n Modernising Medical Careers

Transcription

1 Academy of Medical Royal Colleges n Modernising Medical Careers CURRICULUM FOR THE FOUNDATION YEARS IN POSTGRADUATE EDUCATION AND TRAINING A Paper for Consultation Produced by F2 Curriculum Committee of the Academy of Medical Royal Colleges in co-operation with Modernising Medical Careers Implementation Group in the Department of Health November 2004

2 FOREWORD Dear Colleague Modernising Medical Careers (MMC) aims to produce modern doctors for a modern NHS. In addition to the core Clinical Skills necessary to diagnose, treat and care for patients, today's doctors must be able to deliver care which is of consistently high quality. This means becoming knowledgeable and competent in fields like patient safety, clinical governance, infection control and working in a team that would not in the past have been regarded as a formal part of training curriculum or assessment programmes. This curriculum has been developed in collaboration with the Academy of Medical Royal Colleges (AoMRC) in order to achieve MMC's aims. I would particularly like to thank Dr Edmund Neville (chair of the F2 Curriculum Committee and former Director of General Professional Training, RCP) and Dr Alastair McGowan (MMC representative and President of the Faculty of Emergency Care). It sets out for the first time, a range of competencies against which doctors will be assessed in order to establish future generations of accountable practitioners ACurriculum needs to be owned by all involved in its day to day use. Its development is a complex process and one that we have to get right. It is, therefore, essential that this consultation is as wide as possible. I invite and encourage you to submit written comments on the curriculum in general, or on specific sections, to be submitted during a consultation period commencing from Tuesday 2nd November 2004; ending on Friday 21st January consultation@mmc.nhs.uk Post: Curriculum Consultation Eileen House 2nd Floor, Room Newington Causeway London. SE1 6EF Very best wishes SIR LIAM DONALDSON CHIEF MEDICAL OFFICER

3 CONTENTS FOUNDATION TRAINING CREDO 2 CORE CURRICULUM FOR THE FOUNDATION YEARS IN POST GRADUATE MEDICAL EDUCATION AND TRAINING 3 INTRODUCTION 3 HOW TO USE THIS CURRICULUM 6 PART I: OVERVIEW 9 SUGGESTED LEARNING OPPORTUNITIES 9 CORE COMPETENCIES FOR FOUNDATION YEARS 13 ASSESSMENT WITHIN THE SECOND FOUNDATION YEAR 38 ASSESSMENT TOOLS 39 ACUTE CARE SCENARIOS 44 THE GOVERNANCE OF ASSESSMENT IN F2 47 PART II: THE CORE CURRICULUM 51 GENERIC SKILLS GOOD CLINICAL CARE COMMUNICATION SKILLS MAINTAINING GOOD MEDICAL PRACTICE MAINTAINING TRUST TEACHING AND TRAINING 70 CORE SKILLS IN RELATION TO ACUTE ILLNESS 71 INTRODUCTION 71 2 (A) MANAGEMENT OF ACUTELY ILL PATIENTS 72 2 (B) RESUSCITATION 74 2 (C)i MANAGEMENT OF THE 'TAKE' 74 2 (C)ii DISCHARGE PLANNING 75 SELECTION AND INTERPRETATION OF INVESTIGATIONS 75 INVESTIGATIONS COMMONLY REQUESTED FOR ACUTELY ILL PATIENTS 77 PRACTICAL PROCEDURES 78 PART III: APPENDICES 81 i Multi-Source Feedback for Foundation Programme 81 ii Mini-CEX for Foundation Programmes 86 iii DOPS for Foundation Programmes 91 iv Case Based Discussions for Foundation Programmes 95 v MEMBERSHIP OF F2 CURRICULUM COMMITTEE OF ACADEMY OF MEDICAL ROYAL COLLEGES 100 vi MEMBERSHIP OF F2 ASSESSMENT WORKING PARTY OF LONDON DEANERY 101 PART IV: ANNEX A - GUIDING PRINCIPLES 102 1

4 FOUNDATION TRAINING CREDO Bridging the gap between medical school and specialist training, the foundation curriculum will develop new doctors as accountable team practitioners through establishing a learning environment based on professionalism, integrity and leadership. Excellent communication practice and teamwork will ensure that clinical governance, patient safety and the patient personal experience are at the heart of training doctors for the NHS. 2

5 CORE CURRICULUM FOR THE FOUNDATION YEARS IN POST GRADUATE MEDICAL EDUCATION AND TRAINING INTRODUCTION Healthcare professionals have as their primary goal the care and well being of patients. This requires them to have a clear understanding of the best care and treatment options available, combined with the skills and professional judgement to implement these. Excellent communication, the ability to work effectively in a team, self-awareness and insight, leadership with a clear value based ethical framework underpinned by a holistic and humane understanding, should all characterise the modern medical practitioner. The shift in postgraduate medical education from apprentice style training to working and learning in teams, with shared responsibilities and accountabilities for patient safety and clinical governance is the hallmark of recent changes in medical education. In August 2002, Sir Liam Donaldson published Unfinished Business, which described the two year Foundation Programme, the first roughly equating to the current pre-registration house officer year and the second with the aim (to) imbue trainees with basic practical skills and competencies in medicine. In 2003, he set up a UK Strategy Group to oversee Modernising Medical Careers (MMC), an initiative designed to explain, facilitate and develop the principles underpinning this major reform of postgraduate medical education and training. In conjunction with the NHS, healthcare professionals, educators, patients and students, and under the legislative auspices of the General Medical Council ( GMC) and the Post-graduate Medical Education and Training Board (PMETB), these important changes are being taken forward. While encouraging a wide diversity in competencies to be acquired during foundation training, Unfinished Business emphasised the diagnosis and management of the acutely ill patient as a key aim of the programme. Clinical governance, patient safety, infection control, excellence in 3

6 teamwork and the patient s personal experience are the five lynchpins for securing high quality clinical care. This foundation training aims to establish a new generation of doctors who, early in their careers, are characterised by the behaviours, attitudes and values required for excellent healthcare interactions with patients, their carers and families. This curriculum can also be used in the first foundation year as it maps onto the GMC s The New Doctor. Curriculum development after full registration has been devolved by the Specialist Training Authority (STA) to the Academy of Medical Royal Colleges. The STA and the Joint Committee for Post Graduate Training in General Practice (JCPTGP) play a pivotal role in maintaining standards and approving posts. In the future, these roles will be taken over by PMETB as the Competent Authority for postgraduate training. This curriculum complies with the 10 principles for training produced by that organisation. Achievement of the competencies described in the curriculum is the minimum that must be achieved to successfully complete foundation training. The curriculum is embedded within a structure that embraces GMC and PMETB principles, whilst also being compatible with international frameworks of professional medical practice. Figure 1 (page 5) demonstrates the integration of the key components of the MMC framework. Foundation training is also designed to instil attitudes of life-long learning in foundation trainees in order to underpin continuing professional and career development. During the foundation years, career directions and decisions will be made. Linking life-long learning and attitude towards working practices and a medical career that is flexible and adaptable to the needs of patient care and the NHS is a fundamental aspect of training. The educational aims of the Core Curriculum are to develop generic skills, knowledge, competencies and attitudes to ensure the highest professional performance and conduct. Its explicit standards allow transparent and impartial assessment by informed trainers and observers. As assessment strategies and tools continue to evolve, the methods proposed in this document may be refined or replaced as time progresses. The clinical setting in which assessment is made is vitally important. It is the responsibility of Trusts to ensure an appropriate educational environment with opportunities for the trainee to gain the necessary education and clinical experience to enable them to achieve and 4

7 demonstrate the required competencies. Those who assess the acquisition of competencies in foundation trainees must be trained to do so. The foundation curriculum puts quality of care and patient safety at the centre of clinical practice. The skills, attitudes, behaviours and values that constitute good medical practice are most effective when practiced with in a structure that has patient safety, clinical governance and skilled patient care at its heart (Figure 1). This curriculum is a living document. It will need to grow and develop with experience and as opportunities to innovate are taken. It is our hope that it provides a way forward at a most exciting time of change in the development of the young doctor. (Figure.1) THE ACCOUNTABLE PRACTITIONER PROFESSIONALISM clinical governance skilled patient care safety INTEGRITY COMMUNICATION skilled patient care TEAMWORK LEADERSHIP Also including: Effective relationships with patients Clinical skills in managing acutely ill patients The patient s personal experience Use of evidence and data Time management and decision making skills Information Technology skills Learning and teaching Excellence in teamworking Effective understanding of the different settings in which medicine is practised Ethics and law 5

8 HOW TO USE THIS CURRICULUM The curriculum defines the knowledge, skills and attitudes that trainees should demonstrate that they have learned. It is presented in specific sections as listed below. Members of the public, medical and other professionals not directly involved in the delivery of the curriculum should find what they need to know of this development by reading Part I. Parts II and III go into a level of detail that will be of more use to trainers and trainees directly involved in Foundation Programmes. PART I SUGGESTED LEARNING OPPORTUNITIES. This section gives guidance on how the learning objectives might be achieved. CORE COMPETENCIES These are the Core Competencies in which all trainees will be assessed and signed off by the end of F2. The domains map directly to the Core Curriculum in Part II. ASSESSMENT STRUCTURE This section describes the assessment tools; how and when they will be used mini CEX, multi-source feedback (mini-pat), direct observation of procedural skills (DOPS) and case-based discussion (CBD). It describes the Chief Medical Officer s Good Practice Principles for Assessment. The end point is satisfactory completion of the Foundation Programme. The assessment tools and process are not designed to rank the performance of trainees. ACUTE CARE SCENARIOS FOR ASSESSMENT STRUCTURE OF F2 This section lists a range of core acute presentations in which the trainees performance can be assessed. These acute care scenarios can occur in any area of clinical practice though many of them may appear where acutely ill patients tend to present, ie, in A&E and Acute Medical or Surgical Assessment Units. Trainees should take responsibility for their own assessment taking place in at least one of the acute care scenarios under each heading. The assessment may be in one of several forms (see below). 6

9 THE GOVERNANCE OF ASSESSMENT IN F2 This section lists roles and responsibilities in the implementation of Foundation Programmes. PART II PART III CORE CURRICULUM This is broken down into headings under Generic Skills based on those propounded in the GMC document Good Medical Practice and Core Skills for dealing with the acutely ill patient. GENERIC SKILLS History taking, communication skills, team working, understanding safe and unsafe systems, the principles and practice of clinical governance, the appropriate use of information and evidence to underpin clinical decisions, skills in information technology, recognising and supporting patients with special needs (eg, disabilities), understanding of the need for medical evidence in legal proceedings. Trainees should be able to demonstrate at the end of their second Foundation Year that they have developed their professional conduct to a standard that is appropriate for entry into specialty training. CORE SKILLS For dealing with the acutely ill with special reference to patient safety, specifically in areas of therapeutics, infection control and the use of blood products. APPENDICES This section provides more detail on the assessment methodologies that will be used and includes sample forms and documentation. The curriculum should guide professional development and, as such, it should be used to help prepare Personal Learning Plans as part of the trainee s educational appraisal process. Careers Advice Doctors who require generic or specialty advice should contact their local Director of Postgraduate Education, Clinical or College Tutor. Many specialties will have trainees who intend to take up a career in general 7

10 practice, or are undecided on a career. Doctors who require guidance on training for general practice should contact the local VTS Course Organiser, or the GP Tutor, or could contact the Director of Postgraduate General Practice Education, who will be a member of the Postgraduate Dean s department. The Joint Committee for Postgraduate Training in General Practice issues Certificates of Completion of Vocational Training, and has several useful documents including A Guide to Certification. The Royal College of General Practitioners, in association with a number of specialist Colleges, has produced a series of publications describing the content of training in the medical disciplines relevant to general practice. These booklets are available from the RCGP. Further information can be found on the RCGP website 8

11 PART I: OVERVIEW SUGGESTED LEARNING OPPORTUNITIES Adults learn by Reflecting and building upon their own experiences Identifying what they have learnt and what they need to learn Being involved in planning their education and training Reflecting on the effectiveness of their learning and the nature of learning experiences For trainees to maximise their experiential learning opportunities it is important that they work in a good learning environment. This includes encouragement for self-directed learning as well as recognising the learning potential in all aspects of day-to-day work (eg, what three things have I learnt from this ward round?) and generally adopting a positive attitude to education and training. Learning from peers should also be encouraged and training should be fun and above all stimulating. Active involvement in the group discussion is an important way for doctors to share their understanding and experiences. A good educational programme should not therefore consist solely of lectures but also include small group sessions with and without senior facilitation. A supportive open atmosphere should be cultivated and questions and challenges welcomed. To enhance long term understanding, rather than the mere acquisition of short-term knowledge, trainees should be actively encouraged to record the outcome of key educational experiences in a written or electronic format. 9

