Mini Review
Volume 1 Issue 2 - 2015
TRAINING Matters “A Paediatric Trainee’s Perspective”
Intisar Ulhaq*
Department of Paediatrics, Bristol Royal Hospital for Children, United Kingdom
*Corresponding Author: Intisar Ulhaq, Specialist Paediatrician, Department of Paediatrics (Neurology), Bristol Royal Hospital for Children, Paul O’Gorman Building, Upper Maudlin Street, Bristol, BS2 8BJ. United Kingdom.
Received: April 12, 2015; Published: May 11, 2015
Citation: Intisar Ulhaq. “TRAINING Matters A Paediatric Trainee’s Perspective”. EC Paediatrics 1.2 (2015): 41-45.
Abstract
Paediatrics is a challenging but highly rewarding speciality. After graduation from a medical school, it takes nearly eight years to complete a specialist training programme in the UK. The trainees rotate through various Paediatric sub-specialities to achieve the required clinical and generic competences set by RCPCH (Royal College of Paediatrics and Child health) and GMC (General Medical council).
Patients and their families deserve not only a high standard of care based on the best evidence available, but they also expect the treating Paediatricians to be confident, empathetic, up to date with the latest developments in medicine,good team leaders and excellent communicators.The trainees need guidance and sense of responsibility for self learning throughout their training period. However, as they progress upwards in the training ladders this responsibility increases necessitating a structured approach to achieve the required generic competencies, both on the trainee and the training institutions. In this article these training matters are discussed from a trainee’s perspective.
Keywords: Medical training, paediatrics, learning, feedback, appraisal, communication, clinical governance, team work, adult learning
Introduction and Background
Paediatric training in the UK has 3 levels. Level 1 comprises a three years training as an ST (speciality trainee) which is also called as ST1-3 training period. The trainee in this category is usually the most junior member of the Paediatric team. They are expected to learn by actively participating in the clinical activities and asking for help from the senior trainees (middle grade).
After a successful completion of level 1 training, the trainees progress to next stage, level 2 training. It is also called ST4-ST5 training where the trainees are supposed to act as a middle grade (registrar). They are expected to take decisions and manage the clinical cases with more confidence as they should have achieved the required competencies in the preceding years. However, they should seek senior help in situations where they feel less confident and less competent.Part of their responsibility is to supervise the SHO’s in their day to day activities [1,2].
Level 3 training is the ST6-8 period where the trainees are in the final two years of their training period and by now they should be taking various independent tasks such as conducting ward rounds, running outpatient clinics, admitting and discharging patients. However, they are also expected to ask for consultant’s advice, help and support in difficult circumstances [2,3].
In addition to successfully achieving various clinical competencies, the trainees are also required to achieve various generic skills which are mandatory not only to complement their clinical skills but also very important to make them clinicians of high calibre and expected standards [4].
Trainee’s Perspective
Being a senior trainee who is approaching CCT (certificate of completing of training), if I were to summarise the essential generic skills which one needs to become a competent paediatrician, I would class them as follows:
Team Work
Team work is the key to health care and patient safety and it becomes even more important in a multi-disciplinary speciality such as Paediatrics. A good team has a good team leader as well as effective team members. The paediatric trainees can become effective team members by working in theenvironments in which they can implement their knowledge and skills. The senior clinicians and experienced colleagues in the team need to make sure such environments are available for the trainees.
One way of improving team working skills is by organising regular simulation sessions where members of different grades of medical and nursing teams are involved to learn new skills and improve the existing team working abilities. There is growing evidence that Simulation training is useful in improving both clinical and generic skills [5].
Some specialities are completely based on a team working style and any deviation from it leads to poor performance. Highly specialised sub-specialities such as Paediatric intensive care and Paediatric care prime examples of this. Communication also plays an important role in order to achieve the desired outcome in a team based activity [6].
It would not be wrong to say that communication and team working are interlinked. It is a fact that any break in the communication chain at any level would affect the team performance and hence patient care [7]. Every year health providing institutions pay millions of pounds to patients and families in compensation for substandard care provided or patient/parent dissatisfaction. In addition to other reasons a significant proportion of these claims are either directly or indirectly due to poor communication at various stages of patient’s clinical care [8].
Reflective Practice
Reflective practice is a skill which needs to be learnt and practiced throughout our careers as it allows our natural instincts to interact with a professional approach. Actions are more powerful if they arise from both feelings and thoughts [9].
