Managing transitions and risk in medical education, training and development A regulatory perspective

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Managing transitions and risk in medical
education, training and development A
regulatory perspective

• Paula Robblee, Policy Manager, Education

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• 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

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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?
• Standards and outcomes
• Supervision and support
• Transfer of information
• Streamlining and aligning processes
• Strengthening local systems
• Embedding professionalism

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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
Fitness to Practise
Standards
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Journey from medical student to consultant/ GP
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Why do we care about transitions?

• Changes in patterns of healthcare
• 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
• 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
• Difficult financial climate
• Globalisation alongside move towards localism
• Social networking

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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 (n12,694) of foundation stage doctors said
  rarely or never felt forced to cope with problems
  beyond their clinical competence or experience.

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Perceptions of training by trainees

• My current training is fine. Im working with
  professionals whom I respect, even if they dont
  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

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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

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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
  under-preparedness.
• -Dr Jan Illing et al How prepared are medical
  graduates to begin practice? (2008)

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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).

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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).

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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.

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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).

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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)

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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)

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So what can the regulator do?

• Standards and outcomes
• Supervision and support
• Transfer of information
• Streamlining and aligning processes
• Strengthening local systems
• Embedding professionalism

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Standards and outcomes

• Move towards outcomes-based guidance for medical
  education and training
• Tomorrows Doctors
• The Trainee Doctor
• Standards for specialty training
• Generic outcomes for specialty training
• Guidance for doctors on CPD
• Review of Good Medical Practice

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Supervision and support

• Supplementary advice of Tomorrows Doctors on
• Clinical placements
• Patient and public involvement
• Assessment
• Teaching
• Guidance on prescribing
• Guidance on medical students with disabilities
• Induction, shadowing
• Supervision of trainees

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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

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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

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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

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Embedding professionalism

• Medical Students Professional Values and Fitness
  to Practise
• Medical Students Professional Values in Action
• Good Medical Practice in Action

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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

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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 GMCs 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

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• "Everything should be made as simple as possible,
  but not simpler.
• Albert Einstein
• For further information, questions or comments
• probblee_at_gmc-uk.org