Division of Genomic Medicine, University of Sheffield, Sheffield S10 2BR, UK
Abstract
The training of junior doctors has undergone major changes in recent years. There is now more structure, with defined assessment time points leading to a Certificate of Specialist Training. This certificate provides documentation indicating that the trainee has undergone a satisfactory period of training and that they are sufficiently competent to practise as a specialist, unsupervised. The changes have led to re-examination of the role of, and educational provision for, research training as well as clinical training. In this article we review these issues and argue that the development of masters educational programmes may help to address several concerns.
The revised training structure for specialist medical training often referred to as Calmanization [1], together with the establishment of the specialist registrar post, have had a profound impact on the training of postgraduate medical doctors in the United Kingdom (UK). An overall theme has been the shift from a trainee who primarily carries out clinical service and learns by apprenticeship, to a formal educational programme with a structured curriculum and regular assessment.
One consequence of the Calman changes has been the reduction in the duration of training. This, coupled with the New Deal in the UK and Working Time Directives in Europe has led to the perception by many trainees and most trainers that the training for specialist registrars seeking to obtain their Certificate of Specialist Training (CCST) is inadequate in comparison with that which the pre-Calman senior registrars received [2, 3].
One interesting aspect as far as rheumatology is concerned has been the increasing use of masters (MSc) programmes as an educational vehicle for trainees [4]. In general, MSc programmes usually last between 1 and 2 years full time. In practice they are part time for junior doctors, and taken alongside their clinical commitments. Although the available MSc programmes differ, they all provide core teaching at a postgraduate level together with exposure to research methodology and critical appraisal skills. One main area of difference between the various programmes in rheumatology is in the amount of training provided in clinical skills. Previously, MSc programmes available in rheumatology were mainly taken up by overseas doctors wanting a formal programme to increase their knowledge and skills in rheumatology, culminating in a qualification which they could take back with them to their home country. The recent interest in these MSc programmes is because they provide structured training and encourage the development of a core curriculum [4]. They also spread the teaching load among trainers, or perhaps utilize designated (and specifically paid) trainers. The latter consideration has become more important in the UK owing to the increased time pressures on consultants from the NHS Executive's directive to reduce waiting lists and to deliver the NHS Plan. Clinical academics have the triple pressures of NHS service delivery, research income targets and teaching standards of their university. As Hangartner [5] states Introducing structured training, while at the same time meeting the Government's commitment to reducing junior doctors hours and enabling the move towards a consultant based service can seem like playing three dimensional chess. The trouble is the board is in another room, you rely on secondary information about the position of the pieces, and the players, like the rules, keep changing.
There are several MSc programmes in rheumatology in the UK. The first to be started was in Manchester [6]. This programme attracted a mixture of UK and overseas trainees. More recently, programmes have been established in London and Birmingham. In the South Thames region of London, all specialist registrars are encouraged to enrol, unless they have opted for a research degree.
What is there to commend an MSc qualification for rheumatology? Available as a day release course, it ensures that trainees receive protected core teaching in a systematic and comprehensive fashion. There is scope for short-term research projects in addition to other assignments. Those wishing to obtain more extensive research experience will undoubtedly be best advised to take time out to read for a PhD or MD thesis [7, 8]. On the other hand, an MSc programme is a good way of providing, in the context of a taught course, topics such as research methodology and critical appraisal. Training should encompass a mixture of formal and informal opportunities requiring several learning strategies. Service-based apprenticeship and the more structured learning that an MSc programme provides are complementary and should lead to effective learning. There is also value in peer contact between trainees. It has previously been pointed out that such MSc programmes could be funded from existing sources for trainee hospital posts, thus sparing research charities from being asked to support trainees seeking a higher degree, yet not being fully committed to a research-based career [8]. Since unequivocal academic-track trainees would do better to enrol for a PhD, the pressure to study for an MD degree, with its somewhat equivocal academic significance, might ultimately diminish [9].
An evaluation of the Manchester MSc programme has shown it to be effective in providing a comprehensive curriculum that enables postgraduate trainees to acquire the knowledge, understanding, attitudes and skills relevant to the practice of rheumatology [5]. In addition, the MSc programme provides an understanding of research methodology and an appreciation of the links between basic science and clinical medicine. Eligibility for the Manchester MSc programme requires a medical degree and previous experience in general medicine, but not rheumatology.
