Title: Where have all the doctors gone? An ethnographic study to explore the retention problem in Emergency Medicine
Funder: Department of Health and Social Care

Abstract: Background Retention of doctors in emergency medicine is a problem in the NHS. Half of trainees leave at year three or four of specialty training. One-in-three of those finishing emergency medicine training do not plan on working as NHS consultants. One-in-four advertised consultant posts goes unfilled. These problems are impacting on patient outcomes and costing the NHS money. Previous initiatives to improve retention have shown limited success, perhaps because there is little understanding of what keeps people in practice in emergency medicine.Aims and objectives The aim of this study is to gain a deep understanding of retention in emergency medicine; to elucidate how retention is made possible. This aim requires a study design that can tackle complexity and develop new understandings. The objectives are: To understand in detail the day-to-day lived experience of emergency medicine doctors to identify and explore factors influencing retention. To situate these descriptions within the current educational and health policy contexts. To advance the debate and make policy and practice recommendations based on a detailed understanding of retention of medical staff in emergency medicine.Methods The research will be conducted within an ethnographic framework. This involves detailed observation of the people, culture and environment. This will be supported by interviews as part of the ethnography and with key stakeholders relevant to retention. A scoping review of the academic and grey literature around retention will be performed and key themes incorporated into the ethnographic analysis. The data from the observation, interviews and literature will be analysed using an approach informed by Grounded Theory methods.Timeline for delivery The 3-year PhD started in October 2018. Key deliverable milestones are: Completion of scoping review by March 2019. Ethical approval obtained by June 2019. Data collection completed by February 2020. Data analysis completed by September 2020. Thesis and first version of journal manuscripts submitted before return to clinical training in October 2021. Anticipated impact and dissemination To maximise impact and value for money to the funder, I will develop a detailed dissemination plan. I will present work-in-progress at national academic and clinical meetings (e.g. The Royal College of Emergency Medicine (RCEM) Research Engagement Day) to gain feedback and build interest. The completed work will be published in international journals and presented at relevant conferences focused on emergency medicine and medical education. I will engage key stakeholders including NHS England, Health Education England and RCEM. I will publicise the findings and publications by engaging with RCEM learning online podcast and blog, as this has been shown to increase readership.I aim to publish policy recommendations with key stakeholders by October 2022 with the intention for implementation by April 2024 leading to a reduction in exodus of senior emergency medicine doctors and subsequent improvement in direct patient care by October 2025. I believe that understanding the problem and communicating the findings can lead to change, and I plan on supporting this by designing bespoke interventions, which will be the focus of my research going forward.

Lay abstract: Aim of the research Lots of doctors leave emergency medicine, around half of year three or four trainees resign. This is costing the NHS money and patients can be harmed by the lack of senior doctors. The aim of this study is to learn why some doctors stay working in emergency medicine when many leave. This will help to identify where changes can be made to prevent doctors from leaving, which will then lead to more senior medical staff providing care to patients. This leads to better care, outcomes and patient experience for the millions who have to go to emergency departments ('A&E's) every year.Background to the research How to keep doctors working in emergency medicine is a problem. One in three trainees do not plan to work as NHS consultants after finishing training. Work-life balance, pressured work and night working are problems found by earlier studies. Other research has looked at factors that might add to doctors leaving such as stress. These studies all focus on doctors leaving. This study will look at the problem in a different way to learn what enables doctors to stay. Design and methods used I will use observational methods, watching the people, setting and culture, and documenting what I see. I will also carry out interviews and review other sources, such as journal articles and social media. Data will then be analysed by looking for points that are found many times and that are important for the research question. This method has a strong history for learning about complex problems in science and healthcare.Patient and public involvement I ran a patient and public engagement event. This was funded by the NIHR Research Design Service Public Involvement Fund. The panel members thought the problem was important. The panel did not think the research caused any problems for members of the public. They thought that the stories of those being researched were important to understand the problem. The panel talked about factors that I had not thought about. These were the personality of those choosing emergency medicine and the low chance for emergency medicine doctors to increase their income, unlike other specialties, where private practice is more common.Two members of the public involvement panel have agreed to work with the research steering group. They will ensure the study keeps a public perspective and help to make sure findings are offered in plain English. One panel member will help with the scoping review, checking my findings against the original non-research documents and co-author the paper.At a national level, the public and profession worked together to agree the most urgent problems to research in emergency medicine. This was done with the James Lind Alliance. They are a NIHR funded group who gather research questions and check that an answer has not been found. Staffing, with retention a part of this, was one of the top five research priorities for emergency medicine.Dissemination During the study I will present work in progress at meetings to gain feedback and build interest. These include hospital-wide lunchtime lectures, department audit days and national meetings. The completed work will be presented at national and international meetings on emergency medicine, sociology and medical education. The research will be published in journals. This study addresses a key research priority of the Royal College of Emergency Medicine. As such they will facilitate spreading the findings to the public, profession and press. They will also engage other interested organisations, namely NHS England and Health Education England, supported by the NIHR Incubator for Emergency Care.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE