The first five years: a mixed methods study investigating reflections on working as a hospital consultant

Abstract

Objectives

This paper revisits the same cohort of hospital consultants approximately five years after they were first appointed to investigate their reflections on establishing themselves in their role.

Design

Mixed methods using a short survey and in-depth semistructured interviews.

Setting

The study was conducted within one Deanery in the North of England.

Participants

The same 45 hospital consultants who were invited to participate in the study in 2007 were asked to take part in the second stage of the project in February 2011. These 45 consultants started their appointments no earlier than May 2006 within 12 National Health Service (NHS) Trusts in one Deanery. A total of 16 consultants participated. Six consultants who took part in semistructured interviews in 2007–2008 were invited to be interviewed again. Four consented and participated in a further interview in 2011.

Main outcome measures

Do consultants feel they have completed their transition into their senior clinical posts? Yes, although the ever changing nature of the consultant role means new challenges are always having to be being addressed. What support mechanisms are valued by consultants? Informal support mechanisms are greatly valued by consultants and these are built up over time. Are consultants satisfied that they made the correct specialty choice? Yes, all respondents reported satisfaction in their specialty choice.

Results

After reflecting on five years in post, all agreed that Specialist training prepared them well for the clinical aspects of their role. Ten (62%) felt they were not prepared for dealing with Trust Management issues and 13 (81%) felt unprepared for financial management.

Conclusions

consultants learn on the job and eventually fulfil their potential in the role over time. However, the role is regularly changing so informal support mechanisms are valued to help deal with a highly complex role.

Introduction

This study revisited a small group of hospital consultants in one Deanery who started their first consultant posts between May 2006 and April 2007 and investigated their reflections on their working experiences over approximately the past five years. The first phase of this study by Brown et al.¹ investigated the experiences of newly appointed consultants in 2007 and reported on the challenges faced during and after the transition from Specialist training. This paper revisits the same cohort of hospital consultants approximately five years after they were first appointed to investigate in depth their reflections on establishing themselves in their senior clinical posts. This informs those managing specialty programmes on what aspects of the role need specific consideration as specialty trainees prepare for the transition to senior clinical posts. It also informs Trusts on how best to support new consultants.

Methods

The same 45 hospital consultants who were invited to participate in the study in 2007 were asked to take part in the second stage of the project in February 2011. These 45 consultants started their appointments no earlier than May 2006 within 12 National Health Service (NHS) Trusts in one Deanery. This second stage had two data collection phases:

• Phase 1 (P1): an online questionnaire with open and closed questions;

• Phase 2 (P2): four in-depth semistructured interviews.

Questions that formed the basis of the online survey were developed by JB and NS. The emphasis was placed on qualitative open-ended questions which were informed by the current literature and the findings from the first stage of this study. The survey was piloted to ensure readability and that questions were pertinent and relevant for participants. The findings from the survey informed the development of the semistructured interview schedule.²

Recruitment

All 45 consultants were invited to take part via email with a link to an online survey (Survey Monkey). All six semistructured interviewees from Stage 1 of the study were invited to be interviewed again, over three years since the previous interview. Four agreed to participate.

Ethical considerations

Online questionnaires were submitted anonymously, so consent was implied by completion. To ensure anonymity, findings are reported without naming specific specialties to ensure participants could not be identified. Participation was voluntary. Interviewees signed consent forms and agreed to audio recording. Interviews took place at a time and place suggested by the participant and lasted for no longer than 30 min. All data were anonymised and confidentiality was assured.

Data analysis

Quantitative data were analysed in SPSS 15 and qualitative data were analysed using thematic framework analysis.³

Results

The findings from the online questionnaire are reported first.

P1: Survey

Background

Eleven men (69%) and five women (31%) completed the survey. Nine (56%) were appointed to a newly created post and seven (44%) replaced an outgoing consultant. Twelve (75%) were physicians and four (25%) were surgeons.

Preparation for consultant role

After reflecting on approximately five years in post, there was a unanimity that Specialist training prepared them well for the clinical aspects of their consultant role. Ten (62%) felt they were not prepared for dealing with Trust Management issues and 13 (81%) felt unprepared for financial management. Fifteen (94%) felt prepared or moderately so for leadership.

Main challenges faced as a consultant

The weight of responsibility was the main challenge highlighted: Weight of responsibility on my shoulders, being able to delegate (Respondent (R) 16); Confidence in role. Level of responsibility. Dealing with conflicts (R 11); The amount of responsibility and workload (R 10).

Management and leadership issues had to be confronted: Management issues. Time allocation for administration tasks (R 12); Management issues; Leadership issues (R 15); Managing complaints, understanding the management structure of the Trust. Time management on ward rounds (R 11).

The realization that being a consultant changed the way they were perceived as a person came as a surprise to some: Establishing self in consultant role when previously known as an SpR, without changing my personality (R 4); What you say suddenly is ‘what the consultant said’. I had imagined I would continue to be the same person, but the truth is you are not the reg, you are the consultant, so you are not the same person (R 1).

