Medical Education England, evaluation of Foundation Training Programme

Medical Education England are conducting a consultation on Foundation Training of junior doctors. This is in itself a laudable thing to do, as one might expect from something recommended in the rather marvellous Tooke Report. However, the thankfully-now-departed-Lord Darzi, whose job title I've already paraphrased in my head as "hopelessly out of his depth", decided to remove from the body the budget for medical education.

As president of the Royal College of Surgeons, John Black, has pointed out, this makes it doubtful they'll have the ability to get things changed.

Anyway, their questions are nicely targeted at the key failings of the system as is, so here is my response to it. It is largely rant, but parts of it may be entertaining, and it may make interesting reading for a few of you. Questions from the consultation document are in bold, thus.

1. What were the original objectives of the Foundation Programme?
Respondents may wish to consider both educational objectives and other objectives (e.g. service provision, workforce planning etc.)

In practical terms, the programme was intended to ensure all graduates delivered good clinical care, could work safely and appropriately within teams, and developed from where they were as medical students – or showed potential, if you like. They needed to show that they understood the framework within which we operate as doctors both locally at a community level, nationally, and internationally. It also required that we produce large numbers of workplace assessments with no demonstrated educational value, thereby producing a neat piece of hypocrisy in relation to another of its purported aims, that of encouraging us all to demonstrate evidence-based practice (reminder: per p.39 of the 2008-2009 survey, none of the assessments in use "received a rating higher than 41% from consultants, even from those trained in their use".

Theoretically, it was founded on the Unfinished Business, Modernising Medical Careers, and from the NHS Plan (2000) document (sections 8.27 & 8.28) and its commitment to increasing consultant numbers and modernising the SHO grade. Perhaps most notable are the problems listed in Unfinished Business (p.4) with the old system: (1) poor job structure, (2) poorly planned training, (3) weak selection and appointment procedures, (4) increasing workload, (5) inadequate supervision, assessment, appraisal and career advice, (6) insufficient opportunities for flexible training, (7) unsatisfactory arrangement for meeting the training needs of non-UK graduates, (8) the variability in the relationship between Royal College examinations and their relevance to training programmes.


1.
What were the original objectives of the Foundation Programme?
Respondents may wish to consider both educational objectives and other objectives (e.g. service provision, workforce planning etc.)

In practical terms, the programme was intended to ensure all graduates delivered good clinical care, could work safely and appropriately within teams, and developed from where they were as medical students – or showed potential, if you like. They needed to show that they understood the framework within which we operate as doctors both locally at a community level, nationally, and internationally. It also required that we produce large numbers of workplace assessments with no demonstrated educational value, thereby producing a neat piece of hypocrisy in relation to another of its purported aims, that of encouraging us all to demonstrate evidence-based practice.

Theoretically, it was founded on the Unfinished Business, Modernising Medical Careers, and from the NHS Plan (2000) document (sections 8.27 & 8.28) and its commitment to increasing consultant numbers and modernising the SHO grade. Perhaps most notable are the problems listed in Unfinished Business (p.4) with the old system: (1) poor job structure, (2) poorly planned training, (3) weak selection and appointment procedures, (4) increasing workload, (5) inadequate supervision, assessment, appraisal and career advice, (6) insufficient opportunities for flexible training, (7) unsatisfactory arrangement for meeting the training needs of non-UK graduates, (8) the variability in the relationship between Royal College examinations and their relevance to training programmes.


2. How successfully is the Foundation Programme delivering against those objectives?
Well, to deal with those points in turn:
(1) The new system is more structured than the old. You now know you will be doing 6-8 placements of 3-4 months each at 1-3 hospitals over two years. With that structure, however, you lose flexibility. Whereas in the past trainees in their second year were able to choose jobs which allowed them to try out their possible careers, they’re now not able to do this, and even straightforward requests to swap medical rotations between trainees at the same hospital require an insufferable number of people to sign off that this is okay, when the rotations themselves are nominally all identical anyway. The increase in structure is not a bad thing per se, but it has reduced our ability to investigate our interests and to choose to do a year’s worth of service provision if we have other things (marriage, childbirth, ill relatives) going on.

