Speciality training in paediatric anaesthesia: an update

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Speciality training in paediatric anaesthesia
an update

• Thames PAG 15th May 2008
• Nargis Ahmad

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The changing picture

• Modernising Medical Careers
• Implications for training in anaesthesia
• StR training in paediatric anaesthesia
• Competence revolution in post graduate medical
  education

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The way we were
1993 - Hospital DoctorsTraining for the Future
EU legislation on specialist medical training
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MMC

• August 2002 - Unfinished business
• February 2003 - Modernising Medical Careers -
  initial plans
• April 2004 - MMC The next steps details of the
  new structures
• June 2005 - Curriculum and operational framework
  for Foundation Training published.
• August 2005 - Start of new 2-year Foundation
  programme
• January 2007 - Start of recruitment to Specialty
  Training jobs
• June 2007 - Gold Guide to Postgraduate Specialty
  training
• August 2007 - Start of Specialty Training jobs.

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Influences on training reform

• NHS PLAN
• Need fully trained doctors
• UK self sufficient
• EWTD
• DH removed ring fence around training budgets
  2006
• PMETB
• with the introduction of competence-based,
  assessed, PMETB-approved curricula, explicit
  standards will underpin the new programmes

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Postgraduate Medical Education And Training Board
(PMETB)

• PMETB is the independent regulatory body.
•  
• Established by statute in 2003 took over the
  responsibilities of the STA
• is accountable to Parliament
• acts independently of government as the UK
  competent authority
• Unlike the STA, PMETB is independent of the Royal
  Colleges. PMETB commissions services from the
  Royal Medical Colleges.

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17th March 2007
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MTAS 2007

• 24 April - Sir John Tooke asked to lead
  independent inquiry into implementation of MMC
  and MTAS.
• 12 July - The final report of the Douglas Review
  is published, describing ST selection as "the
  biggest crisis within the medical profession in a
  generation".

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Response to the Tooke Review

• Stakeholders in PG medicine
• agreement
• DH
• Formal response published Feb 2008
• 24/47 accepted
• in principle - most are qualitative with no
  timetable or mechanism for measuring progress
• GMC to merge with PMETB 2010
• 23/47 deferred (NHS MEE) next stage review

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The Health Committee Report on MMC 8 May 2008

• DH and CMO criticised
• NHS MEE
• MMC programme board
• Royal colleges to work with PMETB and deaneries
• Greater differentiation within consultant grade
• Lord Darzi's nationwide vision for next decade
  -June 2008 clinically led-locally driven

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So where are we now?

• 2 years core training
• Uncoupled
• Recruitment
• Staged
• Managed by PG deaneries

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New Curricula

• Developed by the medical Royal Colleges and
  approved by PMETB
• PMETB with the medical Royal Colleges, faculties
  and the speciality associations curricula for
  all 57 medical specialties, plus 30
  sub-specialties.
• Common standards, clarity and transparency to
  training promoting the continuous development
  of doctors skills in order to meet patient need.

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New Curricula
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Training the trainers 2010
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Generic standards for training

• Patient safety
• Quality Assurance, Review and Evaluation
• Equality, Diversity and Opportunity
• Recruitment, selection and appointment
• Delivery of curriculum including assessment
• Support and development of trainees, trainers and
  local faculty
• Management of Education and Training
• Educational resources and capacity
• Outcomes

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Paediatric Anaesthesia Intermediate Level ST3
And ST4

• KEY UNIT OF TRAINING
• 1-3 months
• Competencies relate to knowledge more than to
  skills
• Child protection

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Paediatric Anaesthesia Higher And Advanced
Level(ST Years 5, 6 And 7)

• Preparation for independent professional practice
  in their consultant post of choice
• Higher training for those pursuing a generalist
  career
• Advanced training to become an expert in a
  special interest area -.at least 6 months up to
  a year

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Higher Training In Paediatric Anaesthesia
Objectives

• To develop competence in meeting the anaesthetic
  needs of infants and children for common surgical
  conditions
• To be able to organise and manage safely a list
  of paediatric cases, with consultant supervision
  for neonates and infants under 1 year
• To be able to manage hazards and complications of
  paediatric anaesthesia
• To be able to resuscitate and stabilise a sick
  child for transfer

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Higher Training In Paediatric Anaesthesia

• Skills to acquire
• Skills to enhance
• Training in child protection

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Advanced Training In Paediatric Anaesthesia

• Training objectives
• Indicative clinical experience
• Professional qualities
• Skills
• Minimum case load
• Training environment
• Child protection

