Recent changes in medical training prompted by Modernising Medical Careers and the New Deal requires a more structured, competency based training programme. This paper describes the development of such a programme in an emergency medicine department of a teaching hospital. It describes the process of design and the various aspects incorporated to develop a balanced system of training, appraisal, and assessment.
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Recent years have seen significant changes in the approach to training the junior doctor.1 The principles underlying the Modernising Medical Careers (MMC) initiative along with changes to junior doctors’ working hours necessitate a more structured approach to senior house officer (SHO) training.1–3 Carr1 has already raised concerns that a full-shift working pattern combined with the reduction in working hours may lead to increased intensity of work and more fatigue.1 This may then lead to less time at work for reflective learning and informal learning from peers.1 The response to these issues should be the development of structured, supervised and well organised training.4,5
Emergency medicine departments have traditionally provided an environment rich in clinical material and exposure but often lacking in training frameworks with incorporated appraisal and assessment.6 In this article we outline a competency based training programme for SHOs in emergency medicine.
DESIGNING A NEW TRAINING PROGRAMME
MMC calls for a greater emphasis on trainee appraisal and ongoing assessment.3 The ultimate aim is to promote broad based training with no more than four months spent in each post within a streamed Foundation programme, although initially some posts will be six months long.3 Junior doctors will be expected to have demonstrated core competencies to progress from Foundation training. A core, generic list of competencies will be produced by a central working group. There will also be central guidance relating to the assessment of trainees.
In recognition of the changes ahead it is important that emergency medicine prepares by designing a competency based training programme. The programme in Tayside caters for 18 SHOs, who work on two sites in Dundee and Perth. The service in Dundee has 50 000 new patients per annum and includes an eight bedded short stay ward. The department in Perth has 25 000 new patients per annum. There are six consultants, six full time specialist registrars (SpRs), and one full time and one part time staff grade.
The SHO training programme is run in Dundee and was redesigned over a period of two years with the aim of providing a framework for appraisal and assessment. The redesign was developed jointly by the Accident and Emergency Department (A&E) and the Clinical Skills Unit of Ninewells Hospital, Dundee. This was undertaken by a Consultant in Accident and Emergency and the Director of the Clinical Skills Unit, along with two of the senior SpRs in A&E. Training objectives were related to recommendations for good medical practice issued by the General Medical Council7 (GMC) and the core practical competencies and teaching curriculum agreed by the development group.
The process of developing the programme was based on the assumption that the trainees are adult learners. A formal, structured teaching programme was developed in conjunction with attempts to structure experiential learning according to the steps described by Kolb.8 As such it was expected that the trainees were committed to participating in learning opportunities. Time was protected for teaching, with trainees given three hours of protected time each week during which small group tutorials and SimMan (see below) sessions were scheduled. The trainee should feel supported, have access to a mentor outwith scheduled teaching, and have the opportunity to reflect on their practice. The development involved the following steps:
Defining endpoints for junior trainees
Structuring and developing teaching modalities
Promoting reflective practice
Developing assessment tools
Defining endpoints for emergency medicine training
Central to the process of redesign was the definition of endpoints for emergency medicine junior trainees. These included the following:
SHO training objectives specific to their time in emergency medicine and related to recommendations for good medical practice issued by the GMC (table 1).7
Clinical curriculum listing core subjects to be covered by small group tutorials and hence the core knowledge base expected by the end of training (table 2).
Core practical competencies to be adequately demonstrated by SHOs either on patients or during simulated sessions:
Basic airway management
Basic life support
Advanced life support
Wound description and management
Reduction of dislocation/fracture
Administration of sedation and analgesia
Description of x ray findings
A programme of small group tutorials covered the topics outlined in the clinical curriculum. Tutorials were designed to be as interactive as possible and include practical skills based sessions. These were led by emergency medicine consultants and middle grade staff as well as selected external speakers. Each session was built around defined learning outcomes.
Observed clinical practice
Clinical practice was observed formally and informally. For the majority of trainees clinical practice was observed informally through interaction with senior staff in the clinical setting. A trainee completed, under supervision, the core practical competencies identified in the learning contract. Formal observed clinical practice involved the allocation of a trainee to a member of senior medical staff for a prescribed period. This period provided the opportunity for the trainee to observe an experienced practitioner and for the trainee’s clinical capabilities to be assessed. The sessions aimed to cover common presentations and practical procedures. Our previous experience of formal observed practice of all trainees within the department showed it to be difficult to sustain because of demands on senior staff time. For this reason we reserved this teaching modality for SHOs whose progress had been identified as borderline or unsatisfactory.
Simulated resuscitation (SimMan) teaching
Within the training programme each trainee took part in six simulated resuscitation sessions composed of 10 teaching and two assessment scenarios. Life support teaching has long been a part of emergency medicine training. The use of higher fidelity training mannequins, such as Laerdal’s SimMan (Stavanger, Norway), allows more complex and demanding scenarios to be developed.9 We instituted multidisciplinary teaching scenarios that allowed junior doctors and nursing staff to interact in a simulated setting. The emphasis was on initial assessment, early identification of critical illness, interpretation of clinical data, and instituting appropriate therapy. An observer with knowledge of the sessions learning outcomes evaluated the trainee’s performance. The trainee was provided with immediate feedback and debrief aided by analysis of a computer based event log.
