Here at St.Emlyn’s we’re really interested in education. Everyone on the team takes the supervision and support of trainees seriously and we hope that the blog reflects this, but to be honest all this blogging and podcasting will never have the most influential impact on the trainee experience.
Even the briefest look at the Twitter feeds from trainees (and trainers) will tell you that it is the environment at work which really impacts the trainee experience. Much of that will be a function of operational and organisational pressures but we must also consider the ability of trainers to train.
In truth this blog has been in my mind for some time; the idea that we should ask ourselves whether we are fit to train and whether we have the skills to be the best trainers we can be. It’s taken time as it’s difficult to write about this without coming across as an ivory tower teaching hospital fantasist. That’s not the intention and I apologise if you feel that way at the end of this blog. My hope is that it makes us all stop to think about how we can maximise the experience of training for the next generation of trainees. Consider this a formative idea rather than summative one. The last thing we want to do is discourage trainers; rather, we want to improve training and trainee support.
I suppose I should declare a conflict of interest at this stage as I’m both a trainer, a named educational supervisor, I’m an associate dean for Health Education England and I work for the GMC. The following is entirely my view and does not reflect nor represent any of the organisations for whom I work. Similarly, the ideas expressed here reflect the UK experience, and although I think the principles are valid everywhere they do relate to the UK.
Anyway, over the last 10 years ‘educationalists’ have spent a huge amount of time and energy in structuring post graduate training. Curricula are now better defined, the roles of educational supervisors and clinical supervisors are increasingly recognised and the deaneries, who organise post graduate education in the UK (Ed – they are not officially called deaneries anymore, but we’ll live with the term here) are better organised, more transparent and increasingly held to account in their efforts to deliver high quality training. That journey is not over by any means and there are still huge amounts of work to do, but there have been efforts to improve the learning experience.
Similarly, trainees have been driven to record and justify their training, primarily through the use of electronic portfolios designed to collate evidence of achieving all aspects of the curriculum relevant to each stage of training. Progress in training is assessed annually at the ARCP (Annual Review of Competence Progression) where again a huge amount of time and effort is expended by both trainers and trainees to establish whether they have or have not made progress. Every year our trainees are expected to complete a checklist of achievements including elements such as reflections, multi source feedback, audit, management, exams success, teaching etc.
Irrespective of grade or speciality it’s a real challenge and it takes a great effort to achieve an ‘Outcome 1’ which means the trainee continues in training with a clean bill of health. Failure to achieve can lead to additional tasks, additional training time and even the possibility of getting removed from the training program.
This is high stakes stuff.
Now, the ARCP progress is not perfect and as a result it gets a huge amount of criticism from all quarters. Some of that is undoubtly justified, but this is not the place to discuss that. Rather I am interested in a missing link in the journey to improve trainee experience and the quality of training, and that’s the quality of the educational supervisor.
This is on the money. It's ok for me to lead a trauma centre ED floor at night unsupervised, but not OK for me to self identify competence. https://t.co/P5NHrfGhny
— Jon Bailey (@DrJonBailey) July 16, 2017
As I sit on many ARCP panels across a range of specialities and as an educational supervisor I also support trainees in preparing for their annual assessment and so I think I have a reasonable overview and exposure to the process from a variety of perspectives.
So what’s the issue with trainers?
Basically, it’s seems to me that there is an quite a significant variation in the quality of Educational Supervisors. Some are clearly engaged, fantastic, supportive, honest, truthful, fair and as a result they are highly valued by trainees and by the training program directors who use their experience of working with the trainees in the workplace to make a decision about how a trainee is progressing.
Sadly, this is not always the case. Trainees often describe variable trainers, and it’s clear from reading supervisor reports and in judging the engagement of educational supervisors in trainee portfolios that that perception of variation is true. Why is this? I can’t think of a single educational supervisor who wants to do a bad job; far from it, in fact. Most are great people who want to train, want to do the best for their speciality and it’s future (and our trainees are our future).
So why the variability?
Arguably it’s because the instructions on how to be a good supervisor are somewhat more vague than those that we give our trainees. While it’s now essential for trainers to demonstrate that they have training in the educational domains as described by the GMC, the bar to achieve that is pretty low and they do not relate to what an educational supervisor should actually be doing. In other words, it’s not really very clear what an ES should be doing operationally on an annual basis.
In other words there is no ARCP for being an educational supervisor – but perhaps there should be.
So what would you put in an ES ARCP?
Let’s take lead from our trainees’ assessments. The areas of practice in the ARCP for trainees should be reflected in the abilities and competencies of the trainer. Let’s think about Clinical, Management, Teaching, Audit and Academic work and ask the difficult questions of educational supervision in EM.
