Welcome booklet for doctors new to PGMDE training programmes in HE Thames Valley. Revised July 2014, V5 Gold Guide compliant

Transcription

1 Welcome booklet for doctors new to PGMDE training programmes in HE Thames Valley Revised July 2014, V5 Gold Guide compliant

2 Contents Introduction: Background and importance of supervision for trainees Chapter 1 What to expect from induction Chapter 2 Your responsibilities Chapter 3 What are the essential responsibilities of your supervisors? Chapter 4 Feedback on your Performance Resources A: The Oxford Deanery website (for all policies relevant to training, such as Study Leave, Maternity rights, Inter-deanery transfers, Time Out of Programme for research etc) B: Additional induction support for International Medical Graduates C: ARCP outcomes D: The Oxford Deanery Descriptors of Behaviour

3 Introduction Welcome The expectations of trainees have increased enormously in the last few years. There is now a requirement to properly induct, plan, assess, deliver specific curriculum objectives and vitally, record many aspects of doctors performance during training. There is abundant evidence that well trained and supported doctors work safely, and that those who aren t are more likely to be involved in adverse events which may damage their professional standing, the reputation of the department, Trust or training programme as well as patient harm. We have an Educator Development Strategy (2012) to ensure that all supervisors of postgraduate dental and medical trainees have been adequately trained to do their job of supervising and supporting trainees working across the Thames Valley. All our local Trust Directors of Medical Education and Education Managers, based in the Trust Post Graduate offices, are assisting us to ensure that your trainers have access to the most up to date training to help them do their job. However, you must remember that your post-graduate training and collection of all the evidence to underpin this, is your responsibility! This booklet is to give you assistance to find material to help you get the best experience you can as you work through your training programme, and, where to find help if things are not as you had expected. It is a sister companion to the Field Guide for Supervisors, written by the same team, and contains some identical material. Dr M J Bannon, Post Graduate Dean Note: HE Thames Valley is responsible for training of all members of the NHS workforce. The Oxford PGMDE (or Deanery ) part of HETV is responsible for doctors and dentists. Acknowledgements: This booklet has been compiled with material from senior educators in both primary and secondary care, including John Derry and Chris Smith from the CDU, Jill Edwards (GP Dean), Tony Jefferis (Deputy Dean), Amit Gupta (AD for IMGs), Chris Morris (AD Quality), Simon Street and Greg Simons, both GP Ads and me. Useful comments from GP TPDs were incorporated into initial drafts, so thanks also to Nicky Turner, Mark Reed, Michael Mulholland and Suzanne Gill. Please me with any comments / suggestions for improvement. Jane Siddall Associate Dean for Educator and Faculty Development

4 Chapter 1: Induction Induction is a key period when starting any new post, and usually contains two elements, one being generic to the hospital or other education provider, and the second being specific to the specialty. Specilaty specific induction should include information from the department in which you are working and may included a specialty induction day, typically for trainees at the start of a programme (eg CT or ST1, or at ST3 if you have come into higher specialty training froma Core Programme). Even if you have previously worked in the organisation, or have experience in the specialty, you should expect to attend, and receive, induction training to help you work as effectively as possible from the start of a training post. Every organisation does things slightly differently, and as your training progresses, you are likely to encounter more challenging components in your work as a doctor or dentist, which may require some initial training. Increasingly, you can expect to receive information electronically before starting a new post, and you may be required to complete some online training before you begin work. Passwords for electronic records, pathology etc may be issued only upon completion of online induction training. Some Trusts will also arrange necessary mandatory training, such as resuscitation or manual handling within the first couple of weeks in post. In addition to these group activities, all trainees are required to book their own Induction Meeting with their Educational Supervisor, whose name you should have been given by the Education Centre. He or she may be based in the department you are working in, but in some specialties may be at another location in the Thames Valley. Ideally, we would hope that you can arrange a meeting within the first two weeks of your post, and certainly should have made contact with your supervisor to meet within the month (allowing for holiday and night shift clashes). At your first meeting, you and your Educational Supervisor should both sign a learning Agreement (usually on your eportfolio). If you have any feedback from your last ARCP, this should be shared as it may help outline your Professional Development Plan (PDP) for the first few months. Additional induction programmes for International Medical Graduates IMGs should attend the Trust-run Induction Programme, normally on the first day or two days at the start of the new appointments (in the first week of August or February). Attendance at this is compulsory, as it will provide all the vital local information about working in any particular Trust. The PGMDE also provides an annual induction to the NHS for newly arrived IMGs and an annual update for those who are more established in