To actually influence existing teams and change practice was also seen as a main challenge: Existing teams were very difficult to influence. Many hidden agendas complicated the implementation of suggested improvements (R 2); Concern about being capable and confident enough to do the job. Gaining the respect of colleagues, particularly unfamiliar ones. Trying to arrange/negotiate suitable job plan (R 7); Developing the confidence to redesign/services took some time to acquire. Understand how to manage a team best to achieve still presents difficulties. Developing the confidence to train registrars to carry out major operations comfortably has taken around 2–3 years (R 8); a difficult working environment. Poor communication between immediate colleagues (R 3).

To establish themselves as a consultant in a team where they had practised as an SpR also created challenges: There is a lot to be said in support of taking a period away from a trust where you have been a SpR before returning as a consultant. I stayed at the same trust and so I felt my identity and practice as a consultant took a long time to become established (R 13); It is a difficult time, especially for those who stay in the place where they have been a trainee (R 3).

Those who were trying to set up new clinics perceived this as the biggest challenge: Lack of Nurse Specialist Support. How to set up an outpatient clinic from scratch, particularly balancing new to follow-up slots and the time for both (R 14); Establishing support for my out patients clinic. It has taken four years to get a nurse specialist assigned to my clinic (R 13).

Support mechanisms

Eleven (69%) greatly valued departmental support (consultant colleagues). However, one individual reported difficulties in trying to make, what they saw as, a positive contribution to the department:

I overestimated the amount of autonomy that I thought would be expected of me in my new position. There is a slight climate of fear which operates within the unit, and which consequently undermines some of the more positive contributions that can be made. The perceived power structure seemingly appears threatened by such an approach, which is a shame (R 2).

Formal mentoring was only greatly valued by one respondent. Informal support structures such as friends and family (four respondents specified this when asked for ‘other areas’ of support not listed in the question) and consultants (two respondents specified this as other areas of support) from outside the department were also greatly valued: I don't believe that the department has a strong structure for support[ing] new appointments. Most of my support came from a senior consultant in another department (R 8).

Specialty choice

Thirteen (81%) had never questioned their eventual specialty choice but three (19%) reported they had. Two explained that this was down to the increasing amount of time taken in office-based responsibilities: I found myself doing more office based work than I expected and wonder if I would have been better pursuing a craft surgical speciality (R 13); I'm fortunate in having good practical skills. I fear these will erode over time. If I had chosen a surgical speciality (say ENT) then these skills would be of greater value and benefit to patients. Instead I feel I am becoming more ‘office-bound’ particularly when dealing more with outpatients (R 14).

Completing the transition and becoming established as a consultant

In Phase 1 of the study reported by Brown et al.,¹ anxieties and challenges were reported during the first few months of appointment. Respondents in Phase 2 were asked to quantify the amount of time it took before they felt they had completed the transition and established themselves as a consultant. Table 1 below displays their responses. The vast majority (14, 88%) felt it took a year or longer to feel they had completed the transition into the role as consultant.

Table 1.

Phase 1 of this study demonstrated that there were some anxieties and challenges for many newly appointed Consultants. Could you please try and quantify the amount of time it took before you felt you had completed the transition and had established yourself as a Consultant?

Time	Number of responses
Immediately	0
Within 1 month	1
Between 1 and 3 months	1
Between 4 and 6 months	0
Between 7 and 9 months	0
1 year	4
18 months	3
2 years	2
3 years	4
Ongoing	1

P2: Semistructured interviews

Completing the transition?

Following the online survey where respondents were asked to quantify their transition time, interviewees were asked to reflect on their transition into the role of consultant and to comment on how they had established themselves. There was an acceptance that there was actually an element of constant transition due to the changing aspects of the consultant job:

It is an ongoing process more so because I’ve just not been in the same job. The services have changed so much so that as and when I’ve done my job plan I’ve just had to redo it every year. For me it has been different every year. (Interviewee 2, (I 2))

This was coupled with an acceptance that there is always more to learn:

I was thinking the other day that I still feel like I’ve really only just started. I suppose I’ve done a few things that, I’ve sort of started and I’ve finished, so I’ve sort of completed some things but I still feel I’ve got a massive amount to learn. (I 1)

Two consultants felt they had completed their transition:

I think the transition is over, I feel quite well established in my job and I think, people tell me that I’ve established myself which is nice to hear. (I 3); I was talking to a couple of other people and they felt it took about three years actually where you’d suddenly felt you’d grown in to it and you weren’t just a Registrar anymore. (I 4)

One interviewee explained that the impact of decision-making as a consultant has so much more resonance compared to a SpR and that they have discussed this specific issue with their trainee:

I’ve explained to her (SpR) why because whatever she says gets taken at some nominal value. It really has a crunch when I go and ok it. It suddenly has a lot more value to it and she can see it. I’ve tried to explain to her how it can be frustrating and how then they only really get a niche once they’re a consultant. Then they can run along and have the responsibility but until then they’ve just got to fight their way through I think. (I 2)

