Exploring the experiences and expectations of trainee representatives in medical specialties: A qualitative study in the West Midlands, UK

Abstract

Introduction

Despite its importance, there is a paucity of evidence describing the role and responsibilities of trainee representatives.

Aim

This study explored key stakeholders' experiences and expectations of the trainee representative role.

Method

All eligible individuals in the West Midlands Deanery's School of Medicine were invited to participate in an interview exploring their experiences and expectations of the trainee representative role. Recurring themes were identified through thematic analysis using NVivo12 software.

Results

Five themes—Support for trainee representatives, Deanery events for trainee representatives, Roles and responsibilities of trainee representatives, Representation and recruitment, and Benefits of being a trainee representative—were identified. Formalising appointments to such roles and providing induction and information on key responsibilities were highlighted as steps to minimise the gap.

Conclusion

Trainee representative positions allow trainees to explore leadership roles; however, further work is needed to improve the resources to support the professional development of trainee representatives.

Introduction

Specialty training pathways in the UK aim to produce competent, experienced clinicians who provide holistic patient care.¹ To ensure that training pathways remain relevant to the current clinical environment, trainee representatives are recruited from existing junior doctors enrolled on specialty training.² They play a crucial role regionally and nationally in improving the working environment and supporting curriculum development by providing a trainee viewpoint to improve the overall trainee experience.3, 4, 5, 6

Despite the key responsibilities of trainee representatives, there is limited standardised training available for doctors in these roles, with clinicians likely to have varying experience or knowledge from previous roles.^3,4 Furthermore, the trainee representative role may vary between medical and surgical specialties due to varying trainee population size and differing needs. There is some evidence of specialty-specific publications regarding trainee perspectives on their curriculum and training pathways7, 8, 9, 10; however, there is no reference to the responsibilities of trainee representatives and their role in influencing training pathways. Moreover, there is no independent evaluation of the expectations and experiences of trainee representatives; therefore, this aspect of postgraduate education is currently understudied.

Aims

The study aimed to explore the experiences and expectations of trainee representatives in their roles within medical specialties.

Methods

This qualitative study was conducted in the West Midlands, UK, from July to August 2022. The inclusion criteria included all trainee representatives, training programme directors and stakeholders in the School of Medicine at the West Midlands Deanery. No exclusion criteria were used to maximise participation. All eligible candidates were identified from the deanery database of trainee representatives and training programme directors, and they were invited to a one-to-one semi-structured 15-min interview by email, with a reminder email sent after 2 weeks. The emails had an attachment detailing the purpose of the study.

Two researchers (SKM and PK) collaborated to devise appropriate interview questions to support and guide discussions. These were approved by the head of the School of Medicine at the West Midlands Deanery (Table 1). The questions focused on the ideas and expectations of the trainee representative role. They explored what resources and training were provided before the role commenced and whether they were sufficient for them to carry out their role. These questions were open-ended to allow interviewees to provide further detail from their individual perspectives and add insights that were not anticipated.

Table 1.

Questions asked during interview.

To trainee reps:

1) Why did you apply for a trainee rep position?

2) What are the key roles and responsibilities of a trainee rep?

3) What support did you need for your role as a trainee rep and how much support did you receive?

4) The Deanery has been conducting some training events for trainee reps. What are your thoughts about this? What was done well and what could be done better?

5) Is there anything else you would like to say about your expectations and experiences of being a trainee rep and the programme in general?

To training programme directors and other members in the Deanery:

1) Why should doctors apply for a trainee rep position and what are your expectations of the function of this role?

2) What are the key roles and responsibilities of a trainee rep?

3) What support is available for trainee reps, both prior to starting the position and throughout their time as a trainee rep?

4) The Deanery has been conducting some training events for trainee reps. What are your thoughts about this? What was done well and what could be done better?

5) Is there anything else you would like to say about your expectations of a trainee rep and the programme in general?

Interview process

The interviews were conducted via Zoom videoconferencing software to optimise participation from doctors with busy clinical schedules and commitments by decreasing travel time and costs. Consent was implied with agreement to interview, and further verbal consent for participation in the study was gained from each participant at the start of the interview. The impartiality of the researcher was stated at the beginning of the interview, and they asked the interview questions appropriately to minimise interviewer bias. Interviewees were allowed to speak freely without interruption. No repeat interviews were conducted.

