Managing change in postgraduate medical education: still unfreezing?

Abstract

Background: Modernizing Medical Careers (MMC) is an ambitious project to change the training of UK doctors. A key to its successful implementation is the ways that MMC is perceived and operationalized by senior doctors who act as local educational leaders and supervisors.

Aims: To analyse hospital consultants’ perceptions of the modernization process and its impact on their role as the primary educators of Senior House Officers (SHOs), using Schein's extended model to explain their stage in the process of change.

Methods: We interviewed medical directors, College and clinical tutors and education supervisors at 6 Trusts. The transcripts were analysed using Schein's change model to explore the perceptions and assumptions of senior medical staff and to determine their stage in the process of change.

Results: 12 tutors, 12 supervisors, and 4/6 medical directors approached agreed to participate (28/30). Nine themes emerged from transcript analysis. These were related to the three-stage model of change. Most participants were at the stage of ‘unfreezing’, expressing views around disconfirmation of expectations, guilt and anxiety and feelings of some psychological safety. A smaller number were at the stage of ‘moving to a new position’. There were limited examples of ‘refreezing’.

Conclusions: At the local delivery level, most senior doctors were aware of the need to review their current position and alter their approaches and assumptions about postgraduate medical education. Yet only a minority were moving forward. Considerable work remains for successful implementation of MMC.

Background

To be involved in the education of doctors in training in the UK is to live in interesting times. The publication of Modernising Medical Careers (MMC) has heralded a transformation in the way all doctors are to be trained in future, setting out the UK Government's plans for a wide-ranging overhaul of the structure of postgraduate medical education (NHS Executive 2003). MMC provides the framework for a multiplicity of reforms impacting on doctors in training and requires significant changes in working practices, attitudes and assumptions of hospital consultants, particularly in their role as educators. To add more complexity to the introduction of MMC are continued workload pressures for consultants and general practitioners who are both service providers and role models/faculty for training programmes (Huby et al. 2002; Brettingham 2005). The incorporation of the European Working Time Directive (NHS Executive 1998) into the NHS has had a particular impact on workforce capacity.

Change is recognized to be a major element of health care organization and education in the UK and around the world. The management of change is an established area of academic consideration, gaining momentum as a discipline in the mid-20th century when increasingly large and complex organizations, like the NHS, began to appear (Beckhard & Harris 1987; Ilies & Sutherland 2001). There have been many studies of how the NHS and its constituent organizational sub-groups respond to change and affect the consequences of how plans are implemented (Marshall et al. 2003; Scott et al. 2003). The management of change in medical education has also been explored (Genn 2001; MacFarlene et al. 2002).

Table

Practice points
•Successful implementation of MMC is dependent on how it is perceived and operationalized.
•Schein's model for transitional change may be used to interpret the impact of MMC.
•Consultants are aware of the need to alter their assumptions about postgraduate medical education.
•Most consultants are at the stage of ‘unfreezing’: expressing views around disconfirmation of expectations in relation to change.

Change is a difficult process. There are numerous change models we could have used to interpret our data, such as Gleicher’s Formula (Beckhard 1969), which proposes that the combination of organizational dissatisfaction, vision for the future and the possibility of immediate, tactical action must be stronger than the resistance within the organization in order for meaningful changes to occur. Schön (1974) has theorised about the inherently conservative nature of organizations and the resistance of individual members to constant change. One of the first proponents of what became known as the learning organization, his model of reflection-in-action, the mapping of a process by which this constant change could be coped with, has been applied extensively by researchers. Having considered the various models of change, we selected the one developed by Schein (1987) because his conceptualization focuses on the centrality of the learning process in the development of new attitudes and behaviours: an apt approach when dealing with changes in a professional training system. Schein built on a change model originally devised by Lewin (1951) in the post World War II period. This earlier model considers change as a three stage process:

1. unfreezing the existing organizational equilibrium;

2. moving to a new position;

3. refreezing in a new equilibrium position.

Schein has operationalized each of these stages to make the model more amenable to analysis of both implementation and results.

Aims

The opinions and assumptions of senior medical staff involved in the education of doctors in training at local Trusts will be key factors in the implementation of MMC. The aim of this study was to analyse hospital consultants’ perceptions of the modernization process and its impact on their role as the primary educators of Senior House Officers (SHOs), using Schein's extended model to explain their stage in the process of change.

