This was first writen in 2010 and never published – I was prompted by a recent article in Archives of Disease of Childhood Education and Practice to put it into a blog form.

“Ability is of little account without opportunity”.  ~Napoleon

Prior to the introduction of the Modernising Medical Careers Programme (MMC) it had been recognized that academic medicine was in decline in the UK and there were perceived deterrents to entry into this specialist field. Dr. Mark Walport, the director of the Welcome trust, brought together a number of stakeholders with an aim to use MMC to find solutions to the traditional barriers to an academic career. What emerged from these meetings was the Walport report and the development of an integrated academic training path (table one).

Table One – The Integrated Academic Training path as proposed by the Walport report [1]

(please click on to expand – picture via Imperial College)

So although many doctors were unsettled by the experience of implementing the MMC programme, and even more disaffected by the initial failure of its recruitment method (MTAS), there was one group of trainees who potentially stood to benefit. Those interested in an academic career found themselves able to gain academic experience and competencies without having to go out of programme or at detriment to their careers. Introduced in 2006 the initial recruitment of the Academic Clinical Fellow (ACF) was slow. However as knowledge of these positions has increased they have become increasingly popular and for the 2009 year 260 posts were available.  The concept of the Post is novel and a summary of the role from the Walport report [1] quoted below:

“Each trainee will have the opportunity to develop a flexible training programme to achieve his / her academic and clinical goals, through the provision of an ad personam training programme and mentoring. Delivery of these programmes should be trainee-centred as far as possible, with a single point of contact for the trainee.”

Essentially an ACF is designed to give enthusiastic clinicians protected time (25% over three years) to develop a thesis proposal. When they embark on a PhD or MD their fellowship ends to return afterwards either to a clinical lectureship or back into clinical medicine. Their run through training pathway is protected and, subject to clinical competencies, they would be able to return with minimal disadvantage if their academic career was not successful or didn’t suit them.

So what’s it like to be an ACF and why would you want to be one? There are many popular misconceptions about academic medicine. You do not have to be the cleverest of your peers, have a photographic memory or be a social recluse. I know that because I was an ACF and received no distinctions or awards at medical school (you’ll just have to take my word for it that I have friends.)

Although originally designed for entry at ST1-3 I entered an ACF in paediatric emergency medicine in March 2008 at the level of a year three registrar (ST6). I already had some research experience from a fellowship I undertook in Australia so had a few imprecise academic competencies. Examples of some of these are listed in table two. They are much less specific than clinical ones and some may be interpreted in an open-ended manner. Therefore you need to go out and find the information required; it will certainly not present itself to you fortuitously while you are on call.

The aim was, given a protected day a week, to develop a research proposal which would enable funding to be obtained for a higher degree. I had an office, a desk in a blood taking room with painfully bright lights and a buzzing ultra-low temperature fridge, but away from a nurses’ station and a bleep.

Table Two – Selected Academic Competencies

There is always the potential for resentment from your colleagues when you are given time away from the shop floor. You sense they feel you will be sitting in front of a computer playing solitaire and looking up friends on face book. It is interesting that I am more tired at the end of an academic day than a clinical shift! When you start it is virtually impossible to sit there doing nothing as you have a range of meetings to organise, courses to book and journals to read. You feel guilty (not least because of your colleague’s unseen glares) if you don’t do anything. This is spur enough to wade through a soporific statistical book trying to explain the difference between sensitivity and specificity, something you thought you learnt in medical school but actually never understood.

“Everyone who’s ever taken a shower has an idea.  It’s the person who gets out of the shower, dries off and does something about it who makes a difference”.  ~Nolan Bushnell

The purpose of the ACF programme is to steer you towards obtaining funding for a thesis (MD or PhD). Although the academic department you are based in will have its own research themes this application will not have been written yet. Ownership and development of an idea by the ACF is considered good practice. It is both enjoyable and frustrating to develop a project. The learning process involves being able to formulate a question (very different from an ‘idea’) which is practical, achievable but most importantly fundable. Many of the suggestions you have will be placed on a back burner as, although good, they are just not achievable in time scale available. In order to develop your ideas experienced advice is needed and developing that advice is a useful first lesson. In my first year as an ACF I had 42 distinct meetings with various individuals and groups and many more ad hoc encounters with my research supervisor. While trying to formulate a research question I first approached those who had any potential connection with my planned topic. Those initial discussions spawn many ideas and lead to a cascade of meetings both within and without the university, hospital and even region. You quickly learn it is vital to have a plan or strategy prior to any meeting. All health care professionals whether doctors, academics, research nurses or representatives of funding organisations are busy people. An initial question of “what can you do to help me?” can be easily be perceived as wasting their time. Explaining your background, interests and aims focuses your direction of travel and it is a lot easier for appropriate advice to be given.  Directly associated with this is need to record information effectively. It was three months before one senior lecturer asked me why I was writing everything she said on a small scrap of paper; “how on earth was that going to be useful in the future?” The next day I brought an A4 ring binder and now have an organised log of all meetings and most importantly outcomes. This is not only necessary for project development it was also a vital piece of evidence for my academic ARCP.

