Speciality training in paediatric anaesthesia: an update Thames PAG 15 th May 2008 Nargis Ahmad

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

The way we were Hospital Doctors—Training for the Future EU legislation on specialist medical training

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

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”

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.

17 th March 2007

MTAS 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".

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

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’

So where are we now? 2 years core training Uncoupled Recruitment – Staged – Managed by PG deaneries

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.

New Curricula

Training the trainers 2010

Generic standards for training 1. Patient safety 2. Quality Assurance, Review and Evaluation 3. Equality, Diversity and Opportunity 4. Recruitment, selection and appointment 5. Delivery of curriculum including assessment 6. Support and development of trainees, trainers and local faculty 7. Management of Education and Training 8. Educational resources and capacity 9. Outcomes

Paediatric Anaesthesia: Intermediate Level ST3 And ST4 KEY UNIT OF TRAINING 1-3 months Competencies relate to knowledge more than to skills Child protection

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

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

Higher Training In Paediatric Anaesthesia Skills to acquire Skills to enhance Training in child protection

Advanced Training In Paediatric Anaesthesia Training objectives Indicative clinical experience Professional qualities Skills Minimum case load Training environment Child protection

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

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

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

Generic professional skills attitude and behaviour communication presentation audit teaching ethics and law management

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

DOPS 6 EVERY 6 MONTHS

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

Mini CEX

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

Case Based Discussion 2 EVERY 6 MONTHS

Case Based Discussion

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)

Climbing the pyramid Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine (Supplement) 1990; 65: S63-S7. Knows Shows how Knows how Does Professional authenticity Cognition Behaviour

Climbing the pyramid Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine (Supplement) 1990; 65: S63-S7. Knows Shows how Knows how Does Professional authenticity Competence Performance

Managed Integrated Learning CURRICULUM define learning objectives LEARNING APPRAISAL & MENTORING ASSESSMENT Reliable Valid STANDARD SETTING & RECORDING portfolio

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 can’t measure The trainee in difficulty Trainees work with each individual consultant infrequently EWTD Time needed to perform assessment

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”

………say nothing and try look like you know what you are doing?

…..to be continued