First-hand narratives

‘It happened to me…’: Although patients’ first-hand narratives included communication problems such as being spoken about rather than with (as a patient) and lack of support and involvement (as a carer), participants also narrated positive experiences regarding the care they received by junior doctors, and this was sometimes framed in contrast to the behaviour displayed by seniors: 

On one occasion we had to go to A&E when my husband was quite ill. He has heart failure but he has other problems as well. Now, as we went in the doctor [consultant] said straight away, ‘Now do you want to be resuscitated?’ The other thing, I think he’d had a really bad day this doctor; he turned around and said to my husband, ‘You know you’re taking up a bed, and somebody might be really ill and they might need it more than you?’ And this is actual fact. It’s actually what he said. And yet, one of the junior doctors came up to us and she said, ‘Don’t worry about that, we’re not sending him home.’ (Shirley, Focus Group 6)1

Interestingly, participants’ first-hand narratives were generally more positive than secondhand narratives recounted of others’ experiences and media-influenced personal views. Indeed, when drawing on these latter two sources of knowledge the narratives were predominately negative, as will be illustrated next.

Secondhand narratives

‘It happened to them…’: Participants’ narratives tended to be more negative when sourced from secondhand knowledge (ie, the experiences of friends, family members or colleagues) and focused on problematic role models from which junior doctors were learning:

John: I was speaking to somebody else about the culture in organizations. Within hospitals you have subcultures, and some wards can be very good, and it depends on whose running them, you know, do they listen to patients or whatever.

Liz: Yeah, yeah. In a certain hospital, there are two wards. You go into the one ward and everything is fine. You go into the other ward and it’s terrible. But it does go down to who is in charge and what specialists are on that ward. But if that’s your first ward as a junior doctor that is what you’ll learn. And if it’s the bad ward, you’re learning the bad practice.

John: Yes, definitely.

Liz: It’s terrible really.

(John and Liz, Focus Group 2, Site 1)

Knowledge from the media

‘Did you see the news?’: Participants also tended to be more negative when influenced by the popular press, constructing future hypothetical conversational narratives as they oriented to the world through sensationalised media reports. For example, participants in one focus group joked about the dangers of going into hospital in August during graduates’ first days of work, evidently based on information sourced from the media:

Liz: They [the media] do say, ‘Don’t go into hospital in August because you’ll die.’

John: That’s right, don’t.

Liz: No, they do say that ((General laughter)).

Stephanie: Or at the weekends.

Liz: You know, it’s quite frightening. Don’t get ill. Feed yourself in the house like, you know, but don’t go into hospital.

(Liz, John and Stephanie from Focus Group 2, Site 1)

In contrast, participants constructed positive images of junior doctors when they talked about watching television programmes, leading to them developing a compassionate, understanding and sympathetic notion of junior doctors in comparison to those from previous generations:

Holly: I think the students—doctors today—I think they’ve got a bit more—understanding than the older doctors, you know, they do ask. With older doctors, I suppose it’s the way they were trained, I don’t know, but the students I think have more care—

William: Sympathetic.

Holly: —I’ve been watching them doctors on the telly.

Tom: Compassion.

Megan: Eager to please.

(Holly, William, Tom and Megan from Focus Group 5, Site 1)

To summarise this theme ‘sources of knowledge’, patients and carers drew on first-hand and secondhand experiences, plus their knowledge of the media when articulating their perceptions of and expectations for junior doctors’ preparedness. While they experienced communication problems and a lack of involvement first-hand, they perceived junior doctors’ communication to be superior to those of senior doctors, with their first-hand narratives being more positive than secondhand ones. Indeed, secondhand narratives typically problematised junior doctors’ senior role models, while media representations gave patients and carers’ mixed views of junior doctors’ preparedness, ranging from print media fear—mongering about general junior doctor incompetence to more positive personalised and human representations of junior doctors in TV documentaries. Such patient and carer perceptions are based on these sources of knowledge and intertwined with their perceptions about student/trainee learning, which we discuss next.