Evidence of Reflective practice is a key requirement by the RCPCH and forms part of the Paediatric curriculum and it includes events that have contributed to personal development throughout training. An effective way of writing reflective practice is to record the event soon after it happened since a delay in writing may lead to omission of vital aspect(s) of the concerned event. Reflection of personal practice just before formal training assessments such as ARCP/RITA is counterproductive and hence not recommended.
Appraisal
Trainees are required to have PDPs (personal development plans) during clinical postings. Trainees are expected to meet up with their educational supervisor(s) to discuss their PDPs and ways of achieving those plans. According to GMC it is mandatory that by July 2016 all educational supervisors who work with junior doctors and medical students must have received training in educational supervision.
Trainees are required to have meetings with their supervisors in the beginning, midterm and at the end of each post. Trainees are also required to complete a set minimum number of various WBAs (work based assessments) and discuss their progress with the supervisor on regular basis. A final Trainer’s report is then produced at the end of a clinical rotation which becomes part of ARCP/RITA process [10].
The GMC has also developed GMP (good medical practice) framework for all practicing doctors for appraisal and revalidation [11]. Paediatric trainees are required to have access to an electronic portfolio of their training and assessment. Regular meeting with the educational and clinical supervisors, along with multisource feedbacks are useful tools to achieve development plans, identify training needs and address any concerns during the course of training period. This helps to avoid any last minute “shocks” and disappointments at the time of final ARCP/RITA assessments [12].
Induction
Knowing the environment one is expected to work in helps a great deal. Proper induction programmes and orientation sessions before starting clinical roles can avoid or reduce the difficulties a trainee is likely to face during a new rotation in a new setting. It is the responsibility of the employing trust and concerned department(s) to make arrangements for proper induction sessions for the trainees.
GMC strongly recommends induction mentoring in its ethical guidance [13]. Patient safety can easily be put at risk at “change over” time when new trainees replace the previous ones. A well planned and timely delivered induction session would help to reduce such risks.
Avoiding Negative Critisism
Negative criticism of traineeseven with a good intention could potentially lead to low self-confidence and stress which in turn can have negative impact on career. There is a fine line between negative criticism and bullying at work place. Supervisors and senior colleagues must remain supportive whilst maintaining the professional standards whilst dealing with the trainees.
The GMC conducts an annual trainee survey to look at various aspects of trainees. Its press report in 2014 revealed that nearly one in ten trainees experience workplace bullying [14].
The trainees may experience extra stress during their initial stages of career. Long working hours, lack of sleep, difficult clinical situations, experiences of working out of their comfort zone and other issues such as re-location, financial crisis and disruption of family life are well known factors in doctor’s lives [15]. Any additional stress such as negative criticism and bullying may affect their professional and personal lives further. National and regional guidance is out there for both the trainees and the trainers as to the available support in such cases.
Insight Into Own Training Goals
Doctors are adult learners. Depending upon the level of training, thetrainees should set their own learning goals and ideas to achieve those targets (Table 1). However the trainers and educational supervisors need to be well versed with their knowledge and skills of training others [16,17].
One of the important roles of the trainers is to provide effective and timely feedback to the trainees. The trainees should avail every opportunityto ask for feedback from others.Feedbacks are useful in determining what is “good” and what needs improvement. One of the useful ways of obtaining feedback from various professional colleagues in an MSF (multi source feedback) which is organised by the RCPCH per training year.
Educational supervisors should be passionate and approachable with excellent mentoring skills in order to nurture the trainees learning insight [18]. The RCPCH and the local post graduate deaneries organise various teaching courses for both trainees and the trainers and it is worth attending some of these to have a better understanding of this subject.
Need For Continuous Professional Development (CPD)
Doctors are expected to be in charge of their learning throughout their medical careers and the trainees are no exception to this rule. The GMC has developed guidance on CPD in great detail making doctors responsible for their own learning needs .The guidance also suggests that the employers should facilitate this process [19]. RCPH also provides guidance and support to its members with regards to CPD .
Current training assessments and revalidation process requires all trainees and senior doctors to keep themselves up to date with the knowledge and skills in their respected field. A survey of 18 European countries concluded that legislated revalidation and recertificationare driving factors for the doctors to keep up to date with their field of practice [20].
Clinical Governance
Clinical governance involves activities and duties which focus on patient safety and best current treatment options. The “Good medical practice” by GMCstates that wherever possible, the best possible treatments should be offered to our patients.