5 the UK. Information can be found on the Deanery website in the IMG section of the Trainees area. Chapter 2: Your responsibilities National Training Number (NTN)/Deanery Reference Number (DRN) Specialty Registrars and run-through Academic trainees are issued with a National Training Number on appointment to the training programme. Trainees in Locum Appointment for Training (LAT) and Fixed Term Training Appointments (FTSTA) will be issued with a Deanery Reference Number. The NTN or DRN will be issued once Form R (registering your contact details, specialty etc) is completed. Form R is sent out with the offer letter. Enrolment with the Royal Colleges All trainees must enrol with the relevant Royal College and register for the eportfolio. You will need to contact the relevant administrator at the Royal College. Teaching sessions Formal teaching days are organised in our programmes and are part of the Study Leave allowance allocated each year. Therefore, you are expected to attend unless there is a valid reason, which might include annual leave, or night shifts. Many specialties set out a minimum attendance percentage to satisfy training requirements. You should discuss local arrangements at your specialty induction meeting with your ES. ARCPs You are required to have an annual assessment of your progress in training, and participate in revalidation. In some specialties, all trainees are required to attend an annual debrief meeting with members of the ARCP panel after the outcome decision has been reached, regardless of the outcome decision. Any trainee given an outcome other than 1 or 6, or 7.1 should be debriefed face to face. Once the date has been set, trainees are sent an invitation (to their contact address given to the Deanery when accepted into programme) by the Health Education Thames Valley administration staff, with details of what the trainee needs to provide for their ARCP. Notice is normally given at least six weeks ahead of the ARCP date. Form R and Wider Scope of Practice You are required to complete this demographic form, and describe all roles you undertake as a doctor, plus confirm statements about your involvement (or not) in Serious Incidents or complaints, your health and probity. This MUST be received by HETV 14 calendar days before the ARCP. We advise that it is sent with tracking so that you know it has been received.

6 It is incumbent upon you to ensure that your portfolio of evidence is regularly updated, and that you and your Educational Supervisor review this at regular intervals. The chart below, also used in the Oxford PGMDE Field Guide for Supervisors, outlines the minimum contacts required between you and your supervisor.

7 A suggested flow chart for all supervisors supporting all trainees is shown below: At the start of the post ES to invite trainee to have a formal conversation about their training to date. The meeting should take place within the first two weeks of the trainee taking up the post. Invite them to show you their log of work place based assessments. ES to sign Educational Agreement, and help plan PDP. Ideally WPBAs and meeting notes to be completed electronically onto the trainee s eportfolio in real-time. If this is not possible, ES to keep a copy of the paper documents in a secure filing system just in case the trainee loses their copy. Identify clinical skills training goals together. ES to ensure that the trainee knows what material should be collated for the period of training you are supervising. ES to invite the trainee to make regular, informal contact with you. ES to regularly Share good and positive feedback from colleagues, as well as any issues of concern If there are specific issues or targets to be addressed, write to clinical supervisor and other colleagues as necessary. Copy the trainee in to this letter. This applies to good trainees just as much as those with emerging issues. Trainee: Around the midpoint of the training year Consider whether formal multi source feedback is required: as this is formative, it may be helpful to complete this well before the end of a training year. It is expected at this stage in some specialties. Review PDP with trainee Pre ARCP assessment (month 10) ES to advise trainee to collate all evidence six to eight weeks before ARCP scheduled. Both to ensure that any outstanding material, or concerns from other staff, are communicated to the ES in writing. (This might include written material from patients, complaints, cases reviewed through clinical governance (good or bad care / outcomes) Ideally, trainee will have all necessary material for summative assessment to be made (sufficient WPBA, mini Cex, CbDs, TO1s) and annual assessment review to be written by educational supervisor. Trainee should submit papers or eportfolio of evidence to programme manager at least two weeks before ARCP, as specified in the Gold Guide

