Rheumatology training in the United Kingdom: the trainees' perspective
S. G. Dubey,
C. Roberts,
A. O. Adebajo and
M. L. Snaith
Academic Unit of Medical Education, University of Sheffield, Sheffield, UK.
Correspondence to: S. G. Dubey, Academic Unit of Medical Education, Coleridge House, Northern General Hospital, Sheffield S5 7AU, UK. E-mail: s.dubey{at}shef.ac.uk
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Abstract
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Background. Rheumatology training has undergone significant changes in the last decade with Calmanization, implementation of the New Deal for junior doctors and newer educational strategies for improving musculoskeletal training, like a core curriculum. However, concerns have been expressed about the quality of postgraduate training programmes in the UK.
Objectives. First, to assess current trainees perceptions of the quality of core and subspecialty training, the impact of workload on training, and to explore demographic variations in training experience. Secondly, to identify educational strategies that trainees felt would enhance their training.
Methods. The questionnaire was initially distributed to all specialist registrars attending the BSR Annual Meeting in Brighton in April 2002. Subsequently, the questionnaire was posted to all registrars on the Joint Committee for Higher Medical Training list with a reminder after 4 weeks.
Results. Trainees rated positively training in routine patient care, musculoskeletal examination and injection skills while training in primary care rheumatology, epidemiology, paediatric rheumatology and sports medicine was rated negatively. There is agreement that the reduction in junior doctors hours has adversely affected training, and issues relating to workload have overtaken training issues. Trainees undertaking dual accreditation are more likely to feel this. Educational strategies deemed to enhance training included training workshops focused on specific topics, such as musculoskeletal radiology (89.2%), and an adequate debriefing session after an out-patient clinic (81.6%). An independently administered, reliable and valid scale for quality of training could be used to assess regional variations in training and monitoring quality.
Conclusions. The changes to junior doctors hours, the working patterns of doctors and service commitments have all affected the quality and time available for certain aspects of rheumatological training. A major effort to enhance quality is necessary to ensure that the objectives of training are met within the intended training budget.
KEY WORDS: Musculoskeletal, Rheumatology, Curriculum, Quality of training, Trainee satisfaction, Specialist registrar, United Kingdom
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Introduction
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Training in rheumatology, as in other specialties, has been subject to substantial reform over the last 10 yr. Calmanization, implemented in 1997 [1], abolished the senior registrar grade and created a unified specialist registrar (SpR) grade. More structure and support for trainees was provided through the use of RITAs (Records of In-Training Assessment). Recent strategies for improving musculoskeletal training, include the introduction in 1992 of GALS (gait, arms, legs, spine), a screening examination for the locomotor system [2] and the formalization of generic musculoskeletal examination skills. The Joint Committee for Higher Medical Training (JCHMT) has recently published the core curriculum in rheumatology [3] to guide both trainers and trainees. Recently, the Postgraduate Medical Education and Training Board (PMETB) has been set up to oversee postgraduate education, and part of the remit of its Education and Training Committee is to look at the outcomes to be achieved by that education and training [4].
Concomitantly, there have been changes in working patterns in the National Health Service (NHS) with the implementation of the New Deal for junior doctors hours [5]. There is a perception that training for SpRs seeking to obtain their Certificate for Completion of Specialist Training is inadequate compared with pre-Calman senior registrars [6, 7]. Trainers are under constant pressure, with many clinical academics trying to balance NHS service delivery targets, research income targets and university teaching standards [8]. Consequently, some regions have decided that the best way to deliver training would be with a Masters programme [9]. This has led to a call that the Masters should perhaps be available to all trainees [10].
Concerns have also been expressed about the quality of entrants to training schemes. Thus, despite the prevalence of musculoskeletal diseases in the community [11], musculoskeletal teaching is not adequately represented within the medical undergraduate curriculum [12] and students may lack competence in this field of medicine [13]. Consequently, a good-quality, structured training programme for doctors with rheumatological ambitions becomes even more important. While the satisfaction of SpRs was assessed in a survey conducted by the British Society for Rheumatology (BSR) Education Committee in 1998 (80% of the respondents were satisfied with their overall training [14]), no studies to our knowledge have assessed the quality of delivered training for SpRs in various aspects of rheumatology.