5.Entire ARCP system at odds with reality of the job i.e. Being left in charge of hundreds of people's but not trusted to tick a box alone
— Dr Taryn Youngstein (@TYoungstein) July 15, 2017
At a very basic level we cannot consider an ES to be a competent trainer if they cannot practice at the level required of the curriculum at which they are supposed to be training. What that means is that as an ES you should be able to practice at the level to which you are training. Let’s think of some examples – be warned: this might be painful.
- Ultrasound – it’s a requirement of the curriculum. Can you do it? Do you do it? Are you competent with a probe in hand?
- Critical care – it’s a requirement of the curriculum. Can you do it? Do you do it? Are you competent in the resus room?
Key to this is whether the ES has kept up with changes to the curriculum and whether, as a result, they have developed their practice accordingly. In other words, you can’t consider receipt of your CCT/FRCEM as a lifetime licence to supervise. Read the curriculum and if there are areas that you need to learn then get it into your personal development plan (PDP) and organise some CPD/training.
From a trainee perspective, they want to keep up their clinical skills and in higher training they should be developing and building on their prior experience, not losing it through inaction and a lack of capable supervision.
Why are we given this ICM and Anaesthetics training we'll never use? Is it literally just to trick us into joining the program?
— Jennifer (@coffeeheadaches) July 9, 2017
There is a small caveat here of which we should be mindful. Not all departments see everything in the curriculum. For instance if you work in a department that does not see kids, or gynae, or eyes (for example) then it’s arguably not a requirement to keep up to date in those areas.
Similarly we look after different types of trainees in the ED. The skills and knowledge required to supervise a foundation trainee are not at the same level as those required to supervise a senior EM trainee coming up to their final exams. Arguably we should target and link up trainers skills and knowledge to the level of those required by the trainee. For a higher trainee in emergency medicine then you really should be at the cutting edge of our clinical work, you should be clinically excellent and up to date.
In the UK there are increasing numbers of doctors being appointed to locum consultant posts who do not have a CCT (certificate of completion of training), CESR (certificate of equivalence of specialist training) or pass at FRCEM (Fellowship of the Royal College of Emergency Medicine exam). Some of these individuals are excellent, but that’s not the same as being in a position to be an ediucational supervisor. If appointed to a consultant position there are clearly questions about whether someone without an exam or certificate of completion can or should be in a position to supervise emergency medicine trainees. I have an opinion, and I invite you to form your own. From a training program perspective how might we handle a trainee who fails their ARCP having been supervised by doctors who do not have a CCT/CESR/Exam? I suspect they could generate a rather convincing argument that they were disadvantaged.
Bottom line – when was the last time you (or your boss) actually read the curriculum? Do you have the skills and knowledge needed to pass the exam? If not why not and what are you going to do about it?
Educational supervision is as much about managing the education process as teaching at the bedside and so it’s essential that anyone acting as an ES keeps up to date and that they contribute to the wider teaching program.
- How many formal teaching sessions do they deliver annually?
- How many times do they attend ARCP panels?
- Are they involved in examinations (ideally the RCEM exam process)?
- Do they attend RCEM or deanery conferences and updates?
We’ve spoken before about judgement and self assessment. In general we are not good at assessing our own performance and the same is true of our education abilities. If our supervisors are going to be great educators they need to get feedback on their performance.
- How many formal teaching activities do they deliver?
- How many of these have feedback?
- Has an educational MSF been completed?
It is a constant frustration of trainees that they struggle to get senior educators to complete and then validate their work place based assessments. In recent years the college has required trainers to participate in certain type of assessment (for example ESLEs) but I would argue that trainers should be completing WPBAs on a regular basis.
- How many WPBAs has the ES completed?
- Is there an appropriate range of WPBAs completed? (Ed – get specific feedback on the quality of summary forms)
Reflection is an integral aspect of all ARCP processes as it is for consultant appraisal. Reflections as an ES should include a review of their own performance and that of their department, training program and the trainees they supervise.
Reflect on the latest GMC survey results and contribute to an action plan for improvement.
- Review and reflect on the ARCP outcomes of all trainees (incredibly some supervisors don’t even know what ARCP outcomes their trainees get).
- Reflections on any challenging training related issues (e.g. the management of a trainee with reasonable adjustments to their work schedule).
Does the ES have to be able to do everything or can we supervise as a team?
Inevitably we are going to supervise as a team. EM is the ultimate team sport and we will always work collaboratively to supervise. Our shift patterns and our increasingly portfolio careers mean that we will always struggle to have that 1:1 apprenticeship relationship with our trainees.
