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 Surgeons‘ Experiences 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