Postgraduate training

Chapter 4


Postgraduate training



This chapter is about postgraduate medical education and training, once the doctor has already qualified after a variable number of years at medical school and possesses a basic medical qualification. In many UK medical schools, this is a five-year course, although more recently some medical schools have developed a four-year graduate-only entry medical degree course, as is common in North America.



Introduction



Training grades in the UK


In the UK doctors enter a first (intern) year now called Foundation Year 1. This year provides on-the-job training in a protected and structured environment with regular appraisals and assessments; often now in three posts each of 4 months duration. These are still usually in hospital specialties such as medicine, surgery, paediatrics, obstetrics and gynaecology. This is now followed by Foundation Year 2, with a further three posts of 4 months duration, including a wider range of specialties, including general practice. These general practice posts have proved a great success and are very popular with young doctors.


Following these 2 years, doctors enter specialty training. The time to complete such training varies, from 3 years for general practice to 8 years for some of the surgical specialties. Along the way there are annual assessments and postgraduate examinations to pass.



The historical perspective in the UK


In 1968, the Royal Commission on Medical Education (the Todd Report) commented that the organization of postgraduate medical education at that time could be described as ‘chaotic’. The recommendations were for a pre-registration year, 3 years of general professional training and specialist training after that to reach career grade posts. The training grades were the pre-registration house officer, the senior house officer and the registrar and senior registrar in the specialist training posts.


In the 1990s, Sir Kenneth Calman proposed a reform of specialist training in the UK. This initiative established structured specialist training leading to a Certificate of Completion of Specialist Training (CCST) after a defined number of years of training (between 4 and 6 years), annual assessments and a final assessment. Such doctors were now to be called specialist registrars.


In 2003, The Department of Health began the Modernising Medical Careers movement and established Foundation Year 1 and Foundation Year 2 grades of doctor, and specialty registrars. A new UK-wide appointments process, the Medical Training Application Scheme (MTAS), was set up to go with it, and thus began one of the most disastrous episodes in UK medical education. The whole system did not work, and it left in its wake many thousands of disillusioned young doctors.


In 2007, following the MTAS debacle, Professor John Tooke was invited to report on the state of postgraduate medical education and make appropriate recommendations. He recommended that doctors should serve a 1-year pre-registration Foundation Year 1, then a period of core specialty training in a small number of specialty stems (medical, surgical, family medicine) and then further training in higher specialist training posts (and be called once again specialist registrars or GP registrars). His comments in the Tooke Reports of 2007 and 2008 sound remarkably like those of the earlier Todd Report of 1968.


UK medical and dental education has been regarded as one of the best systems in the world, but, with various changes recently, we have run into greater and greater difficulties. In 1996 the English Department of Health made a move to make postgraduate deans and regional advisers into civil servants and, later, NHS employees of the Strategic Health Authorities. This has led the Tooke Report to comment that ‘… the management and governance of the postgraduate deanery function in England is complex with little relationship to medical schools …’ (Tooke Report 2008). Strategic Health Authorities will be abolished in England in 2013, leaving the postgraduate deaneries with an uncertain future.



International perspective


Postgraduate medical education has become an issue of global significance, appeal and dimensions. While postgraduate educational opportunities in western countries are much sought after by doctors in the rest of the world, many doctors from western nations are equally eager to gain clinical experience working outside their countries. There is also increasing internationalization of the medical workforce following regional and international free trade agreements such as those implemented by the European Union (EU). The National Advice Centre for Postgraduate Medical Education (NACPME) at the British Council provides information to overseas-qualified doctors on postgraduate medical education and training in the UK.


In 2003, the World Federation for Medical Education (WFME) published a comprehensive document titled ‘Postgraduate medical education – WFME global standards for quality improvement’. This publication provides a timely reminder in formulating the postgraduate medical curriculum; taking into account needs of individual countries, as well as of the region and the available human and material resources.



Fundamentals of postgraduate medical education


Doctors go on to develop their competencies and capabilities following the completion of their basic medical qualification. This phase of training is usually conducted in accordance with specified regulations and rules. Similarly to an apprenticeship, trainee doctors are placed in various clinical settings under the guidance of senior and experienced colleagues who take the responsibility for their instruction and supervision (WFME).


Postgraduate medical education initially involves a pre-registration (intern) year which provides on-the-job training in a protected environment. The aim of this 12-month programme is to ensure that the trainees possess the necessary practical knowledge and skills essential for safe medical practice. Successful completion of this internship allows a graduate to register as a medical practitioner with the relevant medical council or board. Graduates are also entitled to enrol for general practice or family medicine training, specialist and sub- or superspecialist training or for other formalized training programmes for defined expert functions. These are organized by the universities, specialist boards, medical societies and colleges or institutes for postgraduate medical education. This further training typically lasts for a period of 6 to 8 years.


