Theme 1.1: Defined expectations

Throughout the NHS, it is commonplace for the most junior members of the ENT team to act in the first on-call role, with senior registrar support available off-site out of hours.^{Reference Powell21} Naturally, to those who have not previously worked within a first on-call role, this can be a shock. Interviewees who had not been counselled on this approach expressed some confusion about the expectations of them within this role. They understood that ENT was a practical and hands-on specialty, but there was no clear guidance as to what skills were expected of them and the limitations of their role.

Junior 3: Your job on General Surgery as an F1 is pushing on bellies and speaking to your Reg. Whereas ENT is unique in that sense that you do so much of it practically on your own.

Given the responsibility and independence given to Juniors in ENT, this pointed towards further confusion and anxiety about when it is appropriate to escalate patients. In other specialties, a top-down referral system means a senior member of the team is aware of emergencies at the time of referral and they can become involved as soon as necessary. In ENT, ENT Juniors are afforded a greater level of independence when managing patients.

Providing new ENT Juniors with a clearer definition of their job role may provide reassurances about what requires escalation to a senior colleague to avoid them having feelings of anxiety when expected to cope with something that they may perceive to be outside their limitations of practice. Those who had been made explicitly aware of the expectations within their role seemed more comfortable with the expectations.

On many occasions, interviewees implied that they wanted to be independent at these skills and able to cope with the demands of the role. Despite there being a recognised pathway to escalate clinical issues to a senior colleague, many felt the expectation was not to disturb their senior and cope regardless of the complexity of the clinical problem.

Thus, there was a tension between ENT Juniors’ awareness of their limited experience and their reluctance to bother a senior colleague for support. The combination of the unfamiliar first on-call role, lack of immediate senior support and expectation for practical skill performance were recurrent themes when interviewees were reflecting on their ENT attachments.

Theme 1.2: Preconceptions from undergraduate ENT curricula

The role of undergraduate medical education is to equip learners with the knowledge and skills they need for clinical practice. Both junior and senior interviewees suggested that medical school did not facilitate the transition from undergraduate medical student to junior doctor effectively. The misalignment between undergraduate and post-graduate training was recognised during interviews with both ENT Juniors and senior supervising clinicians.

Senior 2: The undergraduate courses provide knowledge, basic science and some pattern recognition… but it doesn't provide the practical skills to deal with the problems.

As well as the time limitations on ENT leading to poorly emphasised learning outcomes, there was an apparent feeling that the undergraduate learning outcomes do not marry with the common pathologies seen by junior doctors. This has pitfalls for clinical practice, where one may be equipped with the theoretical knowledge to deal with an acute problem but cannot convert this to interventional management. Obviously, this is a contributing factor to the lack of experience in procedural skills relevant to ENT.

Given the limited time spent in ENT, there is a temptation that the ENT placement becomes a novelty week, and that time is prioritised to advertise the specialty to medical students, rather than being used to see the common presentations that are likely to be encountered in post-graduate practice.

It is possible that at undergraduate level, ENT is pitched as a novelty specialty with little real-world application. If limited emphasis is given to the day-to-day skills needed and undergraduate attachments focus on the ‘sexy’ topics rather than the useful topics for day one of Foundation Year 1, this is unlikely to give people a true representation of the specialty and place their learning in an adequate clinical context.

In relation to educational needs, ENT is perhaps not a felt need as an undergraduate and thus learners are not motivated as a result of perceived clinical irrelevance. A possible solution is to address these needs with further training in proximity of juniors’ upcoming ENT rotations to allow direct application to clinical practice.

Theme 2.1: Theoretical and skills needs

Theme 1.1 has shown that many of those interviewed did not feel that undergraduate education provided the appropriate knowledge base to work in the autonomous role of the ENT first on-call. This had two main implications. Firstly, a lack of knowledge impacted the interviewees’ ability to take referrals from other specialties because they did not understand what needed to be seen by acute ENT services. Secondly, this impacted how they subsequently managed patients in hospital, including the practical skills required for some interventions.