Promoting reflective practice
A majority of junior doctor learning occurs through clinical experience and reflection on that experience. By promoting reflective practice the doctor in training is encouraged to identify and meet learning needs, accumulate meaningful evidence of relevant learning and record and monitor their professional development.1,10
The introduction of a system of mentoring provided a point of contact for both trainee and trainer. Each SHO was allocated a consultant and a specialist registrar to act as mentors. Two formal meetings with both mentors were scheduled during the training programme. A checklist to monitor progress during the training post guided these meetings. Mentoring provided a forum for the early identification of problems and a mechanism by which these could be addressed.11
As part of a NHS Education for Scotland initiative, each SHO was provided with a training portfolio, which acted as a progressive training record. This included an initial self-assessment checklist, an educational training agreement, and record of significant events, interesting cases, and educational activity. SHOs were encouraged to update this record regularly. This provided a reference for the record of in-training assessment (RITA) process and gave the junior doctor a valuable resource outlining their career progression.
Significant event analysis, case presentation, and audit
Within our training framework significant event analysis, case presentation and audit was used to highlight learning points from clinical practice. SHOs were required to record significant events from their clinical experience, identifying the nature of the incident and contributing factors. This was used in discussion during mentor meetings to reflect on experiences and identify further training and educational needs. During their post each SHO was required to present an interesting case as part of the teaching programme.
Each SHO was expected to participate in one of six established key departmental audits. Their involvement was supervised by their mentors and results were periodically presented at departmental meetings.
Appraisal and assessment
Meaningful assessment of a junior doctor’s professional development during a short post was challenging. The use of a range of assessment and appraisal tools allowed the construction of an objective view of progress. The RITA framework allowed this information to be drawn together for feedback to the SHO. The assessment framework is outlined in fig 1.
OSCE and simulated resuscitation
As SHOs commencing a post in A&E often have a varied experience base, an initial computer based OSCE was used to identify learning objectives and training needs. A second OSCE was completed at the end of the post to assess progress. In addition to this, the doctor’s performance of a standardised simulated resuscitation using SimMan was assessed.
Multisourced feedback (peer review questionnaire)
After four weeks in post each SHO was appraised by peer review questionnaires. These were completed by a consultant, specialist registrar, nurse and a fellow SHO. Results were reviewed during the first mentor meeting and the process was repeated before completion of the post. The aim was to distil as much opinion as possible regarding the doctor’s performance in the workplace. Feedback allowed identification of strengths and weaknesses and provided motivation for change. Ramsey and colleagues indicated a minimum of 11 responses were required for formal assessment of a trainee.12,13 In its current form the peer review questionnaire had four respondents per trainee and is used as a screening tool to identify potential problems.
This form of assessment appeared to be particularly useful at appraising “soft skills” such as communication, and multidisciplinary teamworking. It provided objective evidence that usually backed up subjective experience of a trainee’s performance. Within the department, this process had been shown to allow the early identification of problems that were then promptly addressed with a demonstrable improvement in performance.
The introduction of the MMC initiative challenges the traditional approach to the training of junior doctors.3 The emphasis on the provision of acute care as part of the Foundation curriculum3 means emergency medicine has the opportunity to develop a key role. However, as a result of shorter specialty rotations, training will need to be more structured and focused to individual training requirements.1–3 In addition to this a robust system of appraisal and assessment is required to demonstrate competencies and monitor professional development.1,3
The programme described has been developed to test the competence of junior doctors in all areas detailed in Good Medical Practice.7 These include training and assessment in core clinical knowledge, core practical skills, communication skills, teamworking, reflective practice, teaching, and audit. It represents a drawing together of a number of educational initiatives currently under evaluation. It has been possible to implement this training model with minimal disruption to the working of the department but it relies on there being sufficient numbers of senior staff to supervise trainees adequately.6 Meaningful appraisal can only be delivered if trainers have the necessary time and skills. It is also essential to have adequate administrative support to manage the paperwork generated by the increased amount of assessment. These are required if good quality programmes are to be developed as MMC is rolled out.
Managing poor performance has recently been highlighted as a priority for medical training.14 To achieve this, specific weaknesses need to be identified at an early stage and mechanisms provided to address them. The strength of the “Dundee Model” lies in the definition of learning endpoints, a structured pathway of training, and its use of feedback from multiple sources. It tests a breadth of competencies and provides objective evidence to inform assessment of junior trainees. It was designed to conform with educational theory7 in order to produce a valid programme.
Many of the principles identified in this training programme are likely to be developed at a national level.3,15 These will centre on generic competencies for Foundation doctors. It would be valuable if the specialty of Emergency Medicine could develop its own ideal model of training. This would provide trainees with a more focused experience at a point when they will spend less time within the specialty. This should meet the desire of the UK Strategy Group of MMC to see training that is trainee centred, competency assessed, serviced based, flexible, structured, and streamlined.3
Competing interests: none declared