Internationally, there are considerable variations in the number of recognized specialties and expert functions in medicine as well as in the organization, structure, content and requirements of postgraduate medical education. For example, the Hong Kong Academy of Medicine, with its membership of 15 constituent professional colleges, offers postgraduate training in nearly 50 specialties (www.hkam.org.hk). The common curricular approach of all member colleges, of course, centres on the recognized clinical or practical placements, expert supervision, theoretical teaching, research experience, systematic assessments and evaluation of the training programmes.



Transition from medical student to doctor


In the UK the Foundation Year 1 house officer year is the first year of employment which junior hospital doctors undertake following their 5 years of medical undergraduate training. It is necessary to complete this year to obtain full registration with the General Medical Council.


However, this first year as a doctor is seen by many to be a stressful and difficult year, and people have often expressed the idea that they have been ‘thrown in at the deep end’ with little idea of what to expect in the working environment as a result of their undergraduate training. To this end, the General Medical Council has required undergraduate medical students to undertake a period of ‘shadowing’ with a pre-registration house officer as part of their final year. Ideally, this will be in the post in which they will later be working.



image The transition from medical student to doctor is a stressful and difficult transition for many.


In the medical education literature there are several studies which confirm these views. Looking at medical students and young first-year doctors from several medical schools, it appears to be a UK-wide problem. New doctors described their learning of clinical skills as ‘haphazard and random’ and wanted further training in practical skills and procedures, delegation of tasks and time management. Worryingly, 25% of these doctors were experiencing burnout, measured on the Maslach Burnout Inventory. Lack of preparation as an undergraduate was a problem, with only few competencies listed as showing that the young graduates were more than quite well prepared by their medical school education. Consultant education supervisors rated the young graduates as more than quite competent in only three areas: awareness of own limitations, keeping accurate records and working in a team. So the undergraduate course had only partially met its objectives in preparing the young graduates for their pre-registration house officer year.


Also, anecdotal evidence from consultants suggests that with the breakdown of the ‘firm’ structure within hospital practice, the reduction in working hours as a result of the requirements of the European Working Time Directive, and the Terms and Conditions of Service, there is less contact between pre-registration house officer and consultant, and the young doctors are often thought of as less experienced than their predecessors.


In the West Midlands, we studied the young pre-registration house officers and their consultant supervisors to see whether there were differences between how well prepared the pre-registration house officers felt they were and how well the consultants felt they were as a result of their undergraduate medical education. Both groups ranked communication skills areas highest (that is, best prepared) and ranked basic doctoring skills (such as prescribing, treatment, decision making and emergencies) lowest. House officers rated themselves significantly higher than did their consultant supervisors in 13 out of the 17 areas tested (Wall et al 2006).



image Young doctors consistently overestimate their abilities when compared with assessments made of them by their consultant supervisors.


It is not surprising, therefore, that some doctors experience difficulties and may struggle to cope.



Characteristics of postgraduate education


As shown in Fig. 4.1, postgraduate medical training may be summarized as education, exposure and experience leading to expertise, evidence-based practice and excellence.



Postgraduate medicine is a high-stakes education and practice. The ultimate goal in postgraduate medical education has to be that the trainees will, progressively, receive the appropriate clinical exposure to gain the necessary experience required in achieving expertise that allows them to provide a high standard of care in their respective fields. Another chief aim of postgraduate medical education is that the trainee eventually becomes the trainer and goes on to participate in the training of his or her juniors and medical students. The principles of adult learning and the process of structured educational training are both vital in postgraduate medical education with respect to the development of clinical and practical skills. In specialties related to surgery, acquisition of practical or operative skills requires additional attention (Patil et al 2003).



image Compassion, communication, care and competence are essential ingredients of successful clinical practice.


The trainee is moving along the continuum from novice to expert, as described by Dreyfus and Dreyfus (2005). These five steps are as follows:



However, it may take some years as a career grade doctor (consultant or general practitioner principal) to achieve real mastery of one’s subject. Few may ever reach the next level, after a lifetime’s experience, which we have perhaps light-heartedly called the 7th dan.



Standards for training


In the UK, the General Medical Council sets standards for training posts and has required that there be an approved curriculum for the Foundation Programme and for all specialties. Such standards include approved training posts, a curriculum with end point assessments, a named educational supervisor, a protected teaching programme, an induction to the post, regular appraisals, assessments using a range of agreed assessment tools and a balance of appropriate clinical duties and study leave for courses.



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Dec 9, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Postgraduate training

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