There was largely agreement between the two groups about the relevant learning needs for ENT Juniors to begin their attachments. The needs within Table 3 comprise broadly two types: those pathologies that ENT Juniors encounter daily (such as otitis externa, epistaxis, quinsy) and those that are considered the most worrying, yet less common, ENT emergencies (such as stridor and post-tonsillectomy bleed). While the former were discussed on a much more frequent basis, the latter were discussed with much greater feeling.

Interestingly, despite Theme 1.1 highlighting the lack of definition ENT Juniors were given within their role, the prescribed learning needs given by the senior clinicians aligned very closely with the expressed needs of juniors. This included explicit responses explaining when a patient should be escalated to a senior ENT clinician. This example refers to the confusion from a junior about an airway emergency versus the expectation from the senior colleague.

Senior 2: They should know when a patient has got stridor and need to escalate to somebody urgently.

In general, the ability to perform practical skills outweighed the need for theoretical knowledge for most juniors. Many perceived the ability to perform practical skills effectively as a more pertinent patient safety issue than having the underlying knowledge base.

Senior 2: What causes a nosebleed and where the bleed comes from – it's not terribly important because we should stop the patient from bleeding and then worry about what the cause is.

It was not just patient safety that learners felt they needed skills for, but to be able to make their own workload more efficient and minimise discomfort for patients. The nature of many of these skills mandates close contact and can cause discomfort for a patient already in pain.

That said, despite the lack of priority for these theoretical skills amongst junior interviewees, there were knowledge gaps expressed both consciously and subconsciously in relation to anatomy and physiology.

An instance where a good grounding in theoretical knowledge may have benefitted interviewees was when taking a referral or giving advice via the telephone. This was a clear and repeated anxiety amongst the junior cohort. Perhaps this lack of theoretical knowledge did have an impact on this aspect of the job, where interviewees were overwhelmed, unable to organise and gather the information needed to make sense of a case's priority.

Junior 6: I didn't feel that I knew enough initially to reject any referrals, so I was accepting and admitting everything because I wasn't confident enough.

Essentially, many learners prioritised the need for practical skills above knowledge when faced with a patient. This was an interesting perspective given typically one would consider the traditional need for stepwise accumulation of knowledge from anatomy, physiology, pathology, management and then practical intervention. Yet the knowledge needs were not recognised until they were challenged by a referring or senior colleague.

This points to the needs for further training, in a clinically focused setting, in proximity to their ENT attachments to scaffold their learning,

Ultimately, all interviewees alluded to the fact their knowledge was inadequate at the outset to function optimally as the ENT first on-call. This limitation was recognised by those who had insight, but in others their oversight for basic knowledge was illustrated with difficulties in other areas of the role.

Theme 2.2: Validation and competence

When reflecting on the competence needed to perform skills during their ENT attachments, interviewees gave varied interpretations of competence. The ability to perform skills was important to all juniors. For some, this involved a formal process, such as the completion of a workplace-based assessment. Others felt that a more informal process of validation from a senior colleague was an indication of their competence. For others, confidence in the ability to teach others a skill was adequate evidence of competence in a skill.

Junior 6: Teaching the medical students, that's where I was like: OK, now I am confident that I'm teaching these skills to my juniors. So that's how I validated that I've improved.

When reflecting on the idea of competence with a senior interviewee, the limitations of workplace-based assessments were noted from a trainer's perspective.

The above quote recognises a valid limitation of workplace-based assessment: an assessment may only be made during an isolated clinical encounter and is not representative of a learners’ overall clinical competence. However, this contrasts with the juniors’ view because they feel that workplace-based assessments are a valuable tool to reflect and document their progress. A checklist of competency in appropriate skills in both simulated and clinical settings seemed to be a popular notion amongst interviewees. It was felt that this would provide an appropriate tool for new ENT Juniors to begin performing skills independently if approved by a senior colleague.

This aligns with the modern principles of competence-based medical education, where focused training is driven by the development of competencies. In essence, this provides greater learner-centredness, equipping clinicians with focused skills rather than overloading them with extraneous knowledge that does not necessarily correspond with skill acquisition.^{Reference Frank, Mungroo, Ahmad, Wang, De Rossi and Horsley22} In this study, there was an expressed need for a formal validation process to give ENT Juniors the confidence to perform skills independently and give them ownership of their role.

