Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
ST Depression or ST Elevation?
- Chika Uzoigwe, Mark Bishay (12 October 2007)
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Questions for Professor Sir John Tooke
- Jonathan Beard (14 October 2007)
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Improvements to the Foundation Programme
- Stuart H McClelland (15 October 2007)
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Re: Tooke report - Workplace assessment needs to be improved
- D B Double (15 October 2007)
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Deeds not words please
- GH Hall (18 October 2007)
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Tooke report
- John B Cookson (19 October 2007)
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FY Training: The Anatomy and Physiology of Teaching
- Darren James Leaning (20 October 2007)
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Tooke brings focus but no solutions to those seeking global health work within MMC
- David Baguely, Gareth Lewis, Killeen T, Martineau F, Nicholson B on behalf of the Alma Mata Working Group (22 October 2007)
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When beauraucrats believe they are teachers ...
- Andrew Al-Adwani (22 February 2008)
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Chika Uzoigwe, Dept Orthopaedics Milton Keynes General Hospital, Mark Bishay
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The Tooke report, as it exposes MTAS-gate, scrutinises a time when almost the entirety of the medical community was afflicted with ST depression or ST elevation. Despite the preliminary sound bites from the report, it must not be overlooked that there were both winners and losers. After the evolution of round 1.5, most concede that generally, excellent candidates were awarded ST posts. However, unfortunately, there remained still the "tribe" of equally excellent candidates who were not such rewarded for their distinction. The report promises transparency. This is vital and will hopefully allow the excellent and not-so-excellent losers to learn why they were overlooked as well as finding fault with the system. There is consensus that the cream should rise to the top. However after this, there should a natural and gradual sedimentation of quality rather a polarised dichotomy of have's and have-nots; excellent and unexcellent or ST depression and ST elevation. A training programme with a single point of access would jeopardise this principle. The report promises to make uncomfortable reading for doctors and politicians alike but this catharsis is required. Now there appears to be greater collaboration between the government and medical profession, hopefully the Tooke report will take out the depression from ST training. Competing interests: None declared |
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Jonathan Beard, Consultant Vascular Surgeon Sheffield Teaching Hospitals
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Whilst I agree with most of Professor Sir John Tooke's recommendations, II have concern about his proposal to decouple F1 from F2. I have listed my concerns as questions. 1. I share Prof Tooke’s concern about guaranteeing UK Medical School graduates core training in generic medical skills, before specialty selection. Why did he not consider moving full registration back to the end of F2 as this would guarantee all UK medical graduates 2 years of employment? If this requires primary legislation then surely that could be undertaken? 2. Can he reassure us that the motive behind splitting F1 and F2 is not so that universities gain control of the income stream? 3. The Foundation Programme has taken 5 years of piloting and implementation plus a huge amount of work from Foundation Programme Directors and Deaneries (1). There have been some problems with poor quality F2 placements in some Deaneries, partly because some were converted trust grade posts with inadequate educational supervision, but moving them into Core Specialty Training will not improve their quality. Why change the part of training that was working quite well and does he really think that Foundation Schools and Programme Directors have the stomach for more change at this time? 4. Many universities do not place undergraduate teaching or clinical skills training high on their list of priorities. Is he confident that medical schools can be entrusted with F1 if it is decoupled from F2? Many medical schools did not have a good track record in terms of generic skills training and assessment in the PRHO year prior to the introduction of Foundation. 5. The experience of the Foundation programme is that, with the reduction in hours of work, one year is insufficient to ensure the competence of doctors in core generic skills. How will he ensure that such generic skill training is protected in Core Specialty Training? Alternatively the final year of medical school training may have to become even more clinically orientated. The lack of competence in core generic skills is something that will concern the Medical Directors of all Trusts. 6. One deficiency of the Foundation Programme was the lack of a nationally ranked ‘exit’ exam at about 18 months, which could have been used to inform specialty selection. If F1 is decoupled from F2, selection into Core Specialty Training will have to occur at about 6-8 months after graduation. Won’t this be too close to Finals and risk ‘exam’ overload? Wouldn’t it be more sensible to ensure that Medical School Exams are standardised and ranked so that they can contribute to specialty selection? One of the problems of selection into the existing Foundation Programme is this lack of equivalence. 