Informal support mechanisms

All four consultants relied on informal support mechanisms from fellow consultants but often from inside and outside their own department: It's a good set of consultants around who can empathise and help with difficulties as they come along, that part of it has been really, really good. (I 2)

I think something else that’s happened is that I’ve got to know a lot of the other consultants not just in my department but around the hospital and so I feel at ease calling them. (I 1); I think having a bit of, having somebody to bounce off ideas who’s not directly connected it’s invaluable really. (I 4)

One interviewee explained in detail the challenges faced ahead of their appointment. With hindsight, they would have valued the chance to seek advice from a consultant outside the Trust they were applying for:

The job interview time was a very, very tricky time. I didn’t know who I could ask at that time and you kind of want to talk. You get on well with the people you’re applying for but then are they poachers or are they game keepers? Whose side are they on? It would be very useful to have somebody else who is in a separate Trust. One you weren’t applying for that you could say, could I ask for this, how will the interview go and all the rest of it. So I think that would be a very useful time when you first start off. (I 1)

The same interviewee explained that joining an established team of consultants is a major decision and is a big commitment for any individual to make:

Becoming a consultant is a bit like getting married to five or six other people. You are entering a long term relationship with people and you take the good things with the bad things. If you have a big row then you have to live with the consequences of that as well. Working relationships are close and they are long term, you get more of a marriage than a mentorship relationship I think.

One felt their isolation as a consultant had risen as time has gone on in post: I think the isolation that I felt as a consultant has increased as I've gone on really. (I 4)

One proactive newly appointed consultant set up monthly tutorials in one Trust for new appointees to meet with management personnel:

One of my colleagues who started at the same time as me set up a group of tutorials from people in the hospital like the finance director and the complaints manager and we sat down as a group. We had an hour on that once a month for the first year. So that was a very good idea. (I 3)

Discussion

Principal findings

The ever-changing and complex role of the hospital consultant means that the job, even after years in post, involves for some a continued element of transition. Every job has its own individual challenges that lead to some natural uncertainties.^4–6 These are often management and financial issues which are the aspects of the consultant role that take the longest to adapt to.^7,8 This probably explains to some extent why the informal support mechanisms that develop over time are often with consultants from other specialties across their Trust. There does seem to be a difference in terms of becoming a consultant in a unit where they have practised as a SpR previously. Although this does bring with it some useful insight into the way a department works, it also creates the challenge of establishing themselves as a consultant with colleagues who have known them as a specialist trainee.

Despite the ever-changing role, very few consultants who took part in this study have ever considered a change in specialty. Those who have considered it explained that the increasing administrative aspect of their role as a physician has led them to wonder whether a surgical post would at least protect their opportunity to practise their practical clinical skills.

Strengths and weaknesses of the study

This study gave hospital consultants the opportunity to reflect on their job role. Participants provided some powerful and personal accounts of the challenges they have faced as senior clinicians. The sound ethical principles that underpin this study and the experience of JB in conducting these types of interview as a non-clinician facilitated the openness of responses.

Only a small number of participants took part in this study and this is its main weakness. The authors were restricted to approaching only those consultants who took part in the first phase of the study in 2007.

Findings in relation to other studies

It is clear from the findings reported here that consultants have the necessary skills developed over many years in training to deal with the clinical aspects of the role. This was reported in Brown et al.'s paper in 2009, so it comes as no surprise that consultants’ views have not changed four years later. What has changed is the actual job they are undertaking. Work and departmental practices and managerial responsibilities change regularly, so consultants have to constantly adapt to new challenges. One could argue therefore that trying to measure the start and end of a transition is somewhat irrelevant as no job remains the same. Although most respondents felt the initial transition took one year or more to complete, there was one respondent who felt it remained ongoing.

Possible mechanisms and implications for clinicians or policymakers

The findings from this study suggest that consultants learn on the job and eventually fulfil their potential in the role over time. However, the role is regularly changing so informal support mechanisms which build up over time help consultants deal with the everyday challenges of a highly complex role. Although management and leadership programmes are built into specialty training, it is difficult to prepare Specialist Trainees for the localized challenges that consultants face within their Trusts. These findings can inform those delivering Management and Leadership Programmes in Deaneries.

Unanswered questions and future research

It would be useful to undertake further research with a wider group of SpRs and consultants to investigate what are the most effective ways to prepare Specialist Trainees for the management and leadership aspects of the consultant role.

DECLARATIONS

Competing interests

None declared

Funding

There was no external funding for this phase of the study

Ethical approval

This study was granted NHS ethical approval by Sefton Local NHS Research Ethics Committee (06/Q1501/169)

Guarantor

JMB accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish

Contributorship

JMB conceived the design of the study and undertook data collection. JMB undertook data analysis. NJS and DRG acted as advisers. All authors contributed to the writing of the paper. All authors approved the final manuscript

Acknowledgements

We would like to thank all Consultants who took part in this study

Reviewer

Yusuf Rushdi