Transcript Managing transitions and risk in medical education

Managing transitions and risk in
medical education, training and
development
A regulatory perspective
Paula Robblee, Policy Manager, Education
‘Life is pleasant. Death is peaceful.
It's the transition that's troublesome.’
-Isaac Asimov
‘If you have enough information to
make a decision, you're too late.’
-Bill Gates
Overview of presentation
Why do we care about transitions in medical education,
training and development?
Transition and risk– implication from research
What are we doing about transitions and risk?
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Standards and outcomes
Supervision and support
Transfer of information
Streamlining and aligning processes
Strengthening local systems
Embedding professionalism
Our function as a regulator
Our purpose is to protect,
promote and maintain the
health and safety of the public
by ensuring proper standards
in the practice of medicine.
Education
Register
Standards Fitness to
Practise
Journey from medical student to consultant/ GP
Provisional registration
Medical School
(4-6 years)
Student
(not registered)
Full registration
F1 year
(1 year)
Certificate of completion of training (CCT)
F2 year
(1 year)
Specialty/GP
training
(3-8 years)
Employed, in training, registered and licensed by GMC
Specialist/GP
register
(to
retirement)
Employed,
registered, licensed
Why do we care about transitions?
 Changes in patterns of healthcare
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Changing patterns of morbidity and mortality
Shared decision making and self-care; Informed patients
New biomedical advances and technologies
Multi-disciplinary working, professional demographics
Quality data driving improvement
 Changes to the way we regulate
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Merger of GMC and PMETB April 2010
Reviews of the Working Time Directive and the Foundation
Programme
Government initiatives
Divergence in healthcare systems across UK
 The world at large
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Difficult financial climate
Globalisation alongside move towards localism
Social networking
National Training Survey 2010 – Key Findings
79% rated the quality of experience in their
current post as good or excellent, compared
with 77% in 2009.
77% said their current post would be useful
for their future career, compared with 76% in
2009.
58%
foundation doctors felt they were
adequately prepared for their first job.
56% (n=12,694) of foundation stage
doctors said rarely or never felt forced to
cope with problems beyond their clinical
competence or experience.
Perceptions of training by trainees
‘My current training is fine. I’m working with
professionals whom I respect, even if they don’t hold my
hand on ward rounds. Sometimes there are problems
and sometimes it is all hugely frustrating and
disheartening. Most of the time we just get on with it all.’
‘I do not feel that my F1 year (not just this post, but all
three) has been a training post. The emphasis is on
service provision’.
-National Training Survey 2010
Research about transitions in medical education and
training
Preparedness of medical graduates
Transitions to new roles of responsibility
Transitions into the UK workplace by doctors trained
outside the UK
Doctors working in roles with lots of transitions eg
locums
Preparedness of medical graduates
Graduates looked forward to ‘being a doctor’.
While communication is a strong area at graduation, F1s
were under-prepared for some complex communication
tasks.
Other clinical skills are well practised, but not in contexts
which sufficiently mimic the clinical environment.
Knowledge of non-clinical areas such as legal and
ethical issues, and the operation of the NHS, was lacking
at the start of F1.
Prescribing was a significant area of underpreparedness.
-Dr Jan Illing et al: How prepared are medical graduates to
begin practice? (2008)
Transitions to new roles of responsibilities
Learning by trainee doctors during transitions within
the workplace focused on patient-centred aspects
Other learning, such as relationships with colleagues,
processes and practical issues were ignored.
Trainee doctors in transition tended to underperform
(and expected to underperform) at the start of new
clinical rotations.
Colleagues recognised this gap but employers and
regulatory bodies did not acknowledge times of transition
in their expectations of doctors’ performances.
Inconsistent monitoring and support for these doctors
while they tried to integrate into their new roles and
responsibilities.
-Trudie Roberts et al. Learning Responsibility? Exploring
doctors' transitions to new levels of medical responsibility
(2009).
Transitions to new roles of responsibilities
Rates of prescribing errors in hospitals – looked at 124,260
medication orders across 19 hospitals.
11,077 contained errors, an error rate of 8.9%.
Of the total orders checked, 50,016 were written by Foundation 1
doctors, an error rate of 8.4%. Potentially lethal errors were found in
fewer that 2%.
The highest error rate (10.3%) was in Foundation 2 doctors.
A lack of recognition of a ‘safety culture’ in respondents’ discourses of
their prescribing errors, the reported culture of their working
environments, and the reported actions of other doctors.
