Non-traditional skills in undergraduate medical education – the development of a teaching programme

As a junior doctor working in an ‘National Health Service in Crisis’, ¹ I am concerned to see that many of my colleagues have opted not to continue their training. This is reflected in current statistics which show that 46% of foundation doctors do not proceed directly into speciality training. ² Around 30% of these young doctors report being undecided on what their next career move would be. Meanwhile, 14% of those who did not apply for speciality training had already decided to take a career break (two years into their career …) As a junior doctor, who myself left the NHS to train abroad for several years following my first foundation year, I can certainly empathise with how conflicted they undoubtedly feel in deciding not to continue training at this early stage.

Many young doctors, myself included, often feel overwhelmed by the non-clinical demands and management roles forced upon us. We are asked to lead audits with no formal training, discuss funding for procedures with managers and to lobby for our patients with only our clinical skills. Simple procedures, such as carpal tunnel decompressions and removal of benign lesions, are now subject to managerial and funding approval in England. As a junior doctor, I have often been faced in clinic with a patient who has arrived without pre-emptive funding having been arranged by their GP. This creates a difficult situation where I am obliged to send the patient away from clinic without booking them for a procedure which they clearly need. With no training in these matters, I must now complete a funding request form, to allow the patient to undergo a routine operation which 10 years ago would have been booked purely on my clinical judgement of their need. The 2018 King’s fund report has demonstrated that over 70% of Clinical Commissioning Groups plan to reduce the number of funded procedures, meaning this problem is likely to be increasingly seen by junior doctors. ³

As a budding plastic surgeon who has just gained her National Training Number, I am becoming increasingly aware that possessing good management and leadership skills, as well as knowledge of financial planning and commissioning, is now essential for me to be able to do the best for my patients. Whilst post-graduate one-day management courses and enterprise fellowships are available, the teaching of these skills is not integrated into the undergraduate curriculum of any UK medical school. Teaching these skills to our junior medical students, however, has been shown to be beneficial, even at this early stage.^4,5 In incorporating the teaching of these skills at the undergraduate level, we can aim to make them a standard part of medical training, reflecting the fact that they are a standard part of any doctor’s daily work.

We questioned 50 final-year medical students at the University of Dundee regarding their thoughts on the integration of these skills into the curriculum. The questions included whether they had any experience of enterprise, management or leadership training, what their future career plans were and where they thought these sessions could be integrated into their teaching. From this survey, we received interesting results. Out of this group of students, 48% were already considering a career outside of clinical medicine, before even graduating. A distressing statistic indeed.

Almost all (98%) of the students reported having no enterprise or entrepreneurship training during their undergraduate degree and 96% reported having had no managerial teaching. Whilst this may not be entirely surprising, these sessions could provide our students with valuable skills in people, time and resource management as well as communication and team working skills, which are not always easy to frame in clinical teaching. In their free text responses, the students’ thoughts were intriguing, ranging from ‘I think it would be beneficial to direct [the sessions] in the context of […] an NHS career’ and ‘I am conscious that people who go into General practice will be required to have a more business mindset’ to ‘we are already made to learn so much that is extraneous to the clinical teaching we signed up for’. This last comment made me reflect upon the current issues within the NHS. Junior doctors do not realise that they need these valuable skills until it is too late, and they find themselves considering leaving clinical medicine with limited skills beyond patient care.

As a potential solution to this, we have looked to set up a cross-discipline, national teaching programme aiming to incorporate entrepreneurship, management and leadership skills within the undergraduate curriculum. Our first SEED (Skills in Entrepreneurship Education) workshop, held in September 2017, was attended by 30 educators, public sector workers and entrepreneurs. It highlighted that this was not simply a problem within the medical profession. Our colleagues in computing, dentistry and many other faculties have struggled to demonstrate to their students that skills which were not traditionally a core part of their curriculum are becoming increasingly important in the ‘real-world’. Once again, our student’s comment that these skills were ‘extraneous’ comes to mind. It should not be surprising that our students think that learning how to examine the chest will be a larger part of their day-to-day job than understanding how to manage resources or complete a funding form. After completing their first month as a foundation doctor, however, they may have an altered perspective.

The time and resources required to teach our trainee doctors is often in short supply, with students attempting to grasp basic clinical skills, without the addition of another skillset. It could be argued, however, that the teaching of these skills will help in the development of their clinical skills, as well as their overall personal development. Teaching students the importance of understanding budgets could be useful in the prevention of ordering unnecessary tests; helping our students understand idea disruption and generation, which are key skills in entrepreneurship teaching, could allow them to create ingenuous quality improvement projects. It is essential to understand that the aim is not to encourage students to leave clinical medicine, but to allow them to develop an additional set of skills which could help them improve the environment in which they work and the morale of those around them.

As a doctor who has embraced teaching these skills to my colleagues and juniors, I have seen them grow in both their ability to manage patients and deal with challenging situations in all realms of medicine. In a struggling NHS, the teaching of these new skills could improve morale and inspire our next generation of junior doctors to change the health service for the better.