Method

We compiled a list of all acute Trusts in one region in England covered by one Postgraduate Deanery. Deaneries are the regional bodies responsible for implementing MMC, whose wider remit is the management and delivery of postgraduate medical education and the continuing professional development of all doctors. The Deaneries have a considerable degree of autonomy in determining their implementation strategies and as a result there have been regional variations in approaches to MMC (Tooke 2007).

The Postgraduate Deanery in this study had an established network of Postgraduate Clinical Tutors in Trusts with which it communicated directly about the MMC changes for cascading to consultant colleagues. A deanery-appointed MMC Project Manager also co-ordinated direct liaison with medical educators via newsletters, conferences and training sessions, though these had yet to come fully into force in the early stages of MMC implementation when our data were collected from Trusts.

We categorized the Trusts in the jurisdiction of this Deanery according to the three typical environments where SHOs (Residents) are based for their education and training: teaching hospital, district general hospital (DGH) in a conurbation, and DGH in a town location. Two sites were then randomly selected from each of these three categories, so that in total six Trusts were involved. By including a variety of educational environments we hoped to uncover the views and assumptions of key senior medical staff involved in the delivery of medical education in NHS Hospital Trusts.

We focussed on general medicine as providing one of the broad tracks that hospital-based trainees follow in their specialization. A sampling strategy was employed with stratifying criteria based on categories of formal Trust-based roles that have a direct bearing on postgraduate medical education either as education leaders or supervisors of SHOs. The roles identified were those of Postgraduate Clinical Tutor (PCT), Royal College Tutor of Physicians (RCPT), Medical Director (MD) and Educational Supervisor (ES). We used a modified grounded theory approach to the collection and analysis of data (Stern 1980). An initial sample comprising 30 hospital consultants working in the stated roles at six NHS Trusts in one region was identified. The sample could be increased if necessary, as data was collected and analysed, in order to secure saturation of themes. In each of the Trusts, the sample was made up of two Educational Supervisors, randomly selected from a list of consultant physicians, and the single incumbent of each of the other roles.

We sent a letter of invitation to the identified participants and a time to meet was arranged by telephone. Over an 8 month period in 2004/5, semi-structured interviews were conducted in a private location in each hospital Trust. Interviews were conducted using an interview guide that had been designed to identify perceptions of change in medical education. The guide focused on three specific areas: (i) reform to postgraduate medical education; (ii) the culture of education in trusts and region; and (iii) the enhancing and inhibiting factors for consultants’ role in education. Questions were kept sufficiently open-ended and general to give participants the opportunity to expand upon their opinions and experiences (Denzin & Lincoln 2005).

One of the researchers (SA) conducted the interviews, with each lasting approximately 45 minutes. The interviews were digitally recorded and subsequently transcribed verbatim and then carefully checked for accuracy by SA. Using a modified grounded theory approach, and with the assistance of qualitative data analysis software (NVivo), the transcripts were analysed for recurring discourses and themes, as well as contradictions in the ways that the participants discussed these issues. Data collection and analysis were carried out in tandem, repeatedly referring back to each other. The research team acted as co-analysts, and an initial coding framework was devised as a result of their deliberations following initial scrutiny of the transcripts independently. The resulting codes were constantly compared by the team, and relationships between them were established, in order to produce a set of theoretical concepts (see Table 1). These concepts were then considered to determine how they fitted into Schein's extended transitional change model, and thus what the data revealed about consultants’ perceptions of change in relation to their educative role. The results are presented within the structure of the Schein model in order to explain the stage of our sample in relation to the reforms instigated or mandated by MMC.

Table 1.  Initial coding framework derived from the analysis with descriptions

Concept	Description
Tension	Service and training remain dichotomized, with education suffering from increased clinical and administrative pressures.
Infrastructure	Improvements to the education infrastructure in Trusts are seen as vital to the success of modernization in postgraduate medical education.
Profile	Education managers want to see the profile of education raised within Trusts, particularly at Board level.
Recognition	Consultants want to have their educative role more formally recognized.
Formalisation	A lack of dedicated time for consultants to plan and deliver training limits progress in advancing the medical education agenda.
Training	Appropriate and sustained training for consultant trainers is viewed as imperative in helping them deliver education more effectively.
Motivation	Maintaining the motivation and goodwill of educators is necessary to improve the content and delivery of medical education.
Support	Consultants would like more transparent support and detailed guidance from government, deaneries and professional bodies for their educative role.
Symbiosis	All those involved in medical education should consider how the symbiotic relationship between service and training can be maximized, and how the most effective models can be embedded in the culture of NHS organizations.

