Tag Archives: Competence

Surgical spirit: what the surgeons think of their ePortfolio

An article published recently in the Journal of Surgical Education looks at the experience of surgical trainees and their ePortfolio. As a Medical Registrar I am in danger of being disowned by my colleagues for suggesting that we may be able to learn something from the surgeons! But in relation to ePortfolio use, many parallels can be drawn between the experience of surgical and physician trainees.

The surgical ePortfolio (ISCP) became mandatory for British surgical trainees 5 years ago, with a compulsory £125 annual fee. In 2008 widespread dissatisfaction was reported. This article (by Pereira and Dean) surveyed 359 users across all specialities and geographical areas. Although ratings improved between 2005 and 2008 trainees were underwhelmed overall. Unfortunately the article is not open access, and is behind a paywall, so I have selected some quotes for discussion below.

My love don’t cost a thing (but my training does….):

“An evaluation by ASiT estimated conservatively the upward spiralling costs of surgical training to the trainee to be £130,000 even before the introduction of MMC, with ISCP and its mandatory annual fee amounting to an additional £1000 over 8 years of surgical training.”

No medic would claim to be poorly paid, but there must be honesty and transparency with regard to the significant financial burden placed on trainees. This is likely to become more pressing as graduates leave medical school with escalating debts. Value for money is high on the agenda.

The current cost of the physician ePortfolio is only £18 per trainee per year, but perhaps this needs review, especially in the context of calls for investment to improve functionality. Trainees have a poor understanding of the costs of training and there is a disconnect between payment of JRCPTB fees and any visible outcomes in terms of education and training. Surely a lesson for all Colleges and higher bodies is that greater engagement and consultation with trainees could help prevent widespread and growing resentment.

A teacher affects eternity; he can never tell where his influence stops 

Sir William Osler, a great clinical teacher

“..incentive for trainer and assessor engagement remains lacking. It is important that trainers are properly recognized and rewarded for the time that they spend assessing and supervising trainees if obliged to use increasingly time-consuming methods, and we would welcome any system that encourages them.”

We must spare a thought for the Consultants who are striving to support us in our professional development. Demands on their time come from all directions and, unfortunately, postgraduate education and training is often the thing that loses out and gets pushed to the bottom of the mounting to-do pile. The system needs to reward and encourage senior clinicians so that they make time to give high quality feedback to trainees during WPBA completion. But this is a long term aim that feels intangible and unattainable. In the short term, reducing the time it takes to complete WPBA paperwork will make everyone happer. An app seems the quickest way to achieve this.

A call for EBT: Evidence Based Training

“Recently the JCST has specified a minimum of 40 WPBAs per year to be completed as a ‘quality indicator’ for surgical training and career progression…Regional training programs have set directives for mandatory WBAs per annum, ranging from a minimum JCST dictat of 40 to the 80 required in London. These present a great challenge upon time available to any practicing surgeon.”

“…a recent systematic review that includes our first survey suggests that there is no evidence that they [WPBAs] improve physician performance. It goes on to conclude that multisource feedback may be helpful, but that individual factors, context of feedback, and presence of facilitation (ie mentoring) may improve trainee responses.”

These sentiments will sound familiar to physicians, many of whom also feel frustrated at the widespread adoption of WBPAs, for which there is limited evidence of value for trainees in the real world. Valid concerns have been raised about the difficulties of applying theoretically helpful frameworks and tools to the realities of clinical life, and it is unclear where the numbers set by training boards have come from.

“ISCP has improved its interface, but it and other electronic portfolios deliver an increasingly overwhelming bureaucratic burden of WBAs and domains of evidence to include in a portfolio. These have rapidly become entrenched in postgraduate physician training in the UK, spreading a plague of box-ticking exercises that continue to increase year on year….It is of particular concern that so many trainees (80%) felt that ISCP did not improve their training after a modal average of over three years using it.”

Again these feelings will be familiar to many of those who have commented on this site and engaged with the debate on twitter. Time is precious. Many feel that the current demands on trainees, coupled with inadequate technology, steals  it away from busy trainees and trainers.

Perhaps it is time to ask the question, who is the ePortfolio for? Is it a learning tool for trainees? Is it an evidence vault for Royal Colleges to check off competencies of registered members? It is unclear to me what the aims of the NHS physician ePortfolio was at its inception. Has this been reassessed as it has expanded and evolved? These is great potential to improve the ePortfolio so that it serves the needs of trainees, trainers, assessors and higher bodies better. We have an opportunity to seek clarification and contribute to making the aims and expectations explicit. Let’s not let it pass us by.

The authors of the paper conclude:

“The performance of ISCP has improved in the 4 years since its inception with proportionately less negative feedback. British surgeons remain dissatisfied with several of its tools, in particular its workplace-based assessments. Half a decade on, these assessments remain without appropriate evidence of validity despite increasing demands upon trainees to complete quotas of them. With reduced permitted training hours, the growing online bureaucratic burden continues to demoralize busy surgical trainers and trainees.”

These conclusions should ring alarm bells not only for the Royal Colleges, but for the wider community of healthcare leaders. The NHS faces many challenges, and a demoralized workforce will struggle to face them. Physician and surgical trainees feel overburdened and undervalued. The system needs to change. Who will lead this change? And where will the ePortfolio fit in? Answers on a postcard…..

