‘Resilience Training’: Smoke & Mirrors for a System that Seems to Want to Ignore Everything Else

“Doctors will have to demonstrate that they have “emotional resilience” before they are allowed to practice”so writes Laura Donnelly in the Telegraph. The Comments, sparked by an exchange with Professor Terence Stephenson, chairman of the General Medical Council (GMC), seek to highlight the psychological demands placed on junior doctors today.

Emotional resilience is an important skill. There are lots of ways that undergraduate education can help students explore and anticipate difficulties they will encounter in their training. This aspect of training should of course be taken seriously by medical curricula but lets not pretend that resilience is an all or nothing attribute. It is fundamentally fluid. It is not like passing your anatomy exam and suggesting that it will be systematically tested at undergraduate level is frankly absurd. Will there be a resilience OSCE?!! – the mind boggles. Preparation for emotional difficulty is of course an important part of a rounded education but any reasonable approach would add more weight to helping junior doctors feel like there will be a system there to catch them when they fall.

I have a couple of issues though with arguments that tend to band around the word resilience like it is going to solve the problems doctors face in todays society. First of all, medicine has always been difficult. There has always been sadness and trauma. There have always been uncomfortable sights, uncomfortable exchanges and uncomfortable dreams at night. So what has changed? Why is there a sudden concern that doctors have become psychologically inept? After all, burnout is a very real concern. Things we encounter in medicine however are no more sad then they were one-hundred years ago. I would argue that what has changed is everything else.

As I have said before, I strongly believe that the training of junior doctors today breads insecurity. We are constantly forced to move around the country. Each time we are forced to gather proof of our professional attributes from a growing multi-disciplinary team; ward-clerks to health care attendants to physician assistants and consultants; a constant treadmill of snapshot assessments. Sometimes it feels like you may as well be standing in the middle of the room screaming ‘validate me, validate me!’. At the end of each year we have an annual review of competency and progression (ARCP). This process again has been reduced to a kafka-esque farce of box ticking and pseudo-assessment. A colleague of mine has genuinely been held back in training because a supervisor neglected to fill out an end of block report and then retired.

Next we could talk about the actual shape of training pathways in the UK. Young doctors are being forced to make life changing decisions about where their talents lie earlier and earlier in their career. There is no provision for allowing time within the system to time to explore your personal attributes and decide what career path you are best suited to. The treadmill keeps going and will not wait…as the queen of hearts said to Alice ‘My dear, here we must run as fast as we can, just to stay in place. And if you wish to go anywhere you must run twice as fast as that’. Lets not forget that should the DDRB have their way, the ability to change career paths will become such a difficult decision that even more weight will be added to those very early career choices.

Lets talk about down time. Many junior doctors still actually face fixed annual leave. The short rotations and on-call commitments mean organising significant amounts of leave is a administrative nightmare. Junior doctors find themselves begging medical staffing department for rotas just so they can find out if they can attend their best friends wedding, in fact I also know someone who had a great deal of difficulty trying to find out if they needed to worry about being be on call for their own wedding! My current placement means I can’t take any leave for the first three months. I then have 13 days to use up in the remaining 3 months, but I can’t organise these yet because I don’t have my on-call rota for that time. Oh and yes I’ve been warned that if I fail to take my leave, I will not be paid in lieu.

What about job placements? Once you’ve secured your national training number you’re forced to wait it out to find out which part of an often very large deanery you are allocated to. Will you have to move house? Will your children be able to attend their school? Will you be able to live with your partner this year? In a system that claims not to be able to take the vast majority of personal preferences into account, we have young registrars passing four district hospitals just to get to the one they’ve been sent to with absolutely no evidence that there was a logical reason for that choice, either in terms of service provision or training needs. I am one month into a five year training program with a new mortgage and I cannot plan my life past the next three months.

What of the media? Type junior doctor and any tabloid into a search engine and see what news you find. Here’s an example of the first four hits from the Daily Mail:

Daily Mail

Now lets add into this picture the fact that the government with their ‘accept or prepare to be forced mentality’ has recently put us all in mortal fear of their grossly unfair contract proposals.

There are a great many of things responsible for burn-out in junior doctors today, but lets stop banding around the term ‘resilience training’ like it’s the answer. It isn’t. If the powers that be really want to improve the quality of life for thousands of juniors doctors in the country they would do well to focus on everything else.

Physician Associates and Me

Disclaimer: my opinions are as always, a work in progress – but then again why would it be any other way? 

I have lots of concerns about the National Physician Associate Expansion Programme (NPAEP). Sadly, I have no faith in the government’s plan for our NHS (#showusthe7dayplan). I don’t even believe that the intentions of the NPAEP are necessarily honourable….are the government just clutching at straws for a short-term and cheaper fix to the staffing problems in the NHS? Do they have the best interests of the NHS workforce as a whole in mind? Is this actually what they believe is best for patient care? I can’t answer any of these questions. But when it comes down to it, I go to work each day to care for patients on an individual basis. My job, unlike Jeremy Hunt does not involve standing up on a soap box and making sweeping statements about what patient’s should have and what staff should not. I care for the patients on front of me…and I can’t do this without a multidisciplinary team, nor would I want to.