This research had two aims. First, we wished to assess current trainees perceptions of the quality of core and subspecialty training, satisfaction with training, the impact of workload and related issues on training, and to explore variations in training experience by demographic factors using a quality of training scale. Secondly, we wished to identify educational strategies that trainees felt would facilitate their experience of teaching and learning.
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Methods
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The questionnaire was initially distributed to all SpRs at the RATS (Registrars at Training) meeting at the BSR Annual General Meeting in Brighton in April 2002. In view of the relatively poor attendance at this meeting, the questionnaire was sent out by post to all the registrars, using the JCHMT database, with a reminder at 4 weeks. The period of the survey was from April to August 2002.
The scale for evaluation of trainees perceptions of the quality of rheumatological training was devised on the basis of the core rheumatology curriculum [3]. It used five-response bipolar Likert items to evaluate core and advanced aspects of training and consisted of 16 items. Additional items were used to assess overall trainee satisfaction, satisfaction with the level of support from trainers for both clinical work and teaching, the impact of the reduction in junior doctors hours and workload-related issues. The registrars were invited to rate educational strategies that might facilitate delivery of the rheumatology curriculum, including their views about the MSc. Qualitative comments using free text were also invited.
Statistical analysis was carried out using SPSS version 11 (SPSS, Chicago, IL, USA). Free-text comments were analysed using the basic principles of qualitative analysis [15] and were themed to enrich the quantitative data.
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Results
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The response rate to the questionnaire was 67.7% (134/198). The demographics of the respondents are given in Table 1.
Assessment of quality of training
The reliability of the 16-item quality of training scale was 0.87 (Cronbach's alpha). A factor analysis was also undertaken which showed that all items contributed to the measurement of trainee perceptions of the quality of rheumatological training. Additionally, a second component in this analysis confirmed that core and advanced aspects of the training could be considered as distinct entities. Table 2 describes the mean value of ratings for all respondents with 95% confidence intervals. Trainees gave positive ratings for core aspects of training, including routine patient care, musculoskeletal examination, injection skills, research and audit training (Table 2). However, training in primary care rheumatology, epidemiology, paediatric rheumatology and sports medicine was rated negatively.
Satisfaction ratings
Overall, 85.6% (113/132) of the registrars rated their training as satisfactory or better. Similarly, respondents rated highly (satisfactory or better, 93.1%, 122/131) the level of support they received in relation to their clinical workload. Equally so, with the level of support they received from trainers in terms of teaching (satisfactory or better, 87%, 114/131). Formal teaching time was assessed as less than 2 h a week by 19.4% of respondents, 23 h by 35.7%, 34 h by 25.6%, 46 h by 15.5% and more than 6 h by 3.9% of respondents (n = 129). However, registrars undertaking dual accreditation were less likely to be satisfied with support from trainers, both in terms of workload (91.9 vs 95.5%, MannWhitney U 1643, P = 0.021) and teaching (81.9 vs 92.5%, MannWhitney U 1617.50, P = 0.015) (though the figures are high for both groups), and scored lower for the amount of time spent in formal teaching (MannWhitney U 1368.50, P = 0.001).
Impact of workload and related issues
Most (46.5%) respondents agreed that the reduction in junior doctors hours has adversely affected training (Table 3). Half (49.6%) felt that training commitments had been taken over by workload commitments, many (39.8%) not having a weekly day off for study in their timetable. Dual accreditation in rheumatology includes general medicine alongside rheumatology, and rehabilitation alongside rheumatology. In view of the small numbers of trainees doing rehabilitation and rheumatology (n = 3), these were excluded from the analysis of differences between single accreditation and dual accreditation. Registrars undertaking dual accreditation were significantly more likely to feel that training had been superseded by workload (59.6 vs 40.9%, MannWhitney U 1722, P = 0.033) and less likely to have a day off for study (54.2 vs 24.6%, MannWhitney U 1266, P = 0.001). Attendance at teaching sessions was satisfactory, 67.7% of respondents managing to attend more than 70% of the sessions. However, there was a significant reduction in attendance for registrars undertaking dual accreditation (55.7 vs 78.8%, MannWhitney U 1560.50, P = 0.004). The biggest reason for non-attendance was clinical workload (44.1%).
