The 2005 FP curriculum is a long (97 pages) and detailed document. Strikingly, despite its novel approach to early postgraduate education, the assertions it makes in relation to educational theory are almost entirely unreferenced. It is constructed in four sections plus appendices (table 1).
Table 1The format of the Foundation Programme curriculum
It quickly becomes clear on reviewing the curriculum that emergency medicine is a natural key learning environment for many of the clinical objectives of the FP. Year 2 doctors will be expected to demonstrate a wide range of “higher level” competencies in relation to managing acute illness and many of these relate to typical patient presentations within the ED. Each section is now discussed individually to highlight issues of importance and concern to the specialty.
Section 1: core competencies
The opening section of the curriculum is structured around the domains of good medical practice:
- good clinical care;
- maintaining good medical practice;
- partnership with patients;
- working with colleagues and in teams;
- assuring and improving the quality of care;
- teaching and training;
Each of these domains is then subdivided into aspects of competence which are to be achieved by the end of the first (FY1) and second (FY2) years of the FP.
Good clinical care forms the bulk of this section. The target competencies for FY2 trainees contained within this section are highly relevant to emergency medicine. In effect, they form benchmarks for safe clinical care within the department and could usefully be thought of as exemplars of best practice for all grades of medical staff. Three examples from section 1 are shown below:
Confusingly, the concluding part of section 1 does not correspond to a good medical practice domain. Instead it details the specific competencies expected within the management of “acute care”. This part of the curriculum is extremely focused and structured around effective initial assessment, key procedural skills (for example, obtaining and interpreting an arterial blood gas sample), and the need to form a rapid management plan. The issues surrounding Do Not Attempt Resuscitation orders and Advance Directives also form a key competence within the acute care setting.
Although the many core competencies of section 1 are highly relevant to emergency medicine, assessing each one as written would be an impossible task. This reflects an important fundamental weakness of the educational methodology in that the curriculum has been drawn up using an “objectives based” model rather than a truly “competency based” one.6
The end result is a list of lots and lots of objectives in an attempt to include all desirable attributes of a particular aspect of care. Although it is stimulating to see a long list of apparent competencies of this type, they actually represent examples of ideal practice rather than outcomes which are measurable in any practical sense. This is a key issue for implementation, as will be discussed later.
Section 1.0 Good Clinical Care, subsection 1.1 (i‐ii‐iii):
- Demonstrates accomplished, concise and focused history taking & communication, including in difficult circumstances
- Incorporates clinical, social, cultural, nutritional and psychological factors
- Delivers a targeted examination
- On the basis of differential diagnosis, makes a judgement about prioritisation of actions
- Gives clear information to patients.
Section 1.0 Good Clinical Care, subsection 1.1 (v):
- Understands the medico‐legal importance of good record‐keeping and conveys this to others
- Structures (discharge summaries) clearly to communicate findings and outcomes.
Section 1.0 Good Clinical Care, subsection 1.2–1.3 (ii)
- Demonstrates appropriate decision‐making even when under pressure
- Seeks help at an early stage
- Does not operate beyond own competency.
In broad terms, however, section 1 of the Foundation curriculum is a useful platform document to inform practice within the ED and has a useful, wider context than that of Foundation trainees alone.
Section 2: delivery of training
The need for exposure to acute undifferentiated medical illness within the Foundation years means that EDs will have to feature in many of the FY2 programmes. It is only within this setting that trainees will be able to acquire the necessary breadth of competencies.
The FY2 rotations which we devised in our hospital are shown in table 2. One FP trainee occupied each track of the programme.
Foundation trainees nationally are to be provided with a professional development portfolio, which must be kept up to date. Importantly, the competency lists within the portfolio form the basis for personal review of progress.
The educational model underpinning section 2 is that of the “spiral curriculum” and this is the single referenced item within the whole Foundation curriculum document.7
In this model, topics are revisited at increasing levels of complexity as time goes by, each exposure allowing new learning to be integrated into existing knowledge. This is a learning style inherent to daily clinical life in the ED and has been widely practised, albeit without formal mention, for many years. In this respect the educational theory of the delivery of Foundation training is uncontroversial and does not pose a threat to established ways of teaching and working.
The teaching methods to be used for FP trainees are listed within the curriculum as follows:
- small group
- external courses
- personal study
- simulated clinical situations
- identification of role models.
Many of these are familiar. However, FY2 trainees must receive both generic and specialty specific teaching within these models. In real terms this will impact on shopfloor service delivery at SHO level. It also has the potential to generate conflict between “FP” and “non‐FP” junior staff, since Foundation trainees will have to be released for teaching sessions over and above those of their “traditional” peers.
It also has significant implications for the timing, content and style of established departmental teaching programmes. Bearing in mind that FY2 trainees are most likely to rotate every four months, within which they will require a half day equivalent weekly release to attend generic teaching as well as that within the ED, it is highly probable that the traditional local teaching programme will require radical pruning and focus.
This is to be welcomed and reflects wider perceptions that postgraduate medical teaching programmes in general can evolve into “comfort zones”, shaped by selected speakers and favoured topics, rather than being based upon actual educational need.8
The real practical implication, though, is the need to devote considerable effort to the redesign of departmental teaching. This should take place now in anticipation of an influx of Foundation trainees in August 2006.
