1. Physicianly training- next steps The new Internal Medicine Curriculum.
Professor David Black Medical Director JRCPTB
17th January, 2017

2. Learning Current curriculum challenge for Physicians
The new Internal Medicine Curriculum
Greater understanding of outcome based education and CiP’s.
Is it worth having an opening slide explaining just what the federation is and how it oversees MRCP and CPD in addition to JRCPTB. Many College Tutors may think the Federation is something from star wars!

3. Challenges as of 2014 Shape of Training Proposed GMC GPC’s
‘Tick box’ approach to CBME
Medical Registrar concerns

4. Future Hospital Commission
Shape of Training
Respond to the patient and public needs to provide more doctors who are capable of providing general care in broad specialties across a range of different settings and was driven by a growing number of people with multiple co-morbidities, an ageing population, health inequalities and an increase in patient expectation.
A continued need to develop doctors who are trained in more specialist areas to meet local patient and workforce needs.
A sustainable career with opportunities for doctors to change roles and specialties throughout their career.
Future Hospital Commission
A greater proportion of doctors to be trained and deployed to deliver expert (general) internal medicine care and a more structured training programme for (general) internal medicine.
That education in (acute) and or in (general) internal medicine will become a requirement for all medical specialties.

5. The GMC GPC model

6. Full list of GPC domains:
Domain 1: Professional values and behaviours
Domain 2: Professional skills
Domain 3: Professional knowledge
Domain 4: Health promotion and illness prevention
Domain 5: Leadership and team working
Domain 6: Patient safety and quality improvement
Domain 7: Safeguarding vulnerable groups
Domain 8: Education and training
Domain 9: Research and scholarship

7. Improving assessment: STAR

8. WPBA

9. Educational supervisor report
The educational supervisor’s report is pivotal to the ARCP process and should include a summary of multiple consultant reports (MCRs) and multi-source feedback (MSF)
Educational supervisors should report on engagement with the curriculum determined by sampling of evidence and competencies

10. Conclusions in 2014 WPBA: mini CEX, CbD to TEACH (called SLEs)
MRCP exams to ASSESS
Educational supervisors (ES) report to ASSESS
Informed by MCR, MSF and review of eportfolio
But still a long way to go to ensure reliable ES reports and national consistency in ARCP

12. Requirements for Internal Medicine
‘Spine’ of the whole period of training
Must contain GMC ‘Generic capabilities’
Skills in dealing with comorbidities, chronic disease and complexity
Outcome based
14 Competencies in Practice

13. Slides courtesy of Professor Elder
Assessment in 2017
Slides courtesy of Professor Elder

14. Competency based medical education
Can do it
Informing competencies
Subcompetencies
Knowledge, skills, attitudes

15. Competency based medical education
Can do it
Informing competencies
Subcompetencies
Knowledge, skills, attitudes

16. Competency based medical education
Can do it
Informing competencies
Subcompetencies
Knowledge, skills, attitudes

17. Competency based medical education
Can do it
Informing competencies
Subcompetencies 
  
  
  
  
  
  
  

  
  
Knowledge, skills, attitudes

18. Shifting the focus to outcomes
Can do it
Informing competencies
Subcompetencies
  
EPA CiP
Outcome
Knowledge, skills, attitudes

19. Olle ten Cate AMEE Guide 99 2015
So then, what is it?
CiP
“a unit of professional practice that may be trusted to a learner to execute unsupervised, once he or she has demonstrated the required competence”
In the literature called an Entrustable Professional Activity (EPA)
Olle ten Cate AMEE Guide

20. Competencies versus CiPs
Person-descriptors
Knowledge, skills,
attitudes, values
Content expertise
Health system knowledge
Communication ability
Management ability
Professional attitude
Scholarly skills
Work-descriptors
Essential tasks in professional practice
Managing patients in an outpatient clinic
Managing a M.D.T including effective discharge
Delivering effective resuscitation & managing the acutely ill patient
Managing end of life & palliative care
Delivering effective quality improvements in patient care
CiPs require workers with competencies