Management, research and other academic activities are usually focused in particular individuals within the department and thus it’s inevitable that those levels of supervision and support will be disseminated across the consultant workforce.
Inevitably then we must do this as a team, but for me (and it’s just my opinion) the clinical work is paramount. From a role modeling perspective I think we could be challenged about the quality of our training if the ES has fewer clinical skills than the trainee or where they cannot teach to the level required by the curriculum. We should only be sending our trainees to the best trainers, in the best departments and where they can maximise their training opportunities.
So what about an ARCP for trainers?
The ARCP process is not popular and therefore it is never going to be popular to suggest that we should expand it to trainers. I think there is, however, something to be said for having each and every ES checklist themselves against the operational supervision requirements in the same way we expect of our trainees. As I said at the beginning, I don’t represent anyone but myself in this matter – but if someone wanted to develop an ARCP checklist for trainers then it might look a little like this:
What do I do with this checklist?
It’s clearly nothing official, but if you want to use it for your portfolio, for discussions with your college tutor or as evidence for high quality performance then go right ahead. If you’re brave enough then consider sharing it with your trainees. I am going to give myself an Outcome 2 this year as I am missing some reflections, I’ve not done an education MSF in the last 3 years and there are a few areas of deficiency around the curriculum that I need to attend to through some CPD and personal study. I’m not going to sack myself and would prefer to use this as a checklist rather than a mark sheet.
Get real: Is this the usual unrealistic teaching hospital, ivory tower view of training?
Thanks for getting this far. I expect this blog will raise a range of emotions and I expect a few controversies. Some will feel aggrieved that those of us who are perceived to work in the ivory towers of medicine don’t know how lucky we are, and that the reality of some hospitals makes this unachievable. That’s probably true and having recently worked in smaller DGHs as well as the ivory towers of Virchester I do get that. However, as a career educator it’s important that we strive to deliver the best quality training we can.
It’s also a fallacy that larger hospitals will find this easier, or do it better. My impression from sitting on many ARCP panels is that the educational experience and the quality of trainers and training is less a function of the hospital and more a function of the efforts and enthusiasm of the trainers and the training department. There are fabulous small training departments and large ones that struggle, and everything in between. It’s important to recognise this and not to make any assumptions about hospital size or trauma centre designation, or whatever other criteria you might choose.
I’m not sure I’d pass my own ARCP against the checklist above (see my outcome 2) and I’m not expecting you to either. So for now, consider this formative, a checklist for development and improvement rather than as a hoop to jump through. At least that’s the case for us all as we face the challenges of 2017. My personal view is that with a greater focus on the quality of training, and thus the quality of trainers it is only a matter of time before this hypothetical checklist (or something like it) becomes a reality.
We should also be mindful that no-one intends to be a less than perfect ES. It’s often the stress of the job, the workload and the lack of supportive resources that make a difference. Bad departments hurt everyone, and whilst it’s the trainees who suffer at ARCP time, we all get harmed when we can’t do the job that we trained to do.
Dr Suri is so right. We are all in this together. The bad departments are bad for everybody. Sometimes I wonder how their staff keep going! https://t.co/Hvtah6xVWl
— Chris Moulton (@RCEM_VP) July 9, 2017
Are you saying that if you can’t pass the checklist then you should not be a supervisor?
No, but you might want to have a look at any gaps and see what you can do about them, else look around your department and ask who is the best person to supervise which grade of doctor. Alternatively, as the role of educational supervisor becomes more specialised, harder work and more complex, it might lead to education expertise being concentrated in a smaller number of consultants who consider it a specialist area. In the UK that might seem odd for emergency medicine but it’s by no means a new idea. That’s exactly what happens in many parts of the world, and in the UK it’s the model for the professionalisation of training in general practice. Our current model, where pretty much every consultant is an ES of some description, and where there is an assumption that everyone can perform as an ES for every type of trainee may not be the best.
Similarly, it’s not just about EM trainees. There are clear advantages to consultants specialising thematically for different types of educational supervision, for example just focusing on GP trainees, or foundation trainees. All are valid and all are essential.
You should also consider whether you have time to complete these tasks. Educational supervision is hard work and you must have time in your job plan to achieve the tasks required. If you haven’t then perhaps you could use the checklist as a way of influencing that conversation.
Does the Nirvana of training exist where everything is perfect, the rotas are fabulous, the consultants engaged, the case mix exciting and the feedback excellent? Well no, I don’t think it does and I don’t think it will for some time, but that’s no reason not to ask the questions about how we might get there.
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