2013-07-29 tips for trainees final - rcog · 2014-02-21 · rcog tips for trainees...

ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS

TIPS FOR TRAINEES JULY 2013

RCOG Tips for Trainees

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TIPS FOR TRAINEES IN OBSTETRICS AND GYNAECOLOGY

Introduction If you are reading this guide, you may be considering applying for training in obstetrics and gynaecology (O&G), have recently achieved a training position or be in post and still have questions. We understand that there are so many regulations, guidelines and documents that explain what is required of trainees and trainers. Tips for Trainees in O&G will give you an overview of all the most useful information, plus ongoing developments and updates that you should be aware of. We are very excited to be responsible for education and training. We want to encourage trainees to become proactive, dedicated professionals who excel in medical practice and education so that we can be proud to set the highest standards to improve women’s health. We hope you find the information useful and value your feedback and suggestions for improvements.

Commencing specialty training in O&G should be an exciting and inspiring time for you. The specialty can encompass a wide variety of different areas of medicine, making it one of the most diverse areas in which to practise. O&G has often been described as a mixture of medicine and surgery and this is certainly a major attraction for many doctors. The flexibility of this unique and challenging specialty allows you to develop a wide range of interests and skills, such as cutting-‐edge surgery or solving complicated therapeutic problems. The common link is women’s health; before, during and after the reproductive years. Of course, your work is not confined to women – it also includes their partners and children. As a consultant, you would be working across a range of different clinical areas or you might choose to work purely in one field, such as maternal and fetal medicine, oncology or urogynaecology. Whatever you decide to do, a career in O&G is flexible, exciting and rewarding. At times it is demanding and stressful but it is always varied and challenging.


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The direction you follow in O&G will depend on your interests and abilities. Training programmes offer you the option (after completing all intermediate requirements) of undertaking advanced skills training or subspecialty training. Training is a competency-‐based process but it is envisaged that the majority of trainees will take 7 years to complete the programme. On completion of all requirements of the programme, you will be awarded a Certificate of Completion of Training (CCT) or a Certificate for Eligibility of Specialist Registration (through the combined process)(CESR CP) and appointment to the Specialist Register of the General Medical Council (GMC). Interviews and appointments To apply for a specialty post in O&G, you can visit the online recruitment system ‘ObsJobs’, which is available at: https://obsjobs.rcog.org.uk/. Once you have had a successful interview for the Specialty Training and Education Programme in O&G, your year of entry will be decided (usually at ST1) and you will sign an educational agreement with the postgraduate deanery that has responsibility for your appointment. You will remain in that deanery region for the duration of your specialty training, as long as you pass your assessments but you will move around the different hospitals within that region. There is some flexibility within the system should you need to transfer to another region for personal reasons. The length of time you spend at different levels within the programme is flexible. People gain skills at different speeds and so it may be that you spend 12, 18 or even 24 months meeting the requirement of a particular level. You will be given a National Training Number (NTN), which is unique to you, and this number will stay with you throughout your training. This number has three purposes:

• to act as a training ‘passport’ to ensure employment, assuming satisfactory progress • to structure educational planning and management • to provide workforce information.

Your NTN is only changed if you change training programmes through competitive entry. Once you have been allocated a training post, it can only be deferred for statutory reasons (e.g. sick leave or maternity leave).


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The Gold Guide The Gold Guide to Postgraduate Specialty Training in the UK can be obtained through the Modernising Medical Careers (MMC) website (www.mmc.nhs.uk). This guide covers all postgraduate specialty training programmes. The answers to most queries about training can be found here and you should familiarise yourself with this document. Perhaps the most important message is that:

“…as a specialty trainee you are responsible for your own training.”

Contents of The Gold Guide • Introduction and background • Specialty training: policy and the statutory bodies • Key characteristics of specialty training • Setting standards • The structure of training • Becoming a specialty registrar • Progressing as a specialty registrar • Being a specialty registrar and an employee

Who manages training? There is a clear structure of training, which is detailed in The Gold Guide. The curriculum has been researched and developed by the RCOG to meet the needs of the role of a consultant in the NHS, and is regularly reviewed to ensure that training reflects developments in the field. The curriculum is approved by the GMC. The day-‐to-‐day management and quality assurance is provided by the postgraduate deans and the training programme at local level is managed by the Training Programme Director (TPD). It is important that you know who your local TPD is, as they will be able to answer many questions you have about the curriculum and training. Educational supervisor During each post of your specialty training programme you will be allocated an educational supervisor. The purpose of this supervision will be detailed in later sections; it is important to note that clinical supervision is not the same as educational supervision. It is likely that clinical supervision will be provided by a range of consultants and other professional staff during each appointment. You will, however, discuss your training and educational needs within your educational contract between yourself and the postgraduate dean.