(2) Poorly planned training. I take this to encompass both training as a whole and the subset within that of education. Training is now a mess. It is virtually impossible, thanks to the shift patterns worked by all doctors, to find time to spend with patients in the company of a senior viagra cialis online pharmacy pharmacy who can teach you. The workplace assessments hinder this because they are badly thought out, have no appreciable evidence base, and cast spending time with trainees as a box-ticking exercise for senior doctors who find that process as loathsome as most trainees do. You cannot make up for that deficiency in clinical time with your seniors with any amount of well-intentioned “modern adult education”; helpful though things like ALS and simulation training are, they must be adjuncts to and not substitutes for training on the job. Education is haphazard at best, with trusts given the impossible job of delivering the entire Foundation curriculum to a group of shift-workers in disparate geographical locations. Foundation education sessions are therefore variable in quality to say the least, particularly at F2 level where nights and A&E rotas are commoner. Outside education courses, although they are the single most useful things you can do to further your career, are almost never funded and rarely allowed as study leave during the Foundation Programme.

(3) Weak selection and appointment procedures
The application form I went through for the Foundation Programme read like something written by management consultants who hadn’t done very well at university but had read books with titles like “who ate your pineapple” or “the forty-two secrets of successful despots”. It was an awkward, fumbling attempt to embrace tools used carefully, on small groups of people, by experts, as a small part of the selection processes in business, and to clutch these tools to the bosom of an organisation looking to use them on every medical graduate in the country and thousands of others besides, by novices, as the entire selection process, in a government employer. I am an English Graduate, and it being largely a creative writing exercise, I scored exceptionally well on it. It was none the better for that.

(4) Increasing workload. Overall, our hours worked are probably fewer than previously. I know of very, very few F1 and F2 rotas which are honestly EWTD compliant, but few go over 60 hours a week on average (although many go over that regularly). However, we’re now paid less for working fewer hours, training is a disaster, registrars and consultants are less available because they’re working the same diabolical shift patterns we are, and we keep getting told how much better we have it, and that we aren’t working more than 48 hours a week when we patently are. I didn’t work under the old system, but I suspect this feels like harder work.

(5) inadequate supervision, assessment, appraisal and career advice
I’ve covered supervision before – putting the seniors who teach on a shift pattern, and then putting the juniors who need to learn on a different shift pattern, and reducing the hours worked by each, cannot but reduce the amount of clinical supervision the juniors get. Think of it as an equation. On top of that, almost half of trainees who make errors cite inadequate supervision as a reason for it (Table 14, p.29). Assessment is a mixed bag: the tools, with the exception of the “mini-ePAT” (or “feedback”, in English) are a waste of everyone’s time, and you’re that much less likely to get a genuine assessment of your performance as a result. Appraisal, however, is made immeasurably better by having educational supervisors, in my humble opinion, although these should *always* be firm heads for at least one rotation in each year. Career advice, as ever, is best when obtained from the horses’ mouths. The career sessions have seemingly been aimed at telling us what questions we need to ask to decide on a career, which in a group of highly educated graduates is a little insulting if you think it through. What we need, of course, is not to be told we need to think about our work-life balance and whether we want to work independently, or earn lots of money, but answers to these questions in terms of what careers involve, and that doesn’t yet happen and indeed is not something the Foundation Programme is best placed to offer.

(6) insufficient opportunities for flexible training. This is better, and at the moment flexible training through Foundation is a reality. It is also one which the trainees really need to organise themselves, but once funding has been obtained centrally, most people I know have been able to persuade Trusts to let them do whatever rotations they want, making it more flexible than it was perhaps intended to be – something which, given the state of the rest of the system, I’m practically obliged to be heartily in favour of. And so I am.

(7) unsatisfactory arrangement for meeting the training needs of non-UK graduates,
MTAS cleverly improved this arrangement by denying them all careers in the UK, making them emigrate, and causing the British Association of Physicians of Indian Origin to take the perpetrators of this disaster to court in a case which was a classic pyrrhic victory. In terms of European graduates coming over now, I would be fascinated to see stats on Foundation trainees who fail years. My experience has been that they are almost invariably from outside the UK – and I don’t think that’s necessarily because they’re worse doctors. Is the training actually helping meet their needs, then?

