I recall one particular day that took place some years back, when I was serving as a medical officer (MO) in the ICU. A patient had desaturated in the general ward and was intubated before being brought in. It seemed like just another day, until I met a tearful house officer (HO) trailing behind the patient. Before I could take the handover, the HO asked, "Was it my fault?"
I distinctly remember feeling taken aback by the abruptly posed question and perhaps paused a little too long before I responded with somewhat awkward words of comfort. Truth be told, nobody really teaches us how to handle our colleagues' emotions at work, and when giving feedback, it is often hard to tread the line between being falsely reassuring and being perceived as patronising.
This was one of many moments in my last eight years of working in public hospitals that highlighted how stepping up at work was not just a good-to-have habit, but an essential practice. Yet we hardly talk about this, and every year, approximately 800 HOs are bestowed a new MCR number, unceremoniously "becoming" MOs overnight without so much as a formal brief on their newfound roles and responsibilities.
But fret not! In the SMA Doctors-in- Training (DIT) Committee's quest to ease difficult transitions for doctors in training, we have sought to distil the wisdom of generations of seniors who have walked the path before us. To our fellow doctors assuming new roles at work and prospective "black tags", this is for you. Introducing... the DIT 3-2-1 Step Up Model!
D – Define, delegate, and do not forget the little things
Define clearly
The fundamental first step is to know our scope of work. This comprises the "official" terms of reference (eg, important legal responsibilities such as death certification), as well as the "unofficial" duties we are expected to undertake (eg, ensuring our HOs do not skip their meals). Importantly, the process of defining our scope helps us to prepare and remain accountable for our work.
Delegate thoughtfully
As we gain seniority, it is inevitable that we will need to delegate tasks to juniors in the team. When doing so, it is important that we do so with intention, be it as a deliberate learning opportunity or to stretch our juniors and showcase their potential, among other reasons. When tasks are delegated, we should give our juniors a degree of autonomy to complete the task, while remaining accessible to them should help be requested or required.
Do not forget the little things
Little things carry a big impact when managing a team. Learn people's names, find out more about what they do outside of work, show an interest in their growth as fellow human beings. Help your juniors, answer a question they might be fumbling with during the ward round, step in and speak up if you witness non-collegial behaviour. Remember to say thank you for even the simple things, like a timely escalation or a well-curated management plan.
I – Invest in yourself and in others
Investing in yourself
We must dedicate a portion of our time toward personal mastery, lest we fall prey to the Dunning-Kruger effect. Beyond clinical knowledge and skills, we should remain cognisant of and actively work on our deficiencies in communication and documentation, information gathering and synthesis, decision-making and task prioritisation, time and resource management, and systems-based practice. I find Broadwell's Stages of Competence to be a helpful framework to help me assess my degree of competence in any given domain. Many of us find that asking for feedback supplements our reflective learning process as well – this includes feedback from our juniors, nurses, allied health professionals, and even our patients.
Another crucial aspect of investing in ourselves is ensuring that we have downtime to rest, recharge and rejuve¬nate. Stretching ourselves out too thin ultimately comes at the expense of patient safety.1 Even as we rise through the ranks, we must know our limits in order to practise safely, and remember that there are always seniors and trusted colleagues to whom we can turn to seek help or escalate situations to.
Investing in others
Mentorship is a core tenet of our profession. Junior doctors must recognise that they play a pivotal role as near-peer mentors at their workplace.
Most of us would agree that the bulk of our medical practice, especially soft skills such as communicating with patients and other professionals, is invariably learnt through role modelling.2 It is therefore important for all of us to exemplify the good practices and behaviours we hope for our juniors to emulate. It also helps to verbalise our thoughts when we assess patients to facilitate this learning process.
The clinical environment, while at times unforgiving in pace and workload, is rife with teaching moments. We must leverage these teaching moments and make learning visible to our juniors (ie, make explicit what we want them to learn from a specific task or experience). In giving feedback, we should aim for it to be constructive, specific, timely and actionable, and to this end, useful feedback models include Pendleton's Rules and the One-Minute Preceptor.
