Seven FY1s responded to the invitation and were interviewed (5 male and 2 female, aged 23-26 years). The interviews took place between seven to nine months from the FY1s’ start of work and lasted an average of 29 minutes. All major themes are illustrated with quotes; minor themes are listed and quotes only included if there was consensus that they were interesting or insightful.
Early experiences of unpreparedness
Most participants initially felt unprepared in responding to deteriorating patients. They frequently described feeling ‘overwhelmed’, ‘apprehensive’, ‘unsettled’ and ‘out of [their] depth’. Participants did not feel confident in recognising what situations they would be expected to manage on their own as an FY1. Knowing when to escalate, and who to escalate to, were areas of significant concern. In parallel to this, participants felt that at times they were expected to perform beyond their level of competency. They also found situations more challenging when patients did not improve after initial management steps were started.
“Knowing where I’m out of my depth or knowing where I should be out of my depth and where I should just be improving myself… What is expected of me as an F1?” (Respondent G)
In making sense of why participants felt unprepared, we identified a number of contributing factors. A lack of exposure to acute care scenarios at medical school was a recurring theme. Participants felt they had little experience of prioritisation when responding to multiple unwell patients. Initial feelings of preparedness were dependent on the type of emergency situation; for example, participants felt more prepared for managing sepsis or hypotension and less so for reduced level of consciousness. Similarly, many participants admitted they were unaware of the diagnostic possibilities for certain problems. Participants also felt unsure of the timing that investigations or referrals should take place in an acute situation. However, participants did feel confident in using the ABCDE algorithm to structure their initial assessment and management.
“...just [in] real life what you should do and who you should call and how quickly, I had no idea.” (Respondent E)
First experiences of genuine preparedness
All participants reported feeling genuinely prepared to respond to an acutely unwell patient after working for between three to six months. To them, feeling prepared was a combination of understanding the hospital, being comfortable with initial management steps, knowing when to escalate and recognising the seriousness of a situation.
“I think probably most importantly is knowing when to escalate... I think but there’s a balance between okay, I can do the A to E and I can get all the data that I can think of and at what point does my management stop and there is nothing else that I am comfortable administering on my own? [At] what point do I need senior support?” (Respondent D)
Understanding the hospital incorporated both a familiarity of the hospital environment and processes as well as an appreciation of the multidisciplinary team (MDT) in acute situations.
“I always have that support of nurses and physios and everyone, and I think it just wouldn’t be the same if you didn’t take it on board. The nurses always know when something is going wrong and if you don’t listen to them then, yeah, it’s your own head on the line really.” (Respondent B)
Making sense of how they became prepared
In developing preparedness in acute care, participants drew on a range of learning experiences. Hands-on experience consistently ranked as the most essential, with reflection, simulation and MDT team-working also frequently ranked as essential learning experiences (Table 1). Participants felt they had little experience of decision making or taking ownership of an acute situation at medical school, and only developed this after beginning work.
“You take no responsibility at medical school, you are not forced to make decisions... I did observe people assessing acutely unwell [patients] but was never forced to think myself which is probably the harder thing.” (Respondent E)
Observing senior clinicians respond and reflecting on how they approached the situation were seen as valuable real-world learning experiences. These experiences were more beneficial if the participant held some responsibility or investment in the case. The opportunity to shadow the medical emergency team was also felt to be a very useful experience.
“Seeing what a registrar does when they come and how they respond to you, the patient, and the situation are all three things that I try to take on board every time.” (Respondent G)
Learning from hands-on experience was directly related to the volume of exposure. Preparedness was felt to develop more quickly following busy on-call or weekend shifts. Participants on busier, more stressful first rotations felt they had become better doctors as a result, and in hindsight felt grateful for these experiences.
“At the time it was bloody miserable… [Once] you got through that period, I felt that I was probably able to make decisions... Which is probably why I’m quite grateful for having that job now.” (Respondent C)
Both self-reflection and informal debriefing with colleagues were seen as essential parts of learning following hands-on experience. Undergraduate simulation was felt to be another essential experience in developing acute care preparedness, mainly as it gave students an opportunity to think and react under pressure. Participants felt simulation after starting work was more useful as they had more awareness of their actual responsibilities as an FY1 doctor. However, a key criticism was that simulation often does not reflect the uncertainty and unpredictability of the real-world.
"[Simulation] doesn’t take into account the uncertainty that you get sometimes. So, that’s why a simulation feels sometimes feels quite an artificial environment." (Respondent C)
In terms of formal teaching during their undergraduate training, participants felt they had limited teaching on acute care, and the teaching they did receive was too theoretical. They felt that formal teaching could be more focussed on the practicalities of acute care, and suggested this may be better delivered by near-peer trainee doctors. There was also a desire for more combined learning experiences with other members of the MDT. Participants felt that more formalised shadowing of junior doctors or medical emergency teams would be very useful experiences.
“But I think probably the most useful thing would be when you are later on in medical school to be like partnered with an F1 or F2 on-call. And either just observe or where it’s appropriate be like exposed to doing a bit of initial assessment.” (Respondent E)