12 Such records may form part of the trainee learning portfolio, and may form a basis for their professional revalidation portfolio. It should certainly inform their personal learning plan. The list of learning opportunities below offers guidance only, there are other opportunities for learning that are not listed here: A Experiential learning opportunities: Ward based learning including post take, business and teaching ward rounds. Ward rounds, should be led by a consultant or a senior trainee but should be co-ordinated by the trainee. Feedback on clinical and decision-making skills must be given and good patient care ensured by the senior members on the round. It can also be used to direct future learning by highlighting areas where knowledge or understanding requires development. Supervised consultations in out-patient clinics, day hospitals, community visits or other settings. Trainees should have the opportunity to assess both new and follow-up patients and discuss cases with the clinical supervisor to allow feedback on communication and diagnostic skills, as well as the ability to plan investigations. In surgical and craft specialities, theatre or investigation sessions offer practical opportunities for the acquisition of skills and the understanding of clinically relevant anatomy. B Small group learning opportunities: Case studies and presentations with small group discussions, particularly of difficult cases, including quality of care and patient safety, using the electronic classroom where available. Small group bedside teaching, such as training for a Postgraduate diploma particularly covering problem areas identified by trainees. Consultations with simulated patients and subsequent small group discussion. Video consultation with subsequent small group discussion. Small group sessions of data interpretation focused on the learning needs of the trainees. 10

13 Local resuscitation skills review by a resuscitation training officer including simulation with manikins. Active participation in protocol and guide-line development meetings, journal clubs and research presentations. Involvement in audit meetings including information access and use of evidence in practice. Procedural skill training in a Practical Skills Laboratory. 10 Multi-professional case discussion/significant event audit to include quality assurance and risk assessment. C One to one teaching: Review / case presentations with educational supervisor including selected notes, letters and summaries. Discussion between trainee and trainer of knowledge of local protocols. Video consultation with subsequent individual discussion with trainer. Clinical application and development of practical skills. D External courses: 1 2 Lectures or courses, eg, Advanced Life Support course. Formal training in communication skills, eg, use of simulated patients. E Personal study: Personal Study including CD ROM and distance (electronic) learning. Practice examination questions and subsequent reading. Reading journals. F Audit: 1 2 Rationale and methodology. Trainees should be directly involved in the audit process by undertaking one in-depth audit during the foundation years, usually jointly with other trainees. This should be seen as a key part of the wider issues of clinical governance and risk management. 11

14 G Simulated clinical situations: 1 The rapid development of new technologies to simulate real-life clinical situations will open up new opportunities for team-based learning, particularly in dealing with unexpected clinical occurrences and in running patient safety drills. 12

15 CORE COMPETENCIES FOR FOUNDATION YEARS This document outlines core competencies for the second foundation year. It has been prepared on behalf of the Academy of Medical Royal Colleges. These competencies are derived from the GMC document Good Medical Practice and are the basis of the Foundation Year Two Curriculum (Part II). These competencies will empower the young doctor in the treatment of the acutely ill patient. With equal importance, the competencies will develop an understanding of clinical governance, patient safety, by inculcating an awareness of the consequences of courses of action, and infection control that instills in trainees the fundamental public health aspects of infection control. These competencies have explicit incremental standards that will be tested in the workplace or increasingly, in the future, in sophisticated, simulated clinical environments. Competencies can be developed by experiencing a selection of a variety of common and important clinical scenarios (see section 4). The competencies here described together with their nine point scale and descriptors can be formatted to be used as a summative assessment record or, more appropriately, as a formative educational tool. There is some repetition in each competency domain but this overlap is intended to reinforce the importance of some key skills. A particular innovation in this curriculum is that these competencies which include fields beyond traditional clinical skills (including the ability to practise safely, to adopt the principles of clinical governance, to be an effective team member or leader and to give priority to the patient s personal experience). We suggest that competencies assessed as being at levels 1,2 or 3 indicate that further attention is required in these areas. This would represent an unacceptable level of performance for either F1 or F2. Levels 4,5 and 6 represent standards which should be progressively achieved from the beginning of F1 and should allow an incremental progression to standards 7,8 and 9. These should be achieved by the end of F2. If levels 7,8 and 9 are achieved during F1 they should be re-validated in F2, where greater clinical responsibility is expected. Entry into the medical register after completion of F1 is at the discretion of the GMC, who are currently in the process of developing their criteria for this step. The GMC document, The New Doctor is a transition document acknowledging the change from time based assessment to competency based assessment, which will be the norm in the future. 13

16 1.1A (i) Good Clinical Care Core Competencies For Second Foundation Year History Taking Regularly structured interviews for the patient s (carer s) concerns, expectations and understanding to be identified and addressed Incomplete, inaccurate and confusing history taking from, and communication with, patients (carers) Fails to take into account the patients (carers) concerns, expectation or understanding May repeatedly upset patients (carers) Clear history taking and communication with patients (carers) Appreciates the importance of clinical, psychological and social factors Attempts to incorporate the patients (carers) concerns, expectations and understanding Accomplished, concise and focused (targeted) history taking and communication, including difficult circumstances Incorporates clinical, social and psychological factors. Gives clear information to patients (carers), encouraging questions Checks on the patients' (carers') understanding, concerns and expectations (ii) Examination Regularly fails to elicit physical signs of common clinical problems Frequently takes inappropriate short cuts when examining Routinely fails to adequately explain procedures for intimate examinations Explains the examination procedure and minimises patient discomfort Can elicit individual clinical signs but may lack co-ordinated approach and sometimes fails to target detailed examination as suggested from the patient's symptoms Can perform a mental state assessment (see 2A (x) and (xi)) Elicits signs appropriately and with attention to patient dignity Demonstrates examination techniques to others 14

17 1.1A Good Clinical Care (iii) Therapeutics and Safe Prescribing Core Competencies For Second Foundation Year Prescribing regularly shows lack of clarity Repeatedly fails to take account of drug history Frequently fails to prescribe according to standard BNF recommendations, including potentially harmful interactions Takes an accurate drug history Uses the BNF and other sources to access information Prescribes drugs (including oxygen, fluids and blood products) clearly and unambiguously Describes common drug interactions and allergic reactions Fully aware of the sources of medication error and ways to minimise it. Facilitates F1 trainees on taking drug history, obtaining prescribing information and unambiguous prescribing Describes the implications of pregnancy and hepatic and renal dysfunction for safe use of commonly used drugs Routinely makes use of evidence on appropriateness and effectiveness of therapies in making prescribing decisions. 15

18 16 1.1A (iv) Good Clinical Care Documentation, Information Management Keeps accurate, legible, signed notes Core Competencies For Second Foundation Year Keeps inaccurate or illegible notes with key information missing Does not update notes Notes not attributable Routinely records accurate, logical legible history which is timed, dated and clearly attributable Routinely records patients' progress including management plans and discussion with relatives and other health care professionals Utilises information systems effectively. Adapts style to multidisciplinary case record where appropriate Demonstrates record keeping and intra/internet access skills to F1 trainees or students Timely sending out of letters, discharge summaries Structures letters to communicate findings and outcome of episodes clearly Conveys the medico-legal importance of good record-keeping to other trainees 1.1B Time Management and Decision Making Persistently failing to cope with own work, despite advice, support and extra clinical help Decisions frequently questionable Needs occasional help with organisation and prioritisation of tasks Mostly re-prioritises appropriately and usually calls for help when falling behind Decisions generally satisfactory, though occasional inadequacies when under work pressure Prioritises and re-prioritises appropriately Delegates or calls for help in a timely fashion when he/she is falling behind Decision making satisfactory even when under pressure

19 1.1C Quality and Patient Safety (i) Risk Management Core Competencies For Second Foundation Year Lacks knowledge or understanding of common complications/side effects of treatments / procedures Fails to identify signs that might indicate acute illness Does not seek help appropriately Consistently fails to hand over Unaware of structures for clinical governance Is reluctant to report critical incidents Describes common complications and sideeffects of treatments/procedures Identifies and responds appropriately to patients with abnormal signs Recognises personal limitations and seeks help at an early stage Communicates effectively to ensure continuity of care Demonstrates appropriate aseptic techniques to minimise spread of infection Aware of basic clinical governance issues Reports critical incidents appropriately Participates in audit meetings Appropriately discusses potential advantages and disadvantages of treatments/procedures with patients (carers) Encourages F1 trainees in the appropriate response to patients with abnormal signs Sets example by calling for help from appropriate health care professionals in timely fashion Demonstrates good handover to ensure continuity of care Helps others learn safety lessons 17

20 1.1C Quality and Patient Safety (ii) Patient Safety Core Competencies For Second Foundation Year Has little appreciation of the nature of error and how it relates to systems Willing to manage any clinical situation even when unfamiliar with it Cannot give examples from the medical literature of where unsafe systems have caused deaths or serious harm to patients Displays signs of carelessness or lack of conscientiousness Understands the importance of systems factors in promoting patient safety (and can draw parallels with other industries) Can cite examples of clinical situations which are unsafe or have led to harm Brings up safety issues at clinical team meetings and grand rounds as opportunities for learning. Reports adverse events and near misses to local and national reporting systems Demonstrates a full understanding of the scale of adverse events in healthcare and how their impact can be reduced Understands the principles of root cause analysis Is very safety conscious in his/her day-to-day practise Can give examples of where he/she has contributed to effective organisational learning from a patient safety incident 18

21 1.1C Quality and Patient Safety (iii) Clinical Governance Core Competencies For Second Foundation Year Has little understanding of the principles of quality assurance and quality improvement Cannot give clear and comprehensive description of his/her range of competencies Would not see the poor performance of another healthcare professional as his/her business or see a need to do anything about it Understands how specific clinical processes impact on the outcome of care Can demonstrate how particular clinical investigations, treatment or care plans are quality assured Recognises the limits of his/her own competence and does not operate beyond them If he/she has concerns about the standard of care or conduct of another practitioner, does not hesitate to raise them with a senior colleague Regularly identifies opportunities for quality improvement and seeks to get them implemented Seeks and welcomes feedback from patients and colleagues on the quality of care being delivered Works effectively with management and other professional colleagues to create a culture where quality assurance, quality improvement and safety are part of everyday activities Models his/her own style of practise on the best clinical leaders and practitioners 19 2

22 1.1C Quality and Patient Safety (iv) Patient Focus Core Competencies For Second Foundation Year Offhand or brusque manner with patients Regularly shows a lack of respect to patients Condescending or patronising in dealing with patients Allows patients time to talk and listens actively Directs patients and carers to other sources of information & advice Responds appropriately to cultural and communication needs Presents patients as people, not as a collection of pathologies or conditions Explores the social/family context of the patient s health needs and preferences Facilitates self-management by patients Helps patients to express preferences and make personal choices about treatment and care 20

23 1.1D Infection Control Core Competencies For Second Foundation Year Fails to wash hands between patients Fails to apply standard universal precautions Careless with aseptic technique Inappropriate use of antibiotics Is not up to date with own immunisations Competent aseptic technique Considers risk of infection before undertaking any procedure Scrupulously minimises the risk of transferring infection through personal behaviour (eg, washes hands and/or uses alcohol rubs) Follows local guidelines for antibiotic use Avoids posing risk to patients by own health Describes the principles and sources of cross infection Participates in surveillance systems Meticulous in following aseptic technique (eg, in inserting catheters or lines or assessing wound healing) Challenges others not observing best practice in infection control Encourages juniors in making infection control routine part of everyday work 21

24 1.2 Communication Skills (i) Relating to Patients Core Competencies For Second Foundation Year Inconsiderate of patients (carers) views and sensitivities Appears discourteous, insensitive and uncaring Fails to explain or check understanding Short tempered and abrupt Does not listen to patients, their relatives or carers Generally courteous, polite and considerate with appropriate bedside manner Respects patients (carers) views and sensitivities, shows appropriate level of emotional involvement in the patients (carers) and family Explains clearly Demonstrates an ability to anticipate patients (carers) needs, explains clearly and checks understanding (ii) Team Work Displays effective team working Unable to communicate effectively with colleagues and other health care professionals Cannot work to common goal. Appears selfish and inflexible Displays arrogance and autocratic tendencies Listens to other health care professionals and heeds their views Has good understanding of other team members competencies and care philosophies Team goals put before personal agenda Can demonstrate appropriate leadership skills but at the same time works effectively with others towards a common goal 22

25 1.2 Communication Skills Core Competencies For Second Foundation Year (iii) Effectively manages patients at the interface of different specialties including that of Primary Care, Imaging and Laboratory Specialties Fails to recognise the expertise of colleagues in other specialties Takes little or no account of the impact of a patient's discharge into the community Demonstrates no awareness of support service/personnel in primary care Demonstrates an understanding of the challenges of providing optimum care within the unregulated environment of primary care Arranges the referral/dissemination of discharge information on patients to appropriate primary care staff Arranges appropriate urgent instructions and chases results when necessary Consistently seeks to establish effective communication with colleagues in other disciplines Ensures the primary health care team is aware of the discharge of patients, especially those who may experience difficulty on their return to the community 1.3A Maintaining Good Medical Practice Learning (i) + (ii) Regularly takes up learning opportunities and is a reflective self-directed learner Repeatedly fails to take up appropriate educational opportunities Unable to determine learning needs from gaps in experience and/or feedback from others Positive approach to learning. Recognises errors and mistakes and makes a serious attempt to learn from them Requires encouragement to take up learning opportunities Enthusiastic approach to learning Demonstrates educational planning to address relevant needs that arise during the course of clinical practice Appropriate engagement with available learning opportunities 23

