Four themes were developed and are explored with data extracts below. Interview number is indicated numerically in brackets.
The value of teaching
The teaching programme was considered a valuable addition to the department.
“Before this was set up, there was no departmental teaching” (12)
“I found these sessions to be quite useful because on my general surgery job there wasn’t always a lot of teaching other than sporadic here and there on the ward round” (6)
The teaching programme challenged clinicians, encouraging them to develop as educators. Teaching helped speakers deepen their own knowledge on the subject.
“In order to be able to go and teach a subject you need to have the abilities to synthesise lots of information and deliver that information in an effective way, which in turn will also help [your] clinical practice.” (3)
Sessions provided context to daily practices.
“It has added interest and understanding in what people were doing rather than just doing jobs without understanding why they were doing jobs. They were understanding the principles behind, [everything from the] pathology to pathophysiology to clinical management…the bigger picture.” (4)
In particular, the reflective approach to learning helped cultivate a sense of agency. Junior doctors began portraying themselves as both self-directed learners and self-efficacious in bringing about change.
“When people are moving from a university-based education to work, they [junior doctors] expect everything to be delivered to them on a plate, whereas when you go to work, you start having to be the producers of content, rather than just constantly receiving…they start realising that they can impact organisations themselves.” (3)
The programme also provided opportunity for attendees. Junior doctors saw it as a place to access specialist knowledge from experienced surgeons and to further their career aspirations.
“You don’t really get any teaching…and I don’t know where those resources are that would explain it quite so simply and quite so accessibly [as the teaching programme]” (5)
Senior clinicians on the other hand saw it as an opportunity to gain experience in leadership and mentoring.
“More senior trainees can hone their teaching skills and apply things we may have learnt in postgraduate medical certificate diplomas.” (9)
The programme encouraged juniors to acknowledge their agency in learning and provided opportunity for development, irrespective of grade.
Learning as a community
A flattened hierarchy in a learning community does not always come about organically. Participants stressed the importance of cultivating this and often spoke of its benefits.
“Being in a room with all different levels of doctors…we don’t really get that at all.” (1)
Reflective interaction between juniors and seniors allowed for richer learning across grades and specialties.
“…[teaching was an] especially good forum for conversation and questioning…the senior trainees and consultants joined in to make it a much more valuable educational experience than just a standalone lecture” (5)
The involvement of doctors from all grades meant that fresh light could be shed on existing knowledge. Each practitioner could bring their previous experiences and hence their individual perspective to the discussion.
“I quite like it where it is varied, where one week it’s a consultant the next week it’s an F1…they teach differently, and they teach different kinds of things” (10)
Most participants favoured a mixed teaching approach in which sessions were primarily led by juniors and supported by consultants. Appropriately challenging the trainee empowered them to take on responsibility and improved the quality of the content. Supportive consultants were able to facilitate this while identifying and rectifying any errors.
“The content was at a higher level which was actually why it was good teaching…I feel like it should be above our grade to help push us forwards.” (5)
Furthermore, the involvement of a senior clinician can guide the identity formation of a junior doctor into a surgeon, shaping their training and progression.
“When you see your consultants in those teaching sessions giving feedback or giving pointers, it empowers you to feel like they actually care. It is easy to feel like they don’t care about your career or about your training as a doctor. But when you’ve got a formal plan of teaching that happens every week, you see…that they [consultants] do care about your career progression and your training.” (9)
A safe, supportive learning environment can also demystify those at the centre of the community of practice and help foster transparency across the team.
“I even remember meeting consultants who I never would have even spoken to otherwise but because we were put in that environment, I did get chatting to them. And [they] had some really amazing bits of wisdom” (1)
“You have F1s and consultants all sitting down together, all having lunch together, all chatting together. [This] slightly breaks down that hierarchy and the interaction between the F1 and the consultant or SHO and consultant isn’t as serious” (12)
Cultivating a community centred on reflection meant that reciprocal learning could take place. Registrars acknowledged that they too had learnt something from the junior foundation doctors.
“I speak for a few other registrar colleagues when we say, a few of us learnt a lot of up-to-date information that we wouldn’t have known before we started that teaching session. And that was delivered by an F1 [junior] doctor.” (9)
Similarly, other members of the multidisciplinary team were able to demonstrate how their contributions holistically improved patient care.
