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Curriculum Setting, Teaching and Learning

on the Northumbria Vocational Training Scheme

CONTENTS

1.    Rationale for an NVTS curriculum

For some time there have been calls for greater integration of the training and education the registrars receive in their practices and hospital posts with that they receive in their group work and phase 2 modules. With over 200 registrars on the scheme, formal, centralised integration runs the risk of creating a syllabus-driven education, where all registrars study every aspect of a pre-defined curriculum, irrespective of their individual needs.

This would not conform to current educational theories about adult learning. These suggest that education should be flexible and learner-centered; assessment based and relevant to current experience.

To reflect this and in order to sustain the momentum of health policy changes and associated professional and statutory requirements, a curriculum must be both flexible and provide the parameters within which society can be assured of the maintenance of high standards of learning and teaching of future general practitioners.

The purpose of this curriculum is therefore to provide 

2.    Aims

This document describes a curriculum that acts as a framework within which the individual registrar and trainer or educational supervisor can negotiate a learning plan. It has the advantage of flexibility within the parameters of the standards set by the regulatory authorities, whilst taking into account the intellectual freedom of the partners in learning. It provides a framework for coherence and integration between the different elements of the phases within the programme of learning.

In line with the thinking of professional bodies and quality agencies, it is essential that education: 

In practice, the NVTS relies upon the registrar to co-ordinate their own, assessment-based, needs-driven curriculum, in negotiation with the trainers and other learners they come across. There are several measures that are used to enhance this process and ensure that the teaching the registrar receives covers a core curriculum that reflects those aspects of medicine that society and / or the regulatory authorities suggest doctors should know, listed in appendices 1 and 2.

The overall teaching aim is therefore to provide registrars with the opportunities to develop knowledge, skills and attitudes that will enable them to become competent and caring doctors, to work well with others, to encourage critical self-analysis and to develop their own continuing education.

In order to provide continuity and generate ownership of learning, GPRs are required to complete a profile of their experience and achievements as a base line upon which to develop an overarching learning plan. The plan should:

3.    Curricular content

Consistency within a curricular framework and assurance that each GPR is competent and confident must be the base line for all educators.

Many resources provide lists of specific knowledge, skills and attributes[1]. Using the Quality Assurance Agency for Higher Education Benchmark Statements for (undergraduate) medicine[2], the standards set out by the GMC in Tomorrows Doctors[3] and attributes laid down by the JCPTGP[4], a number of themes inform the content of the curriculum, giving it coherence without undue restriction.

They are:

1. clinical competence and relationships with patients
2. policy, organisation, management, ethics, law and probity
3. evidence, research and audit
4. personal professional development, personal health

Learning and teaching strategies

NVTS places the emphasis on helping registrars to learn in a way that is continuable for the rest of their career, rather than spoon feed them for any examination or assessment – on the grounds that doing the former should automatically enable the registrars to pass them. 

The principles underlying this approach are those of adult education[5]. Adults learn best when: 

Experience has shown that different learning resources are appropriate according to the learning need:

In order to inform their actual practice, much of what most registrars need to learn is best studied through facilitated reflection that enhances their theoretical and experiential learning[6]. The role of the learner in this kind of experience is to feed into the teaching process:

To do this, they need to attend, listen, and contribute actively to the reflective process.

The teaching aims to be:

Learning is most effective when the teaching takes account of the registrar's prior level of proficiency in the subject under study and their preferred learning style [7].

The NVTS believes that all of the above strategies are important in learning.

        This approach involves a move from curriculum-driven to facilitated self-directed learning and provides a model for life-long learning[8] [9]. The learning opportunities it provides are listed in appendix 3. A timetable of milestones is listed in appendix 4.

It is anticipated that, although not complete, registrars will already have a relatively high level of knowledge. The truth (or otherwise) of this should be ascertained with each registrar through observation of their work, informal feedback, and formal assessment (appendix 5). The emphasis should then be on remedying identified gaps and putting that knowledge to use in the general practice setting, applying skills (manual, behavioural, diagnostic, intellectual and interpersonal), and exploring attitudes and self-awareness.

The major responsibility for doing this lies with the GP or hospital trainer[10]. Having identified a learning need, the trainer’s response will depend upon the area of study – and may involve direction to other resources. The centrally run group sessions are learner centered, but less individualised, taking into account the group’s wants as well as identified needs, and concentrate on those subjects best learnt in groups.