Approval was obtained from the ethics committees of the NHS Trusts that participated in the study. Approval was also obtained from the University Research Ethics committee and the Regional Ethics Committee. All participants were given written assurances of anonymity at the time the data were recorded and their interviews and other information were made anonymous prior to data analysis.

Results

The sample comprised 28/30 subjects (93%), since two Medical Directors declined to be interviewed due to pressure of work. The preliminary analysis of the data by site and training role revealed no obvious disparity in the concepts we identified through the coding process (see Table 1). The near saturation of concepts was achieved at a mid-point in the data collection process, but we continued to interview all 28 members of the sample in order to ensure that new data were no longer illuminating the concepts. Because of this, the research team did not consider it necessary to recruit additional subjects to the sample. There was a high level of consensus amongst educational supervisors and education leaders across all six Trusts. Their agreement with the nine concepts summarized the difficulties, tensions or barriers that the subjects overtly expressed in delivering educational training.

In the second stage of analysis, our aim was to use the respondents’ comments associated with each concept to determine how the subjects’ views might be explained by Schein's extended transitional change model. Our results revealed that our data could be understood for the most part in terms of the first stage of the model, that of unfreezing the existing equilibrium. Schein divided the first of Lewin's broad stages into subsets, each of which must be present in some degree for motivation for change to develop.

1. Disconfirmation of expectations. That which causes discomfort and disequilibrium in the person's assumptions about his/her current state that cannot be easily rationalized.

2. Creation of guilt or anxiety. The connection of disconfirming evidence to the subject's important goals and ideals.

3. Provision of psychological safety that converts anxiety into motivation to change. A necessary early step, this allows members of the organization to acknowledge and try to adjust to the disconfirming data rather than defensively denying it.

The results reported here are based on the interview data relating to Schein's model of transitional change, and for the most part illustrate the three processes associated with Stage 1: unfreezing.

Stage 1: Unfreezing the existing organizational equilibrium

1. Unfreezing. Disconfirmation of expectations

There were widespread instances of data illustrating disconfirmation of expectations across all our concepts. A common example was the overriding view that the NHS was straining consultants too much, and that change must occur to reduce the prevalent tension between service and training. The perceived service pressures were thought to be having a detrimental effect on the quality of training that educational supervisors and education leaders felt able to deliver. There was widespread acceptance for the need to change alongside a strong sense that effective transformation could not be realized until and unless individual consultants have the support of their Trust, in the form of an appropriate infrastructure to support education, and a formal recognition of consultants’ educative role:

If an employing organization is serious about education they would do a lot more to make us better at it and provide us with support and time and facilities and resources to provide it. (ES)

The recognition that change was necessary appeared to be strongly influenced by the subjects’ recent experiences. The introduction of the European Working Time Directive, limiting the working hours of doctors in training, has had what many saw as a negative impact on the effectiveness of postgraduate medical education, and the capacity of consultants to deliver training:

The ability of the SHO to attend the out-patient clinic is severely curtailed by virtue of colleague leave, the rota, hours’ limitation and cross-cover. You may not actually see the SHO in clinic for weeks, which does significantly interfere with training. (PCT)

Proposed improvements to the structure and content of the SHO grade were perceived as welcome. However, participants were fearful that additional demands on their workload resulting from the change process could not be met. Many interviewees in our sample expressed the view that even with the current manpower arrangements, they simply did not have the capacity to train and assess SHOs as they should.

There aren’t enough senior staff to go round and to provide the level of supervision that the juniors are going to need in order to get trained in a relatively short period of time. (RCPT)

In summary, the analysis showed a consistent recognition that change was necessary together with a general support for the tenets of MMC. Participants broadly embraced the drive of the medical profession and the NHS organization to bring about improvements to postgraduate medical education. This view was based on the subjects’ disconfirmation of their current expectations, primarily relating to service pressures increasingly limiting their ability to deliver a high standard of education unless support in terms of time, manpower, resources, and guidance were provided.

