Higher specialist training in rheumatology

E. Paice and J. Dacre

Higher specialist training in rheumatology, as in other specialties, has recently been subjected to major reforms. In the mid 1990s, Sir Kenneth Calman, then Chief Medical Officer, set out to bring the British system of specialist training into line with the requirements of the European Medical Directives. He chaired a working party that recommended combining the registrar and senior registrar grades into a unified specialist registrar (SpR) grade and defining the entry criteria, curriculum and minimum training period for each specialty. Successful completion would lead to a certificate and admission to the specialist register [1]. Features of the new system were set out in A guide to specialist registrar training [2] and included educational objective-setting, training agreements and induction at the start of each placement, rotational placements designed to offer specified experience, regular feedback and annual assessments. Transition to the new system for the medical specialties took place in 1997.

Entering specialist training

The essential criteria for entry to the SpR grade in rheumatology are (i) 2 yr of general professional training in approved senior house officer posts, and (ii) the MRCP or its equivalent. Previous experience in rheumatology is desirable. Having satisfied the entry criteria, the candidate must gain a place on a regional programme, in open competition, and be awarded a National Training Number (NTN) in rheumatology. Promotion to the SpR grade in rheumatology is swift in comparison with other medical specialties. Unlike in cardiology and neurology, there is no need to have a higher degree to compete successfully. Competition is strong, however, and few trainees are able to enter the specialty late, as a second choice.

The NTN acts both as a passport to training for the trainee and as a means of manpower control for the NHS. The term ‘National’ is something of a misnomer as NTNs are allocated by region and do not give trainees an automatic right to transfer their training to another region. Gaps in a programme—for example, if an SpR is taking time out to do research—may be filled either with overseas doctors on fixed-term training appointments or with locum appointments for training. Such appointments do not confer an NTN, but the trainee may be able to count the time for training purposes if he or she is subsequently able to obtain an NTN.

The curriculum

The Specialist Advisory Committee for Rheumatology has developed a written curriculum [3] detailing the knowledge, skills and attitudes the SpR must attain in order to be declared fit for the award of the Certificate of Completion of Specialist Training (CCST). The duration of training has been agreed as 4 yr for rheumatology alone and 5 yr if certification in general (internal) medicine is also desired. Early versions of the curriculum read like chapter headings in a rheumatology textbook. The most recent version is much more focused on the knowledge, skills and attitudes every rheumatologist should have mastered by the end of training. The curriculum addresses the generic competencies that all doctors should have, as outlined in Good medical practice [4], the general clinical competencies needed by all physicians, and the specialist competencies that are required of a consultant rheumatologist [5, 6].

The educational framework

One of the benefits of the reforms was the introduction of structured training. This means that the job content is organized so as to deliver the curriculum and that trainees are moved on when they have achieved their educational objectives. In order to deliver structured training, an educational framework is required in each placement.

Induction
The importance of a good induction to each new post, both to the hospital as a whole and to the individual department, cannot be overestimated. The days when a new registrar could be expected to set to work in an out-patient clinic immediately on arrival are over. Now it is usual for routine duties to be cancelled for the first day or days of a placement, while the trainee is introduced to key colleagues, shown around the department and taken through policies and protocols.

Setting educational objectives
Soon after starting a new placement, the educational supervisor should sit down with the trainee and discuss what elements of the curriculum the trainee is expecting to cover during the placement and what learning opportunities will be available. They also agree what will be expected of the trainee in terms of attendance at educational events, involvement in audit or research projects and uptake of study leave. The results of the discussion should be written down in a training agreement or educational contract, signed by both trainer and trainee, and should be referred to at appraisal.

Training record
The Joint Committee on Higher Medical Training issues a training record to all SpRs enrolling in a medical specialty, which provides the template for a log of procedures done, cases managed, courses attended and other relevant achievements and experiences. Consultant supervisors should make a point of going through the training record during appraisal, using it as the framework for an educational dialogue.

