Training, Supervision and Competency in Gynaecological Surgery Dr Dina Bisson Consultant Obstetrician and Gynaecologist and Training Programme Director for O & G Severn Institute, Bristol. 26 April 2007 RCOG London

Training Training refers to the acquisition of knowledge, skills, and competencies as a result of the teaching of vocational or practical skills and knowledge that relates to specific useful skills

Supervision Supervision means the act of watching over the work or tasks of another who may lack full knowledge of the concept at hand. Supervision does not mean control of another but guidance in a work, professional or personal context.

Competency Competence is the ability to perform some task Unconscious incompetence Conscious incompetence Conscious competence Unconscious competence

Domains of Learning Knowledge Exams – MRCOG Skills Surgical skills Attitudes TO2

Gynaecological Surgery Selection of appropriate patient and procedure Pre operative preparation Perform operation Deal with complications and post operative care

Competency in Obstetric Practice Decision Making Communication with patient Communication with team Practical skills

Why an Issue in 2007? Incompetent Gynaecological surgeons? Last gynaecologist struck off medical register in 2002 Aware of changes to training and working practices Risk Assessment

Historical Training “See one do one teach one” Numerous opportunities for training Onerous rotas Many “routine” open surgery cases Higher throughput of cases Hands on early in training

Recent Training EWTD/ Shift working Protected teaching and study leave Cancellation of lists Fewer “routine” cases Laparoscopic techniques Senior trainees need experience

Historical Supervision Apprenticeship/ Firm structure Generalists Time expired senior registrars

Current Supervision No firm structure/ lack of continuity Registrars less experienced Lists cancelled if no supervision Specialisation

Historical Competence No test to pass Longer/Time based training Competence assumed FRCS

Recent Competence Core Log Book Trainees decision Lack of responsibility No direct trainee contact Annual RITA Educational Supervisors report “Any concerns about operating skills?” Log of Experience Number of cases/ expected minimum unknown

Conclusions from Recent Situation Training and supervision in O & G undergone radical change requiring innovative methods to define competency. Competency can no longer be assumed.

Current Situation New Curriculum defined by RCOG New Log Book starts in year 1 New Training Programme Competency not time based New methods of assessment Advanced Training Skills Modules

New Curriculum Defines knowledge and skills Courses to attend Methods of assessment

New Log Book Level of competency defined for each level of training No progression if not achieved Evidence required for all signatures Supervisors take responsibility for signatures Procedures broken down into stages

Competency Based Training Allows for different rates of progress Recognises High Flyers Early detection of trainees in difficulty Defined competencies for basic training Targeted training Transfer to another speciality?

Competency Based Assessments CbD Mini CEX OSATS

Case Based Discussion  Medical knowledge  Clinical Decision making  Application of knowledge  Formalised Case Discussion CbD in gynaecological surgery  Selection of appropriate patient and operative procedure  Ability to deal with complications

 Mini clinical evaluation exercise  Generic Tool used in Foundation programmes  Inpatient or outpatient episodes  Direct observation by trainer  Professional and Interpersonal skills  20 minutes per assessment  Immediate feedback to trainee Mini CEX

Mini CEX in gynaecological surgery Taking consent Pre operative assessment Post operative review Explaining results

OSATS Objective Structured Assessment of Technical Skill Developed by University of Toronto in 1997 Measure technical ability of surgeons Standardised bench model simulators Multi station (OSCE) Validity Content Construct Face Predictive

OSATS in O & G University of Washington in 2000 Live animal models 7 station bench assessment Task specific check list/ global rating scale Expensive Validity

OSATS in O & G Simulation Reproducible “blind” assessors Feasible Valid ?face validity Virtual reality simulators Predictive validity?

OSATS in real life Work Based assessments Opportunities for assessment every day Assessments can be repeated 10 procedures in O & G 5 OSATS per procedure before signature Different level of complexity

OSATS Opening and Closing Abdomen Caesarean section Perineal repair Manual removal of placenta Fetal Blood Sampling Operative Vaginal Delivery Evacuation of uterus Diagnostic Laparoscopy Diagnostic Hysteroscopy Operative Laparoscopy

OSATS Two parts to the form Checklist Done independently/ needed help All steps must be completed Generic Technical skills Not relevant to every procedure Majority to the “right” side Must fully understand areas of weakness

Generic Technical Skills Assessment INSIGHT / ATTITUDE Poor understanding of areas of weakness Some understanding of areas of weakness Fully understands areas of weakness RESPECT FOR TISSUE Frequently used unnecessary force on tissue or caused damage by inappropriate use of instruments Careful handling of tissue but occasionally causes inadvertent damage Consistently handled tissues appropriately with minimal damage TIME & MOTIONMany unnecessary moves. Frequently stopped operating or needed to discuss next move. Makes reasonable progress but some unnecessary moves. Sound knowledge of operation but slightly disjointed at times Economy of movement and maximum efficiency. Obviously planned course of operation with effortless flow from one move to the next. KNOWLEDGE / HANDLING OF INSTRUMENTS Lack of knowledge of instrumentsCompetent use of instruments but occasionally awkward or tentative Fluid moves with instruments and no awkwardness and obvious familiarity with instruments

Advanced Training Skills Modules Benign Abdominal Gynaecology Surgery Vaginal Gynaecology Surgery Hysteroscopic Surgery Laparoscopic Gynaecology Surgery

ATSM Curriculum Defined Methods of assessment Completion of module signed off ?may be part of future person specification for consultant posts

Assessment of Consultant Practice Annual Appraisal Record of Adverse Incidents Complication Rates Use of Assessment Methods Evidence of Competency

Conclusion Changes in Working Practices Focussed Training Curriculum Well Defined Supervision Evidence Based Competency

Conclusion Ensure Competent Workforce Maintain Public Confidence