26 1.3B (i) Maintaining Good Medical Practice Evidence, Audit, Guidelines Critically appraises medical evidence including guidelines Core Competencies For Second Foundation Year Fails to demonstrate knowledge or understanding of the evidence base in medical care Avoids discussions with colleagues and patients (carers) on evidence based practice Ignores or unaware of local guidelines/ protocols Able to critically appraise evidence base of medical care Will enter discussions with colleagues and patients (carers) Applies local guidelines/protocols Implements the available evidence base in most areas of clinical care Seeks out opportunities to discuss with colleagues Supports patients (carers) in making sense of the evidence base in terms of their personal circumstances Seeks to refine local guidelines/protocols (ii) Describes how audit can improve personal performance Has no knowledge of the audit cycle, or any recognition of its relevance to the assessment and improvement of clinical standards Understands the audit cycle and recognises how it relates to the improvement of clinical standards Has been actively involved in undertaking a clinical audit, and recognises how it relates to the improvement of clinical standards and addresses the clinical governance agenda 24

27 1.4A (i) Professional Behaviour and Probity Consistently behaves with honesty and sensitivity in a professional manner Core Competencies For Second Foundation Year Poor attitude, exhibits low standards of personal behaviour May be inconsiderate, impolite, discriminatory or judgemental Behaviour may be inappropriate Is sensitive to the feelings and needs of patients and relatives Places the needs of patients above his/her own convenience Recognises challenging or difficult situations and calls for help without causing upset or offence Only shares clinical information, whether spoken or written, with appropriate individuals or groups Appropriate attitude with consistently high standards of preferred behaviour Fosters trust amongst others and promotes sensitivity to others 'feelings' and needs Coaches F1 trainees in these attitudes 25

28 1.4B Ethics and Legal Issues (i) Medical Ethical Principles Core Competencies For Second Foundation Year Unable to provide any meaningful definition of patient's best interest, autonomy and rights in relation to cases he/she has managed Little or no understanding of patient confidentiality Demonstrates a basic understanding of the principles of patient's best interests, autonomy and rights in relation to recent cases Uses and shares clinical information appropriately, or seeks advice when uncertain Appropriately modifies patient's management plans in accordance with the principles of patient's best interests, autonomy and rights Encourages students and F1 Trainees in confidentiality issues. (ii) Valid Consent Fails to demonstrate doctors' responsibilities in obtaining properly valid consent Needs support and advice in understanding what treatments/procedures can/cannot have valid consent obtained by an F1 or F2 (whichever is relevant) trainee Can discuss the implications of a living will or advance directive Can describe the difference between consent, assent and capacity Gives the patient (carer) appropriate information in a manner he/she can understand to obtain valid consent Refers consent requests to appropriate senior colleagues Checks that the patient (carer) has understood the relevant information Describes the uses and limitations of the Mental Health Act in consent issues Instructs F1 trainees or students on living wills and advance directives 26

29 1.4B Ethics and Legal Issues (iii) Legal framework for medical practice Core Competencies For Second Foundation Year Denotes little or no knowledge of this legal framework that relates to medical practice, hence is unaware of the differences between criminal and civil law No familiarity with the concept of legal precedent or the legal principles of negligence Knows about the legal framework that relates to medical practice but experiences some difficulty in applying this to day-to-day management of patients Understands the role of medical evidence in court and other legal proceedings Understands the legal framework that relates to medical practice and utilises this knowledge to modify treatment plans, intervention with other professionals and patients 1.5 Teaching Refuses to take up teaching opportunities and/or support the learning of students Unable to prepare and present an educational event using even the most basic teaching materials Teaches and supports students and trainees in one to one settings Demonstrates some understanding of how adults learn (see 1.3A) Prepares and presents to a small group, using a variety of teaching materials Demonstrates learner-centred approach 27

30 2A (i) Acute Care Promptly assesses airway, breathing, circulation in the collapsed patient Core Competencies For Second Foundation Year Fails to respond promptly to calls for help Slow, incomplete or unstructured initial assessment Completes initial assessment within 2-3 minutes Supports and clears airway Observes respiratory pattern and rate, identifies inadequate ventilation Assesses pulse rate, rhythm, volume Measures blood pressure using automated methods or sphygmomanometer As preceding, plus Makes a clinical assessment of adequacy of cardiac output & oxygen delivery Capable of leading multi-disciplinary team Helps others stay calm 28

31 2A (ii) Acute Care Identifies & responds to acutely abnormal physiology Core Competencies For Second Foundation Year Fails to focus on correcting abnormal physiology as a priority Lacks understanding of clinical relevance of abnormal vital signs Uses oxygen or intravenous fluids in a potentially unsafe manner Prioritisation of initial intervention inappropriate Fails to monitor effect of interventions Administers oxygen safely, monitors efficacy Identifies and attempts to correct hypotension appropriately Identifies oliguria, checks for common causes, intervenes appropriately Interprets abnormal vital signs correctly in context Anticipates and prevents deterioration in vital signs Recognises patients at risk Investigates causes for abnormal vital signs 29

32 2A (iii) Acute Care Where appropriate, delivers a fluid challenge safely to an acutely ill patient Core Competencies For Second Foundation Year Regularly fails to identify need for a fluid challenge Unable to distinguish between different fluids Selects an appropriate fluid for intravenous resuscitation Sets up fluid administration giving set correctly Administers fluid bolus(es), observes response, ensures continued administration with monitoring of effect to desired endpoints Identifies hypokalaemia and chooses a safe & effective method of potassium supplementation Reviews impact of fluid administration on organ system function Considers additional electrolyte replacement requirements (iv) Reassesses acutely ill patients promptly following initiation of treatment Is unreliable in performing regular review of acutely ill or unstable patients Does not pass on information to other members of the health care team to ensure continued review Implements a system of regular checking of unstable patients Calls for help if patient does not respond to initial measures Makes patient safety a priority Provides clear guidance to colleagues about monitoring Supports nursing staff in designing and implementing monitoring or calling criteria 30

33 2A (v) Acute Care Requests senior or more experienced help when appropriate Core Competencies For Second Foundation Year Permits problems to remain unresolved without seeking help Does not make decisions Seeks help all the time Analyses clinical problems, considers possible causes & solutions Calls for help or advice appropriately Prioritises problems Puts the patient first Seniors are confident in his/her judgement Over-confident No insight into own limitations (vi) Undertakes a secondary survey to establish a differential diagnosis Fails to consider underlying cause for deterioration Inaccurate examination technique, mistakes or overlooks important clinical signs Recognises the importance of iterative review Competent history taking and clinical examination Arranges basic laboratory tests Focused further history taking in difficult circumstances and/or when patient unable to co-operate (see 1.A) Rapidly identifies clinical signs, links them to the history to form a differential diagnosis Plans appropriate investigations to confirm or refute a diagnosis 31

34 2A (vii) Acute Care Obtains an arterial blood gas sample safely, interprets results correctly Core Competencies For Second Foundation Year Fails to understand the need for arterial blood gas sampling and often omits or delays taking the sample Does not know the main indications and contraindications for sampling Fails to attend to patient comfort during the procedure Takes an arterial sample safely using a heparinised syringe Describes common causes of abnormal values. Interprets results in context Documents results clearly in the case record Communicates significance of acid base disturbances to others in the team Directs corrective measures (viii) Manages patients with impaired consciousness including fits Omits major supportive measures Unaware of complications of anticonvulsant therapy Fails to provide a safe environment for the patient, including seeking senior assistance Appreciates urgency Administers oxygen, protects airway in unconscious patient Places unconscious patient in recovery position Calls for help if fitting does not respond to immediate measures Follows local protocols Seeks and corrects abnormalities of physiological signs, particularly hypoxaemia, hypotension, hypoglycaemia and electrolyte disturbances Questions and discusses scientific content of protocols in use Capable of leading multidisciplinary team 32

35 2A (ix) Acute Care Safely uses common analgesic drugs Core Competencies For Second Foundation Year Does not routinely seek information about patient comfort Fails to review patient's comfort in a timely manner Lacks knowledge of side effects of commonly used analgesic drugs Prescribes analgesics unsafely Fails to consider interactions between patient's condition and side effects of commonly used analgesics Evaluates the patient in pain Prescribes opioid and non-opioid analgesic drugs safely Re-evaluates the efficacy of analgesia in a timely manner Monitors patients for common side effects of analgesic drugs Safely uses anti-emetic drugs to treat or prevent nausea & vomiting Considers the effect of hepatic and renal dysfunction on analgesic pharmacology Makes patient comfort a priority Assesses the effect of prescribed analgesia in a timely manner 33

36 2A (x) Acute Care Explains the principles of managing a patient following self-harm Core Competencies For Second Foundation Year Fails to consider possibility of self harm as cause for patient's presentation Omits appropriate investigations in patients who present after self-poisoning Does not identify main monitoring goals Focused history taking, including psychosocial causes requiring social services or police intervention Accesses Toxbase when necessary Recognises need for involvement of Mental Health or more experienced personnel Demonstrates tolerance & understanding Performs a mental state assessment Demonstrates an awareness of child protection concerns where appropriate Protects and supports colleagues faced with an abusive patient Anticipates necessary steps to minimise risks to patient Initiates referral to mental health services where appropriate (xi) Describes the management of a patient with an acute psychosis Fails to recognise features of psychosis Recognises diagnostic features of psychosis Protects patient and colleagues from harm Unaware of provisions of Mental Health Act Summons experienced help promptly Safely administers anti-psychotic drugs Discusses safe administration of anti-psychotic drugs Initiates requirements of the Mental Health Act Discusses provisions of Mental Health Act Considers underlying causes of psychosis 34

37 2A (xii) Acute Care Ensures safe continuing care of patients between shifts/on call staff Core Competencies For Second Foundation Year Does not pass on information about at-risk patients Fails to prioritise patients according to their condition Unpunctual, unreliable Fails to complete some important tasks Accurately summarises main points of diagnosis, active problems, and management plan Provides clear information to colleagues Attends handovers punctually Focuses on teamwork Supports colleagues in forward planning at handover Anticipates potential problems for next shift and takes pre-emptive action (xiii) Considers appropriateness of interventions according to patients' wishes Fails to demonstrate sensitivity to patient's preferences and cultural norms Efficiently extracts information from history & examination which would influence treatment intensity decisions Seeks information from relatives if appropriate Discusses factors influencing the use of do-notresuscitate decisions (see 2Bii) Balanced view of benefits and harms of medical treatment Proactive in identifying patients for whom resuscitation or advanced care might be inappropriate (see 2Bii) Demonstrates sensitivity in the planning of complex ethical decisions 35

38 2B (i) Resuscitation Resuscitation training Core Competencies For Second Foundation Year Successfully trained to the STANDARD of Intermediate Life Support (ILS) Successfully trained to the STANDARD of Advanced Life Support (ALS) (ii) Discusses Do Not Attempt Resuscitation (DNAR) orders/advance directives appropriately Does not understand the importance of timely DNAR decisions and their discussion with patients, relations and/or colleagues Ignores advance directives. May cause unnecessary upset Understands the criteria for issuing orders and level of experience required to issue them Can discuss with colleagues including nurses and also relatives Facilitates the regular review of DNAR decisions and understands actions required if decision challenged Discusses the DNAR criteria and their legal framework with colleagues including nurses and also relatives Encourages regular review of this order and takes appropriate action if challenged 36

39 2C (i) Organisation and Teamwork Core Competencies For Second Foundation Year Participates in acute admission management with appropriate organisation and understanding of role(s) Not a team player Does his/her own thing with regard to task performance and takes minimal account of the work level of others around them Missed handovers/briefing on a regular basis Attends hand-over/briefing Accepts direction/advice and allocation of tasks from seniors Prioritises and knows when to seek timely advice from colleagues Can and sometimes does organise hand-over, briefing and task allocation Knows when/who to call for help and advises F1 trainees about this 3 Investigations (i) Requests and deals with common investigations appropriately Regularly fails to order appropriate basic investigations Fails to recognise normal and abnormal results of common investigations Fails to ask for help or take appropriate action thereon Requests common investigations appropriately for patients' needs Discusses risks, possible outcomes and later results with patients (carers) appropriate to level of expertise Recognises normal and abnormal results. Prioritises importance of results and asks for help appropriately Supports F1 trainees or students in making appropriate requests for, interpretation of, and action on, normal and abnormal results, for common investigations Understands local systems and asks for help appropriately from the relevant individuals 37

