CURRICULUM FOR THE

FOUNDATION YEARS IN

POSTGRADUATE EDUCATION

AND TRAINING

A Paper for Consultation

Produced by

F2 Curriculum Committee of the Academy of Medical Royal Colleges

in co-operation with

Modernising Medical Careers Implementation Group in the

Department of Health

Academy of Medical Royal Colleges

Modernising Medical Careersn

November 2004

FOREWORD

Dear Colleague

Modernising Medical Careers (MMC) aims to produce modern doctorsfor a modern NHS. In addition to the core Clinical Skills necessary todiagnose, treat and care for patients, today's doctors must be able todeliver care which is of consistently high quality. This means becomingknowledgeable and competent in fields like patient safety, clinicalgovernance, infection control and working in a team that would not inthe past have been regarded as a formal part of training curriculum orassessment programmes.

This curriculum has been developed in collaboration with the Academyof Medical Royal Colleges (AoMRC) in order to achieve MMC's aims. Iwould particularly like to thank Dr Edmund Neville (chair of the F2Curriculum Committee and former Director of General ProfessionalTraining, RCP) and Dr Alastair McGowan (MMC representative andPresident of the Faculty of Emergency Care). It sets out for the first time,a range of competencies against which doctors will be assessed in orderto establish future generations of accountable practitioners

ACurriculum needs to be owned by all involved in its day to day use. Itsdevelopment is a complex process and one that we have to get right. It is,therefore, essential that this consultation is as wide as possible. I inviteand encourage you to submit written comments on the curriculum ingeneral, or on specific sections, to be submitted during a consultationperiod commencing from Tuesday 2nd November 2004; ending onFriday 21st January 2005.

Email:

Post:Curriculum ConsultationEileen House2nd Floor, Room 21480-94 Newington CausewayLondon.SE1 6EF

consultation@mmc.nhs.uk

Very best wishes

SIR LIAM DONALDSON

CHIEF MEDICAL OFFICER

1

CONTENTS

FOUNDATION TRAINING CREDO 2

CORE CURRICULUM FOR THE FOUNDATION YEARS IN POST

GRADUATE MEDICAL EDUCATION AND TRAINING 3

INTRODUCTION 3

HOW TO USE THIS CURRICULUM 6

PART I: OVERVIEW 9

SUGGESTED LEARNING OPPORTUNITIES 9

CORE COMPETENCIES FOR FOUNDATION YEARS 13

ASSESSMENT WITHIN THE SECOND FOUNDATION YEAR 38

ASSESSMENT TOOLS 39

ACUTE CARE SCENARIOS 44

THE GOVERNANCE OF ASSESSMENT IN F2 47

PART II: THE CORE CURRICULUM 51

GENERIC SKILLS 51

1.1 GOOD CLINICAL CARE 53

1.2 COMMUNICATION SKILLS 60

1.3 MAINTAINING GOOD MEDICAL PRACTICE 62

1.4 MAINTAINING TRUST 64

1.5 TEACHING AND TRAINING 70

CORE SKILLS IN RELATION TO ACUTE ILLNESS 71

INTRODUCTION 71

2 (A) MANAGEMENT OF ACUTELY ILL PATIENTS 72

2 (B) RESUSCITATION 74

2 (C)i MANAGEMENT OF THE 'TAKE' 74

2 (C)ii DISCHARGE PLANNING 75

SELECTION AND INTERPRETATION OF INVESTIGATIONS 75

INVESTIGATIONS COMMONLY REQUESTED FOR

ACUTELY ILL PATIENTS 77

PRACTICAL PROCEDURES 78

PART III: APPENDICES 81

i Multi-Source Feedback for Foundation Programme 81

ii Mini-CEX for Foundation Programmes 86

iii DOPS for Foundation Programmes 91

iv Case Based Discussions for Foundation Programmes 95

v MEMBERSHIP OF F2 CURRICULUM COMMITTEE OF

ACADEMY OF MEDICAL ROYAL COLLEGES 100

vi MEMBERSHIP OF F2 ASSESSMENT WORKING PARTY

OF LONDON DEANERY 101

PART IV: ANNEX A - GUIDING PRINCIPLES 102

FOUNDATION TRAINING CREDO

“Bridging the gap between medical school and

specialist training, the foundation curriculum will

develop new doctors as accountable team

practitioners through establishing a learning

environment based on professionalism, integrity

and leadership.

Excellent communication practice and teamwork

will ensure that clinical governance, patient safety

and the patient personal experience are at the heart

of training doctors for the NHS.”

2

CORE CURRICULUM FOR THE

FOUNDATION YEARS IN POST

GRADUATE MEDICAL EDUCATION

AND TRAINING

INTRODUCTION

Healthcare professionals have as their primary goal the care and well being

of patients. This requires them to have a clear understanding of the best

care and treatment options available, combined with the skills and

professional judgement to implement these. Excellent communication, the

ability to work effectively in a team, self-awareness and insight, leadership

with a clear value based ethical framework underpinned by a holistic and

humane understanding, should all characterise the modern medical

practitioner. The shift in postgraduate medical education from apprentice

style training to working and learning in teams, with shared

responsibilities and accountabilities for patient safety and clinical

governance is the hallmark of recent changes in medical education.

In August 2002, Sir Liam Donaldson published , which

described the two year Foundation Programme, the first roughly equating

to the current pre-registration house officer year and the second with the

“ (to)

In 2003, he set up a UK Strategy Group to oversee

(MMC), an initiative designed to explain, facilitate and develop the

principles underpinning this major reform of postgraduate medical

education and training. In conjunction with the NHS, healthcare

professionals, educators, patients and students, and under the legislative

auspices of the General Medical Council ( GMC) and the Post-graduate

Medical Education and Training Board (PMETB), these important changes

are being taken forward.

While encouraging a wide diversity in competencies to be acquired during

foundation training, emphasised the diagnosis and

management of the acutely ill patient as a key aim of the programme.

Clinical governance, patient safety, infection control, excellence in

Unfinished Business

aim imbue trainees with basic practical skills and competencies in medicine.”

Unfinished Business

Modernising Medical

Careers

3

teamwork and the patient’s personal experience are the five lynchpins for

securing high quality clinical care. This foundation training aims to

establish a new generation of doctors who, early in their careers, are

characterised by the behaviours, attitudes and values required for excellent

healthcare interactions with patients, their carers and families

This curriculum can also be used in the first foundation year as it maps

onto the GMC’s Curriculum development after full

registration has been devolved by the Specialist Training Authority (STA) to

the Academy of Medical Royal Colleges. The STA and the Joint Committee

for Post Graduate Training in General Practice (JCPTGP) play a pivotal role

in maintaining standards and approving posts. In the future, these roles

will be taken over by PMETB as the Competent Authority for postgraduate

training. This curriculum complies with the 10 principles for training

produced by that organisation.

Achievement of the competencies described in the curriculum is the

minimum that must be achieved to successfully complete foundation

training. The curriculum is embedded within a structure that embraces

GMC and PMETB principles, whilst also being compatible with

international frameworks of professional medical practice. Figure 1 (page 5)

demonstrates the integration of the key components of the MMC

framework.

Foundation training is also designed to instil attitudes of life-long learning

in foundation trainees in order to underpin continuing professional and

career development. During the foundation years, career directions and

decisions will be made. Linking life-long learning and attitude towards

working practices and a medical career that is flexible and adaptable to the

needs of patient care and the NHS is a fundamental aspect of training.

The educational aims of the Core Curriculum are to develop generic skills,

knowledge, competencies and attitudes to ensure the highest professional

performance and conduct. Its explicit standards allow transparent and

impartial assessment by informed trainers and observers. As assessment

strategies and tools continue to evolve, the methods proposed in this

document may be refined or replaced as time progresses.

The clinical setting in which assessment is made is vitally important. It is

the responsibility of Trusts to ensure an appropriate educational

environment with opportunities for the trainee to gain the necessary

education and clinical experience to enable them to achieve and

.

The New Doctor.

4

demonstrate the required competencies. Those who assess the acquisition

of competencies in foundation trainees must be trained to do so.

The foundation curriculum puts quality of care and patient safety at the

centre of clinical practice. The skills, attitudes, behaviours and values that

constitute good medical practice are most effective when practiced with in

a structure that has patient safety, clinical governance and skilled patient

care at its heart (Figure 1).

This curriculum is a living document. It will need to grow and develop

with experience and as opportunities to innovate are taken. It is our hope

that it provides a way forward at a most exciting time of change in the

development of the young doctor.

Also including:

Effective relationships with patients

Clinical skills in managing acutely ill patients

The patient’s personal experience

Use of evidence and data

Time management and decision making skills

Information Technology skills

Learning and teaching

Excellence in teamworking

Effective understanding of the different settings in whichmedicine is practised

Ethics and law

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skilled

patient

careINTEGRITY

PROFESSIONALISM

COMMUNICATION

TEAMWORK

LEADERSHIP

clinicalgovernance

skilledpatient

care

safety

(Figure.1) THE ACCOUNTABLE PRACTITIONER

5

HOW TO USE THIS CURRICULUM

PART I

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The curriculum defines the knowledge, skills and attitudes that trainees

should demonstrate that they have learned. It is presented in specific

sections as listed below. Members of the public, medical and other

professionals not directly involved in the delivery of the curriculum should

find what they need to know of this development by reading Part I. Parts II

and III go into a level of detail that will be of more use to trainers and

trainees directly involved in Foundation Programmes.

SUGGESTED LEARNING OPPORTUNITIES.

This section gives guidance on how the learning objectives might

be achieved.

CORE COMPETENCIES

These are the Core Competencies in which all trainees will be

assessed and signed off by the end of F2. The domains map

directly to the Core Curriculum in Part II.

ASSESSMENT STRUCTURE

This section describes the assessment tools; how and when they

will be used – mini CEX, multi-source feedback (mini-PAT), direct

observation of procedural skills (DOPS) and case-based discussion

(CBD). It describes the Chief Medical Officer’s Good Practice

Principles for Assessment. The end point is satisfactory

completion of the Foundation Programme. The assessment tools

and process are not designed to rank the performance of trainees.

ACUTE CARE SCENARIOS FOR ASSESSMENT STRUCTURE OF

F2

This section lists a range of core acute presentations in which the

trainees’ performance can be assessed. These acute care scenarios

can occur in any area of clinical practice though many of them

may appear where acutely ill patients tend to present, ie, in A&E

and Acute Medical or Surgical Assessment Units. Trainees should

take responsibility for their own assessment taking place in at least

one of the acute care scenarios under each heading. The

assessment may be in one of several forms (see below).

6

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PART II

PART III

Careers Advice

THE GOVERNANCE OF ASSESSMENT IN F2

This section lists roles and responsibilities in the implementation

of Foundation Programmes.

CORE CURRICULUM

This is broken down into headings under Generic Skills based on

those propounded in the GMC document ‘Good Medical Practice’

and Core Skills for dealing with the acutely ill patient.

GENERIC SKILLS

History taking, communication skills, team working,

understanding safe and unsafe systems, the principles and practice

of clinical governance, the appropriate use of information and

evidence to underpin clinical decisions, skills in information

technology, recognising and supporting patients with special

needs (eg, disabilities), understanding of the need for medical

evidence in legal proceedings. Trainees should be able to

demonstrate at the end of their second Foundation Year that they

have developed their professional conduct to a standard that is

appropriate for entry into specialty training.

CORE SKILLS

APPENDICES

This section provides more detail on the assessment

methodologies that will be used and includes sample forms and

documentation.

Many

specialties will have trainees who intend to take up a career in general

For dealing with the acutely ill with special reference to patient

safety, specifically in areas of therapeutics, infection control and

the use of blood products.

Doctors who require generic or specialty advice should contact their local

Director of Postgraduate Education, Clinical or College Tutor.

The curriculum should guide professional development and, as such, it

should be used to help prepare Personal Learning Plans as part of the

trainee’s educational appraisal process.

7

practice, or are undecided on a career. Doctors who require guidance on

training for general practice should contact the local VTS Course Organiser,

or the GP Tutor, or could contact the Director of Postgraduate General

Practice Education, who will be a member of the Postgraduate Dean’s

department. The Joint Committee for Postgraduate Training in General

Practice issues Certificates of Completion of Vocational Training, and has

several useful documents including .

The Royal College of General Practitioners, in association with a number of

specialist Colleges, has produced a series of publications describing the

content of training in the medical disciplines relevant to general practice.

These booklets are available from the RCGP. Further information can be

found on the RCGP website

A Guide to Certification

www.rcgp.org.uk.

8

PART I: OVERVIEW

SUGGESTED LEARNING OPPORTUNITIES

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Adults learn by

good learning environment

self-directed learning

learning potential in all aspects of day-to-day work

positive

attitude to education and training

group discussion

supportive

open atmosphere

Reflecting and building upon their own experiences

Identifying what they have learnt and what they need to learn

Being involved in planning their education and training

Reflecting on the effectiveness of their learning and the nature of

learning experiences

For trainees to maximise their experiential learning opportunities it is

important that they work in a ‘ ’. This includes

encouragement for as well as recognising the

(eg, what three things

have I learnt from this ward round?) and generally adopting a

. Learning from peers should also be

encouraged and training should be ‘fun’ and above all stimulating.

Active involvement in the is an important way for

doctors to share their understanding and experiences. A good educational

programme should not therefore consist solely of lectures but also include

small group sessions with and without senior facilitation. A

should be cultivated and questions and challenges

welcomed.

To enhance long term understanding, rather than the mere acquisition of

short-term knowledge, trainees should be actively encouraged to record the

outcome of key educational experiences in a written or electronic format.

9

Such records may form part of the trainee learning portfolio, and may form

a basis for their professional revalidation portfolio. It should certainly

inform their personal learning plan.

Ward based learning including post take, business and teaching

ward rounds. Ward rounds, should be led by a consultant or a

senior trainee but should be co-ordinated by the trainee. Feedback

on clinical and decision-making skills must be given and good

patient care ensured by the senior members on the round. It can

also be used to direct future learning by highlighting areas where

knowledge or understanding requires development.

Supervised consultations in out-patient clinics, day hospitals,

community visits or other settings. Trainees should have the

opportunity to assess both new and follow-up patients and discuss

cases with the clinical supervisor to allow feedback on

communication and diagnostic skills, as well as the ability to plan

investigations.

In surgical and craft specialities, theatre or investigation sessions

offer practical opportunities for the acquisition of skills and the

understanding of clinically relevant anatomy.

Case studies and presentations with small group discussions,

particularly of difficult cases, including quality of care and patient

safety, using the electronic classroom where available.

Small group bedside teaching, such as training for a Postgraduate

diploma particularly covering problem areas identified by

trainees.

Consultations with simulated patients and subsequent small

group discussion.

Video consultation with subsequent small group discussion.

Small group sessions of data interpretation focused on the learning

needs of the trainees.

The list of learning opportunities below offers guidance only, there are

other opportunities for learning that are not listed here:

A Experiential learning opportunities:

1

2

3

B Small group learning opportunities:

1

2

3

4

5

10

6

7

8

9

10

C One to one teaching:

1

2

3

4

D External courses:

1

2

E Personal study:

1

2

3

F Audit:

1

2

Local resuscitation skills review by a resuscitation training officer

including simulation with manikins.

Active participation in protocol and guide-line development

meetings, journal clubs and research presentations.

Involvement in audit meetings including information access and

use of evidence in practice.