8 Chapter 3: What are the roles and responsibilities of supervisors? Definitions The GMC has defined the roles of both clinical and educational supervisors, which are: Named clinical supervisor: a trainer who is responsible for overseeing a specified trainee s clinical work for a placement in a clinical environment and is appropriately trained to do so. He or she will provide constructive feedback during that placement, and inform the decision about whether the trainee should progress to the next stage of their training at the end of that placement and/or series of placements. Named educational supervisor: a trainer who is selected and appropriately trained to be responsible for the overall supervision and management of a trainee s trajectory of learning and educational progress during a placement and/or series of placements. Every trainee must have a named educational supervisor. The educational supervisor s role is to help the trainee to plan their training and achieve agreed learning outcomes. He or she is responsible for the educational agreement and for bringing together all relevant evidence to form a summative judgement at the end of the placement and/or series of placements. It is expected that educational supervisors should have all the attributes expected of trained clinical supervisors. Being an educational supervisor does not necessarily preclude a trainer from having any other educational role, and it is desirable for senior educators to be active educational supervisors. Deanery definitions of other key supervisors are: Academic supervisors are responsible to help the trainee to plan their research activity and achieve agreed outcomes. Even if he or she has a clinical contract, they should not normally be the trainee s educational or clinical supervisor. He or she is required to provide an annual report on a trainee for the ARCP panel. A sessional supervisor is a clinician who supervises a trainee for individual sessions, and who may be required to provide formal assessment and feedback on the trainee to their clinical, or educational, supervisor.

9 Chapter 4: Feedback on performance Receiving, and giving, feedback is an important part of professional development. However, it isn t a skill that people are inherently good at without training and practise. Effective feedback has been defined as Information about a performance or behaviour which leads to action to affirm, or develop, that performance or behaviour. Ideally, feedback should be given close in time to the event, and should be in a private setting (particularly if behaviour modification is mooted). It should also be clear; avoid sandwiching the bit which needs improvement between two nuggets of praise as the trainee will miss hearing the awful bit. This applies both to your trainers, and to you. Please don t use the annual GMC Trainee survey as the sole opportunity to vent your frustration or dissatisfaction with your training: at best, things will change for your successors and not you, if you don t raise issues promptly. If you aren t able to feedback through your clinical or educational supervisor (if, say, they are part of the problem ), then you have recourse to a local College or Specialty Tutor, the Director of Medical Education (DME), your Training Programme Director (TPD) or Head of School. As a rule of thumb, start close to the problem and work up if you need to. There has been a recent BMJ article on this, and another useful resource is on the London Deanery s website Potential bullying, harassment or undermining behaviours If you are upset by someone, or something they said to you, or did, mention things first to this person, as most perceived "offences" or slights are simple miscommunication; an apology and explanation is all that is necessary to restore team harmony. If this does not suffice then your supervisor should be the next port of call. The PGMDE does not condone these behaviours either from trainees towards colleagues, nor from trainers and other health care staff towards trainees or peers. Harassment can take various forms and may be directed against males or females, ethnic minorities or subgroups, towards people because of their age, sexual orientation, physical or mental disability, or some other characteristic. It may involve action, behaviour, comment or physical contact which is found to be objectionable by the recipient or which causes offence and can result in the recipient feeling threatened, humiliated, patronised or

10 isolated. It can also create an intimidating work environment. Harassment may be persistent or occur on a single occasion. It may be intentional or unintentional on the part of the perpetrator, but it is the impact of the behaviour on the recipient, and the deed itself, which constitutes harassment. There is a policy on the Deanery website entitled Dignity at work and the management of harassment and bullying policy

11 Resources A: The Deanery website The Oxford Deanery (PGMDE) website has a huge number of resources which trainees will find helpful. The URL is On the home page there is a What s New section to the right, with quick links to topics of current interest. To the left are the main contents tabs, which are described below. In the middle are quick links to Foundation, General Practice, Specialty and Dental sites.

