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Emergency medicine: what keeps me, what might lose me? A narrative study of consultant views in Wales
  1. Ffion James,
  2. Frances Gerrard
  1. School of Medicine, Cardiff University, Cardiff, UK
  1. Correspondence to Ffion James, 2 Dyffryn Woods, Bryncoch, Neath SA10 7QA, UK; jamesfs{at}cardiff.ac.uk

Abstract

EDs are currently under intense pressure due to increased patient demand. There are major issues with retention of senior personnel, making the specialty a less attractive choice for junior doctors. This study aims to explore what attracted EM consultants to their career and keeps them there. It is hoped this can inform recruitment strategies to increase the popularity of EM to medical students and junior doctors, many of whom have very limited EM exposure.

Methods Semistructured interviews were conducted with 10 consultants from Welsh EDs using a narrative approach.

Results Three main themes emerged that influenced the career choice of the consultants interviewed: (1) early exposure to positive EM role models; (2) non-hierarchical team structure; (3) suitability of EM for flexible working. The main reason for consultants leaving was the pressure of work impacting on patient care.

Conclusion The study findings suggest that EM consultants in post are positive about their careers despite the high volume of consultant attrition. This study reinforces the need for dedicated undergraduate EM placements to stimulate interest and encourage medical student EM aspirations. Consultants identified that improving the physical working environment, including organisation, would increase their effectiveness and the attractiveness of EM as a long-term career.

  • education
  • emergency department
  • HR management

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Key messages

What is already known on this subject?

  • There is currently increased pressure surrounding EDs and EM staff, resulting in attrition from the specialty. While questionnaire research has identified attitudes towards EM from a range of stakeholders, along with reasons for leaving the specialty, what is currently missing from the literature is an understanding of consultants’ original motivations for entering EM and reasons for staying.

What this study adds?

  • The majority of consultants are positive about their careers and this enthusiasm stemmed from inspiring passionate role models they saw on EM placements as undergraduates or junior doctors. This study reinforces the need for dedicated undergraduate EM placements, thus enabling the development of positive EM role models to stimulate interest and encourage EM aspirations.

  • Increased awareness is required of the improved consultant work–life balance and suitability of EM for family life to increase the attractiveness of EM.

Introduction

EDs in the UK are under increasing pressure and often struggle to meet demand.1 There are shortages in middle grade and consultant grade posts, impacting on supervision for junior doctors, and contributing to attrition from training posts.2 While current questionnaire research has identified attitudes towards EM from a range of stakeholders, along with reasons for leaving the specialty,2–4 there is little work exploring consultants’ perceptions of their career path, and motivations for the specialty.

Health Education England 20135 reported that the primary reason for trainees not pursuing a career in EM is the perceived poor quality of life and high levels of unsocial hours consultants work, statements supported by the findings of the 2014 UK EM trainee survey.2

Workforce pressures in Wales are similar to that in England.6 A GMC review 2013 concluded that EM is currently not an attractive career prospect.7In the same year, the Wales Deanery in its written evidence for the Health and Social Care Committee highlighted that only one in eight advertised middle grade EM posts had been filled that year.8 The net effect of increased service provision for trainees has impacted on trainee education and the reputation of such posts, further impacting on recruitment.8 Additionally, 19% of the 63 EM consultants in Wales are over 60 in 2015, presenting an additional risk to ED sustainability.9

There are similar EM recruitment and retention issues and ED pressures worldwide. A 2011 study looking at ED crowding globally found that it is a worsening trend in countries including Australia, Canada, France, India, Iran, Italy, Saudi Arabia and Spain,10 with increasing attendances in an already overburdened system being the primary reason.11

This study aims to explore the views of current EM consultants on positive and negative aspects of their work to help prospective trainees.

Methodology

Study overview

Ten qualitative interviews were undertaken with EM consultants from different EDs across Wales about their motivations to pursue and remain within EM. A multisite convenience sample was obtained.

Participants and recruitment

All EM consultants working in a Welsh Major ED were eligible for this study. Major EDs are defined as departments with a consultant led 24 hours service with appropriate resuscitation facilities and designated accommodation for the reception of A&E patients.12 Initial contact about the study was made via postgraduate departments of each hospital with a major ED asking EM consultants if they would participate in the study. Consultants who wished to participate in the study were asked to contact the researcher directly who then arranged a convenient time to meet; thus, participants showed a desire to participate through actively responding to the invitation e-mail. All interview participants were given information sheets and completed consent forms prior to interview.