Procedural skill training in a Practical Skills Laboratory.

Multi-professional case discussion/significant event audit to

include quality assurance and risk assessment.

Review / case presentations with educational supervisor including

selected notes, letters and summaries.

Discussion between trainee and trainer of knowledge of local

protocols.

Video consultation with subsequent individual discussion with

trainer.

Clinical application and development of practical skills.

Lectures or courses, eg, Advanced Life Support course.

Formal training in communication skills, eg, use of simulated

patients.

Personal Study including CD ROM and distance (electronic)

learning.

Practice examination questions and subsequent reading.

Reading journals.

Rationale and methodology.

Trainees should be directly involved in the audit process by

undertaking one in-depth audit during the foundation years,

usually jointly with other trainees. This should be seen as a key

part of the wider issues of clinical governance and risk

management.

11

G Simulated clinical situations:

The rapid development of new technologies to simulate

real-life clinical situations will open up new

opportunities for team-based learning, particularly in

dealing with unexpected clinical occurrences and in

running patient safety ‘drills’.

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12

CORE COMPETENCIES FOR FOUNDATION YEARS

This document outlines core competencies for the second foundation year.

It has been prepared on behalf of the Academy of Medical Royal Colleges.

These competencies are derived from the GMC document ‘Good Medical

Practice’ and are

will empower the young doctor in the treatment of the

acutely ill patient. With equal importance, the competencies will develop

an , by inculcating an

awareness of the consequences of courses of action, and infection control

that instills in trainees the fundamental public health aspects of infection

control.

These competencies have explicit incremental standards that will be tested

in the workplace or increasingly, in the future, in sophisticated, simulated

clinical environments. Competencies can be developed by experiencing a

selection of a variety of common and important clinical scenarios (see

section 4). The competencies here described together with their nine point

scale and descriptors can be formatted to be used as a summative

assessment record or, more appropriately, as a formative educational tool.

There is some repetition in each competency domain but this overlap is

intended to reinforce the importance of some key skills.

A particular innovation in this curriculum is that these competencies which

include fields beyond traditional clinical skills (including the ability to

practise safely, to adopt the principles of clinical governance, to be an

effective team member or leader and to give priority to the patient’s

personal experience).

We suggest that competencies assessed as being at levels 1,2 or 3 indicate

that further attention is required in these areas. This would represent an

unacceptable level of performance for either F1 or F2.

Levels 4,5 and 6 represent standards which should be progressively

achieved from the beginning of F1 and should allow an incremental

progression to standards 7,8 and 9. These should be achieved by the end of

F2. If levels 7,8 and 9 are achieved during F1 they should be re-validated in

F2, where greater clinical responsibility is expected. Entry into the medical

register after completion of F1 is at the discretion of the GMC, who are

currently in the process of developing their criteria for this step. The GMC

document, ‘The New Doctor’ is a transition document acknowledging the

change from time based assessment to competency based assessment,

which will be the norm in the future.

the basis of the Foundation Year Two Curriculum (Part II).

These competencies

understanding of clinical governance, patient safety

13

(i) History Taking

Regularly structured interviews for the patient’s (carer’s) concerns, expectations and understanding to be identified and addressed

Good Clinical Care

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Accomplished, concise and focused (targeted)

history taking and communication, including

difficult circumstances

Incorporates clinical, social and psychological

factors. Gives clear information to patients

(carers), encouraging questions

Checks on the patients' (carers')

understanding, concerns and expectations

(ii) Examination

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Regularly fails to elicit physical signs of

common clinical problems

Frequently takes inappropriate short cuts

when examining

Routinely fails to adequately explain

procedures for intimate examinations

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Explains the examination procedure and

minimises patient discomfort

Can elicit individual clinical signs but may

lack co-ordinated approach and sometimes

fails to target detailed examination as

suggested from the patient's symptoms

Can perform a mental state assessment (see 2A

(x) and (xi))

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Elicits signs appropriately and with attention

to patient dignity

Demonstrates examination techniques to

others

7 8 9

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Clear history taking and communication with

patients (carers)

Appreciates the importance of clinical,

psychological and social factors

Attempts to incorporate the patients (carers)

concerns, expectations and understanding

4 5 6

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Incomplete, inaccurate and confusing history

taking from, and communication with,

patients (carers)

Fails to take into account the patients (carers)

concerns, expectation or understanding

May repeatedly upset patients (carers)

1 2 3

1.1ACore Competencies For Second Foundation Year

7 8 94 5 61 2 3

14

(iii) Therapeutics and Safe Prescribing

1.1A Good Clinical Care

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Fully aware of the sources of medication error

and ways to minimise it.

Facilitates F1 trainees on taking drug history,

obtaining prescribing information and

unambiguous prescribing

Describes the implications of pregnancy and

hepatic and renal dysfunction for safe use of

commonly used drugs

Routinely makes use of evidence on

appropriateness and effectiveness of therapies

in making prescribing decisions.

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Takes an accurate drug history

Uses the BNF and other sources to access

information

Prescribes drugs (including oxygen, fluids and

blood products) clearly and unambiguously

Describes common drug interactions and

allergic reactions

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Prescribing regularly shows lack of clarity

Repeatedly fails to take account of drug

history

Frequently fails to prescribe according to

standard BNF recommendations, including

potentially harmful interactions

Core Competencies For Second Foundation Year

7 8 94 5 61 2 3

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Time Management and Decision Making

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Prioritises and re-prioritises appropriately

Delegates or calls for help in a timely fashion

when he/she is falling behind

Decision making satisfactory even when under

pressure

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Needs occasional help with organisation and

prioritisation of tasks

Mostly re-prioritises appropriately and usually

calls for help when falling behind

Decisions generally satisfactory, though occasional

inadequacies when under work pressure

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Persistently failing to cope with own work,

despite advice, support and extra clinical help

Decisions frequently questionable

1.1B

Core Competencies For Second Foundation Year

7 8 94 5 61 2 3

(iv) Documentation, Information Management

Keeps accurate, legible, signed notes

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Keeps inaccurate or illegible notes with key

information missing

Does not update notes

Notes not attributable

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Routinely records accurate, logical legible

history which is timed, dated and clearly

attributable

Routinely records patients' progress including

management plans and discussion with

relatives and other health care professionals

Utilises information systems effectively.

Adapts style to multidisciplinary case record

where appropriate

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Demonstrates record keeping and

intra/internet access skills to F1 trainees or

students

Timely sending out of letters, discharge

summaries

Structures letters to communicate findings

and outcome of episodes clearly

Conveys the medico-legal importance of good

record-keeping to other trainees

7 8 94 5 61 2 3

1.1A Good Clinical Care

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Lacks knowledge or understanding of

common complications/side effects of

treatments / procedures

Fails to identify signs that might indicate acute

illness

Does not seek help appropriately

Consistently fails to hand over

Unaware of structures for clinical governance

Is reluctant to report critical incidents

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Describes common complications and side-

effects of treatments/procedures

Identifies and responds appropriately to

patients with abnormal signs

Recognises personal limitations and seeks help

at an early stage

Communicates effectively to ensure continuity

of care

Demonstrates appropriate aseptic techniques

to minimise spread of infection

Aware of basic clinical governance issues

Reports critical incidents appropriately

Participates in audit meetings

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Appropriately discusses potential advantages

and disadvantages of treatments/procedures

with patients (carers)

Encourages F1 trainees in the appropriate

response to patients with abnormal signs

Sets example by calling for help from appropriate

health care professionals in timely fashion

Demonstrates good handover to ensure

continuity of care

Helps others learn safety lessons

Core Competencies For Second Foundation Year

7 8 94 5 61 2 3

1.1C Quality and Patient Safety(i) Risk Management

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Has little appreciation of the nature of error

and how it relates to systems

Willing to manage any clinical situation even

when unfamiliar with it

Cannot give examples from the medical

literature of where unsafe systems have

caused deaths or serious harm to patients

Displays signs of carelessness or lack of

conscientiousness

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Understands the importance of systems factors

in promoting patient safety (and can draw

parallels with other industries)

Can cite examples of clinical situations which

are unsafe or have led to harm

Brings up safety issues at clinical team

meetings and grand rounds as opportunities

for learning.

Reports adverse events and near misses to

local and national reporting systems

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Demonstrates a full understanding of the scale

of adverse events in healthcare and how their

impact can be reduced

Understands the principles of root cause

analysis

Is very safety conscious in his/her day-to-day

practise

Can give examples of where he/she has

contributed to effective organisational learning

from a patient safety incident

Core Competencies For Second Foundation Year

7 8 94 5 61 2 3

1.1C Quality and Patient Safety(ii) Patient Safety

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Has little understanding of the principles of

quality assurance and quality improvement

Cannot give clear and comprehensive

description of his/her range of competencies

Would not see the poor performance of

another healthcare professional as his/her

business or see a need to do anything about it

1 2 3

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Understands how specific clinical processes

impact on the outcome of care

Can demonstrate how particular clinical

investigations, treatment or care plans are

quality assured

Recognises the limits of his/her own

competence and does not operate beyond

them

If he/she has concerns about the standard of

care or conduct of another practitioner, does

not hesitate to raise them with a senior

colleague

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Regularly identifies opportunities for quality

improvement and seeks to get them

implemented

Seeks and welcomes feedback from patients

and colleagues on the quality of care being

delivered

Works effectively with management and other

professional colleagues to create a culture

where quality assurance, quality improvement

and safety are part of everyday activities

Models his/her own style of practise on the best

clinical leaders and practitioners

Core Competencies For Second Foundation Year

7 8 94 5 6

1.1C Quality and Patient Safety(iii) Clinical Governance

2

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Offhand or brusque manner with patients

Regularly shows a lack of respect to patients

Condescending or patronising in dealing with

patients

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Allows patients time to talk and listens

actively

Directs patients and carers to other sources of

information & advice

Responds appropriately to cultural and

communication needs

Presents patients as people, not as a collection

of pathologies or conditions

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Explores the social/family context of the

patient’s health needs and preferences

Facilitates self-management by patients

Helps patients to express preferences and make

personal choices about treatment and care

Core Competencies For Second Foundation Year

7 8 94 5 61 2 3

1.1C Quality and Patient Safety(iv) Patient Focus

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Fails to wash hands between patients

Fails to apply standard universal precautions

Careless with aseptic technique

Inappropriate use of antibiotics

Is not up to date with own immunisations

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Competent aseptic technique

Considers risk of infection before undertaking

any procedure

Scrupulously minimises the risk of

transferring infection through personal

behaviour (eg, washes hands and/or uses

alcohol rubs)

Follows local guidelines for antibiotic use

Avoids posing risk to patients by own health

Describes the principles and sources of cross

infection

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Participates in surveillance systems

Meticulous in following aseptic technique (eg,

in inserting catheters or lines or assessing

wound healing)

Challenges others not observing best practice

in infection control

Encourages juniors in making infection control

routine part of everyday work

Core Competencies For Second Foundation Year

7 8 94 5 61 2 3

1.1D Infection Control

21

(i) Relating to Patients

1.2 Communication Skills

(ii)

Displays effective team working

Team Work

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Unable to communicate effectively with

colleagues and other health care professionals

Cannot work to common goal. Appears selfish

and inflexible

Displays arrogance and autocratic tendencies

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Listens to other health care professionals

and heeds their views

Has good understanding of other team

members’ competencies and care

philosophies

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Team goals put before personal agenda

Can demonstrate appropriate leadership skills

but at the same time works effectively with

others towards a common goal

� Demonstrates an ability to anticipate patients

(carers) needs, explains clearly and checks

understanding

�

�

�

Generally courteous, polite and considerate

with appropriate bedside manner

Respects patients (carers) views and

sensitivities, shows appropriate level of

emotional involvement in the patients (carers)

and family

Explains clearly

�

�

�

�

�

Inconsiderate of patients (carers) views and

sensitivities

Appears discourteous, insensitive and

uncaring

Fails to explain or check understanding

Short tempered and abrupt

Does not listen to patients, their relatives or

carers

Core Competencies For Second Foundation Year

7 8 94 5 61 2 3

7 8 94 5 61 2 3

22

(iii) Effectively manages patients at the interface of different specialties including that of Primary Care, Imaging and Laboratory Specialties.

1.2 Communication Skills

(i) + (ii) Regularly takes up learning opportunities and is a reflective self-directed learner

�

�

Positive approach to learning. Recognises

errors and mistakes and makes a serious

attempt to learn from them

Requires encouragement to take up learning

opportunities

�

�

�

Enthusiastic approach to learning

Demonstrates educational planning to address

relevant needs that arise during the course of

clinical practice

Appropriate engagement with available

learning opportunities

�

�

Consistently seeks to establish effective

communication with colleagues in other

disciplines

Ensures the primary health care team is aware

of the discharge of patients, especially those

who may experience difficulty on their return

to the community

�

�

�

Demonstrates an understanding of the

challenges of providing optimum care within

the unregulated environment of primary care

Arranges the referral/dissemination of

discharge information on patients to

appropriate primary care staff

Arranges appropriate urgent instructions and

chases results when necessary

�

�

�

Fails to recognise the expertise of colleagues in

other specialties

Takes little or no account of the impact of a

patient's discharge into the community

Demonstrates no awareness of support

service/personnel in primary care

1.3A Maintaining Good Medical Practice

Learning

Core Competencies For Second Foundation Year

7 8 94 5 61 2 3

7 8 94 5 61 2 3

�

�

Repeatedly fails to take up appropriate

educational opportunities

Unable to determine learning needs from gaps

in experience and/or feedback from others

23

(i) Critically appraises medical evidence including guidelines

1.3B

Evidence, Audit, Guidelines

(ii) Describes how audit can improve personal performance

� Has no knowledge of the audit cycle, or any

recognition of its relevance to the assessment

and improvement of clinical standards

� Understands the audit cycle and recognises

how it relates to the improvement of clinical

standards

� Has been actively involved in undertaking a

clinical audit, and recognises how it relates to

the improvement of clinical standards and

addresses the clinical governance agenda

�

�

�

�

Implements the available evidence base in

most areas of clinical care

Seeks out opportunities to discuss with

colleagues

Supports patients (carers) in making sense of

the evidence base in terms of their personal

circumstances

Seeks to refine local guidelines/protocols

�

�

�

Able to critically appraise evidence base of

medical care

Will enter discussions with colleagues and

patients (carers)

Applies local guidelines/protocols

�

�

�

Fails to demonstrate knowledge or

understanding of the evidence base in medical

care

Avoids discussions with colleagues and

patients (carers) on evidence based practice

Ignores or unaware of local guidelines/

protocols

Maintaining Good Medical Practice Core Competencies For Second Foundation Year

7 8 94 5 61 2 3

7 8 94 5 61 2 3

24

(i) Consistently behaves with honesty and sensitivity in a professional manner

Professional Behaviour and Probity

�

�

�

Appropriate attitude with consistently high

standards of preferred behaviour

Fosters trust amongst others and promotes

sensitivity to others 'feelings' and needs

Coaches F1 trainees in these attitudes

�

�

�

�

Is sensitive to the feelings and needs of

patients and relatives

Places the needs of patients above his/her own

convenience

Recognises challenging or difficult situations

and calls for help without causing upset or

offence

Only shares clinical information, whether

spoken or written, with appropriate

individuals or groups

�

�

�

Poor attitude, exhibits low standards of

personal behaviour

May be inconsiderate, impolite, discriminatory

or judgemental

Behaviour may be inappropriate

1.4ACore Competencies For Second Foundation Year

7 8 94 5 61 2 3

25

Core Competencies For Second Foundation Year

� Fails to demonstrate doctors' responsibilities in

obtaining properly valid consent

�

�

�

Needs support and advice in understanding

what treatments/procedures can/cannot have

valid consent obtained by an F1 or F2

(whichever is relevant) trainee

Can discuss the implications of a living will or

advance directive

Can describe the difference between consent,

assent and capacity

�

�

�

�

�

Gives the patient (carer) appropriate

information in a manner he/she can

understand to obtain valid consent

Refers consent requests to appropriate senior

colleagues

Checks that the patient (carer) has understood

the relevant information

Describes the uses and limitations of the

Mental Health Act in consent issues

Instructs F1 trainees or students on living wills

and advance directives

(ii) Valid Consent

7 8 94 5 61 2 3

�

�

Unable to provide any meaningful definition

of patient's best interest, autonomy and rights

in relation to cases he/she has managed

Little or no understanding of patient

confidentiality

�

�

Demonstrates a basic understanding of the

principles of patient's best interests, autonomy

and rights in relation to recent cases

Uses and shares clinical information

appropriately, or seeks advice when uncertain

�

�

Appropriately modifies patient's management

plans in accordance with the principles of

patient's best interests, autonomy and rights

Encourages students and F1 Trainees in

confidentiality issues.