12 The first tab on the left is About Oxford Deanery Here you will find another series of left sided tabs addressing Medical and dental policies: including study leave, working during pregnancy, equality& diversity, policy to support trainees who need additional help, statement on absence Deanery extranets Public Health PGMDE Newsletter published twice yearly Trust and PCT partners Useful web links SAS doctors and dentists Primary Care Quality management Clinical Simulation training: generic information about fellowships, rather than specialty specific information

13 Back on the home page, the sixth tab down on the left is for our renowned Career Development Unit ( rebranding as Professional Support Unit). This service can be accessed through self-referral, which may be useful if you are wondering whether you have entered the right specialty, or are considering alternative career options. Supervisors and TPDs may also refer trainees where they have identified a need which is outside their scope of expertise. As a matter of routine, any trainee who receives an outcome 3 at ARCP will be referred for extra assistance.

14 B: Additional Support for IMGs The BMA have published a very useful document entitled: "Working and Training in the United Kingdom National Health Service - a guide for International Medical Graduates (IMGs)", available through its website. The Deanery's Associate Director for Overseas Doctors (IMGs), Dr Amit Gupta has responsibility for matters specific to doctors who have qualified outside the UK, whether in the EEA countries or elsewhere, or whose nationality does not allow automatic right of permanent residence in the UK. These include: guidance regarding visa status career guidance in relation to overseas status advice in connection with training and non-training posts assistance with the Medical Training Initiative Scheme provision of induction for IMGs advice to doctors enquiring from overseas about postgraduate training support for refugee and asylum-seeking doctors in the Oxford area Both IMGs and their supervisors can contact Dr. Amit Gupta, the Associate Dean for IMGs through the Deanery for specific advice at amit.gupta@thamesvalley.hee.nhs.uk

15 C: ARCP outcomes and illustrations Outcome 1 Outcome 2 The trainee has achieved all the required technical and educational targets set for the period of training under review The trainee has almost achieved the targets set, and does not need to have the CCT date delayed. There may be a small shortfall in WPBA numbers, or behaviours flagged up through multi-source feedback which need modification. Exam failure may be such a target, unless the trainee is at a point in training where continued progress demands exam success, when an outcome 3 has to be issued. This outcome is NOT issued to Foundation Trainees at any time. Outcome 3 Outcome 4 Outcome 5 Outcome 6 Outcome 7 Outcome 8 This trainee has not achieved the training targets set for the period of training and will need more time in programme to achieve these targets. Training has already been extended by the maximum time permitted, but the trainee has still not achieved the educational targets required to progress further. Trainees who are leaving to pursue training in a different specialty etc should not be given this outcome, but 1, 2 or 3 as applicable. This trainee has not submitted the required evidence of training to the ARCP panel and a decision on their progress cannot be made. Evidence to support recommendation to revalidation process (Ie enhanced Form R) is included in material required to reach a decision, as this is included on the ARCP outcome form. The trainee is expected to produce the necessary evidence within two to six weeks of the date of the ARCP. This trainee has completed the entire training programme. This is given to Core Trainees at the end of programme and to Specialty Trainees who can then apply for the CCT This prefix is used for trainees in LAT or FTSTA posts. The suffix is.1,.2,.3 as above. This trainee is currently out of programme. This may be for research, specific clinical experience elsewhere, or as a career break.

