General Professional Training Research Articles

Provision of services for the diagnosis and treatment of heart disease. Fourth report of a Joint Cardiology Committee of the Royal College of Physicians of London and the Royal College of Surgeons of England.

The principal conclusions of the fourth report of the Joint Cardiology Committee are: 1 Cardiovascular disease remains a major cause of death and morbidity in the population and of utilisation of medical services. 2 Reduction in the risk of cardiovascular disease is feasible, and better co-ordination is required of strategies most likely to be effective. 3 Pre-hospital care of cardiac emergencies, in particular the provision of facilities for defibrillation, should continue to be developed. 4 There remains a large shortfall in provision of cardiological services with almost one in five district hospitals in England and Wales having no physician with the appropriate training. Few of the larger districts have two cardiologists to meet the recommendation for populations of over 250,000. One hundred and fifty extra consultant posts (in both district and regional centres) together with adequate supporting staff and facilities are urgently needed to provide modest cover for existing requirements. 5 The provision of coronary bypass grafting has expanded since 1985, but few regions have fulfilled the unambitious objectives stated in the Third Joint Cardiology Report. 6 The development of coronary angioplasty has been slow and haphazard. All regional centres should have at least two cardiologists trained in coronary angioplasty and there should be a designated budget. Surgical cover is still required for most procedures and is best provided on site. 7 Advances in the management of arrhythmias, including the use of specialised pacemakers, implantable defibrillators, and percutaneous or surgical ablation of parts of the cardiac conducting system have resulted in great benefit to patients. Planned development of the emerging sub-specialty of arrhythmology is required. 8 Strategies must be developed to limit the increased exposure of cardiologists to ionising radiation which will result from the expansion and increasing complexity of interventional procedures. 9 Supra-regional funding for infant cardiac surgery and transplantation has been successful and should be continued. 10 Despite advances in non-invasive diagnosis of congenital heart disease the amount of cardiac catheterisation of children has risen due to the increase in number of interventional procedures. Vacant consultant posts in paediatric cardiology and the need for an increase in the number of such posts cannot be filled from existing senior registrar posts. All paediatric cardiac units should have a senior registrar and in the meantime it may be necessary to make proleptic appointments to consultant posts with arrangements for the appointees to complete their training. 11 Provision of care for the increasing number of adolescent and adult survivors of complex congenital heart disease is urgently required. The management of these patients is specialised, and the committee recommends that it should ultimately be undertaken by either adult or pediatric cardiologists with appropriate additional training working in supra-regionally funded centers alongside specially trained surgeons. 12 Cardiac rehabilitation should be available to all patients in the United Kingdom. 13 New recommendations for training in cardiology are for a total of at least five years in the specialty after general professional training, plus a year as senior registrar in general medicine. An additional year may be required for those wishing to work in interventional cardiology and adequate provision must be made for those with an academic interest. 14 It is essential that both basic and clinical research is carried out in cardiac centres but these activities are becoming increasingly limited by the lack of properly funded posts in the basic sciences and restriction in the number of honorary posts for clinical research workers. 15 A joint audit committee of the Royal College of Physicians and the British Cardiac Society has been established to coordinate audit in the specialty. All district and regional cardiac centres should cooperate with the work of the committee, in addition to their participation in local audit activities.

Approaches to medical audit.