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The RCOG Trainees’ Register It is mandatory for all Specialty Trainees entering the training programme to be on the RCOG Trainees’ Register. Subscription is renewed annually following payment of a small membership fee. Once registered, if you are an ST1, you will be provided with access to the O&G ePortfolio in time for the start of the programme. Subscribing to the Trainees’ Register has many additional benefits, including:

• access to over 100 StratOG eTutorials • The Obstetrician & Gynaecologist (quarterly) and free access to the online journal • Membership Matters and other RCOG information (three times a year) • NEW: 20% discount on 30 000 academic titles by Cambridge University Press (note: you

need to opt-‐in by providing your contact details to Cambridge University Press) • special price for a subscription to BJOG: An International Journal of Obstetrics and

Gynaecology • TROG Newsletter (three times a year) • access to the Trainees’ section of the RCOG website.

Make sure you have your say Each region has a trainee representative on the RCOG Trainees’ Committee who will be able to provide you with the most up-‐to-‐date information from the College and will speak on your behalf. Snapshot!

“Having your say is very important. The College is formed of practising obstetricians and gynaecologists who work together to manage and develop training and education. You should always offer constructive feedback so that, together, we advance the specialty, provide the highest standards and continue to gain new knowledge and skill both during training and beyond CCT.”

RCOG Trainees’ Committee Member


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Involvement of the RCOG

Departments in the Global Education Directorate support all education, training and assessment requirements for the Specialty Training and Education Programme in Obstetrics and Gynaecology. The curriculum, training/educational events and resources are all governed by committees that report to the Education Board.


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Contacts at the RCOG Specialty training, CCT, ARCP and flexible training enquiries

+44 (0)20 7772 6294 Tania Chambers [email protected]

Trainees’ Register enrolment and enquiries

+44 (0)20 7772 6348 Penny Payne [email protected]

Curriculum and logbook

+44 (0)20 7772 6460

Alice Lambert [email protected]

Workplace-‐based assessment (WBA) content enquiries

+44 (0)20 7772 6308

Alex Landau [email protected]

ePortfolio

+44 (0)20 7772 6204/460

ePortfolio Department [email protected]

Subspecialty training enquiries

+44 (0)20 7772 6203

Bettina Cayetano bcayetano @rcog.org.uk

Ultrasound enquiries

+44 (0)20 7772 6203

Bettina Cayetano bcayetano @rcog.org.uk

Recruitment into O&G training

+44 (0)20 7772 6262

Matt Huggins [email protected]

Overseas training opportunities

+44 (0)20 7772 6223

Binta Patel [email protected]

DRCOG and MRCOG examinations

+44 (0)20 7772 6210

Examinations Department [email protected]

Meetings and conferences office

+44 (0)20 7772 6245

Meetings Department [email protected]

StratOG

+44 (0)20 7772 6324/431

eLearning Department [email protected]

Undermining/workplace behaviour

+44 (0)20 7772 6448

Joseph Boyle [email protected]


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The Curriculum Core modules The content of the programme has been designed by the RCOG and approved by the GMC. To start as a new Specialty Trainee, you will have to complete the Foundation Programme (or be able to demonstrate equivalent competences) and will usually commence training in August (or October in some deaneries). The Core Curriculum consists of 19 modules that must be completed by all Specialty Trainees to be awarded the O&G CCT/CESR(CP).

• Basic Clinical Skills • Teaching Appraisal and Assessment • Information Technology, Clinical Governance and Research • Ethics and Legal Issues • Core Surgical Skills • Postoperative Care • Surgical Procedures • Antenatal Care • Maternal Medicine • Management of Labour • Management of Delivery • Postpartum Problems (the Puerperium) • Gynaecological Problems • Subfertility • Sexual and Reproductive Health • Early Pregnancy Care • Gynaecological Oncology • Urogynaecology and Pelvic Floor Problems • Professional Development

Module format Each module has competences that you must complete either during basic, intermediate or advanced training. The training is structured so that you:

• observe a procedure • carry out the procedure under supervision • carry out the procedure independently.

Attitudes In addition to developing clinical competence, the curriculum structures training so that you:

• have knowledge that meets the required criteria • practise adhering to the professional skills and attitudes requirement • collect evidence of progress, reflection and workplace-‐based assessments, in addition to

meeting the examination requirements.


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Recommended training support lists available guidelines, courses and eLearning support materials, which are recommended but not necessarily mandatory. Some courses are compulsory at particular stages of training and, where appropriate, these requirements are listed. Developing broad-‐based knowledge and expertise The College has developed a Core Curriculum that sets out the criteria and content for training, with guidance on educational support material and training courses. You will be expected to achieve set competences as part of your core training and you will have regular assessments. The time you spend in core training will give you broad-‐based knowledge and expertise on which to establish your further training and career plans. Some trainees have a very clear idea of their specialty interest from the start of their training but most find that they identify their particular interests during core training. If you are interested in a particular aspect of the specialty, start considering the steps required to develop your interest further. Snapshot!

“During a busy clinic, theatre or on a labour ward suite, the role is quite varied. Each day is different. A relaxed approach and the need to remain unflustered is essential, as people do rush you. I think it is very important to spend time talking to patients, no

matter how old or uninterested they appear to be in their treatment… Women you are treating usually have questions and sometimes you need to chat generally to bond with them before

they relax and ask more questions about their treatment.”

