1. The training of doctors: concerns, challenges and developments
Professor Jan Illing
Centre for Medical Education Research
School of Medicine, Pharmacy and Health
Durham University
Do you doctors need to change the culture of training and practice?
In this lecture I talk about
The training of doctors, concerns , challenges and developments

2. Overview of the lecture
My introduction to research in medical education and key influences
The concerns about patient safety
Challenges which research has tried to respond to
Recent developments.
The subtext is the culture of medical training and practice.
Change has occurred, responded to need, but is it like a table cloth
limited in size - when you move it, other areas and problems are
uncovered?
In this lecture I will
Talked about my introduction to medical education r research and important influence's
Then present the three themes
The concerns
Challenges
And developments
Link the themes with the sub text : of medical culture

3. Introduction to Medical Education
Prof Tim van Zwanenberg OBE
Northern Deanery
Prof Ed Peile
Warwick University
Awarded President’s medal of
Academy of Medical Educators
in 2009
Prof John Spencer Prof Jill Morrison
Newcastle University Glasgow University Award in Award in 2010
I started work in medical education about 15 years ago, at that time I had two children, the second Kieran, sitting ? Was just a tiny baby – now he’s taller than me!
I worked for Tim van Zwanenberg, a wonderful boss: he valued my contribution and that made me even more motivated.
My first project involved looking at the added valued of having rotations in general practice –at that time junior doctors did not rotate into general practice – so this was novel and a pilot study. This was first introduction to the medical culture and I soon learnt about doctors who had never worked in GP, were often disparaging about GP referral s into hospital and at times call them, rubbish, rubbish referrals.
This clashed with my perceptions of working with Tim, himself a GP, a man who was highly respected and regarded nationally and internationally and was awarded an OBE the year he decided to retire.
As some one who was non-medical , I realised that what I brought was an outside perspective, and I questioned the ‘norms’, possible at time holding a mirror up to the profession and asking if they could see what I could see.
My second influence, was Ed Peile from Warwick – I meet him at me first medical education conference in And was delighted that we did eventually work together with John Spencer and Jill Morrison on a GMC funded study, I will talk about today.
When preparing my slides for today, I learnt for the first time, that all three, had been awarded the Presidents medal from the Academy of Medical Educations – and I had been fortunate to work will all three.

4. Changes in Medical Education
PMETB to GMC
RITA to ARCP
PRHO to F1
SHO to F2
SpR to ST
EWTD to WTR
Portfolios to ePortfolios
Summative to formative -Supervised Learning Events (SLE)
Teamworking to interprofessional working
New Deal
MMC – Modernising Medical Careers
MTAS –Medical Training Application System
Foundation Programme
Core Training
Competencies
Appraisal
Licensure
Revalidation
Reflection
Workplace-based assessments

5. Changes to training The end of the ‘firm’
Greater focus on patient safety
End of locum opportunities as final year student
More learning away from the wards in classrooms and simulation
More patients ‘boarding’ on other wards
Diffused and transient teams
Older patients with multiple health problems
More acutely unwell patients
Shorter periods in hospital
Reduction in working hours, from 120 to 48 hour week

6. Focus on the transition from medical student to junior doctor

7. Concerns: the junior doctor

8. Believe it or not, medical school largely keeps you away from properly sick patients. So I'm thinking, am I really up to this? Hello, is there anyone around who can help me? "We're just a bleep away, you won't be alone in a situation for long" they reassure us in our induction week. A few days in, and that's exactly what happens. With zero experience, I'm suddenly dealing with acutely ill people, out of hours and on my own. I'd like to think I could rely on other doctors, but I can't – I often find them arrogant and abrupt. Instead the nurses are my allies. I wonder if the patients realise I'm new to the job. I think they'd be shocked if they knew; I had to spend almost an hour on my own in a frightening situation with a very ill young patient. I thought she was going to die on me. I begged two other doctors to help but they were busy with other sick patients. It was OK in the end and the patient survived, but it's not an experience I'm ever going to forget. And I know it will happen again, too soon. (21 September 2012)

9. Guardian 1 August 2012
Jen et al.(2009) Early in-hospital mortality following trainee doctors’ first day at work. PLoS One 4, e7103.

10. Challenge: Are medical graduates prepared for practice?
National survey reported that over 40% of medical graduates did not feel fully prepared to start work as a doctor. (Goldacre, 2003) The study also reported that the level of preparedness varied between medical schools. GMC funded research to explore whether medical graduates were prepared for practice.

11. Our research
Aim: To examine preparedness for practice in three diverse medical schools in order to explore the extent to which three differing medical schools can prepare graduates for the workplace. Medical schools: Newcastle, Warwick and Glasgow. Multi-method: qualitative and quantitative, prospective and cross-sectional.

