During November, Anna Goulding and Daniele Carrieri have been busy interviewing a sample of those who volunteered to be interviewed. Thank you to all of those who have taken part. There are still some more to do – and if you have an invitation you have not yet responded to there will still be time – but December will be largely devoted to analysis.

There are already some very interesting findings emerging, and we look forward to sharing this in our final report next year.

Some of our early findings have been included in the GMC’s State of Medical Education and Practice (SoMEP) 2020. SoMEP is an annual report which reviews trends across medicine. This year it is obviously dominated by COVID-19, and we are pleased our research contributes to understanding of the FiY1 response.

The key points from these interim findings are:

– Graduates undertook FiY1 for a range of reasons, including a desire to help and put their skills into practice, and a pragmatic desire to earn money and do something during lockdown.

-Many graduates were unable to do FiY1 even though they would have liked to, due to logistical and communication issues.

– FiY1s worked in a range of settings, although most worked in clinical wards. A large number had worked in areas where there were COVID-19 patients, with around 30% working in COVID-specific clinical areas.

– F1s who had done an FiY1 post were more prepared for F1 than those who had not.

Full analysis will be in our final report in 2021. You can read SoMEP 2020 here.

One of our key objectives in this study has been to understand how working as an FIY1 and F1 during the pandemic affects wellbeing. This strand links to other work being undertaken by team members in Exeter. In this post, Daniele Carrieri describes that work.

Before the COVID-19 pandemic, stress levels amongst doctors were already incredibly high. As this pandemic unfolds, and as clinical work and training is changing beyond recognition in so many ways, tackling mental ill-health in doctors and medical students is ever more relevant. The growing pressures, uncertainty, demands and challenges of a doctor’s work environment can lead to high levels of stress, anxiety, depression, suicidal feelings, and to broader organisational issues including recruitment and retention of clinical workforce. 

The Care Under Pressure project team undertook a review of the large body of existing literature on interventions, support and advice on treatment for doctors and synthesized it to take in to account factors such as individual, organizational, social and cultural; an approach not considered in existing interventions and initiatives.

The team also drew on the perspectives of a range of stakeholders such as patient representatives, clinicians, doctors in training, medical educators and academics to gain a rounded view on how to develop strategies to effectively tackle mental ill-health and its impacts. 

Feelings of isolation and ill-preparedness for difficult situations were key causes of mental ill-health amongst doctors. A sense of belonging to a team and to a profession and receiving and giving mutual support were key to promoting well-being at work. Experiencing feelings of trust in work colleagues and individuals’ organizations alongside the support of balanced feedback were also found to be key aspects of positive work cultures. These findings were used to produce a report offering guidance and recommendations to policy makers and organization leaders involved in the design of interventions as well as contributing to the development of new approaches to the research of doctors’ mental health. The Care Under Pressure project was undertaken pre-COVID-19. However, the high-level evidence-based principles are transferrable to the current context. 

To support and bring to life the project findings and recommendations the team collaborated with artists and film makers to produce cartoons, a short film, and an animation (see an example of cartoon below). 

Care Under Pressure is funded by the by the National Institute for Health Research (NIHR) HS&DR (project number 16/53/12). For more information, please visit http://sites.exeter.ac.uk/cup/

F1s who started work in August will now be well-established in their jobs, and so after a gap in data collection, we are getting ready for the final phases of the project. In the meantime we have been carrying out some of the early analysis and sharing findings with the GMC. We can’t share those results publicly yet, but there are some really interesting findings.

We received a great response from nearly 600 new F1s to the questionnaire in August. The follow up questionnaire is being distributed from 28th September and will be open for 10 days or so. This will allow us to see whether the experience and wellbeing of F1s has changed across the first two months of work, and whether this is different for those who had undertaken an FiY1 post and those who had not.

We also had a lot of interest in taking part in research interviews, with over 300 volunteering. Unfortunately we can’t interview everyone, so will be selecting a sample, to represent different demographic groups and areas of the country. Those individuals should be getting an email in the next week or so.

In coming weeks we’ll be posting some background to the things we’ve been capturing in the questionnaires.

All F1s have been in their posts for a couple of weeks now, and our questionnaire was distributed to those who had already signed up on Sunday 16th August.

