Understanding Junior Doctors’ Experiences of Teaching on the Acute Take: A Mixed-Methods Study.

Background New medical graduates report signicant unpreparedness in managing acutely unwell patients, due to limited rst-hand clinical exposure in the undergraduate curriculum. Supporting undergraduate learning around acute admissions can be challenging for junior doctors balancing teaching and clinical responsibilities. We aimed to explore junior doctors’ rst-hand experiences of supporting undergraduate education in the acute admissions setting (take). Methods Fourteen junior doctors in one teaching hospital in South West England took part in a short web-based questionnaire exploring frequency, duration, ecacy, planning and delivery of teaching in the clinical environment. Participants subsequently took part in semi-structured focus groups (4-6 participants in each) which were audio-recorded and transcribed verbatim before being thematically analysed. Results Quantitative results demonstrated junior doctors reported diculties nding time to teach, with many feeling their teaching was ineffective and rarely planned, with challenges nding suitable resources to support teaching delivery.

Early clinical experience and shadowing opportunities positively impact on feelings of student preparedness for future practice 8 and furthermore, students that actively interact with the clinical environment whilst on clinical placements feel better prepared for managing acutely unwell patients 9,10 .
Educational theorists recognise the need for learners to contextualise classroom-based learning through active participation in the workplace [11][12][13] and the key role of clinicians in supporting engagement and facilitating learning 14 .
Whilst many of the learning practices in the workplace are opportunistic and informal [15][16][17][18][19] , medical students may expect to be educated through more structured teaching interactions 20 . Clinicians are expected to provide supportive yet challenging educational experiences 14 whilst balancing responsibilities of intensive, timely clinical care and ensuring patient safety 11,20,21 . Junior doctors enjoy teaching and generally perceive themselves as knowledgeable and competent clinical teachers 22 . However, nding the time to teach students effectively in this busy clinical environment is a signi cant challenge 12,23 . This may also compromise the nature of the interactions between students and clinicians, thereby affecting learning experiences; positive interactions are constructive for student engagement 21 whilst negative student-teacher interactions have been shown to hinder learning 12,23 .
Whilst there is signi cant literature exploring student experiences of acute care placements, evidence is lacking on junior doctors' perceptions of teaching in the acute setting. Our study aimed to explore junior doctors' experiences of teaching undergraduates on the acute take; speci cally what is currently being taught, how it is taught, barriers to teaching and to identify areas for possible improvement.

Setting and participants
Clinical teaching fellows and junior doctors with an interest in medical education, based in one teaching hospital in the South West of England, were invited by email to take part in this study.

Data collection
Participants completed a short web-based questionnaire consisting of three questions exploring frequency and duration of teaching in the acute admissions environment followed by eight Likert-based questions around e cacy and relevance of teaching delivered, alongside resources, planning and feedback. All participants subsequently took part in a semi-structured focus group facilitated by one researcher (CH) based on the topic guide ( Figure 1). Focus groups were audio recorded and transcribed verbatim.
The term 'teaching' is used throughout this study to encompass broader concepts such as supervision and coaching alongside more didactic teaching as it was felt to be more relatable to junior doctors who the researchers felt may not perceive themselves as clinical supervisors, but could relate to the term clinical 'teachers'.

Data analysis
Qualitative data were analysed thematically as de ned by Braun and Clarke 24 using NVivo® software (QSR International, Massachusetts, USA) 25 . Transcriptions were read and independently coded by two researchers (CH and AO) before overarching themes were sought by CH. Final thematic structure and hierarchy was reviewed, de ned and named collaboratively by discussion between CH and AO. Data collection was limited by number of respondents, though many themes reached data saturation.

Ethics
Ethical approval for this study was granted from the University of Bristol Ethics Committee (Application ID 93362) on 16th August 2019. Electronic written consent was provided by participants before taking part in this study.

Participants
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.

Quantitative data
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 di culties nding 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 di cult (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.

Qualitative data
Key themes were identi ed 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 con dence 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 nd their consultant or there's nothing going on so like, [the] acute take's their rst 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 speci c idea of what exactly they wanted to achieve which as better when they came to you, so you could facilitate that." -P7 (FG2)

Team factors
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 nd 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 sta ng 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, signi cantly 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 tter 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 speci c 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 exibility 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 bene cial 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 rm 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 ve days you'll see one of everything on the paediatric take and you're all set for nals […] if you stay the whole day for ve days." -P10 (FG2)

Resource factors
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 o ce 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 in uential 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-oor 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)