1. Unfreezing. Creation of guilt or anxiety

There was considerable anxiety amongst our sample with regard to the modernisation process in postgraduate medical education. This included anxiety about the difficulties of providing robust training in the face of service tensions, increased workload and reduced contact with trainees.

They [Trainees] now very often don’t see the consequences of decisions they’ve been part of earlier in their patients’ care and I think that's a real problem … that's driven of course by the European Working Time Directive rather than by design but I do think educationally it's a serious worry because you need to reflect on what you’ve done and the current system mitigates against people doing that so I have anxieties. (ES)

We also identified anxieties that MMC would itself add to the pressures experienced by consultants, building up their educational role with no diminishment in their clinical and managerial responsibilities.

It's a problem for those consultant who are conscientious, who see that there are more requirements for training to come, both student and postgraduate, but they’re sceptical that they’re going to get additional staff hours, consultant or others, to actually carry out the training. (MD)

There was a widely held view across the sample that the major contributory factor to the culture of education within a Trust was motivated consultants: they were the primary resource. However, our analysis showed significant concerns about ability to perform this educational role.

I feel like I just keep my head above water, barely. In theory I have one session but it gets eaten up by other things. (ES)

Many interviewees spoke of a need for additional educators, with the appropriate training and skill set. One Educational Supervisor described consultants, in educational terms, as ‘enthusiastic amateurs’, and spoke of the unrealistic expectation that attending one or two courses at a regional or national level equipped someone to be an effective educator. Whilst the provision of existing education courses, particularly by the Deaneries, was valued, many participants wanted more training opportunities to enable them to develop their educative role.

We identified considerable anxiety about the lack of dedicated time to plan and deliver education. Whilst protecting dedicated sessions for teaching and supervision would inevitably impact on consultants’ direct patient care, protected time for the educators was seen as vital. The majority of our sample wanted the educational function to be built into consultant job plans, with formal recognition given to this aspect of their role.

The consultants are worried, will they have time to train them and assess them, as they should. There aren’t enough of them to do it. So that's a concern and we would like to see time set aside in the consultant contract for supervision, assessment and appraisal which is not formally done at the moment. It is widely done but it isn’t a formal requirement for job plans. (MD)

Among our respondents, many of the Postgraduate Clinical Tutors and Royal College of Physician Tutors, also complained in particular of a lack of time to carry out their duties. A number of interviewees said they were left feeling constantly reactive to Deanery and Trust requests rather than having the capacity to be proactive and take the lead on new initiatives.

There isn’t any real communication about postgraduate education matters of any substance. I suppose there is when they come and inspect us and tell us about all the things we’re doing wrong, but apart from that, I mean that's not terribly supportive really, it's just coming and seeing what they can bash us about the head for. (PCT)

A further concern was that contact with doctors in training had become fragmented as a result of shift systems and reduced hours, and this needed to be counteracted by a new, more structured, educational experience. It was recognised that an aim of the modernisation process was to provide this structure, yet the subjects reported lack of support and guidance on how it would be implemented and sustained.

I think, in an ideal world, it would be helpful to have Trusts which recognize the importance of education so I mean I think I would like to see the Deanery leaning on Trusts to be prescriptive about [the] educational content of [a] consultant['s] contract. (ES)

1. Unfreezing. Provision of psychological safety that converts anxiety into motivation to change.

There was a high degree of awareness of the type of psychological safety that is required in order to allow the reconstruction of assumptions and behaviours that will support change. This was perceived as not being in place at present either for individuals or in structures. In many instances, for example, we found that medical education was perceived as not having a strategic presence in Trusts or a voice at board level:

I don’t think that many Trusts have really grasped the impact of changes in spite of the fact that they’ve known they’ve been coming for a very long time. (ES)

Trusts were often seen as relegating educational duties to the Postgraduate Deanery and Royal Colleges:

In our Trust there isn’t an education directorate or education committee as such although I think there are plans to establish one. It is still pretty much perceived by the Trust that we have regulation from the Deanery and the Royal Colleges and therefore we don’t really need to engage our brains about it. (PCT)