Data analysis

The interviews were audio-recorded, anonymised and later transcribed verbatim on Microsoft Word. Analysis was performed with NVivo 12.0. Using a thematic analysis approach,¹¹ author SKM read through the data to identify and apply codes through open coding. Authors PK and SKM then reviewed the codes and themes to agree with them. Minor revisions were made to the codebook and application of codes, and the resulting agreement regarding data coding was 100%. PK and SKM then completed a ‘domain summary’ type of thematic analysis to identify overarching domains grouping several themes.

Ethical approval

The study was approved by the University of Birmingham ethics committee (ERN_2022_0368).

Results

Of the 64 eligible stakeholders contacted, 12 individuals agreed to participate. Two individuals did not attend the interview and subsequent attempts to contact them received no response. Therefore, 10 participants, consisting of six trainee representatives of a variety of specialties, three TPDs and one deanery official were included in this study (Fig. 1). We had four female and six male interviewees. The themes that emerged from the interview are as follows:

• 1.Support for trainee representatives (94 references by 10 participants).

Fig. 1.

A flow diagram depicting the flow of participants during this study.

The two most common themes were support requested by trainee representatives (60 references by 10 participants) and helpful support provided for trainee representatives (34 references by 10 participants). The main source of support available was from TPDs, who were described positively by trainee representatives. Alongside this, many interviewees reported that a good handover from the outgoing trainee representatives was useful in understanding the role's responsibilities. An example quotation for this domain is below, with further examples in Supplementary Table 1.

Participant 6 (trainee representative): ‘The previous trainee reps were very helpful in showing me how to deal with the technological aspect of the role. Other than that, I had great support from the outgoing trainee reps who did a very good handover and covered what was expected of us in the role which was very helpful.’

Many participants believed that an induction package with a formal description of the duties of a trainee representative would have been helpful at the beginning of their role. Moreover, some interviewees had no training on leadership or how to deal with complaints which they felt was needed for them to fulfil their responsibilities.

Participant 10 (trainee representative): ‘You need to be given training in leadership, because you have to bring together consultants and trainees, often, who have different, slightly conflicting interests because the consultants primarily are talking about a service provision, whereas the trainees are focused on training, and it is about trying to get that middle ground where both groups are happy. Leadership is an important part of being a rep; giving formal training on how to be a leader would be helpful.’

• 2.Deanery events for trainee representatives (41 references by 10 participants)

There were 15 references by nine participants about positive experiences of deanery events, while all participants provided recommendations for future deanery events (26 references). The trainee representatives mentioned the events had a supportive atmosphere, and a range of topics were explored in the lectures, including wellbeing, communication and bullying. They also appreciated the chance to network with trainees from other specialties, allowing them to explore each other's training experiences.

Participant 4 (trainee representative): ‘Not at the start, but probably a few months in, there was an annual deanery-organised training day that wasn’t necessarily about the practicalities of what you do day-to-day as a rep but more in terms of giving us information about who to contact at the deanery and different aspects of being a trainee rep, including a session on wellbeing, and a session on leadership etc.’

However, all six trainee representatives believed that the range of training sessions did not cover the daily practicalities of the role. Some wished for these events to be recorded or available in a hybrid format to maximise attendance and three participants suggested that a mix of workshops and lectures may work better with case-based learning to make the sessions more interactive. Finally, some participants believed there should be more Royal College and TPD presence during these deanery events.

Participant 7 (TPD): ‘As a TPD, I would like to know a little bit more about the agenda of those training days. I want to know what's being discussed, and if there is anything that we can actually help with that. In some sessions, they could potentially invite TPDs from different specialties, for example, if people have queries or things like that. We also work on differential attainment in Health Education England, so if there is a report discussing something like that, within the deanery events that we could be involved in. I do not really know what the trainee rep days are, I only know everything about my own specialty training process. Perhaps linking in with the Royal Colleges would be good, because I know some Royal College regional advisers who will be quite happy to work with the Deanery for these trainee rep events.’

• 3.Roles and responsibilities of a trainee representative (37 references from 10 participants)

All interviewees cited the main responsibility of trainee representatives is to canvas opinions from all trainees and represent them at relevant meetings like specialty training committees; decisions made at these meetings should be disseminated to the wider training population. Furthermore, some trainee representatives were expected to organise teaching programmes and specialty training days independently. The latter included representatives liaising with consultants and industry experts to organise funding, the venue and lecture schedule for trainees. Some participants reported that trainee representatives should support junior trainees in a pastoral capacity; however, the deanery official believed their role should be focused on collating trainee opinions.