Supervised experience
While the reforms moved training away from the apprenticeship model, ‘learning by doing’ is still the cornerstone of training. In a large regional survey of trainees before and after the Calman reforms, the two factors most strongly associated with satisfaction with their post were the hands-on experience acquired and the quality of supervision by consultants [7]. The content of a training post varies with the size of the department, its case mix and the number of specialist services it provides. A nationwide survey of rheumatology SpRs was carried out in 1998 on behalf of the British Society for Rheumatology Education Committee, and attracted 93 responses (response rate 60%). This revealed that most trainees were attending between three and four out-patient clinics per week, usually organized as separate lists for consultants and trainees. Less than a quarter felt they were supernumerary in clinic. On average, each SpR saw four new patients and 10 follow-up patients per clinic. In over 80% of cases, respondents reported easy or very easy access to consultant advice during clinic, if needed, although over half said they rarely discussed clinic cases with the consultant and only a third reported time set aside at the end of the clinic for the purpose of discussion. About 40% of respondents also attended combined paediatric, orthopaedic and/or osteoporosis clinics. Ward-based experience varied widely according to the type of post and whether there were general medical duties.

Formal education
The provision of in-house educational activities, such as departmental research or audit meetings, radiology or pathology meetings, and journal clubs, is a requirement for Royal College approval of a training post. The rheumatology survey showed that SpRs attended an average of 2 h a week of such activities. In addition, the introduction of regional training days has been a feature of most SpR programmes since the introduction of structured training [8]. The frequency with which these events occur varies from region to region, but 1 day a month is a common pattern. They offer a range of activities from hands-on skills training to visiting speakers, and are also valued by trainees as an opportunity to meet their colleagues from other hospitals and compare notes.

Study leave
SpRs have a study leave allocation of up to 30 days a year, subject to the exigencies of the service, and funding for course fees and expenses amounting to an average of £800 per year. This allows the trainees to attend meetings organized by the British Society for Rheumatology and other short courses. In-house activities do not count against study leave allowance, but regional training days usually do. The study leave budget comes from the postgraduate dean and is usually managed by the hospital clinical tutor or director of medical education.

Appraisal
Feedback is an essential element in learning. Without this it is difficult for learners to know when they are getting things right or wrong. In medicine, the tradition had been for the consultant supervisor to give trainees immediate feedback when things went wrong, but to take what they did right for granted. Silence was expected to be taken as approval, or at least as absence of disapproval. This approach fell into disrepute in the early 1990s as organizations outside medicine recognized the importance of regular appraisal against agreed objectives. Translated into educational terms, this means a two-way discussion about how the trainee is progressing with respect to the educational objectives set at the start of the post; what has gone well and what could have gone better; what the obstacles have been and how the training environment can be made more supportive. New or more focused objectives are usually agreed and written down. Appraisal should be a confidential and supportive discussion, with only the fact that the meeting took place and the objectives that were set being recorded.

Assessment
The assessment of competence and/or performance is usefully distinguished from appraisal in that it is objective and based on agreed standards, and its outcomes are a matter of public record. Some Royal Colleges have an examination that must be passed during the course of SpR training if the CCST is to be awarded. In rheumatology, as in the other medical specialties, there is no compulsory examination after the MRCP. Instead, workplace assessments are carried out by the educational supervisor and others in a supervisory role, and the results are reviewed and recorded annually by a regional panel, known as a Record of In-Training Assessments (RITA) panel. This panel checks whether the documentary evidence that assessments have taken place is adequate and whether this evidence indicates satisfactory progress of the trainee. If it does, he or she may progress to the next year of training, and if not the trainee may have to repeat the year, or part of it, with a consequent delay in their CCST date. The robustness of this process and in particular the validity of the methods for carrying out workplace assessments [9] are a matter of concern for postgraduate deans and Royal Colleges alike. Currently, the Royal College of Physicians is working to include a suggested assessment strategy against every element of the curriculum.