ST Trainee


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Different levels Basic level At basic level (ST1 and ST2) you will start to gain experience in all areas of O&G. You will work alongside other new trainees and senior trainees, as well as with several consultants with different skills and interests. A consultant will act as your educational supervisor, who will assist you in coordinating regular assessments of your training with your clinical trainers. At basic level, competences will start to be signed off and all of your training achievements will be recorded in your ePortfolio, which will be added to throughout your training. Waypoints to progress from ST2 to ST3 One of the key assessment steps is the progression from ST2 to ST3; that is, from basic-‐ to intermediate-‐level training. This is where you will progress from ‘first on-‐call’ to ‘second on-‐call’ duties and, having met the requirements, you will to have increased clinical responsibility. At this level, you must be able to competently manage the labour ward independently. This means that you should be able to assess both O&G emergencies and maternal and fetal progress throughout labour, and undertake uncomplicated obstetric deliveries. Most importantly, you must be aware of the situations where you require senior assistance and must realise your limitations. Good communication with patients and relatives, as well as nursing and midwifery staff is essential to your professional development. If you are keen on a particular aspect of the specialty, this is the time to start considering and implementing the steps that you will need to develop your interests further. During your training at ST2 level, it is important to bear in mind the competences that you need to sign-‐off and discuss these with your educational supervisor early in your training. This will require you to highlight your clinical strengths and weakness so that you can concentrate on developing your skills. There are some mandatory requirements for progression from ST2 to ST3:

• attainment of the Part 1 MRCOG examination • completion of the RCOG Basic Practical Skills in O&G course • satisfactory attainment of the relevant competences for independent practice in certain

specific skills. Snapshot!

“Keep checking the curriculum and training guidelines and find opportunities and interesting cases. Trainees need to be

proactive at using trainers and colleagues, not the other way round. We are all professionals and patients would expect doctors

of any level to be responsible.”

ST3 Trainee



Waypoints to progress from ST5 to ST6: advanced training Satisfactory completion of Year 5 means you have completed intermediate-‐level training in O&G. As an ST6/ST7, you will continue to develop and refine general skills in O&G, as well as further your own special interest area. For you to pursue your special interest, it is important that you have completed all the intermediate training requirements in the curriculum and, therefore, this assessment is the second key waypoint in the training programme. It is accepted that trainees acquire skills and learn at different rates but it is essential that the intermediate targets are achieved before progression into Year 6 can be authorised.

Key competences Obstetrics • Competently manage normal antenatal

and postnatal care • Competently manage a wide range of

antenatal fetal and maternal complications • Competently manage postnatal

complications • Efficiently manage a labour ward,

prioritising and assessing risk Obstetric procedures • Independently perform forceps delivery

(non-‐rotational), repeat caesarean section

Gynaecology • Competently manage a wide range of benign

gynaecological conditions, including contraceptive advice

• Have experience of managing malignant conditions

• Competently manage early pregnancy complications

Gynaecological surgical procedures • Independently undertake marsupialisation of

Bartholin’s cysts/abscess, laparotomy for ectopic pregnancy, diagnostic laparoscopy and hysteroscopy

• Undertake a range of gynaecological operations under supervision

Professional skills

• Work well within a team. • Demonstrate good communication skills through satisfactory Team Observation 1 and Team

Observation 2 assessment. • Be able to undertake assessments of junior medical and nursing staff. • Present cases at risk-‐management meetings. • Be able to obtain informed consent. • Undertake audit/research.



Examinations There are two examinations that you will need to pass during the specialty training programme: the Part 1 MRCOG and the Part 2 MRCOG. These examinations are located at the waypoints in the programme: to move from ST2 to ST3, you must have passed the Part 1 MRCOG; to move from ST5 to ST6, you must have passed the Part 2. Once you have passed the Part 2 MRCOG, you will become a member of the RCOG. The Part 1 MRCOG is an assessment of basic sciences relevant to the practice of O&G. The Part 2 MRCOG is an assessment of applied clinical knowledge, and is divided into written and oral components. The content assessed in each examination is outlined clearly in a syllabus, enabling candidates to focus their preparation accordingly.

Snapshot!