Participant 6 (trainee representative): ‘Basically, we arrange the training days, including the topics covered, for the next two years. We allocate the trainees to present these topics and we have to contact consultants to chair the sessions. Also, we have to liaise with different companies because our training days are sponsored by companies, so we have to liaise with them to book our training day venue and then of course the training day feedback certificates need to be made. Also, we deal with trainees’ problems, if they have any issues, because we are the link between the TPD and the trainees.’

There were 35 references by all 10 participants regarding the main responsibilities of trainee representatives, with two references from one interviewee about improvements that need to be made. One participant believed that arranging succession should be the responsibility of the outgoing trainee representative. They suggested that this would support the role handover, ensuring that the new trainee representative was confident and well-equipped to fulfil their responsibilities.

Participant 2 (TPD): ‘Often after 3 years, they say they have finished their duties and it is up to the TPD to arrange someone else for the role. Also, if there is no succession planning, you almost have someone going in cold and if there is no induction package or anything, it can be very difficult for the trainee rep.’

• 4.Representation and recruitment (28 references by 7 participants)

Five interviewees made 21 references regarding specialty representation by trainees, suggesting that it is limited primarily because there are no allocated trainee representatives in that specialty. This is reportedly common in smaller specialties, with participants believing they had no support from the deanery because they were unaware the role was available. Finally, one interviewee could not contact all trainees under their purview because no standardised contact method was available.

Participant 3 (trainee representative): ‘I wish I took [sic] up the role earlier, I didn't know it was even available because it was such a small specialty, I just assumed we did not have one. We did experience a few issues in some departments in the past, and some of it carried on as we rotated between locations.’

There were seven references by five participants who stated there was no formal selection process for recruitment, and often, TPDs or outgoing trainee representatives approached people individually for the job. Only one interviewee was aware of the trainee representative role when approached with the role offer. The Group 2 specialty representative position, which provides feedback regarding all non-acute medical specialties, was recruited by the deanery with a formal selection process.

Participant 1 (trainee representative): ‘It actually became mine by default because [the other trainees]… were busy.’

• 5.Benefits of being a trainee representative (23 references by 10 participants)

All 10 participants made 17 references about the value of the trainee representative role. Many participants focused on the skills gained through the position, particularly leadership and management responsibilities and exposure to medical education, which would support them in their ongoing careers. Furthermore, trainee representative interviewees believed the role facilitated a greater understanding of the training pathway in general and the impact of decision-making on a local and regional level. Interviewees highlighted the opportunities for networking with consultants and other regional officials.

Participant 9 (Deanery official): ‘The key thing would be that the trainee reps are given an exposure to medical education, and then the opportunity to communicate with both TPDs and the deanery as a whole as well as the various trainees across the region. It gives them an opportunity to take a leadership role within their own specialty and get exposed to different leadership styles, both good and bad. Also, they would gain an insight into the system and the way that it works to allow them to become acquainted to people within the deanery with consultants and higher people within the system. They also gain an insight into how decisions are made, especially at a regional level.’

Three interviewees made six references for improvements needed to incentivise the role through additional leadership and education activities because it is not a paid position. The main recommendation by interviewees was for a formal acknowledgement of the role by the deanery for postholders to support their portfolio by highlighting their leadership experience.

Participant 2 (TPD): ‘I think the role needs to be incentivised in some way. I am not talking about money but whether the reps get some sort of CPD [continuing professional development] points or whether they get acknowledgement from the deanery even if it is something like a letter or credit towards leadership and management or something like that.’

Discussion

Main summary findings

To our knowledge, no literature is available regarding the experiences and expectations of trainee representatives from relevant stakeholders. Therefore, this is the first study to provide insight into the experience of medical trainee representatives appointed to specialty training committees within postgraduate medical education.

Overall, all interviewees believed that the trainee representative role was important to improve the regional specialty training experience. However, our findings suggest more clarity and standardisation is needed regarding roles, responsibilities and appointment of trainee representatives.

The qualitative methodology allowed participants to explore their expectations, beliefs and experiences of the role and provided additional unanticipated insights. It also allowed the interviewees to be guided by their responses, ensuring that a detailed overview of their experiences and expectations was elicited by encouraging elaboration of their responses.