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TABLE 3. Comparison of views relating to impact of workload and related issues between trainees doing single and dual accreditation
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Regional variations in training
Table 4 gives overall mean ratings of the training by deanery as well as the mean scores for core and advanced aspects. For these ratings, we have excluded all deaneries with fewer than five responses (the excluded deaneries include the Armed Forces, Mersey and Wales; also, East and West of Scotland data was combined under the heading Scotland). The inter-deanery differences were analysed using KruskalWallis test, a non-parametric test for analysing multiple independent samples, as the data are not normally distributed. This revealed that differences in means of overall scores (
2 = 28.12, P = 0.018), scores for core aspects (
2 = 26.86, P = 0.016) and scores for advanced aspects (
2 = 28.10, P = 0.025) are all statistically significant. We used the MannWhitney test to try to compare individual groups. This revealed that differences between Scotland and North West, for example, were statistically significant (MannWhitney U score 24.50, P = 0.003). Cross-tabulation of the deanery scores with year of SpR training showed that there appeared to be a reasonable spread of the SpRs across the various years, and an imbalance would not have contributed significantly to the overall scores.
Strategies for enhancement of training
Educational strategies that were considered of value in enhancing the quality of training included: training workshops focused on specific topics, such as musculoskeletal radiology (89.2% agreement), a 30-min debriefing session after an out-patient clinic (81.6%), and access to databases for all patients on second-line agents (79%).
Qualitative data
Free-text comments were provided by 32 of the 134 (24%) of respondents. Analysis revealed three broad themes: (i) workload issues for the trainee and the consultant; (ii) structure of training; and (iii) the quality of teaching and learning activities (Box 1). The comments suggest that registrars perceive workload as a major factor in influencing training, affecting not just their ability to attend teaching sessions, but also the consultants, who must find time for postgraduate teaching without compromising service targets. Some of the illustrative comments made by the respondents are reproduced here.
BOX 1. Qualitative comments by the trainees- Workload
- Reduction in junior doctors hours has led to the same clinical workload being squeezed into a smaller time period, hence leaving less time for training.
- Learning has to be self-directed and optional for individuals. I am finding increasingly that this means more work and less private study and teaching.
- Consultant workloads are higher than our own and changes in training need to acknowledge this.
- Cover for consultants to allow time to teach.
- Structure
- I feel that current training does lack central structure, one relies on the spectrum of patients to read around the topics (issues brought up during discussions with patients), inevitably neglecting many areas a particular hospital/consultant doesnt have expertise in. Adding similar structure as in MSc courses with modules on particular group of conditions should be of great help.
- The lack of IT internet access is a major factor in my dissatisfaction with training. We are all being taught to use EBM (evidence-based medicine), but it is impossible without good, quick access to the evidence.
- Not enough opportunity to discuss difficult cases, e.g. seen in clinic. No formal induction prior to starting each job.
- Quality
- Due to the poor quality of our academic afternoons, we have instituted a full day organised by the SpRs every 2 months.
- Teaching from consultants on the job could be better but difficult due to their workload.
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Limitations and future perspectives
The response rate of this questionnaire was less than 70%, which was due partly to a relatively poor response from the trainees doing dual accreditation (56.88 vs 79.07%) and also to the fact that the JCHMT list of registrars was not entirely accurate. In our estimate, between 5 and 10% of the addresses provided by the JCHMT at the time were inaccurate. Also, it is possible that there would be a better response in a particular subgroup, for example, leading to an overestimate of the proportion that might have a Masters degree.
While this research provides useful trends on regional variations in training, these data are meant only as informal feedback. Cumulative data over multiple years with a consistently high response rate would be necessary to verify the reliability of these data.