“Check the MRCOG syllabus and knowledge requirements of the curriculum regularly. Make notes on your own experiences and do

the required reading so that exam preparation is easier and so that it becomes a part of your routine… RCOG guidelines are really useful

to have to hand…”

ST4 trainee

Ultrasound It is mandatory that all trainees who started in ST1–ST3 from August 2008 have both basic ultrasound modules completed by the end of ST5. All trainees starting in August 2013 must have both basic modules completed by the end of ST3. Trainees should aim to have the modules completed by the end of ST3

• Basic early pregnancy ultrasound (8–12 weeks) • Basic ultrasound assessment of fetal size, liquor

and the placenta



Intermediate ultrasound training can only be done after you have completed the basic ultrasound modules. The three intermediate modules are ‘free-‐standing’ but do align with certain Advanced Training Skills Modules (ATSMs) and Subspecialty Training (SST) programmes. Intermediate ultrasound modules will be undertaken selectively. For certain ATSMs, intermediate ultrasound modules may be undertaken prior to (usually at ST4–ST5 level) or parallel with the ATSM (i.e. ST6–ST7 level). Although not a waypoint, trainees should be aware of the intermediate ultrasound requirements to support their chosen advanced training options. Core advanced training All trainees must complete 2 years of advanced training before they can apply for their CCT. This is the time when you continue core training and start to develop your own interests in more detail by completing ATSMs or subspecialty training. You should consider if you see yourself maintaining a range of skills, working as a generalist, either in a centre complementing the interests and skills of the unit or perhaps a smaller hospital where a number of different skills will be required. Do you see yourself in a tertiary referral centre specialising in one area of O&G? As well as practical procedures, core training at advanced level includes areas such as medical management and clinical governance, which properly prepare trainees for the non-‐clinical aspects of working as a consultant in the NHS. ATSMs The ATSMs have been designed to develop skills suitable for future career progress within the consultant career pathways detailed in The Future Role of the Consultant (RCOG, 2005). The modules are designed to allow trainees to develop special interest areas within their clinical practice. They have been developed in conjunction with the specialist societies and a minimum of two ATSMs must be completed to achieve the CCT. There are 20 different modules. Deciding which ATSMs to pursue Some trainees know which special interest area they would like to pursue from the start of their training program, whereas other trainees take longer to decide on their career path. It is important to seek a range of opinions from trainers and colleagues. Within deaneries, career advice is available through the school. While deliberating, trainees should consider their own individual clinical skills and aptitudes when making their decisions and should also consider the future needs of the specialty (The Future Role of the Consultant). Trainees should also consider their ATSM choices well in advance of entering their final 2 years of training. Must I undertake a certain ATSM? Choosing an ATSM is a decision that should be made by both the trainee and their deanery. As many future consultant posts will contain labour ward sessions as part of dedicated daytime commitments or as on-‐call, this should be taken into account. To maximise your suitability for consultancy position, you are strongly advised to consider undertaking the Advanced Labour Ward Practice ATSM. As ATSMs vary considerably in their expected duration and work intensity, each ATSM has been given a work intensity score. This score reflects the nature of competencies that need to be acquired. The larger ATSMs have a score of 2.0 and typically take 12–18 months to complete. These are designed to be career-‐defining ATSMs that equip the trainees to work as a consultant in their key area of clinical interest, whether obstetrics or gynaecology. ATSMs with a score of 1.0 support the career-‐defining ATSMs and allow a more flexible training programme to be developed. Trainees may choose any combination of ATSMs, providing that the total concurrent work intensity score is not greater



than 3.0. Once an ATSM is complete, a trainee may have the opportunity to start another ATSM; this is permissible providing the new total score remains at 3.0 or less. However, the Advanced Labour Ward Practice ATSM (score 1.0) and the Labour Ward Lead ATSM (score 2.0) have a combined score of 2.0 when taken at the same time. This reflects the fact that the Labour Ward Lead module also requires completion of the Advanced Labour Ward Practice module and, when taken concurrently, the clinical areas overlap considerably. The usual scores apply if either ATSM is taken separately. Delivery of ATSM training All training is delivered through deaneries/postgraduate schools. ATSM directors coordinate the delivery of ATSM training within the regions; therefore, they have a good overview of the training opportunities and vacancies. You should discuss your ATSM preferences with the ATSM director, who will be able to advise you. For some of the more popular ATSMs, a process of competitive entry will apply at deanery level and the ATSM director will be able to advise you on this. ATSM preceptors and educational supervisors who are specialists in their field deliver the individual ATSMs. You should discuss the advanced training fields offered with the module preceptor and the deanery or postgraduate schools, as they are responsible for ensuring preceptors are available to help you. Eligibility to undertake ATSMs All those training within O&G and non-‐NTN holders and trainees who have completed their CCT can undertake ATSM training, provided that the deanery agrees. You should register prospectively for ATSMs. Check all ATSM regulations on the College website. Snapshot!

“Trainees should consider their choices for ATSMs well in advance of entering their final 2 years of training…”



Snapshot! Dr Alastair Campbell, RCOG ATSM Officer Dr Campbell is a consultant in Edinburgh Royal Infirmary. His role is to aid with the provision and delivery of ATSMs by working with the RCOG training committees, the deaneries and the ATSM leads who have developed the curriculum for each ATSM. Any feedback regarding all aspects of trainees and trainers experience of ATSMs can be made through the RCOG.