40 ASSESSMENT WITHIN THE SECOND FOUNDATION YEAR AIM: To provide an assessment programme that samples the range of medical practice and is able to facilitate quality improvement. All the assessment tools used within the programme facilitate and enable supportive feedback that will inform personal professional development. The overall assessment record will provide evidence that will inform progress to the next stage of training. Foundation programmes aim to equip the newly registered doctor with the key generic skills required of a medical professional engaged in life long learning. These skills and attributes are listed in the GMC s Good Medical Practice (GMP). In the past, assessment in medicine has tended to focus on the assessment of knowledge. Knowledge is necessary but not sufficient to meet the requirements of GMP. The assessment programme outlined below is designed to measure a doctor s performance in a variety of settings. The F2 assessment programme is intended largely as a formative process of quality improvement that will benefit trainees, assessors and the public. Assessment will be trainee-led with timing of assessments and choice of assessors being trainee determined. All trainees will be expected to maintain a Portfolio that will contain evidence from these assessments. Trainees may wish to collect additional material in their Portfolio to demonstrate their overall professional development. Developmental needs and strengths will be identified from all the assessments which trainees should discuss with their Educational Supervisor. This will inform the individual s personal development plan. A variety of assessment tools will be used which have the common characteristic of seeking to capture what actually happens in practice. The programme will assess performance in relation to the domains of GMP and the core competencies of the F2 curriculum through sampling a range of common and important problems likely to be seen by all trainees in F2. 38

41 The conditions were originally selected from a problem list developed as part of the undergraduate curriculum at Sheffield but have been reduced in number and grouped under appropriate clinical headings. The programme seeks to build on, not revisit that curriculum (see figure 2). These problems are listed as Acute Care Scenarios later in this section. Figure 2: Example spiral curriculum: consent for upper GI endoscopy Educational Environment skills knowledge attitudes Be able to assess capacity Explain to patient and carers benefits vs risks of procedure Answer Qs and concerns Watch an expert obtain consent Know common complications Be able to explain procedure and take consent from a competent patient Visit endoscopy unit and see procedure Heard of the procedure Know indications for procedure Generic skills Acute care Based on Harden RM, Davis MH and Crosby JR. Medical education1997;31: ASSESSMENT TOOLS Multi-source Feedback (Mini-PAT: Peer Assessment Tool) Collated views from a range of co-workers (previously described as 360 assessment). This should be undertaken once in the F2 year. It is suggested that collated feedback be provided after the first six months in programme. The exact timing will depend on the length of posts on the rotation. 39

42 For four month posts, feedback at eight months based on mini- PAT collated from the first and second posts. Trainees nominate eight raters from each of these posts, mid-october and mid-march. For six month posts, feedback at seven months based on first post. Trainees nominate twelve raters mid-november (if three month posts, then six for each part). Majority of raters should be supervising consultants, GP principals, specialist registrars and experienced nursing or Allied Health Professional (AHP) colleagues. Mini Clinical Evaluation Exercise (mini-cex) Evaluation of an observed clinical encounter with developmental feedback provided immediately after the encounter. Suggest six observed encounters over the year (two per four month attachment). Different observer for each. Observers may be experienced SpRs, consultants or GP principals. Each mini-cex represents a different clinical problem sampling each of the acute care categories listed below. Trainee chooses timing, problem and observer. Direct Observation of Procedural Skills (DOPS) Structured check list for the assessment of practical procedures. Suggest 1-2observed procedures per placement. Different observer for each procedure. Observers may be consultants, GPs, SpRs, suitable nurses or AHPs. Each DOPs should represent a different procedure sampling from the acute care skills listed in section II (Page 74-76). Trainee chooses timing, procedure and observer. 40

43 Case Based Discussion (CBD) Structured discussion of clinical cases managed by the trainee. Its particular strength is evaluation of clinical reasoning. This assessment tool will be phased in over second half of year for the F2 pilots commencing August Comprises a structured discussion of real cases in which the trainee has been involved. Allows trainee s decision making and reasoning to be explored in detail. More detailed description of all the methodologies can be found in Part III of this document. Anticipated Time Required It is recognised that meaningful assessment will involve committed time from those involved with the assessment process. In order to minimise the assessment burden, feasibility has been a prime consideration when designing the assessment methodology and implementation. A number of healthcare professionals can be involved so that the burden on any individual should be relatively small. The table below summarises the overall assessment time required per trainee for the whole year. Tool Time per Number of Typical number Total direct assessment assessments of raters/ contact time for supervisor per assessments per year (minutes) placement over year (minutes) Mini-PAT SPRAT 6 5 Up to 16 in first N/A two 4 month placements Mini-CEX DOPS DOPs CBD prep TOTAL time: 4 hrs 20 minutes 41

44 Training the Trainers This programme requires a faculty trained in the methodology and specific content of the assessment strategy. Training in feedback and appraisal skills is also necessary since the assessment process involves formative and summative assessment. Many of the faculty will already be part of the current healthcare workforce and may already have some training in these areas. Training packages, however, need to be sufficiently flexible to train those already in the workforce and to support new entrants. It will need to be accessible to several thousand clinicians, including medical staff (consultants and SpRs), senior nurses, midwives and allied health professionals. While guidance on the assessment tools used in the programme is included in Part III of this document, further training for trainers is essential. There are a number of levels and learning approaches at which such training can be delivered: An e-learning web-based programme can be developed rapidly and has the potential to train a large number of people in workplace assessments by demonstrating the principles and practice through videos and good practice (such a programme is already available for training in appraisal skills and can be accessed at Facilitated training at local trust or Deanery level can be implemented and will support web-based training but will take longer to get wide-coverage and will require a greater and more sustained resource input, both in terms of funding and of faculty/trainee time. 42

45 Assessment framework GMP domains NATIONAL F2 PILOT Mini-CEX Mini-PAT DOPS CBD OTHER POSSIBLE TOOLS Evidence to be retained in portfolio, not centrally submitted Patient Portfolio SLI Video assessment review PROFESSIONALISM* Good clinical care Relationships with patients Working with colleagues Dealing with problems in professional practice Teaching training, assessing, appraising Health and probity Maintaining GMP Clinical care Acute care Decision making Communication skills Communication skills Legal/ethics Time management Maintaining GMP Mini-CEX: Mini- Clinical Encounter Exercise, Mini-PAT = Peer review Assessment Tool (Multi-Source Feedback), DOPS: Direct observation of practical skills, CBD: Case based discussion, SLI - Specific learning incident (Critical incident) 43 *Note: While professionalism encompasses all areas of practice mini-cex includes a specific evaluation of this within the clinical encounter.

46 ACUTE CARE SCENARIOS Generic skills and acute care form the two main themes of F2. By assessing performance in the management of acute cases, we can assess not only the skills of acute care (such as rapid assessment of airway, breathing and circulation) but also the generic skills which underpin that performance (such as team work, communication and identifying priorities). F2 will focus on learning in the workplace and much of the assessment in F2 will occur there. However other learning and assessment environments such as short courses and simulation may be used to supplement experience available in the workplace. The clinical conditions/presentations listed below are offered as a menu from which the trainee should select topics for the assessments. A range of assessment tools will be used to evaluate the acquisition of knowledge, skills and attitudes within a particular setting. The trainee and educational supervisor should ensure that over the course of the year at least one core problem from within each grouping is assessed. The environment in which these conditions are managed will require similar core skills but the management options will be different. For example the management of chest pain in primary care and secondary care have similarities but significant differences. F2 doctors should demonstrate an awareness of how to manage patients in different settings. Acute presentations in any of the workplace settings that will be experienced in F2 can be grouped in terms of patients who have: AIRWAY problems BREATHING problems CIRCULATION problems NEUROLOGICAL problems PSYCHOLOGICAL/BEHAVIOURAL problems PAIN 44

47 All doctors will be expected to: Be aware of any existing national guidelines for the above conditions. Demonstrate the ability to manage a cardiac arrest by having evidence of performance to the STANDARD of ILS or ALS. Understand how the above core presentations differ in the elderly and in children. Recognise vulnerable patients. Understand the principles of child protection. The F2 doctor should be able to recognise and demonstrate their understanding of the management of the following: Airway problems Be able to recognise situations where the airway may be compromised. Perform simple airway manoeuvres (with adjuncts). Know the indications for tracheal intubation. Be able to manage the core presentations of: Unconscious patient Anaphylaxis Stridor Breathing problems Always assess breathing (rate, depth, symmetry, oxygen saturation). Recognise that a high respiratory rate needs further evaluation. Be able to manage the core presentations of: Asthma COPD Chest infection/pneumonia Pneumothorax Left ventricular failure Pulmonary embolism 45

48 Circulation problems Be able to assess the circulation (heart rate, blood pressure, perfusion). Know when a fluid challenge is required. Be able to manage the core presentations of : Bleeding Severe sepsis Tachyarrhythmias Bradyarrhythmias Volume and electrolyte depletion from diarrhoea/vomiting Hypotension in acute coronary syndromes Oliguria Neurological problems In addition to the management of the unconscious patient (above). Be able to manage the core presentations of : Collapse -? cause Seizures Delirium Meningism Hypoglycaemia Acute onset of focal neurological signs Psychological/behavioural problems Demonstrate a basic understanding of the Mental Health Act. Be able to manage the core presentations of : Overdose /other self harm Violence /aggression Substance abuse Acute psychosis 46

49 Treating pain Understand the analgesic ladder. Treat acute pain promptly and effectively( using appropriate analgesia). Be able to manage the core presentations of : Chest pain Abdominal pain Severe acute headache Large joint pain Back pain Injuries THE GOVERNANCE OF ASSESSMENT IN F2 Implementation of Foundation Programmes Postgraduate Deaneries will have overall responsibility for implementing Foundation Programmes. The General Medical Council (GMC) sets the standards for the content and delivery of training for the first Foundation Year (F1/PRHO). These are described in detail in GMC s document, The New Doctor. In practice the operational processes of quality assuring the training during this year is usually delegated to the Postgraduate Dean who undertakes this on behalf of the medical school/university. It is anticipated that these arrangements will continue unchanged. Setting standards for the quality assurance of training in the second foundation year (F2) will be the responsibility of the Postgraduate Medical and Education Training Board (PMETB). The governance structure of Foundation Programmes will be key to their success. Deaneries will be responsible for ensuring that an appropriate structure is put into place, but a framework will need to be consistently applied across all programmes. 47

50 Educational supervisors All Foundation trainees will need to have a named educational supervisor who will act as a source of support and educational advice and be responsible for ensuring that the trainee: Participates in an induction programme Has regular appraisal Understands and engages in the assessment process Educational supervisors will usually be responsible for up to 4-6trainees and will continue to supervise each trainee throughout the F2 year and, preferably, throughout the Foundation Programme. They should be trained for the role and must have designated time to ensure that their responsibilities to trainees are met. They will be the first point of contact for trainees. Many educational supervisors for foundation programmes will already be educational supervisors for PRHOs and will already be trained for the role. If the relationship between educational supervisor and a trainee is perceived to be unsuccessful by either, then the trainee should approach the local Foundation Programme Director or lead who will act as honest broker and allocate a new educational supervisor to the trainee. Responsibilities of the Trainee For successful completion of foundation programmes, trainees will be required to: Demonstrate professional behaviour in accordance with Good Medical Practice (GMP). Seek help from appropriate people to address any problems that may arise. Engage with the processes of education and appraisal eg, attend educational sessions and use documents provided. Proactively take responsibility for their own assessment in the work place and use the available methods. 48

51 Assessment Details of the assessment strategy and process are given earlier in this document. The key principles of the assessment process are that it is: Trainee led Based on in-work assessment Open and transparent process Aiding trainee development Summative It will be based on the Chief Medical Officer s Best Practise Principles in Assessment (Annex A). The outcomes of Foundation Programme assessment are: F1 assessments the areas of competence identified by the GMC in the New Doctor will need to be demonstrated in order that full registration of the doctor can be recommended to the GMC (F1 assessments have not been addressed in this document). F2 assessments the trainee will provide evidence through the in-work assessment tools described in this document that the core areas of F2 competence have been met. A summative assessment process at the end of F2 will consider this evidence and certify that the F2 competencies have been met. Summative assessment Ultimately, it is anticipated that the in-work assessments for each trainee will be collated and analysed across all of the clinical and generic skill domains, enabling the production of a summative assessment for each individual F2 doctor. This will be returned to each deanery and will enable the deanery to sign off F2 doctors as having successfully achieved the competencies required of the second foundation year. Until centralised evaluation is fully implemented, Deaneries will need to set up summative assessment panels to review the work-based assessment 49

52 outcomes. Trainees need not be involved in this final summative process. When things go wrong Although it is anticipated that most F2 trainees will be successful in achieving the F2 competencies there need to be systems in place for doctors who are having difficulties. Doctors in this situation may be identified by: Their reluctance/failure to participate in educational processes Reluctance/failure to engage fully in the assessment process Concerns raised by educational supervisors Serious incidents/events/complaints Under such circumstances it is essential that issues are raised in a timely fashion with the trainee concerned. The education supervisor should seek early advice from the programme director, the Head of the Foundation School or the Deanery. Deaneries should have clear processes in place, of which, both the Foundation School faculty and trainees are aware. It is likely that further assessments that may include tests of knowledge and competence will be necessary for the very small number of trainees who remain in difficulty despite supportive measures (possibly targetted Case Based Discussion). Part of this will require a clear appeals process which trainees can invoke if they feel they are being treated unfairly. Each Deanery must have a written appeals process. 50

