Shape of Training - review questions

The following is the College's response to this consultation.

Over the next 30 years, how do you think the way patients are cared for will change?
Caring for an increasingly ageing population who have both a heavy burden of chronic disease and complex social care needs with the current artificial boundary between primary and secondary care does not work. For example, at any one time as many as 10% of acute inpatient beds are occupied by patients who are fit for medical discharge but who have unresolved social care issues. There is a need for more pathway defined patient management integrating primary and secondary care with seamless input from social services. This is essential if clinical outcomes are to improve, patient satisfaction be maintained and the necessary cost savings accrued by reducing length of stay in hospital.

Conversely future developments in genetics and pharmacology will perhaps lead to an older population enjoying better health, avoiding dementia etc but being increasingly politicised in demands for access to medical intervention.

To support these changes will require enhanced IT systems to support information sharing. Electronic shared care records work well in other countries e.g New Zealand. The 2011 census is an opportunity to harness population data.

Cheaper, more locally accessible diagnostics -which for an ageing population who will wish and need to be cared for at home whenever possible-  are essential.

Although delivery of perioperative care requiring anything other than local anaesthesia will continue to be delivered in secondary care environments there would be scope for preoperative assessment to be conducted with greater use of on-line technologies including Skype© or similar systems with face to face assessment confined to those patients with the most complex problems. Anaesthetists will be pivotal in developing their role as experts in perioperative medicine to support these initiatives.  Enhanced recovery programmes are getting people out of hospitals earlier with the potential that anaesthetic side-effects and complications may be missed.  Early discharge from hospitals in other countries relies on high level support from district nurses. Some system needs to be in place to ensure patients have access to support and are not abandoned at home. Ideally there should be specialised post-operative care district nurses with specialist knowledge and access to anaesthetists for advice.

To improve patient convenience and maximise cost saving greater investment in one-stop treatment should be considered. The current use of this approach in the management of e.g urinary tract bleeding has been highly successful and could be rolled out to other aspects of care including surgical care requiring anaesthesia.

What will this mean for the kinds of doctors that will be needed in primary care? In secondary care? In other kinds of care?
Primary care will need some of its doctors to have enhanced competencies (see below) who are able to rise to challenge of managing more complex, ageing patients in the community. There will be considerable opportunity for engagement of clinical academics integrating research into healthy ageing for benefit of an older population.

Chronic Pain may be seen as a service more appropriately delivered in the community and there are current examples of this trend. Training programmes may need re-design to guarantee appropriate educational opportunities.  Pain medicine training is an essential aspect of anaesthetic training and should not be neglected, particularly at the basic and intermediate levels.  A more detailed response on pain services will be provided by the Faculty of Pain Medicine (FPM)

 Secondary care will require more generalists who are able to manage the bulk of patients presenting to hospital with common conditions and who are also able to recognise and stabilise the more rare and complex problems before referring them on to super-specialists.  The current model of having super specialists for all areas of practice in each locality does not allow adequate competency to be maintained in the management of the rarest conditions and is not cost-effective. Super-specialists should be appointed on a regional or where appropriate national basis to ensure adequate clinical exposure is maintained.

Enhanced on-line diagnostics could be crucial in improving the interface between primary and secondary care and for obtaining super-specialist opinion.

Anaesthesia by its nature as a time critical acute specialty will require generalists who can manage the routine caseload but who are able to rise to the challenge of stabilising life-threatening situations without recourse to their super-specialist colleagues.  This will need to be reflected in anaesthesia training and life long (CPD) learning programmes.

What do you think will be the specific role of general practitioners (GPs) in all of this?
They will remain as gate keepers to services, particularly as presently they hold 90% of all patient information, but they may also develop specialist areas such as respiratory care, diabetes etc to support the care in the community agenda. This may also extend to “fitness for anaesthesia/surgery” assessments although this would ideally involve input in a primary care environment from anaesthetic expert opinion. Primary care doctors need to take more responsibility for preparing patients to be fit for surgery.  If they consider referring the patient for a surgical consultation they should screen them for cardiovascular and respiratory pathology and basic blood tests to rule out hidden renal or liver, endocrine pathology for example, in advance.  GPs should have the skill to do this and the expert anaesthetic opinion should be in the form of training GPs and acting as a link person. Increasing numbers of GPs may become based in ED departments to deal with the primary care caseload, particularly for out of hours provision, so blurring the boundaries between the conventional GP and secondary care doctor.

