COMPETENCY BASED CURRICULUM FOR SPECIALIST TRAINING IN PSYCHIATRY Dr V M Aziz- Old Age Psychiatry Conference Bristol March 2017
AIM To improve recruitment and workforce in old age psychiatry it is important that we develop our curriculum to attract more trainees, to reflect the changing demographics and shape of old age psychiatry We need to be adaptable and integrated in our approach to the care and training
THE PURPOSES OF THE CURRICULUM To outline the competencies that trainees must demonstrate and the learning and assessment processes that must be undertaken for an award of a Certificate of Completion of Training (CCT) in Old Age Psychiatry.
THE ADVANCED TRAINING PROGRAMME Completion of a minimum of 36 months of advanced training in one of the six GMC approved psychiatric specialties from levels ST4 to ST6. Trainees must achieve the competencies as set out in the appropriate advanced curriculum and achieve an ARCP outcome 6 on completion of the training programme.
NEED FOR CHANGE The current Curriculum was developed in 2010 and updated in 2012. The GMC in 2010 also produced guidance on Treatment and care towards the end of life: good practice in decision making and in 2012 Leadership and management for all doctors. In 2014, the Old Age Faculty produced its new criteria that was approved by the College and the GMC after extensive consultations. In 2016, the GMC approved the new Liaison Curriculum in both Adult and Old Age psychiatry. In 2016, the GMC has asked the College to map all curricula to the GMC Good Medical Practice. In 2016, the Royal College of Psychiatrist has set up the Gatsby/Wellcome Neuroscience Project Implementation Group to ensure that neuroscience is reflected in the curriculum and examination syllabus.
NEED FOR CHANGE 2 In 2016, OP100 report Improving the physical health of adults with severe mental illness: essential actions was published by the Academy of Medical Royal Colleges. From 1 July to 27 September 2015, the GMC and the Academy of Medical Royal Colleges consulted jointly on a draft framework for generic professional capabilities (GPCs). GPCs will act as an indicative curriculum framework and will for the first time explicitly state educational outcomes required of all postgraduate medical curricula. On 4 February 2016 the Strategy and Policy Board considered and approved the current draft of the framework. Now, the College is asked to map curricula to the new capabilities.
DEVELOPMENT OF CURRENT CURRICULUM We have reviewed the current curriculum and mapped it to GMC Good Medical Practice in June 2016. We have reviewed GMC approved curricula for related specialties such as British Geriatric Society, Palliative care, Medicine, Neurology and also the Neuropsychiatry curriculum within the College website etc. We have reviewed GMC End of life and Critical care, Leadership and Management for all doctors, GMC GPC and impact analysis process. We have consulted with colleagues from BGS, Palliative Care, Management, Neuropsychiatry etc.
DEVELOPMENT OF CURRENT CURRICULUM 2 The Curriculum was reviewed by patients and carers group via the Alzheimer s Society and Age UK. We have reflected the various discussion, recommendation, and work by the Old Age Faculty, Curriculum and Assessment Committee, and the Education Training Committee. Old Age Faculty Executive granted approval in the Executive meeting on 24 th November 2016. The Curriculum was distributed to the PTC (trainees) for any comments on 30 th September 2016.