Subspecialty training Subspecialty training will appeal to trainees who wish to be leaders and innovators and who are prepared to dedicate the majority (in some cases 100%) of their working life to a subspecialty area. Subspecialty training is a 3-‐year programme and the four subspecialty areas are:

• Gynaecological Oncology • Maternal/Fetal Medicine • Reproductive Medicine • Urogynaecology

You must be aware that research is an important component of the programmes. This is not because it is expected that all subspecialists should be academics; however, if you intend to concentrate your professional career on one of the O&G subspecialties then it makes sense to have developed the skills and understand the theory of scientific research. Entry to subspecialty training Waypoints to access subspecialty training are the same but appointment to a subspecialty training post is through open competition. Subspecialty training is a 3-‐year programme. You may be exempt from undertaking research if you have been awarded either an MD or PhD thesis or have at least two first-‐author papers in citable, refereed journals (this will mean you will enter a 2-‐year programme). You should contact Bettina Cayetano, Advanced Training Coordinator of the Subspecialty Training Committee (SSTC), as soon as you have been appointed. Decisions regarding research exemption will be made by the Subspecialty Training Committee. Your progress in the training programme will be formally assessed annually by two subspecialists nominated by the RCOG. The assessment is comprised of submitted reports, written by both the trainee and the subspecialty training programme supervisor, and a formal review of progress toward the required competences detailed in the subspecialty logbook. This review will be reflected in your Annual Review of Competence Progression (ARCP). As with the rest of your training, you will be expected to complete annual TO1 forms that contribute to the subspecialty assessment and ARCP process. The assessors compile a report, which is submitted to the RCOG Subspecialty Training Committee. Following satisfactory completion of your programme you will be able to apply a CCT with subspecialty accreditation.



Meetings and assessments within training How to get started – the induction interview As a trainee, you will get the most out of your placement in any unit if you know what you want to achieve and you ask the people that work there for their help to achieve it. That is the essence of the induction interview. Trainee tip: preparation before the interview

• Make contact to arrange your induction interview in advance of your start date. This is especially important if you are rotating during a holiday period as your educational supervisor may be away when you start. If this is the case, you might like to arrange to have your induction interview or have an informal meeting before you start.

• Ensure that all the relevant information from your previous posts is available for the induction interview. If some of this is complex, might it be more helpful to ensure that your educational supervisor has time to read it before they meet you.

• If this is not your first post, review your last assessment and list the objectives for your next placement.

• Review the logbook and training material and list your own objectives (do not forget audits, publications and reflective learning).

• Look at relevant websites, such as the RCOG/deanery websites, for appropriate information that you wish to discuss.

• Complete the relevant sections of the induction form. Keeping in touch Appraisal: what to include? The appraisal is a very important component of effective adult learning. The process collates past achievement and plans future progress. It is mandatory but flexible, structured yet informal, challenging yet an opportunity to provide support. It is not a formal assessment, so health and serious conduct issues must be dealt with outside of appraisal in specific meetings, as required. Adult learning is an active process. You must keep your ePortfolio up-‐to-‐date and orderly and use it with the curriculum to inform the next phase of learning. Think about the requirements of training: knowledge, skills and attitudes. Be prepared to value success explicitly and to discuss tough issues thoroughly. Always accentuate the positive comments and have a critical yet constructive approach for progression. Meetings are confidential but not legally privileged and anything that raises safety issues for patients or trainees can be disclosed. You should feel free to discuss obstacles to progress and appraisers should show interest in emotional development. Documentation is important but do not allow it to get in the way of discussion. You should set an agenda of points to be covered, have a good dialogue with your assessor and then complete forms at the end. You may also want to create a checklist of individual targets with timelines to help during future discussions.



Good advice for setting targets and personal development planning S M A R T

Specific Clearly defined. Clear aims for a particular time period. Measurable Divide into components so progress of each component can be

measured and monitored. Achievable To avoid sense of failure and/or despondency, be realistic. Relevant Stay focused on the curriculum and its requirements. Time Agree time period of anticipated development.

Agree jointly, define tightly. Graduate difficulty to build confidence.

Scenario An ST3 moves to a new unit with an excellent history of good progress. A clear and challenging plan is agreed for next 3 months. At 6 weeks, on night duty, there is a serious event on the labour ward. The trainee leads the team to a very good outcome for mother and baby. The trainer praises the team and a workplace-‐based assessment is completed for the trainee. Three days later, the trainee appears red-‐eyed and not confident on ward round. Follow-‐up

• The trainer asks the trainee to meet them in their office urgently and they gently explore how trainee is feeling. Despite knowing that care was excellent, not all competences were achieved and signed off, so the trainee feels that not every aspect was perfect and has been dwelling on events.

• There is a joint agreement for an independent mentor to work with the trainee and they will spend two sessions on labour ward together.

• After factual debrief and sharing of emotional feelings with other team members, the trainee performs well and has the support they feel they need.