Accepted for publication August 1990 The last two or three years have seen an explosion of interest medical audit, phrase hitherto barely used the UK except by few hardy pioneers (for references, see1 2). Then quick succession the last two years appeared the Confidential Enquiry on Perioperative Deaths,3 the Report of the Royal College of Physicians on Medical Audit,4 and the White Paper Working for patients.5 The White Paper provided helpful definition of audit: a systematic critical analysis of the quality of medical care, including the procedures used diagnosis and treatment, the use of resources, and the resulting outcome for the Since the publication of these documents, there have been several conferences about medical audit, and local health authorities the UK should by now have established District Audit Committees. It is perhaps useful time to take stock of the situation, and of the different approaches to medical audit, and attempt to predict the way which matters are likely to develop over the next few years. Conceptually, perhaps the simplest form of audit is review of the medical record. The lessons learnt from the 12 years' experience the Departments of Medicine and Clinical Pharmacology at Birmingham University are described recent article by Heath.1 The advantages of such an audit are that no complex information systems are required, and that review of records, best selected randomly, or of patients with single diagnosis or undergoing single procedure, can be accomplished friendly non-confrontational manner that is enjoyed by many participants. The physicians at Birmingham found that the recording of the initial symptoms of the illness and of the patient's subsequent progress rapidly improved, as did the record of what had been said to the patient. However, once the meetings were well established and the problem of poor quality notes tackled, difficulty arose due to the repetitive nature of the procedure. It became apparent that for audit to continue to be valuable it had to be supported by senior consultants who believed its benefit and who were regular attenders at audit meetings. The Royal College of Physicians now requires that when visiting team from the Training Office reviews post for suitability for General Professional or Higher Medical Training, random sample of records is drawn from the hospital by the visiting Regional Adviser, and the quality of the records inspected this way. The Regional Advisers have reported after the first year of this procedure that there are considerable deficiencies recording what is said to the patient, although general the quality of the initial history and the record of progress appear to be adequate. There seems little doubt from the Birmingham experience that such record review does improve the quality of record keeping, which is essential bearing mind the increasing fragmentation of care amongst different specialist teams, and the shortening of hours of junior doctors recent years, so that patients are often looked after for long periods by young doctors who are not on the team responsible for that patient's primary care. However, review of small sample of clinical records by senior physician, however distinguished, can only give general impression of the quality of care an institution. In the United States medical record (chart) review is more formal. Peer Review organisations are contracted to the Health Care Financing Administration to fulfil statutory obligation that care to Medicare patients will be provided economically and only to the extent medically necessary, will be of quality which meets professionally recognised standards of health care, and will be supported by evidence of medical necessity in such form and fashion and at such time as may reasonably be required by reviewing Peer Review organisation the exercise of its duties and responsibilities. As may be expected from this last clause, vast bureaucratic organisation has grown up to review medical records by registered chart reviewers. The Peer Review organisation for the State of Massachusetts, for example, draws sample of 3?0 of all Medicare discharges for chart review, employs full time medical director, four associate directors, 70 chart reviewers who are registered nurses, and has budget of $7m. The chart reviewers look at the medical record against so called generic quality screens, an example of which is published elsewhere.6 Many of the screening items are comparatively trivial, but the Peer Review organisation system does often reveal misuse of antibiotics, particularly lack of care prescribing aminoglycosides, failure to use antibiotics accord with laboratory determined sensitivities, and failure to seek specialist advice when appropriate. The Peer Review organisations have powerful legal sanctions, including witholding Medicare payments on occasion. However, many physicians the United States are not convinced that the system uses resources

Career progression in psychiatry: perceptions and realities

The guidelines on criteria necessary for promotion to senior registrar grade in psychiatry may be found in The Handbook for Inceptors and Trainees 1987. The criteria are essentially those in the 1980 edition, namely the need for possession of MRCPsych status and completion of at least three years general professional training approved by the College. Yet it is undeniable that in recent years eligible candidates have experienced much more difficulty in achieving appointment as a senior registrar. Indeed Holden (1988) comments that “dedicated clinical service and the qualification of MRCPsych is insufficient to guarantee a registrar success in his or her application for a senior registrar post”. In the increasingly competitive job market research experience, possession of publications, and management training have become valuable assets for prospective candidates. Our concern at the lack of pertinent career guidance for trainee psychiatrists prompted us to look at trainees' perceptions of requirements and at the provisions which exist in their training to enhance their career prospects.

Statement on approval of training schemes for general professional training for the MRCPsych

Every training scheme must have a tutor(s) who is responsible for the running of the scheme. Rotational training schemes should be administered by a training committee which should include the tutor(s) and an adequate number of representatives of the consultants and other teachers involved, as well as representatives of the trainees themselves.

Training for occupational medicine.

The training of occupational physicians has recently undergone profound changes, is still changing, and in the future we may see some of the developments envisaged here. All four of the phases of training are changing: undergraduate, general professional training (basic specialist training), higher specialist training and, finally, continuing education which is maintained throughout professional life. That these separate phases should not be viewed in isolation is not always recognized, particularly by those concerned with the detailed planning of one particular phase.