Patient diversity

Patients and carers expected junior doctors to be trained across a diverse range of patients, preparing them to be responsive to the needs of the population. Patient representatives narrated that trainees should gain direct experience caring for patients from various socioeconomic and cultural backgrounds, learning to consider how such backgrounds affect disease presentation and patients’ abilities to cope. Seeing patients in their own environments, whether at home or in community settings, was suggested as a way to expose students such diversity. One participant illustrates this in his narrative by using metaphorical talk, which along with his use of ‘they’ for junior doctors reveals how he sees the doctor–patient relationship as somewhat adversarial:

… you know, GPs practice for a few months to see the type of patients that will eventually end up in hospital, because… I think a lot of the junior doctors come from middle class backgrounds therefore they might… not know what life is like on the other side of the fence, you see in the poorer quarters, the estates or the ghettos as they call them in America… and there are plenty in this country and in [city]… if they went in a GP practice in certain areas and saw the people and how they live perhaps they’d have a better idea… (Tom, Focus Group 5, Site 1)

Additionally, participants narrated that junior doctors needed to learn how to care for vulnerable groups, such as those with learning disabilities or mental health problems, understanding their specific health and social care needs. Beyond this, participants explained that doctors’ individual attributes affected their abilities to care for diverse patients, suggesting that some of these skills could not be taught. One carer illustrated this point when narrating a series of events around his mother’s carers in a nursing home. He talked about how qualities such as understanding and empathy are innate, although he also employed a powerful metaphor of education as a journey (‘going down a road’), to illustrate that some of these things could be developed:

We’re [patients and doctors] not all equal. So the people [doctors] who are successful with patients at risk or more demanding patients, that’s a special kind of person and although it’s possible to train individual doctors to become more understanding, unless they’ve really got it within them, I think they’re only going to go so far down that road of having full understanding, full empathy, full willingness to spend time—I’ve seen some care staff dealing with my mother who was very aged and in a care home. Some care staff were exceptionally good, and other staff were okay. And I put that down not to their training, not to their age, not to their experience, but to themselves. They just have a better understanding, a better willingness, a better desire to undertake that kind of work. And some doctors will fit that bill but not all. (Jack, Interview 1, Site 2)

Broad training base

As well as diversity in patient background, participants also narrated that students must be taught broadly about all conditions and medical specialties, regardless of their future career plans. For example, Harry narrated the hypothetical thoughts59 of a medical student that he considered appropriate for approaching their learning:

Harry: Well I think any student going into medicine at the moment has got to look at the broader spectrum, and once they’ve got an idea of everything that’s going on, then they can decide in their mind, ‘This is the way I want to go, or that’s the way I want to go.’

Nick: Yeah.

Harry: It’s the benefit obviously of going into the general practices and following your consultants around and everything else. It’s the correct and right way to do it.

(Harry and Nick, Focus Group 5, Site 1)

Lifelong development

Participants also highlighted that all doctors should continue to develop their knowledge and skills throughout their careers, in terms of technical clinical knowledge, and by growing as a person. However, their own experiences of this were not always positive as the following narrative suggests:

Jessie: When we are delivering the 15–20 min presentation to them, they’re not—sort of they are taking it on board—but then we’ve got to go back again, but this time—cause they get passed—we’ve got to do it to the medical students again—and to the nurses and doctors which are on the ward, ‘cause we deliver um—this for the awareness training…to hospital staff, but at the moment—some of them are taking it on board but the hierarchy people—the very hierarchy people—the professional people are not…the doctors who are very high up…’ cause they’re not taking no hand outs no nothing at all…

Danna: they didn’t really take it that good did they?

Jessie: they didn’t take it that good at all…that’s the worst side we saw—so far. 

(Jessie and Danna, Focus Group 3, Site 2)

In-depth clinical reasoning

A number of patient representatives described the issue of what one participant referred to directly as: ‘diagnostic overshadowing’ (Elaine, Focus Group 3, Site 1). Diagnostic overshadowing occurs when once a main diagnosis is made, all other symptoms and issues are associated with that diagnosis, thereby overlooking coexisting conditions. Another participant expressed the need for junior doctors to learn how to listen to carers as a way of preventing such diagnostic overshadowing as she narrated an event involving her husband and the physical pain he was experiencing. In doing so, she revealed two different, but both oppositional, ways in which she understood the doctor–patient relationship: as a game (‘playing the system’) and as war (‘fighting your corner’):

I think too often people are dismissed with one diagnosis, when in fact they’ve got an underlying urinary tract infection, or chest infection, or a pain, which they can’t express anyway. But we know, as their loved ones and their next of kin living with them 24/7, that he is in pain somewhere. And I think that’s probably one of the biggest frustrations that I found. And because I know how to play the system, we got a lot quicker response than many of the thousands of carers out there that don’t know how to do it. And that makes me angry, but you’re going to fight your corner first and foremost. It’s just those sorts of things that make caring so impossible, or so very challenging—so very difficult, and why people collapse under the strain. (Rosie, Focus Group 6, Site 1)

