Postgrad MedJ7 1998;74:41 1-415 C The Fellowship of Postgraduate Medicine, 1998

Induction training, career counselling, andperformance review: views of junior medical staff

J G Williams, W Y Cheung

School ofPostgraduateStudies in Medical &Health Care,Maes-y-Gwernen Hall,Morriston Hospital,Swansea SA6 6NL,Wales, UKJ G WilliamsW Y Cheung

Accepted 16 December 1997

SummarySurveys ofsenior house officers and regis-trars were undertaken by postal question-naire to ascertain views on the need forand content of induction training, careercounselling, and performance review. Thequestionnaire was sent out in May 1990and repeated in May 1996, after measureshad been taken to improve inductiontraining, and assessment and appraisal oftrainees. In 1990 there was a clear wish toreceive information on career prospects,research and education opportunities,and clinical audit, but more ambivalenceregarding information or training in com-munication, discharge policies, stand-ards, and encoding procedures. There wasalso a firm view that career counsellingcould be improved and formal goal settingand performance appraisal interviewswould be welcomed. In 1996 there was dis-appointingly little change in the viewsexpressed by the junior medical staff,though there was a significant increase inconfidence in the role of the consultant incareer counselling.

Keywords: induction training; career counselling; per-formance review; education

In 1990 we were concerned about the difficul-ties we had encountered in establishing formalarrangements for induction training, careercounselling, and performance review for juniormedical staff and felt it appropriate to seek theviews of senior house officers (SHOs) and reg-istrars on these issues. Following this survey,formal induction training was established forall doctors in training, taking place over oneday in August and February at the beginning ofeach junior doctor intake. Greater involvementof consultants in career counselling andperformance review was also encouraged,though formal procedures were not put inplace. Six years after the first survey, the ques-tionnaire was repeated to see if the views ofjunior doctors had changed as a result of themeasures taken.

Methods

A questionnaire was constructed and reviewedby four SHOs before a final version was agreed.The questionnaire was then sent to all SHOsand registrars working in the medical, surgicaland anaesthetic specialties in the three district

general hospitals in West Glamorgan. It wasdistributed in May 1990 and repeated inslightly modified version in May 1996. (Copiesof the full survey are available from thecorresponding author on request.) For bothsurveys, a reminder was sent to all those whohad not replied after six weeks.

METHOD OF ANALYSISEach question in the survey offered three pos-sible responses: 'yes', 'no' or 'indifferent'. Weused the concept of 'valid per cent' to analysethe responses. This is the percentage ofanswersin each of these three categories, to each ques-tion, when missing or non-relevant answershave been excluded. We used this approach asthe number of missing observations for all themajor parameters was small. In addition, twoquestions had a set of sub-questions only forthose who responded 'no'. Chi-square testswere performed, where appropriate, to seewhere the differences between 1990 and 1996were statistically significant.A major interest of the study was the type of

information staff would like to receive at thebeginning of their post. Information for thisparameter was collected by a 13-item question.A principal component analysis' with varimaxrotation was performed to explain individualstaff responses to the 13-item set with arelatively small number of factors. The princi-pal component analysis was used to formuncorrelated linear combinations of the 13observed variables. Each linear combinationformed one component (or factor). The firstcomponent explained the maximum amount ofvariance in the set of the variables observed.Successive components explained smaller por-tions of the variance. Each of the observedvariables would have a factor loading on all theextracted components. Final interpretation ofthe components depended on which observedvariables had a high factor loading on whichcomponent. The varimax rotation was atechnique to minimise the number of variablesthat had high factor loadings on each extractedcomponents and would simplify theinterpretation of the component. A factor wasconsidered important if its 'eigenvalue' (astatistical measure of its power to explain vari-ation between respondents) exceeded 1. 1,1 andit had face validity, that is, if it appeared 'at facevalue' to be measuring a recognisable aspect ofthe type of information junior staff would liketo receive.

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Table 1 Comparison of responses