T – Take a step back
It is oftentimes all too easy to get caught up with the hustle and bustle of everyday life in the wards, and we end up forgetting to take a step back to see the big picture. A key aspect of stepping up at work is seeking to understand the overarching system at play that ultimately influences how patient care is delivered and how we are resourced. Only with this understanding can we begin to challenge the status quo and design solutions to improve the system, beyond improving the care of our patients.
Junior doctors occupy a rather unique position in this regard, having accumulated ground experience while not being completely entrenched in the way things work. This engenders within them a natural inclination to think out of the box – in identifying opportunities to address pain points at their workplaces and potential growth areas in their respective fields of practice.
Closing thoughts
Admittedly, stepping up at work is not always intuitive. By virtue of our vocational training, many physicians value and place our focus on honing our clinical skills, sometimes at the cost of neglecting our development in the leadership domain. We hope to bring to light this critical component of the "hidden curriculum", and encourage junior doctors to continue taking the initiative in stepping up at work – as mentors and team leaders, and as advocates for change. Our patients will be better off for it.
The SMA DIT Committee advocates for junior doctors and medical students, and runs a wide range of initiatives to support them in becoming competent, confident and compassionate healthcare professionals.
The Committee has spoken up and provided recommendations on working hour caps, night call allowances and the float system, leave for National Service call-ups, postgraduate training opportunities, the process for full registration, and junior doctor engagement.
In addition to these advocacy efforts, the Committee operates an "Ask Me Anything" channel, publishes the DIT 101 digital pocketbook, conducts "starter pack" workshops for junior doctors, and organises events for the Medical Association of South East Asian Nations Junior Doctors Network as well as the SMA National Medical Students' Convention.
Join our DIT Telegram channel @helpourjuniordocs and follow our Instagram page @jrdocs.sg to stay up to date regarding our various initiatives. If you are keen to get involved with SMA DIT efforts, please write in to us at ilj@sma.org.sg.
Further information
Dunning-Kruger effect
The Dunning-Kruger effect refers to a cognitive bias where people with limited competence in a particular domain overestimate their abilities in that domain. When we fall prey to the Dunning-Kruger effect, we risk stunting our personal growth by failing to develop the areas in which we are weaker. It is thus important to be able to evaluate your own competencies as accurately as possible.
Broadwell's Stages of Competence
Broadwell's Stages of Competence is a model that classifies the learning process into four stages: (1) unconscious incompetence, (2) conscious incompetence, (3) conscious competence, and (4) unconscious competence. In the first stage, the learner is unaware of his/her own deficit in competence. The learner progresses to the second stage when he/she becomes aware of his/her incompetence in the skill (similar to overcoming the Dunning-Kruger effect). The third stage is attained when the learner is competent in the skill but requires heavy conscious involvement when executing the skill. Finally, the fourth stage is reached when the skill is "second nature" to the learner and can be performed easily.
Pendleton's Rules
Pendleton's Rules comprise five rules intended to guide feedback conversations. They are as follows:
- The feedback provider (FBP) asks the feedback receiver (FBR) to mention two or three points that went well.
- The FBP shares two or three points that went well.
- The FBP asks the FBR to mention two or three points that can be improved.
- The FBP shares two or three points for improvement and discusses strategies based on the input on closing the gap.
- The FBP or FBR summarises the most important points from the conversation.
One-Minute Preceptor
The One-Minute Preceptor is a teaching model that comprises five micro-skills to help facilitate clinical teaching. The five micro-skills are:
- Get a commitment: Ask the learner to articulate his/her own diagnosis or plan.
- Probe for supporting evidence: Evaluate the learner's knowledge or reasoning.
- Teach general rules: Teach the learner common "take-home points" that can be used in future cases, aimed preferably at an area of weakness for the learner.
- Reinforce what was done well: Provide positive feedback.
- Correct errors: Provide constructive feedback with recommendations for improvement.
Mentorship is a core tenet of our profession. Junior doctors must recognise that they play a pivotal role as near-peer mentors at their workplace.