ANAESTHETIC EXPERIENCE—THE VIEW FROM BELOW

The anaesthetic experience gained during general professional training is reviewed, indicating the spectrum of patients managed and training received. The experience gained was broadly in line with the guidelines recommended by the Faculty of Anaesthetists. The advantage of movement between hospitals at a junior level is noted, as is the value of a case record book, for both the individual and the Anaesthetic Department.

Survey of Research Activity by Trainees in the Mersey Region

The Royal College of Psychiatrists has always been keen to promote research by psychiatric trainees. Trainees are becoming increasingly aware of the need to produce research in order to enhance their promotion prospects and to widen their own knowledge and experience. At the University Department of Psychiatry in Liverpool we have taken an active role in its promotion within the region and in the spring of 1986 we decided to conduct a survey into research activity by psychiatric trainees in Mersey Region. We surveyed all psychiatric training posts in the region except those which were an integral part of GP vocational training schemes and those which were vacant or occupied by locums. This left a total of 98 posts. We received 66 replies, giving an overall response rate of 67%; these com prised 36 out of 44 (82%) from the University Linked General Professional Training Scheme, and 17 out of 19 (89%) from the senior registrar (SR) group, but only 13out of 35 (37%) from the other general professional rotations. For the purpose of this analysis we considered the three groups separately. The University rotation gave replies from 36 trainees; 20 of these (10 male, 10 female) were in first and second year posts, whilst 16(9 male, 7 female) were in third and fourth year posts. An interest in research was expressed by 33 (92%) whilst 10(28%) were actually doing it (2 from first and second year and 8 from 3rd and 4th year). One other had started a project but then given up. The Senior Registrar Group (13male, 4 female) showed a response indicating that all 17 (100%) were interested in research whilst 15 (88%) were doing research; 4 reported difficulties in undertaking research in the past due to inadequate supervision or resources but all of these were currently engaged in research. Of the 13 (15%) trainees (10 male, 3 female) from per ipheral rotations two were currently engaged in research whilst one other had previously attempted a project but had given it up. An interest in research was expressed by 12 (92%). Looking at the figures in a slightly different way, 18of the 21 post membership trainees were doing research (86%) whilst 9 of the 46 (20%) pre-membership trainees were involved. All the 27 trainees doing research had supervision but only 17 felt that they had access to adequate statistical advice. Only 10trainees reported attendance at the Univer sity Research Seminars (5 from the University rotation and 5 from the SR Group) and of these 9 were engaged in research. Of those doing research, 8 were involved in their own projects, 12 in joint projects and 7 in both types of project. Only 6 out of the 66 (9%) were registered for higher degrees. 11(17%) had published work whilst 13(20%) had presented papers at meetings. The 27 trainees doing research listed 37 replies to a question on nature of the research interest. The three most common were social and community (32%), psychological/ psychotherapy (27%) and physiological (19%). The trainees were given a choice of five groups with which they could discuss a proposal if wishing to undertake research, i.e. tutor, consultant, senior registrar, university depart ment or other. The 27 currently doing research gave the following response, 36% would go to the University Department, 28% to their consultant, 22% to their tutor, 10% to other and 3% to an SR. Amongst the 39 not doing research, 34% would go to their Consultant, 25% to their Tutor, 22% to the University Department, 6% to an SR, 4% to other and 7% did not know. The Royal College of Psychiatrists has also been keen to encourage more people to take the research option in the membership exam. We therefore also asked about the trainees views on the research option. There were 21 post-membership trainees and none of these had done the research option, although 7 (33%) felt that some form of research option should be available. The 46 pre-membership trainees showed that 11 (24%) had or were considering the research option whilst 20 of the 46 (43%) felt that some form of research option should be present.

Guidelines for the Training of General Psychiatrists in Psychotherapy

This memorandum concerns training in psychotherapy during the initial three year period of general professional training in psychiatry. A brief statement on this training was included in the statement on approval of training schemes for general professional training (1984). This document also stated that every trainee should have a minimum of one year's training in general psychiatry and some experience from among a variety of sub-specialties. At present none of the sub-specialty experience is mandatory, but all training schemes should provide as wide a range of sub-specialty experience as possible.

General professional training in community child health.