Interviews were carried out at the consultant’s own hospital and at a time convenient for the participant to facilitate responses and had the additional benefit of being a familiar setting for consultants, thus making them more at ease to share personal or emotive information.13 Interviews lasted between 40 and 60 min. Participants were recruited from seven hospitals across four health boards in Wales (figure 1). The aim was to conduct 10–12 interviews, and 10 interviews were achieved. This range was chosen as it was deemed a practical amount within the bounds of the study. No follow-up reminders were sent.

Figure 1

Map showing distribution of participating consultants by hospital (number of consultants interviewed).

Design

Interviews were carried out with EM consultants from February to April 2015 by the main researcher FJ, a fourth-year medical student undertaking an intercalated BSc, not previously known to any of the interviewees. The interviews were carried out in person, to allow the opportunity to interpret non-verbal cues including body language, eye contact and facial expression.14 Advice was provided on how to remain assertive and confident through the interviews despite the obvious experiential and hierarchical difference between a medical student and an established consultant. The interviews were narrative in format. This is a well-validated qualitative research tool15 which enables interviewees to discuss the factors that were most important to them in pursuing an EM career. The interviews began with a single question aimed at inducing a narrative to allow the consultant to reflect on their personal experiences. Personal narratives were elicited of why they began their careers in EM, barriers they have faced during their pursuit of a career in EM and an exploration of any times they may have considered leaving the specialty. The participant’s narrative directed the flow of the interview with core questions to establish the dialogue; however, there were well-defined prompts to ensure that all content was covered (see online appendix 1). However, interviewees were allowed to elaborate in an unstructured format to enable coverage of all themes. Additional questions were then asked to gain additional information and clarification and for participants to express their personal views on promoting EM careers and potential barriers to recruitment.

Data analysis

The interviews were audio recorded and transcribed verbatim using a professional company ‘Virtutype’, with a total recording time of 351 minutes. A meeting was held to determine the framework for analysis. It was agreed that the five-stage model of data analysis by Ritchie and Spencer would be adopted: familiarisation, identifying a thematic framework, indexing, charting and mapping and interpretation.16 Transcripts were reviewed with the audiotapes for veracity individually by FJ and FG, and a thematic framework was then created by FJ to cover all themes and subthemes. This framework was reviewed by FG to ensure accuracy. Indexing and charting were performed manually by the researcher and reviewed separately by the supervisor to ensure agreement. Mapping and interpretation were focused around the key research questions.

Results

Ten interviews were conducted with consultants of varying experience and backgrounds. The median age decile of the participants was 40–49 (range 30–69), and the average number of years practising as an EM consultant was 9.2 (range 2–19). There were equal male and female participants (5:5).

Motivations for a career in EM

This research question explored the influential factors underpinning consultant’s original desire to pursue a career in EM (box 1).

Box 1

Key motivators for an EM career

  • Acute presentation, high clinical content job.

  • Role models—positive and negative, especially undergraduate or early postgraduate experiences.

  • Negative experiences of other specialties making EM a more positive career prospect.

Attributes of specialty

Six participants expressed a desire for a dynamic environment as a motivating factor for EM, enjoying the variety and non-routine nature of EM. Participants were attracted to the acute clinical challenges that EM offers as well as its generalist nature. A strong desire to actively help and make a difference to patients was evident among participants, as they identified the continuous patient contact and allocated shop floor time a positive attribute compared with other specialties.

‘I was never bored, which I found different to medicine where I was bored most of the time.’

The fact you made a difference at the end of the day when you went home.

Early EM exposure and role models

Four participants described the positive influence of early EM exposure as a student or junior doctor, identifying the exciting nature of the EM environment and positive role models as influences.

‘One of my final rotations in fifth year was in emergency medicine and one of the registrars there took us under his wing and gave us lots of attention, and it was a really good placement and he was definitely part of why I’ve ended up doing emergency medicine.’

Other careers considered

All participants had considered or were pursuing other career options, frequently surgery, when making their decision. The positive aspects of on call work influenced many to EM with the focus on patients presenting acutely.

‘The best bits of every job I did were in A&E.’

Motivations for continuing an EM career

Participants were asked about why they chose to stay in EM and the following themes emerged (box 2).

Box 2

Key motivators to stay in EM

  • The diagnostic challenges faced in the ED improve job satisfaction.

  • Enjoyment, providing junior teaching and feeling valued are key for job satisfaction.

  • ED team dynamics can influence retention.

  • EM is suited to flexible working and can be compatible with a positive work life.