12. Quantitative data
Cohort questionnaire Questionnaire administered to graduates at all three medical schools during shadowing. Assessment data Learning portfolio assessment data reviewed at the end of first placement. Prescribing assessment Newcastle and Warwick F1s (junior doctors) took part in a prescribing test. Clinical team questionnaire Questionnaire distributed to teams who worked with F1s.

13. Qualitative data
Interviews with c 20 final year students from each medical school at the end of medical school and after 4 and 12 months as an F1 (n=65, 55, 46). Interviews with undergraduate tutors, educational supervisors and key managers (n=92). Focus groups with portfolio assessors (n=3). Findings from 250+ qualitative interviews + focus groups.

14. Findings: areas of preparedness
Communication skills
History taking
Clinical and practical skills
Team working

15. Findings: lack of preparedness
Prescribing
Managing acutely ill patients
Complex procedures
Complex communication
On-call and working nights
Prioritising patients and managing time
Hospital procedures and paperwork
Knowledge of NHS
Legal and Ethical

16. Some illustrative quotes
Ward work “I don’t feel that medical school prepares you at all for any sort of ward work in any sort of way really” (WPS3, follow-up, quartile 1) Managing acute patients “I’ve had difficulty with being in the acute situation…being the first person to initiate basic management for that patient and recognising what’s wrong” (NPS26, follow-up, quartile 4) On nights “In hospital they are very supervised, apart from on nights…that’s the fear, where they are most exposed” (G educational supervisor 5) Paperwork “You… presume if you write urgent on it , it will happen urgently and then it doesn’t” (NPS93, follow-up, quartile 3) Prescribing “There is one area where they aren’t prepared and that’s prescribing” (W educational supervisor 4) (NPS93, follow-up, quartile 3

17. Conclusions
Preparedness for practice was related to exposure to clinical practice.
Lack of preparedness was found in areas of practice that were learned on the job i.e. prescribing, managing acute patients, working on-call and prioritising work.
Minor differences between medical schools - maturity and self directed learning.
Greater knowledge of role, legal and ethical issues and NHS would also be improved by increased exposure through on-the-job training.

18. Recommendations
More structured placements that involve the student in authentic workplace practice as part of the team.
Final year students to have a role in the team.
Prescribing – there needs to be more applied learning.
Improvements to shadowing.

19. Research impact Discussed at the Parliamentary Health Select Committee
for patient safety
Discussed in The Lancet
Discussed in The Times
Discussed on Radio 4
Discussed by BMA
Informed Tomorrow’s Doctors 2009

20. Developments: following the research
GMC introduced student assistantships
Further research supporting findings: Matherson and Matherson, 2009, Brennan et al., 2010, Tallentire et al
Testing student assistantship in Belfast, Braniff 2012
“The majority of medical students feel well prepared for
starting work after completing the student assistantship”

21. The future?
“The reliance upon doctors in training to deliver a 24/7 service has to change.”
“Where clinical need dictates, this may involve 24/7 consultant working.”
“All trainees need to be supported by close, appropriate supervision and
this will then increase the learning opportunities and improve the decision-
making, diagnosis and treatment pathways, improving patient safety.”
“Trainees can no longer be expected to learn simply through being
around the hospital working. Training has to be planned, focused and,
as far as possible directed to the needs of the individual trainee.”
Time for Training, A Review of the impact of the European Working Time Directive on the quality
of training, Temple, 2010 MEE

22. Focus on the transition of overseas qualified doctors to the UK workplace

23. Concerns: overseas qualified doctors

26. Challenge: understanding how to better support non-UK qualified doctors
The NHS depends on overseas doctors to run the NHS.
Of 246,000 doctors on the medical register in the UK in 2011
37% qualified from non-UK medical schools.
Discrimination and bullying (Hoosen et al, 2004; Louis et al, 2010; Esmail, 1997)
A higher risk of referral for under performance (NCAS report 2010)
Over-represented in later stages of GMC Fitness to Practise process
(Humphrey et al, BMJ, 2011)

27. Our research
Aims To compare the transition of non-UK and UK medical graduates to the NHS workplace (F1s) To identify what helped or hindered the transition in the first 12 months ESRC funded

28. Methods Quantitative data Cohort questionnaire
UK (n=480) EU (n=12) IMG (n=68)
Clinical teams questionnaire
UK (n=64) EU/IMG (n=19)
Qualitative data
Interviews: prior to starting work (F1) and after 4 months and 12 months in post.
UK (n=65), EU (n=14), IMG (n=52)
Interviews with educational supervisors (n=28)

29. Findings Cohort questionnaire
Overall, non-UK graduates felt more prepared than UK graduates.
Reflecting cultural issues?
Qualitative data
Both UK and overseas graduates shared concerns about clinical work.
Particularly with prescribing, acute management and on-call.
Concerns reduced for both groups after 12 months.