“The roles of the other MDT [multidisciplinary team] members aren’t always fully appreciated…I think often there’s a lack of understanding from doctors. I think having that opportunity to be able to explain your role in a bit more depth and detail…improves outcomes.” (7)
Barriers to successful training
Study subjects identified several barriers which can preclude effective learning. These were often described in general terms rather than applied specifically to the teaching programme.
The most cited barrier was a lack of time. Junior doctors were often portrayed as being too busy to be able to attend and organise a teaching programme.
“If you’re a junior doctor, you’ll be running around like a madman, you’re always hungry and needing the toilet!” (1)
“Finding a time when everyone’s going to be free. Everyone’s busy. Everyone’s got different schedules, so finding that time is going to be difficult” (11)
Registrars and consultants on the other hand were criticised for not investing their time or appropriately prioritising educational activities.
“Consultants don’t get paid for it [teaching]. Unfortunately for some, that’s what they’re all about. So, if they don’t have the time in their job plans to teach, then they won’t bother.” (2)
“But the truth is [consultants] overall are not interested. This is the truth.” (4)
Lastly, inadequate facilities can affect the continuity or quality of teaching.
“You know there might be some sort of bureaucracy in the way” (3)
“The venue at that particular time wasn’t great because it was quite a small room so there were a lot of people sort of standing up and listening to what was going on” (8)
Time constraints, clinical workload, inadequate facilities and a lack of consultant interest can all negatively affect teaching practices in a department. This can have a significant impact on the way junior doctors perceive general surgery and develop their professional identity.
Culture of surgery
A significant number of participants spoke of a wider culture of surgery in which the teaching programme was situated. While this was rarely in relation to our programme directly, this theme defined the unspoken barriers that prevent peripheral participants from engaging with surgical education.
General surgeons were often portrayed as stereotypically intimidating.
“There’s always that stereotype that they’re very nasty, cutthroat people” (12)
“There’s this big attitude of ‘oooh they’re surgeons, they’re scary’…I do know why it continues.” (1)
The latter subtly illustrates that the persistence of these stereotypes depends at least partially on their reflection of the truth. This was acknowledged with much hesitation. In many instances, previous negative experiences of surgeons shaped a wider perception of surgery.
“There’s that one experience – because it’s such a shocking experience – that story just gets retold and retold and retold. So the…fear of it passes on. It gets continued, it gets propagated.” (1)
Similarly, a culture of teaching and learning through fear was described alongside these stereotypes. This can be particularly harmful as it undermines trainee confidence.
“I think general surgeons in my experience tend to be quite patronising in their teaching methods…they can also be quite mean in their teaching methods…[this can] make you hate surgery even more than you already do.” (10)
“Learning by humiliation…I acknowledged that I had that sort of teaching, but I also realised that it is not the best way to get things out of people.” (2)
While the former quote demonstrates how these experiences can shape lasting perceptions of the specialty, the latter shows how surgeons are starting to acknowledge the damage these interactions can inflict.
“I feel that the F1s and F2s [junior doctors] if they come and say that I want to be a surgeon, they will ‘quote unquote’ “teach them”. If they come and say I want to be anything else, it’s almost seen as a bit of a joke…And they always pre-decide who’s going to be a surgeon, who’s not going to be a surgeon, who they can be bothered to teach and who they can’t be bothered to teach.” (8)
These insidious, unwritten cultural rules can be particularly difficult to challenge and change.
“Most people just get on with things, they just swallow their pride and get on with things. Because there’s almost an expectation that that’s what you’re supposed to do…But actually, the more that we don’t do that [challenge behaviour], the more that we perpetuate that sort of negative behaviour. But I think that’s a really difficult thing to try to fix and it probably requires massive cultural change amongst the general medical and surgical community” (9)
Lastly, the teaching programme provided an opportunity to reassure juniors that an environment of humiliation was neither necessary nor appropriate. Participants acknowledged that a culture of fear no longer had a place in modern surgical practice. They proposed reflective, multidisciplinary surgical education as a driver of change.
“I think it’s the whole aspect of junior-led teaching also helps break down those stereotypes that have formed over the many many decades…And if they [consultants] see that there are juniors that are keen to learn more about surgery and even teach then I feel that that would be a mutually beneficial relationship between the seniors and the juniors” (3)
Critically reflective, inclusive methods of teaching could help deconstruct hierarchy and lead to lasting change.