Clinical satisfaction

Multiple factors affected participants’ job satisfaction with the variety identified as a key component, as well as the diverse case mix and diagnostic challenge of the undifferentiated patient.

‘It’s a diagnostic challenge. That’s always been where I’ve enjoyed it most, I think. You don’t know what’s next and you don’t know what’s wrong with them until you’ve seen them.’

Junior teaching

Another key element of job satisfaction was ensuring a positive and supportive learning environment for juniors, with five hospital sites providing dedicated consultants for junior shop floor teaching. Many consultants identified that providing patients with the best possible standard of care was essential for consultant’s morale and job enjoyment.

‘We prioritise teaching. So we have sessions, consultants on the shop floor. They have no responsibilities except to teach and ensure the juniors get their assessments done.’

Teamwork and value

The non-hierarchical ED team structure creates a supportive atmosphere and some participants chose their department specifically because of the positive team dynamics experienced there as a trainee. Seven participants spoke of feeling valued by the patients and the in-house ED team, and this boosted personal morale.

‘…the fact the nurses and the doctors are a team and it’s much less hierarchical.’

Positive work–life balance

Participants identified EM as being suitable for flexible working and a positive work–life balance, due to its shift pattern nature and minimal patient continuity. Two participants (one male, one female) were currently on less than full-time (LTFT) working and two participants had done so previously to raise their children.

‘So I went 60% and that was fine and I could balance child care, home care, husband care and the work.’

Influencing factors for attrition from EM

Participants were asked factors which may persuade them to leave EM (box 3).

Box 3

Influencing factors for attrition

  • Inability to do their job to best possible standard factors was a major source of frustration for participants.

  • Participants experienced a sense of powerless when unable to give patients the best possible standard of care.

  • Participants enjoy the high-pressure environment of EM, but participants are unsure whether they can maintain this throughout their career.

  • Problems with attrition from and recruitment into the specialty raise doubts over the stability of EM.

Frustration

The inability to perform their job effectively was a key source of dissatisfaction resonating with all participants. Exit block was described as ‘grinding the ED to a halt and a major limiting factor to the capabilities of EDs. Participants felt that there was limited provision of support to ease the issue and restore flow throughout the whole hospital. Eight interviewees identified inadequate space and resources in their ED to cope with increasing workload.

‘It’s not the job that gets you down. It’s the inability to do your job.’

Powerlessness

Being unable to provide patients with the best standard of care due to factors out of the participants’ control created a feeling of powerlessness.

This may be a particular problem in this context as EM consultants tended to identify themselves as liking to make rapid positive differences to patients.

‘We’re all aware that we can do a brilliant job, but the things that are necessary to do that are often out of our control.'

Negative work–life balance

One of the more difficult challenges participants experienced during their training was balancing family, and study commitments with unsocial rota hours. Family and financial stability were the biggest factors preventing participants travelling overseas to practice EM. Anticipating the future, participants were concerned with the lack of career progression into less physically demanding roles with increased age and the continually increasing pressures of growing patient numbers and complexity on a diminishing staff workforce.

‘I was doing huge numbers of weekends and trying to do my first year exams and I had a little baby at home. It was tough.’

Towards the future

When participants were asked to identify the changes that would improve morale and career attractiveness, most felt that problems were extraneous to the specialty itself (box 4).

Box 4

Participant ideas for EM improvements

  • Improving staffing levels throughout all grades and flow throughout the department would help morale in the ED.

  • Undergraduate exposure to EM may increase the attractiveness of EM to medical students.

  • Additional support is required outside of the ED to help mitigate ED pressures.

‘We’re all aware that we can do a brilliant job, but the things that are necessary to do that are often out of our control.’

Improvement: adequate staffing

Adequate staffing at all levels is required to offset the pressure of increased volume of activity and contribute to waiting time reduction. Increased consultant support was identified as necessary to improve the educational environment for juniors and enhance patient safety including reducing inappropriate admissions.

‘One shift I worked my entire team was locum. So I was the only permanent of staff. The difficulty with that is that every locum is an unknown variable if you like.’

Improvement: undergraduate experience

Interviewees stressed the role of EM, as a good clinical teaching environment and an excellent opportunity for students to gain a positive insight into an EM career, provided the environment and staffing levels were favourable.

‘I think, our enthusiasm and our interaction with the students and trainees when they’re here and teaching people and encouraging people is the way to get people interested.’

Improvement: increasing flow

Additional bed capacity including social and community beds was seen as important to improve the working environment as well as patient care.