Education leaders were particularly concerned that the profile of education had to be raised within Trusts combined with a strengthening of the educational infrastructure. Trusts were seen as the primary organizational bodies within the NHS where change must be effected if modernisation was to succeed. It was Trusts that had to provide psychological safety for consultants:

Unless we’re in a position to strengthen our infrastructure to develop training and implement Modernising Medical Careers, it probably isn’t deliverable. We think it's deliverable but only if the resources and infrastructures are put in place in the Trust. (PCT)

Other NHS organizations were identified as motivating forces for the Trusts themselves. A number of interviewees expressed the view that Postgraduate Deaneries should play a more prominent role in supporting the training and support of educators. They were seen as key players in instigating change, influencing and enabling the modernization process in Trusts, and providing them with psychological safety.

I think the Deanery needs to keep pushing, as the Royal College used to keep pushing us, sort of saying ‘Look, what is happening is not good enough. These are the standards we expect, this is how it should be done and this is how we’re going to audit and assess it’ and then they finally need leverage. You need a champion, somebody to champion it, really. (ES)

In summary, the majority of the sample believed that change to postgraduate medical education was necessary, and supported the main tenets of MMC. This view was based on the subjects’ disconfirmation of their current expectations, primarily relating to service pressures increasingly limiting their ability to deliver a high standard of education unless they received more support. There was, however, considerable anxiety amongst our sample with regard to the modernization process in postgraduate medical education, including concerns about the difficulties of providing robust training in the face of service tensions, increased consultant workload and reduced contact with trainees. There was clear awareness of the type of psychological safety that is required in order to allow the reconstruction of assumptions and behaviours that will support change, but was perceived as not being in place at present either for individuals or in structures.

Stage 2: Moving to a new position

Schein's next stage in his model, moving to a new position, involves restructuring one's intellectually-held assumptions and beliefs, often as the result of looking around for new relevant information.

Although we identified some examples of such movement within the interviews, these were limited. The instances were most prevalent amongst the education leaders (Postgraduate Clinical Tutors and Medical Directors), who held a more thorough grasp of educational theories and the drivers for change, perhaps not surprising given their role.

I try not to be a Luddite so, you know, one should look for opportunities to make things better and educate people to do the job that's expected of them and so on so, you know, being imaginative about developing people is maybe no bad thing. (PCT)

A vehicle for restructuring one's beliefs and assumptions can be through a new role model or mentor and with whom there is a psychological identification

And of course it helps to have Dr X in our department because he's a great leader and inspirer and also he's someone that keeps us abreast of all the latest educational thinking, which is very good for us. (MD)

Stage 3: Refreezing

The third stage of Schein's model, refreezing, occurs when the new point of view is integrated into the concept of self-as-educator. There were only occasional examples that seemed to reflect this stage in the data, at least to some extent, and these relate to the possibility of refreezing in the future.

We need to have a structured training programme for our SHOs. We need a collective discussion between the educators every now and then at least twice a year to see what we have learnt …. We never have that … . I need to have feedback from my colleague. (ES)

In conclusion, the dominant views amongst both educational supervisors and leaders led us to conclude that our sample was largely positioned at the unfreezing stage.

Discussion

Through detailed analysis of interviews with key clinical education leaders at a local Trust level, we identified most staff with responsibility for the education of doctors in training in a major specialty as being at the stage of perceiving the need to change and to address their own assumptions about the delivery of postgraduate education. Given that it is at the Trust level that the changes must occur, this finding has implications for projecting the speed of change and allocation of the on-going support needed to successfully implement MMC.

There are, however, several limitations to our study. Firstly, we interviewed staff at a particular stage of implementation of MMC over an eight month period in 2004/5. It is possible that if the interviews were repeated as MMC moves forward then the results would be different. Secondly, our study was confined to exploring the views of clinical education leaders within one particular postgraduate deanery and in one (major) speciality, general internal medicine, which means that generalisation to other deaneries and specialities should only be done cautiously. Thirdly, we conducted interviews with a relatively small number of staff in key roles, and some groups of staff (medical directors) were under-represented because two members of this group declined to participate. We did, however, attempt to minimise these effects through purposive sampling across hospital Trusts in several settings.