1990 (%) 1996 (%)Yes Indifferent No Yes Indifferent No Chi-Square p value

CommunicationHow to communicate with patients 18.1 19.4 62.5 20.7 17.1 62.2 0.2897 0.8652How to communicate with relatives 19.7 18.3 62.0 25.4 15.8 58.8 0.8565 0.6517How to communicate with GPs 21.1 16.9 62.0 22.8 14.9 62.3 0.1668 0.9200Personal developmentCareer prospects 73.6 6.9 19.4 68.7 6.1 25.2 0.8440 0.6557Research opportunities 56.9 20.8 22.2 64.7 12.1 23.3 2.6619 0.2642Postgraduate activities 59.2 11.3 29.6 59.3 8.0 32.7 0.6537 0.7212Individual patient managementClinical policies 67.6 7.0 25.4 70.5 6.3 23.2 0.1780 0.9149Admission and bed policies 57.1 12.9 30.0 42.1 14.9 43.0 4.1016 0.1286Patient discharge policies 43.5 10.1 46.4 36.2 12.9 50.9 1.0471 0.5924Liaison with hospital managementKey management personnel 33.8 21.1 45.1 37.7 38.6 23.7 0.7577 0.6847How to communicate with managers 32.4 22.5 45.1 32.2 20.9 47.0 0.0911 0.9555Information and monitoringDiagnostic encoding procedures 30.9 27.9 41.2 29.8 23.7 46.5 0.5915 0.7440Medical audit procedures 45.1 18.3 36.6 49.1 17.2 33.6 0.2956 0.8626

Results

In 1990, 119 questionnaires were sent out, towhich 73 replies were received (61%), 46 fromSHOs and 27 from registrars. In 1996, thenumber of junior staff in post had increased and198 questionnaires were distributed, to which118 replies were received (59.6%), 85 fromSHOs and 33 from registrars. The analysis didnot reveal any significant difference between theviews of SHOs and registrars, or between thethree hospitals. There were some differencesbetween disciplines, which were largely explica-ble by the nature of the work undertaken. Forexample, anaesthetists were more likely to say'no' to more information on admission and dis-charge policies, while accident and emergencySHOs had less interest in discharge policies, butwere keen to understand more about admissionpolicies. The sample size was not big enough tosupport formal statistical analysis of the differ-ences in preferences between stafffrom differentspecialties. However, the pattern ofresponse andthe comments of the respondents showed anotable preference for specialty-based, ratherthan hospital-wide, induction training.

* Indifferent1E No 3 Yes

Career Research Postgraduate Clinicalprospects opportunities activities policies

Figure 1 Responses to the question: When youstarted in this post, would it have been beneficial toyou to have been given more information on careerprospects, research opportunities, postgraduateactivities, and clinical policies?

Between 1990 and 1996, there was nodirectly observable change in attitude by stafftowards the type ofinformation they would liketo receive at the beginning of their post. Anitem-by-item comparison of the 13-item set bythe chi-square test showed no significantdifference between the 1990 and the 1996group in any of the 13 items (table 1).The majority of both the 1990 and the 1996

groups did not think it beneficial to be givenmore information at their induction on how tocommunicate with patients, relatives, generalpractitioners and managers. By contrast, analy-sis of respondents' free text comments showedthat, although they did not feel the need forinformation on communication applied tothem individually, communication was an

important topic in general.The majority of both the 1990 and the 1996

groups would have liked to have had moreinformation on career prospects, postgraduateactivities, research opportunities and clinicalpolicies (figure 1).

Analysis of respondents' comments showedthat there was a general desire for more adviceand guidance on career progression. There wasa demand for more structured and specialty-based guidance and a dissatisfaction with thepassive way in which career advice wasprovided in the current system, especially fromSHOs, as illustrated by the following quotes.One SHO suggested structured career guid-

ance provided through formal channels:"Currently, most information is got from

colleagues and consultants. I think a more progres-sive advice service, starting in medical school withfollow-up throughout career would be better."A dissatisfaction with the current level of

guidance and a desire for more specialty-basedcareer advice was illustrated by the followingquote:

"The only advice I've been given by educationalsupervisor is 'Pass the exam!'. It would be useful toknow who could provide specific specialty careeradvice locally and regionally."One SHO queried the educational merits of

his current post and bemoaned the passive way

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Indifferent El No E Yes

a

and bed discharge management encoding auditpolicies policies personnel procedure procedures

Figure 2 Responses to the question: When youstarted in this post, would it have been beneficial toyou to have been given more information on admissionand bed policies, patient discharge policies, keymanagement personnel, diagnostic encodingprocedures, and medical audit procedures?

in which career advice was provided in the cur-rent system.

"There is little emphasis placed on SHOexperience..., and very little opportunity to expresswhat the individual hopes to gain from a particu-lar job. Career advice is available but you have toseek out the appropriate person yourself and organ-ise a meeting. Generally speaking, consultants arehelpful when approached but there is very littlespontaneous inputfrom them."

