Where on earth are we with medical training in

Genitourinary Medicine?

Dr Janet Wilson

Consultant in GU Medicine

The General Infirmary at Leeds

Training Programme Director, Yorkshire

Why do trainees go through a specific training programme?

• To get on the Specialist Register

• In order to be appointed as a consultant the person must be on the General Medical Council Specialist Register– By obtaining a Certificate of Completion of

Training (CCT) a doctor gets put onto the Specialist Register, or

– By going on the Specialist Register through Article 14

Calman YearsConsultant

Specialist Registrar – 4 years – CCST(Previously Registrar and Senior Registrar)

Medical SHO posts2 – 4 years

O&G SHO posts2 – 4 years

MRCP MRCOG + 1 year acute medicine

Medical School – 5years

Pre-Registration House Officer Post – 1 year

Direct entryEquivalent training

Hierarchy of Specialist TrainingCalman Years

Specialist Training Authority

Royal College of PhysiciansJoint Committee for Higher Medical Training

Specialist Advisory Committee in Genitourinary Medicine

Postgraduate DeanRegional Specialty Advisor

Regional Programme Director

Educational Supervisor

Specialist Registrar

Hierarchy of Specialist Training with PMETB

Royal College of PhysiciansJoint Committee for Higher Medical Training

Specialist Advisory Committee in Genitourinary Medicine

Postgraduate DeanRegional Specialty Advisor

Regional Programme Director

Educational Supervisor

Specialist Registrar

PMETB

PMETB

Consultant

Specialist Registrar – 4 years - CCT

Medical SHO posts2 – 4 years

O&G SHO posts2 – 4 years

MRCP MRCOG + 1 year acute medicine

Medical School – 5 years

Foundation Training – 2 years

Direct entryArticle 14

PMETB and MMC

Consultant

Specialist Registrar – 4 years - CCT

Core Medical Training2 years

O&G SHO rotation2 – 4 years

MRCP MRCOG + 1 year acute medicine

Medical School – 5years

Foundation Training – 2 years

Certificate of Eligibility of Specialist Training

PMETB and MMC

Consultant

Specialist Registrar – 4 years - CCT

Core Medical Training2 years

Fixed term specialist training posts

MRCPCareer posts eg Staff Grade

Medical School – 5years

Foundation Training – 2 years

Certificate of Eligibility of Specialist Training

Hierarchy of Specialist Training MMC

Postgraduate Medical Education Training Board

Royal College of PhysiciansJoint Royal Colleges of Physicians’ Training Board

Specialist Advisory Committee in Genitourinary Medicine

Postgraduate DeanRegional School of MedicineRegional Programme Director

Educational Supervisor

Specialty Registrar

Yorkshire Deanery

• Postgraduate Deans responsible for local delivery of training programme

• Yorkshire Deanery has delegated medical training to Regional School of Postgraduate Medicine

• Delegated GU Medicine training to Programme Director and Specialty Training Committee

• Programme Director relies on Educational Supervisors to provide day to day training and make assessments

GUM Specialty Registrars

After appointment to Specialty Registrar (StR) the Postgraduate Dean allocates a National Training Number (NTN) and gives training programme details

Each trainee should be allocated a local Educational Supervisor (if rotation may have several different Educational Supervisors)

They should enrol (on line) with the JRCPTB for Higher Medical Training in GU Medicine, and will be given access to the e-portfolio

RITA replaced by Annual Review of Competence Progression (ARCP)

Satisfactory progressUnsatisfactory or insufficient evidence

Development of specific competences required (additional training time not required

Inadequate progress by trainee (additional training time required

Released from training programme (with or without specific competences)

Incomplete evidence presented (additional training time may be required

Recommended for completion of training

Role of Assessment

There has been little guidelines about how this should be done in the past

Often was just a case of “doing time”

Open to great variation in standards, so therefore potentially unfair

and potentially dangerousif poorly performing doctorsnot identified

Assessments

Knowledge

• PMETB has approved Dip GUM as knowledge-based assessment by the end of year 2

• Liverpool Dip GUM, DFFP and Dip HIV were not accepted by PMETB

Assessments

Skills

• Mini-CEX Assessment (Clinical Evaluation Exercise). This is a short structured observation exercise taking about 20 minutes, involving direct observation of the trainee in a consultation

