The titles used to describe junior doctors should be easily distinguishable and convey to staff and patients the individual's role in the team and level of seniority.3
Our results demonstrate considerable confusion among surgical nursing staff regarding the new titles for doctors in training.
Twenty-one percent of nurses surveyed (n = 12) were confident that they understood the new terms, their confidence was correlated to higher scores in the matching test (Spearmans rho = 0.42, p = 0.002). We did not identify a statistically significant association with demographic characteristics (age, gender and experience) and knowledge of the new terms.
Despite the majority of nursing staff demonstrating good knowledge with regards to the role of the foundation doctors (80% staff correctly matched FY1 and 60% correct matching FY2, respectively), our study demonstrated very poor knowledge of the remaining junior doctor titles. Approximately 90% of respondents incorrectly matched equivalent roles for CT/ST and ST3–ST7 positions. Only 9% of nursing staff surveyed correctly identified ST3 as a ‘registrar’ equivalent, with the majority participants incorrectly matching ST3 to the old SHO position. This finding is somewhat concerning given the fact that the majority of patient care in NHS hospitals is Registrar (ST3–ST7) and/or SHO (FY2/CT/ST) led, particularly during the out-of-hours period.
Our study suggests that knowledge of newer titles within the group of nursing staff surveyed was affected by personal factors (views on its importance) and also influenced by their specific working environment. Despite the fact that we did not find statistically significant differences with regard to the subjective knowledge of terms, between the different groups of nurses, based on area of work. Ward-based nursing staff demonstrated significantly more familiarity, with more correct matching of the new terms, than did nursing staff who worked in a non-inpatient setting (p = 0.01). This observation is perhaps not surprising given that ward-based staff work more closely with junior medical staff compared to those nurses working within the outpatient departments and theatres. An interesting finding in our study was that nursing staff who felt that it was ‘very important’ that junior doctor titles convey position/seniority demonstrated greater knowledge of the current terminology compared to staff who felt it was ‘quite important’ and/ or ‘not very important’ (p = 0.02). It could be hypothesized that the perception of the importance of doctors' roles and place within the medical hierarchy may have positively influenced nursing staff motivation to both learn about the titles and one's receptivity to the new terminology.
There are several possible explanations for high levels of confusion with regard to the terminology highlighted in our survey. One of the key factors contributing to confusion is the current ‘mixed economy’ of training structures to meet the needs of individual specialties. Such a system allows for some specialties to continue ‘run through training’ and also affords other specialties the option to de-couple from the run-through training structure and recruit trainees in a more flexible manner. Currently, the presence of different cohorts undertaking training within different structures, within the same institution, and labelled to match the specific model of training the junior doctor is pursuing, e.g. Core Surgical Trainee (CST), Core Medical Trainee (CMT), Specialty Trainee (ST), Primary Care Vocational Training Scheme (GPVTS), Acute Care Common Stem Trainee (ACCS), is undoubtedly contributing to the confusion about terminology and lack of appreciation of the specific role that these doctors play in the team, as highlighted in the present study.
As mentioned earlier, MMC has become extremely unpopular among many medical professionals in the UK. The presidents of the Royal Colleges of Physicians and Surgeons issued a joint statement emphasizing that the medical profession ‘could not underestimate the immense damage inflicted on British medicine by implementation of MMC’ and welcomed the independent review of training.1
Sir John Tooke was commissioned by the Department of Health to carry out an independent review of MMC, and this report was published in 2008.2
Several recommendations were proposed following this Inquiry. In the context of postgraduate training and nomenclature, Tooke recommended specific changes such as breaking the link between the two foundation years and revision of titles. Tooke proposed that FY1s in the future should be called ‘provisionally registered doctors’, and that the current FY2 position should be ‘uncoupled’ and incorporated as the first year of ‘core specialty training’ and that these trainees should be titled ‘registered doctors’. Furthermore, the Tooke inquiry recommended that doctors in higher specialty training, in all specialties, including general practice, should be referred to as ‘specialist registrar’. The aforementioned titles ‘provisionally registered doctors’, ‘registered doctors’ and ‘specialist registrar’ are unambiguous and clearly define the role of the junior doctor, and should be relatively easy to implement since the role of ‘registrar’ is already well-known by patients and nursing staff and other healthcare workers in the NHS organization. The authors would also support the use of the titles ‘intern’ and ‘resident doctor’ similar to that used in the American system which is appropriate and accurately conveys seniority and unlikely to be misconstrued by patients and other healthcare professionals. Such terms are currently in use within some of the member states of the European Union.
Since 1 April 2010 the General Medical Council (GMC) has merged with the Postgraduate Medical Education and Training Board (PMETB), thereby creating a single regulator for medical education. This merger may represent an opportune time to re-visit and re-appraise issues related to professional role and the current terminology.
There are several important discussion issues arising from this survey and may be interesting questions for further research. First, there is a question about transparency. For example, if hospital-based healthcare professionals who work most closely with junior doctors in the perioperative management of surgical patients lack knowledge and familiarity with current terms, is it realistic to expect members of the public to appreciate the subtle differences in nomenclature to describe roles of junior doctor? Do members of the public need to know this information? Another important issue revolves around the different roles of junior and senior doctors and nursing staff expectations with regards to key patient management decisions. The logical question is: could lack of awareness of new grades of doctors and knowledge of the level of responsibility potentially hinder effective communication between doctors and nursing staff and could this have an adverse impact on patient care?
The authors believe that in the modern healthcare environment with increasing focus of interprofessional care and blurring of professional boundaries, members of the public have a right to clear information. It would appear that the current nomenclature with a letter and number is impersonal and lacking in familiarity with staff who work most closely with junior doctors.
There are several limitations to this study worthy of mention, such as the relatively small sample size, survey restricted to surgical nursing staff, and there also issues related to the validity and reliability of the responses obtained from self-reported/questionnaire-based research.
Despite the above limitations our study highlights that further discussion on junior doctor titles are necessary. At the time of writing the Royal College of Psychiatrists is canvassing the views of its members on new titles to inform the debate. As we go through this transition period with the new coalition government, it seems highly likely that the current model of training will be subject to further revision in the near future, with possible introduction of new nomenclature to describe junior doctors. Craddock and van Neikerk3
state that ‘whatever terminology is used, it should be simple, help to indicate with clarity the level of qualification of the practitioner, minimise confusion and have a lifespan that can outlive the inevitable technical changes to training pathways’.