Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Foundation programme - Lapses.
- Visahan Yogendran (2 September 2005)
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The Foundation Programme - A Success?
- Andrew Cook (2 September 2005)
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An opinion far far away.
- Chris Haley (2 September 2005)
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Gaining a Health perspective, while still learning to learn.
- Woody Caan (2 September 2005)
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Working as an F1
- Maxwell A. Allan (5 September 2005)
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All that glitters isn't gold
- Helen E Rumbold (5 September 2005)
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Doctors need to be taught how to teach
- Martyn W Neil (6 September 2005)
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foundation programme
- zak mulk (6 September 2005)
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A good foundation?
- C Wong (7 September 2005)
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What is 'relevant experience'?
- Carmen Eynon Soto (7 September 2005)
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Foundation Programmes - My View
- Rahul Velineni (7 September 2005)
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Foundation Pragramme welcome change-- will it benefit overseas doctors
- satya s toram, MD, MRCP ( Ireland) (7 September 2005)
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Nobody Knows if the Foundation Programme works.
- SHRILAY SINHA (9 September 2005)
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GMC assessment of junior doctors' competency is inadequate or inconsistent
- Nicholas J Matheson, Alex Burns, James Ayres, Ziad Bakri, Simon Peake, and Katherine Henderson (9 September 2005)
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Postgraduate Training in Medical Education
- Bettina Lieske (12 September 2005)
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Foundation years: Missed opportunities for a firm foundation
- George I. Varughese MRCP(Ireland); MRCP (U.K.) (21 September 2005)
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Re: House Officers should manage patients!
- Liz A Tate (22 September 2005)
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Visahan Yogendran, SHO in psychiatry Glasgow
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It is for the first time in English history doctors have been laid off work. This is a truth many in the medical profession will not want to accept or expose. I totally agree with the foundation programme for only one reason- it finds a doctor a job for two years, allowing time to concentrate on the career progress. In the past doctors spent most of their time looking for jobs. But the foundation programme has put many doctors at SHO level out of jobs. ( partly the policies of trusts to cut down on number doctors and flooding of overseas doctors are also responsible of this situation )This introduction of foundation programme should have been more gradual. Competing interests: None declared |
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Andrew Cook, SpR PHM Solihull PCT, B91 3BU
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Professor Hays has a strange view of a successful pilot. My own experience of second year foundation trainees suggests that the foundation programme needs a serious reconfiguration before it can regarded as an adequate replacement for the traditional house officer year followed by time as an SHO in either stand alone posts or a rotation. Increased formal education is a major selling point of the foundation programme but, locally at least, it doesn't happen. Consultants cancel teaching sessions with virtually no notice. They do not value teaching foundation trainees. The programme includes specialties such as General Practice and Public Health Medicine, then insists on assessment tools designed exclusively with acute specialties in mind. There is little knowledge of, or interest in, appropriate assessment tools for disciplines that do not fit the acute medicine model. It is quite clear that the F2 programme is impairing recruitment to less mainstream specialites - such as Public Health Medicine. The trainees passing through the programme locally already know which specialties they wish to work in before they start - and the views do not appear to change at the end of the year. Meanwhile doctors who wish to sample Public Health Medicine before committing to an SpR programme cannot, as all our SHO stand alone posts have been subsumed into F2 schemes. Has this system existed 5 years ago it is very unlikely that I would recently have obtained a CCST in Public Health Medicine, and far more likely that I would have left medicine altogether. Competing interests: None declared |
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Chris Haley, SHO Wythenshawe Hospital, Manchester M23 9LT
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Why is it that the only BMJ featured advocate for the foundation year training is a Professor from Australia? I understand that there are many similarities between the training in the UK and Australia, but surely the absence of and authoritative opinion from our own country is a sign that the new training schemes are far from ready and that the claims of this bold initiative are going to fall well short of any perceived goals. Professor Hays points out that 'the weakness of the previous system has been lack of time, resources, and expertise 'which begs the question, how can a new system which sees overall training years drastically reduced, hours cut and consultants tied up in ever more administrative roles be better? Answers please on a post card, probably from New Zealand this time. Competing interests: None declared |
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Woody Caan, Professor of public health APU, Chelmsford, Essex CM1 1SQ.
