Teaching and learning in an era of time‐based access targets: Impact of a new model of care on junior medical officers (2015)

In order to address the challenges associated with ED overcrowding and access block, governments in the UK then Australasia have implemented time-based access targets for emergency presentations.1-4 In 2011, the Council of Australian Governments (COAG) adopted a National Emergency Access Target (NEAT) for public hospitals, with the intention that, by 2015, 90% of ED patients would be admitted to a ward or discharged within 4 h of arrival.4 The target has driven many Australian EDs to introduce models of care that facilitate early disposition decision-making.5-7 Although data are emerging about the impact of NEAT on quality and timeliness of care,5-11 little is known about its effects on the education and training of junior medical officers (JMOs). Trainees have voiced concerns about potential negative implications,11, 12 but it is unclear if these have been realised. This article draws on qualitative data from a broader study to illustrate teaching and learning practices before and after the introduction of a new model of care at a large metropolitan ED. The Royal Brisbane and Women's Hospital (RBWH) is a tertiary referral centre with an annual ED census of 75 000. In 2013, RBWH ED implemented the Two-Hour Evaluation and Referral Model for Shorter Turnaround Times (Thermostat), a standardised workflow model utilising ‘hot’ assessment zones and ‘cold’ step-down areas to provide accelerated team-based care. Patients undergo early consultant or registrar review in an attempt to finalise disposition within 120 min of arrival, after which they are transferred to a cold zone within the ED to await review by an inpatient unit. Although senior ED staff assume responsibility for decision-making and referrals, JMOs remain heavily involved in all aspects of patient care, including assessment, investigation requests, management and documentation. The introduction of Thermostat was accompanied by a comprehensive change management process, including a pilot programme, training sessions and printed orientation materials. This article explores the impact of Thermostat on teaching and learning. Discussion is grounded on data collected as part of a longitudinal qualitative study funded under an Australian Research Council Linkage Project grant (LP0989662). Data obtained before the introduction of Thermostat include over 600 h observation of clinical shifts and training sessions by independent researchers and 57 formal interviews with ED consultants, registrars, nurses and hospital executives. Data collected post-Thermostat include 160 h of observation of clinical shifts and 25 interviews with consultants. Research methodology followed a standard approach used in qualitative, field-based management studies.13 As with many EDs, the ‘traditional’ model of care at RBWH relied on JMOs undertaking initial assessment and management of the undifferentiated patient and learning through experience and subsequent discussion with a consultant or registrar. One consultant summarised the process to a JMO as, ‘You see the patient and then you tell me a story and I'll tell you where you're wrong or where you're right’. The vignette in Box 1 is illustrative of this approach. In the ED write-up area, JMO 1 presents to Consultant X his assessment of his assigned patient – an alcohol-dependent diabetic presenting with chest pain. Consultant X talks through the JMO's clinical reasoning. JMO 1 departs and, unable to put in an i.v. line, returns. They go together to see the patient and Consultant X demonstrates how to find a vein. Consultant X returns to the write-up area. JMO 2 asks, ‘Can I talk with you about my patient'? She presents her assessment and plan that the patient can be discharged. Consultant X says, ‘Let's go and see’. They talk to the patient and Consultant X conducts a physical exam. Leaving the cubicle, Consultant X explains his assessment that the patient has a hernia and needs surgical review. JMO 1 approaches and asks Consultant X for an opinion on the patient with chest pain, suggesting ‘referral to cardiology’. They discuss the test results and, after reviewing records from the patient's previous presentations, Consultant X indicates that the patient might be better suited to general medicine and proposes further tests. ‘When the results come back, you come and see me and we'll sort out the referral’. JMOs would see patients and present their assessment to the consultant, who asked questions to test their reasoning and provided an ‘expert opinion’. In most cases, the consultant would send the JMO back to the patient to ask further questions, initiate tests and procedures and, at some later point, would usually see the patient themselves. These practices provided opportunities for ‘trial and error learning’, whereby JMOs were allowed to ‘play by making their own mistakes’. Observational field notes reveal that some JMOs enjoyed this experience – ‘I like to be able to have a go even if I'm wrong’ – while others were afraid of making mistakes – ‘My head hurts when I go home because I feel so anxious’. Interviewees pointed out that these practices were inefficient because patients could occasionally wait several hours for a disposition decision, usually the result of inexperienced JMOs ‘floundering’ while awaiting more direct guidance from consultants. Reflecting on the trade-off between efficient patient care and individual learning pre-Thermostat, one interviewee remarked, ‘I learnt a lot by just having to work it out myself. Is that good patient care? Probably not. But am I a better consultant now for it? Probably’. Following the introduction of Thermostat, frontloading of senior decision-making has shifted teaching and learning practices in the ED towards consultant-led task delegation and role modelling. One consultant explained that ‘embracing’ NEAT through the Thermostat model ‘has forced us … to re-appraise how we do our education’. As illustrated in the vignette in Box 2, consultants are now actively involved in early patient assessment to ascertain the patient's presenting complaint and determine a disposition within 120 min of arrival. JMOs generally accompany the consultant, which interviewees noted provides an opportunity to ‘model behaviours, model decision making, model cognitive processes, model practice, model all these things and demonstrate it to our juniors’. Consultant Y and the Hot Team Leader look at the Emergency Department Information System (EDIS) tracking screen, noting