Training, Supervision and Competency in Gynaecological Surgery

1
Training, Supervision and Competency in
Gynaecological Surgery

• Dr Dina Bisson
• Consultant Obstetrician and Gynaecologist and
• Training Programme Director for O G
• Severn Institute, Bristol.
• 26 April 2007
• RCOG
• London

2
Training

• Training refers to the acquisition of knowledge,
  skills, and competencies as a result of the
  teaching of vocational or practical skills and
  knowledge that relates to specific useful skills

3
Supervision

• Supervision means the act of watching over the
  work or tasks of another who may lack full
  knowledge of the concept at hand. Supervision
  does not mean control of another but guidance in
  a work, professional or personal context.

4
Competency

• Competence is the ability to perform some task
• Unconscious incompetence
• Conscious incompetence
• Conscious competence
• Unconscious competence

5
Domains of Learning

• Knowledge
• Exams MRCOG
• Skills
• Surgical skills
• Attitudes
• TO2

6
Gynaecological Surgery

• Selection of appropriate patient and procedure
• Pre operative preparation
• Perform operation
• Deal with complications and post operative care

7
Competency in Obstetric Practice

• Decision Making
• Communication with patient
• Communication with team
• Practical skills

8
(No Transcript)
9
Why an Issue in 2007?

• Incompetent Gynaecological surgeons?
• Last gynaecologist struck off medical register in
  2002
• Aware of changes to training and working
  practices
• Risk Assessment

10
Historical Training

• See one do one teach one
• Numerous opportunities for training
• Onerous rotas
• Many routine open surgery cases
• Higher throughput of cases
• Hands on early in training

11
Recent Training

• EWTD/ Shift working
• Protected teaching and study leave
• Cancellation of lists
• Fewer routine cases
• Laparoscopic techniques
• Senior trainees need experience

12
Historical Supervision

• Apprenticeship/ Firm structure
• Generalists
• Time expired senior registrars

13
Current Supervision

• No firm structure/ lack of continuity
• Registrars less experienced
• Lists cancelled if no supervision
• Specialisation

14
Historical Competence

• No test to pass
• Longer/Time based training
• Competence assumed
• FRCS

15
Recent Competence

• Core Log Book
• Trainees decision
• Lack of responsibility
• No direct trainee contact
• Annual RITA
• Educational Supervisors report
• Any concerns about operating skills?
• Log of Experience
• Number of cases/ expected minimum unknown

16
Conclusions from Recent Situation

• Training and supervision in O G undergone
  radical change requiring innovative methods to
  define competency.
• Competency can no longer be assumed.

17
Current Situation

• New Curriculum defined by RCOG
• New Log Book starts in year 1
• New Training Programme
• Competency not time based
• New methods of assessment
• Advanced Training Skills Modules

18
New Curriculum

• Defines knowledge and skills
• Courses to attend
• Methods of assessment

19
New Log Book

• Level of competency defined for each level of
  training
• No progression if not achieved
• Evidence required for all signatures
• Supervisors take responsibility for signatures
• Procedures broken down into stages

20
Competency Based Training

• Allows for different rates of progress
• Recognises High Flyers
• Early detection of trainees in difficulty
• Defined competencies for basic training
• Targeted training
• Transfer to another speciality?

21
Competency Based Assessments

• CbD
• Mini CEX
• OSATS

22
Case Based Discussion

• Medical knowledge
• Clinical Decision making
• Application of knowledge
• Formalised Case Discussion
• CbD in gynaecological surgery
• Selection of appropriate patient and operative
  procedure
• Ability to deal with complications

23
Mini CEX

• Mini clinical evaluation exercise
• Generic Tool used in Foundation programmes
• Inpatient or outpatient episodes
• Direct observation by trainer
• Professional and Interpersonal skills
• 20 minutes per assessment
• Immediate feedback to trainee

24
Mini CEX in gynaecological surgery

• Taking consent
• Pre operative assessment
• Post operative review
• Explaining results

25
OSATS

• Objective Structured Assessment of Technical
  Skill
• Developed by University of Toronto in 1997
• Measure technical ability of surgeons
• Standardised bench model simulators
• Multi station (OSCE)
• Validity
• Content
• Construct
• Face
• Predictive

26
OSATS in O G

• University of Washington in 2000
• Live animal models
• 7 station bench assessment
• Task specific check list/ global rating scale
• Expensive
• Validity

27
OSATS in O G

• Simulation
• Reproducible
• blind assessors
• Feasible
• Valid
• ?face validity
• Virtual reality simulators
• Predictive validity?