Additionally, carers narrated events suggesting that once a simple diagnosis has been reached, doctors can be reluctant to look for additional complexities:

Yeah, you know when you said about the junior doctor—I’m talking about in the hospital setting when my children finally got to (name of hospital) and we all had to say what—and the junior doctor was taking notes, and so on… and I just feel that they’ve got somewhere there’s an algorithm which they say, ‘ Yeah, yeah, yeah, yeah, diagnosis. Full-stop. Don’t want to know anymore. ’ (Kate, Focus Group 6, Site 1)

The need for support

Finally, participants narrated events that made them conclude that junior doctors needed support: both clinical support on busy wards, as well as pastoral support. It was identified that support from peers and from seniors may both be important in different ways. For example, Liz narrated her in-depth knowledge of junior doctors’ experiences when she told the group about how little she had experienced junior doctors being supported during ward rounds. Interestingly, she demonstrated her empathy with the junior doctors and narrated a future hypothetical event, based on past experiences, by placing herself in the role of the junior doctor (note, Stephanie uses the term ‘the firm’, which no longer exists now, instead of ‘the team’):

Stephanie: I think junior doctors need support beyond the firm they’re working with.

Liz: Because it must get frustrating. I mean if you go around the ward and you count to twenty and they’re [patients] all awkward.

Stephanie: ((laughter)).

Liz: At the end of the ward you think, ‘Ah I’m going to kill them all.’

Stephanie: But you can’t say that to your consultant. Whereas if you had a little group where you could go to where it was acceptable to say that and have a laugh about it that would make a lot of difference. But also you need superiority in there to give you permission, to feel that, you know.

(Stephanie and Liz, Focus Group 2, Site 1)

To summarise this theme ‘desires for student/trainee learning and support’, patients and carers talked about their expectations for student learning so that graduates were properly prepared for practice. Participants had expectations that students were educated to work with diverse patients and vulnerable groups, that they were taught about a diverse range of conditions and specialties, that they were committed to lifelong learning, that they had good clinical reasoning and were open to involving patients and carers in clinical reasoning, and finally, that they were well supported. Such participant desires for students learning and support were related to the key capabilities they wanted from future doctors, which we turn to next.

Patient-centred communication

Participants narrated situations in which they felt disempowered and vulnerable when entering hospital. Ultimately, they felt that junior doctors should be well prepared to communicate effectively with patients on all levels: rapport building with patients who are often nervous in the clinical setting, treating them with respect, dignity and working in partnership with them. For example, Gavin shared his story about how he felt when he arrived at hospital leading him to assert that all doctors should understand and react to patients’ vulnerabilities:

… you come into a strange building, you’re sort of in a state of shock, you don’t know the building, the professionals do, and there’s this, actual almost basic need to be looked after in terms of, being welcome, being reassured. And I think as a junior doctor, or any doctor, you should actually be aware of what their immediate needs are, and get into a relationship. (Gavin, Focus Group 1, Site 3)

Some participants narrated being more active as recipients of poor communication practices by senior clinicians. For example, Suzanne narrated an event in which a senior doctor treated her like an object, with a junior doctor and medical student present. She talked about how she tried to redress the situation by speaking directly to the medical student:

There was no introduction to anybody. She just wafted into my room with two other gentlemen. She [senior doctor] just said to them both [junior doctor and medical student], ‘Have any of you looked at this scar?’ And she just ripped the top of a sixteen-inch piece of plaster off. She said, ‘Why has nobody examined this before?’ and she left it like that and walked out of the room. And I said to the year five student, I said, ‘Can you just come back a minute? Please will you remember never to treat patients, or junior doctors, like that? ’ It was appalling. (Suzanne, Focus Group 1, Site 3)