Theme 3.1: Methods for future learning

All interviewees reflected on the fact that they performed ENT skills for the first time on real patients. This was frequently an anxious time for learners, who did not feel that the mantra of ‘see one, do one, teach one’ was appropriate. There were two solutions to this discussed in detail: the need for a focused ENT induction process and the need for simulated practical skills training.

Participants expressed an interest in bootcamp-style learning prior to entering a new clinical environment.

Senior 2: Bootcamps I think are helpful in this regard. So you know you're actually getting a chance now to do practical stuff and they are a tremendous innovation.

The advantage of this approach is that it ensures that all ENT Juniors starting in a department are given a consistent induction, with a grounding in clinical application and a safe, protected space to learn.

The actual educational approach used can vary, but interviewees valued an integrated approach, building on their schema and climbing Miller's pyramid to achieve competency performing skills.^{Reference Witheridge, Ferns and Scott-Smith6} Simulation was a frequently cited mode of learning that interviewees wished to be exposed to more often.

Senior 2: Having some sort of physical simulation which allows you to replicate what you will do on the living person prior to coming into clinical practice is going to be useful.

Simulation offers the ability to try out skills or scenarios so that there is less focus on the skill itself when it needs to be performed in the clinical scenario. Interviewees recognised the limitation of this approach but acknowledged it may go some way to allay the anxiety of performing a skill on a patient for the first time.

Interestingly, the simulation approach was valued not only for clinical skills, but also non-technical skills such as taking a referral.

Following Theme 1.1, which explored the misalignment of undergraduate curricula and post-graduate expectations, it is important to consider when this form of simulation would be most valuable. Most interviewees recognised that proximity of learning to the need for the skill meant that they were more likely to retain their learning if they could foresee its relevance to clinical practice.

Inevitably, some skills will only come with time and repeated exposure in clinical practice, but the thought of high-fidelity exposure at the start of the placement was generally favoured to help consolidate and enhance future learning.

Designing emergency or practical skill-based simulation scenarios in ENT requires planning to ensure that the scenario is optimised for learning and that simulation is used effectively alongside other training opportunities.^{Reference Ker and Bradley23} For example, the ENT airway emergency is a concern of both juniors and seniors alike. It is vital in this acute, time-critical scenario to ensure that immediate management can be implemented without hesitation. Thus, addressing this emergency in a simulated scenario prepares learners for the urgency, anxiety and need for rationalised management under pressure.

This quote encapsulates the aims of emergency simulation training.

Based on the learners’ expressed need in this study for a rigorous induction and pre-placement training, integrating these simulation stations into a bootcamp-style induction course may be a valuable way of integrating skills, removing the anxiety barriers towards acute scenarios for ENT Juniors and facilitating their learning for application in the clinical setting prior to their first encounter with an ENT emergency.

Theme 3.2: Near-peer learning

When exploring learners’ needs, interviewees reflected on their experiences and how they had fulfilled their learning needs. Aside from private reading and clinical experience, many referred to a near-peer model of learning.^{Reference Ten Cate and Durning24}

As mentioned earlier, some ENT Juniors felt embarrassed that they were unable to carry out what they perceived as basic ENT skills. Seeking advice from a marginally more senior colleague seemed to allay this fear and anxiety of performing skills, highlighting a key attribute of the model. Despite the traditional role of the consultant as the didactic educator, the value of near-peer learning was recognised by both senior interviewees.

Senior 1: The Registrars. In the last few years they've learned the skills. Mastered the skills. Now they're gonna teach the skills and it's in their interest to teach the skills.

However, they recognised the limitation of this approach, particularly when balancing the cognitive congruence of a junior tutor with the clinical expertise of a senior tutor.

This is a recognised limitation of the approach, and thus rigour needs to be applied in any application of near-peer learning to ensure that misconceptions are not inherited by learners. Nevertheless, near-peer learning has potential applications for these learners when designing future learning opportunities to address their learning needs. In addition, this relationship should be encouraged during clinical attachments to allow this near-peer model of learning to blossom, supporting learners throughout their attachments in an informal and mentor-based learning environment.