(i) Medical Ethical Principles

1.4B Ethics and Legal Issues

7 8 94 5 61 2 3

26

Core Competencies For Second Foundation Year1.4B Ethics and Legal Issues

�

�

Denotes little or no knowledge of this legal

framework that relates to medical practice,

hence is unaware of the differences between

criminal and civil law

No familiarity with the concept of legal

precedent or the legal principles of negligence

�

�

Knows about the legal framework that relates

to medical practice but experiences some

difficulty in applying this to day-to-day

management of patients

Understands the role of medical evidence in

court and other legal proceedings

� Understands the legal framework that relates

to medical practice and utilises this knowledge

to modify treatment plans, intervention with

other professionals and patients

(iii) Legal framework for medical practice

7 8 94 5 61 2 3

�

�

Teaches and supports students and trainees in

one to one settings

Demonstrates some understanding of how

adults learn (see 1.3A)

�

�

Prepares and presents to a small group, using

a variety of teaching materials

Demonstrates learner-centred approach

1.5 Teaching

�

�

Refuses to take up teaching opportunities

and/or support the learning of students

Unable to prepare and present an educational

event using even the most basic teaching materials

7 8 94 5 61 2 3

27

Core Competencies For Second Foundation Year

(i) Promptly assesses airway, breathing, circulation in the collapsed patient

Acute Care

As preceding, plus…

Makes a clinical assessment of adequacy of

cardiac output & oxygen delivery

Capable of leading multi-disciplinary team

Helps others stay calm

�

�

�

�

�

�

�

�

Completes initial assessment within 2-3

minutes

Supports and clears airway

Observes respiratory pattern and rate,

identifies inadequate ventilation

Assesses pulse rate, rhythm, volume

Measures blood pressure using automated

methods or sphygmomanometer

�

�

Fails to respond promptly to calls for help

Slow, incomplete or unstructured initial

assessment

2A

7 8 94 5 61 2 3

28

(ii) Identifies & responds to acutely abnormal physiology

7 8 94 5 61 2 3

�

�

�

�

Fails to focus on correcting abnormal

physiology as a priority

Lacks understanding of clinical relevance of

abnormal vital signs

Uses oxygen or intravenous fluids in a

potentially unsafe manner

Prioritisation of initial intervention

inappropriate

� Fails to monitor effect of interventions

�

�

�

Administers oxygen safely, monitors efficacy

Identifies and attempts to correct hypotension

appropriately

Identifies oliguria, checks for common causes,

intervenes appropriately

�

�

�

�

Interprets abnormal vital signs correctly in

context

Anticipates and prevents deterioration in vital

signs

Recognises patients at risk

Investigates causes for abnormal vital signs

2A Acute CareCore Competencies For Second Foundation Year

29

(iv) Reassesses acutely ill patients promptly following initiation of treatment

7 8 94 5 61 2 3

�

�

Is unreliable in performing regular review of

acutely ill or unstable patients

Does not pass on information to other

members of the health care team to ensure

continued review

�

�

�

Implements a system of regular checking of

unstable patients

Calls for help if patient does not respond to

initial measures

Makes patient safety a priority

�

�

Provides clear guidance to colleagues about

monitoring

Supports nursing staff in designing and

implementing monitoring or calling criteria

Core Competencies For Second Foundation Year2A Acute Care

(iii) Where appropriate, delivers a fluid challenge safely to an acutely ill patient

7 8 94 5 61 2 3

�

�

Reviews impact of fluid administration on

organ system function

Considers additional electrolyte replacement

requirements

�

�

�

�

Selects an appropriate fluid for intravenous

resuscitation

Sets up fluid administration giving set

correctly

Administers fluid bolus(es), observes

response, ensures continued administration

with monitoring of effect to desired endpoints

Identifies hypokalaemia and chooses a safe &

effective method of potassium

supplementation

�

�

Regularly fails to identify need for a fluid

challenge

Unable to distinguish between different fluids

30

Core Competencies For Second Foundation Year

(vi) Undertakes a secondary survey to establish a differential diagnosis

�

�

Fails to consider underlying cause for

deterioration

Inaccurate examination technique, mistakes or

overlooks important clinical signs

�

�

�

Recognises the importance of iterative review

Competent history taking and clinical

examination

Arranges basic laboratory tests

�

�

�

Focused further history taking in difficult

circumstances and/or when patient unable to

co-operate (see 1.A)

Rapidly identifies clinical signs, links them to

the history to form a differential diagnosis

Plans appropriate investigations to confirm or

refute a diagnosis

7 8 94 5 61 2 3

2A Acute Care

(v) Requests senior or more experienced help when appropriate

�

�

�

Prioritises problems

Puts the patient first

Seniors are confident in his/her judgement

�

�

Analyses clinical problems, considers possible

causes & solutions

Calls for help or advice appropriately

�

�

�

�

�

Permits problems to remain unresolved

without seeking help

Does not make decisions

Seeks help all the time

Over-confident

No insight into own limitations

7 8 94 5 61 2 3

31

Core Competencies For Second Foundation Year

(viii) Manages patients with impaired consciousness including fits

�

�

�

Omits major supportive measures

Unaware of complications of anticonvulsant

therapy

Fails to provide a safe environment for the

patient, including seeking senior assistance

�

�

�

�

�

Appreciates urgency

Administers oxygen, protects airway in

unconscious patient

Places unconscious patient in recovery position

Calls for help if fitting does not respond to

immediate measures

Follows local protocols

�

�

�

Seeks and corrects abnormalities of

physiological signs, particularly hypoxaemia,

hypotension, hypoglycaemia and electrolyte

disturbances

Questions and discusses scientific content of

protocols in use

Capable of leading multidisciplinary team

7 8 94 5 61 2 3

2A Acute Care

(vii) Obtains an arterial blood gas sample safely, interprets results correctly

�

�

Communicates significance of acid base

disturbances to others in the team

Directs corrective measures

�

�

�

�

Takes an arterial sample safely using a

heparinised syringe

Describes common causes of abnormal values.

Interprets results in context

Documents results clearly in the case record

�

�

�

Fails to understand the need for arterial blood

gas sampling and often omits or delays taking

the sample

Does not know the main indications and

contraindications for sampling

Fails to attend to patient comfort during the

procedure

7 8 94 5 61 2 3

32

Core Competencies For Second Foundation Year2A Acute Care

(ix) Safely uses common analgesic drugs

�

�

�

Considers the effect of hepatic and renal

dysfunction on analgesic pharmacology

Makes patient comfort a priority

Assesses the effect of prescribed analgesia in a

timely manner

�

�

�

�

�

Evaluates the patient in pain

Prescribes opioid and non-opioid analgesic

drugs safely

Re-evaluates the efficacy of analgesia in a

timely manner

Monitors patients for common side effects of

analgesic drugs

Safely uses anti-emetic drugs to treat or

prevent nausea & vomiting

�

�

�

�

�

Does not routinely seek information about

patient comfort

Fails to review patient's comfort in a timely

manner

Lacks knowledge of side effects of commonly

used analgesic drugs

Prescribes analgesics unsafely

Fails to consider interactions between

patient's condition and side effects of

commonly used analgesics

7 84 5 61 2 3 9

33

(xi) Describes the management of a patient with an acute psychosis

�

�

�

�

Protects patient and colleagues from harm

Safely administers anti-psychotic drugs

Initiates requirements of the Mental Health

Act

Considers underlying causes of psychosis

�

�

�

�

Recognises diagnostic features of psychosis

Summons experienced help promptly

Discusses safe administration of anti-psychotic

drugs

Discusses provisions of Mental Health Act

�

�

Fails to recognise features of psychosis

Unaware of provisions of Mental Health Act

Core Competencies For Second Foundation Year

7 8 94 5 61 2 3

2A Acute Care

(x) Explains the principles of managing a patient following self-harm

�

�

�

Fails to consider possibility of self harm as

cause for patient's presentation

Omits appropriate investigations in patients

who present after self-poisoning

Does not identify main monitoring goals

�

�

�

�

�

�

Focused history taking, including

psychosocial causes requiring social services

or police intervention

Accesses Toxbase when necessary

Recognises need for involvement of Mental

Health or more experienced personnel

Demonstrates tolerance & understanding

Performs a mental state assessment

Demonstrates an awareness of child

protection concerns where appropriate

�

�

�

Protects and supports colleagues faced with

an abusive patient

Anticipates necessary steps to minimise risks

to patient

Initiates referral to mental health services

where appropriate

7 8 94 5 61 2 3

34

Core Competencies For Second Foundation Year

(xii) Ensures safe continuing care of patients between shifts/on call staff

�

�

�

�

Does not pass on information about at-risk

patients

Fails to prioritise patients according to their

condition

Unpunctual, unreliable

Fails to complete some important tasks

�

�

�

�

Accurately summarises main points of

diagnosis, active problems, and management

plan

Provides clear information to colleagues

Attends handovers punctually

Focuses on teamwork

�

�

Supports colleagues in forward planning at

handover

Anticipates potential problems for next shift

and takes pre-emptive action

7 8 94 5 61 2 3

(xiii) Considers appropriateness of interventions according to patients' wishes

�

�

Proactive in identifying patients for whom

resuscitation or advanced care might be

inappropriate (see 2Bii)

Demonstrates sensitivity in the planning of

complex ethical decisions

�

�

�

�

Efficiently extracts information from history &

examination which would influence treatment

intensity decisions

Seeks information from relatives if appropriate

Discusses factors influencing the use of do-not-

resuscitate decisions (see 2Bii)

Balanced view of benefits and harms of

medical treatment

� Fails to demonstrate sensitivity to patient's

preferences and cultural norms

7 8 94 5 61 2 3

2A Acute Care

35

Core Competencies For Second Foundation Year

(ii) Discusses Do Not Attempt Resuscitation (DNAR) orders/advance directives appropriately.

�

�

Discusses the DNAR criteria and their legal

framework with colleagues including nurses

and also relatives

Encourages regular review of this order and

takes appropriate action if challenged

�

�

�

Understands the criteria for issuing orders and

level of experience required to issue them

Can discuss with colleagues including nurses

and also relatives

Facilitates the regular review of DNAR

decisions and understands actions required if

decision challenged

�

�

Does not understand the importance of timely

DNAR decisions and their discussion with

patients, relations and/or colleagues

Ignores advance directives. May cause

unnecessary upset

7 8 94 5 61 2 3

Resuscitation2B(i) Resuscitation training

7 8 94 5 61 2 3

Successfully trained to the STANDARD of

Intermediate Life Support (ILS)

Successfully trained to the STANDARD of

Advanced Life Support (ALS)

36

(i) Participates in acute admission management with appropriate organisation and understanding of role(s).

�

�

�

Attends hand-over/briefing

Accepts direction/advice and allocation of

tasks from seniors

Prioritises and knows when to seek timely

advice from colleagues

�

�

Can and sometimes does organise hand-over,

briefing and task allocation

Knows when/who to call for help and advises

F1 trainees about this

Organisation and Teamwork2C

�

�

�

Not a team player

Does his/her own thing with regard to task

performance and takes minimal account of

the work level of others around them

Missed handovers/briefing on a regular basis

7 8 94 5 61 2 3

7 8 94 5 61 2 3

(i) Requests and deals with common investigations appropriately

3 Investigations

�

�

Supports F1 trainees or students in making

appropriate requests for, interpretation of,

and action on, normal and abnormal

results, for common investigations

Understands local systems and asks for

help appropriately from the relevant

individuals

�

�

�

�

Requests common investigations

appropriately for patients' needs

Discusses risks, possible outcomes and later

results with patients (carers) appropriate to

level of expertise

Recognises normal and abnormal results.

Prioritises importance of results and asks

for help appropriately

�

�

�

Regularly fails to order appropriate basic

investigations

Fails to recognise normal and abnormal

results of common investigations

Fails to ask for help or take appropriate

action thereon

Core Competencies For Second Foundation Year

37

ASSESSMENT WITHIN THE SECOND

FOUNDATION YEAR

AIM: To provide an assessment programme that samples the range of

medical practice and is able to facilitate quality improvement. All the

assessment tools used within the programme facilitate and enable

supportive feedback that will inform personal professional development.

The overall assessment record will provide evidence that will inform

progress to the next stage of training.

knowledge

performance

Foundation programmes aim to equip the newly registered doctor with the

key generic skills required of a medical professional engaged in life long

learning. These skills and attributes are listed in the GMC’s

.

In the past, assessment in medicine has tended to focus on the assessment

of . Knowledge is necessary but not sufficient to meet the

requirements of GMP. The assessment programme outlined below is

designed to measure a doctor’s in a variety of settings.

The F2 assessment programme is intended largely as a formative process of

quality improvement that will benefit trainees, assessors and the public.

Assessment will be trainee-led with timing of assessments and choice of

assessors being trainee determined. All trainees will be expected to

maintain a Portfolio that will contain evidence from these assessments.

Trainees may wish to collect additional material in their Portfolio to

demonstrate their overall professional development. Developmental needs

and strengths will be identified from all the assessments which trainees

should discuss with their Educational Supervisor. This will inform the

individual’s personal development plan.

A variety of assessment tools will be used which have the common

characteristic of seeking to capture what actually happens in practice. The

programme will assess performance in relation to the domains of GMP and

the core competencies of the F2 curriculum through sampling a range of

common and important problems likely to be seen by all trainees in F2.

Good Medical

Practice (GMP)

38

Generic skills

Acute care

knowledgeskills

attitudes

The conditions were originally selected from a problem list developed as

part of the undergraduate curriculum at Sheffield but have been reduced in

number and grouped under appropriate clinical headings. The programme

seeks to build on, not revisit that curriculum (see figure 2). These problems

are listed as Acute Care Scenarios later in this section.

Educational Environment

Visit endoscopy unit and see procedure

Heard of the procedure

Know indications for procedure

Watch an expert obtain consent

Know common complications

Be able to explain procedure and take

consent from a competent patient

Be able to assess capacity

Explain to patient and carers

benefits vs risks of procedure

Answer Qs and concerns

Figure 2: Example spiral curriculum: consent for upper GI endoscopy

ASSESSMENT TOOLS

�

�

Multi-source Feedback (Mini-PAT: Peer Assessment Tool)

Collated views from a range of co-workers (previously described as 360

assessment).

