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


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

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
  • 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?
  • 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.

Fitness to Practise
Journey from medical student to consultant/ GP
Why do we care about transitions?
  • Changes in patterns of healthcare
  • Changing patterns of morbidity and mortality
  • Shared decision making and self-care Informed
  • New biomedical advances and technologies
  • Multi-disciplinary working, professional
  • 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

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.

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

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
  • 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
  • -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
  • Other learning, such as relationships with
    colleagues, processes and practical issues were
  • 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
  • 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 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

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
  • -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
  • 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?
  • 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
  • Tomorrows 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 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

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
  • 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
  • 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 GMCs role in CPD including
    guidance for doctors
  • Review of the rule and regulations for
  • 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
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