“Librarian is a service occupation.  Gas station attendant of the mind”. ~Richard Powers

In conjunction with developing your question it is important to understand the background research which already exists in your area of interest. Libraries are familiar places to doctors from the late nights spent trying to cram, now long forgotten, knowledge into your brain prior to finals. Librarians at this stage were of little practical use especially as they never seemed to find riotous laughter as much of an adjunct to revision with friends as you did. However the clinical librarian is a mine field of information and is extremely useful in being able to locate a recent article of the “Journal of Amytrophic Lateral Sclerosis” or a 1974 response to an editorial in “Augmentative and Alternative Communication” (both real journals). They are also extremely skilled in designing literature searches and an hour spent with one reaps many hours saved in the future.

Having reviewed the relevant journals and spoken to various authorities on the subject I began putting together an initial research proposal. This document was subsequently revised 13 times before an acceptable version was submitted for a NIHR Research Doctoral Fellowship. Although the theme, questions and method of the final version was very different from the initial draft it was not unrecognisable. With each draft came an increased focus to the question, a better idea of the projects limits and perhaps most importantly an increased understanding of the style of language needed to write applications. Aside from the draft of the proposal the final application took nearly three months to complete. In applying for grants all monies have to be accounted for, which includes your salary, pension and national insurance contributions. The costs of expenses as simple as paper and pens need to be included and statistical help is unfortunately not free. In hindsight trying to bring a whole application together on a day a week (and I certainly did a lot of work in the evening and weekends) added to the stress of the process. With advance agreement and co-ordination the time taken for research over the three years can be taken in any form up to 25 % of the total clinical time. Some centres provide a six month academic block which is especially useful for laboratory studies and allows the ACF to gain experience to inform the thesis application. Others allow a mix of time dependant on the clinical demands (some attachments require a greater clinical commitment to achieve competencies – neonatology during paediatric training is a good example). It is expected the ACF will progress at a faster rate than their peers enabling the academic time to be taken without prolonging the training programme.

Effective forward thinking is important as decisions on major grant applications may take up to six months. Following submission it may take a month to decide whether to send the proposal for peer review and even then a final decision, based on interview, may not be made for another 4-5 months. In that time there will be other grant applications to write and additional research to be performed. It may be during these periods that a return to full time clinical medicine occurs to obtain competencies and exams.

“Failure is only the opportunity to begin again more intelligently”. ~Henry Ford

My initial NIHR Doctoral Research Fellowship application was unsuccessful. The detailed feedback indicated that although I was a suitable candidate the thesis project and support was not of sufficient quality. It is important for grants that you show that you are a committed potential candidate with a robust project detailing measurable outcomes in the planned time frame. You must also demonstrate your supervisors have sufficient experience to supervise you and a training programme is in place for you to obtain the skills necessary to complete the work. It is easy to forget the latter two points in applications. I had presented a couple of abstracts at national meetings based on reviews and audits performed while an ACF. This improved my academic curriculum vitae however we had not thought carefully enough about some of the research techniques needed for the qualitative components of the project. During the next year we refined the question and developed a project group consisting of my research supervisor but also containing academics with specialists interests which were not present in my academic department. I have subsequently obtained funding for a revised project via a fellowship opportunity which has become available at my trust. This certainly would not have been a possibility without the time available from an ACF position.

I have thoroughly enjoyed my time as an ACF despite the pressures of applications deadlines, hours in front of a keyboard and a buzzing fridge.

Regardless of how my academic career develops the experience has been extremely stimulating and rewarding and will be of benefit to me whatever the future holds.

References

1. Medically- and dentally-qualified academic staff: recommendations for training the researchers and educators of the future (the ‘Walport report’). The Academy of Medical Sciences. 2005.

The issue of whether it is possible to adequately train doctors in a 48 hour average week has long been the subject of discussion  (some background here). A recent piece in the Guardian raised a number of eyebrows from those on either sides of the argument. The article, written by a healthcare software provider, was essentially saying longer individual shifts would be better for all involved. This point didn’t really resonate with those doing the shifts.

https://twitter.com/tweediatrics/status/373269863885991936

However whenever the EWTD (or technically EWTR) gets mentioned the debate re-opens.