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It is wonderful news that the foundation programme for UK medical graduates offers 'new learning opportunities' for public health. [1] The Department of Health has identified a widespread imperative to have medical educators 'promoting public health perspectives', especially a consideration of health in 'the local population'. [2] Who knows, at this early stage of development, whether the foundation programmes will spawn more consultants in public health medicine? However, while new graduates are still learning about their profession and about their own potential, short practical postings in 'public health' [1] could enhance the wider impact of medical practice. The National Health Service has a declared role 'ensuring that service modernisation narrows health inequalities'. [3] The NHS and medical schools must co-operate to ensure this modernisation of medical training is accompanied by varied and 'inspirational' [1] options for public health experience. Perhaps, alongside their necessary learning-in-practice about a spectrum of illness and intervention, junior doctors growing in confidence will, also, learn about the nurturing of health within their patients' lives [4]. 1 Hays R. Foundation programme for newly qualified doctors BMJ 2005; 331: 465-466. 2 Department of Health. Medical Schools: Delivering the Doctors of the Future. London: DH, 2004. 3 Department of Health. Tackling Health Inequalities: A Programme for Action. London: Dh, 2003. 4 Caan W. Framework shows a new vision of health, in life. BMJ 2004; 329: 1239. Competing interests: A public health trainer (for the London Regional Deanery) |
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Maxwell A. Allan, SpR Anaesthetics Wansbeck General
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It is with some distress that I read Dr Hay's editorial about the first foundation year. At no time did he mention that these graduates are doctors who are there to care for patients. F1 should not be purely about educational opportunities but also about delivering health care services to patients. While I agree that many tasks we carry out as junior doctors may lose their educational value after repetition these jobs still need to be done for the patient. Traditionally house officers have been an integral part of the clinical team. If this role is to be replaced by an educational grade, it is unclear who will take on their clinical service responsiblities. Competing interests: None declared |
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Helen E Rumbold, Foundation year 2 SHO Bournemouth
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Having completed my house jobs in August, I felt that obtaining a foundation year 2 post would be the way to go. I thought it would allow me time to develop my "generic" skills, sample three specialities and also mean that I would understand all the three letter abbreviations (eg dops, cbds) in the years to come! Having now worked in the job for a month I have mixed feelings. On the positive side, having a educational advisor means that you actually get careers advice which has always been greatly lacking in the medical profession. One issue with the new rotations is that they often end up incorporating only the not so sort after jobs. I was given a job description that read a weekly timetable of outpatients clinics and theatre slots with a support role for the three houseofficers. This actually turned out to be endless mornings of pre clerking and discharge summaries. The worry I have now is where do I go next: hospitals are no longer offering rotations and seem to offer no contracts longer than a year, presumably as they don't know what is going to happen. Are we going to be allowed to apply for the new scheme in 2007 or are we going to be told we are overqualified? I have no idea whether I will be able to apply for a job that I actually want and after 7 years of very hard work it is an extremely disheartening situation to be in. Competing interests: None declared |
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Martyn W Neil, Orthopaedic Registrar Musgrave Park Hospital, Belfast, BT9 7JB
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Editor - I agree with Professor Hays that there will have to be a rapid expansion in the number of medical graduates who have been taught to teach [1]. The new foundation programme aims to provide new learning opportunities and to assess junior doctors' competencies. Throughout Medicine and Surgery there are plans to improve training and to assess trainees' competencies. In Orthopaedics for example an assessment framework called Orthopaedic Competence Assessment Project (OCAP) has been developed to improve trainers and trainees experience of training [2]. Doctors who will be trainers will need knowledge and skills in facilitating learning opportunities. The trainer should be regarded as an educational facilitator rather than as a teacher. This is in recognition that medical students and junior doctors are adults and that educational experiences should be learner centred. Furthermore this is consistent with the shift in didactic styles of teaching in medical schools towards a problem-based approach [3]. Many doctors accept that teaching is part of their professional duties however few have had the opportunity to study teaching and learning styles. Everyone would like to be thought of as a good, rather than a bad teacher [4]. To be a good teacher or rather a good educational facilitator within the current concepts of training requires an understanding of how adults learn. Therefore doctors who are to train and assess need to know how to teach or facilitate learning. 1 Hays R. Foundation programme for newly qualified doctors. BMJ 2005;331:465-466 2 White C. Innovation in competency based training. BMJ Careers 2005;330(7504):238-239 3 Spencer JA., Jordan RK. Learner centred approaches in medical education. BMJ 1999;318:1280-1283 4 Peyton R. The learning cycle. In: Peyton R ed. Teaching & Learning in medical practice. Heronsgate Rickmansworth: Manticore, 1998:13-19 Competing interests: None declared |
