Paul Grant, Ali Chakera, Kelly Cheer, Roselle Herring, Rahat Maitland, Jyothis George, Milan Piya, Stuart Little
The remit of the YDEF – an organised collective of registrars and newly appointed Consultants from across the UK – is to promote ‘Education, Representation, and Communication’. In addition to providing educational courses and events, YDEF seeks to improve the quality of specialist education by identifying deficiencies in training, and reporting these to those responsible for organising that training, both locally and nationally, with constructive suggestions for improvements.1
Key concerns in the past have been access to training opportunities in elements of the D&E curriculum such as insulin pump experience or specialist pituitary clinics,2 marked variation in the quality and types of training between centres and the different regions, and the constant dilution of specialist training opportunities by the increasing service demands of general internal medicine – the management of the acute take, and of general medical inpatients.
D&E specialist trainees typically undertake training in GIM in parallel with D&E leading to dual certification. This is not the model for all medical specialties, so the available pool of registrars expecting to undertake general medical work (and training) has contracted, and often comprises only D&E and Elderly Medicine trainees. It has been widely acknowledged that the role of a medical registrar has become increasingly challenging and potentially dispiriting.3 As a result of national targets and financial pressures, hospitals are forced to prioritise acute ‘general medical’ issues over long-term outpatient based specialist care. Coupled to this is the fact that there have been significant changes in the speciality over the years (i.e. increased insulin pump use, expansion of community diabetes care and the introduction of a Speciality Certificate Examination). In addition training schemes are struggling to fill vacancies, which further aggravates the situation, impacting negatively on the perception of D&E as a career. These issues have been acknowledged nationally and addressed in recent reports.4,5
There has not been a comprehensive national training survey for some time6,7 and it is important to obtain an up to date ‘state of the nation’ picture of current issues to ensure that the YDEF’s activities, as well as those of other bodies responsible for providing and improving specialist D&E training, remain focused on the needs of trainees.8
The YDEF Training Survey was launched at its annual meeting in March 2014. It was modelled on the recent oncology registrars' training study.9 It included questions covering domains of training such as the balance of time spent between different specialities, the demands of service provision, experience of appraisal and assessment, availability and uptake of study leave, time spent 'out of programme' and measures of the quality and satisfaction with practical experience in the workplace. In addition to quantitative data, respondents were encouraged to add free text responses to explain their answers and provide qualitative information.
There are currently 463 doctors in accredited D&E higher specialist training posts in the UK; 94 (20%) completed the survey.
• Balance of training: trainees reported that at most a third of their time was spent in D&E (Figure 1) with 68% of their time taken up by GIM. Specific comments from trainees relating to this perceived lack of balance in their training included: ‘Heavy commitment towards GIM’, ‘Service provision is taking over’ and ‘Bias to GIM – it seems like we get a lot less training time than other specialities’.
• Clear training plan: when starting in a new training post a clear training plan had been provided to 76% of respondents and 65% had received an appraisal at the beginning or end of their clinical attachment. The majority (81%) had found this a constructive process.
• Study leave and budget: trainees are allocated 30 days study leave per year, but only 72% of trainees were able to take the study leave they needed. The majority spent all of their study budget (approx. £800), spending 60% and 40% on D&E and GIM respectively.
• Training days: registrars were happy (77%) with access to training days but noted the variability in quality of content – the average training day rating was only 6.6 out of 10, with the major criticism being an excess of ‘filler’ content.
• When asked ‘What are the main deficiencies in your training?’ Responses were grouped into similar themes outlined in Table 1; the majority of respondents (55-69%) reported that they were able to discuss a range of issues with their educational or training programme supervisors and that they were able to configure their training rotation to suit their requirements.