@moiraehansen @tweediatrics @threestain I was ready to do middle-grade neonatology after 6 (Band 3) months as an SHO. Who says that now?

— Richard Hansen (@PaedsRH) August 30, 2013

As a member of the Temple report on working hours I was given the opportunity to hear from those of all those involved in training and being trained. As a result I was asked by the BMA (point of note I have never been a member of the Junior Doctors Committee) to write a short article on my personal perspectives. I was surprised to find, despite having  written this in early 2010, I still stand by what I said then:

Reflections on the European Working Time Regulations

“In August 2002 I returned to the UK having spent a year in Perth (Western Australia) after my PRHO year (Foundation year one). I had spent it at a children’s hospital and had thoroughly enjoyed my clinical experiences there ; the 80 hour fortnights also helping take advantage of the sun, sea and surf. I retuned to a tertiary neonatal unit in the East Midlands with a degree of disappointment, worsened by the fact I knew I had to start getting my paediatric membership. The fact that the job was “Band 3” didn’t really mean much to me at the time except I knew it would help clear my substantial travelling debts. In practice “Band 3” meant a 4 and a half week run of shifts with only four days off.  I look back at that period now with mixed feelings. Without a doubt I went from a neonatal novice to being able to make middle grade decisions within six months. The confidence felt by the end of the job certainly outweighted the utter panic of a first night shift spent peering through Perspex glass wondering how I would get a cannula into the minute bag of skin and bones in front of me. To say I enjoyed the experience would be looking back with rose tinted spectacles. During the runs of long days and evenings you resented every little bleep or request for fluids. The maternity theatre bleep was a clever device never going off when you were being grilled on a ward round but waiting until your hurried lunch break. They would be exhausting shifts whether you did them for 10, 40 or 60 hours a week. However having to do them for 50+ meant you were never truly on top of your game. Fortunately the camaraderie of the team of SHOs (specialist trainees) provided an outlet for times when you became utterly frustrated. I count myself lucky though I have experienced both sides of the EWTR coin and am convinced on which side I prefer it fall.

It is clear one size does not fit all but in paediatrics because of the high demands of out of hours working a suitably staffed rota does provide sufficient learning opportunities within the 48 hour framework. It is unfortunate however that many paediatric rotas are not suitably staffed! My experiences with EWTR have been favourable as I have always been rostered to allow exposure to elements in my training that are not just simply deciding whether a feverish child is ill or not.  Others have not been so lucky and Out patient clinics, case conferences or governance meetings which all count as training are easily sacrificed if there is no-one available to clerk the next patient on the assessment unit. Without these opportunities the disadvantages of longer shifts, increased fatigue and less ability to unwind are irrelevant. As a trainee I want to be given the opportunity to train and want the system to flexible enough to allow me to take these opportunities. Ultimately though when frustrated that the systems fails I remember my neonatal job and am glad I don’t have to do it again. However as time progresses my memories will fade and the need to be effectively trained will remain. For paediatrics it is not the 48 hours that is the problem it is the delivery of training within it.”

I have always been clear that training is not one size fits all with the needs of the craft specialties different from the acute ones, and different again from community based services. I wonder as education and training changes over the next decade whether this problem will still persist, and whether I will still feel like this….

The ever thought provoking Javier Benitez (@jvrbntz) had this to say recently

Intriguing "Explicit pre-training instruction does not improve implicit perceptual-motor sequence learning" http://t.co/HHPimn0Lcj #MedEd

— Javier Benítez, MD / Pr(Dz | Data) ≠ Pr(Data | Dz) (@jvrbntz) July 6, 2013

The study in question explores relationships between implicit memory [wikipedia saying Implicit memory is a type of memory in which previous experiences aid in the performance of a task without conscious awareness of these previous experiences] and explicit memory [wiki: Explicit memory is the conscious, intentional recollection of previous experiences and information. People use explicit memory throughout the day, such as remembering the time of an appointment or recollecting an event from years ago]. Essentially in the study the participants where asked to perform a task of pressing one of 4 keys in response to different cues falling down a screen. There were two groups all completing a main task but one group given time to memorise the sequence of the falling cues while the other group just had practice time without realising (or more correctly being told) there was a sequence. In this study sequence learning wasn’t improved by  pre-training memorization of the sequence. The authors hypothesised that explicit and implicit memory may be independent of each other.

In response to an initial question Javier clarified by saying in the context of deliberate practice it may well be worth re-practicing rather than re-reading which was summated as:

@jvrbntz okay, learn by reading<learn by doing, but learn by reading then doing (& doing…) = good and resilient?