°

This should be undertaken once in the F2 year.

It is suggested that collated feedback be provided after the first six

months in programme. The exact timing will depend on the length

of posts on the rotation.

Based on Harden RM, Davis MH and Crosby JR. Medical education1997;31:264-271.

39

�

�

�

�

�

�

�

�

�

�

�

�

�

For four month posts, feedback at eight months based on mini-

PAT collated from the first and second posts. Trainees nominate

eight raters from each of these posts, mid-October and mid-March.

For six month posts, feedback at seven months based on first post.

Trainees nominate twelve raters mid-November (if three month

posts, then six for each part).

Majority of raters should be supervising consultants, GP

principals, specialist registrars and experienced nursing or Allied

Health Professional (AHP) colleagues.

Suggest six observed encounters over the year (two per four

month attachment).

Different observer for each.

Observers may be experienced SpRs, consultants or GP principals.

Each mini-CEX represents a different clinical problem sampling

each of the acute care categories listed below.

Trainee chooses timing, problem and observer.

Suggest 1 - 2 observed procedures per placement.

Different observer for each procedure.

Observers may be consultants, GPs, SpRs, suitable nurses or

AHPs.

Each DOPs should represent a different procedure sampling from

the acute care skills listed in section II (Page 74-76).

Trainee chooses timing, procedure and observer.

Mini Clinical Evaluation Exercise (mini-CEX)

Direct Observation of Procedural Skills (DOPS)

Evaluation of an observed clinical encounter with developmental feedback provided

immediately after the encounter.

Structured check list for the assessment of practical procedures.

40

Case Based Discussion (CBD)

Anticipated Time Required

This assessment tool will be phased in over second half of year for

the F2 pilots commencing August 2004.

Comprises a structured discussion of real cases in which the

trainee has been involved.

Allows trainee’s decision making and reasoning to be explored in

detail.

It is recognised that meaningful assessment will involve committed time

from those involved with the assessment process. In order to minimise the

assessment burden, feasibility has been a prime consideration when

designing the assessment methodology and implementation. A number of

healthcare professionals can be involved so that the burden on any

individual should be relatively small. The table below summarises the

overall assessment time required per trainee for the whole year.

Structured discussion of clinical cases managed by the trainee. Its particular

strength is evaluation of clinical reasoning.

More detailed description of all the methodologies can be found in Part III of this

document.

�

�

�

Time per

assessment

for supervisor

(minutes)

6

20

15

10 + 10 prep

Number of

assessments

per

placement

5

2

1-2

1-2

Typical number

of raters/

assessments

over year

Up to 16 in first

two 4 month

placements

6

4

4

Total direct

contact time

per year

(minutes)

N/A

120

60

80

Tool

SPRAT

Mini-CEX

DOPs

CBD

TOTAL time: 4 hrs 20 minutes

Mini-PAT

DOPS

41

Training the Trainers

This programme requires a faculty trained in the methodology and specific

content of the assessment strategy. Training in feedback and appraisal skills

is also necessary since the assessment process involves formative and

summative assessment. Many of the faculty will already be part of the

current healthcare workforce and may already have some training in these

areas. Training packages, however, need to be sufficiently flexible to train

those already in the workforce and to support new entrants. It will need to

be accessible to several thousand clinicians, including medical staff

(consultants and SpRs), senior nurses, midwives and allied health

professionals. While guidance on the assessment tools used in the

programme is included in Part III of this document, further training for

trainers is essential.

There are a number of levels and learning approaches at which such

training can be delivered:

An e-learning web-based programme can be developed rapidly

and has the potential to train a large number of people in work-

place assessments by demonstrating the principles and practice

through videos and good practice (such a programme is already

available for training in appraisal skills and can be accessed at

www.appraisal-skill.nhs.uk).

Facilitated training at local trust or Deanery level can be

implemented and will support web-based training but will take

longer to get wide-coverage and will require a greater and more

sustained resource input, both in terms of funding and of

faculty/trainee time.

�

�

42

Patient Portfolio SLI Video

assessment review

Clinical care

Acute care

Decision making

Communication

skills

Communication

skills

Legal/ethics

Time management

Maintaining GMP

Assessment framework

GMP domains

Good clinical care

Relationships with

patients

Working with

colleagues

Dealing with

problems in

professional practice

Teaching training,

assessing, appraising

Health and probity

Maintaining GMP

NATIONAL F2 PILOT OTHER POSSIBLE TOOLS

Evidence to be retained in portfolio, not

centrally submitted

Mini-CEX Mini-PAT DOPS CBD

PR

OF

ES

SIO

NA

LIS

M*

Mini-CEX: Mini- Clinical Encounter Exercise, Mini-PAT = Peer review Assessment Tool (Multi-Source Feedback), DOPS: Direct observation of practical

skills, CBD: Case based discussion, SLI - Specific learning incident (Critical incident)

*Note: While professionalism encompasses all areas of practice mini-CEX includes a specific evaluation of this within the clinical encounter.43

ACUTE CARE SCENARIOS

�

�

�

�

�

�

Generic skills acute care

workplace

and form the two main themes of F2. By assessing

performance in the management of acute cases, we can assess not only the skills of

acute care (such as rapid assessment of airway, breathing and circulation) but also

the generic skills which underpin that performance (such as team work,

communication and identifying priorities). F2 will focus on learning in the

and much of the assessment in F2 will occur there. However other

learning and assessment environments such as short courses and simulation may

be used to supplement experience available in the workplace.

The clinical conditions/presentations listed below are offered as a “menu”

from which the trainee should select topics for the assessments. A range of

assessment tools will be used to evaluate the acquisition of knowledge,

skills and attitudes within a particular setting. The trainee and educational

supervisor should ensure that over the course of the year at least core

problem from within each grouping is assessed.

The environment in which these conditions are managed will require

similar core skills but the management options will be different. For

example the management of chest pain in primary care and secondary care

have similarities but significant differences. F2 doctors should demonstrate

an awareness of how to manage patients in different settings.

Acute presentations in any of the workplace settings that will be

experienced in F2 can be grouped in terms of patients who have:

AIRWAY problems

BREATHING problems

CIRCULATION problems

NEUROLOGICAL problems

PSYCHOLOGICAL/BEHAVIOURAL problems

PAIN

one

44

All doctors will be expected to:

Be aware of any existing national guidelines for the above

conditions.

Demonstrate the ability to manage a cardiac arrest by having

evidence of performance to the STANDARD of ILS or ALS.

Understand how the above core presentations differ in the elderly

and in children.

Recognise vulnerable patients.

Understand the principles of child protection.

Be able to recognise situations where the airway may be

compromised.

Perform simple airway manoeuvres (with adjuncts).

Know the indications for tracheal intubation.

Be able to manage the core presentations of:

Unconscious patient

Anaphylaxis

Stridor

Always assess breathing (rate, depth, symmetry, oxygen

saturation).

Recognise that a high respiratory rate needs further evaluation.

Be able to manage the core presentations of:

Asthma

COPD

Chest infection/pneumonia

Pneumothorax

Left ventricular failure

Pulmonary embolism

The F2 doctor should be able to recognise and demonstrate their

understanding of the management of the following:

Airway problems

Breathing problems

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Circulation problems

Neurological problems

Psychological/behavioural problems

Be able to assess the circulation (heart rate, blood pressure,

perfusion).

Know when a fluid challenge is required.

Be able to manage the core presentations of :

Bleeding

Severe sepsis

Tachyarrhythmias

Bradyarrhythmias

Volume and electrolyte depletion from diarrhoea/vomiting

Hypotension in acute coronary syndromes

Oliguria

In addition to the management of the unconscious patient (above).

Be able to manage the core presentations of :

Collapse - ? cause

Seizures

Delirium

Meningism

Hypoglycaemia

Acute onset of focal neurological signs

Demonstrate a basic understanding of the Mental Health Act.

Be able to manage the core presentations of :

Overdose /other self harm

Violence /aggression

Substance abuse

Acute psychosis

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Treating pain

Implementation of Foundation Programmes

Understand the analgesic ladder.

Treat acute pain promptly and effectively( using appropriate

analgesia).

Be able to manage the core presentations of :

Chest pain

Abdominal pain

Severe acute headache

Large joint pain

Back pain

Injuries

Postgraduate Deaneries will have overall responsibility for implementing

Foundation Programmes. The General Medical Council (GMC) sets the

standards for the content and delivery of training for the first Foundation

Year (F1/PRHO). These are described in detail in GMC’s document,

. In practice the operational processes of quality assuring the

training during this year is usually delegated to the Postgraduate Dean

who undertakes this on behalf of the medical school/University. It is

anticipated that these arrangements will continue unchanged.

Setting standards for the quality assurance of training in the second

foundation year (F2) will be the responsibility of the Postgraduate Medical

and Education Training Board (PMETB).

The governance structure of Foundation Programmes will be key to their

success. Deaneries will be responsible for ensuring that an appropriate

structure is put into place, but a framework will need to be consistently

applied across all programmes.

The

New Doctor

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THE GOVERNANCE OF ASSESSMENT IN F2

47

Educational supervisors

Responsibilities of the Trainee

All Foundation trainees will need to have a named educational supervisor

who will act as a source of support and educational advice and be

responsible for ensuring that the trainee:

Participates in an induction programme

Has regular appraisal

Understands and engages in the assessment process

Educational supervisors will usually be responsible for up to 4 - 6 trainees

and will continue to supervise each trainee throughout the F2 year and,

preferably, throughout the Foundation Programme. They should be trained

for the role and must have designated time to ensure that their

responsibilities to trainees are met. They will be the first point of contact

for trainees. Many educational supervisors for foundation programmes will

already be educational supervisors for PRHOs and will already be trained

for the role.

If the relationship between educational supervisor and a trainee is

perceived to be unsuccessful by either, then the trainee should approach

the local Foundation Programme Director or lead who will act as “honest

broker” and allocate a new educational supervisor to the trainee.

For successful completion of foundation programmes, trainees will be

required to:

Demonstrate professional behaviour in accordance with Good

Medical Practice (GMP).

Seek help from appropriate people to address any problems that

may arise.

Engage with the processes of education and appraisal eg, attend

educational sessions and use documents provided.

Proactively take responsibility for their own assessment in the

work place and use the available methods.

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Assessment

F1 assessments

F2 assessments

Summative assessment

Details of the assessment strategy and process are given earlier in this

document. The key principles of the assessment process are that it is:

Trainee led

Based on in-work assessment

Open and transparent process

Aiding trainee development

Summative

It will be based on the Chief Medical Officer’s Best Practise Principles in

Assessment (Annex A).

The outcomes of Foundation Programme assessment are:

– the areas of competence identified by the GMC in the

New Doctor will need to be demonstrated in order that full

registration of the doctor can be recommended to the GMC (F1

assessments have not been addressed in this document).

– the trainee will provide evidence through the in-work

assessment tools described in this document that the core areas of F2

competence have been met. A summative assessment process at

the end of F2 will consider this evidence and certify that the F2

competencies have been met.

Ultimately, it is anticipated that the in-work assessments for each trainee

will be collated and analysed across all of the clinical and generic skill

domains, enabling the production of a summative assessment for each

individual F2 doctor. This will be returned to each deanery and will enable

the deanery to sign off F2 doctors as having successfully achieved the

competencies required of the second foundation year.

Until centralised evaluation is fully implemented, Deaneries will need to

set up summative assessment panels to review the work-based assessment

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outcomes. Trainees need not be involved in this final summative process.

Although it is anticipated that most F2 trainees will be successful in

achieving the F2 competencies there need to be systems in place for doctors

who are having difficulties. Doctors in this situation may be identified by:

Their reluctance/failure to participate in educational processes

Reluctance/failure to engage fully in the assessment process

Concerns raised by educational supervisors

Serious incidents/events/complaints

Under such circumstances it is essential that issues are raised in a timely

fashion with the trainee concerned. The education supervisor should seek

early advice from the programme director, the Head of the Foundation

School or the Deanery. Deaneries should have clear processes in place, of

which, both the Foundation School faculty and trainees are aware. It is

likely that further assessments that may include tests of knowledge and

competence will be necessary for the very small number of trainees who

remain in difficulty despite supportive measures (possibly targetted Case

Based Discussion).

Part of this will require a clear appeals process which trainees can invoke if

they feel they are being treated unfairly. Each Deanery must have a written

appeals process.

When things go wrong

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PART II: THE CORE CURRICULUM

GENERIC SKILLS

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INTRODUCTION

During postgraduate educational training all trainees should acquire skills

that are ‘generic’ to all doctors irrespective of the specific training post or

whether it is in primary or secondary care. Many of these issues and others

are outlined in the GMC document . During the

foundation programme years there is an exciting opportunity to build upon

skills already established as an undergraduate and to develop a sound

foundation for future Programme Based Training. The following seeks to

provide trainees and trainers with guidance to recognise opportunities for

learning, to reflect on clinical practice and to become self-critical in these

vital areas. Anticipated learning outcomes, knowledge, competencies, skills

and attitudes are outlined for the following ‘generic areas’:

Good Clinical Care

History taking and examination

Safe prescribing

Relevant contemporaneous note keeping

Time management and decision making

Quality and Patient Safety

Risk management

Patient safety

Clinical governance

Patient focus

Communication Skills

Within a consultation

Breaking bad news

With colleagues and in teams

Complaints

Maintaining Good Medical Practice

Life-long learning

Evidence, audit and guidelines

“Good Medical Practice”

Infection control

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Maintaining Trust

Professional behaviour and probity

Working with colleagues and in teams

Ethical and legal issues

Patient partnership and health promotion/disease prevention

Teaching and Training

These objectives should not constrain learning to just these areas, they do

however, outline the minimum requirements for satisfactory completion of

general professional training. They can be met in the acute care setting

complimented by experiences in other clinical areas.

To provide doctors in training with the knowledge, skills, competencies

and attitudes to provide high standard medical care to all patients. A

positive attitude to lifelong learning will be encouraged. At the end of the

process trainees will be equipped with the knowledge and skills to

commence the next phase of their training. A wide spectrum of clinical

experience will be required to achieve these goals.

Learning theory emphasises that learners’ attitude to a curriculum is

predominantly influenced by the assessment process. It is therefore

essential that formal assessments and the process of educational

supervision seek to confirm the balanced and inclusive nature of this

curriculum.

Please refer to the separate section on assessment, which provides more

information on this critical topic.

AIMS

52

1.1 GOOD CLINICAL CARE

(A) HISTORY, EXAMINATION & RECORD KEEPING SKILLS

Outcome: The trainee will demonstrate the knowledge and skills and attitudes to be able to take a history and examine patients, prescribe

safely and keep an accurate and relevant medical record.