21. Most CiPs require multiple competencies
Clinical Skills ++ +
Team working
Breaking bad news
Knowledge of the law in medicine
Shared decision making
Understanding of principles of research
Personal behaviour

22. Competencies in Practice “about TRUST”
COMPETENCIES IN PRACTICE: GRADED SUPERVISION ALLOW FOR:
Level 1 -observations of the activity – no execution
Level 2 -acting with direct, practice supervision
Level 3 -acting with supervision available quickly
Level 4 -acting unsupervised (with clinical oversight)

23. Growth of competence over time

24. When is “competence” reached?
When a professional activity is mastered
…on a threshold level
…that permits trust
…to act unsupervised
Competence is a stage in a continuum of development

25. 14 CiPs Managing an acute medical take
Managing an acute specialty related take
Providing inpatient continuity of care
Managing patients in an outpatients
Managing medical problems in other specialties
Managing an MDT
Delivering effective rescusitation
8 . Managing end of life care 9. Patient safety and quality improvement 10. Carrying out research 11. Acting as clinical teacher and supervisor 12. Dealing with ethical and legal issues 13. Ability to function successfully in the NHS 14. Competent in procedural skills.

26. Example
4. Managing patients in an outpatient clinic, ambulatory or community setting, including management of long term conditions
demonstrates behaviour appropriately with regard to patients
demonstrates behaviour appropriately with regard to clinical and other professional colleagues
demonstrates effective consultation skills including challenging circumstances
accurate diagnosis and appropriate comprehensive management of patients referred to an outpatient clinic, ambulatory or community setting
appropriate management of comorbidities in an outpatient clinic
appropriate management of comorbidities in ambulatory or community setting
MCR
ACAT
mini-CEX
Patient survey
Letters generated at OP clinics
clinical skills (2)
knowledge of common (‘top’) medical presentations, other important presentations and relevant system specific competencies (2)
underlying causes and comorbidities (2)
therapeutics and self-prescribing (2)
time management and decision making (2)
personal and professional values and behaviours (1)
decision making and clinical reasoning (1,2)
delegation, health promotion and public health
relationship with patient, shared decision making and communications within a consultation (2,5)
managing long term conditions and promoting self-care (2)
breaking bad news (2)
patient as the central focus of care (2)
legal framework for practice (1,3)

27. Psychology of traditional workplace assessment
He’s nice and works hard. It won’t hurt and will stimulate if I mark him above average
Please…mark me above average

28. Psychology of CiPs-based workplace assessment
He’s nice and works hard, but it may hurt my patients if I mark him to be trusted for unsupervised practice
Please…mark me above average

29. An individualised workplace curriculum
Graded supervision allows for 1
Observing the activity 2
Acting with direct supervision present in the room 3
Acting with supervision available within minutes 4
Acting unsupervised, ie under clinical oversight
Portfolio of:
Dr Jones
PGY1
PGY2
PGY3
PGY4
CiP a 1 2 3 4
CiP b
CiP c
CiP d

30. CiPs approach serves flexibility
Intra-trainee variation: trainees do not reach competence for everything on last day of training
Inter-trainee variation: different prior knowledge and skills, learning ability, general attitude
Context variation: variable clinical opportunities, local practice (epidemiology, facilities, culture), education-mindedness of staff

31. Illustrative blueprint for a flexible Internal Medicine curriculum
Version 17

32. Challenges as of 2017 Shape and GPC are both important changes
‘Entrusted’ outcomes seem more authentic
Developed a New IM Curriculum
Timetable challenging:
- Four country sign off by Shape Steering Group
- New curriculum approval by GMC summer 2017
- Planning for recruitment in autumn 2017
- Start August 2018

33. End of presentation
The JRCPTB is part of the Federation of the Royal Colleges of Physicians of the United Kingdom