Learning needs

In the context of this kind of education, identifying the registrars learning needs is fundamental because, once these are identified, objectives can be set and appropriate methods selected. Whilst formal assessments are important, it is essential that registrars are taught the skills of reflection so that they can think critically about what they want to get out of working and learning in each post or attachment. Review of their learning needs must take place regularly. This enables them to take an active part in the process through enquiry and self-direction.

There are many different ways to identify learning needs. The formal tools listed in appendix 4 should be complemented by less formal, more dynamic methods such as log diaries[11], case analysis[12] and reflective  diaries[13] [14] [15]. The exact programme of learning is up to each registrar to negotiate – with help and support, and, where necessary, direction, from their trainer or other educational supervisor.

                                        To help co-ordinate this, a course organiser will in future be responsible for an individual’s progress through six-monthly appraisal during their entire time on the scheme. Methods of more direct communication between course organisers and an individual registrar’s trainers and educational supervisors are being developed.

Educational records

Written records are important in the co-ordination of an individual’s progress through the scheme. Trainers and course organisers should record, in the form of a brief synopsis, the content and process of each tutorial in much the same way as they do consultations with patients. The record should be a summary of the main points covered, relevant evidence to support conclusions being drawn and suggestions for future learning. It is also helpful if the registrar is asked for feedback on both content and process[16]. An action pack describing this with sample forms is available through the scheme office.

These documents should be used to inform the ongoing curriculum, for educo-legal purposes and to inform mid and end-point appraisals. A summary of the end-point appraisal (using the official NVTS format) should be sent to the scheme office where it is forwarded to the next trainer and used to inform the registrar’s appraisal by a course organiser. The whole process should not only inform and enable their ongoing learning and development while on the NVTS, it should also prepare them for the process of appraisal, personal development plans and revalidation.

Any concerns with individual registrars should (after discussion with the registrar), be shared with the trainer, central teaching group leader or scheme organiser as appropriate. Any concerns that might lead to failure to sign a VTR form or the summative assessment trainer’s report should be discussed at an early stage with the registrar and the other people involved teaching them.

5.    Summary

Both process and outcome of the teaching depend upon the teacher, the learner and the material being studied. The aim of the NVTS is to facilitate an individual registrar’s journey from wherever they are on entering the scheme to further down the path of understanding in the field of medicine. The objectives are to:

The attributes expected of them (and hence the syllabus for study) are listed in the documents from the JCTPGP and GMC. Lists of specific topics to be covered are available in standard training texts such as Middleton and Field (2001).

Bibliography

Dearing,R 1997 Report of the National Committee of Inquiry into Higher Education. Newcombe House London

General Medical Council 1998 The New Doctor - Supplement on general clinical training in general practice GMC London

Hawkins, P. Shohet,R.1989 Supervision in the Helping Professions. Open University Press. Buckingham

Norman G R 1988 Problem solving skills, solving problems and problem-based learning Medical Education, 22;279-286

Samuel O 1990 Towards a Curriculum for General Practice Training  Occasional Paper 44 The Royal College of General Practitioners London

Savage R1991Continuing education for general practice: a life long journey BJGP;41;311-314

GPC 2002 Good medical practice for General Practitioners RCGP London

www.pimd.co.uk

Appendix 1: THE ATTRIBUTES OF THE GENERAL PRACTITIONER

 This is what the profession expects.

(Adapted from JCPTGP Guidance, 1992.)

General Practitioners must be able to provide easily accessible, high quality primary and continuing care for individuals and the population of people registered with them irrespective of the patients’ age, sex or state of health.   To achieve this they must be able to offer a broad range of services to individual patients and groups of people on their lists.   These services will include the diagnosis and management of acute illness, the continuing care of patients with chronic condition, the prevention of disease and the promotion of health, the provision of emergency care, and access when appropriate to other medical services and the social services.

Although the emphasis of the work of general practitioners may vary from time to time to reflect the current needs of each patient, the practice population, and changes in the organisation of health care in the National Health Service, their basic responsibilities are likely to remain essentially the same.   They must be able to combine efficiency and effectiveness in the services offered, with compassion and fellow feeling for their patients’ welfare.   General practitioners must care about, as well as for, patients and their relatives.

It follows that the quality of a general practitioner’s performance will depend on the possession of attributes comprising the values and attitudes appropriate to good patient care, clinical competence and the skills required for effective practice management.  These attributes, all equally important, are elaborated below.

1)              Values and attitudes

Fully trained general practitioners are expected to be:

(a) Caring and understanding of patients and their families;

(b) Committed to providing high quality care;

(c) Aware of the need to be readily accessible and available to patients.

