Introduction
ENT surgery has been found to have poor exposure in UK medical schools undergraduate curricula, with medical students often spending five days or fewer on ENT rotations.Reference Powell, Cooles, Carrie and Paleri1
Resident doctors in training may have limited experience in managing ENT conditions prior to commencing their postgraduate job in this speciality. Therefore, a comprehensive and structured induction is vital for those entering an ENT post for the first time, in order to improve familiarity and confidence with basic ENT clinical assessment and procedural skills.Reference Aryasomayajula, Raithatha, Haywood, Jobanputra, Roplekar and Acharya2, Reference Kucheria, Bastianpillai, Khan and Acharya3
Based on the results of a recent national survey of junior doctors rotating through ENT in 2023, this qualitative study sought to further explore resident doctors’ experiences of ENT induction in the UK.
Methods
Data were collected via a multi-centre, retrospective cross-sectional survey entitled “RecENT SHO,” targeting resident doctors currently undertaking their first ENT rotation or those who had completed their first ENT rotation within the preceding year. A Web-based survey was created using Google Forms and disseminated via local leads (resident doctors with ENT interests) across 15 UK deaneries utilising social media and email. Local leads acted as project representatives in each UK deanery, working to promote the survey and collect responses at the local level.
Survey responses were collected over a two-month period, from 16 March 2022 to 20 May 2022. The survey included multiple-choice, Likert scales and free-text questions relating to induction practices as well as qualitative impressions of induction effectiveness. Responses were anonymously stored and analysed thematically using ATLAS.ti software.4 Key themes about were captured and developed from responses to the following survey questions:
1. “What went well about your induction?”
2. “What could have been improved about your induction?”
3. “What could have been improved about your induction?”
Results
A total of 429 survey responses were received, of which 380 were eligible for analysis. Responses were collected from every training region within the United Kingdom. Thematic analysis of free text responses to the questions detailed in the methods section are shown in Figures 1–4. Four key themes are discussed in the results section Table 1.
Number of survey respondents per region in the UK.
Themes reflected upon in response to “What went well about your induction?”.
Themes reflected upon in response to “What could have been improved about your induction?”.
Themes reflected upon in response to “What support would have helped you feel more prepared as a resident ENT doctor?”.
Table demonstrating direct survey responses categorised by theme and subtheme
Theme 1: induction methodology
Respondents were required to define the format of their induction, specifying whether it was virtual, face-to-face or a hybrid format combining both approaches. Further specification delineated teaching methods; didactic lecture-based approaches, practical skills teaching and the inclusion of simulation training for practical skills were discussed in the survey responses.
• 64 respondents (17%) received entirely virtual inductions. There were no positive responses to entirely virtual inductions
• 72 respondents (19%) positively reflected on face-to-face inductions involving practical skills such as flexible nasendoscopy and microsuction
• 121 respondents (32%) desired more practical skill training; 36 specifically requested simulation training and 38 specifically requested additional tracheostomy training.
Theme 2: induction duration
• Mean induction duration was 2.75 hours, with a mode duration of one hour
• Only 68 respondents (18%) reported inductions lasting more than eight hours
• 29 respondents (8%) received no formal induction at all
• 34 respondents (9%) requested longer induction periods.
Theme 3: senior clinician involvement
• Inductions delivered by: Registrars (198), Consultants (123), Senior House Officer (SHO) (42), Nurse Practitioners (6)
• 20 respondents (5%) highlighted senior involvement as highly beneficial with inadequate senior involvement cited negatively by others.
Theme 4: post-induction support
• 59 respondents (16%) desired more senior support initially
• 46 respondents (12%) requested ongoing clinical skill supervision
• 11 (3%) respondents recommended regular teaching sessions post-induction.
Discussion
It is well documented that ENT is under-represented at the undergraduate level and th most common ENT emergencies include epistaxis, otitis externa and otitis media.Reference Kitcher, Jangu and Baidoo5 Chawdhary et al. recruited 311 final year medical students who had just completed a week’s ENT rotation.Reference Chawdhary, Ho and Minhas6 The proportion of these students who felt underprepared to manage ENT emergencies and common ENT presentations was 77 per cent and 72 per cent, respectively. A further study, recruiting 518 students across 9 UK medical schools, demonstrated that 47 per cent of participants not being offered any formal ENT rotation.Reference Khan and Saeed7 This highlights the necessity of comprehensive ENT inductions to suitably prepare resident doctors for a role in which they will likely feel underprepared at the start.
This study provides the first qualitative analysis of ENT resident doctor induction experiences across the UK. Our findings highlight significant variability in induction duration, with a mean duration of only 2.75 hours, this is inadequate for comprehensive skill and knowledge acquisition. 72 respondents (19%) valued practical training, particularly in flexible nasendoscopy and microsuction, and expressed preference for face-to-face, simulation-based formats.