53 PART II: THE CORE CURRICULUM GENERIC SKILLS INTRODUCTION During postgraduate educational training all trainees should acquire skills that are generic to all doctors irrespective of the specific training post or whether it is in primary or secondary care. Many of these issues and others are outlined in the GMC document Good Medical Practice. During the foundation programme years there is an exciting opportunity to build upon skills already established as an undergraduate and to develop a sound foundation for future Programme Based Training. The following seeks to provide trainees and trainers with guidance to recognise opportunities for learning, to reflect on clinical practice and to become self-critical in these vital areas. Anticipated learning outcomes, knowledge, competencies, skills and attitudes are outlined for the following generic areas : Good Clinical Care History taking and examination Safe prescribing Relevant contemporaneous note keeping Time management and decision making Infection control Quality and Patient Safety Risk management Patient safety Clinical governance Patient focus Communication Skills Within a consultation Breaking bad news With colleagues and in teams Complaints Maintaining Good Medical Practice Life-long learning Evidence, audit and guidelines 51

54 Maintaining Trust Professional behaviour and probity Working with colleagues and in teams Ethical and legal issues Patient partnership and health promotion/disease prevention Teaching and Training These objectives should not constrain learning to just these areas, they do however, outline the minimum requirements for satisfactory completion of general professional training. They can be met in the acute care setting complimented by experiences in other clinical areas. AIMS To provide doctors in training with the knowledge, skills, competencies and attitudes to provide high standard medical care to all patients. A positive attitude to lifelong learning will be encouraged. At the end of the process trainees will be equipped with the knowledge and skills to commence the next phase of their training. A wide spectrum of clinical experience will be required to achieve these goals. Learning theory emphasises that learners attitude to a curriculum is predominantly influenced by the assessment process. It is therefore essential that formal assessments and the process of educational supervision seek to confirm the balanced and inclusive nature of this curriculum. Please refer to the separate section on assessment, which provides more information on this critical topic. 52

55 1.1 GOOD CLINICAL CARE (A) HISTORY, EXAMINATION & RECORD KEEPING SKILLS Outcome: The trainee will demonstrate the knowledge and skills and attitudes to be able to take a history and examine patients, prescribe safely and keep an accurate and relevant medical record. Subject Knowledge Skills Attitudes (i) History Symptom patterns Able to elicit a relevant history Consider the impact of: Alarm symptoms Understands the use of open/closed questions Identify and synthesise problems Take a history in difficult circumstances eg: when English is not the patient s* first language confused patients* physical problems on psychological and social well being physical illness presenting with psychiatric symptoms deaf patients* patients* with psychiatric/psychological problems where there are doubts over the informant s reliability psychiatric illness presenting with physical symptoms psychological / social distress on physical symptoms (somatisation) patients* with special educational needs family dynamics questions regarding sexual behaviour and orientation children where parent is the informant possible child abuse/neglect * The term patient should include where appropriate patient and parent, guardian or carer 53

56 1.1 GOOD CLINICAL CARE (A) HISTORY, EXAMINATION & RECORD KEEPING SKILLS (cont d) Subject Knowledge Skills Attitudes (ii) Examination Patterns of clinical signs including mental state Explain examination procedure and minimise patient discomfort Elicit signs and use instruments appropriately Able to examine children of all ages Consider: patient* dignity the need for a chaperone willing to share expertise with other (less experienced) trainees (iii) Safe Prescribing Effects of disease on prescribing: hepatic renal Effects of patient factors on prescribing: drugs allergy genetic susceptibility to adverse drug reactions pregnancy Effects of drug interactions: Take a drug history Use the BNF and other sources of information Write a clear and unambiguous prescription Liaise with ward pharmacist Explain drug therapy to patient Prescribe common drugs safely with hepatic or renal dysfunction Show appropriate attitudes to patients and their symptoms and be conscious of religious and other beliefs, notably in the area of blood products. Clearly and openly explain treatments and side-effects of medication Understand the security and safety issues regarding prescriptions cultural religious belief metabolism by CYP450 isoenzymes drugs that require therapeutic monitoring Evidence-based prescribing Safely prescribe in pregnancy Notify drug monitoring systems of significant drug interaction problems Prescribe oxygen and blood products safely Understanding safe prescribing of oxygen and blood products Initiate management of carbon dioxide retention and transfusion reactions if they arise * The term patient should include where appropriate patient and parent, guardian or carer 54

57 1.1 GOOD CLINICAL CARE (A) HISTORY, EXAMINATION & RECORD KEEPING SKILLS (cont d) Subject Knowledge Skills Attitudes (iv) Medical record keeping, letters etc Structure of: medical notes discharge letters discharge summaries outpatient letters prescriptions Role of medical records in generation of central data returns and audit Importance of good medical records as a sound basis for any subsequent legal action Record accurately and legibly in the medical notes including: history examination summary problem list differential diagnosis initial investigation and management plan investigation results and action taken conversations e.g. between team members and patient/relatives Update medical notes on a regular basis Each entry to be timed, dated and the name of the individual to be clearly identifiable Strive to ensure that notes are accessible to all members of the team and patients /relatives under certain circumstances Consider the importance of: timely dictation cost-effective use of medical secretary time prompt and accurate communication between primary and secondary care Understand the importance of clear definition of diagnosis and procedures for coding for central returns Keen to use/learn about new technology and update computer records appropriately Appropriate IT skills 55

58 1.1 GOOD CLINICAL CARE (B) TIME MANAGEMENT AND DECISION MAKING Outcome: The trainee will demonstrate the knowledge, skills and attitudes to manage time and clinical priorities effectively. Subject Knowledge Skills Attitudes (i) Time management Which patients/tasks take priority Which patients/tasks need formal hand-over Start with the most important tasks Work more efficiently as clinical skills develop Recognise when he/she is falling behind and reprioritise and/or call for help Have realistic expectations of tasks to be completed by self and others Willingness to consult and work as part of a team Allow time for effective hand-over (ii)decision making Clinical priorities for investigation and management Analyse and manage clinical problems Involve patients and other professionals Be flexible and willing to change Be willing to consider who is the most appropriate decision maker 56 * The term patient should include where appropriate patient and parent, guardian or carer

59 1.1 GOOD CLINICAL CARE (C) QUALITY AND PATIENT SAFETY Outcome: The trainee will demonstrate the knowledge, skills and attitudes to ensure safe, quality assured care and to seek opportunities for quality improvement. Subject Quality and Patient Safety Knowledge Complications and side effects of treatments Knows the physical signs that suggest imminent or actual acute illness Aware of principles of risk management Understands the principles of Clinical Governance Knows in general terms how processes of medical care affect outcomes (and can cite examples) Fully familiar with the GMC s Good Medical Practise Understands the nature of human error and the importance of systems factors in relation to Patient Safety Skills Describe common complications and side effects of treatments/ procedures to patients* Identify and respond appropriately to patients with abnormal signs. Recognise personal limitation and seek help at an early stage. Communicate effectively to ensure continuity of care. Use local and national reporting systems for adverse events and patient safety incidents Identify potentially unsafe situations and present them to senior colleagues and the management team effectively and so as to promote change Identify poor performance and unsatisfactory conduct in a colleague or other healthcare professional and take appropriate action to ensure patients are protected Use clinical information to assess the clinical performance of a service and benchmark it against best practise Use the principles of quality assurance and quality improvement to maintain a high standard of practise Attitudes Understand epidemiology of clinical presentation in primary care High level of safety awareness and safety consciousness at all times Seek to ensure (whenever appropriate) that patients are cared for in a way that he/she or his/her family would want to be cared for Always seeking opportunities to make care better Welcome feedback from patients and professional colleagues Take every opportunity to learn effectively from things that go wrong Seek out role models and tries to learn from and adopt the behaviours of the best clinical practitioners and the best clinical leaders 57 Identify signs of possible patient abuse and alert the appropriate colleagues and agencies in a timely fashion * The term patient should include where appropriate patient and parent, guardian or carer

60 1.1 GOOD CLINICAL CARE (C) QUALITY AND PATIENT SAFETY (cont d) Subject Knowledge Skills Attitudes Quality and Patient Safety Knows how adverse events and patient safety incidents can be analysed as a source of learning to make care safer Can explain what it would feel like to be a patient and what their needs and wants are likely to be Aware of the prevailing NHS best practice standards (including those published by NICE and in NSFs) Maintain a strong and consistent focus on the needs of the patients Work collaboratively with managers and professional colleagues to promote a culture of high quality and safety as part of everyday activities 58 * The term patient should include where appropriate patient and parent, guardian or carer

61 1.1 GOOD CLINICAL CARE (D) INFECTION CONTROL Outcome: The trainee will demonstrate the knowledge, skills and attitudes to reduce the risk of cross-infection. Subject Knowledge Skills Attitudes Infection control Understands importance of hand washing Knows how to use antibiotics appropriately Is familiar with local resistance patterns Understands appropriate use of isolation facilities and side rooms Applies standard universal precautions Uses competent aseptic technique for IV Cannulation, Urinary Catherterisation and other applicable procedures Disposes of sharps safely Attends infection control teaching sessions Considers risk of infection before undertaking any procedure Participates in surveillance system Is up to date with own immunisations Aware of potential risk posed to patients by own health status Does not allow own health status to put patients at risk of infection Makes prevention of infection associated healthcare a routine part of everyday work 59 * The term patient should include where appropriate patient and parent, guardian or carer

62 1.2 COMMUNICATION SKILLS Outcome: The trainee will demonstrate the knowledge, skills and attitudes to be able to communicate effectively with patients, relatives and colleagues in the circumstances outlined below. Circumstance Knowledge Skills Attitudes (i) Within a consultation (see also 1.1A.i) How to structure the interview to identify the patient's*: concerns / problem list expectations understanding acceptance Listen Use of appropriate questioning techniques including open and closed questions Avoid jargon and use familiar language Use interpreters appropriately Give clear information and feedback to patients* and share information with relatives when appropriate Reassure 'worried well' patients* Telephone skills Possess empathy and ability to form constructive therapeutic relationships with patients* Develop a courteous, polite, professional and considerate manner Consider the importance of: involving patients* in decisions offering choices respecting views of patients* when to involve senior help (ii) Breaking bad news How to structure the interview and where it should take place Normal bereavement process and behaviour Awareness of organ donation procedure and role of local transplant co-ordinators Choose an appropriate setting with the presence of individuals to support both the doctor and the patient. Avoid jargon and use clear, familiar language Encourage questions, and confirm understanding Avoid conveying unrealistic optimism and undue pessimism Act with empathy, honesty and sensitivity Respect cultural and religious diversity * The term patient should include where appropriate patient and parent, guardian or carer 60

63 1.2 COMMUNICATION SKILLS Circumstance Knowledge Skills Attitudes (iii) With colleagues How and when to communicate effectively with other members of the care team and with other medical colleagues especially at handovers How clinical information is conveyed from primary to secondary care on admission and in the reverse direction on discharge Communicate patient's* anxieties and issues of concern Listen to other health care professionals and heed their views Is flexible and prepared to change in the face of valid argument but is capable of supplying own view when supported by appropriate evidence Is polite and responsive to telephone requests Make polite and reasonable telephone and personally delivered requests to laboratory and imaging staff Make discharge information available to appropriate primary care staff Understands: who needs to know what information others' perspectives in contributing to management decisions the challenges of providing optimum care within the undifferentiated environment of primary care the process of admission from primary to secondary care (iv) Complaints Awareness of the local complaints procedure Adopt behaviour likely to prevent a complaint occurring Act with honesty and sensitivity in a non-confrontational manner Deal appropriately with dissatisfied patients / relatives * The term patient should include where appropriate patient and parent, guardian or carer 61

64 1.3 MAINTAINING GOOD MEDICAL PRACTICE (A) LEARNING (see also 1.6): Subject Knowledge Skills Attitudes (i) Life long learning Define continuing professional development Understand the role of appraisal Understand the role of assessment Recognise and use learning opportunities Maximise the potential of personal study Compose and revise a personal learning plan Be: personally motivated to learn eager to learn willing to learn from colleagues willing to critically evaluate own work and make appropriate changes willing to consider criticism (B) EVIDENCE, AUDIT AND GUIDELINES: Outcome: The trainee will demonstrate knowledge, skills and attitudes to use evidence, guidelines and audit to benefit patient care. Subject Knowledge Skills Attitudes (i) Evidence based medicine (EBM) Principles of EBM Types of clinical trial Limitations of the existing evidence base Competent use of databases, the library and the internet Implement the available evidence base in most areas of clinical care Discuss relevance of available evidence with individual patients Keen to use evidence to support patient care 62

