Dr Grumble is responsible for a large number of doctors in training. Not as many as 100 but close to 100. There has been a great deal of focus on the training of junior doctors in recent years. Who advised on this Dr Grumble has no idea but he does wonder. Whether any practising doctors were involved Dr Grumble has no idea. He wonders about that too. Because, as we all know, what our junior doctors have ended up with is lots of boxes to get ticked. It seems that the process is more to do with covering the backs of managers than training doctors to a high standard. After all if a doctor has lots of competency boxes ticked there can't be a problem, can there? But, in reality, we all know that these boxes only score adequacy at a very basic level. They are not about excellence. The competencies are not the same as understanding. They do not measure the higher level functioning of a professional. Come to think of it, they do not seem to measure anything useful at all. So it does not surprise Dr Grumble to learn that there is actually no evidence to support their use. So, if there is no evidence, why was this rolled out the way it was across the nation in every specialty? That's something else Dr Grumble does not know the answer to.
Wind back now to when Dr Grumble was a junior doctor. The NHS then was thronging with junior doctors. There were few consultants. The junior doctors spent long hours in a learning environment called a hospital where they worked at being doctors. They learned a lot. They became enormously experienced. Many worked more hours as junior doctors than some people work in a whole lifetime. It was a training that worked and worked well. Doctors came from around the globe to train in the UK. Not just from deprived parts of the world, Australians and the like used to come too. But now it's the other way around, our doctors are leaving to train in the Antipodes. Now why do you think that is?
So where did the competency model that we had no need for come from? It was actually from industry. The idea is that you have a task in, say, a factory and you break it down into its component parts. You then assess the trainee on each of the stages involved. Perhaps it is appropriate to the production line. Dr Grumble has no idea. But is it appropriate to the practice of medicine? Meeting competency criteria are certainly not the same as being professionally competent but our masters seem to make out that it is. Being able to give an anaesthetic might seem to an outsider to be a straightforward competence that you can tick a box on but even an ordinary doctor like Grumble knows that anaesthesia is much more than that. And so, of course, is the rest of medicine. It is about professionalism. It is about high level complex decision making based on experiential learning. True professionals don't just follow rules. That's not what they are there for. They are there to think on their feet at a high level. They are there to deal with uncertainty. They work in areas of greyness. The practice of medicine is not about simple competencies. It is about multifaceted high-level professional competence. These are not things that can be simply measured. They are too complex for that though they can be recognised when you see them. Sadly, appraisal, grading and league tables seem to be the order of the day for our political masters. There is no getting away from them. And now it is reaching really absurd levels.
Can we do better in our assessment of junior doctors? Dr Grumble does not think we easily can. We do not yet even understand the heuristic processes by which a doctor makes a diagnosis. If we don't even understand how good doctors do these basic things how can we easily appraise learners?
And, to make matters potentially worse, we are now going to have to reduce the hours our doctors work whether we or they like it or not. There are 168 hours of the week when care needs to be given. If hours are too short consultants and juniors will only meet like ships in the night.
Whatever happened to Tooke? Sometimes there seems to be no progress at all and that our masters keep blundering on.
15 March 2009