Junior Hospital Doctors Research Articles

A quality improvement project for the ECG interpretation skills of junior doctors in West Suffolk Hospital

A quality improvement project for the ECG interpretation skills of junior doctors in West Suffolk Hospital

Rates of delirium referrals to the Neuropsychiatry Service in a tertiary referral centre hospital

IntroductionBeaumont Hospital is the National Neurosurgical Centre in Ireland. Due to the high numbers of referrals from Neurology and Neurosurgery, The Department of Psychiatry established a specialist Neuropsychiatry inpatient Liaison service and a weekly Neuropsychiatry outpatient clinic. Many of the referrals that the service receive involve the management of delirium. Delirium is a common medical complication, particularly in neurosurgical settings. Delirium causes significant symptom burden which can lead to distress to all involved and impacts quality of life.ObjectivesThe aim was to improve the rates of referrals for delirium presentations and referral rates overall from Neurology and Neurosurgery. The neuropsychiatry service have implemented a delirium protocol for all medical and surgical teams in Beaumont Hospital. This protocol can be accessed through the Beaumont hospital phone app, or on site on each ward. For this reason, delirium can be managed by medical teams in the first instance. If this is not successful, neuropsychiatry can be contacted for further advice or review of patients with more complicated presentations.MethodsThe neuropsychiatry service receives referrals through the Patient Information Profile Explorer system which is accessed through the Beaumont Hospital online portal. In the event of an urgent referral, neurology or neurosurgery teams can contact the neuropsychiatry service directly by phone. Referrals are logged on the team referral log book, and details of the referral are recorded along with diagnosis and management. Data was collected retrospectively from the PIPE and log book to measure the rates and reasons for referrals over a one year period. Rates and details of referrals were initially recorded between July-December 2022. An educational intervention was provided where psychoeducation was provided to junior hospital doctors during protected teaching times and further education was provided over the phone when referrals were discussed between team members. Rates and details of referrals were then recorded between January-July 2023.ResultsThere was a reduction in referrals when comparing the two six month periods. There were 115 neuropsychiatry referrals from July to December 2022 and 78 referrals from January to July 2023. Rates of delirium referrals also reduced from 31% to 25% after psychoeducation was provided to junior doctors.ConclusionsThis audit highlights the importance of communication and education for medical and surgical trainees in the management of delirium. There is a high rate of turnover of junior doctors throughout the year in Beaumont Hospital. For this reason, it is imperative that continued education is provided to allow them to follow the delirium protocol independently before seeking tertiary service assistance. Ultimately, early and rapid intervention of delirium can have a positive impact on patient care and prognosisDisclosure of InterestNone Declared

How Institutional Logics Inform Emotional Labour: An Ethnography of Junior Doctors

Sociological analysis of emotional labour can be aided by considering how institutional logics inform the performance of emotional labour. We consider the link between institutional logics and emotional labour by conducting an in-depth case study of junior doctors in a large UK hospital. We point to three key institutional logics – bureaucratic, consumerist and professional logics – and show how they inform the emotional labour of junior doctors. We also consider how doctors respond to these logics through enactment processes of choice, resistance and negotiation. In this way, we make an important theoretical contribution by identifying the way that institutional logics relate to the performance of emotional labour. We also make an important empirical contribution by contributing to a growing body of ethnographies on the emotional labour of doctors.

Differential Impact of COVID-19 on Junior Doctors

The COVID-19 pandemic had a significant impact on the working circumstances for doctors. To cope with increased workload, hospitals had to increase working hours, reallocate vacation and study leaves and rotations. This impacted the physical and mental well-being of all doctors, particularly international medical graduates (IMG). We explored the differential impact on junior doctors working in a district general hospital. In a mixed methods study, we evaluated the experience and perception of junior doctors in a United Kingdom district hospital in the south of England during the first wave of COVID-19 between March 2020 and September 2020. The study was conducted in two phases: creating a questionnaire followed by an evaluation of qualitative and quantitative content. About 83% doctors in non-consultant grades responded and 37.8% were IMG. The study found that IMG were significantly more likely to experience stress when compared to UK medical graduates (p = 0.008). They were also more worried about contracting the virus when compared to UK medical graduates (p = 0.004). Both groups felt that their training and career progression had been adversely affected. Various factors could play a role in increased stress in IMG when compared to UK medical graduates. These factors included: adjusting to a new system, being away from family, exams and interviews being cancelled, and reports suggesting that members of the the Black, Asian and Minority Ethnic (BAME) community were more likely to be affected by serious illness if contracted COVID-19. This highlights the need for additional support for IMG.