Mini-CEX Assessment

Assessments

Attitudes and generic skills

• Multi-source feedback (MSF) – these will be given to 20 individuals to complete. They will be sent back to the educational supervisor who will “pool” the results and discuss the findings with the trainee

3600 assessment form

Future assessments

Knowledge and skills

• Case based Discussion – indicates competence in clinical reasoning, decision making and application of medical knowledge in relation to patient care

MTAS

The numbers that broke MTAS in 2007Applicants Eligible total 27,800

UK graduates 13,600 IMG doctors 12,100

Training posts Total 15,604Run through training 11,800

FTSTA 3,627 Academic fellowships 177

Acceptances UK graduates 9,800 69% IMGs 3,950 28% EAA 750 3%

England, data from MMC Programme Board October 2007

MTAS

MMC

Aspiring to Excellence

• Interim Report published on 8th October 2007

• 8 key issues identified with suggested corrective actions

• On-line consultation now taking place on the recommendations at www.mmcinquiry.org.uk until 20 November 2007

Findings and Corrective Action - 1

• MMC Policy objectives unclear, compounded by workforce imperatives

• Guiding principles lacking flexibility and ‘broad based beginnings’ lost

• Clear, shared principles for Postgraduate Training that emphasise

- flexibility- aspiration to excellence

Findings and Corrective Action - 2

Doctor Role Clarity• Trainees increasingly supernumerary• Post CCT role unresolved

against a background of deficient acknowledgement of what a doctor brings to the healthcare team

• Consensus on the role of the doctor needs to be reached by end 2008 and service contribution of trainees better acknowledged

Findings and Corrective Action - 3

• Weak DH Policy development, implementation and governance

• Poor intra- and interdepartmental links, particularly health:education sector partnership

• DH Policy development, implementation and governance strengthened with Medical Education lead

• Health:education sector partnership strengthened

Findings and Corrective Action - 4 • Medical Workforce Planning hampered by lack of clarity

of doctor’ role• Policy vacuum regarding increased numbers of

prospective trainees; FTSTAs – the new lost tribe?

• Training budgets vulnerable now held at SHA level

• Revised medical workforce advisory machinery with oversight and scrutiny of SHA roles

• Policy regarding international medical graduates and the future career path of FTSTAs needs urgent resolution

Findings and Corrective Action - 5Medical Professional Engagement• Despite involvement influence weak

• The profession should develop a mechanism for providing coherent advice on matters affecting the entire profession

Findings and Corrective Action - 6Management of Postgraduate Trainingin England

• Lack of cohesion

• Suboptimal relationships with service and academia

• Postgraduate Deaneries should be reviewed to ensure they deliver against guiding principles (flexibility, aspiration to excellence) and NHS priority of equity of access

• In England trial ‘Graduate Schools’ where supported locally

Findings and Corrective Action - 7

Regulation• The split between two bodies, GMC and PMETB

creates diseconomies (finance and expertise)

PMETB merged within GMC offering:• Economy of scale• A common approach• Linkage of accreditation with registration• Sharing of quality enhancement expertise• Reporting direct to Parliament, rather than through

monopoly employer

Findings and Corrective Action - 8

Structure of Postgraduate Training with MMC• Lacks broad based beginnings• Lacks flexibility• Doesn’t encourage excellence• Non resolution of NCCG contract and FTSTA plight

• The structure of Postgraduate Training should be modified to provide a broad based platform for subsequent higher specialist training, increased flexibility, the valuing of experience and the promotion of excellence

Key training recommendations (1)

• FY1 doctors renamed Pre Registration Doctors- linked to local medical schools

• FY2 year cease in 2009, jobs move into Core training – medicine, surgery, O&G, family medicine etc

• Selection into one of a small number of broad based core specialty systems after FY1

• Core training increased to 3 years - called Registered Doctors

• Hybrid training of 2 years for “uncommitted”• Modular curricula to aid flexibility / transferability

Key training recommendations (2)

• Standardised short listing and selection processes across Deaneries within 2 years

• “Trust registrar” is the new Staff grade and must be destigmatised - eligible for some HST positions and Article 14 (CESR) route

• Entry into HST three times a year by National Assessment Centres

Postgraduate training - inquiry recommendations

Conclusions of Tooke Report

From this damaging episode for British Medicine must come a recommitment to optimal standards of postgraduate medical education and training.This will require a new partnership between DH and the profession, and health and education.An aspiration to excellence must prevail in the interests of patients.