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Discussion
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Certain aspects of core rheumatology training are clearly well delivered, as perceived by the trainees (Table 2). However, there appears to be not enough emphasis on the teaching and learning of rheumatology in primary care. This is of concern, given the wide range of musculoskeletal services in the community sector [16]. Many of these are delivered by physiotherapists or general practitioners, the training of whom is uncertain [17]. In terms of advanced aspects, this study suggests that there are concerns about training in paediatric rheumatology, epidemiology and sports medicine. Given the importance of these areas in the rheumatology curriculum, course planners may need to revisit the quantity and quality of training devoted to them.
The impact of change in junior doctors hours on rheumatology registrar training has not been ascertained in any publications to date. Previous studies that have sought the opinions of Senior House Officers (SHOs) on the impact of these changes have indicated that workload was a major factor influencing training [18]. These results would support the general concern that workload has had and will continue to have a substantial impact on training (Table 3). Although time spent on patient care might be expected to contribute to learning, the evidence is that learning needs the right environment, which can be difficult to create [19]. The environment in the NHS is becoming increasingly focused on service demands, potentially creating an environment not conducive to effective learning. Trainees appear to be saying that the balance between workload and training is not appropriate and that this balance is worse for trainees doing general medicine alongside rheumatology. With the increased emphasis placed on dual accreditation by the Royal Colleges, there is a risk of worsening this situation. The reasons for the difference between these two accreditation types perhaps need to be explored further, though it could be argued that the difference may be partly explained by the differences in workload and attendance at teaching sessions.
The highest-ranked strategy for changes to optimize training in this cohort of trainees was having training workshops focused on specific topics. Trainees would thus appear not to value traditional didactic lectures but to wish for an emphasis on experiential interactive learning with experts in a learning environment free from workload pressures. The other strategy that ranked highly in this survey was having debriefing sessions after out-patient clinics. There is much experience of using debriefing in other settings; e.g. general practice training. For the trainer, debriefing sessions at the end of every teaching out-patient session might be the equivalent of cancelling two follow-up patient slots, and similarly for the trainee. This strategy would need some negotiations between the consultants and managers to ensure that the time for debriefing came out of the overall planned teaching time for the week, perhaps at the expense of less effective teaching methods.
The success of a good training programme might be measured by how effectively and efficiently it is run [9]. The league table of deaneries is intended to illustrate what is possible in the provision of a quality assurance system by collating trainee evaluation data nationally (Table 4). The scale used is highly reliable, achieving above the figure of 0.8, which is normally considered the gold standard for summative purposes. There would appear to be some regional variations in trainee perceptions of training. However, to be meaningful, comparative data would needed to be collected over a number of years with a response rate of at least 70% from trainees. It would perhaps be wise if the deanery were not the evaluator of the quality of training. This evaluation of training might be best done independently through either the Education Committee of the BSR or, perhaps, the Postgraduate Medical Education and Training Board (PMETB) [4]. These results, however, could be used by the deaneries as formative feedback on their training programmes.
Overall, there seems to be a view in support of the MSc, with 68% agreement for an optional MSc compared with 53.4% for a mandatory MSc (Table 4). The variations in the objectives and the structure of the MSc courses currently available in the UK make it hard to compare them with one another [20] and this appears to be reflected in the mixed views of the registrars (75.8% agreement in favour of MSc among trainees from North West, whilst the comparative figures for West Midlands and S. Thames are 69.20 and 55.40% respectively). The reported success of the North Western Deanery may, however, relate in part to a training programme reliant on a well-structured MSc aiming to provide good training to the registrars [9]. Nonetheless, there may be other options that may have more appeal than a university-based higher degree. One notion is a summative exit examination to drive teaching and learning strategies [21]. However current trainees would not appreciate this (Table 5). Given the remit of the PMETB [4] to look at outcomes of education and training, the rheumatological community in the UK may need first to set up clearly defined measurable outcome objectives for specialist training in rheumatology based on what would be expected for a newly appointed consultant. This, in turn, begins the debate about the format and structure of the teaching and learning programme required to train the consultants of tomorrow and the appropriate assessment strategy for ensuring delivery of this programme.
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Acknowledgments
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We would like to thank Ms Jean Russell for help with the statistical analysis of these data. This research was possible through the funding provided by Arthritis Research Campaign to support the post of the first author.
The authors have declared no conflicts of interest.
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Submitted 27 October 2003;
revised version accepted 12 March 2004.