Table 2 Results of factor analysis to explain variations in responses in 1990

Items with high factor loading on each of the % of variationfactors explained

Factor 1 How to communicate with patients 24.7Communication How to communicate with relatives

How to communicate with managersHow to communicate with GPs

Factor 2 Key management personnel 15.6Monitoring and management Medical audit procedure

Clinical policiesDiagnostic encoding procedures

Factor 3 Postgraduate activities 12.0Personal development Career prospects

Research opportunitiesFactor 4 Patient discharge policies 9.4Individual patient management Admission and bed policies

Table 3 Results of factor analysis to explain variations in responses in 1996

Items with high factor loading on each of % of variationthe factors explained

Factor 1 How to communicate with relatives 23.5Communication How to communicate with patients

How to communicate with GPsFactor 2 Research opportunities 15.1Personal development Career prospects

Postgraduate activitiesFactor 3 Patient discharge policies 11.9Individual patient management Admission and bed policies

Clinical policiesFactor 4 How to communicate with managers 9.4Liaison with hospital management Key management personnelFactor 5 Diagnostic encoding procedure 8.7Information and monitoring Medical audit procedure

A dissatisfaction with the educational meritof their current post were reflected in com-ments by other respondents, and some weredissatisfied with the arrangements for studyleave. There was anxiety about the impact ofthe Calman reforms on training as illustratedby the following quote:

"I am in a career post that will take me toaccreditation but no-one knows how the rotationwill proceed because of introduction of Calman!"

This anxiety about Calman was found in fiveout of the seven registrars who had made free-text comments in their questionnaires.There was less interest in learning about

admission and bed policies, patient dischargepolicies, key management personnel, diagnos-tic encoding procedures, and medical auditprocedures (figure 2). There was a noticeabletrend for the answers to these questions torelate to the appropriateness of the specialty.

Nevertheless, the factor analysis found somesubtle changes in the inter-relationships of theitems about the type of information staffwouldlike to receive at the beginning of their postbetween 1990 and 1996. Four underlyingdimensions were identified from the 1990findings, which would be able to explain most(61.7%) of the variations in staff response(table 2).Thus, factor analysis for the 1990 group

showed that staff response to the type of infor-mation they would like to receive at the begin-ning of their post could be broadly summarisedby their attitude towards the four factors: com-munication; monitoring and management;personal development; and individual patientmanagement. By contrast, five underlyingdimensions were identified from the 1996findings which would be able to explain most(68.6%) of the variations in staff response(table 3). These five factors could be broadlysummarised as: communication, personal de-velopment, individual patient management,liaison with hospital management, and infor-mation and monitoring.

This represents a change in attitude of juniorstaff. In 1990, the items on how to communi-cate with patients, relatives, general practition-ers and managers were related to each other.However, in 1996, the item how to communi-cate with managers no longer related to theother three items about communication. In-stead, this item was inter-related with the itemabout key management personnel to form anindependent factor. Liaison with hospital man-agement had become, for the juniors in 1996,an element worthy of consideration in its ownright. Furthermore, the items about medicalaudit procedures and diagnostic encoding pro-cedures were no longer related to the same fac-tor with the items key management personneland clinical policies in 1996. The only dimen-sion which remained unchanged was the factorof personal development, which included edu-cation, research and career prospects. Thesechanges were consistent with recent develop-ments in the NHS, such as the introduction ofgeneral management and the emphasis onmedical audit.

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1990

Would you have valuedthe opportunity to

discuss your immediategoals with a consultant?

1996 * Indifferent E No O Yes

Did you have theopportunity to discussyour immediate goalswith a consultant?

1UU

o 50

If no, would you havevalued the

opportunity?

Figure 3 Responses to the question: When you started in this post: 1990: Wouldyou have valued the opportunity to discuss your immediate goals with a consultant?1996: Did you have the opportunity to discuss your immediate goals with aconsultant? If no, would you have valued the opportunity?

The majority of 1990 respondents (73%)would have valued an opportunity to discusstheir immediate goals in terms of experienceand training. There was still a substantialnumber of the 1996 group (36%) who did nothave this opportunity (figure 3).Towards the end of their time in post, 83.6%

of the 1990 group and 86.3% of the 1996group would have liked to be given adviceregarding their next move. There was no statis-tically significant difference between the twogroups in this. The percentage of staff whowould like to discuss goal achievement in termsof training and experience in 1996 (85.2%) washigher than that of 1990 (76.1%), but the dif-ference did not reach statistical significance .

The percentage of staff who would like toreceive a formal performance review in 1996(78.3%) was also higher than that of 1990(68.5%), but again, the difference did notreach statistical significance.