Doctors relied heavily on pharmacists and nurses to identify and
correct errors.
FY1 trainees were often inadequately supported when prescribing,
particularly on-call and during ward rounds.
-Tim Dornan et al. An in depth investigation into causes of
prescribing errors by foundation trainees in relation to their
medical education (2010).
Transitions to new roles of responsibilities
New consultants felt that their specialty
training had prepared them less well for
managerial roles
In particular managing targets, inputting
into business plans, designing or changing
services, and managing resources than for
clinical and communication skills.
-Gill Morrow et al. Are specialist registrars fully prepared for
the role of consultant? Clinical Teacher (2009). Gill Morrow et
al. How well does specialty training prepare new consultants
for different aspects of their role? A questionnaire study.
ASME 2010.
Transitions by doctors trained outside the UK
Doctors who qualify outside the UK face difficulties in
moving to the UK, many of which are practical, but some
of which relate to cultural influences on their working.
A more varied group than UK graduates, and, as such,
may have a wider range of less predictable problems
relating to their individual experiences and to the systems
and cultures in which they have trained.
As undergraduate and postgraduate education in the
UK becomes more 'joined up', it may have unintended
consequences of making overseas doctors less aligned
with the NHS when they begin work.
-Jan Illing and colleagues The experiences of UK, EU and non-EU
medical graduates making the transitions to the UK workplace (2009).
Transitions by doctors trained outside the UK
A lack of relevant information about legal, ethical and
professional standards and guidance prior to registration
Variable levels of training and support specifically in the
areas of communication and ethical decision making
Isolation in non-training posts
A key difference between non-UK qualifiers and UK
qualifiers is the emphasis on individual autonomy and
shared decision making between doctor and patient.
Non-UK qualifiers lacked the tacit knowledge held by
UK graduates of the context in which the law and
guidance was developed.
-Anne Slowther et al. Non UK qualified doctors and Good
Medical Practice: the experience of working within a different
professional framework (2009)
Doctors working in roles with lots of transitions
Sessional GPs raised concerns relating to
management, leadership, supervision, support
and getting to grip with new responsibilities.
-Morrow, G et al. Support for Sessional GPs: Report for the Royal
Medical Benevolent Fund (July 2010)
So what can the regulator do?
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Standards and outcomes
Supervision and support
Transfer of information
Streamlining and aligning processes
Strengthening local systems
Embedding professionalism
Standards and outcomes
Move towards outcomes-based guidance for
medical education and training
 Tomorrow’s Doctors
 The Trainee Doctor
 Standards for specialty training
 Generic outcomes for specialty training
Guidance for doctors on CPD
Review of Good Medical Practice
Supervision and support
Supplementary advice of Tomorrow’s Doctors
on:
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Clinical placements
Patient and public involvement
Assessment
Teaching
Guidance on prescribing
Guidance on medical students with disabilities
Induction, shadowing
Supervision of trainees
Transfer of information
Medical Schools Council Transition Group – implementing TD
(09) recommendations
Assuring local processes for sharing information
Testing transition outcomes – trainee survey?
Annual review of competence and progression for every
trainee (ARCP)
Depends on requirements of curriculum and assessment
system – usually includes specialty exams, workplace based
assessment and feedback from supervisors and others
Streamlining and aligning processes
Quality Improvement Framework
Review of assessment systems
Review of the routes to the Speciality and
GP Registers
Review on limiting provisional registration
Strengthening local systems
Approval of trainers
Embedding continuing professional development into
appraisal
Revalidation and the role of Responsible Officers
Employment Liaison Advisers and Regional Liaison
Officers
Review of the way the GMC quality assures medical
education and training
Embedding professionalism
Medical Students Professional Values and
Fitness to Practise
Medical Students Professional Values in
Action
Good Medical Practice in Action
Ongoing research to support transitions
 Research
about our quality assurance processes
Further work on prescribing
Impact on the Working Time Directive
Overview of assessment and assessment systems
CPD and impact on performance
Upcoming consultations
Opportunities to feedback to us on our direction of travel:
From 17 October 2011 to 27 January 2012
Review of Good Medical Practice
Review of the GMC’s role in CPD including guidance for
doctors
Review of the rule and regulations for revalidation
Consultations in 2012
Review of the routes to the registers
Approval of trainers
"Everything should be made as simple as possible, but not
simpler.“
–Albert Einstein
For further information, questions or comments:
[email protected]