Making friends with RITABMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7181.2 (Published 13 February 1999) Cite this as: BMJ 1999;318:S2-7181
Bureaucratic chore or educational opportunity? John Bache discusses the record of in-training assessment, a compulsory part of specialist registrar training
The Calman reforms are now established. Specialist registrars have been appointed, registrars are extinct, and senior registrars have virtually disappeared. One of the features of the reforms is the record of in-training assessment (RITA), a record of the annual review of specialist registrars' progress through their training programme. RITA could easily become a purely bureaucratic exercise, generating paperwork but fulfilling no useful purpose. Alternatively, it could be extremely beneficial for all parties.
Who should benefit?
Everyone: primarily the specialist registrars, but also those responsible for the training, both directly (supervising consultants) and indirectly (directors of training programmes, postgraduate deans, etc), and the health service and thus patients.
Specialist registrars want to establish basic facts, such as the expected date of their certificate of completion of specialist training. They want to review their training to date, particularly that of the previous year, and ensure that their future training will be of maximum benefit and will rectify any deficits in their knowledge and skills. They want to ensure that all their requirements can be satisfied before the date of their certificate of completion of specialist training. As this date approaches, they want to know that their career plans are realistic.
The trainers will also need to satisfy themselves that specialist registrars' requirements are met. They will wish to ensure that the specialist registrars have received valuable and relevant training to date and that this will continue. They need to know where good training is available and, equally important, which hospitals are failing to deliver. They need to establish reasons for failure, on the part of either the trainees or the trainers. It is clearly essential that the process is confidential, mutually honest, and non-threatening. Adequate preparation is mandatory. The number of people involved should be no greater than necessary, but it is essential that the key people are present so that any problems identified can be addressed. Time is always a problem: each specialist registrar should feel that he or she receives a fair and unrushed hearing, but obviously some will require more time than others, and this can usually (though not always) be anticipated when planning the timetable.
About six months before the annual review, a panel is established. The essential participants are the postgraduate dean (or representative), the programme director, the chairperson of the specialty training committee, and the regional adviser. There is also a university representative, and, for a penultimate or final review, there may be an external assessor or a representative of the specialist advisory committee. It is often possible for individuals to combine these functions in order to limit the size of the committee. Those specialist registrars to be assessed are identified and informed of the date, the purpose of the assessment, and the likely constitution of the panel. The consultant responsible for the training during the year to be assessed is also identified and informed of the date. For obvious reasons, it is most important that all parties are given sufficient notice.
It is clearly sensible to interview as many of the specialist registrars in a specialty as is reasonable on a single date, but there are practical implications to this. Even the simplest assessment will take about 20 minutes, and some may take considerably longer. Some slack must be available in the timetable. More than 20 assessments a day is probably unfair to the specialist registrars and assessors alike, and the ideal number is probably about 15. Two assessment days a week, with 15 assessments a day, would allow about 1400 assessments a year.
A trainee assessment form is sent to the supervising consultant of each specialist registrar to be assessed, which is completed by the consultant and specialist registrar before the assessment. It provides background information and allows specific aspects of training to be discussed. It will have been developed by the relevant specialty and will include aspects such as clinical skills (for example, history taking and technical ability), knowledge, postgraduate activities (such as case presentation and teaching skills), and attitudes (for example, leadership and communication skills). There is also space for further comments. The form is signed by both the supervising consultant and the specialist registrar and is returned to the deanery in good time to be available to the panel on the day of assessment. The specialist registrar is also requested to forward an up to date curriculum vitae and is reminded to bring his or her training record to the assessment.
The day of assessment
On the arranged date the panel meets about 30 minutes before the first assessment, in order to discuss the logistics of the day and any anticipated difficulties. The panel is usually chaired by the postgraduate dean (or his or her representative), who will emphasise the importance of adhering to allotted times, particularly if a large number of assessments are scheduled. A member of the panel is asked to check that the training record has been adequately completed. The panel will decide whether the format of the discussion will be closed or open ended. It is normal practice to give both specialist registrar and supervising consultant an opportunity to make comments in confidence, while the other is out of the room. However, it is hoped that nothing derogatory will be forthcoming, because the whole process should be open, honest, and non-threatening so that comments “behind closed doors” should be unnecessary.