One-to-one interviews were conducted rather than focus groups^12,13 because it increased rapport between the interviewer and respondent and encouraged a broader range of items to be covered as the flow of conversation was guided by the interviewee. Interviews were expected to be a minimum of 15 min in duration, but they continued until the interviewee offered no further new insights. Zoom videoconferencing system was utilised to accommodate interviewees’ schedules, ensuring there were limited time and financial constraints for interviewees to increase participation.

Limitations

This study had a relatively small sample size despite all eligible participants being approached via email multiple times. While the response rate to participate in our study was low, a 15.6% uptake is typical of surveys and interviews,^14,15 suggesting our sample size is acceptable. Overall, there are 28 trainee representatives and 35 TPDs who were invited to interview, of which six trainee representatives and three TPDs were interviewed. This represents 21.4% of trainee representatives and 8.57% of eligible TPDs. Interviews were limited to 15 min to maximise participation from busy clinicians; however, this may have limited the depth of responses from interviewees. We aim to increase the interview length in future studies to gain further insights.

This study focused on trainee representatives from medical specialties so the results may not apply to trainee representatives from surgical specialties. Although this study focused on the West Midlands Deanery, UK Deaneries may operate on a similar footing nationwide, the results of this study may prove to be pertinent elsewhere. Moreover, we aim to plan future work incorporating trainee representatives from other specialties to provide greater insight into the variation of their experiences across different specialties.

Recommendations for the future

In response to the findings of this study, we propose to develop an updated roles and responsibilities document for trainee representatives locally, with an associated training resource that will be delivered to trainee representatives to provide useful information and support on how these responsibilities can be fulfilled. A training session is recommended over paper or online resources to encourage active learning.¹⁶ An evaluation pre- and post-event can help assess the effectiveness of this training programme by evaluating trainee representatives’ self-reported confidence in fulfilling their role. Including deanery officials, TPDs and Royal College of Physicians representatives may help build the holistic nature of such a training programme.

The challenges associated with providing educational sessions by deaneries for trainee representatives necessitate a strategic approach to developing training programmes that can effectively cater to the requirements of newly appointed and incumbent trainee representatives. In light of this, we propose recommendations for forthcoming training events. These recommendations will encompass a foundational framework encompassing essential subject matter to empower trainee representatives in fulfilling their responsibilities and supplementary content intended to address trainee representatives' personal and professional development aspirations.

To ascertain the fundamental content required, we suggest employing a Delphi-style interview methodology involving stakeholders, including trainee representatives, Training Programme Directors (TPDs), and officials from the deanery. This structured approach will facilitate systematically identifying core instructional content based on collective expert opinion.

Furthermore, we advocate for systematically collecting feedback from trainee representatives following each training session. This feedback mechanism will elucidate their perspectives regarding the core content and additional elements they perceive as essential for their professional advancement and overall development.

Limited literature explores trainee representatives' role in medical education, and further studies are required nationally. We recommend that trainees are included as stakeholders in future research to explore the perspective of the end beneficiaries of the work completed by trainee representatives and to understand whether this model of representation is appropriate and effective for trainees. Alongside this, the role of trainee representatives for various organisations, including the Royal Colleges, should be evaluated to understand their impact on improving training and curriculum development.

Conclusion

Trainee representative positions are generally considered a good opportunity to explore leadership roles; however, deanery-led training events often do not prepare them for their role, particularly at the start, when they can go a long time without formal guidance. An induction session highlighting the key responsibilities of trainee representatives and providing advice on the practicalities of the role may address this gap. Further research is crucial to evaluate the provision and planning of teaching sessions to ensure they add value and support trainee representatives' personal and professional development.

Funding statement

None.

Ethics approval statement

This study has been granted ethical approval from the University of Birmingham ethics committee.

Patient consent statement

All participants provided informed consent to be included in the study. All participant data has been anonymised.

CRediT authorship contribution statement

Saima Kauser-Malik: Conceptualization, Data curation, Investigation, Methodology, Formal analysis, Writing – original draft, Writing – review & editing. Dr Jyoti Baharani: Conceptualization, Data curation, Investigation, Methodology, Writing – review & editing. Dr Phillip Bright: Conceptualization, Data curation, Investigation, Methodology, Writing – review & editing. Dr Punith Kempegowda: Conceptualization, Data curation, Investigation, Methodology, Formal analysis, Writing – review & editing.

Declaration of competing interest

There are no conflicts of interests to declared.