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zak mulk, locum sho southport
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i have just completed my foundation year 2 in southport.It was supposed to be a training base to enter specialities but the number of post for basic specialities are less as compared to the increasing number of aaplicants. i applied for GP training and was termed overqualified!!! now i am forced to do locums even after applying for many training and trust posts. I beleive there should be a systemetic way to solve the problems for those who have completed their f2 and now are dissappointed. Competing interests: None declared |
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C Wong, SpR cardiology macclesfield
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Having worked in the NHS for the last 6 years I have experienced first hand the changes in working practices. My belief is that the foundation course looks good on paper but in practice is in danger of producing a generation of well taught junior doctors with limited experience who are incapable of performing the tasks they are paid to do. Being a junior doctor means one has to actually treat patients as well as learning about how to treat patients. This I can already see is having a detrimental affect on both junior doctor morale and patient care. Competing interests: None declared |
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Carmen Eynon Soto, Medical Student Barts and the London, E1 2JJ
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Editor: As a medical student I have observed the changes to my chosen career path with some trepidation. One of my concerns about the new foundation course is precisely the removal of 'less-relevant' training and experience from the teaching scene. I have always felt that all experiences in medicine are relevant and important to my training. This is surely most important at this early stage of our careers, when nearly everything is new. The choice of programmes and posts currently available for the foundation course does not provide the same degree of exposure for all specialities, which means that much of the information gained in these posts may not be applicable to our future careers. In this case, surely it is better to view the foundation years as a basis for general medicine, and not as a means of stream-lining medical education? I feel that this is especially important to consider when combined with the plans for shortened run-through grades, when every second of clinical experience will be more and more valuable. I fear that my generation will form a cohort of consultant doctors in name, but with less medical exposure and general experience than the current workforce Competing interests: None declared |
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Rahul Velineni, House Officer Medway Maritime Hospital, Kent, ME7 5NY
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Editor Although I can sympathise to an extent with the views of the foundation programme organisers and the modernising medical careers quango, I am of the opinion that there are some big defects. This is based on my experience as working as a house officer. It seems as postgraduate training has been hijacked by self styled 'medical educationists' who in mainly academic exposures or as in this case viewers from another country with a different agenda to the thousands of trained and training doctors who work on the coalface i.e. clinical medicine. In the reams of literature and hours of talks it seems that patient care has been forgotten with numerous assessments (with funny names!) of topics and skills learnt at medical school, talk of audit and portfolios. I just want to do a good job for my patients and that is what I have been eagerly waiting for since finals. I recognise that we need to have some sort of close supervision in the embryonic days of our medical careers but we also need to provide service and we can learn by providing good clinical care with senior supervision to as many patients as we can. I and many colleagues feel that after six hard years at medical school that we are becoming deskilled and disheartened. Is this what I went to medical school for? Competing interests: None declared |
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satya s toram, MD, MRCP ( Ireland), Resident Unity health System, Rochester, USA
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The Foundation Programme is a welcome change to the training system in United Kingdom. Having passed PLAB exams in year 2000 and then working around hospitals in United Kingdom as a House officer for 6 months before being kicked out to another hospital and then another. Finally after working 6 different hospitals and obtaining MRCP, I got Specialist registrar post. By this time I completed USMLE exams and move to United States of America.The training which is similar to foundation year includes rotating among different subspecialities. being attached to one hospital creates a special bond to serve the hospital. No major examinations are involved in Residency. This helps to concentrate on clinical work. Hope the Foundation system of training starts in every hospital in United Kingdom. This will eliminate the unnecessary paperwork a junior doctor has to go through every 6 months or an year. This is especially true in case of overseas doctors who have to concentrate on obtaining a job and sorting their visas rather than on patients. I hope United Kingdom learns from Residency programme and starts a match programme nationwide for foundation year to save manpower and resources. This could have a positive impact on patient care. Competing interests: None declared |