30. Overseas doctors had additional hurdles compared to UK doctors
Some started work late, missed shadowing and induction
Those without family and friends needed help with accommodation and opening a bank account etc.
Cultural differences
Communication with patients – NHS has patient centred care
Communication with clinical team – NHS often less hierarchical, differing team expertise, and relationships
Different way of working in a team – NHS shared decisions,
less ‘doctor knows best’
Different illnesses, equipment and tests in the NHS
Different language, colloquial expressions and non-verbal behaviour
Different legal and ethical issues

31. Legal and ethical issues
“I don’t know if a doctor for example is shadowing, at that time is he actually allowed to, for example, to take blood from a patient or put in a cannula, or does he have to be registered”. (IMG, ID29c) “I think it’s different between here and other countries, like for example when do you really need a chaperone, and if you need a chaperone, what do you need to document, the name of the chaperone not just put in ‘chaperoned’.” (IMG, ID49c)

32. What hindered the transition to the workplace for non-UK doctors?
A long gap before starting work
Lack of exposure to clinical practice in UK
Lack of information about living and working in UK
Lack of support
Lack of feedback about progress

33. What helped the transition to the workplace for non-UK doctors?
GMC tests for International Medical Graduate doctors (PLAB)
Clinical attachments – shadowing
Induction to NHS system, ward and to roles and responsibilities
Shadowing the post – longer for non-UK doctors
On-going support and feedback when in post

34. Conclusions The NHS depends on overseas doctors to fill rota gaps
Overseas doctors are trained in a different system and arrive with a different training culture and need to adapt.
There is limited recognition of important influence of early medical training on practice.
The NHS provides little support to help adjust to the UK workplace
Like UK graduates, overseas graduates need experience of clinical practice in the UK and do this safely.
Lack of support may lead to difficulties later and explain some of the referrals for underperformance.

35. Recommendations
Support before work Provide clear information about the process of starting work in the UK Support clinical attachments Support on starting work Support inductions for overseas doctors Provide shadowing of own job Support in workplace Support buddying and mentoring schemes Increased cultural awareness from other staff Provide on-going feedback

36. Research impact GMC to introduce induction pilot in 2013
“Based on research we’ve commissioned and other available evidence, we believe that doctors new to practice could benefit from additional support before they start practising in the UK.” GMC website 2012
Informed Northern Deanery induction programme for overseas doctors.
Informed local Trusts who set up induction programme for overseas doctors.

37. Recent developments
“Doctors who qualified outside the UK were proportionally more likely to be subject to a GMC investigation about issues such as poor clinical skills and knowledge, lack of knowledge of the law or codes, and an inadequate participation in medical education. They were also more likely to be investigated about these issues within the first two years of joining the UK register”
“However, doctors who trained abroad can face difficulties when they start to practise in the UK, including unfamiliarity with health systems, communication and cultural differences, and lack of proficiency in English. We believe that these doctors may need greater support with adapting to UK practice than has previously been recognised.”
(The State of Medical Education and Practice in the UK, GMC report 2012)

38. Focus on the introduction of revalidation

39. Concerns: rooting out bad doctors
Doctors are still the most trusted profession but due to several public

41. Number of complaints to UK health professional regulators (2007-11)

42. Revalidation
“The purpose of revalidation is to provide greater assurance to patients and the public, employers and other healthcare professionals that licensed doctors are up-to-date and fit to practise.” (GMC website, 2012) “Licensed doctors will have to revalidate, usually every five years, by having regular appraisals that are based on our core guidance for doctors Good Medical Practice” (GMC website, 2012) “These regular checks on doctors will be a world leading system that will help improve the quality of care received by patients.” (GMC website, 2012) Revalidation will start on 3 December 2012.

43. Supporting information
Doctors will be expected to provide six types of information for discussion during appraisal at least once in each five year cycle. They are: 1. Continuing professional development 2. Quality improvement activity 3. Significant events 4. Feedback from colleagues 5. Feedback from patients 6. Review of complaints and compliments

44. Our Research
Study for RCGP on the feasibility of collecting evidence for revalidation for
GPs working peripatetically as locums, out of hours and in remote places
Aim: To explore the potential problems locum, sessional and
remote GPs may have collecting the following evidence for revalidation:
Clinical audit (quality improvement activity)
Significant Event Analysis
Colleague Feedback
Patient Feedback

45. Method
53 GPs recruited, asked to collect evidence required for revalidation
10 focus groups
12 telephone interviews
33 GPs followed up to identify any difficulties in collecting evidence
8 focus groups
10 telephone interviews