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Advanced Training In Paediatric Anaesthesia
Training Objectives

• FT either in a specialist paediatric hospital or
  a tertiary referral centre, or lead consultant
  for paediatric anaesthesia in a district general
  hospital
• To acquire an in-depth knowledge and
  understanding of the anatomical, physiological,
  pharmacological and psychological differences
  between adults and children, and be aware of the
  changes associated with growth and development,
  and with co-existing disease
• To be competent in relation to every aspect of
  the peri-operative management of children of all
  ages, from the very premature neonates to those
  children with complex coexisting disease

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Advanced Training In Paediatric Anaesthesia
Training Objectives

• To become skilled in communicating with children,
  parents and other carers throughout the surgical
  episode, and also become an effective
  communicator within the multi-disciplinary
  paediatric team
• To understand the legality of consent in
  children, in relation to research, restraint and
  procedures
• To acquire leadership skills when managing both
  elective and emergency paediatric cases and also
  when supervising more junior trainees

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Advanced Training In Paediatric Anaesthesia
Indicative Clinical Experience

• Enhance basic and higher training
• Minimum 6 months
• Experience in full range of paediatric spectrum
• Direct supervision in first 3 months
• Experience as lead clinician elective
  emergency
• 1-2 months PICU
• Acute pain
• Specialist interest areas
• Wider aspect of paediatric care

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Generic professional skills

• attitude and behaviour
• communication
• presentation
• audit
• teaching
• ethics and law
• management

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Clinical Assessment Tools

• ..the RCoA has decided that common tools and
  documentation should be used for workplace based
  assessment,
• The tools to be used are
• Multi- Source Feedback
• Mini-Clinical Assessment Evaluation Exercise
• Direct Observation of Procedural Skills
• Case Based Discussion

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DOPS
6 EVERY 6 MONTHS
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Mini-Clinical Assessment Evaluation Exercise
(mini-CEX)

• The key learning event in anaesthetic training is
  the supervised operating list, where management
  plans are formulated, problems are discussed,
  techniques and procedures taught and behaviours
  learnt.
• The mini-CEX is intended to evaluate the core
  skills that trainees employ in many clinical
  scenarios throughout the curriculum
• Thought processes and management decisions not
  knowledge

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Mini CEX
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Case-based Discussion (CbD)

• Designed to evaluate decision making,
  interpretation and application of evidence by
  reviewing a record of anaesthetic practice
• It is intended to assess the clinical
  decision-making process and the way in which the
  trainee used medical knowledge when managing a
  single case

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Case Based Discussion
2 EVERY 6 MONTHS
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Case Based Discussion
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Multi-source Feedback (MSF)

• Examine behaviour. They mostly rely on feedback
  ratings obtained from colleagues and/or patients.
  All require a considerable commitment of time and
  resources if they are to be done fairly and
  safely. If not done properly, with appropriate
  collation of evidence and the provision of
  careful and sensitive feedback, they can be
• devastating to trainees.
• In due course central guidance and or direction
  on this may be given by the PMETB e.g. by the
  introduction of a nationally validated system of
  Multisource Feedback (MSF)

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Climbing the pyramid
Does
Shows how
Knows how
Knows
Miller GE. The assessment of clinical
skills/competence/performance. Academic Medicine
(Supplement) 1990 65 S63-S7.
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Climbing the pyramid
Does
Shows how
Knows how
Knows
Miller GE. The assessment of clinical
skills/competence/performance. Academic Medicine
(Supplement) 1990 65 S63-S7.
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Managed Integrated Learning
LEARNING
ASSESSMENT Reliable Valid
CURRICULUM define learning objectives
APPRAISAL MENTORING
STANDARD SETTING RECORDING portfolio
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Challenges

• Assessment should be a positive process, must be
  robust i.e. objective, reliable and valid as
  consequences may be serious for any trainee
• Be careful of what you measure and what you cant
  measure
• The trainee in difficulty
• Trainees work with each individual consultant
  infrequently
• EWTD
• Time needed to perform assessment

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The Northern Ireland Experience

• Pilot Aug 2005
• Each 3/12
• 2 DOPS
• 1 Anaes-CEX
• 1 CBD
• MSF end year 1

• DOPS 25mins (10-85)
• Anaes CEX 38mins (10-100)
• CBD 38 mins (20-75mins)

In our experience the new assessment tools are
better at identifying weaker trainees than
rewarding and motivating those who are excellent
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say nothing and try look like you know what
you are doing?
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• ..to be continued