A total of 121 respondents (32%) indicated that current induction practices lack sufficient practical training, potentially compromising not only resident doctor confidence but more importantly patient safety. The 2014 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) identified poor tracheostomy care as a “significant patient safety issue.”Reference Khan and Saeed7 ENT resident doctors are the first point of call for tracheostomy complications, therefore effective knowledge pertaining to emergency treatment algorithms must be an essential component of any ENT induction. Simulation uniquely enables error based learning, objective performance analysis and a standardised learning process,Reference Johnson8 our survey responces indicate desire for simulation training in tracheostomy management to form part of any ENT induction. Findlay et al. circulated a questionnaire to 38 resident doctors enquiring about their confidence in recognising airway compromise in tracheostomy patients.Reference Findlay and Abbas9 Only eight (21.1%) felt confident in recognising airway obstruction and 6 (15.8%) felt confident or very confident in initiating initial management for a blocked or displaced tracheostomy. The responses to our survey indicate that tracheostomy training within ENT inductions in the UK is insufficient, despite the strong desire for such training.
Senior clinician involvement was strongly associated with positive induction experiences; however, inconsistencies in senior presence were frequently noted. A total of 59 respondents (16%) highlighted the need for increased senior support, particularly during initial clinical duties, in order to enhance patient safety and resident doctor confidence. It is well documented that regular support and supervision from senior colleagues are fundamental factors contributing to the mental health of resident doctors.Reference Radcliffe and Lester10–Reference Teoh, Hassard and Cox13 Ongoing clinical supervision and structured teaching sessions post-induction were also recommended to reinforce practical skills and address knowledge gaps (46 and 11 respondents, respectively).
• ENT inductions are essential for new postgraduate doctors in training
• This is the first published study exploring ENT resident doctors’ experience of their induction; there is no equivocal work within the current literature
• Four major themes emerged, namely methodology of induction and key induction inclusion criteria, duration of induction, seniority of clinician delivering the induction and post-induction support
• ENT resident doctors desire inductions facilitating the practical acquisition new skills under senior supervision
• Post-induction support is necessary to ease transitioning into the ENT postgraduate doctor in training role
• These themes must be considered when guiding the development of optimal inductions for ENT postgraduate doctor in training inductions in the UK
What is already known about this subject:
• ENT training is inadequately represented in UK undergraduate medical education
• Resident doctors frequently begin ENT rotations with limited practical experience
• Effective inductions can significantly impact resident doctors’ confidence and ultimately patient care
What this paper adds:
• This study is the first qualitative exploration of UK ENT resident doctors’ induction experiences
• Identifies simulation training and practical skill development under senior supervision as essential components for a high-quality induction programme
• Suggests improvements to induction duration, senior clinician involvement and ongoing post-induction support
Strengths and limitations of study
A lack of objective outcome measures relating to ENT resident doctors in training performance, in the context of their induction format, would be the main limitation of this study. This qualitative analysis obtained subjective feedback pertaining to ENT resident doctors’ confidence and preparedness proceeding their induction. Whilst ENT resident doctors may describe a general feeling of under preparedness, this may not directly correlate to worse clinical skill acquisition and care provision.
Furthermore, no feedback was sought from facilitators of ENT inductions. This may bias the feedback; time restrictions and hospital resources available for inductions have also not been accounted for in this analysis. Future surveys may explore the perspective of organisers and facilitators for ENT resident doctor inductions.
Data collection for this study was conducted during and following the Covid-19 pandemic. This was a period during which hospital policies placed variable restrictions on face-to-face contact. Furthermore, several ENT procedural skills were designated aerosol generating procedures, requiring extensive personal protective equipment to perform safely. This would preclude several ENT procedural skills from ward-based teaching demonstration. Induction feedback data may therefore not represent practise outside of the pandemic context.
There is a large amount of educational material available online pertaining to ENT training and practical skills. This survey has not accounted for signposting to supplementary revision material that may be made during the induction process. Access to reputable information, such as that on the ENT UK website,Reference UK14 is available to supplement ENT inductions and should be showcased to new ENT resident doctors in training. However, our study clearly demonstrates that resident doctors desire face-to-face inductions, with senior direction and opportunity to receive feedback on practical skills. Another caveat that may undermine the necessity for ENT resident doctors inductions, is that management of conditions and use of practical skills will be continuously learned “on the job.” That being said, our survey responses again consistently reflected how resident doctors entering their new role without induction felt under skilled and compromised in their ability to provide safe patient care. Not only this, but responses alluded to how ineffective induction practices may negatively impact resident doctors’ mental wellbeing.
The recommendations of this study must be observed in the context of the time restraints and local availability of hospital resources. Nevertheless, our results underscore critical areas for improvement in ENT induction programmes, recommending greater practical skill emphasis, increased senior clinician involvement and structured post-induction support.
Conclusion
This study identifies essential factors for improving ENT resident doctor inductions, highlighting the importance of practical skills training, simulation-based induction methods, senior clinician involvement and structured post-induction support. Implementation of these measures can significantly enhance resident doctor preparedness and patient safety as well as contribute valuable guidance to the existing literature on ENT education and training.
Funding
No funding was awarded for the writing of this article.
Statement of ethics
The Medical Research Authority (MRA) Ethics tool was used to assess whether this project required formal ethical approval. No patient-identifiable data or intervention were involved in this study. The MRA tool, therefore, concluded that this project did not require formal ethical approval, as such this project was not presented to an ethics committee.
Competing interests
Authors have no conflicting interests to declare.
Data sharing and data availability
Available on request.
Authorship statement
The project was conceived by L.G., L.G., O.G. and B.T. designed the survey. O.G. led the qualitative data analysis and write up. L.H., C.G. and A.K. were key data collectors and were also responsible for manuscript editing. All authors were involved with final paper write up and are accountable for all aspects of the work.