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?
GP training may need to be extended to allow for increased competency in a defined sub-specialty area of practice to be obtained and to ensure that all GPs have experience in core areas such as paediatrics and psychiatry. This extra training should be largely community rather than hospital based to ensure that the speciality experience gained is relevant to general practice.

To ensure greater confidence and competence to practice as a generalist there will be a need for all doctors to acquire broad-based experience particularly at early stages of training via ‘common stem’ rotations. For the critical care specialties, including anaesthesia, ACCS training is already proving to be a great success in this regard.  There should also be a positive move to break down the traditional barriers and rivalries between primary and secondary care specialists, often driven by culture but also by budgets.  Joined up training and cooperation in the delivery of training programmes will be the key to moving pre-operative and some post-operative services into the community.  Colleges and the AoMRC will have a pivotal role is achieving this by understanding the requirement to train other specialties.  

The term ‘generalists’ will need clarification. Does this mean a CCT holder with no sub-speciality area of practice or could it mean a doctor leaving training at some other waypoint?  For anaesthesia with only the potential for a dual CCT in ICM or Pre-Hospital Emergency Medicine (PHEM) it means that that the vast majority of those completing training are generalists with a CCT programme designed to produce broad competence rather than mastery in sub-specialist practice.

Although many anaesthetists gain some extra sub-specialty experience in CCT programmes this rarely produces a fully experienced practitioner with full mastery of their area of interest on appointment to consultancy. Post CCT training packages via Fellowship posts are becoming increasingly common across the profession including sub-specialty areas of anaesthetic practice. The RCoA is currently developing a template to define the content of a high quality post-CCT programmes.  

For all doctors there must be commitment from employers that completion of formal training represents just the start rather than the end of learning and professional development. CPD should be fully resourced not just to meet the relatively ‘low-bar’ revalidation requirements but ensure a clinically excellent workforce.

How can the need for clinical academics and researchers be best accommodated within such changes?
Trainees in all specialities including general practice should have the opportunity to develop areas of research and as a minimum learn the fundamental principles of research methodology and critical appraisal of research literature to allow them to make better choices for their patients as medical practice evolves.

For those committed to a research career, CCT programmes should be bespoke to allow clinical and research training to be integrated. It may be that doctors with research aspirations should be routinely affiliated to a university as well as to a Deanery to ensure greater exposure to academia and research opportunities.

There need to be clear incentives to recruit and retain high quality academics as their outputs ultimately result in improved clinical outcomes. This should start at the undergraduate level with maintaining ring-fenced funding for intercalated BSc courses and encouraging strategies such as the Cambridge integrated MB-PhD programme. There is a need to review role of HEIs as NHS and HEI funded systems have become very different.

How would a more flexible approach to postgraduate training look in relation to: Need to define more “more flexible approach” – working pattern, training pattern, moving between training types etc (CD forum comment)

Doctors in training as employees?
Employment and responsibility at an early stage drives learning.

Although some degree of flexibility is beneficial, perhaps as part of early broad-based training, excessive flexibility may result in unacceptably low achievement of competence resulting in a workforce which lacks confidence and is not fit for purpose for any of the roles they are asked to perform.  Ensuring that broad-based training results in transferable competencies that meet current service as well as future training needs will be a challenge.

However it needs to be acknowledged that with limited hours of working and relatively short rotations during Foundation years young doctors are not always confident to make a firm commitment to a specialty within the current tight time frames for decision making.

Doctors need to be given individual responsibility at as early an opportunity as possible. It was very noticeable that when F1 doctors were introduced to anaesthesia they were initially treated very much like medical students, entirely supernumerary with little responsibility.  They then behaved like students with a poor attendance record and a lack of motivation.  Once given specific roles, with duties that would not be performed by anyone else if they did not do them, not only do they carry out these duties diligently but they behave more professionally when acting in a supernumerary capacity. They need to feel an essential part of the team.

Anaesthetic trainees value the intense support that they get for the first 3 months of their training because they see that they are soon going to be an essential part in the service provision. Some non-anaesthetic ACCS doctors have been a challenge because they do not see independent anaesthesia practice as a necessary achievement.

The service and workforce planning?
Development of a greater commitment to transferable competencies with training may allow easier sideways moves between specialties by trainees who wish to do so depending on their career development, aptitude for their chosen specialty and career opportunities. However, wide-scale movement between specialties particularly after appointment to the specialist registrar grade may be destabilising and make workforce planning more difficult than it already is now.