65 1.3 MAINTAINING GOOD MEDICAL PRACTICE Subject Knowledge Skills Attitudes (ii) Audit The audit cycle Be involved in on-going audit Consider the relevance of audit to: Data sources for audit Manage change benefit developing patient care Understand data confidentiality clinical governance risk management (iii) Guidelines Advantages and limitations of guidelines and protocols Apply local guidelines/ protocols in context Consider individual patient needs when using guidelines and protocols Methods of determining best practice 63

66 1.4 MAINTAINING TRUST (A) PROFESSIONAL BEHAVIOUR AND PROBITY: Outcome: The trainees will have developed the knowledge, skills and attitudes to act in a professional manner at all times. Subject Knowledge Skills Attitudes (i) Doctorpatient relationship Aspects of an effective professional relationship Avoid unnecessary personal comments Ensure all discussion / examination is relevant Deal with inappropriate behaviour in patients* eg, aggression, violence, sexual harassment Adopt a non-discriminatory attitude to all patients* and recognise their needs as individuals Broad willingness to place need of patients above own convenience Be aware of patients' expectations around personal presentation of individual doctors Behave with honesty and probity (ii) Continuity of care (see 1.1Bii) Relevance of continuity of care Understand personal and collective responsibility for patient welfare Ensure satisfactory completion of reasonable tasks at the end of the shift/day with appropriate handover Produce accurate handover documentation Recognise the importance of: punctuality attention to detail availability when on call Ensure forward planning, information giving and liaison with colleagues Make adequate arrangements to cover leave * The term patient should include where appropriate patient and parent, guardian or carer 64

67 1.4 MAINTAINING TRUST Subject Knowledge Skills Attitudes (iii) Stress The effects of stress Knowledge of support facilities Develop coping mechanisms for stress and ability to seek help if appropriate Recognise the manifestations of stress in self & others (iv) Interaction with other professionals including members of a team hospital & GP hospital & other agencies eg, social services (see 1.2ii & iii) Roles and responsibilities of team members and other professionals in patient* care How teams work effectively When to involve other members of the multidisciplinary team in care decisions Seek to involve other professionals in the management of patients and their illnesses where appropriate Delegate, show leadership and supervise safely Handover safely Seek advice if unsure Communication between team members Be tolerant, flexible and respectful of other professional viewpoints and recognise good advice Be conscientious and behave with honesty Recognise own limitations (v) Relevance of outside bodies The relevance to professional life of: Recognise situations when appropriate to involve these bodies/individuals Accept professional regulation The Royal Colleges GMC Postgraduate Dean Defence organisations BMA PMETB * The term patient should include where appropriate patient and parent, guardian or carer 65

68 1.4 MAINTAINING TRUST (B) ETHICS AND LEGAL ISSUES Outcome: The trainee will demonstrate the knowledge and skills to cope with ethical and legal issues which occur during the management of patients with general medical problems. Subject Knowledge Skills Attitudes (i) Medical ethical principles and Confidentiality Principles of patients * best interests, autonomy and rights Strategies to ensure confidentiality Functions of Caldecott Guardians Limits to confidentiality Use and share all information appropriately Avoid discussing one patient in front of another Ensure privacy when discussing sensitive issues While respecting confidentiality, seek appropriate, timely advice where patient abuse is suspected Respect the right to autonomy and confidentiality Data Protection Act provisions (ii) Valid consent Process for gaining informed consent Associated legal framework Give appropriate information in a manner patients* understand and be able to obtain consent from patients* Consider the patient's needs as an individual The difference between consent and assent Refer some consent requests to appropriate senior colleagues Children's rights including Gillick competency Deal with patients* who cannot give valid consent Adults with incapacity (Scotland) Appropriate use of leaflets and written material Implications of HIV testing Check that the patient* has understood the relevant information * The term patient should include where appropriate patient and parent, guardian or carer 66

69 1.4 MAINTAINING TRUST Subject Knowledge Skills Attitudes (iii) Legal framework for medical practice, particularly relating to: death certification role of the Coroner/ Procurator Fiscal mental illness advance directives and living wills DVLA Legal responsibilities for completing death certificates Types of deaths to be referred to the Coroner/ Procurator Fiscal Situations where compulsory detention under a section of the Mental Health Act would be appropriate Conditions that patients should report to the DVLA and doctors' responsibilities if they fail to do so Complete death certificates Liaise with the Coroner/Procurator Fiscal Discuss whether the patient has an advance directive or living will and its current validity Share information in professional manner with inter agency team members Show attention to detail and recognise pressures of time Respect living wills and advance directives whilst recognising their limitations Non judgemental compassionate approach child protection Child protection procedures, inter agency referral routes (eg, police, Social Services) and when to involve them 67

70 1.4 MAINTAINING TRUST (C) PATIENT PARTNERSHIP AND HEALTH PROMOTION: Outcome: The trainee will demonstrate the knowledge, skills and attitudes to be able to educate patients* effectively. Subject Knowledge Skills Attitudes (i) Educating patients* about: disease investigations therapy Natural history of common diseases Investigation procedures including possible alternatives / choices Strategies to improve adherence to therapies Give information to patients* clearly Encourage questions Negotiate individual treatment plans, encouraging ownership and responsibility for action to be taken by the patient on deterioration or improvement Consider involving patients* in developing mutually acceptable investigation and management plans Encourage patients* to access: further information patient* support groups (ii) Environmental & lifestyle risk factors Risk factors for disease including: diet exercise social deprivation sexual behaviour occupation Advise on lifestyle changes Involve other health care workers, social workers and teachers as appropriate Assess an individual patient's risk factors Have a non-judgemental approach Consider the social, familial and environmental circumstances of patients* substance abuse accidents and child abuse genetic * The term patient should include where appropriate patient and parent, guardian or carer 68

71 1.4 MAINTAINING TRUST Subject Knowledge Skills Attitudes (iii) Smoking Effects of smoking on health of smoker and others Implications of addiction Identify 'ready to quit' smokers Advise on smoking cessation and supportive measures Have a non-judgemental approach Consider the importance of support during smoking cessation Smoking cessation strategies (iv) Alcohol Effects of alcohol on health and psychosocial well-being Local support groups /agencies Take an alcohol history Advise on appropriate drinking levels or drinking cessation Have a non-judgemental approach Suggest patient support groups as appropriate (v) Epidemiology & screening Data collection methods and their limitations Notifiable diseases Principles of prevention, health surveillance & screening Assess an individual patient's risk factors Encourage participation in appropriate disease prevention or screening programmes Consider the: positive & negative aspects of prevention importance of patient* confidentiality Respect patient* autonomy (vi) Infection control Prevention of spread of infection: hand washing (eg, for MRSA) and need for isolation facility for multi-resistant organisms (eg, MDRTB) Be familiar with common infection control procedures including universal precautions against blood-borne viruses Attend infection control education programme Recognise when to involve infection control team * The term patient should include where appropriate patient and parent, guardian or carer 69

72 1.5 TEACHING AND TRAINING (see also 1.3): Outcome: The trainee will demonstrate the knowledge, skills and attitudes to become life-long learners and teachers. Subject Knowledge Skills Attitudes (i) Teaching How adults learn Learner-centred approach Use opportunities for teaching Communicate and share information one-to-one and in small groups Demonstrate willingness, enthusiasm and patience to teach Always seek feedback (ii) Presentations Features of an effective presentation Give presentations to small groups e.g. journal club Be confident and not intimidated when presenting Ability to present material in a logical and concise fashion Embrace new technology Present material in different presentation media 70

73 CORE SKILLS IN RELATION TO ACUTE ILLNESS INTRODUCTION This section of the curriculum outlines areas in which all junior doctors should acquire clinical experience and receive training. It, therefore, forms a fundamental component of the foundation programme. The objectives cover problems that are cross-specialty, as well as common problems encountered in emergency patients. It is expected that on completion of the two years all trainees should be competent and feel confident in the areas outlined appropriate to the specialties covered. In addition trainees will be expected to demonstrate how individual competencies can be combined to provide appropriate and timely care within the clinical settings of primary and secondary care. It is recognised that the application of skills and knowledge will vary according to the site in which care is provided, trainees must for example, tailor their approach within a primary care setting and manage patients appropriately despite the lack of investigations which they might ordinarily have available in hospital. Furthermore, trainees working with children must recognise that the trajectory of illness is generally different for adults, and the signs of critical illness often subtle or vague in the early stages. This is a minimum standard and is not meant to constrain learning to just these areas. 71

74 2 (A) MANAGEMENT OF ACUTELY ILL PATIENTS Outcome: The trainee will demonstrate the knowledge and skills to be able to assess and initiate management of patients presenting as emergencies with the problems outlined below. Attitudes throughout this section are as described in the previous Generic Skills section. For each scenario (see PART I, Section 4) trainees should in particular gain knowledge, competencies and skills to recognise the critically ill and: Immediately assess and resuscitate if necessary Formulate a differential diagnosis and refer as appropriate Select relevant investigations and accurately interpret reports/results Communicate the diagnosis and prognosis - see Generic Skills Reassess as appropriate Knowledge Common presenting symptoms and signs of acute illness including breathlessness, hypoxaemia, hypotension, oliguria, chest pain, nausea, vomiting headache, and confusion or coma Frequently occurring causes of the above Clinical interpretation of acutely abnormal physiology Common derangements of arterial blood gases Causes of impaired level of consciousness including fits and faints Causes of acute abdominal pain, including gastrointestinal, surgical, gynaecological/urological, cardiac/vascular, and neurogenic Skills Identify, assess, and initiate treatment in critically ill patients appropriate to the site of care (eg, hospital, home, GP surgery) Promptly assess the airway, breathing and circulation in the collapsed patient Document acutely abnormal physiology Establish venous access with attention to infection control measures Deliver a fluid challenge safely to acutely ill patients to optimise cardiac output Reassess acutely ill patients within an appropriate period following initiation of treatment Undertake a focused history and examination to establish a differential diagnosis including difficult circumstances Select appropriate initial investigations to explore the differential diagnosis 72

75 Knowledge Safe oxygen therapy Safe use of analgesic drugs; routes and methods of administration Acute confusional states including acute psychosis: causes, assessment and initial management Deliberate self-harm: modes of presentation, causation, initial treatment for most common forms of self-poisoning, psychological and mental health team support Causes of acute visual impairment Resuscitation protocols to Immediate Life Support level (PRHOs = F1) Resuscitation protocols to Advanced Life Support level (by end of foundation years) Skills Request senior or more experienced help when appropriate Succinctly present the relevant clinical details of an acutely ill patient to a senior doctor Communicate effectively with other specialties when appropriate Assess level of consciousness Manage patients with impaired consciousness including fits and faints Determine need for nil by mouth status Insert a naso-gastric tube Identify concurrent comorbid diseases and their relevance to the acute illness Select, prescribe and monitor safe and effective analgesia for patients with acute pain (see also 1.1Aiii) Initiate resuscitation of the patient who has sustained a cardiorespiratory arrest (2Bii) Safe defibrillation (2Bii) 73

76 2 (B) RESUSCITATION Outcome: The trainee will demonstrate the knowledge, competencies and skills to be able to recognise critically ill patients, take part in advanced life support, feel confident to initiate resuscitation and use the local protocol for deciding when not to resuscitate patients. Subject (i) Resuscitation (ii) Do not attempt resuscitation orders (DNAR) Knowledge Contents of Advanced Life Support course Local and national protocols for DNAR orders Legal and ethical considerations Skills Be ALS certified Discuss DNAR criteria with colleagues, patients and relatives Encourage regular review of DNAR orders Support patients and families Respect living wills and advance directives Act with empathy and sensitivity Breaking bad news see 1.2ii 2 (C)i MANAGEMENT OF THE 'TAKE' Outcome: The trainee will demonstrate the knowledge, competencies and skills to be able to safely function in an acute 'take' team. Subject (i) 'Take' management Knowledge Indications for urgent investigation and therapy Skills and capabilities of members of the 'on-take' team When and from whom to seek help in appropriate circumstances Skills Ability to prioritise Interact effectively with other health care professionals Keep patients and relatives informed Receive and make referrals appropriately Cope with stress Delegate effectively and safely Keep an accurate patient list Handover safely with appropriate documentation 74

77 2 (C)ii DISCHARGE PLANNING Outcome: The trainee will demonstrate the knowledge and skills to be able to plan discharges for patients starting from the point of admission. Subject Discharge planning Knowledge Impact of physical problems on activities of daily living Roles and skills of members of the multidisciplinary team including nurses, OTs, physiotherapists, discharge coordinators and social workers Impact of unnecessary hospitalisation Available support in primary care Skills Recognise when in-patient care is not required Start planning discharge from the time of admission. Partake in discharge planning meetings Liaison and communication with patient, family and primary care Be aware of family dynamics and socio-economic factors influencing success of discharge Ensure the primary care team are aware of the discharge of patients with appropriate, timely information Write reports for appropriate bodies SELECTION AND INTERPRETATION OF INVESTIGATIONS INTRODUCTION The foundation programme years are a phase of increasing clinical responsibility, a key element of this is the ability of doctors to select appropriate investigations and interpret the reports. Training in selection, requesting and interpretation of results of some investigations may have taken place as an undergraduate, however, it is important that these skills are developed and widened. It is also vital that trainees learn to critically evaluate when investigations are not required and are not cost effective. The balance will vary according to the site in which clinical care is conducted. Investigations valid in a hospital setting may be impractical in general practice. Where national and local guidelines on selection of investigations exist, they should be used. For example, the 75

