Gynaecological Surgery d Bisson
Transcript of Gynaecological Surgery d Bisson
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Training, Supervision andCompetency in Gynaecological
SurgeryDr Dina Bisson
Consultant Obstetrician and Gynaecologist andTraining Programme Director for O & G
Severn Institute, Bristol.
26 April 2007RCOG
London
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Training
Training refers to the acquisition ofknowledge, skills, and competencies as aresult of the teaching of vocational orpractical skills and knowledge that relatesto specific useful skills
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Supervision
Supervision means the act of watchingover the work or tasks of another who maylack full knowledge of the concept at hand.Supervision does not mean control ofanother but guidance in a work,
professional or personal context.
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Competency
Competence is the ability to performsome task
Unconscious incompetence
Conscious incompetence
Conscious competence
Unconscious competence
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Domains of Learning
Knowledge Exams MRCOG
Skills Surgical skills
Attitudes TO2
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Gynaecological Surgery
Selection of appropriate patient andprocedure
Pre operative preparation
Perform operation
Deal with complications and post operativecare
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Competency in Obstetric Practice
Decision Making
Communication with patient Communication with team
Practical skills
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Why an Issue in 2007?
Incompetent Gynaecological surgeons?
Last gynaecologist struck off medicalregister in 2002
Aware of changes to training and workingpractices
Risk Assessment
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Historical Training
See one do one teach one
Numerous opportunities for training Onerous rotas
Many routine open surgery cases
Higher throughput of cases
Hands on early in training
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Recent Training
EWTD/ Shift working
Protected teaching and study leave Cancellation of lists
Fewer routine cases
Laparoscopic techniques
Senior trainees need experience
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Historical Supervision
Apprenticeship/ Firm structure
Generalists Time expired senior registrars
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Current Supervision
No firm structure/ lack of continuity
Registrars less experienced Lists cancelled if no supervision
Specialisation
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Historical Competence
No test to pass
Longer/Time based training Competence assumed
FRCS
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Recent Competence
Core Log Book
Trainees decision
Lack of responsibility
No direct trainee contact
Annual RITA
Educational Supervisors report
Any concerns about operating skills?
Log of Experience
Number of cases/ expected minimum unknown
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Conclusions from Recent
Situation
Training and supervision in O & Gundergone radical change requiringinnovative methods to define competency.
Competency can no longer be assumed.
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Current Situation
New Curriculum defined by RCOG
New Log Book starts in year 1 New Training Programme
Competency not time based
New methods of assessment
Advanced Training Skills Modules
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New Curriculum
Defines knowledge and skills
Courses to attend
Methods of assessment
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New Log Book
Level of competency defined for each levelof training
No progression if not achieved
Evidence required for all signatures
Supervisors take responsibility for
signatures
Procedures broken down into stages
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Competency Based Training
Allows for different rates of progress
RecognisesH
igh Flyers Early detection of trainees in difficulty
Defined competencies for basic training
Targeted training
Transfer to another speciality?
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Competency Based Assessments
CbD
Mini CEX OSATS
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Case Based Discussion
Medical knowledge Clinical Decision making
Application of knowledge Formalised Case Discussion
CbD in gynaecological surgery
Selection of appropriate patient and operativeprocedure
Ability to deal with complications
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Mini clinical evaluation exercise Generic Tool used in Foundation programmes
Inpatient or outpatient episodes Direct observation by trainer Professional and Interpersonal skills 20 minutes per assessment
Immediate feedback to trainee
Mini CEX
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Mini CEX in gynaecological
surgery
Taking consent
Pre operative assessment Post operative review
Explaining results
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OSATS
Objective Structured Assessment ofTechnical Skill
Developed byU
niversity of Toronto in 1997 Measure technical ability of surgeons Standardised bench model simulators Multi station (OSCE) Validity
Content Construct Face Predictive
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OSATS in O & G
University ofWashington in 2000
Live animal models 7 station bench assessment
Task specific check list/ global rating scale
Expensive
Validity
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OSATS in O & G
Simulation
Reproducible
blind assessors
Feasible
Valid
?face validityVirtual reality simulators
Predictive validity?
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OSATS in real life
Work Based assessments
Opportunities for assessment every dayAssessments can be repeated
10 procedures in O & G
5 OSATS per procedure before signature
Different level of complexity
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OSATS
Opening and Closing Abdomen
Caesarean section
Perineal repair Manual removal of placenta
Fetal Blood Sampling
Operative Vaginal Delivery
Evacuation of uterus
Diagnostic Laparoscopy Diagnostic Hysteroscopy
Operative Laparoscopy
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OSATS
Two parts to the form
Checklist
Done independently/ needed help
All steps must be completed
Generic Technical skills
Not relevant to every procedure
Majority to the right side
Must fully understand areas of weakness
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Generic Technical Skills Assessment
INSIGHT /
ATTITUDE
Poor understanding of areas of
weakness
Some understanding
of areas of weakness
Fully understands areas of weakness
RESPECT FORTISSUE
Frequently used unnecessary force ontissue or caused damage by inappropriate
use of instruments
Careful handling of tissuebut occasionally causes
inadvertent damage
Consistently handled tissues appropriatelywith minimal damage
TIME & MOTION Many unnecessary moves. Frequently
stopped operating or needed to discussnext move.
Makes reasonable progress
but some unnecessarymoves. Sound knowledgeof operation but slightly
disjointed at times
Economy of movement and maximum
efficiency. Obviously planned course ofoperation with effortless flow from one
move to the next.
KNOWLEDGE /HANDLINGOFINSTRUMENTS
Lack of knowledge of instruments Competent use of
instruments butoccasionally awkward or
tentative
Fluid moves with instruments and no
awkwardness and obvious familiarity withinstruments
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Advanced Training Skills Modules
Benign Abdominal Gynaecology Surgery
Vaginal Gynaecology Surgery Hysteroscopic Surgery
Laparoscopic Gynaecology Surgery
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ATSM
Curriculum Defined
Methods of assessment Completion of module signed off
?may be part of future person specificationfor consultant posts
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Assessment of Consultant
Practice
Annual Appraisal
Record of Adverse Incidents Complication Rates
Use of Assessment Methods
Evidence of Competency
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Conclusion
Changes in Working Practices
Focussed Training Curriculum
Well Defined Supervision
Evidence Based Competency
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Conclusion
Ensure CompetentWorkforce
Maintain Public Confidence