Intended for healthcare professionals

Career Focus


BMJ 1997; 315 doi: (Published 18 October 1997) Cite this as: BMJ 1997;315:S2-7114
  1. Jamie Bahrami, The Surgery
  1. Station Road Clayton Bradford BD14 6JE

    MJ 7114 Volume 315: Saturday 18 October 1997Career focus Remediation

    Doctors who fail regulatory end point assessments are in a difficult position. Yorkshire's regional adviser in general practice Jamie Bahrami discusses the delicate task of bringing trainees up to par - while maintaining the confidence of the profession and the public.

    With the introduction of summative assessment at the end of vocational training,1 general practice is now faced with the challenge of what to do about those trainees who fail. Evidence from the west of Scotland suggests that approximately 5% of trainees who undertake summative assessment will fail to reach the minimum standard of competence necessary for entry into independent medical practice.2 Generalised across the UK, this represents 100 trainees3 each year who either have to re-take the package (or elements of it) until they pass, or give up all aspirations to a career in general practice. This is a huge waste of resource, and requires urgent attention.

    Summative assessments

    In the past three years, a great deal of work has been carried out to produce a reasonably valid and reliable package of summative assessment4 for the end of vocational training in general practice. Also, lengthy debates have taken place about the grassroot opposition to the package and its legality in terms of vocational training regulations5. In addition, each deanery has spent a great deal of time and money to implement the package, selecting and training an adequate number of assessors, training the trainers, devising appropriate procedures, and having a mechanism to deal with appeals. Sadly, however, there has been little opportunity to seriously consider the fate of those who will fail, and our professional, ethical and moral obligations to them. Admittedly, under the current regulations,6 subject to the recommendations of the Joint Committee of Postgraduate Training in General Practice (JCPTGP) and subsequent approval of the secretary of state, the failed trainees can be offered an extended period of training up to twelve months in general practice. Although this may provide a breathing space, we need to explore in much more depth the reasons why individuals fail, and the appropriateness of opportunities which should be available for remediation.

    Positive strategy is needed

    At a personal level, failure in any test is disappointing but, to fail in summative assessment which, after all, is a test of minimum competence at the end of nearly ten years of education and training (from entry to medical school to the end of vocational training), must be traumatic. The result has serious implications for the livelihood, career progression, and individual self esteem of the failed trainee. At a more general level, with the worsening crisis in GP recruitment and retentions7 and the implied threat to the future of a primary care led NHS8 there is an added urgency that these trainees should be identified and rescued as early in their career as possible. But, in the current climate of opinion, the profession seems to have taken the easy way out by stating simply that patient interest comes first, and they must be protected from incompetent doctors at all costs.9 This seemingly unchallengeable attitude disguises the cold face of a supposedly caring profession which has little time or compassion for the victims of its education system. The crucial questions which we need to address are how to reduce the number of failures in summative assessment, and what arrangements should there be for additional training or restraining of those who fail? In a well structured

    training programme - as vocational training for general practice claims to be - there should be well defined criteria of entry.10 This is particularly important at a time when vocational training is faced with an acute recruitment crisis and relies heavily on candidates from differing educational and cultural backgrounds. There is already a growing anxiety amongst the trainers, course organisers and others, that the quality of some of the trainees leaves a lot to be desired. There is an urgent need to introduce appropriate criteria and procedure for entry into vocational training. This will help to safeguard standards and ensure that those who enter the training programme at least have the potential of passing the test of summative assessment.

    Formative assessments

    Next most important is a mandatory system of formative assessment11 which will allow early recognition of deficiencies, and prompt and appropriate remedial action whenever necessary. At present, the pressures of time and short duration of training in general practice, mean that not enough attention is being paid to formative assessment. At best it tends to be subjective and, at worst, replaced by summative assessment. However, even with a proper system of formative assessment in place, there is no guarantee that we can stop all failures. After all, any test of competence, set at a reasonable standard, will always have its casualties. Therefore, it is crucial that we should develop a system of remediation for those who fail and wish to pursue their career intentions of becoming a general practitioner. In its document The Advanced Training Practices12 a working party of the Committee of Regional Advisers in General Practice outlined a proposal to select a number of existing training practices which could provide additional training for trainees who fail summative assessment. These practices would have to meet certain additional criteria and demonstrate a total commitment towards those trainees who fail summative assessment. Alas, there are indications already that not many trainers want to be involved in this high risk challenge. The reasons, though complex, are perfectly understandable. These relate to the legal, ethical, and organisational implications of such an undertaking, and the time that these trainees require for remediation. It is also anticipated that such trainers will require specific training and a proper system of support for remediation. Many feel that the current training grant is already insufficient to cover the time, effort, and commitment that this work demands. However, even if by some miracle of goodwill there were an adequate number of trained trainers in advanced training practices, there would still be a minefield of complex ethical and legal issues related to patients who are managed by doctors who have failed the test of minimum competence. For instance, how many patients would give informed consent to treatment by a doctor who has been found to be incompetent? And, more seriously, who will be responsible for any possible errors in diagnosis and management?

    Australians lead the way

    In Australia, where the subject has been explored with much more vigour, regional general practice training and education centres have been specially set up to deal with trainees in the “borderline zone of competence”. The centre is based at a district general hospital with two full time and two half time general practice supervisors. It is equipped with consulting rooms, each with video cameras, and the time each trainee spends in the centre is “individually determined”.

    Staged approach model

    There is a well defined process of remediation taking place in five stages. In the first stage, the medical staff at the unit gather all assessments of the trainee and determine whether he or she will benefit from remediation. At the second stage, the Trainee is informed about the concerns held about their competence. At the third stage, the first four weeks is spent in the centre, where a remediation plan is formulated and agreed. At the fourth stage, time is devoted to carrying out the learning plan, which is variable, and depends on the difficulties identified. Finally, at the fifth stage, a decision has to be taken on whether the Registrar has achieved the desired goals, or whether he or she will require further support and supervision.13 With some modifications, I believe this represents a reasonable model of remediation which we can build and develop further in our deaneries in the United Kingdom. Each centre will be supported with the necessary infrastructure and expert staff. The staff would have the time and the training to provide a truly learner-centred education plan for each individual trainee. They can also provide personal mentoring by appointing suitable mentors for the purpose. Also, in the protected environment of a centre, the ethical questions of patient management will be less difficult to handle. Most crucially, a centre can provide a whole range of educational opportunities which are not normally available in one training practice. To set up such centres, undoubtedly, we will need additional resources, but most of this can be met through the existing funds available to vocational training, particularly when this becomes part of the medical and dental education levy.14 The centres may also provide opportunities for those Trainers who, at present, do not have trainees in post, and wish to develop new expertise in remediation training. The JCGPPT will need to consider further changes to the vocational training regulations so that such remedial centres can be accredited and treated in the same way as training practices. This model may also be of crucial importance to those doctors who may be found wanting through the GMC's performance review procedure, which started in September 1997.

    In summary, having introduced summative assessment for many good reasons, there is now an urgent need to do all we can to reduce and prevent failures and, in parallel, set up specific remediation centres that can help those who fail. The same centres, with minor modifications, may also be used in appropriate cases to help doctors who have been referred through the GMC performance review procedure.


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