The skills of our New Zealand junior doctors--what are these skills and how do they get them?

Mike Ardagh

In this issue of the Journal, Andrew Old, Gill Naden, and Stephen Child present data suggesting first-year postgraduate doctors at Auckland District Health Board do not have the skills expected of them.1 Are they right? Are first-year postgraduate doctors deficient in their skills, or do we expect too much of them?

Although their paper has limitations, which they concede, most would agree they are correct stating that first-year postgraduate doctors do not have the skills expected of them. Furthermore, as their well-referenced discussion attests, this observation is being made throughout the Western World. Indeed, further evidence from New Zealand, recently published,2,3 suggests that the resuscitation skills of our new graduates are below that expected. Of concern, some of these new graduates were in positions in New Zealand hospitals where they were the only doctor responding to patients in need of resuscitation.

So, are our new graduates deficient or do we expect too much or them? Perhaps, as Old, Naden, and Child suggest, both are contributing. If this is so, then two further questions arise. First, how do we define what skills are expected of our new graduates? And, second, how do we ensure they achieve these expectations?

Skill acquisition is a continuum, with steps variously described--but usually including an initial gaining of appropriate knowledge of the skill; and including its context, purpose, indications, and so on. Steps of psychomotor mastering of the skill then follow. Often (although perhaps less than in the past) these steps consist of seeing it done in a real clinical context, doing it with or without supervision, and then helping junior colleagues through the same experience--the infamous 'see one, do one, teach one' approach.

Most recognise that using the patient as the substrate in this somewhat serendipitous, poorly structured, and variably supervised approach is bad medicine. Instead, we should add the steps of 'seeing' and 'doing' in a simulated context, with mastery in this environment before attempts begin on patients. Then, with decreasing supervision and greater independence, the skill is practised in the clinical environment, culminating in independent mastery and a genuine ability to be a teacher. To complete this process, formal credentialling of the doctor should be recognised as essential, with the implication that those who are not...