Key ndings and relation to literature
The acute take is perceived as a highly pressurised clinical environment with increasingly comorbid patients presenting with complex problems 3,24 , which presents clinical challenges to deliver safe and timely clinical care 1 . However, this environment presents unique learning opportunities across a broad range of presentations alongside development of essential tacit skills such as clinical reasoning, decision making, prioritisation, interprofessional working and communication with colleagues. Extensive literature describes feelings of unpreparedness of new medical graduates in managing acutely ill patients [4][5][6][7][8] , which is re ected in our participants' uncertainty of their ability to provide good clinical care in a timely and organised manner, as doctors with ve or fewer years post-graduate experience. This may re ect di culties learning from the informal and hidden curricula in an environment where non-technical competencies are as important as textbook knowledge 25 . Several papers have described the diverse nature of student experiences in emergency care, where clinicians' attitudes and enacted behaviours impact both positively and negatively on students' perception of medical professionals [26][27][28] . Our participants are perhaps more aware of their own competencies and behaviours when observed by students. Existing work recognises the importance of acute clinical placements in building the necessary skills for competent and con dent practice in the acute admissions environment 4,7,8 , suggesting investment in improving education now, will foster more competent clinicians who go on to become more competent clinical teachers in the future.
Junior doctors have recognised challenges balancing clinical needs of patients with delivery of quality clinical teaching and described tensions arising between balancing their roles of medical practitioner and clinical teacher which are noted in other studies 29,30 . Few participants perceived their teaching to be effective, with many citing concerns over lack of time to provide engaging, focused activities which echoes previous work 31,32 . Our quantitative data corroborate ndings from focus groups, reinforcing that junior doctors nd it di cult to make time to teach on the acute take, that this teaching is rarely planned, and resources are challenging to nd. Evidence suggests that students value placements in emergency care 6,33 and previous work is reassuring in that student satisfaction is no worse when clinical workload is higher 2,34 , instead noting that teachers who are willing to teach, welcoming into the team and discuss their own decision making are much more in uential 2,21,35 .
Our participants highlighted a need for shared consensus over learning goals from acute admissions placements though they recognise teaching is opportunistic and clinical teachers need to formulate learning activities in response 36 . Many researchers have described the need for student engagement in active, well-supported experiential learning 12,14,37 . Active learner participation in patient care can be hugely valuable in areas such as diagnostic reasoning and patient safety 38,39 and they should be encouraged to engage with the wider clinical team 40 . Our work adds that junior doctors feel unprepared for this supervisory role and the challenges balancing caring and teaching responsibilities and suggest that continuity of attachment to the same clinical team may mitigate this. Junior doctors make effective near-peer tutors 32 , though studies recognise that doctors' perceived lack of competence in uences their supervisory behaviours [41][42][43] . Others advocate for formalised training to support development of clinical teaching skills 31,44 which may also help to form an institution-wide culture where teaching is valued 45 . Such programmes have been shown to develop student-centredness and promote enthusiasm for teaching 46 .
Our study reinforces junior doctors' awareness of this teaching culture and its' impact on their behaviours. Participants felt that this culture is driven by senior clinicians, consistent with previous theoretical work 12 and should be better recognised by local service providers -re ecting the view of professional regulators 47 . This includes appropriate provision of easily accessible resources to support clinical teaching delivery to underpin and reinforce experiential learning.

Strengths and limitations
This study offers a rich narrative, offering novel perspectives on clinical teaching in the workplace, with participants drawing on their experiences of clinical teaching across a range of specialties and hospitals, underpinned by their own experiences of learning. Given most participants' background in a split educational-clinical role, they are actively engaged with local educational providers, with some understanding of formal teaching theories and methods, though this may be limited as the study was conducted within 6 weeks of commencing their placements. This purposive sampling means we lack insight from those less inclined to teach, nor do we gain much appreciation of any signi cant barriers to engagement in undergraduate clinical teaching.

Implications for practice
Opportunities for improvement were identi ed in three in three key areas. Firstly, educational providers and clinical teams should work collaboratively to facilitate an active role for medical students on the acute take, under appropriate supervision. Secondly, to support junior doctors within a culture that encourages teaching and enables them to balance clinical and educational roles, underpinned by appropriate training. Finally, we support the provision of resources to facilitate teaching in the acute admissions environment, accounting for the breadth and variability of opportunities that present themselves. This may include designated time for teaching, though recognising this may impact on authenticity of learning.

Conclusion
The acute admissions environment presents myriad opportunities for undergraduate learning and many challenges for junior doctors in managing responsibilities of patient care with clinical teaching. This exploratory study provides focus for targeted improvement to the delivery of near-peer clinical education through highlighting learning opportunities for students' supported participation, fostering junior clinicians' teaching skills with provision of necessary resources, to maximise learning yield from authentic experiences. Through this insight, we hope to encourage development of a supportive culture for clinical teaching and undergraduate education within a busy, but rich learning environment.

Consent for publication
Participants in this study gave electronic written consent to publication of their anonymised data.

Availability of data and materials
A full summary of the main thematic framework with supporting quotes can be found in Appendix I.

Competing interests
The authors declare that they have no competing interests.

Funding
There was no speci c funding required to undertake this study. Both CH and AO completed this study as part of their Clinical Teaching Fellow programme at the Bristol Royal In rmary.
Authors' contributions CH conceived this study and led in data collection, analysis and writing of the paper. AO contributed to data analysis and contributed to writing the paper. JRa performed the background literature review and contributed to writing the paper. JRe contributed to writing the paper. All authors read and approved the nal manuscript.