In recent years, there have been radical changes to the staffing and training of junior doctors in emergency departments (EDs). Modernising medical careers (MMC) ¹ and educationalists² have proposed a competency-based approach to training, with doctors creating portfolios of evidence to demonstrate these competencies. In addition to the change in foundation training, the increased use of locums in some departments and the subspecialty training of our middle-grade doctors means that it is often difficult to determine what skills our junior doctors actually have. We sought a method to communicate a doctor’s competencies to other health professionals in a way that allowed a rapid and clear illustration of their abilities.

THE SOLUTION

Visual clues to competencies have been used in many organisations, notably the Scouting movement that has used a system of merit badges to demonstrate that a Scout has learnt and demonstrated competency in a given skill or task.³ This is very similar to the approach taken in MMC, and we have therefore developed a system of competency badges worn on the doctor’s uniform for use in the ED. The department awards badges when a junior doctor has satisfactorily completed an assessment. The assessment method is task specific. For example, cannulation is assessed using the current direct observation of procedural skills (DOPS) ⁴ system as detailed in MMC. We also produce badges as and when junior doctors complete external courses, such as advanced paediatric life support (APLS).⁵

These badges give a visual representation of the skill that has been assessed. In general, the illustration is on a red background. However, for skill assessors (or instructors in the case of courses) the badge has a gold background to demonstrate a higher level of ability. Examples can be seen in fig 1.

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Figure 1

 Merit badges showing a vsiual representation of the various skills that have been assessed.

Benefits

• In the resuscitation room, you can quickly determine the skill mix of the team and delegate roles appropriately.

• The system is a motivator for learning and for completing assessments early. Keen junior doctors rapidly become “badge collectors”.

• Educational leads can rapidly see the rate of progress throughout a cohort of trainees. Individuals who are falling behind are easily and rapidly spotted.

• If a doctor, nurse or patient challenges your competence, you can simply point to the badge and win the argument.

Disadvantages

• Infection control policies have recently forced us to move from long to short-sleeve uniforms. For some of our better trainees this has resulted in the need to apply the badges to the chest or shoulder, which is aesthetically less pleasing.

• It is possible that other clinicians or even patients may become aware of the system and refuse to be seen by, or accept referrals from doctors, without the relevant competency.

• There is the potential for badge swapping for some of the more difficult to obtain badges. There was concern that the surgical airway badge appeared on eBay, but it was removed before this rumour was confirmed. In future we will issue a unique bar code with each badge to prevent this from happening again.

We are piloting the scheme with our F2 doctors this year. The department will be fully compliant across all grades of doctors on 1 April next year.

Should you wish to view a greater selection of badges, then please visit the electronic version of the paper on the EMJ website.