• Group of local trainers meet and realise that caution is required to prevent similar events. Quality supervision and building confidence A trainee may be self-‐assured but they will also benefit from explicit praise. To be effective, praise must be specific, sincere and frequent. Your trainers should discuss your achievements in terms of what went well, what was learned and how things could be improved. Your trainer should aim to end meetings on a positive note. What happens if there is regular trainee and educational supervisor disagreement? A good relationship is crucial. You should not blame any training system or employment deficiencies on your educational supervisor or any clinical trainer. You must take responsibility for your own training. If you or your educational supervisor feels that a relationship cannot be made to work, request a change by contacting the TPD or Head of School. What constitutes as ‘evidence’ of achievement? Workplace-‐based assessments play a large part in training and document progress from year to year. Whether educational supervisors or clinical assessors complete assessments for trainees, all evidence should be collected in the ePortfolio. Do not think that you only need to retain ‘good’ assessments (those that demonstrate that you are competent and have met the requirements of the



curriculum). OSATS are formative so each and every one of them is valuable. You should collect the assessments that record your difficult experiences, where you have required assistance, or where you have simply observed procedures. When you complete case-‐based discussions (CbDs), you should discuss complicated situations where any trainee would struggle until they are competent and experienced. If you had an OSATS with notes explaining your difficulties, you could then do a CbD assessment that would re-‐assess your difficulties and be educationally beneficial. Unless trainees keep evidence of progress, future educational supervisors cannot get to know them and determine what degree of support to provide. Every trainee progresses at a different rate and has different requirements. Therefore, a competence-‐based training programme allows you to progress at your own rate and develop skill and confidence as and when you become exposed to cases. Assessments Objective Structured Assessment of Technical Competences (OSATS)

• Used to help to assess the trainee and provides structured assessment (formative). • Completed throughout training until the trainee is competent to practise independently. • May be used to assess increasing levels of complexity for any particular procedure. • The eLogbook is approved when the trainee is deemed competent to practise independently

(summative assessment). • At least two assessors should be involved in completing OSATS for trainees. • Once fully competent for independent practice, it is recommended that the trainee

undergoes an annual OSATS assessment to demonstrate continued competency. One OSATS for each procedure should be completed annually until CCT.

• The traines must also keep a count of procedures completed annually until CCT.



Mini-‐Clinical Evaluation Exercise (Mini-‐CEX) • Tests many different and varied

competences. It is a generic tool. • Enables the trainer to directly observe and

assess in the process of history-‐taking, clinical examination, formulating management plans and communicating with patients.

• Designed to take ~20 minutes to perform. • Results should be fed back and discussed

immediately after the assessment. • It is suggested that a minimum of ten mini-‐

CEX assessments should be completed satisfactorily for each clinical encounter with a variety of different trainers before the competency is signed off (liaise with your educational supervisor as you progress to establish ‘how many’ trainers you need, based on your progress).

Case-‐based discussion • A generic tool that formalises

hypothetical case discussions with trainers.

• Relevant to knowledge criteria and competences in the curriculum.

• Used to assess clinical decision-‐making, knowledge, and application of knowledge.

• Each CbD should involve slightly different clinical situations in the area to be tested.

• Discussion will focus on the information that would be given to the patient and recorded in the notes.

• A minimum of six successfully completed CbDs will be required to have a competency signed off (see notes on number).



Team observation forms The TO1 form is a multi-‐source feedback tool based on The Principles of Good Medical Practice, as defined by the GMC. The TO1 is not a confidential document and you should be aware of the contents. However, the educational supervisor should manage the release of the forms to you so that they can assist you with the interpretation of comments and explain how the comments will be constructive for your development. The TO2 form is a summary of TO1 forms. It plays an important part in the ARCP process. The educational supervisor certifies that this form is a correct summary of the TO1 forms received and adds comments provided from personal observation. You and your educational supervisor should agree on at least ten assessors to complete TO1 forms for you. It is suggested that you include at least three senior medical colleagues (consultant or senior specialty registrar), a senior midwife on a delivery suite and from a antenatal clinic, a senior nurse from the gynaecology ward and a member of the theatre team in your list of assessors. Other appropriate staff includes midwives from other areas, staff from the specialist clinics, anaesthetic and paediatric colleagues. Generally, it is thought not to be appropriate to ask clerical and support staff to complete TO1 forms although, in certain situations, your educational supervisor may request TO1 forms from non-‐clinical colleagues.

Professionalism and judgment, outcomes possibilities

• How will the assessments inform progress? • Role of the supervisor as an ‘expert’

Workplace-‐based assessments aim to evaluate trainees’ progress over time and it is likely that they will be implemented to assess qualified doctors as a part of recertification and revalidation. The aim of workplace-‐based assessments is to link teaching, learning and assessment in a structured way. To gain an accurate picture of an individual, several workplace-‐based assessments need to be used and evaluated together at routine appraisals. The aim of an assessment is not necessarily to indicate that a trainee is completely competent but to indicate strengths and weaknesses. This helps educational supervisors to support the trainee as necessary. The only way of identifying a trainee with problems early is if trainers monitor your workplace-‐based assessments and identify areas where you may not otherwise admit that you are struggling to progress. If you are struggling, do not feel ashamed; identify the areas where you struggle early on and speak to someone.