THE NEW CURRICULUM THE COMPETENCIES IN THE CURRICULUM ARE ARRANGED UNDER THE GENERIC PROFESSIONAL CAPABILITIES HEADINGS Domain 1: Professional values and behaviours Domain 2: Professional skills Domain 3: Professional knowledge Domain 4: Capabilities in health promotion and illness prevention Domain 5: Capabilities in leadership and team working Domain 6: Capabilities in patient safety and quality improvement Domain 7: Capabilities in safeguarding vulnerable groups Domain 8: Capabilities in education and training Domain 9: Capabilities in research and scholarship
DOMAINS 1-3 Domain 1: Professional Values and behaviour. Demonstrate appropriate personal and professional values and behaviours. Domain 2: Professional Skills. Practical skills and capabilities that are fundamentally important to safe and effective patient care. Domain 3: Professional Knowledge. Awareness of and adherence to the GMC s professional requirements
INTENDED LEARNING OUTCOME (ILO) 1 The doctor will be able to perform specialist assessment and management of patients and document relevant history and examination on culturally diverse patients to include: Comprehensive clinical history Mental state examination Constructing formulation Differential diagnosis Recommending relevant investigations and treatment in the context of the clinical management plan
Knowledge Awareness of clinical evidence-based practice, basic neuroscience and outcome measures in old age Demonstrate an understanding of community assessment and management and work effectively in a variety of settings e.g. outpatient, day patient, residential and inpatient facilities with older patients Understand the principles of understand the principles of appropriate resource utilization and its application in old age psychiatry such as: Achieve health and wellbeing with the public, patients and professionals as equal partners through co-production; Care for those with the greatest health need first, making the most effective use of all skills and resources; Do only what is needed, no more, no less; and do no harm. Reduce inappropriate variation using evidence based practices consistently and transparently. CBD, Supervisors report, Reflection, Selfdirected learning ACE, Mini-ACE, CBD, Mini-PAT CBD, Reflection, DONCS, Self-directed learning and Supervisor report Skills Elicit information required for each component of a psychiatric history; in situations of urgency, prioritise what is immediately needed; and gather this information in difficult or complicated situations Able to use neuroscientific basis and outcome measures in old age psychiatry Assess and diagnose patients with multiple and complicated pathologies Take a history from patients and others that include factors relevant for diagnosis and management of an older patient including those with intellectual disabilities/autism Make a mental state examination with detailed assessment of cognitive function Able to identify psychopathology in all clinical situations, including those that are urgent and/or complex Demonstrates capability in taking decisions about access to medical care and pathways to recovery out of medical care Formulate comprehensive person-centered management, treatment and interventions on the basis of a completed psychiatric assessment (history, examination and diagnosis) Use appropriate investigations in old age psychiatry, including neuropsychology and neuroimaging Able to obtain consent to treatment, safely prescribe wisely, monitor and, where appropriate, deliver the full range of physical treatments that are required to treat the psychiatric problems that are experienced by older adults ACE, Mini-ACE, CBD ACE, Mini-ACE, CBD ACE, Mini-ACE, CBD, ACE, Mini-ACE, CBD ACE, Mini-ACE, CBD ACE, Mini-ACE, CBD ACE, Mini-ACE, CBD, CP ACE, Mini-ACE, CBD, CP CBD, CP, Mini-PAT, supervisors report CBD, CP, Mini-PAT, supervisors report Attitudes demonstrated through behaviours Display an awareness of complex needs Professionalism, person-centered care and prudent care ACE, Mini-ACE, CBD, Mini-PAT ACE, Mini-ACE, CBD, Mini-PAT, Reflection, Caselog
INTENDED LEARNING OUTCOME (ILO) 2 The doctor will develop the ability to carry out specialist assessment and treatment of patients with chronic and severe mental disorders and to demonstrate effective management of these disease states. This will include both functional and organic mental disorders, and their biological neuroscience basis.
ILO3 Neuropsychiatry and neuroscience relevant to Old Age Psychiatry. Understanding of neurobiological and neuroscience basis of psychiatric and neurological disorders, neuroimaging, EEG and other neuropsychological investigations and their interpretation and co-existing neurological disorders that will affect management including psychopharmacology. Principles of treatment of major neurological disorders and neuropsychiatric complications of such treatments, understanding of drug interactions between psychiatric and neurological treatments including psychotropic medication use in neuropsychiatric disorders.