Clinical governance activities for a paediatric trainee include applying EBM (evidence based medicine), participating in the clinical audits to improve patient care and critically appraising published research. There should be training opportunities in order to gain these competencies. The trainees should be encouraged and supported to participate in the departmental clinical audits, journal clubs and clinical governance meetings.
EBM is vital in providing the best available treatment to our patients. Trainees have a duty to exercise evidence based practice by asking the right questions regarding the management of a particular patient [21].
Clinical governance in general is an area where improvements are constantly required. From a trainee’s perspective it is vitally important to identify local clinical governance issues, active participation in finding the solutions and making efforts to implement any recommendations for service improvement. The educational supervisors and the local managers should facilitate this process and guide the trainee through various stages of such projects [22].
Knowles’ Key Features of The Adult Learner
  1. Is independent and self-directing (has self-concept)
  2. Has accumulated a great deal of experience which is a rich resource for learning (experienced)
  3. Values learning that integrates with the demands of their everyday life (readiness to learn)
  4. Is more interested in immediate, problem-centred approaches than in the subject-centred ones (orientation to learning)
  5. Is more motivated to learn by internal drives than by external ones (motivation to learn)
Table 1 [23]
Summary
To summarise these generic skills, I would recommend remembering the mnemonic “TRAINING”.
  Essential TRAINING competencies
T Team work
R Reflective practice
A Appraisal
I Induction
N Avoiding Negative criticism
I Insight into own training goals
N Need for continuous professional development
G Clinical Governance
Table 2
Contributory Statement
Dr. Intisar Ulhaq is the sole author of this article with regards to topic selection, literature review, manuscript writing and collating references.
Bibliography
  1. RCPCH: “General Paediatric training”
  2. “Good Medical practice by GMC” (2013)
  3. GMC: “Post graduate standards and guidance”
  4. Jim C and Helena D. “Doctors' consultations with children and their parents: a model of competencies, outcomes and confounding influences”. Medical Education 39.8 (2005): 807-819.
  5. David JG and Stephen CM. “Training using medical simulation”. Archives of Disease in Childhood97.3 (2012): 255-259.
  6. RK Kumar. “Teamwork in pediatric heart care”. Annals of Pediatric Cardiology 2.2 (2009): 140-145.
  7. Hilary MH and Patricia JH. “Assessing Teamwork and Communication in the Authentic Patient Care Learning Environment”. Pediatrics 127.4 (2011): 601-603.
  8. JE Raine., et al. “An analysis of successful litigation claims in children”. Archives of Disease in Childhood 96.9 (2011): 838-840.
  9. Mamede S and Schmidt HG. “The structure of reflective practice in medicine”. Medical Education 38.12 (2004): 1302-1308.
  10. RCPCH: “Educational supervision”
  11. “GMP framework for appraisal and revalidation”.
  12. JS Sprigge., et al. “Appraisal, assessment and career development for doctors in training”: the Mersey Deanery personal development portfolio”. Journal of the Royal Society of Medicine 99.10 (2006): 521-526.
  13. Working with doctors Working for patients: “ Induction and Mentoring”.
  14. GMC: “National training survey 2014 bullying and undermining”.
  15. Levey RE. “Sources of Stress for Residents and Recommendations for Programs to Assist Them”. AcademicMedicine 76.2 (2001): 142-150.
  16. David M Kaufman. “ABC of learning and teaching in medicine. Applying educational theory in practice”. BMJ 326.7382 (2003): 213-216.
  17. Stagnaro-Green A. “Applying adult learning principles to medical education in the United States”. Medical Teacher 26.1 (2004): 79-85.
  18. Harden RM and Crosby JR. “AMEE Education Guide No 20: “The good teacher is more than a lecturer-the twelve roles of the teacher”. Medical Teacher 22.4 (2000): 334-347.
  19. Continuous professional development: “Guidance for all doctors. June 2012”
  20. Cathy Peck., et al. “Continuing medical education and continuing professional development: international comparisons”. BMJ 320.7232 (2000): 432-435.
  21. A K Akobeng. “Evidence in practice”. Archives of Disease in Childhood 90.8 (2005): 849-852.
  22. Robin G and Simon H. “Healthcare professionals’ perceptions of clinical governance implementation: a qualitative New Zealand study of 3205 open-ended survey comments”. BMJ Open 5 (2015): e006157.
  23. Knowles MS., et al. “The Adult Learner”. 6th edn. Oxford: Butterworth-Heineman (2005): 282-292.
Copyright: © 2015 Intisar Ulhaq. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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