A scheme providing general professional training for doctors in community child health is described. The scheme covers three years and gives broad clinical experience in general hospital paediatrics, community paediatrics, psychiatry, and general practice. The aims of the scheme and service needs and future structure for our trainees are discussed.

The university between general education and professional training

The harmony of research, general education and professional training, which was an essential element of the classical German university, has been deeply disturbed by the enormous increase of student numbers. We discuss, whether the demands for a transfer of technology and for a training of an elite of specialists can be combined with the task of a helpful education for the majority of our students. As an example for a flexible solution we present the program of summer-schools ("Ferienakademieprogramm") of the Technical University of Munich.

Therapists with disabilities: theoretical and clinical issues.

Disability as a characteristic of the therapist needs to be addressed for several reasons. First, substantial evidence indicates that people without visible disabilities or physical differences regard persons who diverge from ideals of physical perfection and norms of physical acceptability with a variety of emotions which--at the very least--alter ordinary social interaction. Second, the psychoanalytic literature on therapy with disabled patients and the developmental literature about people with disabilities reinforce the generally negative or ambivalent attitudes about the mental well-being and potential for productivity and intimacy of people with disabilities. As a consequence of both general acculturation and professional training in psychology and psychoanalysis, professionals in charge of admissions have frequently denied competent disabled people the graduate education which is prerequisite to psychoanalytic training and professional employment. Mental health practitioners who make up the training committees of analytic institutes have frequently been reluctant to accept a disabled candidate for psychotherapy or psychoanalytic training. Once trained, many disabled clinicians have faced hurdles in obtaining employment, in advancing within their profession, in being selected as faculty members or supervisors, and even in obtaining referrals from nondisabled colleagues. After briefly describing the literature on attitudes of the nondisabled toward people with physical impairments, we will present the reasons for the reluctance to train disabled people as therapists. We will include material on how disabled people work with their disabilities in the analytic process and will bring in analogies to practitioners who are members of racial or cultural minority groups.

Psychiatric Training in Avon—Integrated or Separate Posts?

General professional training in psychiatry under the eye of the College has changed rapidly over the past twenty years providing benefit, as well as upheaval, for trainee and trainer alike. Along with the increased structure of training has come a change in trainees' career planning—as in all branches of medicine, perhaps—so that less sampling of different specialties and earlier commitment to a final career specialty is now taking place. This, together with the more formalized and structured training stipulations, has led to the development of so-called integrated training schemes in many centres. In Avon it has been felt that such a scheme would be neither practical nor in the trainees' best interests; but a persistent call by a proportion of trainees has fuelled continuing debate over several years.

How to… Organize Rotational Training Schemes in Medicine

In this article, the author describes the trials, tribulations and rewards of organizing and running rotational training schemes based on his experience at Newcastle, England, where he was until recently Professor of Medicine. Dr Kerr offers advice on how to encourage consultant colleagues to participate in senior house officer/registrar rotations for general professional training, and discusses the advantages and disadvantages of 2-year and 3-year schemes. Important questions such as who should appoint SHOs, when should posts be advertised, how to organize study leave and how to fill gaps left by early departure from 3-year schemes are also discussed. Senior registrar rotations are even more difficult to organize. Dr Kerr describes their advantages and related problems-especially that of rotation to district general hospitals, with hints on how to bend the rules to help trainees.

Recognition of Senior House Officer posts for general professional training

Recognition of Senior House Officer posts for general professional training

The MRCPsych Examination: Time for Change?

Examinations loom large in the minds of trainees. Rightly, trainees see passing the MRCPsych as official confirmation that they have successfully concluded their period of general professional training and may now advance to higher training and, almost inevitably, to Consultant status. They may assume, and in this the College does nothing to dissuade them, that they have been tested in the skills needed to practise psychiatry. Enumeration of such facts as are to be enumerated and the observation of external behaviour stand high in the lexicon of success. Listening and understanding, tolerance and compassion are also-runs. The examination does not merely reflect the form of the training but dictates the order of priorities. What the exam values, the trainee values. What the exam ignores, the trainee, unless strongly motivated, will be tempted to ignore.

Flexibility in general professional training.

Flexibility in general professional training.