Evaluation of rural general practice experiences for pre-vocational medical graduates.

Despite substantial investment in rural workforce support, sustaining the necessary recruitment and retention of general practitioners (GPs) in rural areas remains a challenge. Insufficient medical graduates are choosing a general/rural practice career. Medical training at postgraduate level, particularly for those 'between' undergraduate medical education and specialty training, remains strongly reliant on hospital experience in larger hospitals, potentially diverting interest away from general/rural practice. The Rural Junior Doctor Training Innovation Fund (RJDTIF) program offered junior hospital doctors (interns) an experience of 10 weeks in a rural general practice, aiming to increase their consideration of general/rural practice careers This study aimed to evaluate the educational and potential workforce impact of the RJDTIF program. Up to 110 places were established during 2019-2020 for Queensland's interns to undertake an 8-12-week rotation (depending on individual hospital rosters) out of regional hospitals to work in a rural general practice. Participants were surveyed before and after the placement, although only 86 were invited due to the disruption caused by the COVID-19 pandemic. Descriptive quantitative statistics were applied to the survey data. Four semi-structured interviews were conducted to further explore the experiences post-placement, with audio-recordings transcribed verbatim. Semi-structured interview data were analysed using inductive, reflexive thematic analysis. In total, 60 interns completed either survey, although only 25 were matched as completing both surveys. About half (48%) indicated they had preferenced the rural GP term and 48% indicated strong enthusiasm for the experience. General practice was indicated as the most likely career option for 50%, other general specialty 28% and subspecialty 22%. Likelihood to be working in a regional/rural location in 10 years was indicated as 'likely' or 'very likely' for 40%, 'unlikely' for 24% and 'unsure' for 36%. The two most common reasons for preferencing a rural GP term were experiencing training in a primary care setting (50%) and gaining more clinical skills through increased patient exposure (22%). The overall impact on pursuing a primary care career was self-assessed as much more likely by 41%, but much less by 15%. Interest in a rural location was less influenced. Those rating the term poor or average had low pre-placement enthusiasm for the term. The qualitative analysis of interview data produced two themes: importance of the rural GP term for interns (hands-on learning, skills improvement, influence on future career choice and engagement with the local community), and potential improvements to rural intern GP rotations. Most participants reported a positive experience from their rural GP rotation, which was recognised as a sound learning experience at an important time with respect to choosing a specialty. Despite the challenges posed by the pandemic, this evidence supports the investment in programs that provide opportunities for junior doctors to experience rural general practice in these formative postgraduate years to stimulate interest in this much-needed career pathway. Focusing resources on those who have at least some interest and enthusiasm may improve its workforce impact.

Will clinical signs become myth? Developing structured Signs Circuits to improve medical students’ exposure to and confidence examining clinical signs

ABSTRACT Background Correctly eliciting and interpreting physical examination (PEx) signs contributes to successful diagnosis and is fundamental to patient care. A significant decline in the time spent acquiring these skills by medical students, and the decreased ability to elicit and recognise signs is widely acknowledged. However, organising teaching to counteract this in the busy clinical environment is challenging. We evaluated the prior exposure to clinical signs, and experience of examination teaching among a cohort of final-year medical students. Following this, we assessed the utility of a structured circuit-based approach (Signs Circuits) using hospital inpatients and junior doctors to provide high-yield PEx teaching and overcome these limitations. Materials and methods Qualitative and quantitative survey feedback, including a standardised list of 62 clinical signs, was sought from final-year medical students during their rotations at a teaching hospital in London, UK, before and after the provision of Signs Circuits. Results Prior to the course the 63 students reported limited exposure to even the most common clinical signs. For example, the murmurs of mitral and tricuspid regurgitation and the sound of lung crackles eluded 43%, 87%, and 32%, respectively. From qualitative feedback, the reasons for this included that much of their prior PEx experience had focused on the performance of appropriate examination steps and techniques in patients without pathology. During the course, students were exposed to an average of 4.4 new signs, and left with increased confidence examining and eliciting signs, and a firmer belief in their importance to diagnosis. Conclusion Medical students continue to have limited exposure to clinical signs in medical school. This signs-focused approach to PEx teaching is an effective and reproducible way to counter the deficiencies identified in signs exposure.