7. What will be the criteria for selection into Core Specialty Training? Presumably the computer adaptive tests that he refers to will map to the F1 syllabus and the potential for specialty training? 8. One of the key aims of the 2 year Foundation Programme was to give more opportunity for young doctors to gain work experience in more specialties, before having to make a career decision. This has proved very successful for some ‘less popular’ specialties, as well as primary care. Won’t there be less rather than more time for career decisions if doctors have to choose a Core Specialty after only one year? 9. What happens to those doctors who make the wrong choice of Core Specialty? What are his plans for inter-specialty transfer and the recognition of cross-competencies? His suggestion of hybrid rotations will be regarded as ‘second-class training’ by many specialties. A limited number of broad-based Core Specialties will help to address this problem. 1. Developing an education and assessment framework for the Foundation Programme. Beard JD, Strachan A Davies H, Patterson F, Stark P, Ball S, Taylor P, Thomas S. Medical Education 2005; 39: 841-851 Competing interests: Foundation Programme Director |
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Stuart H McClelland, SpR Anaesthetics Queen's Medical Centre, Nottingham, NG7 2UH
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Jonathan Beard is right to question the decoupling of the F1 and F2 years. The Foundation Programme concept has two main benefits as I see it. Firstly, compared to the old House Officer year, a prolonged period in which to obtain the core generic skills required of all doctors, prior to becoming focused on one speciality, is desirable and may be necessary given reducing working hours. Secondly, it is important for doctors to have knowledge of the philosophy, approach and constraints of specialities outside of their own. There is not enough time in the overburdened medical school curriculum to gain this fully. Specialities such as anaesthesia often used to advise prospective trainees to “do something else first”, after the House year, but prior to commencing speciality training, and GP training is not undertaken solely in general practices, but also in secondary care. However, that is not to say that the Foundation Programme cannot be improved. I feel there has been a missed opportunity to concentrate on the educational aims of the programme, rather than just looking at where the jobs are and producing rotations to cover them. If we accept that four month placements are optimal at this level of training, then I believe there is an argument for most doctors doing general medicine, surgery, general practice, emergency medicine (A&E), and critical care, (anaesthetics/ITU/HDU). That would leave room for one ‘elective’ or ‘taster’, speciality. This might involve a change in working patterns, to accommodate the change in the balance of trainees between areas, but would ensure that doctors leaving the Foundation Programme are well grounded for their subsequent speciality training, particularly the care of the acutely unwell, which often seems to be neglected in preference to chronic conditions at medical school. Competing interests: None declared |
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D B Double, Consultant Psychiatrist Norfolk & Waveney Mental Health Partnership NHS Trust, Peddars Centre, Norwich NR6 5BE
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The interim Tooke report into Modernising Medical Careers (MMC) concentrates too much on further potential structural changes in specialist training.1 Surely the last thing we want is another major overhaul of specialist training. Delamothe's editorial notes that the inquiry comments on the lack of consensus for training and the role of doctors in general.2 However much these issues may have contributed to the MTAS fiasco, we do need to make good the current position of specialist trainees with some urgency. No one training structure is necessarily any better than another, and we need to make the most of the system we have to avoid unduly upsetting it again. Although the report obviously recognises that MMC involves much greater reliance on structured, competence based training, it suggests it may take two to three years to develop relevant core curricula and owned and trialled assessment methodologies. This is too long and will lead to the same sort of negative comments about such training that the report found amongst foundation year doctors. Despite identifying the required significant increase in time commitment from both senior and junior doctors, it makes no recommendation about providing this as a priority. There is a major need for consultants to be trained in workplace assessments if the current specialist trainees are not to be let down by the new system. I agree about the need for flexibility of speciality choice at the beginning of training, but I do not see why this cannot be provided on the basis of the present structure of two years of foundation training with run through specialist training. Let's get on and implement this system now, or we will be accused of continuing to play politics with the careers of doctors in training.