Discussion

Main findings

This is the first study using a seminarrative approach that explores the career perception of EM consultants in Wales. Despite divergences in the health services in England and Wales, many of the issues discussed are likely to be applicable to England as well as other countries.

This study found that consultants had chosen EM careers mainly because they were fast-paced high clinical, and demand led. International studies such as Kazzi et al 17 in the USA and Celenza et al 18 in Australia support this, although patient care did not rate as highly as a motivator in the Celenza et al study.18

The high-pressured EM environment was a key motivator for an EM career; however, there is concern over the sustainability of this long term with a risk of career burnout due to lack of transition into ‘wind down’ career pathways. An Royal College of Emergency Medicine (RCEM) study supports these findings, revealing that 65% of Welsh EM consultants believed that their job was unsustainable in its current form3

Role models had a strong influence on participant’s motivations for a career in EM. There is a wealth of literature exploring the influence of role models in many specialties, for example, Ravindra and Fitzgerald19 found a significant link between identifying a surgical role model and aspirations of a surgical career and Steele et al 20 identified how the presence of role models can encourage retention of doctors within academic medicine.

Role modelling for medical students and junior doctors featured as a strong motivator, and this has been seen in studies looking at other specialties.21 It is clear that this is a common influence on medical pathways.

In this study, many of the participants had undertaken various posts before selecting EM as a career, and it may be that the perceived lack of flexibility of current training could adversely affect later entry into EM.

The non-hierarchical and supportive ED team were key aspects of job satisfaction for participants, and a UK EM trainee survey found that colleagues and team dynamics were the most influential factor on consultant post location.2

However, over-reliance on locum doctors and the inability to recruit a stable workforce threatens to destroy this key area of job satisfaction. In England, locum doctors make up one-fifth of the ED workforce on weekends, and approximately 13% on week days.22 Comparable Welsh data are currently not available, but the reliance on locums was identified by several interviewees. Over-reliance on locums and inexperienced staff has serious implications for patient safety23 with these viewpoints being mirrored by the participants.

Four participants have undertaken LTFT working during their EM career. These participants were strong advocates of the suitability of EM to LTFT due to its shift work pattern and limited patient continuity. An RCEM survey of current EM consultants found that 12% worked part time hours,3 compared with 8.5% of anaesthetic24 consultants All participants believed that consultant work–life balance was positive; however, this view is not widely accepted among UK EM trainees2 and non-EM trainees,25 but EM is viewed as having a positive work–life balance in America due to its ‘controllable lifestyle’.26

Limitations of this study

This study explored the views of 10 consultants, and although these represented most of the EM departments in Wales, and there was a high concordance of views expressed, clearly other EM consultants may have raised different points. Although care was taken to ensure a range of experiences, ages and representation of both genders, it should be noted that the current EM consultant gender distribution is 7:3 male to female.3 Working conditions in Wales in EM are broadly similar to other areas in the UK; however, there are differences in funding due to different government policies. The data were collected mainly over the winter period. Could this have influenced the views of the interviewees given that this study was conducted at the busier portion of the year? This study might have benefitted from increased size with more interviewers, but to ensure face validity the script was carefully followed and all interviewees were interviewed following a tight protocol approved by the ethics committee with analysis performed by both authors.

Conclusion

The majority of consultants participating in this study were still positive about both their original choice of a career in EM and their decision to stay with their specialty. The main features that both attracted them to EM and kept them working in EM were the variety of acute clinical challenges and the opportunity to enhance patient care. Team working and the non-hierarchical structure were also identified as positive features. However, participants were clear and consistent in identifying perceived threats to recruitment and retention, particularly citing staff shortfall, with rota gaps and locum usage, and pressures of increased service use with slow through put of patients as huge risks to both patient safety and job satisfaction. The solutions therefore are multifactorial, but an improved strategy for exposure to EM as a career and undergraduate and postgraduate level with greater levels of senior cover for training grades is likely to help. However, it is also important to address the wider issue of increased usage of EM departments, and improved strategies for transferring patient who require ongoing monitoring to make EM an attractive option for the next generation of doctors.

References

View Abstract

Footnotes

  • Contributor FJ and FG both conceived the study. FG initated the study design, and FJ carried out the data collection and primary data analysis and interpretation. FG supervised this role. FJ drafted the original article, with FG providing critical analyses for the revision of the article. Both FJ and FG approved the final manuscript.

  • Competing interests None declare.

  • Ethics approval Ethical approval was obtained from CURES (SMREC Ref 15/04).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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