The outcome of training – the kinds and functions of doctors?
The majority of doctors will train as generalists with a smaller number of sub-specialists. There will still need to be a hierarchical structure with senior doctors of the current consultant model at its pinnacle who will lead teams of doctors and non-medical personnel in supporting roles.

The current postgraduate medical education and training structure itself (including clinical academic structures)?
Overall the current model has been a success for many specialities, including anaesthesia, producing doctors who are largely fit for purpose. However too much sub-specialisation at too early a stage in some specialties has resulted in a shortage of doctors who have the enthusiasm and ability to manage the commoner acute and chronic conditions that constitute the majority of healthcare needs of the UK population.  A more flexible approach to training with a more broad- based curriculum would allow doctors to be adequately equipped to treat the patient profile that society requires.

How should the way doctors’ train and work change in order to meet their patients' needs over the next 30 years?
Doctors will need to have greater in depth training and understanding of the demographic that they will be involved with treating on a day to day basis. For example enhanced knowledge of the issues (clinical and societal) relating to ageing , obesity and the consequences of chronic disease are relevant to all doctors if they are to manage these patients confidently and provide appropriately individualised care. 

Doctors – particularly as part of CPD - will probably do more online and distant learning consolidated by local practical days. Enhanced IT will also increase the amount of telemedicine although this will need to be balanced with the desire for patients to meet their doctors in face to face consultations.

Patients need a high-quality service, delivered by highly trained professionals, using up-to-date techniques in a safe environment but they need to be disabused of unrealistic expectations of what healthcare can provide and they need to be educated to take ownership for their own illness and work in partnership with their carers.

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 probably does not matter a great deal; patients are generally more concerned about the competency of the doctor treating them rather than titles. They want to be treated by someone who is adequately trained and/or appropriately supervised. Most patients recognise and accept that training is necessary and that trainee doctors will be part of the team cares for them. However current nomenclature can be confusing for both patients and hospital colleagues. Previously most patients would have some understanding of e.g the title Senior Registrar… is doubtful that the same would apply to “ST5”.

How should the rise of multi professional teams to provide care affect the way doctors are trained?
The multi professional approach to healthcare is already a reality and we need to embrace this as largely an opportunity rather than a threat. Anaesthesia has always been to a certain degree multi professional, and will no doubt remain so. This is unlikely to affect future training significantly although the opportunities to achieve competence in practical skills may be diluted if other healthcare professionals e.g. physician assistants become more prevalent and compete for the available training opportunities.  Management and leadership training needs to be raised to a whole new level; input from organisations such as the Faculty of Medical Leadership and Management will be important.

Are the doctors coming out of training now able to step into consultant level jobs as we currently understand them?
Not all; in anaesthesia, most doctors coming out of CCT programmes are reasonably well prepared for posts working as a generalist but are less confident to fulfil some subspecialty roles (e.g. paediatrics,  cardiothoracic, neuro) such  that further training beyond that provided by the CCT program is often required . See also comments in item 4. It is rare, for example, for a doctor to be appointed to a Consultant post in cardiothoracic anaesthesia without having undertaken an extra year of post CCT training either in the UK or overseas.

Is the current length and end point of training right?
In order to produce generalist anaesthetists the current length of training is about right. However sub-speciality training may require extra time with an additional year likely to benefit overall smooth passage to consultant status. Whether this should be part of or additional to a CCT programme is a matter for debate.

If training is made more general, how should the meaning of the CCT change and what are the implications for doctors’ subsequent CPD?
The CCT should be regarded as more of a driving licence designed to produce doctors who are broadly competent generalists. Individual specialties will need to debate what should be part of a generalist CCT programme and what will constitute sub-specialist training that may need to be delivered, for example, as part of post-CCT Fellowship.  There will be a need to have clearly and well defined learning outcomes and curricula for generalist programmes in particular. A generalist CCT should be regarded as the beginning not the end of the life-long learning. Achievement of additional competencies should occur throughout the professional life-time of a doctor’s career. CPD, which is currently being presented as a relatively low-bar part of the revalidation process, will be crucial to this life-long learning agenda.