How should the required generic teaching be provided, and how much time does it actually take? The first thing to remember is that the generic
teaching programme for years 1 and 2 is just that, and not the sole responsibility of the ED. The decision to provide generic teaching en bloc as stand alone modules throughout the FY2 year, or as half day or day release sessions will be a local one. Early evidence favours the stand alone model: group dynamics are enhanced and attendance rates are high.9
Using this approach, the required annual generic content can be delivered in eight whole day equivalents. There will be organisational difficulties within this model for smaller hospitals, but there is nothing to prevent interhospital generic teaching programmes within the FP or, for that matter, interhospital emergency medicine teaching programmes.
One aspect of the delivery of teaching which will definitely be worth exploring locally is the potential contribution which the ED can make to FY1 teaching in particular: many of this year's objectives in relation to good clinical care are concerned with recognition and basic management of serious illness; ED staff are highly credible educators for these sessions, and will reap the rewards when the same trainees rotate into the department within FY2.
This in itself may reduce the burden now placed on the local weekly teaching programme.
It will be useful for ED consultants to liaise with FY1 tutors within their hospitals and identify suitable teaching sessions for this purpose. Again, now is the time to get involved as programmes are drafted and finalised through 2006.
The curriculum highlights the fact that educational credibility rests upon effective training of the trainers. What is lacking within it, however, is any concrete commitment to expand and fund the required courses. We would advise prospective clinical and educational supervisors to seek a place on a Training the trainers type course at the earliest opportunity.
Although the teaching methods listed in the FP curriculum are generally widely employed within emergency medicine, it is not stipulated that all trainees need exposure to all modalities. Some, such as simulator experience, will be impossible to access in high fidelity format for many units. For EDs, the fact that one‐to‐one and role modelling paradigms are formally included is a real acknowledgement of the role of traditional “apprenticeship” teaching. Postgraduate medical education has perhaps overemphasised the utility of problem based learning in recent years. Objective outcome measures for the success of PBL remain as elusive as ever,10
and there will be no requirement for local FP directors to devise new problem based learning type packages.
Section 3: feedback and assessment
Concerns have already been raised nationally that there is to be “too much” assessment of FY2 trainees. Rather controversially, the curriculum quite clearly states that trainees will have a free choice of both the timing of workplace assessments and the assessor who will undertake them. This removes an important element of objectivity from the assessment philosophy. Although the assessment tools are admittedly still in a developmental stage, the fundamental components are well established (see box).
Clearly there is a significant burden attached to FY2 assessment and this mandates forward planning, particularly as the timings and assessor are ostensibly for each trainee to decide. Local experience in our unit suggests that an equivalent of 0.5 programmed activities per week is required from the consultant pool to facilitate the support and assessment process for three Foundation trainees. Putting this into practice will require robust discussion between colleagues and the executive team at Trust level. Importantly, there may be a need to provide “… additional tests of competence or knowledge … focused or additional training … (and) further assessments” (p47) within a placement for those trainees failing to progress satisfactorily. The potential extra burden from this activity needs to be considered in job planning but is impossible to quantify. In our experience, however, the need for such input has been non‐existent to date.
Components of assessment during the FY2 training year
- Peer Assessment Tool, one per four months
- “360 degree assessment”
- Twelve independent raters to be used.
- Mini‐Clinical Evaluation Exercise, two per four months
- Trainee chooses timing and observer (mix of CEX and DOPS).
- Direct Observation of Procedural Skills
- Trainee chooses timing, skill, observer.
- Case based discussion, two per four months
- Structured discussion of real cases.
Familiarisation with the assessment tools certainly requires practice. “Roadshow” workshops have been established in the North West Deanery (for all hospital and primary care stakeholders, not just emergency medicine) which have been well attended and informative. Similar initiatives are taking place across the UK. It is important that as many staff attend as possible from the department, as we have found it difficult to appreciate the nuances of FP assessment second hand in local cascade workshops.
The role of effective feedback is strengthened in the curriculum and few would argue with its inclusion. Feedback must be immediate and structured; there should be an opportunity to reciprocate the feedback, and this must be facilitated without prejudice.
The assessments which each trainee must receive are to be collated into an individual Educational Supervisor's Report for each FY2 trainee. The quantity of assessment required demands tight administration: deadlines must be met, and it must be clear to whom paperwork is to be sent in order to allow for a smooth transition between placements. In particular, trainees who have experienced difficulties must have a clearly documented account of each aspect of the relevant assessment.
Section 4: foundation programme syllabus
This last, and large, part of the FP curriculum outlines the generic formal teaching which is expected to occur at both F1 and F2 levels, then quickly goes on to detail the good medical practice which trainees should demonstrate by the end of each year. The “knowledge/skills/attitudes” model employed in this section is rather educationally dated and has been superseded by the competency based approach mentioned earlier. As a result the same limitations arise as before: it is impossible to think of a way in which the content of pages 54 to 89 of the curriculum—all of which lists objectives in the form of a syllabus—could realistically be assessed.
This part of the curriculum is therefore interesting but not especially meaningful. It almost forms a “wish list” of best clinical care. Curiously, “attitudes” are omitted from the last 10 pages of the syllabus, even though the objectives within this section refer to management of acutely ill patients, resuscitation, and other attitudinally important topics. At the very least, however, these lists serve as discussion documents with which to inform best practice within the ED, and form a useful platform on which to base reformed departmental teaching.