A further limitation in interpreting our results is that the study was carried out at the time that the pre-registration house-officer posts (interns) were just being replaced by a structured two year foundation programme encompassing the first 2 years following graduation from medical school (NHS Executive 2004). This was the initial reform proposed under MMC and so the participants have been interviewed at a relatively early stage in MMC, where experience was limited. This instability within postgraduate medical education may have biased the views of a proportion of our sample. The revealing of underlying assumptions and beliefs at the time of major change considerably offsets this limitation.

The attitude of professional groups to change is a subject that has been widely documented in literature on the sociology of the professions (Dingwell 1979; Freidson 2001;). Freidson (1970) notably argued that altruistic concern for the welfare of others in society has conserved the medical profession's right to continued self-regulation and the relative independence of its practitioners from State control. He suggested that this autonomy has also conserved the profession's right to train its future members, and resulted in an intrinsic resistance to change imposed from outwith the profession. Our sample's values and beliefs about MMC appear to support the general argument for change resistance, although Schein's transitional change model permits a more subtle interpretation of the underlying reasons for resistance.

Larson (1977) argued that the basis of professional dominance itself centres upon a process by which members mystify their competence and thereby obscure the basis of their authority, restricting access to the profession, and controlling training. The change process resulting from MMC has had a long gestation which has been instigated by government but devised largely by senior educationalists from within the medical profession itself. Perhaps this explains why resistance to the principles of change to postgraduate medical education, principles formulated by a stratum of the profession itself, has not been overtly apparent in this study, but rather has manifested as a resistance to imposition without sufficient safeguards for clinical educators.

Schein makes clear that it is not an uncommon situation for disconfirming data to have existed for a long time but, because of a lack of psychological safety, an organisation or group of individuals will continue to avoid anxiety or guilt through repression or denial of the relevance, validity, or even the existence of the data. The essence of psychological safety is to create the conditions that allow the consideration of needed change without feeling a loss of integrity or identity.

In applying Schein's model, the results revealed multiple examples of disconfirmation of expectations and levels of anxiety. We were able to discern little evidence of psychological safety, provided either by the instigators or implementers of modernisation, and for the majority of our participants the motivation to change was not yet paramount. The data suggested, for example, that many consultants did not believe that their role as educators was properly valued or effectively recognized within Trusts, which influenced their receptivity to change. Like Lowry (1993), and Biggs et al. (1994), in their respective studies of the educational role of consultants, we found that clinical educators wanted the role to be formalised in contracts and timetables if this component of their professional life was to be protected from service erosion. This is probably even more important following the implementation of the new consultant contract and the pressure of supporting programmed activities, which include teaching (Department of Health 2003). This may also explain why the data contains little evidence of consultants having adopted the MMC principle of focusing on learning through doing rather than set educational protected times. It may be that, as educational principles of MMC become more firmly embedded in the culture of postgraduate medical training, the emphasis on protected learning time may lessen in importance and thereby move to another position. At the time of this study, however, many in our sample believed that Trusts were failing in their provision of psychological safety by denying the relevance of consultants’ educative role in the face, perhaps, of service-related pressures.

The perceived lack of recognition also appeared to make it more difficult to engender an educational ethos within Trusts, especially amongst colleagues who were less committed to their training role and consequently may have been likely to repress disconfirming data on the importance of their educative role. In the data this was seen as recognition of disconfirming data in the transitional change model, but not carried through to unfreezing as this was viewed as untenable because of the perceived tension between service and training, and the lack of institutional commitment to educational goals and to motivate change.

A prominent finding arising from the data was a general lack of knowledge, and a concern amongst educational supervisors, as well as education leaders, about the modernization process in postgraduate medical education and its impact on their role. There was a sense that the change process had not been effectively communicated by the national bodies that had instigated the modernization process, which had affected the Deanery and the Trusts as well as individual clinical educators. By inference, the psychological safety being provided by all these bodies was insufficient. However, the complicity of the consultant body in the knowledge vacuum must be acknowledged. Some consultants admitted that they had a constant stream of new directives landing on their desks, and did little to take account of them until they were explicitly required to do so. This resistance to change, given the day-to-day pressures of clinical life, will remain unless disconfirming data within an organization supports the change process. However, as MMC is a dynamic process, it is probable that consultants are now much more aware of the implications of this shift in postgraduate training. Nevertheless, we would argue that there is still evidence from both the consultant body and the trainees that there is insufficient detailed information about how the changes will affect them (Coombes 2007).

