Tag Archives: postgraduate

Shape of Training – influence the next 30 years of medical training!

You have only days left to shape medical training for the next 30 years.

The Shape of Training review aims to plan how doctors should work and train in the next 30 years. This is your chance to directly tell decision-makers what you want postgraduate training to look like.

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  • Should we have more generalists and fewer specialists?
  • Should there be a speciality of General Internal Medicine (distinct from Geris)?
  • Should all medical trainees CCT in GIM before starting speciality training?
  • Should more specialities dual-accredit and therefore contribute to the acute take (hello Rheumatology, Dermatology, Renal, Oncology……)?
  • Should F2 be abolished?
  • Is training flexible enough?
  • How can trainees be supported to learn from their experiences?  
  • Is the balance right in the current system between training and service provision?

I have strong views on many of these questions (the answer to the last one is NO!)

“This review takes place in a rapidly changing environment. Medical and scientific advances, evolving healthcare and population needs, changes to healthcare systems and professional roles, the push towards more care provided in the community, the information and communications technology (ICT) revolution, and changing patient and public expectations will all affect how doctors will practise in the future. We therefore need to consider what these changes mean for the way doctors are trained.”

The survey is long, but is so important that it’s worth the effort. I recommend you put aside some time, make an extra large cup of tea, and really dedicate some brainpower to your answers. This is the best chance you will ever have of influencing the shape of medical training. Don’t let it slip through your fingers.

In particular I would consider mentioning your views on WPBAs and the ePortfolio in questions

  • 13: How do we make sure doctors in training get the right breadth and quality of learning experiences and time to reflect on these experiences?  (Better software in which reflection could be logged on the go, and reflections could be tagged and organised/visualised/shared more flexibly would help. Time spent with mentors instead of filling in paperwork would also be great)
  • 14: What needs to be done to improve the transitions as doctors move between the different stages of their training and then into independent practice? (Interoperability of ePortfolio systems would be a start)
  • 18: Are there other changes needed to the organisation of medical education and training to make sure it remains fit for purpose in 30 years time that we have not touched on so far in this written call for evidence? (yes…..)

Go on. Respond… 

Acronym Soup: RCP, JRCPTB, WPBA, SLE, AoP, AoMRC ATDG

The Royal College of Physicians

This week I met with the Royal College of Physicians in London to discuss the NHS ePortfolio. After the many discussions I have had with trainees and trainers on this blog, on Twitter and in person I felt well prepared. I was sure the RCP should be taking a keen interest in the ePortfolio and it’s place in the wider context of Postgraduate Education, and through some brief email conversations I felt we were likely to have common ground. But as I walked through the falling leaves of Regent’s Park, I wondered what they would make of me and my graffiti-decorated blog…

It would have been unrealistic to expect to leave the meetings with all the answers, but I truly believe we have taken the first step towards a better solution. There are lots of details to work out, and I found myself discussing things like commissioning and procurement – yet another new language to learn! What was so positive was that there was an acknowledgement that trainees (and trainers) are dissatisfied with the ePortfolio, and that the concerns being raised are not idle complaining, but are educationally valid.

This is an important issue because it affects thousands of doctors, and because it relates to other areas of Postgraduate Training. The RCP wants to support trainees in their professional development and acknowledge that the ePortfolio is part of this process. There is also a realisation that technology has moved on, that the ePortfolio was not future-proofed, and that it is important to take stock and think about how to move forward. Financial contraints will impact on these plans and we need to be both realistic and imaginative in our decision making. The fact that the new RCP revalidation tools for Consultants have no interface or link with the trainee ePortfolio is another example of a lack of joined up thinking which we must avoid in future.

I was happy to hear that the RCP have almost finalised the details of the new ePortfolio User Reference group, which will have several trainee representatives. Hopefully this will not only impact on decision making, but also improve communication, so that we don’t in future have changes appear with no warning. It was also encouraging to hear more about the research being done on WPBAs/ SLEs. The RCP are putting considerable time and resources into reviewing the use and utility of WPBAs and the results of this research is likely to have a significant impact on the assessment systems for all medical specialties and shape training for the next 10 years. This is a great opportunity to engage with the College and have a real impact on Postgraduate Training.

There are many questions that do not yet have answers, in particular the question of funding and commissioning ePortfolio systems in the future. All doctors have a core set of common needs and I believe it is essential that we define these together and press for collaboration across Colleges, and open-ness in every part of the process.  The Trainee Roadmap is a first attempt at this, and I encourage you to contribute. The RCP seem to truly be putting trainees’ needs at the heart of what they do, and are (slowly) responding to the concerns of the thousands of you who have visited this site. But the structures of these organisations are complex and my attempts to find a way through the committees and funding streams of the RCP, the JRCPTB and others is already bringing on a headache.

We need to make sure this stays at the top of the agenda for the College, and I look forward to follow-up meetings in the future. I hope the other Colleges are watching, and are considering their own strategies. Otherwise they may find their trainees asking questions they can’t answer….

The Academy of Medical Royal Colleges Trainee Doctor Group

Coincidentally, in the same week I also went to give a presentation at the AoMRC ATDG (seriously, the number of acronyms in the world of medical education is mind-boggling).

There were many nods of assent as I described my frustrations with the current ePortfolio, and the demands placed on trainees and trainers to complete activities with little educational value. The representatives at the ATDG come from a wide spectrum of specialities including O&G, General Surgery, Anaesthetics and Intensive Care, Emergency Medicine, Pathology, General Practice, Ophthalmology, Psychiatry, Radiology and Medicine. Various ePortfolio systems are used by these trainees and some, such as the Haematologists, have to use two systems which, of course, do not talk to each other.

There was also great enthusiasm for sharing information, and for collaboration across Colleges. There was agreement that there are common needs for tools that support learning and professional development, capture workplace learning, log assessments, and provide evidence for appraisal. These needs are shared by doctors of all specialities and span the start of FY1 to retirement (in fact, since four UK medical schools use the NHS ePortfolio, these needs span Undergraduate as well as Postgraduate training). Technical aspects were touched on, and some absolutes were identified: such as a single sign on for all systems; a set of core standards for any ePortfolio used by doctors; and the need for flexibility for Colleges/Specialities and individuals. There was enthusiasm and hope for a future in which there is a simple but flexible ePortfolio system, with mobile support, that truly supports learning, and that makes people smile not scream when they login!

This committee is unique in bringing together trainees across specialities. It’s also full of lovely and enthusiastic people. The representatives are going back to their respective College trainee groups to gather information on what systems are used, and what trainees think of them. I hope we can then finalise a Trainee Roadmap and Core Requirements document, that will help us move forward.

Watch this space!

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

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.