1' Qo/L 00 Oo/0

1.7%3%

53.0%1990 1996

E Yes .i No * Indifferent

Figure 4 Percentage of staff who felt that career counselling was adequate. 'asked with whom they would like a formal, arranged interview, there was nopreference between their consultant, the postgraduate organiser or the spetutor, though a non-significant increase in confidence in the consultant and spetutor was apparent between 1990 and 1996 (figure 5)

Whenclear

!cialty!cialty

Consultant rostraauate Specialty Any o thne Otnersorganiser tutor above

Figure 5 Person with whom staff would like aformal, arranged interview

About half of the respondents in both the1990 (52.5%) and the 1996 group (53.0%) didnot feel that the career counselling they werecurrently receiving was adequate (figure 4).There was no statistically significant change inthis aspect between the two groups.

In summary, there were no significantchanges between 1990 and 1996 in terms ofmost of the parameters with regard to careercounselling. There were some changes of staffattitude to the type of information they wouldlike to receive at the beginning of their post.These changes were largely confined to theinter-relationships of some parts of the servicecomponent of their post. Their attitude to-wards the training component remained largelyunchanged.

Discussion

The first survey in 1990 was undertakenagainst a background of major change to thestaffing2 and organisation3 of the health service,and the knowledge that the introduction of for-mal career counselling and performance reviewwas much needed,4 as was formal inductiontraining. The results of the first surveyconfirmed that there was a need for change inthe form of formal induction training andencouragement of consultants to be more

proactive in meeting the appraisal needs oftheir junior staff. There has, however, been dis-appointing progress, as judged by these viewsof junior staff.Although formal induction training was

introduced after the first questionnaire, itwould appear that this is inappropriatelytargeted and it may well be that it would bemore appropriately delivered on a specialtybasis. The replies to both questionnairesindicate an indifference to advice on dischargepolicies, standards for discharge summariesand encoding procedures, which suggested a

degree of complacency in areas where it iswidely believed there is room for improvement.A perceived need for further information onadmission and bed policies probably reflectsthe local difficulties that junior medical staffencounter in finding beds for acute admissions.

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The rejection by many junior doctors ofinduction training in communication, dis-charge polices and encoding procedures doesnot reflect the known problems in these areas,and suggests that attitudes, as well as knowl-edge and skills, need to be addressed in orderto achieve improvements. Present arrange-ments for induction training, which arehospital-wide and look largely at process meas-ures relating to the delivery of healthcare, donot meet all the needs of doctors in trainingwhen they start an appointment. These issuesremain highly topical5 6 and further effort isclearly required to effect adequate change. Itcould be argued that some of these issues couldbe covered in more depth in undergraduate

training, for example, the need for betterundergraduate training in communication is-sues has already been suggested by the GeneralMedical Council.7A striking finding from these two surveys is

that there remains a clear wish from junior stafffor performance review and career counselling,and this need is not yet being met. A largemajority of respondents wished to receive moreformal goal-setting interviews at the beginningof an appointment and performance reviewlater. This will be introduced as a formal proc-ess for specialist registrars under the imple-mentation of the Calman reforms, but is notformally in place for SHOs, who also wish toreceive it.

1 Jollife IT, Morgan BJ. Principal component analysis andexploratory factor analysis. Stat Meth Med Res 1992;1:69-95.

2 Department of Health & Social Security. Hospital medicalstaffing: achieving a balance. London: DHSS, 1986.

3 Department of Health & Social Security. Working forpatients. London: HMSO, 1989.

4 Garrud P. Counselling needs and experience of junior doc-tors. BMJ 1990;300:445-57.

5 Cantwell BM, Ramirez AJ. Doctor-patient communication:a study of junior house officers. Med Educ 1997;31:17-21.

6 Spencer J, Stacy R. Interpersonal skills are being taught bet-ter, but more work is needed (letter). BMJ 1997;314:1203.

7 George C, ed. The new doctor. London: General MedicalCouncil, April 1997.

Images in medicine

Retroperitoneal haematoma

A 77-year-old woman was admitted withunstable angina. She was treated withintravenous heparin in addition to otheranti-anginal medication. On the fifth day ofadmission, her blood pressure suddenlydropped and she went into hypotensive shock.Abdominal examination revealed a diffuse ten-der swelling in the left illiac fossa. Investigationsshowed moderate renal impairment and a 5 g/dlfall in her haemoglobin since admission. Therewas no evidence of overt bleeding and coagula-tion screen remained normal. A computedtomographic scan of the abdomen revealed twoseparate retroperitoneal haematomata (twocontinuous lines marked 1 and 2 on the figure).Heparin was stopped and she was resusci-

tated with a blood transfusion. She made anuneventful recovery and was discharged home.

MANSOOR AHMEDDepartment of Geriatrics, Poole Hospital NHS Trust,

Poole, Dorset BH15 2HP, UKH SIMPSON

Royal Berkshire Hospital,Reading, Berkshire RG1 SAN, UK

Accepted 19 November 1998

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