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Training 21st Century Clinical Leaders: References and Appendices A Review of the Royal College of Physicians of Ireland Training Programmes by Professor Kevin Imrie July 2014

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Page 1: Training 21st Century Clinical Leaders Training 21st ... · Training 21st Century Clinical Leaders ACGME Accreditation Council for Graduate Medical Education AMU Acute Medical Unit

Training 21st Century Clinical Leaders

Training 21st Century Clinical Leaders:References and AppendicesA Review of the Royal College of Physicians of Ireland Training Programmes by Professor Kevin Imrie

July 2014

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ACGME Accreditation Council for Graduate Medical Education

AMU Acute Medical Unit

AFMC Association of Faculties of Medicine of Canada

BST Basic Specialist Training

CBME Competency-based Medical Education

DoHC Department of Health and Children

EWTD European Working Time Directive

HIQA Health Information and Quality Authority

HSE Health Service Executive

HST Higher Specialist Training

IMO Irish Medical Organisation

MET Health Service Executive Medical Education and Training Unit

NCHD Non-consultant Hospital Doctor

RCPI Royal College of Physicians of Ireland

RCSI Royal College of Surgeons in Ireland

PGME Postgraduate Medical Education

PGTB Postgraduate Training Body

SHO Senior House Officer

SpR Specialist Registrar

UHI Universal Health Insurance

Glossary of Terms

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ACGME (2012) ACGME Data Resource Book, Chicago, IL: Department of Applications and Data Analysis. Available at: http://www.acgme.org/acgmeweb/Portals/0/PFAssets/PublicationsBooks/2011-2012_ACGME_DATABOOK_DOCUMENT_Final.pdf [Accessed 3 June 2014].

Australian Medical Council (2013) Review of the Accreditation Standards for Specialist Medical Education and Continuing Professional Development Programs, Kingston ACT: Australian Medical Council. Available at: http://www.amc.org.au/images/Accreditation/2013-standards-sme-consultation-20130825.pdf [Accessed 3 June 2014].

Buttimer, J., et al. (2006) Preparing Ireland’s Doctors to meet the Health Needs of the 21st Century, Dublin: Department of Health. Available at: http://www.hrb.ie/fileadmin/Staging/Documents/RSF/PEER/Policy_Docs/Relevant_reports/buttimer.pdf [Accessed 3 June 2014].

Calman, K (1995) ‘Hospital Doctors: Training for the Future’, BJOG: An International Journal of Obstetrics & Gynaecology, 102(5), pp. 354-356.

Cooke, M. (2006) ‘American medical education 100 years after the Flexner report’, New England Journal of Medicine, 355 (13), pp. 1339-44.

Crisp, N. (2014) ‘Global Supply of Health Professionals’, New England Journal of Medicine, 370, pp. 950-957.

Department of Health (2007) Medical Practitioners Act 2007. Dublin. Available at: http://www.dohc.ie/publications/pdf/medical_practitioners_act_2007.pdf [Accessed 3 June 2014].

Department of Health (2012) Future Health – A Strategic Framework for Reform of the Health Service 2012 - 2015. Dublin. Available at: http://www.dohc.ie/publications/Future_Health.html [Accessed 3 June 2014].Department of Health (2013) Money Follows the Patient: Policy Paper on Hospital Financing, Dublin: Department of Health.

Department of Health (2013) The Path to Universal Healthcare - Preliminary Paper on Universal Health Insurance, Dublin: Department of Health.

Flexner A. (1910) Medical Education in the United States and Canada, Washington, DC: Science and Health Publications, Inc.

Fottrell, P., et al. (2006) Medical Education in Ireland: A New Direction, Dublin: Department of Health. Available at: http://www.dohc.ie/publications/pdf/fottrell.pdf?direct=1 [Accessed 3 June 2014].

Frenk J, Chen L., et al. (2010) ‘Health professionals for a new century: transforming education to strengthen health systems in an interdependent world’, The Lancet, 376, pp. 1923-58. Available at: http://www.healthprofessionals21.org/docs/HealthProfNewCent.pdf[Accessed 3 June 2014].