several new arrivals and other patients close to breeching their 120 min time target. ‘That patient has been referred and can be moved to cold. Waiting on bloods for those two’, he says. Consultant Y takes JMO 1 to see a new patient who has presented with throat pain and difficulty swallowing after a sports incident. Assessing the patient, Consultant Y is concerned about a possible impact injury and asks JMO 1 to request a head and neck CT. Later, JMO 1 accompanies Consultant Y as he assesses an elderly patient who has had a fall. After questioning the patient and his daughter and conducting a physical exam, Consultant Y concludes the patient will need to be admitted. As they leave the cubicle, Consultant Y explains his concerns about the patient's increased seizures and fall, and advises JMO 1 on which tests and scans to request. Consultant Y checks EDIS and does a walk-around of the beds in his pod. The CT scans for the throat patient are back. Studying the images with JMO 1, Consultant Y points to a possible injury to the oesophagus. They go together to update the patient and then return to the write-up area so Consultant Y can seek advice from the ENT team on this ‘unusual case’. Mindful that other patients need to be progressed, Consultant Y asks JMO 1 to phone the medical registrar and refer the elderly seizure patient for medical admission. Seeing the JMO's hesitation, Consultant Y says, ‘No, I'll do it. I'll get you to write up the patient notes’. Consultants acknowledge that Thermostat poses teaching challenges on busy shifts, namely ‘how to provide a learning opportunity for the resident without giving them all the answers’ and not reducing their training to ‘performing tasks’ like i.v. lines, venepuncture and requesting investigations. To address these issues, consultants verbalise the clinical reasoning and professional judgment underpinning their decisions and behaviours, encourage junior doctors to ask clarifying questions, and seek out quiet spaces in the corridor or notes write-up area to debrief after patient interactions. One consultant explained, ‘It is incumbent on us to turn every episode into a teaching episode’. Several interviewees suggested that the previous practice of expecting juniors to ‘learn to think like a doctor’ through trial and error and consultant critique, rather than active role modelling, was ‘fairly illogical’ and ‘flawed thinking’. Another consultant summed up the potential teaching and learning benefits of Thermostat's frontloading as follows: ‘Residents have fairly early senior input so they're not left to sink or swim. It's allowing them to model their thinking more, refine their thinking a little bit more, so instead of them just blindly wading through this pool, we're giving them a bit of focus. So I think it's a different educational experience for them but it's probably as good, if not a better, educational experience’. Others were more cautionary about the impact on teaching and learning. One interviewee noted, ‘I still think that we can find time to go in and review the patients together even with the clock ticking. … [However] if we get to the stage where the juniors aren't taking a history, then I think we've failed and if we get to the stage where the consultants are seeing a patient and then telling a resident to do a few tests, then I think that's terrible’. Some JMOs also stated that their responsibilities have decreased, to the detriment of their decision-making capacity: ‘We work under a registrar and a consultant and it's pretty routine. You have to get bloods for every patient, do some obs, take a history. We don't really make decisions. The registrar and consultant do that’. As the vignettes illustrate, the approach to teaching and learning for junior doctors has fundamentally changed. Although an ED rotation still provides essential exposure to the assessment and management of the undifferentiated patient, senior staff now explicitly model expected behaviours and partner with junior doctors in the management of patients throughout their (now shorter) ED journey. The long-term impact on JMO skill and knowledge acquisition has not been formally evaluated. This approach seems to complement other components of the ED education programme at RBWH, including case-based teaching through the More Learning for Interns in Emergency (MoLIE) and House Officer Training in Emergency (HOTIE) initiatives.14, 15 It is also consistent with contemporary trends towards ‘work integrated learning’ in healthcare, in which tacit knowledge and skills are more effectively acquired through direct participation in a team, rather than models where ‘learning’ might be separated from ‘practice’.16 Concerns that JMOs working in ED would be reduced to triage and referral officers have not been realised. Similarly, fears that there would be little opportunity for bedside or opportunistic teaching with the introduction of NEAT have not played out. This is supported by JMO feedback obtained through term evaluations (Centre for Medical Officer Recruitment and Education, RBWH, pers. comm., May 2015). Although the present paper has not explicitly discussed the impact of NEAT on supervision and teaching of ED registrars, the new model also allows trainees to in turn take a more active role in the supervision of junior doctors. It also allows them to develop skills in patient flow, task prioritisation and clinical leadership. The interactions described reflect the experience following the introduction of a specific patient-flow model, and might not necessarily be generalisable to other models introduced to respond to NEAT. Nevertheless, reflecting on the expectations and experiences of JMOs in EDs and adapting these to new patient-flow processes might provide opportunities for a more meaningful learning experience. Suggestions for identifying and utilising ‘teachable moments’ in the era of NEAT are outlined in Box 3. The present paper describes the impact of a new model of care on the supervision and teaching of JMOs. In the case of this ED, Thermostat facilitated a shift from training through ‘trial and error’ to senior role modelling and work integrated learning. Although the future of NEAT is uncertain, system changes provide an important opportunity to review and optimise the ED training experience. The authors acknowledge the support of the Australian Research Council in providing funding for this project under Linkage Project grant LP0989662. RM is a section editor for Emergency Medicine Australasia and AFB is the immediate past Editor-in-Chief of Emergency Medicine Australasia.