Subject

(i) History

Knowledge

Symptom patterns

Alarm symptoms

Understands the use of

open/closed questions

Skills

Able to elicit a relevant history

Identify and synthesise problems

Take a history in difficult circumstances eg:

when English is not the patient’s* first language

confused patients*

deaf patients*

patients* with psychiatric/psychological

problems where there are doubts over the

informant’s reliability

patients* with special educational needs

questions regarding sexual behaviour and

orientation

children where parent is the informant

possible child abuse/neglect

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Attitudes

Consider the impact of:

physical problems on

psychological and social well

being

physical illness presenting with

psychiatric symptoms

psychiatric illness presenting with

physical symptoms

psychological / social distress on

physical symptoms (somatisation)

family dynamics

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* The term patient should include where appropriate “patient and parent, guardian or carer”

53

Subject

(ii) Examination

Knowledge

Patterns of clinical signs including

mental state

Skills

Able to examine children of all ages

Explain examination procedure and

minimise patient discomfort

Elicit signs and use instruments

appropriately

Attitudes

Consider:

patient* dignity

the need for a chaperone

willing to share expertise with

other (less experienced) trainees

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(iii) Safe

Prescribing

Effects of disease on prescribing:

hepatic

renal

Effects of patient factors on prescribing:

drugs allergy

genetic susceptibility to adverse drug

reactions

pregnancy

Effects of drug interactions:

cultural religious belief

metabolism by CYP450 isoenzymes

drugs that require therapeutic

monitoring

Evidence-based prescribing

Understanding safe prescribing of

oxygen and blood products

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Take a drug history

Use the BNF and other sources of

information

Write a clear and unambiguous

prescription

Liaise with ward pharmacist

Explain drug therapy to patient

Prescribe common drugs safely with

hepatic or renal dysfunction

Safely prescribe in pregnancy

Notify drug monitoring systems of

significant drug interaction problems

Prescribe oxygen and blood products

safely

Initiate management of carbon

dioxide retention and transfusion

reactions if they arise

Show appropriate attitudes to

patients and their symptoms and

be conscious of religious and

other beliefs, notably in the area

of blood products. Clearly and

openly explain treatments and

side-effects of medication

Understand the security and

safety issues regarding

prescriptions

* The term patient should include where appropriate “patient and parent, guardian or carer”

1.1 GOOD CLINICAL CARE(A) HISTORY, EXAMINATION & RECORD KEEPING SKILLS (cont’d)

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Subject

(iv) Medical

record keeping,

letters etc

Knowledge

Structure of:

medical notes

discharge letters

discharge summaries

outpatient letters

prescriptions

Role of medical records

in generation of central

data returns and audit

Importance of good

medical records as a

sound basis for any

subsequent legal action

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Skills

Record accurately and legibly in the medical

notes including:

history

examination

summary

problem list

differential diagnosis

initial investigation and management plan

investigation results and action taken

conversations e.g. between team members

and patient/relatives

Update medical notes on a regular basis

Each entry to be timed, dated and the name of

the individual to be clearly identifiable

Appropriate IT skills

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Attitudes

Strive to ensure that notes are accessible

to all members of the team and patients

/relatives under certain circumstances

Consider the importance of:

timely dictation

cost-effective use of medical secretary

time

prompt and accurate communication

between primary and secondary care

Understand the importance of clear

definition of diagnosis and procedures

for coding for central returns

Keen to use/learn about new technology

and update computer records

appropriately

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1.1 GOOD CLINICAL CARE(A) HISTORY, EXAMINATION & RECORD KEEPING SKILLS (cont’d)

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(B) TIME MANAGEMENT AND DECISION MAKING

Outcome: The trainee will demonstrate the knowledge, skills and attitudes to manage time and clinical priorities effectively.

Subject

(i) Time

management

Knowledge

Which patients/tasks take

priority

Which patients/tasks

need formal hand-over

Skills

Start with the most important tasks

Work more efficiently as clinical skills develop

Recognise when he/she is falling behind and re-

prioritise and/or call for help

Allow time for effective hand-over

Attitudes

Have realistic expectations of tasks

to be completed by self and others

Willingness to consult and work as

part of a team

* The term patient should include where appropriate “patient and parent, guardian or carer”

(ii)Decision

making

Clinical priorities for

investigation and

management

Analyse and manage clinical problems

Involve patients and other professionals

Be flexible and willing to change

Be willing to consider who is the

most appropriate decision maker

1.1 GOOD CLINICAL CARE

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(C) QUALITY AND PATIENT SAFETY

Outcome: The trainee will demonstrate the knowledge, skills and attitudes to ensure safe, quality assured care and to seek opportunities

for quality improvement.

Quality and

Patient Safety

* The term patient should include where appropriate “patient and parent, guardian or carer”

Complications and side

effects of treatments

Knows the physical signs

that suggest imminent or

actual acute illness

Aware of principles of

risk management

Understands the

principles of Clinical

Governance

Knows in general terms

how processes of medical

care affect outcomes (and

can cite examples)

Fully familiar with the

GMC’s Good Medical

Practise

Understands the nature

of human error and the

importance of systems

factors in relation to

Patient Safety

Describe common complications and side effects of

treatments/ procedures to patients*

Identify and respond appropriately to patients

with abnormal signs.

Recognise personal limitation and seek help at an

early stage. Communicate effectively to ensure

continuity of care.

Use local and national reporting systems for

adverse events and patient safety incidents

Identify potentially unsafe situations and present

them to senior colleagues and the management

team effectively and so as to promote change

Identify poor performance and unsatisfactory

conduct in a colleague or other healthcare

professional and take appropriate action to ensure

patients are protected

Use clinical information to assess the clinical

performance of a service and benchmark it against

best practise

Use the principles of quality assurance and quality

improvement to maintain a high standard of

practise

Identify signs of possible patient abuse and alert

the appropriate colleagues and agencies in a timely

fashion

Understand epidemiology of

clinical presentation in primary

care

High level of safety awareness and

safety consciousness at all times

Seek to ensure (whenever

appropriate) that patients are cared

for in a way that he/she or his/her

family would want to be cared for

Always seeking opportunities to

make care better

Welcome feedback from patients

and professional colleagues

Take every opportunity to learn

effectively from things that go

wrong

Seek out role models and tries to

learn from and adopt the

behaviours of the best clinical

practitioners and the best clinical

leaders

Subject

1.1 GOOD CLINICAL CARE

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SkillsKnowledge Attitudes

(C) QUALITY AND PATIENT SAFETY (cont’d)

* The term patient should include where appropriate “patient and parent, guardian or carer”

Quality and

Patient Safety

Knowledge Skills Attitudes

Knows how adverse

events and patient safety

incidents can be analysed

as a source of learning to

make care safer

Can explain what it

would feel like to be a

patient and what their

needs and wants are

likely to be

Aware of the prevailing

NHS best practice

standards (including

those published by NICE

and in NSFs)

Maintain a strong and consistent focus on the

needs of the patients

Work collaboratively with managers and

professional colleagues to promote a culture of

high quality and safety as part of everyday

activities

Subject

1.1 GOOD CLINICAL CARE

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(D) INFECTION CONTROL

Outcome: The trainee will demonstrate the knowledge, skills and attitudes to reduce the risk of cross-infection.

Subject

Infection control

Knowledge Skills Attitudes

* The term patient should include where appropriate “patient and parent, guardian or carer”

Understands importance

of hand washing

Knows how to use

antibiotics appropriately

Is familiar with local

resistance patterns

Understands appropriate

use of isolation facilities

and side rooms

Applies standard universal precautions

Uses competent aseptic technique for IV

Cannulation, Urinary Catherterisation and

other applicable procedures

Disposes of sharps safely

Attends infection control teaching sessions

Considers risk of infection before

undertaking any procedure

Participates in surveillance system

Is up to date with own immunisations

Aware of potential risk posed to patients by

own health status

Does not allow own health status to put

patients at risk of infection

Makes prevention of infection associated

healthcare a routine part of everyday work

1.1 GOOD CLINICAL CARE

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1.2 COMMUNICATION SKILLS

Outcome: The trainee will demonstrate the knowledge, skills and attitudes to be able to communicate effectively with patients, relatives

and colleagues in the circumstances outlined below.

Circumstance

(i) Within a

consultation

(see also 1.1A.i)

Knowledge

How to structure the

interview to identify the

patient's*:

concerns / problem list

expectations

understanding

acceptance

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Listen

Use of appropriate questioning techniques

including open and closed questions

Avoid jargon and use familiar language

Use interpreters appropriately

Give clear information and feedback to

patients* and share information with relatives

when appropriate

Reassure 'worried well' patients*

Telephone skills

Attitudes

Possess empathy and ability to form

constructive therapeutic

relationships with patients*

Develop a courteous, polite,

professional and considerate

manner

Consider the importance of:

involving patients* in decisions

offering choices

respecting views of

when to involve senior help

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* The term patient should include where appropriate “patient and parent, guardian or carer”

(ii) Breaking

bad news

How to structure the

interview and where it should

take place

Normal bereavement process

and behaviour

Awareness of organ donation

procedure and role of local

transplant co-ordinators

Choose an appropriate setting with the presence

of individuals to support both the doctor and the

patient.

Avoid jargon and use clear, familiar language

Encourage questions, and confirm understanding

Avoid conveying unrealistic optimism and undue

pessimism

Act with empathy, honesty and

sensitivity

Respect cultural and religious

diversity

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Circumstance

(iii) With

colleagues

Knowledge

How and when to

communicate effectively

with other members of the

care team and with other

medical colleagues

especially at handovers

How clinical information is

conveyed from primary to

secondary care on

admission and in the reverse

direction on discharge

Skills

Communicate patient's* anxieties and issues of

concern

Listen to other health care professionals and

heed their views

Is flexible and prepared to change in the face of

valid argument but is capable of supplying own

view when supported by appropriate evidence

Is polite and responsive to telephone requests

Make polite and reasonable telephone and

personally delivered requests to laboratory and

imaging staff

Make discharge information available to

appropriate primary care staff

Attitudes

Understands:

who needs to know what

information

others' perspectives in

contributing to management

decisions

the challenges of providing

optimum care within the

undifferentiated environment of

primary care

the process of admission from

primary to secondary care

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Complaints

Awareness of the local

complaints procedure

Adopt behaviour likely to prevent a complaint

occurring

Deal appropriately with dissatisfied patients /

relatives

Act with honesty and sensitivity in

a non-confrontational manner

1.2 COMMUNICATION SKILLS

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* The term patient should include where appropriate “patient and parent, guardian or carer”

1.3 MAINTAINING GOOD MEDICAL PRACTICE

(A) LEARNING (see also 1.6):

Subject

(i) Life long

learning

Knowledge

Define continuing

professional development

Understand the role of

appraisal

Understand the role of

assessment

Skills

Recognise and use learning opportunities

Maximise the potential of personal study

Compose and revise a personal learning

plan

Attitudes

Be:

personally motivated to learn

eager to learn

willing to learn from colleagues

willing to critically evaluate own work

and make appropriate changes

willing to consider criticism

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Outcome: The trainee will demonstrate knowledge, skills and attitudes to use evidence, guidelines and audit to benefit patient care.

Subject

(i) Evidence

based

medicine

(EBM)

Knowledge

Principles of EBM

Types of clinical trial

Limitations of the existing

evidence base

Skills

Competent use of databases, the library

and the internet

Implement the available evidence base in

most areas of clinical care

Discuss relevance of available evidence

with individual patients

Attitudes

Keen to use evidence to support patient

care

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Subject

(ii) Audit

Knowledge

The audit cycle

Data sources for audit

Understand data confidentiality

Skills

Be involved in on-going audit

Manage change

Attitudes

Consider the relevance of audit to:

benefit developing patient care

clinical governance

risk management

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guidelines and protocols

Methods of determining best

practice

Apply local guidelines/

protocols in context

Consider individual patient needs when

using guidelines and protocols

1.3 MAINTAINING GOOD MEDICAL PRACTICE

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1.4 MAINTAINING TRUST

(A) PROFESSIONAL BEHAVIOUR AND PROBITY:

Outcome: The trainees will have developed the knowledge, skills and attitudes to act in a professional manner at all times.

Subject

(i) Doctor-

patient

relationship

Skills

Avoid unnecessary personal

comments

Ensure all discussion / examination is

relevant

Deal with inappropriate behaviour in

patients* eg, aggression, violence,

sexual harassment

Attitudes

Adopt a non-discriminatory attitude

to all patients* and recognise their

needs as individuals

Broad willingness to place need of

patients above own convenience

Be aware of patients' expectations

around personal presentation of

individual doctors

Behave with honesty and probity

Knowledge

Aspects of an effective professional

relationship

(ii) Continuity

of care

(see 1.1Bii)

Ensure satisfactory completion of

reasonable tasks at the end of the

shift/day with appropriate handover

Produce accurate handover

documentation

Ensure forward planning,

information giving and liaison with

colleagues

Make adequate arrangements to

cover leave

Recognise the importance of:

punctuality

attention to detail

availability when on call

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Understand personal and collective

responsibility for patient welfare

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* The term patient should include where appropriate “patient and parent, guardian or carer”

Subject

(iii) Stress

Knowledge

The effects of stress

Knowledge of support facilities

Skills

Develop coping mechanisms for stress

and ability to seek help if appropriate

Attitudes

Recognise the manifestations

of stress in self & others

(iv) Interaction with other

professionals including

members of a team

hospital & GP

hospital & other

agencies eg, social

services

(see 1.2ii & iii)

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Roles and responsibilities of

team members and other

professionals in patient* care

How teams work effectively

When to involve other

members of the

multidisciplinary team in care

decisions

Seek to involve other professionals in

the management of patients and their

illnesses where appropriate

Delegate, show leadership and

supervise safely

Handover safely

Seek advice if unsure

Communication between team

members

Be tolerant, flexible and

respectful of other professional

viewpoints and recognise

good advice

Be conscientious and behave

with honesty

Recognise own limitations

(v) Relevance of outside

bodies

The relevance to professional

life of:

The Royal Colleges

GMC

Postgraduate Dean

Defence organisations

BMA

PMETB

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Recognise situations when appropriate

to involve these bodies/individuals

Accept professional regulation

* The term patient should include where appropriate “patient and parent, guardian or carer”

1.4 MAINTAINING TRUST

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(B) ETHICS AND LEGAL ISSUES

Outcome: The trainee will demonstrate the knowledge and skills to cope with ethical and legal issues which occur during the

management of patients with general medical problems.

(ii) Valid

consent

Give appropriate information in a manner

patients* understand and be able to obtain

consent from patients*

Refer some consent requests to appropriate

senior colleagues

Deal with patients* who cannot give valid

consent

Appropriate use of leaflets and written material

Check that the patient* has understood the

relevant information

Consider the patient's

needs as an individual

Process for gaining informed

consent

Associated legal framework

The difference between consent

and assent

Children's rights including Gillick

competency

Adults with incapacity (Scotland)

Implications of HIV testing

Subject

(i) Medical

ethical

principles and

Confidentiality

Skills

Use and share all information appropriately

Avoid discussing one patient in front of another

Ensure privacy when discussing sensitive issues

While respecting confidentiality, seek

appropriate, timely advice where patient abuse

is suspected

Attitudes

Respect the right to

autonomy and

confidentiality

Knowledge

Principles of patients’* best

interests, autonomy and rights

Strategies to ensure

confidentiality

Functions of Caldecott Guardians

Limits to confidentiality

Data Protection Act provisions

* The term patient should include where appropriate “patient and parent, guardian or carer”

1.4 MAINTAINING TRUST

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Subject

(iii) Legal framework for

medical practice,

particularly relating to:

death certification

role of the Coroner/

Procurator Fiscal

mental illness

advance directives and

living wills

DVLA

child protection

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Knowledge

Legal responsibilities for completing death

certificates

Types of deaths to be referred to the Coroner/

Procurator Fiscal

Situations where compulsory detention under

a section of the Mental Health Act would be

appropriate

Conditions that patients should report to the

DVLA and doctors' responsibilities if they fail

to do so

Child protection procedures, inter agency

referral routes (eg, police, Social Services) and

when to involve them

Skills

Complete death certificates

Liaise with the

Coroner/Procurator Fiscal

Discuss whether the patient

has an advance directive or

living will and its current

validity

Share information in

professional manner with

inter agency team members

Attitudes

Show attention to

detail and recognise

pressures of time

Respect living wills

and advance directives

whilst recognising their

limitations

Non judgemental

compassionate

approach

1.4 MAINTAINING TRUST

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(C) PATIENT PARTNERSHIP AND HEALTH PROMOTION:

Outcome: The trainee will demonstrate the knowledge, skills and attitudes to be able to educate patients* effectively.

