Embedding into the ways of working in the NHS: A seamless transition and reflective learning as a clinical observer in general internal medicine

Abstract

The transition of embedding into the National Health Service (NHS) healthcare system in the UK is accompanied by significant social, cultural and educational challenges. The common educational barriers faced by international medical graduates (IMGs) are usually related to lack of appreciation of the values and structure of the NHS as well as understanding the ethical and medicolegal issues. Clinical observer roles or attachments are an opportunity for doctors who are IMGs to gain direct experience of the NHS system, enhancing their knowledge of the ways of working in the UK, and thereby improving their chances of getting to know the system and potentially assisting with finding employment. The UK will remain reliant on the skills and expertise of IMGs for the foreseeable future; predicted 32 % IMG doctors in 2036 according to the General Medical Council (GMC). They will therefore represent an important part of the NHS workforce, many of whom commence work as locally employed doctors (LEDs) and contribute significantly to the success of NHS services. This article describes the information gathered from clinical observers within one department at an NHS trust in general internal medicine (GIM). We elaborate on how this experience enabled an enhanced awareness of knowing how to go about the routine daily working pattern in the NHS. The recent Royal College of Physicians (RCP) guidance on LEDs and IMGs highlights the importance of educational supervision for this group of doctors within the NHS workforce. Similarly, the GMC has reiterated the need to support the growing number of LEDs in their latest workforce planning report 2024.

Introduction

Clinical observer roles or attachments are an opportunity for doctors who are international medical graduates (IMGs) to gain direct experience of the National Health Service (NHS) system, enhancing their knowledge of the ways of working in the UK, and thereby improving their chances of getting to know the system and potentially assisting with finding employment. Unfortunately, these placements are very hard to find these days, and the experience can be variable.¹

This article describes the information gathered from clinical observers from one department at an NHS hospital in general internal medicine (GIM) and elaborates on how this experience enabled an enhanced awareness for not only IMG doctors, but also work experience secondary school students aspiring to work in the NHS and for educational supervisors (ES) to view things from a very different perspective.

The mutually beneficial shared learning obtained from directly observing the patient journey on a general medical ward, with the support and guidance from UK qualified resident doctors in training, are invaluable.

Background

The transition of embedding into the NHS healthcare system in the UK is accompanied by significant social, cultural and educational challenges. The common educational barriers faced by IMGs are usually related to lack of appreciation of the values and structure of the NHS as well as understanding the ethical and medicolegal issues. This warrants the need to address specific educational needs such as NHS structure at all levels, including the various administrative protocols, hospital policies and community services, as well as receiving feedback from colleagues about the different learning strategies in the UK.²

Clinical observer roles or attachments are a useful introduction into the ways of working to the NHS and previous studies have demonstrated that 90.4 % of responders found it to be helpful. 56.8 % would not wish to take up a substantive post without having done a voluntary placement, giving reasons of increased responsibility and, in addition, it makes it easier to apply for substantive posts.³

Overseas doctors continue to contribute significantly to the UK NHS, but arriving from a different culture and healthcare system creates specific challenges. IMGs need to understand the differences, while the organisation can help by making important information about the NHS and British culture readily accessible.⁴ IMGs represent an important part of the NHS workforce and contribute significantly to the success of NHS services. Despite this, they continue to face important challenges and unique obstacles compared to their British peers, particularly during their first transition year.⁵ It is therefore essential that doctors from a range of backgrounds are welcomed into supportive teams as per the vision and recommendations of the General Medical Council (GMC).

It is well recognised that IMGs face many difficulties when applying for their first post in the UK, as they spend long periods of time unemployed while waiting for examination results, sponsorship and registration processes before commencing their first post in the NHS.⁶

In the past, recommendations have been made to ensure that locally employed doctors (LEDs) appointed by NHS trusts should be developed with the same educational structure as training posts and the flexibility to suit the varying educational requirements of an IMG, with more than a third of the doctors working in the UK having qualified abroad.^6,7

Discussion

We discuss the social, cultural and educational aspects as well as the awareness of various aspects of settling into a new system from a very broad context and perspective to help new IMGs and LEDs embed into the NHS.

Patient-centred decision making

Decision making, communication and the evidence base: The concept of shared decision making, when both parties adopt an approach where clinicians and patients make decisions jointly together using the best available evidence, is not necessarily always the case in some countries outside the UK.⁸ The most rewarding aspect was to see that shared decision making respects patient autonomy and promotes patient engagement. Effective communication between clinicians and their patients has a positive impact indeed, not only on clinical outcomes but also on their overall experience of care.⁹ These patient-centred experience models have been instrumental in enhancing evidence-based clinical care guidelines.¹⁰