How do we make sure doctors in training get the right breadth and quality of learning experiences and time to reflect on these experiences?
This should be part of the life-long learning agenda with training based in locations that offer not only adequate breadth of experience but high quality training from dedicated trainers.  This will inevitably mean that not all hospitals will engage in formal post graduate training of doctors in traditional CCT programmes but all health care institutions must be fully committed to the life-long learning agenda for its employees. Training institutions will need to receive adequate incentives and resources to deliver training with a set of metrics developed to evaluate training programmes.

The current model of shoe-horning training around service delivery is unsatisfactory and there will be a need to separate service from training at least for some sections of the training pathway. Making trainees fully supernumerary for some sections of their training would then be combined with other periods of predominantly service delivery to allow consolidation and reflection on their learning as part of a more immersive, apprenticeship based experience. Important attributes such as team working, continuity of care, greater sense of responsibility for patients and ability to develop care plans for patients as individuals rather than disease states will be developed during the service periods. This will need modification to the existing  assessment and competency framework, including examinations, and the strengthening of mentoring schemes.

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 difficulty transitions are from medical student to foundation program, foundation program to core/specialist training and then from specialist trainee to independent practice. Changes in undergraduate curricula removed from a ward based, apprentice type structure in the later years seem to have impaired the ability of newly qualified doctors to function as clinicians. A national undergraduate curriculum would improve the disparity in undergraduates being fit for purpose at qualification. The foundation program often poorly prepares trainees for core training, and would be improved by greater flexibility both in terms of its content and duration, to allow trainees to achieve the breath of experience that is necessary to build broad based competence.

Trainees in specialist training approaching accreditation need to achieve greater clinical independence to allow them to develop essential attributes such as confidence in their own decision making, leadership skills and team working.

Support from senior colleagues and all multi-disciplinary team members is essential to smooth the transitions with initiatives such as development of mentoring schemes, electronic discussion forums and cross specialty sharing of experiences being important.

Have we currently got the right balance between trainees delivering service and having opportunities to learn through experience?
Probably not. There are often insufficient opportunities for service commitment particularly for senior trainees. This is particularly true for the craft specialties such as anaesthesia and surgery, where the number of cases managed is an essential part of trainee development. Acute specialties such as anaesthesia are by their nature 24/7 activities and the opportunity to achieve the experience of managing the less common but nevertheless life threatening scenarios often do not present during the EWTD restricted clinical exposure. Acquisition of competence is not just about signing off a limited list of cases but obtaining other essential skills such as clinical judgement which are achieved by gaining a large body of experience with adequate opportunity for reflection.

Are there other ways trainees can work and train within the service? Should the service be dependent on delivery by trainees at all?
It is important that trainees deliver service as part of their training. Good quality care involves aspects beyond those of simple practical confidence or application of knowledge, such as taking responsibility, exercising clinical judgement, organisation and prioritisation. A training program which does not provide opportunity for independent practice with appropriate supervision will not create doctors with the ability to perform independently at consultant level.

What is good in the current system and should not be lost in any changes?
The current national postgraduate curricula have generally worked well. Undergraduate training would benefit from implementing this national model.

National assessment frameworks with the well established postgraduate examinations, work-place based assessments and ARCPs although imperfect have brought more structure and objectivity to trainee assessment.  

Trainees are generally better supervised than in the past which is of benefit to patients. Getting the balance between direct and distant supervision particularly for more senior trainees to maximise their confidence and independence without compromising patient safety remains a challenge.

National recruitment. It is not possible to separate training from workforce needs and there is a real concern that a local delivered healthcare strategy including medical manpower could destabilise existing high quality training programmes. A national strategy for trainee recruitment must remain as part of any future developments.

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?
There is currently huge change fatigue amongst all those involved in healthcare, not least amongst those responsible for delivering medical training.  If there must be change then a subsequent extended period of stability must ensue with clear definition of the roles for the various bodies involved, including the medical Royal Colleges.

It is vitally important that any changes to the shape of training are implemented equitably with a robust evidence base. It is essential that senior clinicians including representatives of the medical Royal Colleges are actively involved in making these decisions rather than deferring to the current fad of the educationalists.

Any change must ensure that medical careers remain attractive if we are to ensure that the brightest and the best enter the profession. If some specialties are seen as being more suitable for mid-point credentialing with limited prospects of achieving the current model of consultant status then they are likely to be viewed as being less attractive to prospective trainees. This will have the undesirable effect of decreasing applications from the best young doctors which will ultimately be to the detriment of patients.

31 January 2013