Differential Impacts of the COVID-19 Pandemic on Mental Health Symptoms and Working Conditions for Senior and Junior Doctors in Australian Hospitals.

This study investigated severity, prevalence, and predictors of workplace disruption and mental health symptoms in Australian junior and senior hospital medical staff during the COVID-19 pandemic. A cross-sectional survey collected data on demographics, workplace disruption, personal relationships, and mental health. One thousand twenty-one (62.1%) senior and 745 (37.9%) junior medical staff, located primarily in Victoria, completed the survey. Work disruptions were common but varied by seniority, withjunior staff more frequently exposed to COVID- 19 (P < 0.001). Symptoms of anxiety, depression, post-traumatic stress disorder and burnout were common but significantly higher in junior doctors (P = 0.011 to < 0.001). Common predictors for experiencing mental health symptoms were identified, including prior mental health diagnoses and worsening personal relationships. COVID-19 has had significant but varied impacts on junior and senior doctors, with junior doctors particularly susceptible to harm to mental health. Interventions to safeguard hospital medical staff and prevent attrition of this important workforce are urgently needed.

A Model of Doctor-Patient Communication and Information Seeking a Study Among Trainee or Junior Doctors in Malaysian Hospital

The purpose of this study is to evaluate the doctors-patients communication style and their information seeking practiced among doctors under training or junior doctors in Malaysian hospital. Two types of communication styles evaluated are doctor centered and patient centered communication. Meanwhile, elements of information seeking practice evaluated are exploration of the reason for encounter, history taking, concrete solutions, structuring the interview, interpersonal skills and communicative skills. These six elements were categorized into interview skills and process skills. This information seeking skills have been derived from meta-analysis conducted by Stewart and Roter (1989). We combined the doctors-patients communication style and information seeking practice to develop a model based on four quadrants namely doctors-interview, doctors-process, patient-interview and patient-process. The subjects for this research are doctors under training or junior doctors in Malaysia. This explorative research distributed a set of questionnaires in order to collect data for analysis. The result show that the doctors under training or junior doctors tend to practice doctor-centered styles compare to patient-centered. Meanwhile, most of them demonstrate all the information seeking practice at a high level. Based on four quadrants developed by researcher, research shows that the doctors mostly categorized in doctor-centered communication style and interview information-seeking skills. We suggested that doctors should be more patient-oriented rather than doctor oriented. We also suggested the model that we developed can be used as a model of communication pattern of the doctors and can be used for future research.

‘…the way it was staffed during COVID is the way it should be staffed in real life…’: a qualitative study of the impact of COVID-19 on the working conditions of junior hospital doctors

ObjectivesCOVID-19 has prompted the reconfiguration of hospital services and medical workforces in countries across the world, bringing significant transformations to the work environments of hospital doctors. Before the pandemic, the...

Twelve-week project to improve medication reconciliation at hospitals in Wellington, New Zealand

Inaccurate prescribing of medications on admission to hospital exposes patients to significant risk, both during the admission and at discharge. Initial data at Capital and Coast District Health Board (CCDHB,...

Consequences of ineffective information and knowledge management (IKM) in hospitals: junior doctors’ perspectives

ABSTRACT Information and knowledge represent important organisational assets. In healthcare environments, patient wellbeing depends on effective management of these assets. This paper describes junior doctors’ perspectives of adverse consequences of ineffective information and knowledge management (IKM) practices. The research for this phenomenological study consisted of semi-structured interviews with ten junior doctors in public hospitals in Adelaide, South Australia. The reasons for ineffective IKM include limited access to information, inadequate clinical handover, inappropriate use of information systems, and incomplete documentation. Adverse medical events resulting from ineffective IKM practices include medication errors, delays in patient care or discharge, poor post-discharge care, confidentiality breaches, acting against patient wishes, disability or even death. Junior doctors regard health information systems and access to electronic patient medical records as important for improving IKM. Behaviour of staff often results in ineffective IKM and the paper suggests that an IKM-focused culture should be driven by hospital management.

Doctor Retention: A Cross-sectional Study of How Ireland Has Been Losing the Battle.