Participants talked about the need for junior doctors to understand how and when to involve carers in consultations, and to understand that issues such as confidentiality should be addressed with both the patient and the carer. Specifically, carers narrated situations when they felt exasperated when information was denied. For example, using more metaphorical talk for exclusion, Kate (Focus Group 6, Site 1) narrated how she felt she came ‘across a brick wall all the time’ in her encounters with receptionists, nurses and doctors. Appropriate carer involvement was associated with more positive narratives of care from carers and patients. In addition, patient representatives emphasised through their stories how it was essential for junior doctors to be prepared to give full and clear information, empowering patients to be involved in making decisions. Further, through their narratives participants emphasised the need for all healthcare professionals to tailor their approach appropriately to individual patient needs and capabilities. For example, Grace narrated a situation involving her sister who was assisted in using her inhaler by a healthcare professional following a junior doctor’s assumption that she understood their instructions. Grace uses sarcasm as the person explaining clearly thought the task was simple and could not see that actually, for a patient with dementia, following those instructions was going to be very difficult:

My sister has Alzheimer’s, I don’t think she would have the concept of ‘hold this thing [Metre dosed inhaler], put the thing at the end, press it in, inhale it’. So she [healthcare professional, not junior doctor] said, ‘Well, it’s very simple’ [said sarcastically]. (Grace, Focus Group 4, Site 1)

Greater respect

Patient representatives shared several narratives illustrating a lack of respect towards vulnerable patients. The narratives portrayed unacceptable care, causing high levels of stress for patients and carers. Concerns regarding undignified care were expressed with regard to junior doctors, nurses and nursing home staff. One carer narrated a future hypothetical situation in which she described that she feared how hospital staff would treat her loved one more than the consequences of her illness, dementia:

Grace: … It should not be like that. That I’m not fearing the illness [dementia] itself, that I’m afraid of how she’s going to be treated.

Catherine: But she will have support.

Grace: Yes, and that’s the big difference for me. I’m not frightened of the illness, I can deal with that. We as a family can deal with it, we’re all very close. But all of us are terrified of how she’s going to be treated. (Catherine and Grace, Focus Group 4, Site 1)

Participants narrated the importance of respect and for newly qualified doctors to be aware of this. They also spoke of the importance of senior doctors as role models for developing respectful attitudes, emphasising how critical their input is, especially within the first few months of junior doctors’ careers. For example, Liz drew on her experience of the healthcare setting as she narrated a generalised situation in which junior doctors begin to learn how to become doctors:

… when you become a junior doctor, you work within one firm, and really your role models are very limited. And your attitudes will actually be formed by the attitudes of those senior doctors. And I think during that year or first two years, housemen [junior doctors] really need the opportunity to discuss what they’re learning, and what they’re experiencing, with a wider group of people than the firm they’re working for, so that they can actually stand back from what’s going on and say, ‘Well you know, that’s not quite so good, you don’t need to do it that way.’ Because as I say, you’re [junior doctor] the lost one. Because you’re in the rough-and-tumble and everything’s new. You form your attitudes very early on really. (Liz, Focus Group 2, Site 1)

Finally, participants described how a lack of consideration for individual patient needs could cause significant stress and emotional burden for patients and carers, as well as for junior doctors and other professionals involved in their care. This is illustrated by a carer’s narrative, in which she describes an event when her husband broke the nose of a junior doctor who ignored her advice regarding the best way to approach her husband:

I can certainly share from a personal perspective, feeling a great deal of empathy for the junior doctor, who obviously didn’t have a clue what they were doing, as didn’t have any idea how to speak with my husband- did not say to me—this was in a hospital setting, in an acute setting, when I had obviously said—he was in the earlier stages of dementia looked a very fit healthy specimen, but I did kind of say I needed to be with him whilst he was examined—that was all fine, but I did kind of say, ‘Can I just advise you how to do this?’ The answer basically was ‘no’, so I sat back and thought, ‘Now, wait for it.’ So, it was the same speak as you would speak to any other adult, but no chance to assimilate, to even test to see if there was any level of understanding. But I looked at my husband’s eyes and thought, ‘There’s a belt coming, I can see it.’ He was smiling. So with that, he broke the nose of—bang—and I did say, ‘Actually, I did try and point out about his dignity da-dee-da-da-da’ because what he did, this guy, was go straight to my husband’s stomach. (Rosie, Focus Group 6, Site 1)

To summarise this theme ‘future doctors’, participants talked about the key skills/qualities they wanted in their doctors specifically around patient-centred communication and respect. While they commonly narrated patient experiences (themselves or their loved ones) of feeling vulnerable, disempowered and disrespected in the healthcare setting, they instead wanted effective communication, respect, dignity, partnership working, clear information, empowerment and involvement, and they expected that senior doctors should role-model those behaviours to their junior colleagues.