We wanted to wait a little while to distribute this questionnaire because we know things change rapidly in the first week or so of work as an F1, and we want to capture perceptions once any initial shock of transition has passed.

Similarly, this questionnaire will only be open until midnight on Monday 24th August – so if you have been sent a link, please do follow it before then.

If you have not signed up, or no longer have access to a university email, there is still time to sign up at tiny.cc/f1-signup – this link includes both the questionnaire and sign-up details.

Dr Emma Farrington has been part of our project advisory group, and is starting F1 in the Northern Foundation School.

In our study we are looking at the work doctors do, and using a range of measures related to wellbeing, including stress and burnout. In this post Dr Jason Hancock (Consultant Liaison Psychiatrist, Devon Partnership Trust & Honorary Clinical Lecturer, University of Exeter Medical School) writes about another of our key measures which may play an important role in wellbeing.

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As part of this study we are collecting data on how interim F1 doctors respond to ambiguity in clinical practice. Both ambiguity and uncertainty are inherent within the practice of medicine. I recall when I was a foundation doctor even seemingly simple tasks, such as prescribing Warfarin, would be associated with significant uncertainty. For example it was often unclear what the patient’s usual Warfarin prescription was, why they were taking Warfarin, what their target INR should be, how much Warfarin they had actually been taking before admission, and if any changes to other medications since admission would be impacting on the metabolism of Warfarin. While some of the challenges associated with the prescription of Warfarin may have now reduced with the rise of new anticoagulant medications, the issue of managing and tolerating uncertainty remains. 

One of the challenges with research into this field to date has been the interchangeable use of the terms ambiguity and uncertainty. When we refer to ambiguity we mean a clinical situation where there is imprecise, missing, or conflicting information. When we refer to uncertainty we mean a clinical situation where we are consciously aware that we do not know what the outcome will be. This can be caused by many things including ambiguity or complexity. 

As a psychiatrist I am particularly interested in how our ability as doctors to tolerate ambiguity or uncertainty may be linked to our own psychological well-being, and his has been the focus of my research to date. 

To help evaluate how tolerant of ambiguity medical students and junior doctors are within clinical practice we developed the TAMSAD (Tolerance of Ambiguity in Medical Students and Doctors) scale. This scale was initially developed and validated in a population of medical students and foundation doctors in Exeter, and has since been used in a wide range of populations including veterinary students. 

Through taking part in this research and completing the TAMSAD, alongside other measures, you will help us understand how an ability to tolerate ambiguity may be linked to your own psychological well-being as doctors. It will also provide us with valuable information about the how doctors working in rapidly developed and novel roles such as yours tolerate ambiguity, and how practising within the context of a global pandemic can impact on your own ability to tolerate ambiguity and uncertainty in clinical practice.

Through better understanding these potential associations we hope to be better placed to develop educational interventions to help newly qualified doctors, such as you, tolerate and practice within an ambiguous and uncertainty clinical world. 

As FiY1 posts come to an end, so too does Phase 1 of our project. We have some great data on the work activity and wellbeing of doctors in those posts. Our sincere thanks to those who have taken the time to complete questionnaires.

At the moment we have responses from about 10% of FiY1s, although with some regions better represented than others. FiY1s who have completed their posts in the last three weeks will have a final opportunity to add to this dataset at the end of FiY1 before we move on to Phase 2.

Phase 2 – welcome to new F1s

So far we have been concerned with the work and wellbeing of those in FiY1 posts. In Phase 2, the scope broadens to encompass all doctors starting F1. We will be collecting data in August – within the first two weeks of starting F1 after shadowing – and in September, when F1s will have become more accustomed to their new roles.

These questionnaires will be similar to that completed during FiY1, but with an additional focus on how prepared for different aspects of work new doctors feel.

All new F1s should get a reminder about the study during their F1 induction. If you have already signed up to take part in the study you will receive a questionnaire link at the email you signed up with. If not (or if you are unsure) you can still sign up at https://tiny.cc/F1-signup

In this post, Professor Karen Mattick from the University of Exeter gives a personal view on the importance of this study.

My interest in the study is three-fold: firstly, the opportunity to research something as important and timely as Covid-19; secondly, to extend our existing Exeter-based research on wellbeing and tolerance of ambiguity; and thirdly, the chance to collaborate with a national consortium of highly-regarded medical education researchers doing impactful work supported by the UK professional regulator.