The assessment interview
The chairperson welcomes the specialist registrar, introduces the panel, and explains the purpose of the assessment. The registrar's training number is confirmed, together with the expected date of certificate of completion of specialist training, which may require adjustment. The year of the programme reviewed will be the year that has just been completed or is near to completion.
The specialist registrar is then asked to comment on the training received to date, particularly in the year under review. Where has he or she been? What knowledge and practical experience have been acquired? Has it been useful? What are the good points? What are the bad points? Have there been adequate opportunities to increase skills? Is there adequate supervision? Is there sufficient time for private study? Are all necessary facilities readily available? Much of this information will have been obtained from the trainee assessment form, but it can be expanded if necessary.
The panel will then discuss competencies yet to be acquired. What further skills must be obtained or improved before the date of certificate of completion of specialist training? In particular, what skills should be obtained over the next 12 months? How is this to be arranged? Where? How will the specialist registrar's needs be accommodated in conjunction with those of other specialist registrars? Are there any particular problems that need to be addressed? Such problems may be specific (for example, further experience of laparoscopic surgery) or general (such as communication skills, interpersonal relationships, or examination technique). The panel must ensure that competencies which cannot be acquired within the next 12 months can be obtained before the date of certificate of completion of specialist training. The specialist registrar should leave the assessment knowing where he or she is likely to be working over the next 12 months, what skills should be acquired during this time, and how this will be achieved.
Research and audit
The importance of research and audit depends to some extent on the specialty and the specialist registrar's likely choice of consultant post. Gaining experience outside the training programme requires the prospective approval of the postgraduate dean and of the specialist advisory committee or royal college or faculty if the specialist registrar wishes it to count towards a certificate of completion of specialist training. However, all specialist registrars need to have a working knowledge of the audit process and a good understanding of the principles of research.
All applicants for consultant posts will have a certificate of completion of specialist training, and it follows that one method of differentiating between candidates is the amount of research they have done and what papers they have presented and published. Papers can range from a major piece of research published in a prestigious journal and possibly emanating from an MD thesis to a case report in a non-peer reviewed journal. In either case, however, it is easier to obtain publications at a relatively relaxed pace three or four years before the date of certificate of completion of specialist training than to try to squeeze a few publications into a busy final year. This may seem obvious but it is overlooked surprisingly often.
The opportunities for time out for research towards a higher degree can be discussed if the specialist registrar wishes to consider this possibility. It should certainly be mentioned. Time out for research, fellowships in Britain or abroad, and other commitments outside the programme all need to be planned well in advance, and the annual assessment is an ideal opportunity as many of the relevant individuals are likely to be present.
Career intentions should be discussed. At the start of specialist registrar training, individuals' ambitions for a consultant appointment can, and probably should, be relatively vague (orthopaedic surgeon, for example). However, as they approach completion of their specialist training, their intentions certainly need to be more specific and may need to be more realistic, according to the posts that are likely to become available around the appropriate time (an orthopaedic surgeon with a particular interest in knee surgery working in a district general hospital). It is surprising how often fairly senior specialist registrars have unrealistic ambitions, aiming for posts that are unlikely to materialise. Regional advisers should be able to make informed comments but may not be able to speak with certainty.
Finally, there should be a conclusion stating what has been achieved to date and specific plans for the future. A RITA form C, D, E, F, or G is then issued for the appropriate year (see box). For most trainees, the annual reviews will confirm that they are on course to complete training. For those who do not progress as expected, additional help and support will be provided. The need for any additional help should become apparent at an early stage. This might involve extra supervision, counselling, or specially focused training.
A - Core information on the trainee
B - Changes to core information
C - Record of satisfactory progress within the specialist registrar grade
D - Recommendation for targeted training (stage 1 of “required additional training”)
E - Recommendation for intensified supervision or repeated experience (stage 2 of “required additional training”)
F - Record of experience outside training programme
G - Final record of satisfactory progress
After the assessment
The postgraduate dean writes a record of each interview, and this is forwarded to the specialist registrar and all members of the panel. A copy of the completed RITA form is sent to the relevant royal college, faculty, or specialist advisory committee. Any necessary action should be taken. Problems should be addressed with honesty, whether this involves the specialist registrar, one or more trainers, or a particular unit.