78 Royal College of Radiologists' document 'Making best use of a Department of Clinical Radiology' gives helpful guidance to doctors requesting imaging and trainee doctors should be familiar with this. The investigations listed are those that are very frequently requested on acutely ill patients with detailed objectives, skills and knowledge. As in the core skills section the objectives listed below apply to all trainees on completion of the two years. Again this is a minimum standard and not meant to be restrictive. AIMS: To produce doctors who are competent and confident in selecting, requesting and interpreting reports of commonly used investigations required for the diagnosis and management of patients who present as emergencies or who are potentially acutely or critically ill. OUTCOMES: For each of the investigations listed in this section: Trainees should be able to: Explain the nature of the investigation to patients Explain why it is required Explain the implications of possible results and actual results when available Gain informed consent Trainees should also learn to: Recognise the need for an investigation result to impact on management Avoid unnecessary investigations Recognise that investigation reports often require the professional opinion of an individual who therefore needs relevant information on the request form Recognise that reports may need review in the light of changing circumstances Act on the results in a timely and appropriate fashion Prioritise the importance of results and ask for help appropriately 76

79 INVESTIGATIONS COMMONLY REQUESTED FOR ACUTELY ILL PATIENTS Outcome: The trainee will demonstrate the knowledge and skills to be able to select, request appropriately and accurately interpret reports of the frequently used investigations, used to manage acutely ill patients, listed below. For all investigations it is vital that trainees recognise abnormalities which require immediate action. Investigation Full blood count Urea and electrolytes Blood glucose Cardiac markers Liver function tests Amylase Calcium and phosphate Coagulation studies Arterial blood gases Inflammatory markers 12 lead ECG Knowledge Circumstances requiring urgent results Significance of major abnormalities and general irrelevance of minor variations from normal values Normal ECG patterns Patterns for common abnormalities Skills Use results reporting system Record and tabulate where appropriate Interpret results and when to request further specialist advice Use of ECG machines including how to connect limb and chest leads Recognise: common abnormalities normal variants abnormally connected leads when to repeat 77

80 Investigation Chest X-ray Abdominal X-ray Ultrasound, CT and MRI Microbiological samples Knowledge Circumstances requiring: urgent requests particular views Normal findings of chest and abdominal X- rays Imaging appearances of common abnormalities on chest and abdominal X-rays Recognition of the risks of radiation Type of samples and collection method required Skills Communicate well with radiologists, radiographers and other staff Recognise common abnormalities Recognise the need for radiological advice Identify when ultrasound, CT or MRI might be required Interpret results PRACTICAL PROCEDURES INTRODUCTION Training in some practical procedures may have taken place in the undergraduate years and/or in the first foundation programme (PRHO) year but it is important that skills are developed and widened in the second year so that trainees become competent and feel confident to perform commonly required practical procedures. Listed here are those procedures that doctors at the end of the foundation years should be competent and feel confident to perform. Again these are a minimum standard and not meant to be restrictive. AIMS: To produce doctors who are competent and confident to perform common practical procedures required for diagnosis and management of patients who present acutely. 78

81 OUTCOMES: A. GENERAL KNOWLEDGE AND SKILLS: For each procedure doctors should: and be able to: Know indications and contraindications Explain the procedure to the patient including possible complications and gain informed consent for procedures carried out by the trainee Prepare the required equipment including a sterile field Position the patient and give premed / sedation as required, involving the anaesthetist where appropriate Adequately prepare the skin including local anaesthetic Arrange appropriate aftercare /monitoring Safely dispose of equipment including sharps Document the procedure, including labelling of samples and instructions for monitoring post procedure Record complications Recognise and be able to undertake emergency management of common complications At all times doctors should recognise what are the limits of their competency and to seek advice and help where appropriate 79

82 PROCEDURES THAT PRHOS (F1) SHOULD BE COMPETENT AND CONFIDENT TO PERFORM. TRAINEES ARE EXPECTED TO MAINTAIN AND IMPROVE THESE SKILLS SUCH THAT BY THE END OF F2 THEY SHOULD BE ABLE TO HELP OTHERS WHEN THE PROCEDURES ARE DIFFICULT. Venepuncture and cannulation Blood cultures from peripheral and central sites Intravenous infusions including the prescription of fluids, blood and blood products Performing an ECG Arterial blood sampling Injection - subcutaneous, intradermal, intramuscular and intravenous Urethral catheterisation Airway care including simple adjuncts Nasogastric tube insertion BY THE END OF F2 YEAR, TRAINEES SHOULD ALSO BE COMPETENT AND CONFIDENT TO PERFORM: All of the above to a level where the trainee is able to pass on the skills to others less competent. Each specialty will also specify a range of procedures relevant to that specialty in which the trainees will be expected to become proficient eg, pleural aspiration, skin suturing, lumbar puncture. METHODS OF LEARNING: In general, training in practical procedures should include: Reading up on the theory or studying virtual training packages on the Internet Where available use a skills laboratory Observing first hand Being themselves observed performing the procedure by a competent practitioner who has recent relevant experience of the procedure 80

83 PART III: APPENDICES i Multi-Source Feedback for Foundation Programme Mini-PAT (Peer Assessment Tool) for Foundation Programme The description and documentation described below is applicable to F2 workplace based assessment but the process is readily adaptable for use in F1/PRHO work-place based assessments. Background: PMETB and GMC have identified peer ratings as suitable for postgraduate assessment and revalidation evidence. A number of groups have been involved in developing and evaluating MSF for trainees. The tool being evaluated for this project for use in foundation training assessment, mini-pat (peer assessment tool) builds on this work. It is derived from the Sheffield Peer Review Assessment Tool (SPRAT) and has been shortened on the basis of content validity in relation to the MMC curriculum. Additionally other modifications have been made to incorporate feedback from COPMED (eg, a question on health and probity has been added) and other UK work in this area. It is an assessment tool that is explicitly mapped to Good Medical Practice (GMP), the General Medical Council's framework for good practice for all doctors in the UK. Evidence from the US and Canada supports the use of peer ratings as part of work-place based assessment programmes. Peer-rating would normally constitute only part of an overall assessment strategy. Mini-PAT consists of 15 questions mapped to the five main domains of GMP and a global rating scale. Free text comments by the assessors are encouraged. The rating scale is a 6 point rating scale with an unable to comment option for raters to use where they have not observed a given aspect of professional practice. Experience to date would suggest that collated feedback from 5 or more raters produces acceptable confidence intervals for its use as part of a work-place based assessment programme. Mini-PAT for Foundation SHOs Purpose Mini-PAT provides feedback from a range of co-workers across the domains of 81

84 GMP. These can be mapped to the core objectives of the F2 curriculum. In foundation years, feedback will be entirely developmental with the trainee and educational supervisor agreeing strengths and key areas for development from collated feedback. All the forms returned will be collated and fed back to the trainees via their nominated supervisor. Practicalities Number and frequency of assessments The exact timing will depend on the length of posts on the rotation. For the Foundation pilots: Trainees in 4 month posts will be approached as soon as possible after completion of their first post and asked to nominate 8 raters. Trainees in 3 or 6 month posts will be approached at 5-6 months and asked to nominate 8 raters from the previous 6 months. Those in 3 month placements must include raters from both placements. Trainees will be asked to then nominate a second set of raters from their next post at 9-10 months. The initial round of feedback will be for formative purposes only. Collated feedback from all their placements will be provided as soon as possible th after the 10 month to allow time to plan how any issues identified will be addressed. Individual Foundation programme leads will be notified of precise timings for their trainees based on details of their rotations. Choosing raters The majority of raters should be selected from supervising consultants, GP principals, specialist registrars and experienced nursing or Allied Health Professional colleagues. All trainees must include the supervising clinical consultant they work most closely with in secondary care or their GP trainer if in primary care. All trainees complete a self-assessment using the same questionnaire. Administration Trainees will be provided with a mini-pat pack through their Foundation Programme lead. To ensure that all trainees receive their packs they should sign 82

85 to confirm that they have received them Trainees then return their self- ratings and a list of nominated raters. Mini-PAT forms for completion are sent directly to the raters from the central office and are subsequently returned directly by the rater for scanning into the database. This ensures that the individual raters' views remain unknown to the trainee. Feedback A chart of the individual's mean score per question and of the global rating compared to their self-rating and a second chart showing the overall score for the doctor compared with their overall self mean are provided. Comparison of the raters' perceptions with their own is a very useful part of the process for trainees. Where there are significant differences between the two this merits discussion. Any comments are anonymised prior to feedback to the doctor but they are produced verbatim. It is essential that raters take into consideration verbatim reporting of free text comments and take care to word this as constructively as possible. The covering letter for raters emphasises this. To maximise the usefulness of the process the feedback will be delivered by an appropriate supervisor/mentor or appraiser. Two copies of the feedback for all the F2 trainees in each programme will be returned to the Programme Director. Their supervisor will discuss the feedback with the trainee and the trainee retains a copy in their Portfolio. Our experience has shown that doctors, however well they have done, often focus on any obvious areas for development, sometimes ignoring those areas where they have done well. Discussion should facilitate personal development for the doctor by focusing on areas of strength to enable the doctor to build on these. It should also clearly identify areas for development by formulating at least one learning objective for their next personal development plan linked directly to their feedback. What about doctors where problems are identified? A very small number of doctors will have significant problems identified as a result of this process. Receiving such feedback is highly stressful for any individual and it is essential that appropriate support is available for all doctors. Further diagnostic assessment may be required to clarify the nature of problems identified in a given domain. Where a problem does need addressing a framework for doing so and a plan for re-assessment should be agreed with the doctor. 83

86 mini-pat (Peer Assessment Tool) Please complete the questions using a dash: - Please use black ink and CAPITAL LETTERS A doctor who is performing at the expected level for completion of the Foundation programme scores 4 Doctor's Surname Forename GMC Number: Form Number: How do you rate this Doctor in their: Good Clinical Care 1 Ability to diagnose patient problems 2 Ability to formulate appropriate management plans 3 Awareness of their own limitations 4 Ability to respond to psychosocial aspects of illness 5 Appropriate utilisation of resources e.g. ordering investigations Maintaining good medical practice 6 Ability to manage time effectively / prioritise 7 Technical skills (appropriate to current practice) Teaching and Training, Appraising and Assessing: 8 Willingness and effectiveness when teaching/training colleagues Relationship with Patients: 9 Communication with patients 10 Communication with carers and/or family 11 Respect for patients and their right to confidentiality Working with colleagues: 12 Verbal communication with colleagues 13 Written communication with colleagues 14 Ability to recognise and value the contribution of others 15 Accessibility/Reliability 16 Overall, how do you rate this doctor compared to another doctor of the same grade? Meets Below expectations Borderline expectations Above expectations Sample X X X X X X X U/C* Do you have any concerns about this doctor's probity or health? Yes No If yes please state your concerns: *U/C Please mark this if you have not observed the behaviour and therefore feel unable to comment

87 Anything especially good? Please describe any behaviour that has raised concerns or should be a particular focus for development: Your Sex: Male Which environment have you primarily observed the doctor in? (Please choose one answer only) Your position: Female Inpatients Intensive Care Outpatients Sample X Theatre Both In and Out-patients A&E/Admissions General Practice Other (Please specify) Community Speciality Laboratory/Research Consultant SASG SpR Foundation/PRHO Nurse SHO Allied Health Professional GP Other (Please specify) Length of working relationship (in months): How long has it taken you to complete this form (in minutes)?: Your Name: Surname Forename Your Signature:... Date: / / Acknowledgements: mini-pat is derived from SPRAT (Sheffield Peer Review Assessment Tool)

88 ii Mini-CEX for Foundation Programmes Background: Mini-CEX was originally developed in the US by the American Board of Internal Medicine. What was the original purpose of the Mini-CEX? The mini-cex was designed to assess the clinical skills, attitudes, and behaviours of US junior doctors (residents) essential to providing high quality patient care. It was conceptualized as a minute snapshot of a doctor/patient interaction. Data from the US has shown that mini-cex is reliable and valid and that it is acceptable to both trainees and their clinical supervisors. The Royal College of Physicians have used a modified version of mini-cex as part of their work evaluating tools for performance assessment. Evaluation of mini-cex US data suggests that 4 mini-cex evaluations are sufficient to make a reliable judgement. The mini-cex format was viewed positively by the trainees (particularly the opportunity for feedback) and their satisfaction was not associated with performance ratings. The time (median) committed to encounters was 15 minutes for observation and five minutes for feedback. Mini-CEX for Foundation SHOs. Purpose 86