Knowledge Behavioural, cognitive and psychiatric presentations of acute & chronic/ progressive neurological disease, brain lesion or injury to CNS. Effect of neuropsychiatric syndrome and neurological symptoms on QoL and function of the patient and burden on the carer. Understanding of neurobiological and neuroscience basis of psychiatric and neurological disorders, neuroimaging, EEG and other neuropsychological investigations and their interpretation and co-existing neurological disorders that will affect management including psychopharmacology. Principles of treatment of major neurological disorders and neuropsychiatric complications of such treatments, understanding of drug interactions between psychiatric and neurological treatments including psychotropic medication use in neuropsychiatric disorders. ACE, Mini-ACE, CP, CBD. ACE, Mini-ACE, CBD. ACE, Mini-ACE, CBD. ACE, Mini-ACE, CBD Skills Neuropsychiatry assessment focussing on neurological illnesses or injury to CNS and its neurocognitive, neurobehavioral or neuropsychiatric manifestation Assessment of medically unexplained neurological symptoms. Formulation (bio-psycho-social) incorporating developmental, neurological, psychological, and social factors in predisposing, precipitating and perpetuating and protecting against various neuropsychiatric disorders. Common psychiatric disorders in neurological and neurosurgical patients; use screening instruments and be aware of advantages and disadvantages of them. Monitor compliance with treatment and manage noncompliance and contribute to the care plan of patients with neurological disorders who show problem behaviour. Recognise and identify neurological manifestations and complications of psychiatric treatment in patients with NPD and advice patients and professionals in order to minimise their occurrence and severity. Ability to work jointly with neurology colleagues. Attitudes demonstrated through behaviours Demonstrate professional attitude in dealing with difficult situations. Display willingness to seek advice and supervision for complex patients. Be willing and available to provide assessments and to supervise and help other professionals in their assessments. Demonstrate ongoing acquisition and practice of relevant skills. ACE, Mini-ACE, CBD. ACE, Mini-ACE, CBD, CBD, Mini-ACE, ACE CBD, Mini-ACE, ACE CBD, Mini-ACE, ACE CBD, Mini-ACE, ACE CBD, Mini-ACE, ACE, supervisor report Supervisors report, ACE, Mini-ACE, CBD
ILO4 Based on a comprehensive psychiatric assessment, demonstrate the ability to comprehensively assess and document patient s potential risks for self-harm or harm to others. This would include an assessment of risk, knowledge of involuntary treatment standards and procedures, the ability to intervene effectively to minimise risk and the ability to implement prevention methods against self-harm and harm to others. This will be displayed whenever appropriate, including in emergencies. The doctor will demonstrate practical knowledge of the relevant legislation of the different jurisdictions of the various home nations and its relevance to Old Age Psychiatry such as mental health legislations (MHA, MCA, DoLS), Mental Health Measure (Wales) 2010, Mental Health (Care and Treatment) Scotland Act 2003, the Adults with Incapacity (Scotland) Act 2000 and the Adult Support and Protection (Scotland) Act 2007) and the broader legal framework (e.g. Human Rights Act and European Convention of Human Rights, Equality Act).
ILO5 Based on the full psychiatric assessment, demonstrate the ability to conduct therapeutic interviews; that is to collect and use clinically relevant material. The doctor will also demonstrate the ability to conduct a range of individual, group and family therapies using standard accepted models and to integrate these psychotherapies into everyday treatment, including biological and socio-cultural interventions. The following Old Age Faculty guidelines should be considered: Trainees should discuss with their local psychotherapy tutors and TPDs what the expectations are in regards to local ARCPs in terms of psychotherapy requirements (including required relevant WPBAs such as SAPE). It should not be expected by supervisors that time should be taken out of special interest or research sessions to undertake further psychotherapy training (although of course trainees may choose to use their session for this if suitable experiences are available). This requirement should be discussed with local clinical and educational supervisors at the start of posts. Local psychotherapy tutors and TPDs must be able to furnish higher trainees with suitable experiences to achieve these competences. There is no requirement for psychotherapy training at higher level to be old-age specific. Whilst it would be preferable for older adult specific psychotherapy experience to be undertaken, the faculty recognises that services for OA psychology/psychotherapy are by no means uniform. Trainees should therefore avail themselves of any available psychotherapy experience, which may include experience of chairing Balint groups, facilitating CST where available, family therapy and reflecting teams etc as well as more traditional experiences such as long and short cases with appropriate supervision.