(8) the variability in the relationship between Royal College examinations and their relevance to training programmes.
You’ll be relieved to hear that for the first time I don’t feel in a position to comment on this, except to point out that baldly listing pass rates for different Royal College examinations without looking at the differences between those Colleges and what they’re assessing isn’t much of an “analysis”.


3. What are the future needs of the service and trainees from the first two post-graduate years (PGY1 and PGY2)?
Respondents may wish to consider both educational objectives and other objectives (e.g., service provision, workforce planning, etc.)
First, prompted by the “PGY” TLA, and most importantly: no more name changes to the years. “House officer”, and “Senior house office” work fine.
The service needs are simple: there aren’t enough trainees to fill the rotas. What the service requires is, er, a way of appointing doctors to non-training “service roles” for short periods to increase the quality of training posts. That would also stop them haemorrhaging cash on locums when budgets are being cut left right and centre.
Trainees need less layers of management in their Foundation Years. I would guess that fewer than 1% of trainees could accurately describe the relationship they have as individuals with Trust, Deanery, and Foundation Programme, never mind what the LAB, LFG, and LNC do. I’m not sure I can answer either question despite taking an interest in these things, having been to meetings of all three of the latter committees, and having served as a rep in both my foundation years.
We need to be allowed to play the game. We are not responsible for the system; we have no ability to change it at present. When the benefits of postgraduate exams in terms of securing specialty training are so huge, therefore, we must be allowed to use our education time and study budgets to prepare for these exams. No one will get a ST job in surgery because they went to a session on reflective practice, and no one will get a ST job in obstetrics because they understand the different types of antipsychotic. You are welcome to tell us that we are adults and need to take responsibility for our own ongoing education, but please understand that we will therefore expect you to put in place a system which does not prescribe education to us regardless of our needs as the current one does.
We need a system where we can spend time at the bedside with senior doctors. That means less shift patterns, and perhaps longer hours: fine. Let us get our training in a way that works, and stop making training juniors into something seniors are obliged to do.


4. How successfully is the Foundation Programme delivering against those future needs?
It’s making limited progress in a small number of important areas (continuity of educational supervision/appraisal, flexible training), and it is losing important ground in a large number of others (training, service provision, encouraging self-reliance and self-determination).

5. What changes are needed to ensure that PGY1 and PGY2 deliver against future needs?
Respondents may wish to consider changes to the purpose, curricula, length, rotational structure, assessments, educational environment, selection processes, governance, career advice, and implications for training both pre-and post PGY1 and PGY2
FY1 teaching can be generic: it is appropriate then to have a series of pre-determined lectures on core topics. These should be assessed by F1s, and their own feedback should be available to them immediately alongside that of previous years for the same sessions, thus allowing them to establish whether it had improved or not. Trusts should engage them in the process of designing and improving teaching sessions. Medway was excellent at this in 2008-2009. FY2 teaching should be entirely self-determined – if trainees want to go and do a course for MRCP, let them and pay for it. Don’t hire someone to hector them about career choices, nor ship in a (rightly) terrified infection control nurse, nor tell GPs that for some reason they’re not allowed study leave for their membership exam.
FY2 as currently limits our ability to explore our career choices prior to being obliged to choose one. The process of organising swaps within and between Trusts must be easier, clearer, and should not require the approval of anyone beyond the two trainees involved and their educational supervisors, with an appeals process if one or both educational supervisors disagree. No deanery involvement, no FP involvement: if you tell us that the programme is generic and that one rotation is the same as another, you cannot then add “…but they’re different enough for us to have to approve swapping them”.
The relationship between FY2 and ST1 needs to be more carefully thought out. We are being made to choose careers before we’re ready. The Tooke report revealed how few F2s knew what they wanted to specialise in at the start of F2, and how many of them changed their mind during it. Why then have we moved to a system which brings forward that decision while reducing our ability to explore it beforehand?