16 D: Good Medical Practice: Indicators for assessors of trainees in Oxford PGMDE programmes (Core and Specialty). N.B. GP trainees are assessed by mapping against GP competence framework in the GPe Portfolio. This section contains the indicators your assessors use in secondary care. You might find it useful, particularly if you are required to either self rate as part of multi-source feedback, assess colleagues, or indeed reflect on situations where things didn t go as well as you had hoped / imagined. 1 Good Clinical Care History Taking 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). Examination Regularly fails to elicit physical signs of common clinical problems. Poor technique Frequently takes inappropriate short cuts when examining. Routinely fails to adequately explain procedures for intimate examinations. Cannot get patient co-operation for examination Investigations Regularly fails to order appropriate basic investigations Orders inappropriate, random unnecessary investigations, no thought given Often fails to perform investigations requested Fails to recognise normal and abnormal results of common investigations. Fails to ask for help or take appropriate action thereon. History Taking Clear history taking and communication with patients (carers). Uses open & closed questions appropriately Knowledge of alarm symptoms Appreciates the importance of clinical, psychological and social factors. Attempts to incorporate the patients (carers) concerns, expectations and understanding. Ability to take specialised histories: mental health, sexual health, from children / parents Examination Explains the examination procedure and minimises patient discomfort. Uses chaperones appropriately 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. Able to use instruments appropriately Investigations Requests common investigations appropriately for patients needs. Ensures investigations requested by team are completed 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. Understands local systems and asks for help appropriately from the relevant individuals. History Taking Accomplished, concise and focused (targeted) history taking and communication, including difficult circumstances (when English not the patients first language; confused patients or other psychiatric / psychological problem or special educational needs; deaf patients; child abuse / neglect. Examination Elicits signs appropriately and with attention to patient dignity. Skilled examination technique Teaches examination techniques. Able to examine children of all ages Investigations Arranges, completes & acts on investigations intelligently, economically & diligently Teaches F1 trainees about requests for, interpretation of and action on normal and abnormal results, for common investigations.

17 1 Good Clinical Care (2) Making a diagnosis / management plan Decisions frequently questionable Unable to make decisions or even make a working diagnosis Seeks help all the time Fails to involve patients in decision making Making a diagnosis / management plan Decisions generally satisfactory, though occasional inadequacies when under work pressure. Can make a sound diagnosis & produce safe, appropriate management plans Involves patients (& other professionals where appropriate aware of own skill & competency) Making a diagnosis / management plan Decision making satisfactory even when under pressure Shows intelligent interpretation of available data to form an effective hypothesis, understands the importance of probability in diagnosis Teaches F1 trainees on taking drug history, obtaining prescribing information and unambiguous prescribing. Describes the implications of pregnancy for safe use of commonly used drugs. Therapeutics 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. Record Keeping Keeps inaccurate or illegible notes with key information missing. Fails to sign entries Clinical Risk Management Lacks knowledge or understanding of common complications/side effects of treatments / procedures. Fails to identify signs that might indicate acute illness. Therapeutics 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. Understands the implications of religious beliefs Describes common drug interactions and allergic reactions. Record Keeping Routinely records accurate, logical legible history, which is timed, dated and clearly attributable. Medico legally sound 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. Clinical Risk Management Describes common complications and side-effects of treatments/procedures. Identifies and responds appropriately to patients with abnormal signs. Therapeutics Teaches on common drug interactions and management of allergic reactions. Ability to manage adverse drug reactions Record Keeping Teaches record keeping and intra/internet access skills to F1 trainees. Timely sending out of letters, discharge summaries. Structures letters to communicate findings and outcome of episodes clearly. Clinical Risk Management Appropriately discusses potential advantages and disadvantages of treatments/procedures with patients (carers). Teaches F1 trainees the appropriate

18 Does not seek help appropriately. Consistently fails to hand over. Recognises personal limitations and seeks help at an early stage. Communicates effectively to ensure continuity of care. 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. Involvement in critical incident analysis

19 Management of Acutely Ill patients (1) (i) Promptly assesses airway, breathing, circulation in the collapsed patient 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 multidisciplinary team Helps others stay calm (ii). Identifies & responds to acutely abnormal physiology 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 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 (iii) Where appropriate, delivers a fluid challenge safely to an acutely ill patient 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

20 Management of Acutely Ill patients (2) (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 (v) Requests senior or more experienced help when appropriate Permits problems to remain unresolved without seeking help Does not make decisions Seeks help all the time Over-confident No insight into own limitations 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 (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 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

21 Management of Acutely Ill patients (3) (vii) Obtains an arterial blood gas sample safely, interprets results correctly 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 ( ix) Safely uses common analgesic drugs 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