Competing interests: None declared |
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GH Hall, Retired physician and ex chairman of Central Manpower Committee. EX1 2HW
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Professor Tooke could set a good example to those involved in picking up the pieces from the MMC fiasco by offering to decommission the Peninsula medical school, of which he is Dean. This would kick start the process of reducing oversupply of medical graduates, which is urgently needed. Competing interests: None declared |
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John B Cookson, Undergraduate Dean Hull York Medical School University of York YO10 5DD
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I think it is an excellent report not only because the recommendations are sound but because the ideas underpinning it are right and I really hope that it is accepted. To me it hits the spot every time and says things that a number of people have been saying (but not loudly enough) over a long time. The desegregation of FY1 and FY2 and the incorporation of FY2 into a three year basic training grade is very good. It will make it clear again that the first postgraduate year should a culmination of the undergraduate course. It will deal with the perception of FY2 doctors that they were not making progress from FY1. The current foundation year curriculum covers two years but many consider that the first year competencies are mostly achieved in the undergraduate course so I think that both years could be combined into one. A three year programme after registration acknowledges that there are large commonalities between different specialties and that many patients, particularly the elderly, can have more than one diagnosis. Six monthly attachments will be long enough for doctors to become useful and prevent the current perception that doctors remain trainees for long periods with no service function. The report is much clearer than some documents on what assessments should be trying to achieve and identifies the confusion between formative and summative assessment. It also makes a clear distinction between assessment designed to ensure when a basic competency has been reached and the assessment needed to grade applicants on a scale when they are in competition for a limited posts. It identifies the limitations of a competency-based framework where a course is divided into small discrete competencies each of which is tested individually without any recognition that merely putting those competencies is insufficient for the practice of medicine. It makes clear that the practice of medicine is a much more complex task than is generally conceded by politicians. My only reservation is the emphasis on using written assessments. They are cheaper and it is easier to reach good levels of reliability than with clinical assessment. Nevertheless at this stage we should be aiming to test ‘does’ not just ‘knows’. Written assessments may drive candidates to the library rather than to the bedside. I think this could be a great step forward. The two linked anxieties are whether the Department of Health will accept it and whether the profession will show a united front at least to the principles if not always some of the specifics. The worry will be that a divided profession might send mixed messages from which the Department picks off the ones it wants. Competing interests: None declared |
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Darren James Leaning, FY2 Grimsby DN33 2BA
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Dear BMJ editor I write this article in response to the way in which foundation school teaching seems at times so irrelevant to what we as junior doctors interpret our educational needs to be. I am becoming increasingly frustrated with interruptions to traditional medical teaching in preference for communication skills and teaching skills, skills which we apparently do not have even though we have to pass the same competencies at medical school, we still get the same messages drummed into us as a junior doctor. Generic teaching is ridiculous. Here is an excerpt from a typical foundation training day. I find it somewhat condescending to our intellect, what is more only one of the six supervisors for the day is medically trained. We endure a whole 5 days a year of this as mandatory training, taking a large chunk of our annual study leave entitlements. The general consensus of colleagues spoken to is a strong sense of condescendment and am impulsed to voice an opinion. Here is a brief for our up and coming generic training day from the Hull and East Yorkshire Deanery. (Foundation Curriculum reference: - Core Competences 2.1 and 3.0)
As knowledge in the field of medical sciences advances, it appears we as the physicians of the future have uncovered more than Henry Gray, Leonardo Da Vinci, Claude Bernard and Hippocrates could ever have dreamed possible. From careful, diligent human dissection to unravelling the human genome, nothing could have prepared us for the skill we as foundation year two doctors in our generic training are about to discover, the anatomy and physiology of teaching! What are we to use for this exciting, unparalleled quest? How will we dissect into the belly of the adverb? Should we sharpen our scalpels and minds? Well apparently, in accordance to the brief for my mandatory training day’s task we are expected to prepare two six minute presentations on acetate overheads, (Microsoft PowerPoint is strongly discouraged), in which we will endeavour to divulge to fellow foundation year two comrades, basic foundation year doctor competencies; how to insert a venous cannula, suture a simple wound, insert a nasogastric tube and manage an airway. We will tackle and contemplate the consent procedure understand the complexities of the Glasgow Coma Scale, learn the intricacies of death certification and the greatest mystery in all medicine surely must be the meaning behind the urinalysis reagent (known to many as the dipstick). I can hardly believe we will fit all of these topics into one day, but this is what we must do! Failure to comply, sorry complete this day will result in failure of foundation year two. Whilst we learn how to bond in pairs and sometimes teams, my team at work and the patients we look after manage with one less doctor for the day as I take the time out for a compulsory day of higher learning, of which I am told will make me a better doctor. I feel privileged to be at the brink of