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SHRILAY SINHA, SpR Radiology Wrexham LL13 7TD
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I am baffled how Professor Hays can come up with an article where he claims the pilots for the Foundation Years have worked. As far as I am aware nobody knows if it has worked and nobody will know if it progresses to be successful until August 2007. The F1 has begun from this year but the F2 is now in its second year as a pilot scheme and does not officially begin till August 2006. So please can somebody explain to me what doctors are meant to do who have completed their F2 year this year or next year. Where do they go from there? They will not get entry on any Specialist Training rotation without the necessary qualifications or experience required. The supposed implementation of the new style specialist traning for MMC does not start till 2007, so hence we have a lot of doctors in limbo who are looking for posts and unfortunately are not able to find any SHO posts. All specialities are competetive and nobody will want somebody with less experience and no higher diploma/degree (MRCS/MRCP)training as a specialist registrar in their scheme. Not even the Royal Colleges know what impact the foundation scheme and MMC is going to have on training so for Professor Hays to suggest that it is successful is ludicrous. There is still a lot more information required by doctors undertaking training as to what they should do both in terms of attaining higher diplomas and experience. Competing interests: None declared |
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Nicholas J Matheson, SHO in Neurology The National Hospital for Neurology and Neurosurgery, Alex Burns, James Ayres, Ziad Bakri, Simon Peake, and Katherine Henderson
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In his article on the new UK Foundation Programme Richard Hays states that ‘assessment will focus on practical aspects of medical work rather than examinations’ (1). An examination already exists, however, which is explicitly set to correspond with the level of knowledge expected of a doctor at the end of Foundation Year One. This is the Professional and Linguistic Assessment Board Test (PLAB), administered by the GMC to assess whether international medical graduates have the ability to practice safely as senior house officers (SHOs) in UK hospitals (2). It takes the form of a written paper (Part I) and an OSCE (Part II). Pass marks for the Part I Extended Matching Question (EMQ) examinations in 2004 ranged from 59.6% to 65.5% (Jo Mullin, GMC PLAB Test Section, personal communication). We conducted an audit of UK graduates taking up SHO posts in Accident and Emergency medicine at a major London teaching hospital. A question paper comprising 50 EMQs was derived from a popular PLAB revision aid (3,4) and then edited by an experienced former PLAB examiner to confirm that it accurately reflected the standard of the PLAB examination. 28 SHOs sat the test in November 2004 and March 2005. Only 4 scored less than 60% (mean mark 64%, SD 11%) but, of these, 2 scored only 38% and 40% respectively – well below the pass mark and more than 2 standard deviations below the mean. How many doctors completing the Foundation Programme would be found wanting if tested by this benchmark? We think there is a strong case for a PLAB-style examination to form part of the Foundation Year One or Two assessment processes, thereby providing a level playing field for UK and international medical graduates. Alternatively, if examinations are no longer felt to relevant, the PLAB assessment should be revised. References: 1. Hays R. Foundation programme for newly qualified doctors. BMJ 2005; 331:465-6. 2.GMC. Guidance for PLAB test candidates: PLAB Part I. http://www.gmc -uk.org/register/plab_part1_involved.htm (accessed 6 September 2005). 3.Kroker P. PLAB Part 1 EMQ Pocket Book 2. Knutsford: PasTest, 2001. 4.Harris J, Roberts P, Saich A. PLAB Part 1 EMQ Pocket Book 4. Knutsford: PasTest, 2004. Competing interests: None declared |
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Bettina Lieske, SpR General Surgery currently off work
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Editor- Teaching has got a long tradition in the medical profession, and did we, as members of this profession, not get involved with teaching medical students and younger colleagues as soon as we graduated from medical school and started working in the profession. How many of us did have any formal training in methods of teaching and learning? Doctors have always been assumed to be able to pass on knowledge and skills to juniors and "teaching the medical students" is a well known lunch time activity to a lot of us. Come the Foundation Scheme and all of a sudden formal training in postgraduate medical education is demanded. To foster the assessment process, accountability and quality assurance of the new Foundation Programme we as teachers in the medical profession have to be accountable for our teaching as well and therefore need some formal training in medical education. Medical students and junior doctors have a right to be taught and trained properly. The days of lectures delivered over sandwiches and the SHOs or SpRs send to teach the medical students for an hour in between outpatient clinic and the next theatre session are soon to be over. Lucky the ones how manage to fit a part-time degree in medical education into their schedule, whilst trying to get onto an SpR Training Programme, doing research to get the necessary publications and keeping up to date with their clinical work. Competing interests: None declared |
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George I. Varughese MRCP(Ireland); MRCP (U.K.), Clinical Research Fellow University Department of Medicine, ASCOT Centre, City Hospital, Birmingham B18 7QH - U.K.