— Todd Raine (@RaineDoc) July 7, 2013

At this point yours truly, having not really read the initial paper properly, but enough to notice that the task used in the study was similar to sequencing required in a popular game, waded in with:

@RaineDoc @jvrbntz but task was predictable, and previously practiced "guitar hero!' i.e. is it translatable to teaching on airway station?

— Damian Roland (@Damian_Roland) July 7, 2013

Javier pointed out that the tasks needed to be predictable but the overall philosophy was that implicit and explicity are different points of memory.

@Damian_Roland @RaineDoc Deliberate practice needs to be predictable. see chess & music.Their point = implict & explicit r different memory

— Javier Benítez, MD / Pr(Dz | Data) ≠ Pr(Data | Dz) (@jvrbntz) July 7, 2013

Now fully acknowledging I had waded into an area in which I am not familiar (and it’s not great practice to pick up “tweetends” without knowing context!) it still got me thinking about how this piece of research was really applicable to post graduate medical practice, and in particular the busy world of emergency medicine. If we take, for example, putting in a interosseus needle the espouced theory may have some merit. Yes an understanding of the theory is needed but actually it’s not really until you have done it in a real patient (or even a dummy) that you can really understand the practicality of it i.e memorise the sequence all you want but you really need to ‘play’ the game to get the hang of it.

However much of what we practice in emergency medicine at a senior level is a complex array of operations of which are not predictable or follow algorithms. So I responded with

@jvrbntz @RaineDoc Higher level cognition (leading multi-trauma) is by definition unpredictable. ?Memory irrelevant here as not a "skill"

— Damian Roland (@Damian_Roland) July 8, 2013

At that point I confused poor old Javier a bit and this blog serves as a way of clarifying my thought trail (and conveniently may help me frame an argument in one of the chapters of my Phd on junior doctors perceptions of competence and confidence). Does this implicit/explicit memory split really hold for complex tasks? And how would we test if it does. So an open question to the (#FOAMed) world:

It’s 6pm. The Emergency Department is heaving. Red phone goes off. Nine year old, hit by car at 40mph, thrown off bonnet. Initially agitated now quiet, clear open right femur and obvious trauma to chest.

You are team leader: what memory is going to get you through the next 20 minutes….

The Shape of Training Review is looking at potential reforms in the structure of Medical Education in the UK. As I was not part of any organisation, or acting in a representative capacity, my response is a more personal reflection on the key issues in post graduate medical education in the UK at present (and hence the reason for adding it to my blog!)

My key recommendations were as follows (followed by responses to each of the questions)

1) The training of Doctors is not seen in isolation of the potential large upheavals needed in acute and community care. Any significant changes in training pathways must be future proofed to be able to flexible to changing patient demographics and service requirements.

2) HEE and the (National Commissioning Board/ NHS England) should agree a joint strategy and policy for proportion of care delivered by health care professionals in training.

3) The AoMRC should produce a joint statement on watershed roles between specialties in relation to service delivery and education. This would inform the specialty/generalist debate started by the RCGP.

4) If this review is to alter the CCT (certificate of completion of training) as an endpoint the views of trainees and newly qualified consultants must be heard during oral evidence.

5) A core group of Stakeholders including but not restricted to the FMLM, Academy of Medical Sciences, Academy of Medical Educators and  Health Policy Groups should meet to plan a strategy for expanding the Walport scheme beyond academic training.

1. Over the next 30 years, how do you think the way patients are cared for will change?

 It is unlikely that despite advances in technology (heart surgery, prosthetics, drug delivery etc.) the fundamental nature of health care professional interaction with their patients will alter. There will always be a need for face-to-face contact, communication skills demonstrating empathy, examination skills that elucidate key findings and an ability to make decisions based on clinical, social and ethical factors.  Regardless of the state of finances, political systems or even the construct of the NHS training doctors in good patient interaction, history taking, examination and technical intervention will be no less needed than it is now.   It is likely that more practice will happen via teleconference, closer to patients home or by non-medically trained practitioners. This does not diminish the need for well trained medical staff with core skills in history, examination and management.

2. What will this mean for the kinds of doctors that will be needed in primary care? In secondary care? In other kinds of care?

What is almost certain is that doctors will work in different ways and with different medical devices. Therefore as well as maintaining high standards of care doctors will also need to be able to respond to a rapidly changing technological arena.   The changing demographic of the population will mean a breaking down of divisions between primary and secondary care and re-thinking of this arbitrary divide. The concept of a community specialist or a hospital acute generalist are likely to become increasingly common. It is vital that the Royal Colleges are flexible and engaged with workforce needs to avoid ‘silo’ roles developing and there being inflexibility in career pathways.

