Core medical training needs “urgent” reform to drive up quality, says RCP

Authors: Abi Rimmer 

Publication date:  02 Apr 2014


Urgent changes are needed to improve the quality of core medical training (CMT), a report by the Royal College of Physicians (RCP) and the Joint Royal Colleges of Physicians Training Board (JRCPTB) has suggested.

The report found that CMT trainees were spending too much time providing services and not enough time receiving training. It also raised concerns that trainees were often not able to attend outpatient clinics and training sessions, and that many did not receive enough feedback from senior colleagues.

The RCP carried out a survey in June last year of junior doctors undertaking CMT, and received responses from 779 trainees. In a report on the survey, the RCP warned the findings suggested that, if CMT were not improved, recruitment to the programme would “continue to decrease” and it would become increasingly difficult to recruit to medical specialties.[1] “Urgent changes must be made to improve the quality of training for CMT trainees who are the future consultants of our medical workforce,” the report said.

In total, 91% of respondents to the survey said that they had spent 80% to 100% of their time during CMT on service delivery rather than on training. “Only 2% spent less than 40% of their time on service,” the report said. The average shift for a CMT trainee involved writing three discharge summaries, taking blood three times, filling in 10 forms, and handling 10 phone calls, the survey found.

Although 89% of respondents said that outpatient clinics were valuable to their training, 81% said that they were frequently prevented from attending these clinics because of ward commitments. Just 4% of trainees said that this never occurred.

In addition, 41% said that they were frequently prevented from attending teaching sessions at their local hospital, and 36% said that they were frequently prevented from attending regional teaching sessions held by their deanery.

The report warned that the “conflict” between service and training was a barrier to trainees wanting to expand their skills. “Considerable changes to the ways wards are staffed are needed to allow appropriate training of the future medical workforce,” it said. “Trainee attendance at training sessions also needs to be supported by seniors, so that trainees are able to progress through the programme.”

Despite these concerns, the report said that it was important not to discount how valuable service provision could be for learning, “provided that time to train and to receive feedback is available and learning opportunities are not lost.”

Many trainees also believed that educational supervision by senior colleagues was limited in CMT. Almost three quarters of respondents said that gaining feedback from consultants was very valuable, but 45% of trainees stated that they reviewed fewer than half their patients with a senior colleague. “Time dedicated to teaching and giving feedback to trainees is required by the General Medical Council, but this requirement is frequently not being met. It is crucial that consultants are allocated time to supervise, teach and give feedback to trainees,” the report said.

CMT trainees also suffer from a fall in the time available to gain experience in emergency situations and procedural skills due to reductions in working hours brought about by the implementation of the European Working Time Directive, the report said. Simulation training may be one way of increasing experience in these areas, the report said. Such training has shown “large, statistically significant benefits in the areas of knowledge, skills, and behaviours in the context of actual patient care,” it argued. However, results from the survey suggest that simulation training is being underused. Only 28% of respondents said that simulation training was available locally, and just 33% said that it was available regionally.

Results from the survey also suggested that many trainees had been deterred from pursuing acute medical specialties by their experiences of CMT. “The choices of specialty that were most likely to be abandoned were acute and general medicine, gastroenterology and renal medicine,” the report said. “Of those trainees who had originally chosen these careers, only 13%, 34% and 35%, respectively, wanted to continue to apply for these specialties after starting their CMT.”

Expanding the number of trainees working in general internal medicine, as the The Shape of Training report has recommended, may not be popular with some trainees, the findings of the survey suggest. “Specialties that currently do not have a (general) internal medicine component after CMT are more often pursued by those who had chosen them before starting the programme,” the report said. “The reasons for this are unclear but may relate in part to the perception of the medical registrar role, the work/life balance offered by less acute medical specialties and the lack of exposure to more acute specialties in the first year of foundation training.”

Responding to the survey, Kitty Mohan, co-chair of the BMA Junior Doctors Committee, said, “It’s vitally important that training and development opportunities for junior doctors are protected and prioritised, yet these survey findings show that training is being compromised in the face of rising demand and increasing pressure on an already over stretched medical workforce.”

She added, “We are investigating ways in which we can improve access to training in our contract negotiations with NHS Employers but, ultimately, addressing this issue will require greater commitment from employers to protect—and truly value—both training opportunities for junior doctors and supervising time for consultants.”

Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

References

  1. Royal College of Physicians. Survey of core medical trainees in the United Kingdom 2013: inconsistencies in training experience and competing with service demands. 2 April 2014. [Link] [Link]

Abi Rimmer BMJ Careers

 arimmer@bmj.com

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