ILO6 Develop the ability to carry out comprehensive assessment and treatment of patients with physical health problems. Assess the physical health of patients on admission and at appropriate intervals thereafter, including the assessment for the presence or absence of illness, injury or disability, and any of the following receiving a medical history, making a functional enquiry, undertaking a physical examination, arranging blood tests and other investigations for the presence of an underlying physical cause, as necessary. Recognition of acute illness (the deteriorating patient ): this includes measuring physiological parameters, using NEWS (National Early Warning Score) system, making the first response to an acute illness, and using effective communication and resuscitation techniques. Monitor and provide treatment for long-term conditions in collaboration with specialists including the awareness of all medicines prescribed for the patient.
ILO7 Develop the ability to ensure good practice when providing treatment and care for patients who are reaching the end of their lives. Knowledge of major cultural and religious customs which relate to medical practice, dying and bereavement. Recognise the role of care pathways in improving care of the dying. Providing ongoing care for dying patients and their families together with Palliative Care team. Advance Care Planning (ACP) understanding Advance Decisions to Refuse Treatment, and advance care plans generally and understanding its place in early dementia (as well as the role of best interest s decisions in later dementia).
ILO8 Use effective communication with patients, relatives and carers. This includes development of therapeutic alliance and the ability to conduct interviews in a manner that facilitates information gathering and the formation of therapeutic alliances. Establish and maintain working relationship with relatives and carers and take into account their needs. Use effective communication with colleagues and demonstrate the knowledge, skills and behaviours to manage time and problems effectively. Prepare and deliver reports for different jurisdictions of the various home nations such as Mental Health Tribunals, Inquests and Fatal Accident Inquiries (FAIs), Managers Hearings, Coroners Courts and Courts of Law. Understand the roles and responsibilities of an expert witness and the nature of potential or actual conflicts of interest. Work in collaboration with patients and the multi-disciplinary team to enable safe and positive decision-making.
ILO9 Develop professional values and behaviours. The habits of lifelong learning by keeping abreast of neuroscientific developments and basis for mental disorder in old age, especially dementia. Doctor patient relationship by fostering positive and professional attitudes to old people and act as an advocate for their needs in the health and social care system. The doctors will ensure that they act in a professional manner at all times and recognise own limitations.
DOMAIN 4: CAPABILITIES IN HEALTH PROMOTION AND ILLNESS PREVENTION ILO10: To develop an understanding and awareness of health promotion and illness prevention. Be aware of and understand of the relationship of the physical, economic and cultural environment to health. Understand basic principles of public health, including population health, promoting health, nutrition, exercise, vaccination and preventing illness. Be aware of health promotion and disease prevention strategies, including physical activity, diet, oral health, sexual health and smoking cessation, prevention of falls, immunisation and infection control measures. Be aware of screening tools for the assessment of physical health risks (e.g. venous thromboembolism risks, tissue viability, nutritional risk factors and cardiovascular risks).
DOMAIN 5: CAPABILITIES IN PATIENT LEADERSHIP AND TEAM WORKING ILO 11 ILO 12 ILO13 ILO 14
ILO11 To demonstrate the ability to work effectively with colleagues, including team working. Maintain and apply a current working knowledge of the law as it applies to working relationships. Demonstrate an understanding of the responsibility of the team with regard to patient safety. Demonstrate an understanding of how a team works and develops effectively and understanding of time management, values based practice and information management. Be able to work with service managers and commissioners and demonstrate management skills such as understanding the principles of developing a business plan.