ReSPECT (DNAR), palliative care, end of life journey and bereavement: Patients and their relatives having the right to be consulted before a Do nNot Attempt Resuscitation (DNAR) documentation,¹¹ and the involvement of terminally ill patients and the next of kin at their request, in deciding on the next course of action is readily seen. The early implementation of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), which replaced the previous documentation of DNAR, embeds cardiopulmonary resuscitation (CPR) and gives recommendations within wider emergency treatment plans.¹² In conjunction, the involvement of hospital-based specialist palliative care offers immense benefits for person-centred outcomes, including health-related quality of life, as well as symptom burden, incorporating patient depression scores and satisfaction with care, while also increasing the chances of patients dying at their preferred place of choice with little evidence of harm.¹³

Witnessing and recognising that a patient may be nearing the end of their life is a key consideration and early recognition of dying is vital to allow discussions to be started about the patient’s wishes.¹⁴ Observing how rapid discharge home in the patient’s last days of life is possible and can happen, with the involvement of local specialist palliative care teams who are very knowledgeable. The intricacies of how sensitive communication needs to take place between the dying person, and those friends and family identified as important and close to them with participation of members of the healthcare team were clearly noticeable. Of note, bereavement follow-up with relatives was another conspicuous practice that was evident, making collaboration easier thereafter with near and dear ones of the patient who died.¹⁵

Clinical governance and patient safety

Clinical governance is the framework for ownership and accountability in the NHS and is certainly not an optional prerequisite, but a mandatory requirement to work in the UK,¹⁶ as this may not always be defined similarly in other countries.

Medical examiner: The role of the medical examiner in finding facts about avoidable hospital deaths, working in partnership with families and carers, in identifying the cause of death was very informative.¹⁷ It is therefore crucial to understand the discussions about each death, which happens in a supportive and constructive manner. Similarly, it is imperative to know about harm reduction, root-cause analysis, incident reporting, datix and risk assessment when things happen that should not have occurred, and when things that should not have happened did unfortunately occur due to negligence, oversight or unforeseen circumstances.18, 19, 20, 21, 22

Infection prevention and antibiotic stewardship: This may be an unknown entity for some trainees who transitioned across from another continent; however, it is of paramount importance in the NHS, and one needs to embrace the underlying ethos of this agenda. The RCP has provided effective guidance on antibiotic prescribing, and the purpose of antibiotic stewardship has two primary goals – (1) to ensure effective treatment for patients with bacterial infection and (2) to reduce unnecessary antibiotic use and minimise collateral damage.23, 24, 25 At a patient level, stewardship has been defined as ‘the optimal selection, dosage and duration of antimicrobial treatment that results in the best clinical outcomes’.²³

Support services – BNF, TOXBASE, PACS: It is also prudent to be aware of using the aid of the British National Formulary (BNF) before prescribing medications to avoid drug and dosing errors,²⁶ and if in doubt always check with the ward pharmacists who are more than happy to help. It is equally important to be aware of TOXBASE and the National Poisons Information Service and how to access this, especially when attending to specific clinical situations.²⁷ Another very useful service for patients who have been to other hospitals within the UK is the option to transfer images through the PACS link system via radiology.²⁸

DoLs, MCA, PALS and never events: These are abbreviations used commonly, but for an IMG who is new to the system, it is very tricky to understand the meaning or their importance and it takes a while to appreciate the finer details, hence it is always worth exploring with colleagues who know more and also read about them.29, 30, 31 Deprivation of Liberty Safeguards (DoLS), ‘best interest’ Mental Capacity Act (MCA) and Patient Advice and Liaison Services (PALS) are systems in place to protect patients and one needs to know about these and enquire with the relevant personnel. What an NHS ‘never event’ means is important to assimilate.³²

Interdisciplinary working and learning

Allied healthcare professionals and inter-professional learning: It is helpful to meet and be aware of allied healthcare professionals who visit the ward, with whom we must work together and foster a collaborative approach. These are healthcare staff in niche areas with expertise that help our patients during their hospital stay. In addition to physiotherapists, occupational therapists and pharmacists based on the ward, there are other staff with specific skills such as speech and language therapists, tissue viability nurses, diabetes specialist nurses, clinical nurse specialists for cancer-related illness or other benign conditions such as thrombosis, stoma care, spinal injury team, podiatrists, district nurses in the community and several other staff with whom we need to establish a rapport that will make the routine daily work seamless.33, 34, 35, 36, 37 In other healthcare systems, there may not necessarily be named personnel for such specific roles. There are also lots of opportunities to learn from the specialist skill mix of these various professionals in their respective areas of expertise while discussing mutual patients on the ward.

One must also make an effort, to understand the difference between advanced nurse practitioners (ANP) and clinical nurse specialists (CNS). ANPs are clinically based with education, leadership and research components, while CNS roles are specialist.³⁸ It is important to recognise their defined individual domains as CNS teams are always the link for patients with their specialist teams, while ANPs have more generic roles in ensuring that routine clinical care happens effectively and efficiently. There is a lot to learn from both ANP and CNS colleagues, given their wealth of experience within their respective roles in clinical medicine.