The importance of the study is vital. Given the monumental changes to healthcare driven by Covid-19, it is vital that we evaluate the impact on healthcare professionals, both their WORK and their WELLBEING.  This project provides an opportunity to focus on one of most affected groups: new doctors graduating in 2020.

The opening sentence of a New England Journal of Medicine article by Pfefferbaum & North in April 2020 reads “Uncertain prognoses, looming severe shortages of resources for testing and treatment and for protecting responders and health care providers from infection, imposition of unfamiliar public health measures that infringe on personal freedoms, large and growing financial losses, and conflicting messages from authorities are among the major stressors that undoubtedly will contribute to widespread emotional distress and increased risk for psychiatric illness associated with Covid-19”.  Our project provides an opportunity to focus on a group which may be one of the most affected by all this uncertainty: new doctors graduating in 2020.  

Early data analysis is already providing intriguing insights into the experiences of new medical graduates during Covid and we look forward to sharing those in coming months.

There has been lots of interest in the experience of doctors in FiY1 posts over the last few months. Dr Molly Dineen has been working as FiY1 in Truro. Here she shares some of her experiences.

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At the end of February I was travelling to New York for my medical elective, excited for the two months which I was about to spend in the USA and South Africa. Two weeks later I was on my way home, as COVID-19 began to spread across the globe and just a few weeks after that, I was starting work as a junior doctor in the NHS.

The decision to graduate early and start work, three months earlier than expected, was not an easy one. I was aware I would be entering the NHS at a challenging time, but ultimately I wanted to do my bit to help, and to relieve pressure on the more senior doctors who were already working so hard.

I was lucky to have had lots of clinical experience throughout my medical degree at Exeter and having completed our final exams at the end of our fourth year, the last year was focused on gaining experience in practice. This clinical experience meant I felt ready to take on the role of an interim Foundation Year 1 doctor. I felt privileged to be in a position where I could use the skills gained over the last five years to help.

I started working at the Royal Cornwall Hospitals Trust (RCHT) on the Acute Medical Unit, seeing all medical admissions, of all ages and conditions. Starting work as a junior doctor in the middle of a worldwide pandemic was quite frankly terrifying, but the experience turned out to be enjoyable and rewarding.

The biggest challenges that I experienced were adapting the skills learned during medical school to the new environment where we were social distancing and wearing personal protective equipment. Whilst our number of covid-19 cases remained low, we still worked to prevent further spread. I had to communicate with patients through a mask, using only my eyes to express my thoughts and only my patient’s eyes to understand their emotions. I had to re-learn to conduct basic examinations at a safe distance with protective clothing on, and to take a full history from a patient without paper notes, to reduce contamination. 

I had to adapt to this new environment in a matter of hours as I also adjusted to being a new doctor. I had to attempt to ignore all that was going on around me as I faced the challenging questions: “Do you think its cancer?”, “Is she going to die?”. It had been easy to forget that in many ways life continued despite the restrictions, and returning to the hospital was a clear reminder of that. 

The whole team I worked with – nurses, doctors, physiotherapists, occupational therapists, ward clerks, porters, cleaners, physician associates and emergency medical technician – remained positive and upbeat despite the challenges. There was a great sense of team spirit and I have felt so lucky to be welcomed into this team of people who have been working so hard for many months through the Covid-19 pandemic. 

As lockdown rules continue to ease, there will be many more people heading back to work, adapting their own environments and putting themselves at risk in order to help us all move back to normality. I hope that we all continue to work as one big team to reduce the spread of Covid-19 and that we respect the challenges that everyone faces. My new understanding of the challenges, even in an area which has been less affected than some, has emphasised the importance of this to me.  The fewer the cases, the fewer restrictions we will have on access to healthcare and the more normal life can become again.

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Blog adapted from articles here and here. Many thanks to Molly for allowing us to reproduce her words.

Molly has also kept a video diary which was featured on BBC News: https://www.bbc.co.uk/news/av/uk-england-hampshire-53219810/coronavirus-junior-doctor-keeps-pandemic-video-diary

Don’t forget, participants in this project can contribute their own stories to our analysis through the free text link included in the questionnaire email.