Background: The failure of some high-income countries to retain their medical graduates is one driver of doctor immigration from low- and middle-income countries. Ireland, which attracts many international medical graduates, implemented a doctor retention strategy from early 2015. This study measures junior doctors’ migration intentions, the reasons they leave and likelihood of them returning. The aim is to identify the characteristics and patterns of doctors who plan to emigrate to inform targeted measures to retain these doctors. Methods: A national sample of 1148 junior hospital doctors completed an online survey in early 2018, eliciting their experiences of training and working conditions. Respondents were asked to choose between the following career options: remain in Ireland, go and return, go and stay away, or quit medicine. Bivariate analyses and a two-stage multivariable analysis were used to model the factors associated with these outcomes. Results: 45% of respondents planned to remain in Ireland, 35% leave but return later, 17% leave and not return; and 3% to quit medicine. An intention to go abroad versus remain in Ireland was independently associated (P <.05) with the doctor being under 30 years (odds ratio [OR]=1.09 per year under 30), a non-European Union (EU) national (OR=1.54), a trainee (OR=1.50), and with hospital specialization, especially in Anesthesiology (OR=5.09). Respondents were more likely to remain if they had experienced improvements in supervision and training costs. Intention to go abroad and not return versus go and return was independently associated (P <.05) with: age over 30 years (OR=1.16 per year over 30); being a non-EU (OR=9.85) or non-Irish EU (OR=3.42) national; having trained through a graduate entry pathway (OR=2.17), specializing in Psychiatry (OR=4.76) and reporting that mentoring had become worse (OR=5.85). Conclusion: Ireland’s doctor retention strategy has not addressed the root causes of poor training and working experiences in Irish hospitals. It needs a more diversified retention strategy that addresses under-staffing, facilitates circular migration by younger trainees who choose to train abroad, identifies and addresses specialty-specific factors, and builds mentoring linkages between trainees and senior specialists.

Junior Doctor Evaluation of Radiation Oncology Education and Training in Medical Schools and Prevocational Training in Australia.

The purpose of this study is to evaluate radiation oncology (RO)-specific education, confidence and knowledge of junior doctors in Australian teaching hospitals. A 38-item web-based survey was emailed to prevocational junior doctors working in Australian hospitals in New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD) between November 2017 and January 2018. The survey evaluated RO educational and clinical exposure of participants during medical school, and prevocational training and their confidence and knowledge of the specialty. A total of 183 respondents across 17 Australian hospital networks completed the survey. During medical school, 53.4% had RO incorporated into their formal curriculum, 19.5% had no formal lectures and 51.7% had never visited a RO department. As a junior doctor, 73.8% of respondents did not receive any formal RO education. When compared with other oncology specialties, fewer junior doctors were confident in consulting the RO team (21.0%) compared with medical oncology (42.0%), palliative care (75.2%) and haematology (40.1%). Majority of respondents (61.6%) showed limited understanding of radiation safety. On multivariate sub-group analysis, both confidence and knowledge in RO improved when RO was incorporated into the formal medical school curriculum. This survey highlights the current low confidence and poor knowledge standard amongst Australian junior doctors on RO due to inadequate teaching during medical school and prevocational training and suggests improvement through standardisation of formal RO curriculum teaching within medical school and prevocational training.

Foundation Year Doctors need more support.

The introduction of new rotas, rota gaps, poor handover arrangements, the junior hospital doctors' strike, the imposition of a new contract after a four-year period of contract negotiation, the Bawa-Garba case, the abolition of the "Firm", poor rest facilities and bullying have all contributed to eroding the morale of junior doctors. The retention of newly registered doctors is falling. Recent evidence shows that in 2010 83% of Foundation Year 2's went straight into training compared to 38% in 2018. This study was undertaken to assess the extent to which the plans and intentions of current Foundation Year Doctors have been influenced by recent history. With the large volume of complaints and their associated costs on the NHS, the study included questions to identify whether junior doctors feel prepared to deal with the medico-legal issues.

Barriers to the implementation of exception reporting at a busy district general hospital.