3.  What do you think will be the specific role of general practitioners (GPs) in all of this?

The fundamental right to see a health care professional regarding a range of health issues, at a local level, who has a skill set to manage minor illness but be simultaneously cognisant of serious and rare disease is unlikely ever to be allowed to diminish by the general public and profession alike. Regardless of the changes made to delivery of care to patients requiring ‘admission’ GPs will need to retain a breadth of experience and expertise. This will be the only way to ensure quality care is received in the most relevant location for patients.

4. If the balance between general practitioners, generalists and specialists will be different in the future, how should doctors’ training (including GP training) change to meet these needs?  

The foundation curriculum has helped to some extent but we are still not entirely clear on the attributes we would like all doctors to have. We are also tied to a system that means everyone has experience of acute medical care. It is right and proper that this is the case but it has meant hospitals have always had their basic service commitments fulfilled by an excess of doctors at a junior level (but who often only perform very basic tasks or tasks beyond their competence – Collins Report)   If the balance of doctors is to change; the environment in which doctors can learn the requisite skills to move from having knowledge (medical student) to applying practice (foundation doctors) to delivering care (specialty trainees) will need to change as well. This does not just involve curriculum alteration but will require a system wide evaluation of the deployment of foundation doctors in the acute care system.

5. How can the need for clinical academics and researchers best be accommodated within such changes?  

I contributed to this question on behalf of the Academy of Royal Colleges Trainee Doctors Group. Please see their response as well.

It is important to differentiate between the need to train the whole medical workforce in the core principles of research, related ethics and good clinical practice (GCP) and those who will become established academics with a full or partial whole time equivalent research brief. It should not be the case that there is a clear divide between the two but ignoring the needs of either group risks jeopardizing both the strong UK academic standing in medicine and ultimately patient care. Currently there remains an artificial, and sometimes stereotypical, divide between those with a clear research interest and those without. This is not aided by poor awareness of where to seek advice on academia and research. A recent survey of paediatric trainees revealed only a third were able to identify who their local regional academic advisor was and other surveys of specialties suggest similar results.

The creation of the Walport training scheme has transformed the ability of a core group of potential academics to learn and develop research skills. However, as with all pathways, there is the potential to reduce opportunities to those uncertain about careers choices in their early clinical years. Any system of developing a future academic workforce needs to be cogniscent of the fact that research interests develop over time, that certain specialties have optimal and suboptimal periods of undertaking substantial research endeavors and that for many pursuing a long term academic career is not viable or desired.

In developing a new training structure the following should be considered:

i. It should be the responsibility of LETBs (in England), Deaneries (elsewhere in the UK) and Colleges, in collaboration, to establish fail safe mechanisms for trainees to access individuals and resources to advise on research and academic careers.

ii. Mechanisms for advancing and assisting those with potential and a clear interest must exist at all levels of training e.g. Medical School MB-PhDs, Foundation Year Academic Programmes and Academic Clinical Fellow/Lecturer posts.

iii. It should always be possible, but not necessarily an individual guarantee, to be able to undertake research activity within a training programme even if an accredited research pathway is not being undertaken.

iv. The concept of OOPE should be expanded to be able to undertake small research projects, as well as QI initiatives and education fellowships. These should be considered distinct from OOPR which should be reserved for those on research degree programmes. LETBs should ensure that work force planning and service needs allow for a number of OOPEs to be always available across specialties for those with an interest in research, but without funding, to undertake activity which may lead to a higher degree but also allows for return to clinical work without prejudice.

6. How would a more flexible approach to postgraduate training look in relation to: 6a.  Doctors in training as employees?

Doctors have traditionally been employed by their trust. Employing doctors at a regional (or even national level) would enable great flexibility in rotations and remove issues with multiple CRB checks and some parts of induction.

6b. The service and workforce planning?

 The fundamental problem with developing a flexible and dynamic training programme is that it is designed around service needs rather than vice-versa. It is clearly not simple to suggest that trainees are placed into training posts once the service needs have been met. But it would be possible over the next decade to start thinking about the need to make this change. It will not be possible to allow a flexible training programme if for example only one OOPE is available at any given time.  A debate on “extra-curricular” training i.e. skills in education, research, leadership and policy development must be had. One to determine why it is current training is felt to be inadequate to develop these skills (as evidenced by the high number of requests to undertake such activity) and secondly to understand how important they are in sustaining a high quality medical workforce in the future.

6c. The outcome of training; the kinds and functions of doctors?