(d) Aware of their own limitations and willing to seek help from others when appropriate.

(e) Committed to keeping up to date with developments in practice – both clinical and organisational;

(f)  Committed to improving the quality of their professional performance through active participation in audit and quality assurance;

(g) Aware of the ethical principles with govern the medical profession and committed to observing them;

(h) Appreciative of the value of teamwork to patient care in general practice;

(i)   Willing to teach others, including colleagues and practice staff, and willing to acquire the teaching skills necessary for this;

(j)  Willing to contribute, when possible, to the advancement of medical knowledge;

(k) Able to care for themselves and to balance the demands of a busy professional life with the need for personal time.

2)              Clinical competence

General Practitioners are expected to be:

(a) Knowledgeable about clinical general practice.   This will require an appropriate level of understanding of the physical, behavioural, epidemiological and clinical sciences of medicine, the aetiology and natural history of disease, the impact of psychological factors upon illness, and of illness upon patients and their families and of the social, cultural and environmental factors that contribute to health and illness;

(b) Skilled in recognizing and making appropriate decisions about all problems presented by their patients;

(c) Able to examine a patient’s physical and mental state and to investigate further as appropriate;

(d) Able to assess symptoms and physical signs, to establish a diagnosis when possible, and to exercise sound clinical judgment in further management;

(e) Skilled in communication and in the processes of the consultation.    This will include the ability to listen carefully and to explain effectively to patients in decisions about their health care;

(f)  Able to contribute to the prevention of illness and the promotion of health, and to understand a doctor’s role and that of others in these;

(g) Able and willing to deal with common medical emergencies appropriately;

(h) Able to prescribe effectively and with due thought to economy;

(i)   Able to keep clear, coherent and up-to-date medical records for each patient using a format that enables information to be easily identified for clinical and auditing purposes.

3)              Organisational ability

General Practitioners are expected to be:

(a) Able to assess the health status, needs and expectations of the practice population;

(b) Able to plan, organise and manage a practice to provide a broad range of accessible services including the management of acute and chronic illness, medical emergencies, health promotion and preventative activities;

(c) Able to function as a member of a multidisciplinary, practice based team and, when appropriate, able to assume the responsibilities of team leader.   This will involve an understanding and appreciation of the roles, responsibilities and skills of other health care workers such as community nurses, practice nurses, health visitors and midwives;

(d) Able to make effective use of resources including, for example, money, time, skills, both within the outwith the practice setting;

(e) Able to organise and carry out effective clinical audit; and have the skills necessary to bring about change in the practice where audit shows this to be necessary;

(f)  Conversant with and willing to participate in the work of organisations that advise, plan and assist in the development and administration of health services, such as NHS authorities, medical Royal Colleges, professional associations, local medical committees and regional medical committees.

4)      The curriculum

The purpose of vocational training is to enable the GPRs to acquire the attributes described above.   Success will depend partly on the motivation and ability of the learner, partly on the quality of the learning opportunities provided in teaching practices and hospital posts, and partly on supporting courses and other educational activities.

The Joint Committee holds that it is the responsibility of regional postgraduate organisations to produce curricula and training programmes that will result in the achievement of the attributes described.   In this way regions and schemes can develop their own approach to a common goal, and through such diversity encourage innovation in the pursuit of high standards of training.

For the Joint Committee the test, when deciding on accreditation, is the extent to which the providers of training are able to demonstrate in objective terms that their trainees acquire the desired attributes both individually and collectively.

Appendix 2:        DUTIES OF A DOCTOR

·      make the care of your patient your first concern;

·      treat every patient politely and considerably;

·      respect patients’ dignity and privacy;

·      listen to patients and respect their views;

·      give patients information in a way they can understand;

·      respect the rights of patients to be fully involved in decisions about their care;

·      keep your professional knowledge and skills up to date;

·      recognise the limits of your professional competence;

·      be honest and trustworthy;

·      respect and protect confidential information;

·      make sure that your personal beliefs do not prejudice your patients’ care;

·      act quickly to protect patients from risk if you have good reason to believe that you or a colleague may not be fit to practice;

·      avoid abusing your position as a doctor; and

·      work with colleagues in the ways that best serve patients’ interests.

In all these matters you will never discriminate unfairly against your patients or colleagues.  And you will always be prepared to justify your actions to them.  For further information on how to apply these principles, please read our booklet ‘Good medical practice’.