One change implemented with the 2016 junior doctor contract was the advent of a system of exception reporting. This enables doctors to report either loss of educational opportunities or breaches of safe working hours (including working extra hours, inability to take breaks and unsafe conditions). The outcomes of exception reporting could include compensation (with time or pay), with the process enabling unsafe working conditions to be flagged up to relevant stakeholders. The novelty of exception reporting means that there is a paucity of data regarding uptake or improvement outcomes. One recent study from Barts Health NHS Trust explored this issue.1 The authors surveyed junior doctors within the trust and found that 35% had submitted an exception report, with 29% of respondents reporting being told not to exception report by their seniors. Following discussions with junior doctors, it was observed that the numbers of submitted exception reports might not reflect those anticipated, given known issues with staffing levels and rota gaps. Therefore, this study was designed to establish what percentage of eligible shifts are exception reported by junior doctors in a busy district general hospital, and the reasons behind any discrepancies in the observed pattern of exception reporting.

Barriers to effective, safe communication and workflow between nurses and non-consultant hospital doctors during out-of-hours.

This study aimed to evaluate the nature and type of communication and workflow arrangements between nurses and doctors out-of-hours (OOH). Effective communication and workflow arrangements between nurses and doctors are essential to minimize risk in hospital settings, particularly in the out-of-hour's period. Timely patient flow is a priority for all healthcare organizations and the quality of communication and workflow arrangements influences patient safety. Qualitative descriptive design and data collection methods included focus groups and individual interviews. A 500 bed tertiary referral acute hospital in Ireland. Junior and senior Non-Consultant Hospital Doctors, staff nurses and nurse managers. Both nurses and doctors acknowledged the importance of good interdisciplinary communication and collaborative working, in sustaining effective workflow and enabling a supportive working environment and patient safety. Indeed, issues of safety and missed care OOH were found to be primarily due to difficulties of communication and workflow. Medical workflow OOH is often dependent on cues and communication to/from nursing. However, communication systems and, in particular the bleep system, considered central to the process of communication between doctors and nurses OOH, can contribute to workflow challenges and increased staff stress. It was reported as commonplace for routine work, that should be completed during normal hours, to fall into OOH when resources were most limited, further compounding risk to patient safety. Enhancement of communication strategies between nurses and doctors has the potential to remove barriers to effective decision-making and patient flow.

Do peer review models affect clinicians\u2019 trust in journals? A survey of junior doctors

BackgroundThe aim of this survey was to determine the level of awareness and understanding of peer review and peer review models amongst junior hospital doctors and whether this influences clinical decision-making.MethodsA 30-question online anonymous survey was developed aimed at determining awareness of peer review models and the purpose of peer review, perceived trustworthiness of different peer review models and the role of peer review in clinical decision-making. It was sent to 800 trainee doctors in medical specialties on the University College London Partners trainee database.ResultsThe response rate was (178/800) 22%. Most respondents were specialist registrars. Checking that research is conducted correctly (152/178, 85%) and the data interpreted correctly (148/178, 83%) were viewed as the most important purposes of peer review. Most respondents were aware of open (133/178, 75%), double-blind (125/178, 70%) and single-blind peer review (121/178, 68%). 101/178 (57%) had heard of collaborative, 87/178 (49%) of post publication and 29/178 (16%) of decoupled peer review. Of those who were aware of double-blind, single-blind open and collaborative peer review, 85 (68%), 82 (68%), 74 (56%) and 24 (24%), respectively, understood how they worked. The NEJM, Lancet and The BMJ were deemed to have most trustworthy peer review, 137/178 (77%), 129/178 (72%) and 115/178 (65%), respectively. That peer review had taken place was important for a journal content to be used for clinical decision-making 152/178 (85%), but the ability to see peer review reports was not as important 22/178 (12%). Most felt there was a need for peer review training and that this should be at the specialist registrar stage of training.ConclusionsJunior hospital doctors view peer review to be important as a means of quality control, but do not value the ability to scrutinize peer review themselves. The unquestioning acceptance of peer review as final validation in the field of medicine emphasises not only the responsibility held by medical journals to ensure peer review is done well but also the need to raise awareness amongst the medical community of the limitations of the current peer review process.