Subject

(i) Educating

patients* about:

disease

investigations

therapy

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Give information to patients* clearly

Encourage questions

Negotiate individual treatment plans,

encouraging ownership and

responsibility for action to be taken by

the patient on deterioration or

improvement

Attitudes

Consider involving patients* in

developing mutually acceptable

investigation and management

plans

Encourage patients* to access:

further information

patient* support groups

Knowledge

Natural history of common diseases

Investigation procedures including

possible alternatives / choices

Strategies to improve adherence to

therapies

* The term patient should include where appropriate “patient and parent, guardian or carer”

(ii)

Environmental

& lifestyle risk

factors

Advise on lifestyle changes

Involve other health care workers,

social workers and teachers as

appropriate

Assess an individual patient's risk

factors

Have a non-judgemental approach

Consider the social, familial and

environmental circumstances of

patients*

Risk factors for disease including:

diet

exercise

social deprivation

sexual behaviour

occupation

substance abuse

accidents and child abuse

genetic

�

�

�

�

�

�

�

�

1.4 MAINTAINING TRUST

68

Subject

(iii) Smoking

Skills

Identify 'ready to quit' smokers

Advise on smoking cessation and

supportive measures

Attitudes

Have a non-judgemental approach

Consider the importance of

support during smoking cessation

Knowledge

Effects of smoking on health of

smoker and others

Implications of addiction

Smoking cessation strategies

(iv) Alcohol Take an alcohol history

Advise on appropriate drinking levels

or drinking cessation

Have a non-judgemental approach

Suggest patient support groups as

appropriate

Effects of alcohol on health and

psychosocial well-being

Local support groups /agencies

(v)

Epidemiology

& screening

Assess an individual patient's risk

factors

Encourage participation in

appropriate disease prevention or

screening programmes

Consider the:

positive & negative aspects of

prevention

importance of patient*

confidentiality

Respect patient* autonomy

�

�

Data collection methods and their

limitations

Notifiable diseases

Principles of prevention, health

surveillance & screening

(vi) Infection

control

Attend infection control education

programme

Recognise when to involve

infection control team

Prevention of spread of infection: hand washing (eg, for MRSA) and need for

isolation facility for multi-resistant organisms (eg, MDRTB)

Be familiar with common infection control procedures including universal

precautions against blood-borne viruses

* The term patient should include where appropriate “patient and parent, guardian or carer”

1.4 MAINTAINING TRUST

69

1.5 TEACHING AND TRAINING (see also 1.3):

Outcome: The trainee will demonstrate the knowledge, skills and attitudes to become life-long learners and teachers.

Subject

(i) Teaching

Skills

Use opportunities for teaching

Communicate and share information one-to-one

and in small groups

Always seek feedback

Attitudes

Demonstrate willingness,

enthusiasm and patience to teach

Knowledge

How adults learn

Learner-centred

approach

(ii)

Presentations

Give presentations to small groups e.g. journal

club

Ability to present material in a logical and concise

fashion

Present material in different presentation media

Be confident and not intimidated

when presenting

Embrace new technology

Features of an effective

presentation

70

CORE SKILLS IN RELATION TO ACUTE ILLNESS

INTRODUCTION

completion

This section of the curriculum outlines areas in which all junior doctors

should acquire clinical experience and receive training. It, therefore, forms

a fundamental component of the foundation programme.

The objectives cover problems that are cross-specialty, as well as common

problems encountered in emergency patients.

It is expected that on of the two years all trainees should be

competent and feel confident in the areas outlined appropriate to the

specialties covered. In addition trainees will be expected to demonstrate

how individual competencies can be combined to provide appropriate and

timely care within the clinical settings of primary and secondary care.

It is recognised that the application of skills and knowledge will vary

according to the site in which care is provided, trainees must for example,

tailor their approach within a primary care setting and manage patients

appropriately despite the lack of investigations which they might

ordinarily have available in hospital. Furthermore, trainees working with

children must recognise that the trajectory of illness is generally different

for adults, and the signs of critical illness often subtle or vague in the early

stages.

This is a minimum standard and is not meant to constrain learning to just

these areas.

71

2 (A) MANAGEMENT OF ACUTELY ILL PATIENTS

Outcome: The trainee will demonstrate the knowledge and skills to be able

to assess and initiate management of patients presenting as emergencies

with the problems outlined below. Attitudes throughout this section are as

described in the previous Generic Skills section. For each scenario (see

PART I, Section 4) trainees should in particular gain knowledge,

competencies and skills to recognise the critically ill and:

Immediately assess and resuscitate if necessary

Formulate a differential diagnosis and refer as appropriate

Select relevant investigations and accurately interpret

reports/results

Communicate the diagnosis and prognosis - see Generic Skills

Reassess as appropriate

�

�

�

�

�

SkillsKnowledge

�

�

�

�

�

�

�

�

Identify, assess, and initiate treatment

in critically ill patients appropriate to

the site of care (eg, hospital, home, GP

surgery)

Promptly assess the airway, breathing

and circulation in the collapsed patient

Document acutely abnormal

physiology

Establish venous access with attention

to infection control measures

Deliver a fluid challenge safely to

acutely ill patients to optimise cardiac

output

Reassess acutely ill patients within an

appropriate period following initiation

of treatment

Undertake a focused history and

examination to establish a differential

diagnosis including difficult

circumstances

Select appropriate initial investigations

to explore the differential diagnosis

�

�

�

�

�

�

Common presenting

symptoms and signs of

acute illness including

breathlessness,

hypoxaemia, hypotension,

oliguria, chest pain, nausea,

vomiting headache, and

confusion or coma

Frequently occurring causes

of the above

Clinical interpretation of

acutely abnormal

physiology

Common derangements of

arterial blood gases

Causes of impaired level of

consciousness including fits

and faints

Causes of acute abdominal

pain, including

gastrointestinal, surgical,

gynaecological/urological,

cardiac/vascular, and

neurogenic

72

SkillsKnowledge

�

�

�

�

�

�

�

�

�

�

�

Request senior or more experienced

help when appropriate

Succinctly present the relevant clinical

details of an acutely ill patient to a

senior doctor

Communicate effectively with other

specialties when appropriate

Assess level of consciousness

Manage patients with impaired

consciousness including fits and

faints

Determine need for “nil by mouth”

status

Insert a naso-gastric tube

Identify concurrent comorbid diseases

and their relevance to the acute illness

Select, prescribe and monitor safe and

effective analgesia for patients with

acute pain (see also 1.1Aiii)

Initiate resuscitation of the patient

who has sustained a cardio-

respiratory arrest (2Bii)

Safe defibrillation (2Bii)

�

�

�

�

�

�

�

Safe oxygen therapy

Safe use of analgesic

drugs; routes and methods

of administration

Acute confusional states

including acute psychosis:

causes, assessment and

initial management

Deliberate self-harm:

modes of presentation,

causation, initial treatment

for most common forms of

self-poisoning,

psychological and mental

health team support

Causes of acute visual

impairment

Resuscitation protocols to

Immediate Life Support

level (PRHOs = F1)

Resuscitation protocols to

Advanced Life Support

level (by end of foundation

years)

73

2 (B) RESUSCITATION

Outcome: The trainee will demonstrate the knowledge, competencies and

skills to be able to recognise critically ill patients, take part in advanced life

support, feel confident to initiate resuscitation and use the local protocol for

deciding when not to resuscitate patients.

SkillsKnowledge

Be ALS certifiedContents of

Advanced Life

Support course

Subject

(i)

Resuscitation

Discuss DNAR criteria with

colleagues, patients and relatives

Encourage regular review of DNAR

orders

Support patients and families

Respect living wills and advance

directives

Act with empathy and sensitivity

Breaking bad news see 1.2ii

Local and national

protocols for

DNAR orders

Legal and ethical

considerations

(ii) Do not

attempt

resuscitation

orders

(DNAR)

2 (C)i MANAGEMENT OF THE 'TAKE'

Outcome: The trainee will demonstrate the knowledge, competencies and

skills to be able to safely function in an acute 'take' team.

SkillsKnowledge

Ability to prioritise

Interact effectively with other health

care professionals

Keep patients and relatives informed

Receive and make referrals

appropriately

Cope with stress

Delegate effectively and safely

Keep an accurate patient list

Handover safely with appropriate

documentation

Indications for

urgent

investigation and

therapy

Skills and

capabilities of

members of the

'on-take' team

When and from

whom to seek

help in

appropriate

circumstances

Subject

(i) 'Take'

management

74

2 (C)ii DISCHARGE PLANNING

Outcome: The trainee will demonstrate the knowledge and skills to be able

to plan discharges for patients starting from the point of admission.

SkillsKnowledge

Recognise when in-patient care is

not required

Start planning discharge from the

time of admission.

Partake in discharge planning

meetings

Liaison and communication with

patient, family and primary care

Be aware of family dynamics and

socio-economic factors influencing

success of discharge

Ensure the primary care team are

aware of the discharge of patients

with appropriate, timely

information

Write reports for appropriate bodies

Impact of physical

problems on

activities of daily

living

Roles and skills of

members of the

multidisciplinary

team including

nurses, OTs,

physiotherapists,

discharge co-

ordinators and

social workers

Impact of

unnecessary

hospitalisation

Available support

in primary care

Subject

Discharge

planning

SELECTION AND INTERPRETATION OF INVESTIGATIONS

not

INTRODUCTION

The foundation programme years are a phase of increasing clinical

responsibility, a key element of this is the ability of doctors to select

appropriate investigations and interpret the reports.

Training in selection, requesting and interpretation of results of some

investigations may have taken place as an undergraduate, however, it is

important that these skills are developed and widened. It is also vital that

trainees learn to critically evaluate when investigations are required

and are not cost effective. The balance will vary according to the site in

which clinical care is conducted. Investigations valid in a hospital setting

may be impractical in general practice. Where national and local guidelines

on selection of investigations exist, they should be used. For example, the

75

Royal College of Radiologists' document 'Making best use of a Department

of Clinical Radiology' gives helpful guidance to doctors requesting imaging

and trainee doctors should be familiar with this.

The investigations listed are those that are very frequently requested on

acutely ill patients with detailed objectives, skills and knowledge.

As in the core skills section the objectives listed below apply to trainees

of the two years.

Again this is a minimum standard and not meant to be restrictive.

AIMS:

To produce doctors who are competent and confident in selecting,

requesting and interpreting reports of commonly used investigations

required for the diagnosis and management of patients who present as

emergencies or who are potentially acutely or critically ill.

OUTCOMES:

For each of the investigations listed in this section:

Trainees should be able to:

Explain the nature of the investigation to patients

Explain why it is required

Explain the implications of possible results and actual results

when available

Gain informed consent

Trainees should also learn to:

Recognise the need for an investigation result to impact on

management

Avoid unnecessary investigations

Recognise that investigation reports often require the

professional opinion of an individual who therefore needs

relevant information on the request form

Recognise that reports may need review in the light of

changing circumstances

Act on the results in a timely and appropriate fashion

Prioritise the importance of results and ask for help

appropriately

all

on completion

�

�

�

�

�

�

�

�

�

�

�

�

76

INVESTIGATIONS COMMONLY REQUESTED FOR ACUTELY ILL

PATIENTS

Outcome: The trainee will demonstrate the knowledge and skills to be able

to select, request appropriately and accurately interpret reports of the

frequently used investigations, used to manage acutely ill patients, listed

below. For all investigations it is vital that trainees recognise abnormalities

which require immediate action.

SkillsKnowledge

Use results reporting

system

Record and tabulate

where appropriate

Interpret results and

when to request further

specialist advice

Circumstances

requiring urgent results

Significance of major

abnormalities and

general irrelevance of

minor variations from

“normal” values

Investigation

Full blood count

Urea and electrolytes

Blood glucose

Cardiac markers

Liver function tests

Amylase

Calcium and

phosphate

Coagulation studies

Arterial blood gases

Inflammatory

markers

Use of ECG machines

including how to

connect limb and chest

leads

Recognise:

common

abnormalities

normal variants

abnormally

connected leads

when to repeat

�

�

�

�

Normal ECG patterns

Patterns for common

abnormalities

12 lead ECG

77

SkillsKnowledge

Communicate well

with radiologists,

radiographers and

other staff

Recognise common

abnormalities

Recognise the need for

radiological advice

Identify when

ultrasound, CT or MRI

might be required

Circumstances

requiring:

urgent requests

particular views

Normal findings of

chest and abdominal X-

rays

Imaging appearances of

common abnormalities

on chest and abdominal

X-rays

Recognition of the risks

of radiation

�

�

Investigation

Chest X-ray

Abdominal X-ray

Ultrasound, CT and

MRI

Interpret resultsType of samples and

collection method

required

Microbiological

samples

PRACTICAL PROCEDURES

INTRODUCTION

Training in some practical procedures may have taken place in the

undergraduate years and/or in the first foundation programme (PRHO)

year but it is important that skills are developed and widened in the second

year so that trainees become competent and feel confident to perform

commonly required practical procedures. Listed here are those procedures

that doctors at the end of the foundation years should be competent and

feel confident to perform.

Again these are a minimum standard and not meant to be restrictive.

AIMS:

To produce doctors who are competent and confident to perform common

practical procedures required for diagnosis and management of patients

who present acutely.

78

OUTCOMES:

A. GENERAL KNOWLEDGE AND SKILLS:

For each procedure doctors should:

Know indications and contraindications

and be able to:

Explain the procedure to the patient including possible

complications and gain informed consent for procedures carried

out by the trainee

Prepare the required equipment including a sterile field

Position the patient and give premed / sedation as required,

involving the anaesthetist where appropriate

Adequately prepare the skin including local anaesthetic

Arrange appropriate aftercare /monitoring

Safely dispose of equipment including sharps

Document the procedure, including labelling of samples and

instructions for monitoring post procedure

Record complications

Recognise and be able to undertake emergency management of

common complications

At all times doctors should recognise what are the limits of their

competency and to seek advice and help where appropriate

�

�

�

�

�

�

�

�

�

�

79

PROCEDURES THAT PRHOS (F1) SHOULD BE COMPETENT AND

CONFIDENT TO PERFORM. TRAINEES ARE EXPECTED TO

MAINTAIN AND IMPROVE THESE SKILLS SUCH THAT BY THE END

OF F2 THEY SHOULD BE ABLE TO HELP OTHERS WHEN THE

PROCEDURES ARE DIFFICULT.

