Reviews Personal views

Assessment of doctors in training: should patients give consent?

BMJ 2006; 332 doi: (Published 16 February 2006) Cite this as: BMJ 2006;332:431
  1. P G Lawler, medical director (plawler{at}
  1. Iodem Health, Darlington

    In the past, long hours and many years spent as junior doctors resulted in consultants who, at appointment, had considerable skill and experience. The volume and variety of experience ensured that there were no gaps.

    Over the past decade, however, the need to align UK specialist training programmes with those in Europe, now coupled with the exigencies of the Working Time Directive, has resulted in a quantum change in the time available for training doctors to the UK consultant standard. Postgraduate training programmes have had to be revitalised to deliver a similar consultant “product.” Shortened specialist training programmes, devised by the royal colleges, faculties, and other bodies, such as the Resuscitation Council, now aim to accelerate the development of trainees' skills but in a structured and supervised manner, with an analysis of their training record to expose gaps.

    The educational contract should now be considered to include the patient

    At all levels, programmes have objectives and standards, many with teeth. In anaesthesia, for instance, the “initial assessment of competency” for senior house officers, an assessment normally undergone after three months' training, was one of the first documented assessments in which failure prevented the trainee joining an on-call roster and would thus have an effect on service provision. New programmes have developed the theme of documentation and the need for demonstrable achievement through formal examination and sign-off—attendance at ward rounds, clinics, or theatres is no longer equated with achievement.

    Foundation programme trainees must undergo a number of assessments. These include “mini-CEX” (the mini clinical encounter exercise), an assessment of history taking, physical examination, and allied skills (communication and judgment), and “DOPS” (direct observation of procedural skills), an assessment of a procedure in a genuine clinical encounter. These assessments are effectively the doctor's first exposure to postgraduate examination. Competency based specialist training programmes likewise require similar examination of clinical practice.

    Doctors are used to taking examinations. They also believe that examination “practice” is worth the effort. The evidence for this, as every college tutor knows, lies in the crescendo of requests for the in-house pre-examination viva training and in the numerous examination and crammer courses advertised each month in this and similar journals. The purpose of such courses is not just so that candidates can spot examination or viva questions (and to provide pat answers) but to familiarise them with the nature of the questions and the examination environment. Doctors believe that they may get anxious and that practice and familiarity will improve their performance.

    Mini-CEX and DOPS require that foundation stage trainees are assessed during a clinical encounter. When the assessment involves only history taking and examination (mini-CEX), there will be little consequence to the patient should the trainee candidate's performance be poor; the consultant (or other) observer can later review the patient. For DOPS, however, anxieties associated with the observed assessment and its environment—even if the patient is unconscious—may result in the patient receiving suboptimal care.

    The foundation programme's DOPS is limited to simple procedures, such as insertion of a nasogastric tube, with little potential for hazard to the patient should the trainee perform poorly. However, it is reasonable to expect that this formal assessment tool will migrate and be used to check more complex procedures undertaken by specialist registrars. Although some invasive procedures may do no harm to the patient (supervised tracheal intubation, gastrointestinal endoscopy), others have the potential to cause irreversible damage. An example might be a supervised surgical procedure such as herniorrhaphy, with the trainee as the operator and the consultant assessor as the first assistant.

    Because the trainee will not perform to the same calibre as that of the consultant assessor and may also perform poorly under examination conditions, it is reasonable that patients should provide genuinely informed, written consent. It is not enough that the candidate simply asks the patient whether it is “OK” or that the assessor checks that the patient is “aware.”

    Consultant assessors may not be happy with the bureaucratic need to obtain written, informed consent, but doing so would ensure that assessors are confident that trainees are up to the job. The educational contract should now be considered to include the patient. Training systems and programmes will be better for a requirement for patients to consent to taking part in the assessment process.


    • Competing interests Iodem Health advises NHS trusts on risk, poor performance, and conflict resolution.

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