89 F2 Mini-CEX: Competencies Assessed and Descriptors Core objectives of the F2 curriculum are shown in italics below each question area Question area History taking Good clinical care Physical examination Good clinical care Professionalism Legal/ethics Descriptor Facilitates patient s telling of story, effectively uses appropriate questions to obtain accurate, adequate information, responds appropriately to verbal and non-verbal cues Follows efficient, logical sequence; examination appropriate to clinical problem, explains to patient; sensitive to patient s comfort, modesty Shows respect, compassion, empathy, establishes trust; Attends to patient s needs of comfort, respect, confidentiality. Behaves in an ethical manner, awareness of any relevant legal frameworks Aware of limitations Clinical judgement Decision making Good clinical care Communication skills Communication Organization/ efficiency Makes appropriate diagnosis and formulates a suitable management plan. Selectively orders/performs appropriate diagnostic studies, considers risks, benefits. Explores patients perspective, jargon free, open and honest, empathic, agrees management plan/therapy with patient Prioritizes; is timely, succinct. Summarises Time management Overall clinical care Acute care Good clinical care Decision making Demonstrates judgment, synthesis, caring, effectiveness Efficiency, appropriate use of resources, balances risks and benefits, awareness of own limitations 87

90 F2 mini-cex is designed to provide feedback on skills essential to the provision of good clinical care. In keeping with the F2 quality improvement assessment model, strengths, areas for development and agreed action points will be identified following each mini-cex Modifications to original form: A number of modifications to the original mini-cex rating form have been made. The questions have been anglicised to facilitate their use by UK trainees and raters. In addition the content has been mapped to the F2 outcomes identified within the curriculum to ensure consistency. Together these changes mean that: Medical interviewing skills has been changed to History Taking Humanistic Qualities/Professionalism has been changed to Professionalism Counselling Skills has been changed to Communication Skills Overall Clinical Competence has been changed to Overall Clinical Care In addition, the scale has been changed so that it is a 6 point scale in line with the other assessment tools being used in this study for foundation training assessment. Because it is anticipated that many of the skills being observed by mini-cex will need development the descriptor category of below expectations or borderline is anticipated for many trainees. The forms will include demographic data essential to the quality assurance process of the overall assessment system. Practicalities: Number and frequency of assessments. Trainees will be provided with triplicate forms in pads. They will be asked to undertake 6 observed encounters during the year with a different observer for each encounter. (Having a different observer for each encounter will improve reliability). Observers may be experienced SpRs or consultants in a secondary care setting. The GP trainer and other GPs are appropriate in a primary care setting. Each mini-cex should represent a different clinical problem and trainees should sample from each of the core problem groups identified in the F2 curriculum by the end of the year. The trainee chooses the timing, problem and observer although the direct 88

91 supervising consultant should be one of the observers for each clinical placement. F2 mini-cex is suitable for use in an out-patient, in-patient or acute care setting. Administration Trainees will be provided with a pack of mini-cex forms by the nominated Foundation Programme lead for each placement. To ensure that all trainees receive their packs they should sign to confirm that they have received them. Trainees will be asked to return their completed top copy of mini-cex to their local Foundation lead (who will return all forms from trainees on a fortnightly basis to the assessment centre). They should retain a copy in their portfolio and give the third copy to their educational supervisor. Feedback Immediate feedback will be provided after each encounter by the observer rating the trainee. Observers will be encouraged to use the full range of the rating scale and both trainees and trainers should be reassured that some ratings below the satisfactory range are in keeping with an F2 trainee's level of experience. Comparison should be made with a doctor who is ready to complete the F2 programme. Thus, it would be anticipated that over time the number of ratings in the satisfactory or above range will increase as the trainees increase their expertise. In order to maximise the educational impact of using F2 mini-cex trainees and trainers will need to identify agreed strengths, areas for development and an action plan for each encounter. Collated feedback for the whole year will be provided for each trainee once 6 mini-cex encounters have been submitted centrally. Two copies of the feedback for all the F2 trainees in each programme will be returned to the programme director. Their supervisor will discuss the feedback with the trainee and the trainee retains a copy in their portfolio. 89

92 Doctor's Name Assessor's Name F2 Mini-Clinical Evaluation Exercise (CEX) Date DD/MM/YY / / GMC No. Clinical setting A&E OPD In-patient Acute admission GP Other Clinical problem category Airway Breathing Circulatory Neuro Psych/Behav Pain Complexity of case Low Average High Focus History Diagnosis Management Explanation Number times pt seen before by trainee >10 Assessor's position GP Consultant SpR Please grade the following areas using the scale below:- Please rate the trainee compared to a competent doctor at completion of F2 NOT compared to their current level of experience Below expectations Borderline Meets expectations Above expectations History Taking (not observed) Physical examination skills (not observed) Communication skills Clinical judgement Professionalism Organization / Efficiency Overall clinical care Sample Please use this space to record areas of strength or any suggestions for development. Strengths Suggestions for development Agreed action to address development needs: Trainee satisfaction with mini-cex Trainee satisfaction with mini-cex Time taken for observation (hrs:mins) Time taken for feedback (hrs:mins) : : Acknowledgments: Adapted with permission from American Board of Internal Medicine (ABIM) mini-cex tool. Draft 90

93 iii DOPS for Foundation Programmes Background: Direct observation of procedural skills (DOPS) was originally developed by the Royal College of Physicians (London). What was the original purpose of DOPS? DOPS was designed to assess procedural skills using a similar format to mini- CEX. It was originally utilised for Specialist Registrars in Medicine. The RCP evaluated both procedure specific DOPS (such as renal biopsy) and a generic form. A generic form only is being used in the Foundation setting although it asks for the procedure being observed to be recorded. Evaluation of DOPS Preliminary data from the RCP suggests that 4 raters assessing a single encounter each are needed to achieve acceptable reliability for work-place based assessment. The time (median) committed to encounters was 20 minutes for observation and five minutes for feedback. DOPS for Foundation SHOs. Purpose F2 DOPS is designed to provide feedback on procedural skills essential to the provision of good clinical care at this level. There is space to record any particular strengths or areas for development. Selection of procedures to be assessed should be informed by the Foundation curriculum. Practicalities: Number and frequency of assessments. Trainees will be provided with triplicate forms in a pad. They will be asked to undertake 6 observed procedures during the year with a different observer for each encounter. (Having a different observer for each encounter will improve reliability). Observers may be experienced SpRs, appropriate nursing staff or consultants in a secondary care setting. The GP trainer, appropriate nurses and other GPs are appropriate in a primary care setting. Each DOPS should represent a different procedure and trainees should sample from the core problem procedures identified in the F2 curriculum by the end of the year. The trainee chooses the timing, procedure and observer. 91

94 Administration Trainees will be provided with a pack of DOPS forms by the Foundation Programme Lead for each placement. To ensure that all trainees receive their packs they should sign to confirm that they have received them. Trainees will be asked to return their completed top copy of DOPS to their local Foundation lead/administrator (who will return all forms from trainees on a fortnightly basis to the assessment centre) They should retain a copy in their portfolio and give the third copy to their educational supervisor. Feedback Immediate feedback will be provided after each encounter by the observer rating the trainee. Observers will be encouraged to use the full range of the rating scale and both trainees and trainers reassured that some ratings below the satisfactory range are in keeping with an F2 trainee's level of experience. Comparison should be made with a doctor who is ready to complete the F2 programme. Thus, it would be anticipated that over time the number of ratings in the satisfactory or above range will increase as the trainees increase their expertise. Collated feedback for the whole year will be provided for each trainee once 6 DOPS encounters have been submitted centrally. Two copies of the feedback for all the F2 trainees in each programme will be returned to the programme director. Their supervisor will discuss the feedback with the trainee and the trainee retains a copy in their Portfolio. A sample form follows. 92

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97 iv Case Based Discussions for Foundation Programmes Background: Case-based discussion (CbD) is used to enable the documenting of conversations about, and presentations of, cases by trainees. This activity happens throughout training, but is rarely conducted in a way that provides systematic assessment and structured feedback. The approach is called chart stimulated recall in the US and Canada, and is widely used for the assessment of residents and of established doctors who are in difficulty. In the UK it is used, and is being evaluated, by both the NCAA and the GMC in the assessment of established practitioners. The purpose CbD is designed to assess clinical decision-making and the application or use of medical knowledge in the care of the trainee's own patients. It also enables the discussion of the ethical and legal framework of practice, and in all instances, it allows trainees to discuss why they acted as they did, i.e. aspects of professionalism. Although the primary purpose is not to assess medical record keeping, as the actual record is the focus for the discussion, the assessor can also evaluate the record keeping in that instance. How were the CbD forms and rating scales developed? While the CbD for F2 is based on previous work in the UK and the US and Canada, the forms and the rating scales have been designed, for ease of use, to be in a similar format to those for the F2 mini-cex, DOPS and mini-pat (multi-source feedback tool). CbD for Foundation SHOs. Purpose F2 CbD is designed to provide feedback on skills essential to the provision of good clinical care. In keeping with the F2 quality improvement assessment model, strengths, areas for development and agreed action points will be identified following each CbD session. It allows sampling of a range of areas within the F2 curriculum and can be mapped to Good Medical Practice (GMP). The scale is a 6 point scale in line with the other tools being utilised. At this stage of training it is anticipated that many of the skills being assessed 95

98 during a CbD will need development, hence ratings within the descriptor category of below expectations or borderline are anticipated for many trainees. The forms will include demographic data essential to the quality assurance process of the overall assessment system. Practicalities: Number and frequency of assessments. Trainees will be provided with triplicate forms in pads. They will be asked to undertake 6 sessions of CbD during the year with a different assessor for each session as this will help to improve reliability of the overall process. Assessors may be experienced SpRs or consultants in a secondary care setting. The trainer and other GPs are appropriate in a primary care setting. Each CbD should represent a different clinical problem and trainees should sample from each of the core problem groups identified in the F2 curriculum by the end of the year.. The trainee will select 2 case records from patients they have seen recently, and in whose notes they have made an entry. The assessor will select one of these, for the CbD session. The trainee will choose the timing, the cases and the assessor, but the direct supervising consultant should be one of the observers for each clinical placement. An assessment record should be filled out for each case discussed, and the whole session should take no longer than minutes including feedback and completion of the assessment form. The discussion must start from and be centred on the trainee's own record in the notes. CbD is suitable for use in an out-patient, in-patient or acute care setting. Administration Packs of CbD forms will be sent directly to the Foundation Programme Pilot leads who should distribute them to the trainees. To ensure that all trainees receive their packs they should sign to confirm that they have received them. Trainees will be asked to return their completed top copy of the CbD form to their local Foundation administrator (who will return all forms from trainees on a fortnightly basis to the assessment centre). They should retain a copy in their portfolio and give the third copy to their educational supervisor. 96

99 F2 CbD: Competencies Assessed and Descriptors Core objectives of the F2 curriculum are shown in italics below each question area Question area Medical record keeping Communication skills (working with colleagues) Clinical assessment Good clinical care Clinical judgement Decision making Good clinical care Professionalism Legal/ ethics Descriptor The record is legible, signed, dated, and appropriate to the problem, understandable in relation to, and in sequence with, other entries. It helps the next clinician who uses the record, to give effective and appropriate care. Can discuss how they understood the patient's story and how, through the use of further questions and an examination appropriate to the clinical problem, a clinical assessment was made from which further action was derived. Can discuss the rationale for the diagnosis and formulation of the management plan. Shows understanding of why diagnostic studies were ordered/performed, including the risks and benefits. Can discuss how the care of this patient, as recorded, demonstrated respect, compassion, empathy, and established trust. Can discuss how the patient's needs for comfort, respect, confidentiality were, attended to. Can show how the record demonstrated an ethical approach, and awareness of any relevant legal frameworks. Has insight into own limitations. Organization/ efficiency Time management Overall clinical care Acute care Good clinical care Can discuss how the care which was recorded, demonstrates ability to prioritise; and was timely, and succinct. Can discuss own judgment, synthesis, caring, effectiveness, for this patient at the time that this record was made. Decision making 97

100 Feedback Immediate feedback will be provided after each encounter by the observer rating the trainee. Observers will be encouraged to use the full range of the rating scale and both trainees and trainers reassured that some ratings below the satisfactory range are in keeping with an F2 trainee's level of experience. Comparison should be made with a doctor who is ready to complete their Foundation training. Thus, it would be anticipated that over time the number of ratings in the satisfactory or above range will increase as the trainees increase their expertise. In order to maximise the educational impact of using F2 CbD trainees and trainers will need to identify agreed strengths, areas for development and an action plan for each encounter. Collated feedback for the whole year will be provided for each trainee once 6 CbD sessions have been submitted centrally. Two copies of the feedback for all the F2 trainees in each programme will be returned to the programme director. Their supervisor will discuss the feedback with the trainee and the trainee retains a copy in their portfolio. All of the assessments submitted centrally will form a record of in-training assessment for F2, to include comparison with the national cohort. 98

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