Venepuncture and cannulation

Blood cultures from peripheral and central sites

Intravenous infusions including the prescription of fluids, blood

and blood products

Performing an ECG

Arterial blood sampling

Injection - subcutaneous, intradermal, intramuscular and

intravenous

Urethral catheterisation

Airway care including simple adjuncts

Nasogastric tube insertion

BY THE END OF F2 YEAR, TRAINEES SHOULD ALSO BE COMPETENT

AND CONFIDENT TO PERFORM:

All of the above to a level where the trainee is able to pass on the

skills to others less competent.

Each specialty will also specify a range of procedures relevant to that

specialty in which the trainees will be expected to become proficient eg,

pleural aspiration, skin suturing, lumbar puncture.

METHODS OF LEARNING:

In general, training in practical procedures should include:

Reading up on the theory or studying virtual training packages on

the Internet

Where available use a skills laboratory

Observing first hand

Being themselves observed performing the procedure by a

competent practitioner who has recent relevant experience of the

procedure

�

�

�

�

�

�

�

�

�

�

�

�

�

�

80

PART III: APPENDICES

i Multi-Source Feedback for Foundation Programme

Mini-PAT (Peer Assessment Tool) for Foundation Programme

The description and documentation described below is applicable to F2 work-

place based assessment but the process is readily adaptable for use in F1/PRHO

work-place based assessments.

Background:

PMETB and GMC have identified peer ratings as suitable for postgraduate

assessment and revalidation evidence. A number of groups have been involved in

developing and evaluating MSF for trainees. The tool being evaluated for this

project for use in foundation training assessment, mini-PAT (peer assessment tool)

builds on this work. It is derived from the Sheffield Peer Review Assessment Tool

(SPRAT) and has been shortened on the basis of content validity in relation to the

MMC curriculum. Additionally other modifications have been made to

incorporate feedback from COPMED (eg, a question on health and probity has

been added) and other UK work in this area. It is an assessment tool that is

explicitly mapped to (GMP), the General Medical

Council's framework for good practice for all doctors in the UK.

Evidence from the US and Canada supports the use of peer ratings as part of

work-place based assessment programmes. Peer-rating would normally constitute

only part of an overall assessment strategy. Mini-PAT consists of 15 questions

mapped to the five main domains of GMP and a global rating scale. Free text

comments by the assessors are encouraged. The rating scale is a 6 point rating

scale with an “unable to comment” option for raters to use where they have not

observed a given aspect of professional practice.

Experience to date would suggest that collated feedback from 5 or more raters

produces acceptable confidence intervals for its use as part of a work-place based

assessment programme.

Mini-PAT provides feedback from a range of co-workers across the domains of

Good Medical Practice

Mini-PAT for Foundation SHOs

Purpose

81

GMP. These can be mapped to the core objectives of the F2 curriculum. In

foundation years, feedback will be entirely developmental with the trainee and

educational supervisor agreeing strengths and key areas for development from

collated feedback.

All the forms returned will be collated and fed back to the trainees via their

nominated supervisor.

The exact timing will depend on the length of posts on the rotation.

For the Foundation pilots:

Trainees in 4 month posts will be approached as soon as possible after completion

of their first post and asked to nominate 8 raters.

Trainees in 3 or 6 month posts will be approached at 5-6 months and asked to

nominate 8 raters from the previous 6 months. Those in 3 month placements must

include raters from both placements.

Trainees will be asked to then nominate a second set of raters from their next post

at 9-10 months. The initial round of feedback will be for formative purposes only.

Collated feedback from all their placements will be provided as soon as possible

after the 10 month to allow time to plan how any issues identified will be

addressed.

Individual Foundation programme leads will be notified of precise timings for

their trainees based on details of their rotations.

The majority of raters should be selected from supervising consultants, GP

principals, specialist registrars and experienced nursing or Allied Health

Professional colleagues. All trainees must include the supervising clinical

consultant they work most closely with in secondary care or their GP trainer if in

primary care. All trainees complete a self-assessment using the same

questionnaire.

Trainees will be provided with a mini-PAT pack through their Foundation

Programme lead. To ensure that all trainees receive their packs they should sign

Practicalities

Number and frequency of assessments

Choosing raters

Administration

th

82

to confirm that they have received them Trainees then return their self- ratings

and a list of nominated raters. Mini-PAT forms for completion are sent directly to

the raters from the central office and are subsequently returned directly by the

rater for scanning into the database. This ensures that the individual raters' views

remain unknown to the trainee.

A chart of the individual's mean score per question and of the global rating

compared to their self-rating and a second chart showing the overall score for the

doctor compared with their overall self mean are provided. Comparison of the

raters' perceptions with their own is a very useful part of the process for trainees.

Where there are significant differences between the two this merits discussion.

Any comments are anonymised prior to feedback to the doctor but they are

produced verbatim. It is essential that raters take into consideration verbatim

reporting of free text comments and take care to word this as constructively as

possible. The covering letter for raters emphasises this.

To maximise the usefulness of the process the feedback will be delivered by an

appropriate supervisor/mentor or appraiser. Two copies of the feedback for all the

F2 trainees in each programme will be returned to the Programme Director. Their

supervisor will discuss the feedback with the trainee and the trainee retains a

copy in their Portfolio.

Our experience has shown that doctors, however well they have done, often focus

on any obvious areas for development, sometimes ignoring those areas where

they have done well. Discussion should facilitate personal development for the

doctor by focusing on areas of strength to enable the doctor to build on these. It

should also clearly identify areas for development by formulating at least one

learning objective for their next personal development plan linked directly to their

feedback.

A very small number of doctors will have significant problems identified as a

result of this process. Receiving such feedback is highly stressful for any

individual and it is essential that appropriate support is available for all doctors.

Further “diagnostic” assessment may be required to clarify the nature of

problems identified in a given domain. Where a problem does need addressing a

framework for doing so and a plan for re-assessment should be agreed with the

doctor.

Feedback

What about doctors where problems are identified?

83

84

Sam

ple

A doctor who is performing at the expected level for completion of the Foundation programme scores 4

X X X X X X X

12 Verbal communication with

colleagues

7 Technical skills (appropriate tocurrent practice)

6 Ability to manage time effectively /prioritise

3 Awareness of their own limitations

4 Ability to respond to psychosocialaspects of illness

5 Appropriate utilisation of resources

e.g. ordering investigations

How do you rate thisDoctor in their:

Good Clinical Care

U/C*

1 Ability to diagnose patient problems

2 Ability to formulate appropriatemanagement plans

Maintaining good medical practice

Teaching and Training, Appraising and Assessing:

8 Willingness and effectivenesswhen teaching/training colleagues

Relationship with Patients:

Working with colleagues:

9 Communication with patients

10 Communication with carersand/or family

11 Respect for patients and theirright to confidentiality

13 Written communication withcolleagues

14 Ability to recognise and value thecontribution of others

15 Accessibility/Reliability

16 Overall, how do you rate thisdoctor compared to anotherdoctor of the same grade?

Forename

SurnameDoctor's

Below expectations Borderline Above expectations

42 3 5 61

mini-PAT (Peer Assessment Tool)Please use black ink and CAPITAL LETTERSPlease complete the questions using a dash: -

Meetsexpectations

If yes please state your concerns:

Do you have any concerns about this doctor's probity or health? Yes No

GMC Number: Form Number:

*U/C Please mark this if you have not observed the behaviour and therefore feel unable to comment. 9690204943

85

Sam

ple

X

Length of working relationship(in months):

How long has it taken you to complete this form (in minutes)?:

SurnameYour Name:

Forename

Acknowledgements: mini-PAT is derived from SPRAT (Sheffield Peer Review Assessment Tool)

Anything especially good? Please describe any behaviour thathas raised concerns or should be a

particular focus for development:

Male FemaleYour Sex:

Which environment have you primarilyobserved the doctor in?

(Please choose one answer only)

Inpatients

Outpatients

Both In and Out-patients

A&E/Admissions

Intensive Care

Theatre

General Practice

Other (Please specify)

Community Speciality

Laboratory/Research

Consultant SASG SpR

SHONurse Allied Health Professional

GP

Foundation/PRHO

Other (Please specify)

Your position:

/ /Your Signature: ........................................................... Date:

6975204946

ii Mini-CEX for Foundation Programmes

Background:

Mini-CEX for Foundation SHOs.

Mini-CEX was originally developed in the US by the American Board of

Internal Medicine.

The mini-CEX was designed to assess the clinical skills, attitudes, and

behaviours of US junior doctors (residents) essential to providing high

quality patient care. It was conceptualized as a 15-20 minute snapshot of a

doctor/patient interaction. Data from the US has shown that mini-CEX is

reliable and valid and that it is acceptable to both trainees and their clinical

supervisors. The Royal College of Physicians have used a modified version

of mini-CEX as part of their work evaluating tools for performance

assessment.

US data suggests that 4 mini-CEX evaluations are sufficient to make a

reliable judgement. The mini-CEX format was viewed positively by the

trainees (particularly the opportunity for feedback) and their satisfaction

was not associated with performance ratings. The time (median) committed

to encounters was 15 minutes for observation and five minutes for

feedback.

What was the original purpose of the Mini-CEX?

Evaluation of mini-CEX

Purpose

86

Question area

History taking

Physical examination

Good clinical care

Good clinical care

Descriptor

Facilitates patient’s telling of story, effectively

uses appropriate questions to obtain accurate,

adequate information, responds appropriately to

verbal and non-verbal cues

Follows efficient, logical sequence; examination

appropriate to clinical problem, explains to

patient; sensitive to patient’s comfort, modesty

Professionalism

Legal/ethics

Shows respect, compassion, empathy, establishes

trust;

Attends to patient’s needs of comfort, respect,

confidentiality. Behaves in an ethical manner,

awareness of any relevant legal frameworks

Aware of limitations

Clinical judgement

Communication

skills

Decision making

Good clinical care

Communication

Makes appropriate diagnosis and formulates a

suitable management plan. Selectively

orders/performs appropriate diagnostic studies,

considers risks, benefits.

Explores patients perspective, jargon free, open

and honest, empathic, agrees management

plan/therapy with patient

Organization/

efficiency

Time management

Prioritizes; is timely, succinct. Summarises

Overall clinical care

Acute care

Good clinical care

Decision making

Demonstrates judgment, synthesis, caring,

effectiveness

Efficiency, appropriate use of resources, balances

risks and benefits, awareness of own limitations

F2 Mini-CEX: Competencies Assessed and Descriptors

Core objectives of the F2 curriculum are shown in italics below each question area

87

F2 mini-CEX is designed to provide feedback on skills essential to the

provision of good clinical care. In keeping with the F2 quality improvement

assessment model, strengths, areas for development and agreed action

points will be identified following each mini-CEX

A number of modifications to the original mini-CEX rating form have been

made. The questions have been anglicised to facilitate their use by UK

trainees and raters. In addition the content has been mapped to the F2

outcomes identified within the curriculum to ensure consistency. Together

these changes mean that:

· Medical interviewing skills has been changed to History Taking

· Humanistic Qualities/Professionalism has been changed to

Professionalism

· Counselling Skills has been changed to Communication Skills

· Overall Clinical Competence has been changed to Overall Clinical

Care

In addition, the scale has been changed so that it is a 6 point scale in line

with the other assessment tools being used in this study for foundation

training assessment. Because it is anticipated that many of the skills being

observed by mini-CEX will need development the descriptor category of

or is anticipated for many trainees.

The forms will include demographic data essential to the quality assurance

process of the overall assessment system.

Trainees will be provided with triplicate forms in pads. They will be asked

to undertake 6 observed encounters during the year with a different

observer for each encounter. (Having a different observer for each

encounter will improve reliability). Observers may be experienced SpRs or

consultants in a secondary care setting. The GP trainer and other GPs are

appropriate in a primary care setting.

Each mini-CEX should represent a different clinical problem and trainees

should sample from each of the core problem groups identified in the F2

curriculum by the end of the year.

The trainee chooses the timing, problem and observer although the direct

Modifications to original form:

“below expectations” “borderline”

Number and frequency of assessments.

Practicalities:

88

supervising consultant should be one of the observers for each clinical

placement.

F2 mini-CEX is suitable for use in an out-patient, in-patient or acute care

setting.

Trainees will be provided with a pack of mini-CEX forms by the nominated

Foundation Programme lead for each placement. To ensure that all trainees

receive their packs they should sign to confirm that they have received

them.

Trainees will be asked to return their completed top copy of mini-CEX to

their local Foundation lead (who will return all forms from trainees on a

fortnightly basis to the assessment centre). They should retain a copy in

their portfolio and give the third copy to their educational supervisor.

Immediate feedback will be provided after each encounter by the observer

rating the trainee. Observers will be encouraged to use the full range of the

rating scale and both trainees and trainers should be reassured that some

ratings below the satisfactory range are in keeping with an F2 trainee's level

of experience. Comparison should be made with a doctor who is ready to

complete the F2 programme. Thus, it would be anticipated that over time

the number of ratings in the satisfactory or above range will increase as the

trainees increase their expertise.

In order to maximise the educational impact of using F2 mini-CEX trainees

and trainers will need to identify agreed strengths, areas for development

and an action plan for each encounter.

Collated feedback for the whole year will be provided for each trainee once

6 mini-CEX encounters have been submitted centrally. Two copies of the

feedback for all the F2 trainees in each programme will be returned to the

programme director. Their supervisor will discuss the feedback with the

trainee and the trainee retains a copy in their portfolio.

Administration

Feedback

89

Sam

ple

Doctor's Name

Assessor's Name

GMC No.

F2 Mini-Clinical Evaluation Exercise (CEX)

Please grade the following areas using the scale below:- Please rate the trainee compared to a competent doctor at

completion of F2 NOT compared to their current level of experience

Clinical setting A&E OPD In-patient Acute admission GP Other

Number times pt seen before by trainee 0 1-4 5-9 >10

Complexity of case Low Average High

Clinical problem category Airway Breathing Circulatory Neuro Psych/Behav Pain

Focus History Diagnosis Management Explanation

Assessor's position GP Consultant SpR

Below expectations Meets expectations

1 2 3 4 5 6

:

Time taken for observation (hrs:mins)

Acknowledgments: Adapted with permission from American Board of Internal Medicine (ABIM) mini-CEX tool.

Time taken for feedback (hrs:mins)

Trainee satisfaction with mini-CEX

/ /Date DD/MM/YY

1 2 3 4 5 6 7 8 9 10

Trainee satisfaction with mini-CEX 1 2 3 4 5 6 7 8 9 10

Please use this space to record areas of strength or any suggestions for development.

Strengths Suggestions for development

:

Agreed action to address development needs:

Above expectations

1 History Taking (not observed)

2. Physical examination skills (not observed)

1 2 3 4 5 6

1 2 3 4 5 6

3. Communication skills

4. Clinical judgement

5. Professionalism

6. Organization / Efficiency

7. Overall clinical care

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

Draft

Borderline

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iii DOPS for Foundation Programmes

Background:

Direct observation of procedural skills (DOPS) was originally developed by the

Royal College of Physicians (London).

DOPS was designed to assess procedural skills using a similar format to mini-

CEX. It was originally utilised for Specialist Registrars in Medicine. The RCP

evaluated both procedure specific DOPS (such as renal biopsy) and a generic form.

A generic form only is being used in the Foundation setting although it asks for the

procedure being observed to be recorded.

Preliminary data from the RCP suggests that 4 raters assessing a single encounter

each are needed to achieve acceptable reliability for work-place based assessment.

The time (median) committed to encounters was 20 minutes for observation and

five minutes for feedback.