Educational supervision for IMGs and LEDs new to the NHS

An ES can only help if the trainee appreciates what they also need to do from their perspective. Acting as an ES to a trainee is the first and foremost relationship between the ES and the allocated trainee, in which the trainee’s personal and professional development is the primary focus. A good ES is an individual who puts the trainee’s personal and professional relationship in focus and, at the same time, one who understands the importance of fairness, empathy and trust involved in that specific role. At the same time the ES is also willing to invest both time and emotional effort in the development of the trainee on a personal and professional basis. They should be able to commit to the extra challenges that may have to be faced, the skills that may have to be used and to devote in the time needed to provide support to the trainee.³⁹ However, the LED/IMG trainee, who has not got formal NHS England annual review of competencies (ARCP) in place, has also got to mutually engage in the process with their appraisals. They need to familiarise themselves with what it entails to complete their electronic portfolios for appraisals and revalidation, in addition to getting involved in audit projects for their own learning, leadership skills and self-development.40, 41, 42

Teaching and feedback: There are enormous opportunities to teach undergraduate students who are always keen to be taught if pitched at their level of understanding.⁴³ In addition, students from allied healthcare-related affiliated courses are usually on placement in general medical wards and it helps to learn from one another to benefit from the skill mix among all healthcare professions. Formal feedback can be obtained using validated forms, which can be used for appraisal portfolios. The offer to teach and practice objective structured clinical examination (OSCE) skills⁴⁴ are always available with supervision from the resident doctors in training.

Exception reporting and guardian of safe working: While LED appointments do not usually fall under the remit of exception reporting,⁴⁵ there is no reason why individual NHS trusts cannot implement these for this cohort of doctors. LEDs always have the option to contact the freedom to speak up guardian if ever needed.⁴⁶ It is therefore essential for IMGs to be on board with the terminology that is commonly used in educational discussion forums.

IMGs through these observerships can recognise the importance of being able to adjust to the needs of individual patients and approaching them sensitively while taking a history, are essential communication skills. They also appreciate the empathy and compassion shown to patients, to display understanding and resilience, with the potential frustration of their current illness, situational needs, and circumstances in hospital. However, in the process everyone values the enhanced knowledge gained through these observed clinical attachments.⁴⁷

Conclusion

We feel that the prospects to learn as an IMG and LED new to the NHS are significant,^48,49 and there are vast opportunities for acculturation and a seamless transition as an observer to acquire clinical acumen. In addition, one can also learn about organisation, management, leadership, teaching, and training-related skills to adopt to the various aspects of working in GIM. One must embrace change and adapt to the NHS ethos to embed seamlessly, and ES roles should encompass these factors for LEDs and IMGs. In addition, the NHS remains a benchmark for postgraduate training worldwide, and working in GIM prepares one to be well on track for the well-recognised membership (MRCP) examination conducted by the Federation of the Royal Colleges of Physicians.⁵⁰ Above all, what has been apparent to the IMGs is the impact of being polite and courteous all the time with one another and the kindness between teams as well as the compassion and empathy towards our patients. The collaborative approach of teamwork, and helping one another is very obvious in the NHS.

There is a call for more generalist physicians in the NHS with the various challenges in the system.51, 52, 53 Several of the doctors who applied and were appointed in the initial rounds of the recruitment process for standalone GIM training posts were IMGs who came via the ‘alternate route’ of certification.^52,54 The current and evolving trends to enhance the experience of LEDs and IMGs is promising.⁵⁵ The State of Medical Education and Practice Workforce report 2023,⁵⁶ from the GMC suggests that the UK will remain reliant on the skills and expertise of IMGs for the foreseeable future (predicted 32 % IMG doctors in 2036). The need to support the growing number of LEDs has been specifically cited, highlighted and endorsed in the recent 2024 workforce report from the GMC.⁵⁷ Moreover, the RCP has also produced guidance on LEDs and IMGs.⁵⁸ The GMC’s Welcome to UK practice workshop highlights the need to adapt to the UK medical culture and ethics, which can be difficult for any doctor, regardless of their ethnicity and prior experience, while NHS trusts can arrange organised programmes to acculturate IMGs and deliver high-quality doctors who value patient safety.⁵⁹

Disclosures

The views expressed in this article are those of the authors both from the perspective of providing placements and also thriving from opportunities for learning by observing as well, from the viewpoint as a clinical observer and we feel this will help new entrants into the NHS to get to grips with the routine working pattern.

Funding

None.

CRediT authorship contribution statement

George I Varughese: Writing – review & editing, Writing – original draft, Validation, Supervision, Resources, Formal analysis, Data curation, Conceptualization. Jovito James: Writing – original draft. Athira Mukunda: Writing – original draft. Rhea Jacob: Writing – original draft. Victoria Burnham: Writing – review & editing, Supervision, Formal analysis.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: George I Varughese (GIV) and Victoria Burnham (VB) are project leads to scope the unmet need for training and mentoring of locally employed doctors and international medical graduates and involved with the recruitment of doctors. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

• No data involved - this is a generic opinion article from evidence in the literature - no data or patient information included.