 Is this question asking whether it is possible to have an endpoint of training that doesn’t produce an independent practitioner (whether GP or Consultant)?  Decisions made by junior doctors to apply to specialty or VTS training is made on the basis of reaching the consultant or GP end-point. Ensuring flexibility in training must always bear this in mind, and while some trainees, wish to undertake SASG roles there is no convincing evidence that this is their primary intention (further research is clearly needed in this area). The public also have a clear understanding of what a consultant or GP is. Therefore a flexible approach to training would still need to maintain a clear standard to achieve at its completion. The definition of a independent, unsupervised practitioner is a standard that is clear to all who aspire to do it and regulate its attainment.

6d. The current postgraduate medical education and training structure itself (including clinical academic structures)?

6d and 6b are integrally linked. There already exists a huge flexibility in the system from anaesthetics trainees being supernumerary in the first few months, to the cohort of medical director clinical fellows and also the integration of academia as evidenced by the Walport scheme. The ACCS programme has demonstrated, as will hopefully the broad based training pathway, how rigidity can be taken out of current training programmes to the benefit of trainees.   Perhaps no new flexibility is needed just an increased opportunity for trainees to partake in the experiences on offer. This is entirely dependant on service need and its potential reconfiguration.

7. How should the way doctors train and work change in order to meet their patients’ needs over the next 30 years?  

There have been few fundamental reforms of medical education since the Flexner report at the beginning of the last century. Of course nominology has altered, the training time frame has been adjusted and curriculums have been completely revised. But the core nature of medical training has stuck to some fundamental principles: At medical school a framework of basic science and key skill sets in each of the specialties learned. In the early years doctors clerk new patients and perform routine day to day care.  As they progress skills widen with experiences in clinics and theatres while greater responsibility is placed on leading juniors and making decisions.   Both the Temple and Collins reports highlighted current issues with this approach.

1) The need to provide a constant 24/7 general acute service was reducing learning opportunities once the core skills sets of dealing with acutely unwell patients had been learnt.

2) Supervision from supervisors was inadequate.

Neither report mentioned another issue with current education policy: “one size does not fit all in medical education”. Although generic skills are vital it cannot be the case that the training of a surgeon should match that of a psychiatrist. The current debate on working hours has always been flawed in its approach that everyone needs 56+ hours or that all patients are potentially unsafe unless we are rigid with 48 hours.   A surgeon may get rest at night and have their learning enhanced by operating on the patient they saw the night before whereas it would be catastrophic for a neonatal SpR who will have had little rest on a night shift in a tertiary NICU to have to continue onto an out patient clinic.   It should not be for this review to determine the individual needs of each specialty and I don’t think it intends to. However recommendations on training pathways must be flexible to individual specialty needs and in keeping with current workforce policy and regulations.

8. Are there ways that we can clarify for patients the different roles and responsibilities of doctors at different points in their training and career and does this matter? 

This does matter but requires national co-ordinated action. If each LETB/Trust etc. choose a different method it would cause confusion.

9. How should the rise of multi professional teams to provide care affect the way doctors are trained?

Currently there is little work done on assessing health care professional interaction and learning in a post graduate medical education context. Simply encouraging engagement will have little training benefit unless some core competencies can be defined. The rise of MPT in more integrated services will mean this area must be explored.

10. Are the doctors coming out of training now able to step into consultant level jobs as we currently understand them? 

Yes they are – there is little evidence of serious harm although it is clear the support given by colleagues is much improved from a decade ago.   The problem for this review of post graduate medical education is that it depends on the concept of a consultant/GP remaining static otherwise the end product will not meet the current health system requirements.

11. Is the current length and end point of training right?

Interesting question as the length of training is substantially different between specialties. Despite not feeling confident many trainees do feel competent to be consultants (anecdote I’m afraid!) although this maybe biased because they have deliberately extended their training. Qualitative and Quantitative research in the patient and personal outcomes of specialty trainees who have completed training entirely according to the pathway i.e. ST1-6 with no breaks and are no consultants is needed.

12. If training is made more general, how should the meaning of the CCT change and what are the implications for doctors subsequent CPD? 

This is an interesting question as it implies training may be made more general. What if the question were if training became more specialist?   As stated previously a CCT should remain as the benchmark to reach when you can be an independent practitioner. If less specialty accreditation was on offer the meaning of the CCT should remain unchanged. It would be possible post CCT to pursue education in more specialist areas but this would not devalue the important or relevance of CCT.

13. How do we make sure doctors in training get the right breadth and quality of learning experiences and time to reflect on these experiences?