Frank, JR., Jabbour M., et al. (2005) Report of the CanMEDS Phase IV Working Groups. Ottawa: The Royal College of Physicians and Surgeons of Canada. Available at: http://www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/framework/the_7_canmeds_roles_e.pdf [Accessed 3 June 2014].

Frank, J.R., Mungroo, R., Ahmad, Y., Wang, M., de Rossi, S. and Horsley, T. (2010). Toward a definition of competency-based education in medicine: a systematic review of published definitions. Medical Teacher 32: 631-637

References

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Frank, JR, Snell LS, Sherbino J, et al. (2014) Draft CanMEDS 2015 Milestones Guide – May 2014. Ottawa: The Royal College of Physicians and Surgeons of Canada; 2014 May. Available at: http://www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/framework/canmeds2015_draft_milestones_e.pdf [Accessed 3 June 2014].

General Medical Council (2014) Report of the Review of Quality Assurance of Medical Education and Training, London: General Medical Council. Available at: http://www.gmc-uk.org/06___Report_of_the_Review_of_Quality_Assurance_of_Medical_Education_and_Training.pdf_55154276.pdf [Accessed 3 June 2014].

Greenaway, D., et al. (2013) Shape of Training: Securing the future of excellent patient care, London: General Medical Council. Available at: http://www.shapeoftraining.co.uk/static/documents/content/Shape_of_training_FINAL_Report.pdf_53977887.pdf[Accessed 3 June 2014].

Hanly, D., et al. (2001) The Report of the National Joint Steering Group on the Working Hours of Non Consultant Hospital Doctors, Dublin: Health Service Executive. Available at: http://lenus.ie/hse/bitstream/10147/42535/1/1902.pdf [Accessed 3 June 2014].

Health Canada (2012) A Collective Vision for Postgraduate Medical Education in Canada, Canada: Health Canada. Available at: http://www.afmc.ca/future-of-medical-education-in-canada/postgraduate-project/final-report.php[Accessed 3 June 2014].

Healthcare Commission (2009) Investigation into Mid Staffordshire NHS Foundation Trust, London: Commission for Healthcare Audit and Inspection. Available at: http://webarchive.nationalarchives.gov.uk/20110504135228/http:/www.cqc.org.uk/_db/_documents/Investigation_into_Mid_Staffordshire_NHS_Foundation_Trust.pdf[Accessed 3 June 2014].

Health Information and Quality Authority (2012) National Standards for Safer Better Healthcare, Dublin: Health Information and Quality Authority. Available at: http://www.hiqa.ie/publications/national-standards-safer-better-healthcare [Accessed 3 June 2014].

Health Service Executive (2007) Medical Education, Training & Research: HSE Strategy, Dublin: Health Service Executive. Available at: http://www.hrb.ie/fileadmin/Staging/Documents/RSF/PEER/Policy_Docs/Relevant_reports/HSE_METR_Strategy_Final_October_2007.pdf [Accessed 3 June 2014].

Health Service Executive (2012) Consultants’ Contract. Dublin. Available at: http://www.hse.ie/eng/staff/Resources/Terms_Conditions_of_Employment/ccontract/ContractNov2012.pdf [Accessed 3 June 2014].

Health Service Executive (2013) Open Disclosure: National Policy, Dublin: Health Service Executive.

Health Workforce Australia (2011) A Strategic Study of Postgraduate Medical Training: Baseline Report, Adelaide SA: Health Workforce Australia. Available at: http://www.hwa.gov.au/sites/uploads/hwa-postgraduate-medical-training-study-010611_0.pdf [Accessed 3 June 2014].

Higgins, J., et al. (2013) The Establishment of Hospital Groups as a transition to Independent Hospital Trusts, Dublin: Department of Health. Available at: http://www.dohc.ie/publications/pdf/IndHospTrusts.pdf?direct=1 [Accessed 3 June 2014].

Independent Working Time Regulations Taskforce (2014) The Implementation of the Working Time Directive, and its Impact on the NHS and Health Professionals, London: RCS Publications. Available at: http://www.rcseng.ac.uk/policy/documents/wtd-taskforce-report-2014[Accessed 3 June 2014].