ILO12 Integrated care. Develop a good understanding of interfaces between old age psychiatry and other psychiatric specialties, other branches of medicine and other service providers. Understand delivery of health and social services with intensified community-based interventions for frail elderly persons. Demonstrate an understanding and knowledge of models of integrated working across health and social care in the community, and in hospital or residential settings. Demonstrate understanding of the principles of leadership and management across sectors to deliver effective patient care. Ability to contribute to mapping and development of effective integrated services for older people with dementia, psychiatric illnesses and other physical health co-morbidities. Develop and maintain effective relationships with primary care, local authority and other care providers, for example the voluntary sector, leading to effective referral mechanisms and educational systems.
ILO13 Management. Demonstrate an understanding of effective resource management. Demonstrate understanding of commissioning services for the wider population of patients and how finance being delivered differently to Trusts/Health Boards across the different nations. Demonstrate understanding of how finances are allocated and managed in the local services and demonstrate knowledge of how management processes work and how they affect the delivery of patient care. Understand the role of a consultant in leading and influencing service provision and development. Contribute to waste minimisation, improve services and promote the effective use of resources by taking financial responsibility for delivering services at appropriate level to their role. Provide the best service possible within the resources available. Make sure that decisions about setting priorities that affect patients are fair and based on clinical need and the likely effectiveness of treatments, and are not based on factors that may introduce discriminatory access to care.
ILO14 Develop appropriate leadership skills. Demonstrate an understanding of the differing approaches and styles of leadership and of the role, responsibility and accountability of the leader in a team. Understand and contribute to the organization of urgent care in the locality. Demonstrate an understanding of the structures of the NHS and social care organisations. Demonstrate an understanding of organisational policy and practice at a national and local level in the wider health and social care economy. Demonstrate an understanding of the principles of change management. Demonstrate a range of appropriate leadership and supervision skills including: Coordinating, observing and being assured of effective team working; Setting intended learning outcomes; Planning; Motivating; Delegating; Organising; Negotiating; Example setting; Mediating / conflict resolution; and Monitoring performance.
DOMAINS 6 & 7 Domain6: Capabilities in patient safety and quality improvement Domain 7: Capabilities in safeguarding vulnerable groups
ILO15 Develop the ability to conduct and complete quality assurance and quality improvement project in clinical practice. Demonstrate a knowledge of different quality assurance/ improvement/ audit methods. Demonstrate a knowledge of obtaining feedback from patients, the public, staff and other interested groups. Undertake a quality assurance/ improvement/ audit project of at least one area of practice in old age psychiatry. Be able to measure changes in practice and to effectively apply audit principles to own work, to team practice and in a service wide context, including to relevant organisational and management systems.
ILO16 To develop an understanding of the implementation of clinical governance. Demonstrate a knowledge of relevant risk management issues; including risks to patients, carers, staff and members of the public. Demonstrate a knowledge of how healthcare governance influences patient care, research and educational activities at a local, regional and national level. Demonstrate a knowledge of safeguarding laws and regulations for vulnerable groups including domestic violence and abuse in the elderly. Develop and adopt clinical guidelines and integrated care pathways. Report and take appropriate action following serious untoward incidents. Assess and analyse situations, services and facilities in order to minimize risk to patients, carers, staff and the public. Monitor the safety of services and appropriately refer to forensic services when there are significant risks identified.
DOMAIN 8: CAPABILITIES IN EDUCATION AND TRAINING ILO17: To develop the ability to teach, assess, supervise and appraise. Demonstrate an understanding of the principles of different learning theories such as adult learning and experiential learning. Demonstrate deep knowledge of the subjects they teach and of different teaching techniques and demonstrate how these can be used effectively in different teaching settings relevant to Old Age Psychiatry, in a hospital or community based clinical setting. Use appropriate, approved assessment methods; give feedback in a timely and constructive manner, and provide supervision to others undertaking these tasks. Demonstrate an understanding of the principles of appraisal and the professional obligations placed on doctors by the GMC and the importance of appraisal for the doctor s professional development. Demonstrate a knowledge of the principles of clinical supervision and their practical application (NB this competency applies across all the intended learning outcomes and subjects of this domain).