What was the original purpose of DOPS?

Evaluation of DOPS

Purpose

Number and frequency of assessments.

DOPS for Foundation SHOs.

Practicalities:

F2 DOPS is designed to provide feedback on procedural skills essential to the provision of

good clinical care at this level. There is space to record any particular strengths or areas for

development. Selection of procedures to be assessed should be informed by the

Foundation curriculum.

Trainees will be provided with triplicate forms in a pad. They will be asked to undertake 6

observed procedures during the year with a different observer for each encounter. (Having a

different observer for each encounter will improve reliability). Observers may be experienced

SpRs, appropriate nursing staff or consultants in a secondary care setting. The GP trainer,

appropriate nurses and other GPs are appropriate in a primary care setting.

Each DOPS should represent a different procedure and trainees should sample from the

core problem procedures identified in the F2 curriculum by the end of the year. The trainee

chooses the timing, procedure and observer.

91

Administration

Feedback

Trainees will be provided with a pack of DOPS forms by the Foundation Programme Lead

for each placement. To ensure that all trainees receive their packs they should sign to

confirm that they have received them.

Trainees will be asked to return their completed top copy of DOPS to their local Foundation

lead/administrator (who will return all forms from trainees on a fortnightly basis to the

assessment centre) They should retain a copy in their portfolio and give the third copy to

their educational supervisor.

Immediate feedback will be provided after each encounter by the observer rating the

trainee. Observers will be encouraged to use the full range of the rating scale and both

trainees and trainers reassured that some ratings below the satisfactory range are in

keeping with an F2 trainee's level of experience. Comparison should be made with a doctor

who is ready to complete the F2 programme. Thus, it would be anticipated that over time the

number of ratings in the satisfactory or above range will increase as the trainees increase

their expertise.

Collated feedback for the whole year will be provided for each trainee once 6 DOPS

encounters have been submitted centrally. Two copies of the feedback for all the F2 trainees

in each programme will be returned to the programme director. Their supervisor will discuss

the feedback with the trainee and the trainee retains a copy in their Portfolio.

A sample form follows.

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93

94

iv Case Based Discussions for Foundation Programmes

Background:

Case-based discussion (CbD) is used to enable the documenting of

conversations about, and presentations of, cases by trainees. This activity

happens throughout training, but is rarely conducted in a way that

provides systematic assessment and structured feedback. The approach is

called in the US and Canada, and is widely used for

the assessment of residents and of established doctors who are in difficulty.

In the UK it is used, and is being evaluated, by both the NCAA and the

GMC in the assessment of established practitioners.

CbD is designed to assess clinical decision-making and the application or

use of medical knowledge in the care of the trainee's own patients. It also

enables the discussion of the ethical and legal framework of practice, and in

all instances, it allows trainees to discuss they acted as they did, i.e.

aspects of professionalism. Although the primary purpose is not to assess

medical record keeping, as the actual record is the focus for the discussion,

the assessor can also evaluate the record keeping in that instance.

While the CbD for F2 is based on previous work in the UK and the US and

Canada, the forms and the rating scales have been designed, for ease of use,

to be in a similar format to those for the F2 mini-CEX, DOPS and mini-PAT

(multi-source feedback tool).

F2 CbD is designed to provide feedback on skills essential to the provision

of good clinical care. In keeping with the F2 quality improvement

assessment model, strengths, areas for development and agreed action

points will be identified following each CbD session. It allows sampling of

a range of areas within the F2 curriculum and can be mapped to

(GMP).

The scale is a 6 point scale in line with the other tools being utilised. At this

stage of training it is anticipated that many of the skills being assessed

chart stimulated recall

The purpose

why

How were the CbD forms and rating scales developed?

Purpose

CbD for Foundation SHOs.

Good

Medical Practice

95

during a CbD will need development, hence ratings within the descriptor

category of are anticipated for many

trainees.

The forms will include demographic data essential to the quality assurance

process of the overall assessment system.

Trainees will be provided with triplicate forms in pads. They will be asked

to undertake 6 sessions of CbD during the year with a different assessor for

each session as this will help to improve reliability of the overall process.

Assessors may be experienced SpRs or consultants in a secondary care

setting. The trainer and other GPs are appropriate in a primary care setting.

Each CbD should represent a different clinical problem and trainees should

sample from each of the core problem groups identified in the F2

curriculum by the end of the year..

The trainee will select 2 case records from patients they have seen recently,

and in whose notes they have made an entry. The assessor will select one of

these, for the CbD session.

The trainee will choose the timing, the cases and the assessor, but the direct

supervising consultant should be one of the observers for each clinical

placement. An assessment record should be filled out for each case

discussed, and the whole session should take no longer than 20 -30 minutes

including feedback and completion of the assessment form. The discussion

must start from and be centred on the trainee's own record in the notes.

CbD is suitable for use in an out-patient, in-patient or acute care setting.

Packs of CbD forms will be sent directly to the Foundation Programme

Pilot leads who should distribute them to the trainees. To ensure that all

trainees receive their packs they should sign to confirm that they have

received them.

Trainees will be asked to return their completed top copy of the CbD form

to their local Foundation administrator (who will return all forms from

trainees on a fortnightly basis to the assessment centre). They should retain

a copy in their portfolio and give the third copy to their educational

supervisor.

“below expectations” or “borderline”

Number and frequency of assessments.

Administration

Practicalities:

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Question area

Medical record

keeping

Communication skills

(working with

colleagues)

Descriptor

The record is legible, signed, dated, and

appropriate to the problem, understandable in

relation to, and in sequence with, other entries. It

helps the next clinician who uses the record, to

give effective and appropriate care.

Clinical assessment

Good clinical care

Can discuss how they understood the patient's

story and how, through the use of further

questions and an examination appropriate to the

clinical problem, a clinical assessment was made

from which further action was derived.

Clinical judgement

Decision making

Good clinical care

Can discuss the rationale for the diagnosis and

formulation of the management plan. Shows

understanding of why diagnostic studies were

ordered/performed, including the risks and

benefits.

Organization/

efficiency

Time management

Can discuss how the care which was recorded,

demonstrates ability to prioritise; and was timely,

and succinct.

Overall clinical care

Acute care

Good clinical care

Decision making

Can discuss own judgment, synthesis, caring,

effectiveness, for this patient at the time that this

record was made.

F2 CbD: Competencies Assessed and Descriptors

Core objectives of the F2 curriculum are shown in italics below each

question area

Professionalism

Legal/ ethics

Can discuss how the care of this patient, as

recorded, demonstrated respect, compassion,

empathy, and established trust.

Can discuss how the patient's needs for

comfort, respect, confidentiality were, attended

to.

Can show how the record demonstrated an

ethical approach, and awareness of any relevant

legal frameworks. Has insight into own

limitations.

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Feedback

Immediate feedback will be provided after each encounter by the observer

rating the trainee. Observers will be encouraged to use the full range of the

rating scale and both trainees and trainers reassured that some ratings

below the satisfactory range are in keeping with an F2 trainee's level of

experience. Comparison should be made with a doctor who is ready to

complete their Foundation training. Thus, it would be anticipated that over

time the number of ratings in the satisfactory or above range will increase

as the trainees increase their expertise.

In order to maximise the educational impact of using F2 CbD trainees and

trainers will need to identify agreed strengths, areas for development and

an action plan for each encounter.

Collated feedback for the whole year will be provided for each trainee once

6 CbD sessions have been submitted centrally. Two copies of the feedback

for all the F2 trainees in each programme will be returned to the

programme director. Their supervisor will discuss the feedback with the

trainee and the trainee retains a copy in their portfolio. All of the

assessments submitted centrally will form a record of in-training

assessment for F2, to include comparison with the national cohort.

98

99

v MEMBERSHIP OF F2 CURRICULUM COMMITTEE OF

ACADEMY OF MEDICAL ROYAL COLLEGES

Name Affiliation

JANET ANDERSON RCPCH

JULIAN BION Intercollegiate Board for Training in

Intensive Care Medicine

JEREMY BOLTON RCPsych.

LINDA DE COSSART RCS London

ALAN CROCKARD Modernising Medical Careers (MMC)

NEIL DOUGLAS RCPE/ AoMRC

CHARLES GILLBE RC Anaesthetists

IAN GILMORE RCP London

ARTHUR HIBBLE Director of PGGPE

(COGPED)

DEREK GALLEN

Is alternative to HIBBLE as COGPED rep. (COGPED)

ALASTAIR McGOWAN President Faculty of A&E Medicine

Also: MMC

PHILIP MURRAY RC Ophthalmologists

ED NEVILLE (Committee Chair) RCP London

MARGARET ROBERTS RCPS Glasgow

DAVID SOWDEN PG Dean – Mid Trent

ANTHONY STARCZEWSKI Associate Dean for SHOs - Wales

WINNIE WADE RCP London

MIKE WATSON RCP Edinburgh

CHARLES WRIGHT RCOG

Director of PGGPE

The community acknowledges and thanks Mrs Maureen Pembroke and her

team at the General Professional Training department at the RCP London

for continuing professional support.

Stephen Beglan is thanked for his hard work as committee co-ordinator.

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vi MEMBERSHIP OF F2 ASSESSMENT WORKING PARTY

OF LONDON DEANERY

Name Affiliation

DR HELENA DAVIES SHEFFIELD CHILDREN’S HOSPITAL

PROFESSOR SHELLEY HEARD LONDON DEANERY

DR BRENDON HICKS KSS DEANERY

DR ANDREW LONG NACT

DR ROSIE LUSZNAT WESSEX DEANERY

PROFESSOR PAULINE MCAVOY NCAA

DR ALASTAIR MCGOWAN MMC

DR ED NEVILLE ACADEMY OF MEDICAL ROYAL COLLEGES

PROFESSOR ELIZABETH PACE LONDON DEANERY

DAME LESLEY SOUTHGATE LONDON DEANERY

DR PATSY STARK UNIVERSITY OF SHEFFIELD

MRS WINNIE WADE RCP LONDON

101

ANNEX A

102

PART IV: ANNEX A

TOWARDS EXCELLENCE IN ASSESSMENT IN MEDICINE:

GUIDING PRINCIPLES

Assessment has always been a major part of the process of assuring and

improving the quality of medical training, of qualified doctors and of clinical

practice. It will become more so in the future.

Assessment is defined here as the formal measurement of performance by

specially developed and validated methods for the purposes of classifying an

individual against a standard. Such assessment is generally called

`summative'. Assessment drives learning and encourages understanding.

Learning and understanding are at the heart of patient care.

Other methodologies may assess systems and processes in which individuals

work and both training programmes and training organisations. Assessment

is an effective tool at all stages of a doctor's career and supports continuing

professional development. Indeed, assessment is a continuous process

involving self-assessment, lifelong learning using modern technologies such

as web-based tools and linked to personal development plans, appraisal and

General Medical Council (GMC) revalidation. Assessment plays a vital role in

both personal and organisational development.

Assessment is used in a wide variety of contexts: in delivering educational

curricula, in training programmes, in ensuring effective continuing

professional development, in examinations for the award of degrees and

professional qualifications, in judgements about the quality of health care

provided, in measuring performance in post, in determining whether practice

is meeting professional standards and job objectives and in determining

competence and in determining fitness to practise.

Assessment of many different kinds is a process integral to the work of a large

number of organisations in the health and health care arena in this country

including: higher education institutions, the GMC, Royal Colleges and other

professional organisations, the NHS and national agencies and independent

bodies which support it. It is fair to say that reliable methods of assessment

are in many cases still evolving.

In recognition of the importance of assessment for the quality and safety of

professional practice and of health care more generally, the adherence to the

principles of Good Medical Practice set out by the GMC and acknowledging

the range of organisations involved in assessment and the diversity of

techniques involved, the Chief Medical Officer convened a series of informal

meetings with some of the bodies concerned to discuss the issues.

Out of the discussions came the proposal to seek agreement on a set of

principles which could then be promoted with the aim of encouraging the

quest for excellence and consistency in all forms of assessment relevant to

clinical practice and healthcare.

In proposing a set of principles, it must be acknowledged that there are

organisational and resource consequences inherent in seeking high standards

of assessment. The intention is that by establishing firm principles, credible

and practical arrangements can be developed which demonstrate clear

benefits both in educational and service terms. This is particularly important

as the level of work-based assessment increases.

Set out below are the principles. They have been subject to wide consultation

amongst interested bodies and the object now is to invite all organisations

involved in assessment to sign up to a commitment to achieving excellence in

the assessment methods used in their fields of endeavour. Unless standards

for assessment are set and implemented, consistency and excellence will not

be achieved.

1. The purpose of the assessment procedure and the educational or other goal

it supports should be clear, well communicated and well understood by all

those participating.

Guiding principles

2. There must a clear, consistent and effective relationship between the

assessment process and the quality assurance and quality improvement

goals being sought in the field of activity concerned; for example:

· education and training

· continuing professional development

· clinical performance

103

3. The format and design of the overall assessment system and its

constituent methods need to be appropriate to what is being tested; for

example:

· clinical skills

· knowledge and decision-making

· interpersonal qualities

· attitudes and behaviour

· competency in particular interventions

· communication skills.

4. The detailed assessment methods must be:

· fair

· appropriate in content and method

· valid

· reliable

· practical

· proportionate.

5. Assessment where possible should be evidence-based and benchmarked

well against best-practice in other settings and best practice in other

countries. Assessment should be transparent, free from discrimination,

capable of recognising wide diversity and open to appeal.

6. The detailed assessment methods should be standardised as fully as

possible in respect of:

· procedures for administering the test or assessment and using its

result to classify and support those assessed

· setting the standards for pass/fail

· making observations or marking

· the format for recording and communicating the results of the

assessment

· handling the component of an assessment process that relies on the

professional judgement of the assessor.

7. It is essential that the overall assessment process and the detailed methods

within it are referenced to objective sets of criteria where appropriate.

104

8. High quality documentation and quality assurance underpinned by

standardised methodology and effective records should support the

overall assessment system and the detailed assessment methods within it.

9. The overall assessment system and detailed methods within it should be

subject to quality assurance which is independent and external to those

responsible for developing and managing them.

10. Those carrying out assessments or tests and examinations (as part of the

overall assessment process and including external examiners) should be

fully trained, competent in them and be able to apply them consistently.

11. Serious errors or misjudgements about those being assessed are not

common but the process should build in feedback. Two-way feedback is

necessary for the benefit of assessors, the assessment process and those

being assessed.

12. National assessments (including examinations) should, as a minimum,

test the knowledge, skills and attitudes that are necessary for effective and

safe clinical practice although no single assessment is likely to cover all of

these comprehensively.

13. In-training assessments (often a national process administered locally)

should, as a minimum, test the competence of the trainee in applying the

knowledge tested by national examinations and in areas of diagnosis and

patient management appropriate to practise at the point where the

assessment is delivered.

14. Work-based assessments which are increasingly a feature of postgraduate

medical education should be sensitive to service delivery.

15. Patients and their representative organisations should play an important

part in the overall assessment system in design, participation in assessing

bodies and reviewing processes and methodology. The external

validation of assessment processes implies input from all stakeholders

including candidates.

16. The relationship between national and local assessments and the link

between national standards and local administration must be clearly

defined and understood in the context of educational goals and curricula.

17. The timing of assessments and their relation to examinations and to

educational programmes and outcomes is of crucial importance.

Prepared by the Chief Medical Officer and modified after consultation, in

October 2004.

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