Reviews of teacher training and teacher performance in developing countries: Beeby revisited (2)

The effects of teacher training and qualifications on teacher and student performance in developing countries have been matters of considerable interest recently. A forerunner to this debate was a relationship hypothesized by C.E. Beeby between levels of general education and professional training of teachers and passage through stages of educational development. In a recent critique of Beeby's stages, it was argued that the stages concept is theoretically and methodologically unsound; however, the relationship between teachers' training and performance received only cursory attention. This article pursues the issue further through an analysis of recent literature reviews on teacher effectiveness in developing countries. Given the objections to stage analysis, Beeby's hypothesis was recast to predict a positive relationship between teachers' general education and professional training as independent variables and teachers' performance as dependent variable. The two less restrictive and more wide-ranging of the literature reviews provided considerable support for this hypothesis in developing countries, but made clear that the exact nature of the relationship is complex and varies considerably between different educational and cultural contexts. It was noted that considerable attention is needed to operational specification of the hypothesis according to the needs of individual countries. Research should no longer concentrate on whether such a relationship exists, but should seek to establish the particular nature of the relationship in the different contexts.

Survey of hospital doctors' training goals in diagnosis and management of pulmonary diseases.

Although subspecialty training goals for junior hospital doctors have not been evaluated, they are potentially useful for assessing clinical competence. A questionnaire was sent to medical residents, full-time pulmonary teaching staff, and community-based physicians who were asked to rate the importance of diagnosing and managing selected pulmonary diseases for the future practices of young hospital doctors. The latter also rated their perceived preparedness for the same training goals. Generally good intra- and intergroup agreement about the relevance of most of the training goals was observed, although the hospital doctors rated a greater number of items to be more important than did the two other groups. This finding may be attributed to institutional influences and to many clinical abilities expected of all physicians. Immunological or fibrotic and paediatric respiratory disorders were rated least important by most respondents. The hospital doctors disagreed on the basis of the distribution of their ratings about their preparedness for the same goals, which probably reflects varying training experiences and background. The process of developing general professional training goals in a subspecialty requires discussion, identification, and consensus to identify and potentially correct areas of weakness, with allowance for institutional training patterns. A survey such as described in this study can provide data that can help measure clinical competence and support or define curricular changes.

Rotational Training Schemes in Psychiatry and Assessment of Trainees

Council have given consideration to the organization of rotational training schemes in psychiatry at senior house officer and registrar level and the assessment of trainees. Council are conscious of the wide range of opinion held within the profession about the content of general professional (i.e. pre-MRCPsych) training and the need for any guidance offered to be sufficiently flexible to accommodate a variety of viewpoints. Nonetheless, it is felt that reasonably clear advice can be given about the main components of general professional training. It is hoped that this report will be helpful to psychiatric tutors and others responsible for organizing training schemes. The College has already issued guidance on some of the matters with which this report is concerned in its pamphlet Educational Programmes for Trainees in Psychiatry and in an article entitled ‘Approval Visits: Guidelines on Criteria and Facilities for Training’ (Bulletin, September 1978, pp 158–59).

Development in education in occupational medicine in the United Kingdom.

Postgraduate medical education in the United Kingdom has changed. Now, five years of undergraduate training merely prepare a doctor for postgraduate training, whatever his specialty will be. After undergraduate training (and a year in hospital) all doctors do three years General Professional Training followed by some four years Higher Specialist Training. Occupational physicians do the same General Professional Training as physicians or primary care general practitioners. Their Higher Specialist Training lasts four years and is based on supervised practical experience in the factory or other place of work. After the first two years of this they take an examination covering the broad field of occupational medicine (AFOM). After the next two years of supervised practical experience the doctor has to present evidence of special study and can then become specialist (MFOM). In the U.K. about 70% of occupational physicians work part time. Their supervised practical experience is therefore spread over a long period. Many stop at the AFOM. If, later in their career, they change to full time in occupational medicine, they can proceed to the specialist qualification (MFOM). Most part-timers do other work and therefore cannot go away to one of the few universities that provide courses for the AFOM. Those who live near one of the few universities can go on day release. A "distance teaching" project has been started to take teaching material on occupational medicine such as audio tapes, tape slides, and video tapes to these doctor. It will be supplemented by local seminars and short courses at universities.