28
OSATS in real life

• Work Based assessments
• Opportunities for assessment every day
• Assessments can be repeated
• 10 procedures in O G
• 5 OSATS per procedure before signature
• Different level of complexity

29
OSATS

• Opening and Closing Abdomen
• Caesarean section
• Perineal repair
• Manual removal of placenta
• Fetal Blood Sampling
• Operative Vaginal Delivery
• Evacuation of uterus
• Diagnostic Laparoscopy
• Diagnostic Hysteroscopy
• Operative Laparoscopy

30
OSATS

• Two parts to the form
• Checklist
• Done independently/ needed help
• All steps must be completed
• Generic Technical skills
• Not relevant to every procedure
• Majority to the right side
• Must fully understand areas of weakness

31
Generic Technical Skills Assessment
INSIGHT / ATTITUDE Poor understanding of areas of weakness Poor understanding of areas of weakness Some understanding of areas of weakness Some understanding of areas of weakness Fully understands areas of weakness Fully understands areas of weakness

RESPECT FOR TISSUE Frequently used unnecessary force on tissue or caused damage by inappropriate use of instruments Frequently used unnecessary force on tissue or caused damage by inappropriate use of instruments Frequently used unnecessary force on tissue or caused damage by inappropriate use of instruments Careful handling of tissue but occasionally causes inadvertent damage Careful handling of tissue but occasionally causes inadvertent damage Careful handling of tissue but occasionally causes inadvertent damage Consistently handled tissues appropriately with minimal damage Consistently handled tissues appropriately with minimal damage Consistently handled tissues appropriately with minimal damage

TIME MOTION Many unnecessary moves. Frequently stopped operating or needed to discuss next move. Many unnecessary moves. Frequently stopped operating or needed to discuss next move. Many unnecessary moves. Frequently stopped operating or needed to discuss next move. Makes reasonable progress but some unnecessary moves. Sound knowledge of operation but slightly disjointed at times Makes reasonable progress but some unnecessary moves. Sound knowledge of operation but slightly disjointed at times Makes reasonable progress but some unnecessary moves. Sound knowledge of operation but slightly disjointed at times Economy of movement and maximum efficiency. Obviously planned course of operation with effortless flow from one move to the next. Economy of movement and maximum efficiency. Obviously planned course of operation with effortless flow from one move to the next. Economy of movement and maximum efficiency. Obviously planned course of operation with effortless flow from one move to the next.

KNOWLEDGE / HANDLING OF INSTRUMENTS Lack of knowledge of instruments Lack of knowledge of instruments Lack of knowledge of instruments Competent use of instruments but occasionally awkward or tentative Competent use of instruments but occasionally awkward or tentative Competent use of instruments but occasionally awkward or tentative Fluid moves with instruments and no awkwardness and obvious familiarity with instruments Fluid moves with instruments and no awkwardness and obvious familiarity with instruments Fluid moves with instruments and no awkwardness and obvious familiarity with instruments

32
Advanced Training Skills Modules

• Benign Abdominal Gynaecology Surgery
• Vaginal Gynaecology Surgery
• Hysteroscopic Surgery
• Laparoscopic Gynaecology Surgery

33
ATSM

• Curriculum Defined
• Methods of assessment
• Completion of module signed off
• ?may be part of future person specification for
  consultant posts

34
Assessment of Consultant Practice

• Annual Appraisal
• Record of Adverse Incidents
• Complication Rates
• Use of Assessment Methods
• Evidence of Competency

35
Conclusion

• Changes in Working Practices
• Focussed Training Curriculum
• Well Defined Supervision
• Evidence Based Competency

36
Conclusion

• Ensure Competent Workforce
• Maintain Public Confidence