG3)
“in something like ortho where it was just wildly variable - you could have two referrals a day or twenty!” – P9 (FG2)
The clinical acuity of patients affected the educational opportunities the students could participate in (4.4a) and the degree to which clinicians had to actively engage in supporting them. Participants also described the complexity of patients, particularly between specialties, significantly affected their ability to deliver focused teaching around the case (4.4b). This was noted in particular by more junior participants.
“I sometimes feel nervous about the acuity of the patients as well, so if you're going to put your name next to that person, you're taking responsibility“ – P6 (FG1)
"with surgical and paediatric patients in my opinion […] tend on the whole to be a little younger, a little bit fitter and be less comorbid, […] they're presenting with A problem which then it's quite nice for a medical student to approach that as one problem“ – P9 (FG2)
Educational service factors
Junior doctors highlighted the breadth of learning opportunities that arise on the medical take – from clinical skills and knowledge around specific conditions to more abstract concepts such as clinical reasoning and prioritization (5.1)
“we'd go through x-rays, ECGs, gases, differentials, more resource-based than actually at the bedside, unless someone had something really interesting, I was like 'oh come and look at this sign'. Yeah. Kind of bits around [the case].” – P4 (FG1)
They stressed the need for flexibility in delivery of teaching in response to these opportunistic moments (5.2) and that the value of learning on the acute take was through active participation and experiences (5.3).
“I do think that because probably on the take and with on the wards it's slightly pot-luck as to whether something that's of educational value happens to happen that day or when that happens [...] it's just a different type of education and actually those opportunistic moments are really, really important and yeah. You can't get them from a book.” – P9 (FG2)
“forcing them to think rather than be passive listeners which they would be in a ward round or a clinic. If you get them to clerk on the acute take or get them to go and look things up on the acute take I think it's much more real and relevant and stimulating. – P10 (FG2)
Participants felt a degree of continuity of supervision was beneficial to learners’ experiences to ensure progression of learning (5.4a) and that a longer duration of attachment would be a valuable experience (5.4b).
“without sounding falsely nostalgic, the loss of the firm structure […] you'd get to know them and they would be able to teach you stuff much more consistently and build on the previous teaching sessions.” - P10 (FG2)
" If you come in for five days you'll see one of everything on the paediatric take and you're all set for finals […] if you stay the whole day for five days.” – P10 (FG2)
Scarcity of resources was a factor in the delivering of teaching, with participants noting that whatever resources were available were consistently prioritized for patient care (6.1).
“you often wouldn't be able to get to a computer to order your investigation let alone get up resources for them to learn from so...that was a big problem” – P11 (FG3)
Physical resources such as computer facilities to cross-reference or research topics were hard to come by (6.2a) as were protected teaching spaces (6.2b). Some noted that educational resources would be valuable to reinforce educational concepts and allow clinicians time to deliver care (6.2c).
“in AMU the clerking office is literally like a cupboard and if you were to get a student in to look at an x-ray or you know go through a case with them, somebody else is trying to come in and use the label printer, someone else is trying to come in and carry on with their clerking and actually it's just not a good space to learn in.” – P7 (FG2)
Having resources available - quick things that are quick access that will help and, like if there is any way that you can like send them away to do things while you still get on with something else, that will still be valuable for their time and that would be useful”. - P11 (FG3)
Other resources noted to be influential included the provision of protected time for clinical teaching (6.3a) and variability in the number of appropriate patients to engage in real-patient learning (6.3b).
“You could have a half hour slot or something where you can say 'I'm taking myself out of the take, this is going to be purely education’, so you're a shop-floor teacher for that time - just so you don't have to then worry about the other things and everyone knows that's what you're doing at that time, so you're not to be hounded for charts and all these other things.”- P4 (FG1)
“I think on surgery that we're actually quite lucky in a sense that actually sometimes it's quite quiet and often you don't have patients to take the students around” – P1 (FG1)