To some, an MSc programme is the worst of both the research and the clinical worlds, with the trainees neither carrying out a proper research thesis with the skills that this brings, nor being encouraged to develop the richness and intensity of self-directed learning and career development expected of a trainee at this level [10]. It is also argued that most topics given in the MSc programmes are usually already covered in daily learning opportunities on the wards and in clinics, as well as through departmental case presentations: in other words, that the MSc programmes offer little more than structured postgraduate training. The trainers may feel relieved of a burden, but is that appropriate? Should a trainer not take on all aspects of a pupil? Is mentoring truly outdated? It could also be argued that the MSc programme is only of benefit where there is a critical mass of trainees and not much competition for tenured posts!
However, if an MSc is a career advantage, is it equitable that it is in practice only available in metropolitan areas? In North Trent, we have for some time been considering the pros and cons of a distance learning MSc Programme in rheumatic diseases. In 1999 we conducted a survey amongst specialist registrars in rheumatology in the UK to seek their views on the perceived need for an MSc and the acceptability of a distance learning method of delivery. There was considerable interest in such a programme amongst those who had no access to one of the established programmes and had no interest in reading for a PhD or MD. This is important, as it is essential that trainees are both involved in and have confidence in the learning programmes that are planned for them.
We would envisage a distance learning MSc programme as being interactive, Web based and Web delivered. These programmes could be further supplemented by face-to-face meetings during British Society for Rheumatology or EULAR conferences. Distance learning courses can also be made flexible, so as to meet individual learning needs. Interaction between trainees and trainers could be achieved using chat rooms and email notice boards [11]. We would anticipate the use of a modular design for the MSc programme. This would mean that even those medical trainees not wishing to undertake the full MSc programme (for example those who already hold a PhD or even an MD) could undertake one or more modules of interest. On the other hand, a trainee who completes the MSc programme could also go on to carry out an extended programme of research leading to an MD or PhD [6]. Such a design would also facilitate multi-professional education, since non-medical learners, such as nurses or therapists, could take modules. However, since clinical training is crucial to a rheumatology trainee, the MSc degree in clinical rheumatology would only be available to those in accredited training posts. Furthermore, a European-wide accredited training programme would be facilitated by a transportable qualification. This is in keeping with recent moves to try to standardize postgraduate medical training across Europe [3]. It also provides a solution to the vexed issue of an exit examination [11]. We envisage the proposed distance learning MSc programme as being based upon collaboration, with staff from several institutions across Europe contributing material as tutors and supervising a limited number of trainees over a period of 4 years. An MSc tutor could be from the trainee's own institution if preferred.
Evaluation could occur asynchronously through case scenarios, extended matching questions, projects, assignments and dissertations, similarly to those used as part of continuous professional development by some journals. Traditional face-to-face evaluation methods could also be used, such as written or clinical examination, objective structured clinical examination or clinical cases.
Overall, such an MSc programme has the potential to maximize learning opportunities for critical reflection on professional practice, to integrate existing knowledge and experience with new perspectives, for practical workplace applications of learning. A combination of distance learning interaction supplemented by face-to-face meetings would lead to a harnessing of the dialogic and social dimensions of the distance learning experience, which are critical to effective learning [9, 12]. It would facilitate intellectual exchange amongst trainees across Europe and enable standardization of assessment.
In conclusion, the last 10 years has seen a time of great change with regard to the training of junior doctors and appears to have thrown up almost as many questions as answers. We consider that there is a role for MSc programmes for rheumatology trainees and others. In particular, there is a clear potential for a distance learning MSc programme. We recognize that its initial development would be labour intensive and would require significant initial capital investment [13]. However, the more equitable availability of a specialist qualification should be supplemented by its potential attraction to non-UK-based trainees, in Europe and elsewhere. This could go some way to offset the concern expressed by UK MSc organizers who have come to depend upon fees from the existing, geographically restricted, MSc programmes. We also conclude that if an MSc is a worthwhile contribution to professional development, to the extent that it forms a scheduled part of some training programmes, then it should be available to all trainees. The only way we can see for this to happen in practice is to develop distance learning programmes.
Notes
Correspondence to: M. L. Snaith. E-mail: m.snaith{at}sheffield.ac.uk
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