A significant proportion of the interviewees saw themselves as lacking the appropriate training and skill set to enable them to work as educators at an optimal level. This perception may have been the result of the shift away from the traditional apprenticeship model in medical education (Pratt & Johnson 1998), and raises the question of whether consultants now feel less comfortable with their role as educators, or whether it is simply that they have a greater awareness of their educative role (Wall & McAleer 2000). It is fifteen years since England's then national Standing Committee for Postgraduate Medical Education recommended that those who train doctors be provided with the opportunities to acquire the skills necessary to teach (SCOPME 1992). A considerable amount has been achieved in the intervening period. Medical Educationalists have advanced the debate (Grant 1998) and Postgraduate Deans have made significant strides in establishing ‘training the trainers’ programmes. However, our study indicates that there is still a way to go, particularly within Trust structures, to facilitate the educative role of consultants. From Schein's perspective, there remains a considerable degree of cognitive restructuring (changing assumptions and behaviours) to be done by the consultant body to achieve a move towards a perception of self as a professional educator as well as a professional practitioner, thereby representing attainment of the third level, refreezing, in the transitional change model.

Conclusion

Overall, we found the model for transitional change to be a useful tool for gauging the extent of change within an organization. By interpreting our data through this conceptual lens, we conclude that, at the time of the study, the full impact of MMC still had not been felt by the organizations and individuals who are best responsible for delivering its agenda. Hospital consultants clearly valued their educational role, and responsibility for training the next generation of colleagues remained a vital component of the culture of medicine. There was broad support for MMC and its underlying ethos, indeed the changes were widely considered overdue, which was in line with the findings of previous studies into the state of SHO education (Baldwin et al. 1997; Cooke & Hurlock 1999). There was also recognition that change was necessary if the European Working-Time Directive is to be met and the tenets of Improving Working Lives embraced (Department of Health 2000).

There was concern amongst consultants about the impact of modernization on their role. There was a fear that they will be left to implement change with insufficient resources, training and support. Many consultants perceived themselves as being pulled in different directions and, for the majority, service and training remain dichotomised. The accelerated period of change in postgraduate medical training that was instigated by MMC is continuing, therefore the research described in this paper may be seen as a baseline study. It would be useful to follow up this work with some further research to gauge the extent of change now that MMC is at a more advanced stage. It might, for example, be productive to conduct a randomized controlled trial which measures the extent of change within postgraduate medical education across the different Medical Royal Colleges and Deaneries. The recent debates about MTAS and the MMC review suggest that many rank-and-file consultants remain at an early stage of transitional change and therefore are experiencing huge upheavals (Department of Health 2007a, b). The leaders of MMC need to ensure that consultants feel supported in their role, and have capacity for development as educators if the opportunities afforded by MMC are to be realized and the refreezing into a stronger culture of education is to be achieved for trainers and trainees alike.

Acknowledgements

We are very grateful to the participants in the study and the hospital Trusts in which the interviews took place. Mrs Catherine Roberts expertly transcribed the interview recordings and helped enormously in the administration of the study. The North West Postgraduate Medical Deanery supported the study both financially and in time for the lead author.

The research was funded by the North Western Deanery. Data was collected from medical staff working at 6 NHS hospital Trusts in the North West region.

Conflict of Interests

Steven Agius is employed by the North Western Deanery, which provided funding for the study. All other authors have nothing to declare.

Additional information

Notes on contributors

Steven J. Agius

STEVEN J. AGIUS BA (Hons), MA, PhD, is a Research Fellow in Medical Education at the North Western Deanery, based in Manchester.

Sarah C. Willis

SARAH C. WILLIS, BA (Hons), MA (Econ), has worked for the University of Manchester for several years and, having previously worked for the Medical School, is currently working as a Research Fellow in the School of Pharmacy.

Patricia J. McArdle

PATRICIA J. McARDLE, AB, MS (Epidemiology) EdD, is Medical Education consultant for the Department of Medicine, Bay State Medical Centre, MA.

Paul A. O’Neill

PAUL A. O'NEILL, BSc (Hons) MB ChB, MD, FRCP (Lond) is Professor of Medical Education and head of the Manchester Medical School.