• Quality of clinical experience: trainees ranked individual aspects of their D&E training exposure in order to gauge not the volume of exposure but the depth and the quality. Results varied, with outpatient endocrinology experience faring better than diabetes outpatients (54% good or excellent vs only 33% good or excellent for diabetes). Fewer respondents thought their diabetes inpatient experience was good (20% good or excellent vs 25% poor or very poor ratings), however 71% of respondents were more than satisfied with the quality of their MDT experiences. Figure 2 provides a detailed breakdown of how respondents viewed different training areas. Only a minority (18%) of respondents were dissatisfied with their training overall (Figure 3).
• In response to the question, ”What do you consider the best aspects of your training?”, some of the free-text comments included; ‘having time to enjoy and understand my speciality’, weekly case discussions’, ‘free courses from the YDEF’, ‘academic opportunities’, endocrine clinics and post clinic meetings’, ‘courses and conferences’ and ‘interesting case mix’.
• Engagement in audit /research /service improvement: clinical research was generally considered an extra- curricular activity, but 24% of responders had experience of clinical research, even fewer (14%) had been involved in service improvement (e.g. introducing a diabetes admissions avoidance plan10 or an insulin safety group11), but 82% had undertaken obligatory audits. It is noteworthy that several trainees (49%) were pursuing additional qualifications (Figure 4). Reasons for this included: academic interest, personal interests/curiosity, opportunity for career promotion, opportunities to have children and to improve one’s job prospects/CV.
Discussion
Questionnaire surveys of doctors in training often suffer from poor response rates, marked differences in perceptions regarding expectations, regional variations in experience, differences in stage of training and biases from trainees which may or may not be justified. These issues have hopefully been overcome by rolling out the survey at the largest D&E annual training meeting and achieving a relatively high response rate (20%) and by also publishing the questionnaire online for remote access for those unable to attend.
The balance of registrar workload appears skewed towards GIM, and this is frequently a source of great frustration and disappointment to trainees who are keen to pursue experience in D&E. When compared with other medical specialities such as respiratory medicine or gastroenterology, it would appear that diabetes trainees have an excessive proportion of GIM activity. Whilst recognising the importance of GIM as a specialty, and the benefits of a dual CCT, shortfall in dedicated time to pure specialty training has been highlighted. Consequently, a proportion of D&E trainees feel inadequately prepared or experienced for specialist consultant posts following CCT.
Previous studies have documented a lack of confidence amongst junior doctors in the management of diabetes relative to the management of other common medical conditions.12 As these junior doctors progress through the specialist training programme, a clear emphasis has to be placedon the acquisition of specialist skills in D&E. Our survey suggests that the pressures of service commitments in GIM adversely affect the opportunities and ability to acquire these vital skills.
It is difficult to attempt to suggest that the achievement of certain curriculum matched competencies, knowledge standards and quantities of clinical attendances translate into a well rounded new consultant by the time of CCT.13 Few would disagree that there is a substantial variation in the quality of trainees and new consultants and it is clear that the newly qualified consultant should not be viewed as the ‘finished product’. From this survey there appear to be some recurrent problems with the delivery and experience of training for D&E registrars.
Trainees should be supported in four main ways;
1. Provision and awareness of existing training opportunities – from pump clinics to clinical commissioning meetings.
2. Release from the burden of GIM in line with the other major medical specialites, for at least one year.
3. Closer educational supervision and support, which should include regular clinical case discussion, direct observation and feedback on clinical activities and communication – both verbal and written, plus opportunities for supported tutorials.
4. Exposure to and experience of management and leadership opportunities to ensure the service developers of the future are adequately prepared to play an active role.
It could be argued that registrars themselves should be proactive in striving to improve their training.1 There is a need to recognise when things are sub-optimal and to get up and do something about gaps in training. This survey shows variation in training opportunities and quality across the UK and that the disparity of the GIM burden continues. Ultimately, better training will lead to better doctors and better patient care.14,15
Dr Paul Grant
E-mail: drpaul.grant@doctors.org.uk
http://dx.doi.org/10.15277/bjdvd.2014.028
Br J Diabetes Vasc Dis 2014;14:120-23
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