The way I see it

Never too late to learn

Authors: Paul Streets 

Publication date:  26 Feb 2008

If the United Kingdom is to maintain its well earned reputation for excellence in medical education and training, the most important questions we must address today are ones of content and delivery.

Firstly, how are we going to achieve a meaningful patient-professional partnership? One that enables shared decision making and, where appropriate, self management, in increasingly well informed patients with complex comorbidities and conditions?

Secondly, how will we meet service needs in a rapidly changing and devolved NHS, characterised, in England at least, by a mixed economy of providers?

Thirdly, how will we create a more flexible workforce equipped to respond to rapid changes in technology and service, which can render the skills of today obsolete tomorrow?

And finally, how do we deliver competent doctors and address the aspirations of trainees for excellence given the European Working Time Directive?

These are big agendas for change: one might—justifiably—ask how they can be done within the time available.

Patients and trainees might sensibly ask whether we can train safe doctors in less than half the time, given the need to educate for competence andcapability in an increasingly complex world with an ever expanding evidence base.[1]

To address these issues there have been calls for longer training, a reduction in the breadth of the certificate of completion of training; the break up of training programmes into modules; and the need to acknowledge that we should aspire to a consultant led not consultant delivered service.[2] [3]

All of these present problems. Longer training might reduce flexibility if it locked trainees in for a greater part of their working lives. A narrower certificate of completion of training and “modularisation” might assist flexibility if it enabled the acquisition of new skills and knowledge throughout a doctor’s working life.

But it could present challenges to the aspiration of a patient centred NHS, especially if it means patients fall between the gaps, or across the divides, created by increasing specialisation.

Indeed there is a debate about the need for more generalists, not more specialisation. The consultant led-consultant delivered-subspecialist debate may be a fascinating political minefield but it misses the central point about the need for doctors to be competent and capable whatever they are called.

But we won’t be able to deal with issues of content and structure unless we address how training is delivered.

The “hidden agenda in curriculum” that rests in the attitudes and behaviours that trainees acquire from their trainers and in the real world post-medical school is key.[4]

The BMA Education Committee warned in 2006 that the role of the doctor as teacher should not be acquired through chance, aptitude, or inclination alone.[5] It is worth reflecting on the differences between general practitioner (GP) and hospital specialist training. GP trainers are selected, trained, and paid for the job.

Unlike GP trainers, the majority of trainers in hospital medicine are not trained to train, and they work in an environment characterised by increasing service pressures and the demands of the consultant contract and the job plan. A recent survey of consultants in Scotland indicated that only 6% had a qualification in training and 48% had not even attended a workshop on education.[6] The 2006 Postgraduate Medical Education and Training Board survey of 25 000 trainees suggested that this difference is reflected in the relative satisfaction of GP trainees with the training they receive—a factor that is directly related to supervision. As indeed was the self reporting of medical error by trainees.[7]

None of this is to deny the enormous commitment to excellence in training of many dedicated consultants and doctors across the NHS, but it is right, given the pressures we face, to question whether the current system of training can continue to deliver.

Regulation is a part of the answer, adopting a more explicit approach to that which previously might have been implicit. Over the past two years the Postgraduate Medical Education and Training Board has worked with the medical royal colleges to ensure that, for the first time in the UK, there are generic standards, curriculums and assessment frameworks for every specialty. After consultation, as part of our new quality framework we have added standards for trainers to our generic standards for training. As part of our Future Doctors project (www.pmetb.org.uk)this summer we will be asking questions about whether the regulator should take a more prescriptive approach towards monitoring how training is delivered. The outcome will influence how we approach our role going forward.

But you can’t manage delivery through regulation—government and the NHS must do their part.

Nationally there may be a case for considering the wider adoption of the GP trainer model with funding and financial recognition for trainers and financial incentives to trusts, boards, and trainers to train. The Postgraduate Medical Education and Training Board is beginning to produce comparative performance data that could provide a benchmark to support this.

Regulatory standards must also be met. This role lies with those who hold the money and are responsible for delivery of education on the ground. They must be tasked by the four departments of health to strike a better balance between the targets and priorities of today and the medium term objectives focused on delivering the doctors, and other professionals, for patients and services of the future.

Many of the challenges facing us are not unique to the UK. The Tooke Inquiry report should be a wake up call to meet them head on if we are to retain our international reputation for excellence in medical education and training.[8] The price of not doing so will be a heavy one for the patients of tomorrow.

Paul Streets chief executive officer Postgraduate Medical Education and Training Board