Global judgment When a trainer is satisfied that a trainee is competent, it is entirely appropriate for them to sign-‐off competences, recognising that any numbers suggested in the curriculum are a guideline and benchmark for the majority. Judgment of a trainee’s performance by a trainer is a global judgment and these global judgments allow trainers to assess competence in the context of skill and professionalism, which ensures the curriculum is used to produce the obstetricians and gynaecologists of the future. Annual review of competence progression Unlike an appraisal, the ARCP is an external assessment of progress. If the trainee passes, they advance to the next stage of training. If the trainee’s achievement is poor or a lack of documentation does not provide sufficient evidence of progress and competence, the ARCP may be repeated with special monitoring. Ultimately, the ARCP documentation is an important component of authorisation that is annually collected and recorded as evidence for the certificate of completion of training (CCT). The Gold Guide has full details of the ARCP process, including the panel composition and requirements. What is the ARCP meeting like? The meeting is formal but the ARCP panel, which may include a lay representative and/or a representative specialist assessor from the RCOG, is understanding. Your e-‐Portfolio will be available to the panel and other documentation may be needed. Trainees should be able to give reasonable explanations as to why a target could not be met. You must show evidence of how you plan to rectify a situation and make progress. Evidence needs to be comprehensive and the documentation should outline audits and projects in detail. If you cannot show evidence, the panel might suspect that your role was limited and that you have limited experience, and they may request an enquiry. How many assessments? The evidence base for numbers of procedures necessary to confer competence is not particularly robust. A minimum number (for observation, carrying out under supervision and independently) and also regular exposure is thought to be educationally valid.

"At present, the curriculum and logbook requirements for numbers are for guidance only…"

It is obvious that each trainee will develop at a different rate. Some trainees will carry out more supervised procedures than others before the trainer is satisfied that competence has been achieved and the trainee can practise independently. To provide some structure to the delivery of elements of training and to recognise the relative importance of different procedures within the curriculum, suggested numbers of procedures were initially included in the training documentation. There is considerable experience in the use of OSATS for the assessment of trainees in obstetrics and gynaecology. Analysing OSATS (both the content of and, in some respects, the number of OSATS) is particularly important at times of appraisal and particularly at the designated waypoints in the training programme.



What to do if no one wants to do assessments and where to get help You are responsible for organising your workplace-‐based assessments. You and your educational supervisor should discuss the areas in which an assessment is required at particular stages; this is based on the unit in which you are working. Whether you are being assessed by your educational supervisor or another clinical trainer, you should plan ahead so that you are not completing all of the necessary assessments in the lead up to an appraisal or an annual review. If you are struggling to have assessments completed in your unit, speak to your educational supervisor as soon as possible. Do not wait for appraisals but make contact to explain the difficulties that you are having. Why do trainees fail to progress? Failure to achieve learning targets and a poor attitude is a common reason for trainees not progressing but a lack of collated evidence is probably the most common reason.

Evidence is extremely important. How to ensure progression

• Use the RCOG Training Matrix as a guide. • Set a good plan and keep planning. • Review targets frequently. • Ensure collation of evidence throughout the year because leaving things until the last

minute will cause problems for you. • Keep a record of experiences and do not worry about paying attention to the details of its

presentation. • Short, regular, reflective notes of experiences will be invaluable for the rest of your career. • Keep up-‐to-‐date with workplace-‐based assessments. You will not complete workplace-‐based

assessments all the time but you should undertake them periodically to demonstrate your progression. Contrary to previous terminology, there is no such thing as a ‘failed’ workplace-‐based assessment. Each assessment is useful for you and your educational supervisor, whether you have shown complete competence or not.

• Take training seriously. • Appear professional and conscientious. • Keep evidence and well-‐ordered documentation because, like patient records, training

documentation is also an official record. Upload your assessments to your ePortfolio on a regular basis and not just before the ARCP.



Is there a right to appeal? Yes, there is a right to appeal but it is far easier to follow the guidance and make sure you do what is expected of you and that you get it right the first time.

Scenario! A highly talented ST5 is working in a district general hospital. Having completed a successful project on ovarian cancer, the trainee plans to be gynaecological oncologist and wants to start a subspecialty training fellowship within the next year. Enthused by the success of the project, the trainee concentrates on writing-‐up research and plans to cram other core tasks into the last part of the attachment. However, the trainee them develops a severe chest infection and requires 4 weeks off work. Two weeks before the submission deadline for the trainee’s ARCP, the trainee realises that no OSATS have been done, she cannot find her Mini-‐CEX certificates, nor has she completed an audit and has not attended a compulsory course. A perceived lack of interest in maternity care has resulted in poor multi-‐source feedback from midwives. Consequences Panellists know that the trainee has excellent capabilities but are concerned by a lack of application. The trainee's progress is deferred. The trainee is asked to produce completed documentation within 2 months and must repeat multi-‐source feedback at 6 months. The trainee is unable to apply to the subspecialty training fellowship.