Twenty-five years on: outcomes of a longitudinal evaluation of the NSW Rural Resident Medical Officer Cadetship Program

The New South Wales Rural Resident Medical Officer Cadetship Program began in 1988 as a strategy to increase the numbers of junior doctors in rural hospitals. This article outlines the results of an evaluation undertaken in 2014. Specifically, it will look at where former cadets who entered the program between 1989 and 2010 were working in 2014, what training programs they chose and their attitudes toward the program. Data were collected using a semi-structured questionnaire sent to all the former cadets who entered the program from 1989 until 2010. This included self-administered questions relating to background (where the majority of the students' primary schooling was undertaken), vocational training, current role, current work location and attitudes towards the cadetship. Responses were received from 142 of the 211 cadets in the study (67%). Of the 142 former cadets who responded to the questionnaire, 90 had completed a vocational training program and were working as fully qualified medical practitioners. A further 44 were trainees, six were non-specialist hospital doctors and two were no longer practising. Overall, the most popular vocational training programs among fully qualified doctors and trainees combined were general practice, anaesthetics/intensive care and emergency medicine. Over half of the cadets included in the analysis (<i>n</i>=74, 53%) were working in rural areas (Australian Standard Geographical Classification Remoteness Areas 2-5) in 2014 and practice location was significantly (<i>p</i><0.001) influenced by career choice. Of the cadets working in rural locations, the majority (58%) were working as general practitioners while 38% had chosen other specialties and 4% were working as hospital non-specialists. An equal proportion of cadets came from urban and rural backgrounds while a small proportion grew up overseas. The cadets with rural backgrounds were more likely to choose general practice than those from urban backgrounds. A similar analysis of cadets comparing geographic background and practice location showed cadets of rural background were more likely to be working in a rural location than cadets of urban background. The cadetship is an effective link between medical school and rural practice. The success of the program relies in part on the mentoring, networking and other educational opportunities available to cadets, which serve to foster their interest and provide a structured pathway to long-term rural practice. It has been demonstrated that targeted incentive based scholarship schemes with a return-of-service component can be beneficial, particularly where they include ongoing support and reinforcement throughout the transition from undergraduate to postgraduate training.

Substance Use Disorders Among Danish Physicians: An Explorative Study of the Professional Socialization and Management of Colleagues With Substance Use Disorders.

This study has 2 aims. Firstly, we explore and analyze the associations between physicians' unhealthy substance use and various work-cultural and social aspects; secondly, we describe how substance use disorder (SUD defined as by Alcohol Use Disorders Identification Test [AUDIT] and Drug Use Disorders Identification Test [DUDIT]) among colleagues is managed and how physicians seek help. During the spring of 2014, a nationwide cross-sectional study was conducted as an anonymous electronic survey among a randomly weighted sample of medical specialists, junior hospital doctors, and general practitioners in Denmark. A total of 4000 physicians (approximately 1333 from each group) were sampled, and 1943 responded (49%). The survey included the AUDIT, the DUDIT, and questions on health and psychological issues. Among the physicians in our study, 18.3% had an AUDIT exceeding 8 (hazardous or harmful alcohol use) and 3.2% had a DUDIT exceeding 1. Of these, 12.9% reported that their substance use had negative consequences for their social networks, and 34% to 42% reported no openness about substance use at their workplace. In total, 4 physicians (1%) of the 383 physicians with risky substance use reported to have been in regular treatment for SUDs. Most of the physicians with an unhealthy consumption of substances (78%) reported that it was irrelevant for them to seek help. Half of them reported that they had limited or insufficient knowledge of SUD. Around 55% of the physicians would encourage colleagues with SUDs to seek treatment. Around 50% of physicians reported that their "SUD knowledge" was relevant, but limited or not satisfactory. One-third never experienced openness about SUD at work. More than half wished to encourage a colleague with SUD to seek treatment. Three quarters of the physicians with unhealthy substance use reported that they found it irrelevant to seek help.

Awareness of clinical coding: A survey of junior hospital doctors

Background: Clinical coding is an integral part of the NHS and is one of the main methods of gathering clinical data. Since the introduction of payment by results (PbR) in 2004 there has been an increasing emphasis on gathering good quality data to ensure hospitals are being remunerated accurately based on their workload. Method: We conducted a survey of 100 junior doctors looking at their knowledge and awareness of clinical coding. Results: Only 39% of doctors had attended a recent induction programme, and over half felt they knew little to nothing of the clinical coding system. A questionnaire of the coding system highlighted that neither the time since induction nor a self-assessment of knowledge made any difference to the questionnaire score. Conclusion: There is insufficient engagement of junior doctors with the clinical coding process and widespread attitude changes are needed to change this.