This post is about my personal journey with Physician Associates (PAs)

When I first started working with PAs I was a CT1 in medicine. I arrived to a district general hospital which I hadn’t been to since my medical student days and I felt vulnerable. I had that heart sinking dread of not knowing whether the nurses would ‘like’ me or if my consultant was the supportive kind or the pop-in every so often kind. I didn’t quite know what was expected of me and I had never even heard of PAs, I had no introduction from the hospital as to who they were or what they were about. I knew that they weren’t doctors. I was incredibly confused about whether their supervision was my responsibility or the consultant’s and I had no idea what was within their competencies. To add to this mix, the PAs were fixed entities. They knew the hospital and it’s quirks. They didn’t have to struggle to figure out how MRIs were requested or what that hospital’s guidelines were, they already had working relationships with the consultants, they could use the IT systems and their passwords all worked. In short, it felt like they had the upper-hand.

As the weeks progressed, I remained uncomfortable. The PA I worked with seemed perfectly competent but when she came and asked me to sign her fluid prescriptions I honestly felt suspicious. This was my GMC number…..am I supposed to go and re-review this patient? Was it going to create conflict if I asked her to explain her clinical decisions to me in detail?

Of course, everything is clearer with hindsight, but I can honestly say that the more senior I got the better the role ‘sat’ with me. There wasn’t a eureka moment where my attitude shifted, but when I look back on this time I realise that a lot of what I felt in those first few months was about me and where things stood with my professional development. Looking back now……

  • Junior doctor training breeds insecurity: we are constantly moving and constantly forced to anticipate our need for validation from other staff (multi-consultant reports, TAB/MSF assessments….). To add fuel to this fire we often feel victimised by media and this situation is not at all helped by the current climate of DDRB induced uncertainty. I felt vulnerable. I was unsure of myself and so I felt defensive; this was nothing to do with the PA I worked with.
  • Anticipating conflict when it comes to scrutinising everything a PA asks me to sign is not the same as there actually being conflict. It was perfectly ok for me to ask a PA to explain themselves in this context. I have to be honest and say that there were times when one specific PA I worked with seemed to resent this, but I got on with it and did what was right for the patient; team work in the NHS is full of potential for uncomfortable exchanges; whether it’s between a midwife and an obstetrician, nurse specialist and an SpR or a PA and an SHO. There really was no reason to carry any chip around on my shoulder in relation to this member of the team specifically.
  • It was ok for me not to completely trust in the PA in the beginning. Trust requires a relationship and once I started to make an effort to cultivate working relationships with individual PAs, rather than having everything overshadowed by my skepticism about the profession, things became a whole lot easier.

A consultant at that hospital told me ‘every member of a team is useful, that is what the NHS is all about’ – now I know that is a fairly broad statement, which many will pass off as a platitude, but for some reason it struck a cord.

Every member of the team is useful.

I know my own coming to terms with the PA role doesn’t answer lots of questions about where things are heading for the NHS. So yes, there are several things that for me remain topical:

  • I strongly believe that PAs require mandatory regulation and licensing. Patients depend on the NHS to be as sure as they can that the care they are offering is in the very least safe. For this to happen there needs to be appropriate licensing. I have yet to meet a PA who does not feel the exact same.
  • I believe that a significant number of PAs would serve the NHS, and their potential, much better if they spent two more years at university and got a postgraduate medical qualification. I can’t help feeling that investment to create more home-grown doctors would be a better option for the NHS as a whole. But it would be more expensive, astronomically more so…..and can we afford it?
  • I don’t feel like the potential of PAs will be adequately met in the long-term. I feel their lack of scope for progression means we may find PAs pushing into roles which are not necessarily appropriate. You simply can’t stop an engaged, hard working PA who has spent years in the NHS from acquiring extremely valuable high-level skills within the context of healthcare delivery. I don’t believe that this fact has been adequately thought through or planned for. This view may of course just be coloured by the fact that as a junior doctor who is constantly aspiring to be a senior doctor at the top of my profession, I struggle to comprehend the mindset of wanting to be in a job which such limited progression. this makes me skeptical, but of course does not necessarily make me right. There are after all lots of perfectly satisfied people in the world working jobs with similar limited avenues for progression.
  • I am apprehensive about why PAs should need prescribing rights. I don’t understand where this fits within the context of their role and how that would make their value different from that of a doctor. I think this issue in particular requires more open dialogue so that if prescribing rights are granted, doctors feel secure with the situation. Doctors need to be able to ask questions and have them answered honestly…after all, this is a new role within our ranks – why would we already understand it? Of course we have questions.

The bottom line is, I have delivered high quality care to my patients with the help of PAs…and they did not ‘replace’ any doctors at that hospital.  That is my experience. Can I say I have liked every single PA I have worked with in the last two years? Of course not. But then I wouldn’t say that about every doctor, nurse, health care attendant or ward-clerk either.