What else makes a good O&G doctor? Management, research and teaching: going beyond the written curriculum The ability to combine clinical practice with basic research in a field that is of direct clinical relevance is very rewarding. Research is the basis on which modern medicine is practised. New developments in our understanding of disease processes and their treatment rely on both basic science and clinical research. Many trainees undertake a period of between 1 and 3 years in a research post, which can be carried out at any stage of training. Posts are advertised by universities within the careers section of the BMJ. Research may be undertaken in a laboratory setting or as part of a clinical research team. Although research is not an essential part of training to obtain a consultant post, many trainees report that their experience of research gives them an excellent insight into the use of statistics and other research methodologies and an understanding of how science influences clinical practice. For many trainees, a research project can be the impetus to proceeding down a particular pathway of training and development of an area of particular interest as a consultant.



Academic training in O&G is essential for the future development of the specialty. Academic departments of O&G operate within the teaching hospital framework and may be independent or integrated into larger units. All work closely with their NHS counterparts. Career paths in academic medicine have been redefined recently to enable access to academic training at all postgraduate levels. A number of academic Foundation Year posts will provide interested trainees with a ‘taste’ of academia, while dedicated academic training programmes now exist to enable academic training run in conjunction to normal clinical training. To obtain senior position in an academic department as a consultant, you will need to have taken an academic clinical career path involving a period of research training, leading to publications, as well as have a higher degree, such as PhD or MD. Using other learning methods The curriculum requests trainees develop competence by observing a procedure, carrying out the procedure under direct supervision and then carrying out the procedure independently. When trainees are unlikely to be able to see rare clinical presentations to develop competency, it would not be beneficial to remove these rare occurrences from the curriculum so, instead, trainees and trainers must be aware that, in such circumstances, trainees do not have to observe or perform the relevant procedure to be successfully assessed and to progress through training. Instead, alternative training methods should be used (such as drills and eLearning) and CbD assessments should be completed until all expectations within the assessment are met. eLearning StratOG StratOG has been designed as a self-‐assessed learning online tool for those specialising in O&G. As an interactive resource, StratOG includes:

• eTutorials that contain: o interactive assessments and the facility to save assessment scores o videos of procedures and scans o animations to simplify complex principles o links to guidelines and reading material o a reflective notes facility so users can reflect on their learning.

• A bank of single-‐best answer questions to help trainees preparation for the MRCOG Part 1

• Access to online lectures and workplace videos on best practise in specialty training

StratOG can be accessed at www.rcog.org.uk/stratog. If you are a trainee on the Trainees' Register, access to the Core Training eTutorials in StratOG is a benefit of membership. If you have any questions about eLearning, contact the StratOG team at [email protected].



ePortfolio The O&G ePortfolio is now compulsory for all eligible trainees (that is, everyone except those in their last year of training or who are already in subspecialty training by August 2013). Providing the portfolio in an electronic format enables more practical, portable recording of clinical skill development and the electronic format also improves the process for quickly locating and accessing information within the curriculum. In addition, the ePortfolio provides opportunities for trainees to note reflections of their learning experiences and identify future learning needs. Reflective entries can be typed within organised logs and associated with workplace-‐based assessments. The electronic format is proven to encourage organisation of reflective entries more so than in a paper format. You can type messages, which are stored by date and can be linked for formal assessments.

The degree to which you and your trainers use the ePortfolio is entirely dependent on the relationship that you have and whether you prefer face-‐to-‐face or online communication. Whether you find it easier to use paper and then upload data periodically or whether it is possible to sit down at a computer every week with an educational supervisor, the system is entirely flexible. The e-‐Portfolio allows deaneries, schools, college tutors and training programme directors to keep an eye on your progress when data are presented online. It is also a crucial element of the ARCP process. When trainees and supervisors are so busy, it is very difficult to schedule meetings but when communication and progress can be monitored online, you should feel well supported. If you have any queries regarding the ePortfolio, you can contact the ePortfolio helpdesk. Electronic Fetal Monitoring (EFM) EFM is an online learning resource that has been created by eLearning For Healthcare and is supported by the RCOG and the Royal College of Midwives. EFM educates learners using assessment-‐driven case-‐based learning in the area of fetal heart rate monitoring. The interactive learning sessions test knowledge of CTG interpretation and clinical management and provide feedback to the learner regarding their performance. The resource is split in to three sections:



• knowledge-‐based interactive tutorial section • case-‐based study section that allows the learner to practice their skills on actual fetal heart

rate recordings and subsequent management in a virtual labour ward setting • assessment section that formally tests the knowledge the learner has acquired from the

knowledge-‐based sessions. For more information regarding this resource please contact Navin Jaitly on 020 7772 6460. TIPS FOR TRAINEES IN O&G If you think we should cover any other points in this resource, please email Kim Scrivener, Director of Education Policy & Quality ([email protected]).

2013-07-29 tips for trainees final - rcog · 2014-02-21 · rcog tips for trainees...

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