‘Duties of a Doctor’, General Medical Council 1995

Appendix 3: LEARNING OPPORTUNITIES FOR NVTS REGISTRARS

 Notes:

You will be informed about all of the above opportunities by email or letter. The invitation will specify deadlines for application.

Further details of the PIMD courses are available from www.pimd.co.uk

Appendix 4: TIMETABLE OF MILESTONES FOR REGISTRARS

Appendix 5: MINIMUM CRITERIA FOR FORMATIVE (EDUCATIONAL) ASSESSMENT

NORTHERN DEANERY October 1996

As a minimum, the following formative assessments should be documented in each GP registrar's file. The file should also demonstrate that the educational programme is based upon the results of the assessments.

a)  Initial assessment

During the first month of each period of training in general practice GP registrars should complete a confidence rating and an MCQ.

b)  Regular assessment

Videotape assessment or joint consulting using a recognised assessment instrument should be completed at least monthly throughout the general practice component of training.

c)   Rating scales

A rating scale should be completed at least once during each period of training in general practice.

Examples of assessment instruments (not exclusive):

Overall rating scales

New Manchester Rating Scale, (available through the scheme office) New Northumbria Rating Scale (available at www.wellclosesquare.co.uk/training)

MCQ

'PEP' programme (which includes both an MCQ and a confidence rating scale (available from PEP office, RCGP (Scotland), 25 Queens Street, Edinburgh EH2 1JX) Northern Regional MCQ (available from the Cleveland Scheme Office, telephone number 01642 304151)

Video assessment

Northern Regional Video Assessment Instrument, LAP, Pendleton et al. (available at www.wellclosesquare.co.uk/training)

Confidence Rating scales

Northumbria confidence rating scale (available from scheme office), PEP (which includes both an MCQ and a confidence rating scale (available from PEP office, RCGP (Scotland), 25 Queens Street, Edinburgh EH2 1JX).

References

[1] Middleton and Field 2001 The GP Trainer’s Handbook Radcliffe Medical Press London   [2] Quality Assurance Agency for Higher Education 2002 Subject Benchmark Statement for Medicine QAA Gloucester   [3] General Medical Council 1993 Tomorrows Doctors GMC London   [4] Joint Committee in Postgraduate Training for General Practice 2003 Attribute Guide & Instructions JCPTGP London.   [5] Davis L N, McCallon E 1974 Planning, conducting and evaluating workshops – a practitioner’s guide to adult education. Learning concepts, Austin, Texas [6] Kolb D A, Rubin I M, McIntyre J M 1971 Organisational Psychology: an Experiential Approach Prentice Hall New York   [7] Bedi A 2002 Student profiling: the Dreyfus model revisited Education for Primary Care 2002, 14, 360-363   [8] Savage,R. 1991 Continuing education for general practice: a life long journey British Journal of General Practice 41: 311 –314   [9] Savage R, Savage S. 1994 From Curriculum to self-directed learning with vocational trainees. Education for General Practice.;5:120-134   [10] Department of Health 2000 The GP Registrar Scheme Vocational Training for General Practice. The UK Guide. DoH. London   [11] Dodd, M. J. Rutt, G.A. and Suchdev, M.S. 2002, Identifying and addressing registrar’s                             concerns and educational needs using a discomfort log Education for Primary Care, 13,490-496   [12] Neighbour R 1992 The Inner Apprentice Kluwer Academic London   [13] Howard, J. 1997 The emotional diary – a framework for reflective practice. Education for General Practice 8, 275-378   [14] Eve, R. 2000 Learning with PUNs and DENs – a method for determining educational needs and the evaluation of its use in primary care. Education for General Practice 11,73-79   [15] Freeman, M. 2001 Reflective logs: an aid to clinical teaching and learning International Journal of Language and Communication Disorders 36:411-416 [16] Rutt,GA. Dodd, MJ. 2002 Tutorial recording and feedback and its relationship with curriculum development, end-point assessment and appraisal Education for Primary Care 13: 358 –391

November 2003

Source:

Authors: NVTS

Editors: Hazel Chalmers and Graham Rutt, on behalf of the curriculum working party 2003

Acknowledgements: this document has evolved from the first edition in the 1980s. It represents a distillation of the views of many of the course organisers and trainers on the NVTS over that time. It is a living document and hence subject to constant review.

Address for correspondence:

Graham.Rutt@unn.ac.uk

Room A212

Coach Lane Campus

Benton

Newcastle upon Tyne

NE7 7XA

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