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Prof. Hays editorial on the 'success' of foundation years [1]. He has rightly commented on the fact that "learners learn more effectively when they are responsible for their actions, and it has always been the early hospital years that allowed graduates to develop the confidence to become competent practitioners". However, I am sorry to say that the 'early hospital years' are much different from when I was a house officer in the NHS in 1998. Gone are the days when house officers would arrive at a differential diagnosis and formulate a plan of action for each patient. Nowadays, the only plan made for every patient is 1] Bloods - routine, 2] CXR (Chest X-ray) and 3] Reg (Registrar) review. This is an opinion which would be endorsed by a majority of medical registrars (who had trained in the good old system) working in the NHS today. Many a times, I wonder what happened to all those five years of medical school training. On a similar note, exposure to clinical procedures are far less for the FY1 and FY2 team members (partly due to the EWTD also). I have had the opportunity to perform 25 central venous catheter procedures, 50 chest drain insertion (working on a respiratory ward) and at least 10 abdominal paracenteses to name a few during my memorable six months as a medical house officer on a 1:3 rota at a district general hospital, seven years ago. I do not think that any of the foundation year trainees would be able to boast of less than half of these numbers after two years in this era! One should not forget that these are the doctors of tommorrow who would be seeking entry into the specialist register in the years to come. Therefore, though Prof. Hays may think that the grass is greener on the other side, I am quite confident that many of our NHS Consultants would agree to disagree with the 'success' of the foundation years, which is still lacking a firm foundation. 1. Hays R. Foundation programme for newly qualified doctors. BMJ 2005; 331:465-6. Competing interests: GIV is a Specialist Registrar in Endocrinology & General (Internal) Medicine on the West Midlands rotational training programme. |
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Liz A Tate, F2 SHO Psychiatry Woodhaven Hospital, Totton, SO40 2TA
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Whilst I agree with George Varughese that experience in clinical procedures is not what it used to be for house officers, I take issue with his lament for the days when house officers made a differential disgnosis and management plan for each patient. As (recent) medical house officers my colleagues and I always made differential diagnoses and management plans, in part because it was our job but also because it made the otherwise sometimes tedious job much more fun. I also recall that no registrar worth their salt would have reviewed a patient of mine if I had not done so. New house officers are usually unsure of themselves and their clinical expertise and if they perceive it to be normal and acceptable will request senior reviews early so as not to exceed their boundaries ('knowing your limits' appears on every appraisal form now). Registrars must make their expectations clear early. As for lack of practical experience, this is certainly a fact but hardly the fault of the Foundation Programme co-ordinators. As a house officer in a large teaching hospital I achieved a measley handful of procedures, yet still more than many of my colleagues because I was keen and opportunistic! Fewer procedures are done on the wards now, and even then often by interventional radiologists. And of course, years of ever expanding medical training have left a whole generation of juniors fighting over every chest drain like hyenas over carrion. Competing interests: Recent house officer and F2 pioneer |
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