deciphering the art of teaching, something never studied by doctors before. Perhaps we might even find the initiative to start medical schools! If this sounds unintelligible I am sorry, it probably is. But this is how the foundation years sound and feel to me. As traditional ward teaching seems to be dying a slow death, we find multidisciplinary team tasks are at the fore front of medical education for junior doctors, where we learn to share problems, communicate and teach one another, with quintessential adjuncts from professional educators and specialists from non-allied medical backgrounds tell us how we should be doing our jobs I am surprised that the consultants of today have managed to function in their contracted role without such gems of advice and is probably why the consultant will become as extinct as the dodo with MMC –Making Medics Concede, sorry Modernising Medical Careers throws away such unnecessary roles as we all exist in a unified team together – strong. Hail MMC! Competing interests: None declared |
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David Baguely, FHO1 Respiratory Medicine Southampton General Hospital, Tremona Road, Southampton SO16 6YD, Gareth Lewis, Killeen T, Martineau F, Nicholson B on behalf of the Alma Mata Working Group
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The recent interim report of the independent enquiry into Modernising Medical Careers (MMC) led by Sir John Tooke highlights the lack of flexibility that was being offered by the proposed run-through training programs. It forced junior doctors to rethink their future career options, none more so than those wanting to gain overseas experience (1). This was illustrated through the lack of flexibility, along with programme provision and training, for those wishing to gain experience globally within or outside the Specialist Training (ST) program. The positive impact of the skills and knowledge brought back to the NHS by UK medics returning from overseas work is well documented , and acknowledged by the recent CMO and Crisp reports (2,3). These reports were highlighted by Tooke et al, and also outline the potential for fresh incorporation and recognition of the value of overseas experience at all levels of medical training, along with the consequent need for collaboration with the relevant accreditation authorities in order to recognise this experience. Furthermore, work of this sort, if managed correctly, can play an important part in fulfilling the UK’s key obligations in aid and development, with UK workers contributing to workforce capacity in those areas of the world in greatest need (2,3). The significant desire of a body of UK medical students and graduates to work internationally (4,5) should be encouraged and catered for by the postgraduate system. Initially, MMC promised to deliver this through the principle of increased flexibility that was one of its cornerstones (6). However, in its final incarnation, it failed to do so. We welcome the specific acknowledgement in Sir John’s report of the threat to international health and the highly representative case study which illustrated his argument(1). However, specific outlines and guidelines as to how international work could fit into his recommendations are notably absent. With increased government funding for development in the recent comprehensive spending review, combined with the recommendations of the Crisp and CMO reports, it is time to ensure that policy is put into practice on this issue. A coherent, clearly defined, and adequately funded mechanism through which UK medical Post Graduates can contribute to health in the developing world is needed. This must come with a guarantee of retention of a place on, and gaining accreditation for, the UK career ladder, or we are likely to fall into the same fragmented situation as before and fall short of our development aspirations and obligations. We hope and trust that these issues will be further explored in the final document and solid, practical recommendations are made to not only preserve but strengthen and promote the valuable contribution that UK doctors, particularly in the formative stage of their careers, make to health in the wider world. 1. Tooke J. 4.4.8 Special Case: Contributions to Global Health. In: Aspiring to Excellence: Findings and recommendations of the Independent Enquiry into Modernising Medical Careers. London, MMC Enquiry 2007. 2. Crisp N. Global Health Partnerships: The UK contribution to health in developing countries; Chapter 6: The UK contribution – Making it Even More Effective and Sustainable. London, COI. 2007. 3. Donaldson, L. Health is Global: Proposals for a UK-wide Government strategy. London, COI, 2007. 4. Nicholson B, Lewis G, Martineau F. International health foundation programmes. BMJ Careers 2007; 334: 23-25 5. BMA HPERU. Cohort Study of 2006 Medical Graduates: First report. BMA, 2007. 6. Delamothe, T. Modernising Medical Careers laid bare. BMJ 2007; 335; 733 -4 Competing interests: None declared |
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Andrew Al-Adwani, Psychiatrist Great Oaks, Ashby High Street, Scunthorpe, North Lincolnshire, DN16 2JX
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Sir: The laudable aim to make "an honest attempt to accelerate training and assure the fundamental abilities of the next generation of doctors" was fatally flawed when the acceleration was always going to be over a shorter course given the restrictions of the European Working Time Directive. To then compound this by favouring, for instance, a Bulgarian over a doctor from the Indian subcontinent who has spoken English virually from birth is to concoct an unpalatable stew. And now we go full circle with the proposal that F2s become ST1s begging the question why was the transition of house officer to senior house officer system ever tinkered with. The suspicion is always that cost savings are buried somewhere in all changes and disempowerment through oversupply is a hidden agenda. The fact is the system MMC tried to implement was a bastardisation of American residency programmes that took no account of their system's being designed for private care and being unrestricted by working time directives. So, as usual, more NHS money down the drain and, especially if the non-EU doctors legal appeal succeeds, we begin where we started; and people wonder why all the money invested in the NHS has produced so little. Competing interests: None declared |
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