22 Management of Acutely Ill patients (4) (x) Explains the principles of managing a patient following self-harm Fails to consider possibility of self harm as cause for patient s presentation Omits appropriate investigations in patients who present after selfpoisoning Does not identify main monitoring goals Focussed history taking, including psychosocial causes requiring social services or police intervention Can access Toxbase Recognises need for involvement of Mental Health or more experienced personnel Demonstrates tolerance & understanding Protects and supports colleagues faced with an abusive patient Anticipates necessary steps to minimise risks to patient Can perform a mental state assessment (xi) Describes the management of a patient with an acute psychosis Fails to recognize features of psychosis Unaware of provisions of Mental Health Act Recognizes diagnostic features of psychosis Summons experienced help promptly can discuss safe administration of antipsychotic drugs Can discuss provisions of Mental Health Act Protects patient and colleagues from harm Can safely administer antipsychotic drugs Can initiate requirements of the Mental Health Act Considers underlying causes of psychosis (xii) Resuscitation training No certification or indication of not reaching the required standard Trained to Intermediate Life Support (ILS) standard. Trained to Advanced Life Support (ALS) standard. (xiii) 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.

23 Practical procedures High failure rate for simple procedures Hurts patients Ignores patients feeling and wishes Unsafe, prepares badly Unclear and worrying consent Muddled records For each procedure consider the following: 1. Knowledge of indications & contraindications 2. Explanation to the patient 3. Skill in gaining informed consent 4. Preparation of equipment 5. Preparation of the skin where appropriate 6. Positioning of the patient 7. Trainees hygiene where appropriate 8. Sharing of information and aftercare arrangements 9. Monitoring of the patient 10. Disposal of equipment 11. Documentation of procedure 12. Recording complications A model performer, seen as the example to follow. Contributes to the improvement of this aspect of the service Procedures Venepuncture, cannulation and venesection Central venous access 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, intravenous Urethral catheterisation, male and female Airway care, oxygen, nebulisers Respiratory function tests spirometry, peak flow rate Nasogastric tube insertion Urinalysis Proctoscopy Pleural aspiration Lumbar puncture diagnostic and therapeutic Skin suturing

24 2 Maintaining good medical practice Learning Lazy Never turns up to timetabled teaching sessions. Never voluntarily addresses gaps in their knowledge. When assessed for a second time on core knowledge has made no progress. Does not learn from mistakes No use of IT No personal learning plan No engagement with the e portfolio Inadequate number of SLEs/WPBAs Clustering of SLEs, over reliance on other trainees and allied health professionals Evidence / audit / guidelines Fails to show any knowledge or understanding of the evidence base in medical care. Avoids discussions with colleagues and patients (carers) in this area. Ignores or unaware of local guidelines/protocols. Has no knowledge of the audit cycle, or any recognition of its relevance to the assessment and improvement of clinical standards. Learning Hard working Regular and active contribution at organised teaching sessions. (>50% attendance) Uses sensible methods to build up their knowledge and skills. When assessed for a second time on core knowledge has a well formulated answer. Awareness of & can access electronic learning resources, databases,library Personal learning plan (reflective learner) Contemporaneous engagement with the e portfolio Prescribed number of SLEs/WPBAs Regular SLEs, mainly by consultants. Evidence / audit / guidelines Demonstrates a clear ability to critically appraise evidence base of medical care. Willing to discuss with colleagues and seeks to inform patients (carers) appropriately. Applies local guidelines/protocols. Understands the audit cycle and recognises how it relates to the improvement of clinical standards. Learning Exemplary Sets standards (>75% attendance at teaching sessions) Always has a well researched and organised approach to medical practice Reports own errors unhesitatingly & shows ability to learn from the experience Actively evolving personal learning plan (reflective self-directed learner) E portfolio exemplary organisation More than enough SLEs: with evidence that the curriculum is being systematically covered. Evidence / audit / guidelines 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 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.