The setting for training

The practice of rheumatology is increasingly moving out of the ward into the clinic, and out of the hospital into the community. Training must reflect this shift and attention must be paid to ensuring that time and space are allocated for training in these settings [10]. The heavy service demands on trainees in the UK system [11] and the reliance of hospitals on their contribution to out-of-hours cover often militates against effective and efficient training. There is a danger that the implementation of the European Working Time Directive will further erode training time if the hours that are reduced are the daytime weekday hours when the ambulatory care service is being delivered. Trainees must have the opportunity to experience every step of the patient's journey and must learn to work effectively with all the colleagues who impact on the patient en route.

Research and higher degrees

The curriculum lists an understanding of research methodology and critical appraisal skills amongst the attributes that should be gained by the end of the training programme. Neither time out for full-time research nor a higher degree is necessary for satisfactory completion of training. However, many trainees are able to find the funding for a full-time research project leading to an MD or PhD degree. Some undertake an MSc, often on a day-release basis, while continuing to train. In the rheumatology survey described above, 36 (39%) respondents had already obtained or were currently working towards a higher degree (15 PhD, 15 MD, six MSc) [12] The benefits of the various higher degrees have been reviewed. Only a third of those with no research experience had no plans to take time out for full-time research in the future. One of the benefits to trainees of the reforms has been the opportunity to take time out of the SpR programme for research, secure in the knowledge that the NTN represents a passport to training and employment when the research is completed. Usually from 1 to 3 yr out in research is allowed by the postgraduate dean, of which 1 yr can count towards training to CCST. The new Clinical Scientist Award system allows a longer period of combined clinical and scientific training for a highly select few. Details of the awards, which are gained in national competition, can be found at the following web site: http://www.doh.gov.uk/research.

General medical duties

Trainees have the choice whether to aim for accreditation in rheumatology alone or in both rheumatology and general (internal) medicine. The latter option takes 1 yr longer. In our survey, 60% of respondents were aiming for CCST in rheumatology alone. Trainees in programmes based in London and the Southeast were more likely to undertake a dual CCST and to want a consultant post with general medical duties than those from other parts of the UK. The proportion of general medicine that can be included within a post without compromising rheumatology training is a question currently exercising the Rheumatology Specialist Advisory Committee.

What makes a good job?

Most of the respondents in our rheumatology survey were satisfied with their current post. Eighty per cent rated it as 3 or 4 on a four-point scale, where 1 was poor and 4 was very good. Factors correlated with a favourable overall rating were the quality of training in clinic, ease of consultant access in clinic, time set aside at the end of a clinic to discuss patients, access to an orthopaedic combined clinic and total hours of formal teaching per week. Factors that were not correlated with the overall rating included attendance at other specialist clinics, supernumerary status in clinic, the average number of new or follow-up patients seen in clinic and the number of in-patients managed.

Innovations in training

With the changes in current medical school curricula throughout the UK, knowledge of educational theory is percolating into the postgraduate arena [13]. One of the effects of this has been to change the way that teaching programmes have been run. Trainees are now responsible for stating and addressing their own educational needs. They are more likely to be learning in smaller groups with less emphasis on didactic lectures, and will use small-group methods such as self-directed learning and problem-based learning to help with the learning process.

With the development of the NHS Plan, there is an increase in the importance of training in communication skills and the attitudes that befit a consultant rheumatologist. These areas are being added to local curricula and trainees are now learning about teaching skills, appraisal skills and managing life in the NHS, among other areas. There is also a rheumatology curriculum available on the internet. There is increased emphasis on inter-professional training and working, although there is as yet not a huge body of evidence that it is effective [14]. This is an area particularly suited to rheumatology, where interaction with allied health-care professionals is vital to the effective management of our patients. The doctor–patient relationship in rheumatology is evolving into one of empowerment rather than direction, and training programmes are increasingly finding that working with patients is an effective way of learning.

Standardised Patient Programmes have been running for some years and more recently the Patient Partner Programmes have been developed in rheumatoid arthritis, where patients with a condition are trained to teach doctors about that condition, including clinical examination.

Finally, it is an adage in medical education that assessment drives learning. At the moment there is no compulsory exit examination for rheumatology or any other medical specialty. However, it is likely that such an examination will become mandatory in the future and that innovations in training will be partnered by innovations in clinical assessments.

References

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Submitted 16 November 2001; Accepted 26 April 2002