HEE and the Commissioning Board must meet and re-appraise the core duties of junior doctors in providing acute care. Although it is not necessary in all specialties and environments it is quite clear that Emergency Medicine is suffering from trainees having little time to do anything other than constantly see patients. Although this is clearly a fundamental part of their training, only reflection and mentoring can avoid poor habits becoming ingrained and learning from mistakes turned into a positive experience.

14. What needs to be done to improve the transitions as doctors move between the different stages of their training and then into independent practice? 

The introduction of accreditation of educational supervisors will be instrumental in improving mentoring of doctors and providing better and more comprehensive cover of their transitions. It is vital that the GMC are robust in their processes to ensure that standards remain high.

15. Have we currently got the right balance between trainees delivering service and having opportunities to learn through experience?  

 No (The Temple and other reports demonstrate this)   Confusion has been created by the belief that trainees either deliver service or they don”t. In order to learn doctors must see patients in a supervised manner. However currently some patients are dependant on trainees for the care they receive i.e the medical assessment unit staffed overnight by an ST4 and two ST2s. It is entirely reasonable for learning experiences to take place in this setting. Unfortunately pressures on acute services will mean those doctors will see patients in a way that ensure throughput rather than learning opportunity. The same unit with additional SASGs, nurse practioners and consultants takes the pressure off, especially junior staff, meeting trust targets as well as meet the needs of their curriculum.  As stated previously changes in population demographics mean the Health Service must examine who is providing patient care and what is a sustainable way of delivering education. The two are intertwined but should not be dependant.

16. Are there other ways trainees can work and train within the service? Should the service be dependent on delivery by trainees at all?

See question above. Service entirely independent of trainees would be a tough financial and workforce ask. The review of Emergency Medicine by the Department of Health is a good example of work that could be performed in all specialties to review the delivery of acute (and community) care.

17. What is good in the current system and should not be lost in any changes? 

Clear steps from Novice (Foundation) to Expert (Consultant)  A defined end point  The ability to undertake OOPE and OOPT.

18. Are there other changes needed to the organisation of medical education and training to make sure it remains fit for purpose in 30 years time that we have not touched on so far in this written call for evidence?

The Walport system has transformed academic training. Although there are still some bugs to be ironed out the inception of protected out of clinical time is clearly beneficial. This principle should and could be applied to Medical Education, Leadership and Management and Health Policy.  Leadership and Management, especially in the light of Francis, have been neglected for decades in the training of junior doctors. It is vital if we are too develop a generation of consultants and GPS who can transform services and deliver high quality care that this is remedied. The FMLM response to shape of training has clear recommendations in this regard.

It all started with the following tweet:

#FOAMEd Want to be able to encrypt patient photos (ECGs, radiology, skin) taken on iPaD – any suggestions?

— Chris Edwards (@EMtraveller) February 6, 2013

and in no time at all the enthusiasm for all things #FOAMed found ourselves with a number of volunteers, a catchy 4’D’ mnemonic courtesy of Mike Cadogan and a working title “ConsentCam”

• Dissemination: the power of global conversation through #FOAMed
• Discussion: it marks the starting point for a conversation which can continue on twitter and through blogs, then onto #SMAC2013 so that a global perspective can be obtained
• Development: the seedling inclination to pursue a random thought can be magnified with altruistic assistance
• Deployment: this may well result in a collaboration which leads to the production of an essential element for medical education provision

An neat summary can be found here – please do contribute to the ongoing discussion and upload your consent forms to the dropbox!

Just wanted to answer a few questions which have sprung up during the process which I thought might be useful to clarify.

Do we want this?

The proof of the pudding for me is the fact that as soon as you mention consent, apps and patients on social media you are guaranteed to get a reply. Not always constructive I may add but the debate is there. Health care professionals want to be able to share key learning points with others and audio-visual media represents a great way of doing this. If you can find me a clinician who wouldn’t want a quick way of taking a picture and obtaining patient consent with regulatory approval then I will pledge to dance the funky chicken on a live you-tube feed on #nhschangeday

Do we need this?

Using audio-visual media to enhance medical education has been happening since even before we had VHS (thats a long time for those who have never actually seen a video cassette). Discussion fora, blogs and publications abound on the use of photos to highlight key clinical signs (although probably need to be clear that the evidence of clear benefit of video does still need demonstrating!). Is it an absolute necessity that a simpler way of simultaneously consenting and taking pictures is found – probably not. Would it transform resources such as gmep.org very much so.

Can we do this?

The appetite for #FOAMed extends to peoples own time and resources. The increasing use of hack days to create bespoke health care devices and an appetite for app development at a government level means the market is awash with individuals willing to give for free their skills to make ConsentCam a possibility

Are we allowed to do this?