E.A. Pereira B.J. Dean.British SurgeonsExperiences of a Mandatory Online Workplace Based Assessment Portfolio Resurveyed Three Years On. Journal of Surgical Education. J Surg Educ. (2012) doi: 10.1016/j.jsurg.2012.06.019

A. Miller, J. Archer Impact of workplace based assessment on doctors’ education and performance: A systematic review. BMJ, 341 (2011), p. c5064

E.A. Pereira, B.J. Dean British surgeons’ experiences of mandatory online workplace-based assessment J R Soc Med, 102 (2009), pp. 287–293

S.A. Welchman Educating the surgeons of the future: The successes, pitfalls and principles of the ISCP. Bull R Coll Surg Engl, 94 (2012) online

W.C. Leung. Competency based medical training. Review, 325 (2002), pp. 693–696

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Competency: necessary but not sufficient

This site is primarily a forum for highlighting limitations and frustrations with technical aspects of the the NHS ePortfolio. However, inevitably the discussion often broadens to problems with the ethos of training, or how it is perceived, and specific problems with the tools currently used to assess trainees. I was pointed in the direction of this paper by Dr AnneMarie Cunningham via Twitter. It highlights some of the issues with respect to the limitations of competency-based assessment of complex professional abilities.

A few points that struck a chord were:

* Competence does not necessarily predict performance

The sum of what professionals do is far greater than any parts that can be described in competence terms

* How do we assess “trustworthiness?”  –>  otherwise known as “the granny test”? The question “would you trust this doctor to care for your unwell grandmother?” may be a better test of trainee progress than any competency test

* The idea of trust reflects a dimension of competence that reaches further than observed ability. It includes the real outcome of training—that is, the quality of care

*  Innovation of postgraduate training should focus on expert appraisal of performance in practice

I hope that those responsible for postgraduate training engage trainees and ensure any future changes are; appropriate, of benefit to trainees and trainers, are evidence-based and “real-world tested.” A common theme from trainees is that current training is tick-box, uninspiring and lacks true mentor/mentee relationships. Olle Ten Cate’s paper contributes to this debate by highlighting the concept of trust and the complexity of assessing professional activities.

Postgraduate training can be better. But it requires enthusiastic mentors who are given the time, support, and freedom to educate and inspire the next generation of doctors.

The Bigger Picture

The NHS ePortfolio started as a local pilot project. It’s use was then expanded and expanded. There was no budget for this, and no vision for how trainees might want it to look and feel. It fulfills it’s purpose, is functional and allows trainees to record meetings and assessments. But is “functional” really good enough?

Here are some quotes from the ePortfolio site, and the JRCPTB (who fund the Physician version):

The NES (NHS Education for Scotland) ePortfolio has grown rapidly since its inception in August 2005 and now comprises over 20 versions for over 35,000 healthcare trainees within Scotland (Nursing, Midwifery, Dentistry and Pharmacy), across the United Kingdom (Medicine), and The Republic of Ireland (Medicine).

This ePortfolio is designed to support learning by providing a secure record of appraisal discussions, an ongoing personal development plan, workplace assessments plus reflection on clinical and other learning events. The ePortfolio links to the relevant GMC approved curricula appropriate to your stage of training.

The ePortfolio is designed to help gather and organise evidence in a way that is trainee centred and user friendly. The emphasis for this is on you as the trainee with support from your supervisor.

If the emphasis is on the trainee to gather and organise evidence, then the emphasis should be on the trainee to determine how that is done. There has been a lack of investment in the ePortfolio which has resulted in the current slow, unimaginative, frustrating version. This needs to change. As trainees we need to demand more.

Direct feedback to developers is needed to bring about improvements in day to day usability. Feedback to Royal Colleges etc is needed to communicate the need for investment in the overall structure and function of the system. We need an app and we need an overhaul of how the ePortfolio works in order to encourage trainee  and supervisor engagement. There is no obvious way in which this feedback can be given, hence this site….

Practice what you (aspire to) preach

What I don’t think the Colleges etc realise is that the ePortfolio is the only concrete thing we see as a result of handing over large amounts of money in JRCPTB fees.  Therefore in surveys it is said to be “poor value for money.”

Even more importantly the ePortfolio itself is a reflection of how training is currently viewed. It feels to many that we are aiming for competence – how uninspiring! What happened to striving for excellence? What happened to valuing the diversity and individuality of talent and interest amongst trainees? What happened to mentorship? Many trainees feel like just a number on a rota spreadsheet, getting through the day, jumping through hoops for assessments that often become tick-box exercises of no educational value. Of course competency in the required knowledge and skills is essential, but competency is a MINIMUM requirement. It often feels that this is all that is expected. Many trainees do extraordinary things but their supervisors and deaneries would never know this. One trainee’s portfolio looks just like any others, the only difference being whether they have done 6 mini-cex’s or 7.

If we want to inspire excellence, we need to show this in everything we do, and in every system we create. Trainees need a system that allows them to not only demonstrate that they have reached the minimum standard to progress, but that they are so much more than the sum of a few WPBAs. They need to be proud of their portfolio. Currently the system is failing them, with the danger of producing uninspired, undervalued, underachieving, burnt out doctors. Bad for trainees, bad for Trusts, bad for patients.

Time for a fresh look at what we expect of trainees, and what trainees can expect of the system.