46. Findings: cultural issues
“Nobody sees you and nobody knows you. I’ve done locums in practices where nobody’s even said anything…they won’t even take the time to put in your details – you’re just ‘Doctor Locum’.” (initial focus group 5)
Experience of isolation
Perceptions of not being valued
Lack of interest in supporting education
Lack of support to facilitate the collection of evidence for revalidation

47. Findings: quality improvement activity and significant events
Audits were difficult to achieve without access to a practice computer.
Lack of interest in informing sessional doctors about significant events
Awareness that some significant events could be viewed as threatening if identified by an “outsider”

48. Findings: feedback from colleagues and patients
Colleague feedback
Lack of direct contact with other colleagues
Fewer colleagues to ask for feedback
Some GPs refused to provide feedback
Patient feedback
Lack of support from practices to facilitate patient feedback
Feedback based on less doctor contact, could be more negative
Some patients failed to understand the purpose of feedback
Colleague and patient feedback was difficult to achieve
for locum, OOHs and GPs working in remote places.

49. Conclusions from the research
Some doctors will have more difficulty collecting evidence for revalidation.
Locums and those in non-standard settings.
Ensuring equal opportunity for revalidation will require a culture change,
to ensure all doctors are supported during this process.
There is an assumption that revalidation will identify poorly performing doctors
Assumes reasonable knowledge of that doctor
Requires high numbers to be reliable

50. Research impact
“General practices, federations and out-of-hours organisations that frequently
employ GPs on short-term, sessional contracts must recognise their
responsibility to all their employees, including these doctors.
They should inform and involve doctors in any significant event or
complaint that relates to them; they should facilitate access to the clinical
records of patients treated by these doctors for the purposes of clinical audit and
Quality improvement; and they should support the conduct of patient surveys”
The RCGP Guide to the Revalidation of General Practitioners,v7, June 2012, RCGP.

51. Validity of workplace-based assessments questioned?
Assessment of Foundation doctors is considered to be excessive, onerous and not valued (30 per trainee)
The validity of the tools has been questioned due to the lack of training to use them, lack of time and the substantial demands on trainer time.
Tools do not discriminate at top end - focus is on competence
not excellence (Prof John Collins, 2010, Foundation for Excellence. An Evaluation of the Foundation Programme, MEE)
Research on feedback highlights that change depends on who provides the feedback and on knowledge of the individual (Sargeant et al., 2010)
Qualitative feedback is preferred to quantitative feedback (Burford et al., 2010)
Qualitative feedback tells you how to get better (van der Vleuten, 2012)

52. Revalidation: an equal opportunity?
Revalidation will depend on annual appraisals
Currently all doctors do not have annual appraisals: those in non-training
posts, Staff, Associate Specialist and Specialty grade and locums
“There is some evidence that doctors in postgraduate training who
gained their primary medical qualification overseas are proportionally
more likely to experience challenges in progressing through training.”
(The State of Medical Education and Practice in the UK, GMC report 2012)
Overseas qualified doctors were
significantly more likely to have an
unsatisfactory outcome in 2010–11.
(The State of Medical Education and Practice in the UK,
GMC report 2012)

53. The failure rate for international medical graduates taking the CSA component of the MRCGP was 63%
compared to 9% of UK graduates. 13 November 2012
Problems in progressing are about culture not ethnicity.

54. Conclusion
Can revalidation identify underperformers and at the same time drive up quality?
Might the evidence from the problems with workplace-based assessments also apply to revalidation?
Without a culture change is a subgroup of doctors at risk of not being revalidated? What are the consequences for the NHS if these doctors are not supported?

55. Final conclusions
The concerns raised all focus on patient safety The challenge and developments are directed at doctors A culture change is required: to avoid the reliance on junior doctors providing 24/7 care. to recognise different early training and support non-UK qualified doctors. to support doctors in non-standard practice and ensure they are supported in the process towards revalidation.

56. Final comments on progress
“Properly planned and carefully conducted medical education is the foundation of a comprehensive health service”
The Training of Doctors, Report by Goodenough Committee 1944
Recommendations:
Overhaul of undergraduate training, attention to social medicine and health promotion as well as cure
Co-education and equality in hospital appointments
Reform of examination system
Compulsory hospital appointments after qualification
Comprehensive system for the training of specialists
Linking major hospitals with teaching centres
Greatly increased Exchequer grants for medical education and research!

57. A few words of thanks to -

58. From the Northern Deanery to Durham University

59. Having fun teaming building in 2008

60. Meet the team Christmas 2011 Madeline Neill Tracy Paul Gill Charlotte
Bryan

61. My other team!

62. Thank you! Professor Jan Illing Centre for Medical Education Research
School of Medicine, Pharmacy and Health
Durham University