25 3a Relationship with Patients A: patient centredness Discourteous, inconsiderate of patients views, preferences, cultural norms, dignity & privacy. Discusses one patient in front of another Unable to reassure, subject of repeated complaints. Discriminates against patients with disabilities Exploits relationships with patients to own advantage Has inappropriate financial or personal relationships with patients B: Communication Skills Consistently ignores, interrupts or contradicts patients A: patient centredness Respects the autonomy, dignity, confidentiality & privacy of the patient. Knowledge of limits to confidentiality Elicits the patients hopes, fears & expectations Relates to patients as equal partners, encourages questions Knowledge of children s rights B: Communication Skills Courteous, polite, communicates well with patients Demonstrates active listening & an ability to establish trust & rapport Able to break bad news to patients sensitively, & avoid conveying unrealistic optimism & undue pessimism Able to handle difficult patient interactions reassurance of the worried well, self discharge, complaints, do not resuscitate decisions Avoids jargon Telephone skills A: patient centredness Able to anticipate patients emotional & physical needs & plans to meet them Recognises & responds to their health beliefs B: Communication skills Explains clearly & checks understanding Able to apply models of the consultation appropriately Able to use language (and interpreters) appropriately; including communicating with patients with a disability e.g. deafness, visual impairment Respond to a patients understanding when breaking bad news or in discussion of life threatening or terminal illness Able to handle difficult patient interactions advance directives / living wills, organ donation, reporting patients to DVLA, compulsory detention under a section of the Mental Health Act

26 3b Relationship with Patients C: Patient Involvement: Ignores the patients best interests when deciding about treatment or referral Fails to obtain patients consent to treatment C: Patient Involvement: Explain the concept of risk to a patient Knowledge of legal framework of consent Apply the rules of consent gain consent for a variety of procedures Able to provide patients with understandable information Appropriate use of leaflets & written information D: Patient in Context Understanding of the impact of the patient as a person in a family E: Relationship with patients relatives / carers Can gain consent for a postmortem Able to break bad news to relatives sensitively Able to share decision making with relatives F: Health Promotion Give simple health promotion advice C: Patient Involvement: Respond to a patients understanding & attitude towards risk Ensure patients are able to make informed choices in health care decisions Respects the rights of patients to refuse treatments or tests Share an understanding of printed or internet information to enhance the patients concordance with management plans & prescriptions D: Patient in Context Gain understanding of physical, psychological, social & cultural dimensions of problems presented E: Relationship with patients relatives / carers Able to deal with patients who cannot give informed consent F: Health Promotion Assess an individuals risk factors & tailor make health promotion advice

27 4 Working with Colleagues Team working a. Communication Unable / refuses to communicate with colleagues Intolerant of other professional viewpoint b. Team Working Does not know the members of the team in which they work Does not partake in team meetings Does not know what skills other team members have Delegates tasks to other members of the team for which they don t have the appropriate skills Bullies or harasses her colleagues Can t work to a common goal selfish, inflexible c. Referral and handover Doesn t pass on information to colleagues about at-risk patients Dismisses patients requests for a second opinion Refers patients for care which they should be able to provide Does not provide information in a referral that enables the second opinion to give appropriate advice a. Communication Listens to colleagues, accepts the views of others Able to communicate effectively with other members of the team & interprofessional communication (nursing staff / social services / coroner ) Able to communicate effectively with other teams (hand over) Able to communicate effectively with GP colleagues -(telephone referrals on take ) -written communication (discharges) Able to present a case clearly b. Team working Attends & contributes to team meetings Knows how to contact team outside meetings Ensures satisfactory completion of reasonable tasks by the end of the day / shift Arranges cover for duties with colleagues Flexible ability to change in the face of a valid argument a. Referral and handover Knowledge of roles & responsibilities of team members & other professionals in patient care, able to involve them in care appropriately Accompanies referrals with the information needed by the second opinion to make an appropriate and efficient evaluation of the patients problem a. Communication Able to bring together views for a common goal b. Team Working Anticipates problems for next shift & takes pre-emptive action Able to lead and facilitate team meetings Able to facilitate change Team goal is put before personal agenda Able to facilitate the development of colleagues a. Referral and handover Where appropriate feeds back to specialists views on the quality of their care Uses handovers systematically for training other doctors and nurses.

28 5 Teaching and Training Teaching No interesting teaching, mentoring and/or supervising more junior doctors / medical students Few teaching skills Presentations Absent themselves at the last minute, poor preparation and structure Teaching Beginning to develop teaching skills, supervising more junior doctors & medical students Presentations Gives presentations to small groups e.g. journal club Teaching Actively involved in teaching, enthusiastic, able to motivate. Clear demonstration of teaching skills Presentations Confident, embraces new technology Able to present material using different media