This is probably the only significant issue so far. As long as patient confidentiality is not breached or impinged and the data is secure it should be possible to gain approval. There will be initial caution, and potentially some critics, but the very production of guidance on audiovisual records and social media by regulators such as the GMC means engagement is more likely to happen now than ever before.

So -please do comment on the life in the fastline blog and lets make the first #FOAMed inspired, designed, produced and utilised app a reality

The implementation of work place based assessments (WPBA) into curricula, partly as a result of the modernising  medical careers programme, has generated a great deal of commentary and angst amongst trainees and trainers[1,2,3]. Recently as a result of communication via twitter a blog – “The NHS Portfolio revolution starts here” has promoted discussion on the use of the e-portfolio. The Academy of Medical Royal Colleges (AoMRC) Trainee Doctors Group (mission statement) met with Karen Begg (ePortfolio Projects Manager at NHS Education for Scotland). Formal minutes of that meeting will be available when approved by the ATDG.  In the interim the following represents some key points to consider when developing future policy. They are the views of the author (Damian Roland and NOT the AoMRC).

• The e-portfolio is a repository of information and assessments which are devised by individual colleges and the foundation school programme. The educational principles surrounding the delivery and use of WPBA should not be confused with the educational and practical delivery of the e-portfolio.

• E-portfolios are have been delivered by organizations which also create and define assessment standards, including WPBAs. RPscyh and RCS are examples of this. NHS Education for Scotland delivers portfolios for a number of colleges and although a bespoke interface is devised for each, the underlying construct (and server) is the same. Assessors need consistency in their interfaces but may deal with trainees from a number of difference colleges. This inherently produces difficulties. Reviewing the tradeoff between generic and specialty specific e-portfolio is important.

• Updating and technological enhancing any large scale electronic interface is a resource intensive activity. Ensuring contracts with developers allow for open source software to be developed may reduce these costs

• Trainee engagement should occur at all phases of e-portfolio design and testing. Developers, Colleges, and Trainee groups must all work together to ensure representation is occurring and appropriately governed.

• Training in utilising WPBA and the e-portfolio for Trainees and Assessors (of all grades) must be relevant and obtainable. The GMC’s proposed  accreditation of trainers will be valuable in this regard.

There remain significant challenges to ensuring the assessment of postgraduate medical education training is valid and reliable. Continuing engagement by all parties in a constructive manner is vital but is important that credible change is seen to occur as the status quo is ultimately not in patients best interests

[1] Miller A and Archer J. Impact of workplace based assessment on doctors’ education and performance: a systematic review BMJ 2010; 341 doi: 10.1136/bmj.c5064

[2] Pathan T and Salter M. Attitude to workplace-based assessment Psychiatric Bulletin September 2008 32:359;

[3] Roland D, Brown C, Long A and Newell S. Paediatric Consultants experience of WPBA. Oral presentation at Association of Medical Education Europe Glasgow 2010 and A Trainee’s view of workplace based assessment [NCAT National Multispecialty Conference 2011]

There is a spectrum from technology-enhanced learning to technology-impairing learning #asme2012

Virtual patients: the teaching should drive the technology design rather than the technology driving the instructional design#asme2012

The distinction between content, outcome and process is important in assessing or evaluating performance in medical education#asme2012

“Students want more formative assessment” – how do anecdotes about what this means differ from literature about what this means?#asme2012

@rakeshspatel @atthepage the missing discourse at #asme2012 – theoretical framings of medical education?

MT @andrewspong: Ten reasons why doctors should use Twitterhttp://bit.ly/NIGIuR | STweM #hcsmeu #hcsmin #asme2012 #hcp#meded @amcunningham

@RonanTKavanagh @nlafferty I have read more journal articles via twitter links than i’ve ever read before. #asme2012 ‏@rakeshspatel

@amcunningham model of care should/is moving to consultant delivered care – trainee numbers are going down – the change will come! #asme2012

“@rakeshspatel: Jane Currie … “There will be more reflection at#asme2012 than in a hall of mirrors!”” I stole that from twitter already!

#ASME2012 preliminary findings on virtual patient design indicate students prefer the simpler linear cases to more complex branching ones

#asme2012 when researchers gave professional med student dilemma scenarios to faculty… There was disagreement +++#professionalism

I think the distinction between ‘expert’ and student is a bit over simplistic… What is an expert, and in which realms? #asme2012

@welsh_gas_doc @dr_fiona there are a few talks at #asme2012about use of WBAs and reflection. Am I naive to think improvements can be made?