DOMAIN 9: CAPABILITIES IN RESEARCH AND SCHOLARSHIP ILO18: To develop an understanding of research methodology and critical appraisal of the research literature. Demonstrate an understanding of advanced research methodology including both quantitative and qualitative techniques. Demonstrates an understanding of the research governance framework including the implications for the local employer (NHS Trust, health boards or equivalent) of research. Demonstrates an understanding of the work of research ethics committees and is aware of any ethical implications of a proposed research study. Demonstrate an understanding of how to design and conduct a research study including the use of appropriate statistical methods and the ability to write a scientific paper. Demonstrate an understanding of the principles of critical appraisal. Demonstrate an understanding of the principles of evidence-based medicine, including the educational prescription. Demonstrate knowledge of how to search the literature using a variety of databases. Able to communicate clearly and concisely with non-medical professionals, i.e. other members of the multidisciplinary team, and staff from other agencies, regarding the importance of applying research findings in everyday practice. Able to translate research findings to everyday clinical practice. Inclusion of research findings in case summaries and formulations and in letters to medical colleagues. Able to appreciate the scientific unknowns in the relevant field psychiatric practice.
THE SUGGESTED MINIMUM NUMBER OF WPBAS FOR TRAINEES IN OLD AGE PSYCHIATRY TRAINING WPBA Minimum number required per year CT1 CT2 CT3 ST4 ST5 ST6 ACE 2 3 3 2 1 1 mini-ace 4 4 4 2 2 2 CbD 4 4 4 6 4 4 mini-pat 1 1 1 1 1 1 SAPE 1 1 1 1 1 1 AoT * * * 2 2 2 DONCS * * * 3 3 3 CBDGA 2 0 0 * * * JCP 1 1 1 * * * CP 1 1 1 * * *
SUPERVISED LEARNING EVENTS (SLE) A SLE is an interaction between a trainee doctor and a trainer which leads to immediate feedback and reflective learning. They are designed to help trainee doctors develop and improve their clinical and professional practice and to set targets for future achievements. SLEs are not assessments but they are used for feeding back on progress (formative). However, the clinical supervisor s end of placement report, which forms part of the assessment will draw upon evidence of engagement in the SLE process but not the SLE outcomes. SLEs are not assessments; trainee doctor cannot pass or fail. It is important to remember that assessment facilitates learning and this can be done via feedback, reflection and planning further learning.
SLE The topics covered by SLE should reflect and map the Curriculum. As the aim of SLEs is for the trainee doctor to learn and develop, ideal topics should be those which the doctor finds challenging, difficult or they wish to improve upon. It is the trainee doctor s responsibility to arrange an appropriate range as well as the required number of SLEs. Discussion should include the management of long-term aspects of patients conditions.
The Old Age Faculty wanted to provide a curriculum that is attractive and reflective to the changing needs of old age psychiatry
REFERENCES: The GMC (2010). Treatment and care towards the end of life: good practice in decision making. www.gmc-uk.org/end_of_life.pdf_32486688.pdf The GMC (2012). Leadership and management for all doctors. http://www.gmcuk.org/leadership_and_management_for_all_doctors_final.pdf_47234529.pdf The GMC (2016). Framework for generic professional capabilities (GPCs). http://www.gmc-uk.org/education/23581.asp The Royal College of Psychiatrist (2016). The Gatsby/Wellcome Neuroscience Project. http://www.rcpsych.ac.uk/pdf/neuroscience_presentation_june_2016_wb.pdf the Academy of Medical Royal Colleges (2016). OP100 report Improving the physical health of adults with severe mental illness: essential actions. http://www.rcpsych.ac.uk/files/pdfversion/op100.pdf