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Jippes, E., van Luijk S.J., Pols, J., Achterkamp, M.C., Brand, P.L.P. and van Engelen, J.M.L. (2012) Facilitators and barriers to a nationwide implementation of competency-based postgraduate medical curricula: a qualitative study. Medical Teacher 34: e589-e602

Kjaer, N.K., Kodal T., Shaughnessy, A. and Qvesel, D. (2011) Introducing competency-based postgraduate medical training: gains and losses. International Journal of Medical Education 2: 110-115MacCraith, B., et al. (2013) Strategic Review of Medical Training and Career Structure Interim Report, Dublin: Department of Health. Available at: http://www.dohc.ie/publications/pdf/SRMTCS_Interim_Report_FINAL.pdf?direct=1 [Accessed 3 June 2014].

MacCraith, B., et al. (2014) Strategic Review of Medical Training and Career Structure: Report on Medical Career Structures and Pathways Following Completion of Specialist Training, Dublin: Department of Health. Available at: http://health.gov.ie/wp-content/uploads/2014/04/SRMTCS_CareerStructures_Report_FINAL.pdf[Accessed 3 June 2014].

Madden, D. (2008) Building a Culture of Patient Safety: Report of the Commission on Patient Safety and Quality Assurance, Dublin: Department of Health.

Medical Council (2010) Eight Domains of Good Professional Practice as devised by Medical Council, Dublin: Medical Council. Available at: http://www.medicalcouncil.ie/Information-for-Doctors/Good-Professional-Practice/Eight-Domains-of-Good-Professional-Practice-as-devised-by-Medical-Council.pdf [Accessed 3 June 2014].

Medical Council (2011) Medical Council Accreditation Standards for Postgraduate Medical Education and Training, Dublin: Medical Council. Available at: http://www.medicalcouncil.ie/Education-and-Training/Postgraduate-Medical-Education/Medical-Council-Accreditation-Standards-for-Postgraduate-Medical-Education-and-Training-Revised-Oct-2011.pdf [Accessed 3 June 2014].

Medical Council (2012) Medical Workforce Intelligence Report, Dublin: Medical Council. Available at: http://www.medicalcouncil.ie/News-and-Publications/Publications/Annual-Reports-Statistics-/Medical-workforce-intelligence-report-.pdf[Accessed 3 June 2014].

Medical Council (2014) Medical Education, Training and Practice in Ireland 2008-2013 A Progress Report, Dublin: Medical Council. Available at: http://www.medicalcouncil.ie/News-and-Publications/Publications/Education-Training/Progress-Report-on-Medical-Education,-Training-and-Practice.pdf[Accessed 3 June 2014].

Medical Council (2014) Medical Council Statement of Strategy 2014 - 2018, Dublin: Medical Council. Available at: http://www.medicalcouncil.ie/News-and-Publications/Publications/Strategy-/Statement-of-Strategy-2014-2018/Statement-of-Strategy-2014-2018-.pdf [Accessed 3 June 2014].

Ringsted, C. (2014) Transformative thinking needed for transformative postgraduate education. Medical Teacher 36: 95-96

Royal College of Physicians of Ireland (2013) Position Paper on EWTD, Dublin: RCPI. Available at: http://www.rcpi.ie/content/docs/000001/1225_5_media.pdf [Accessed 3 June 2014].

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Royal College of Physicians (2013) The medical registrar: Empowering the unsung heroes of patient care, London: RCP. Available at: http://www.rcplondon.ac.uk/sites/default/files/future-medical-registrar_1.pdf[Accessed 3 June 2014].

Sundhedsstyrelsen (2012) Postgraduate Medical Training in Denmark- status and future perspectives, Copenhagen: National Board of Health. Available at: http://sundhedsstyrelsen.dk/publ/Publ2012/EFUA/Laeger/SummaryPostgradMedTraining.pdf [Accessed 3 June 2014]

Temple, J., et. al. (2002) Future Practice: A Review of the Scottish Medical Workforce, Edinburgh: Scottish Executive to Review the Scottish Medical Workforce. Available at: http://www.scotland.gov.uk/Resource/Doc/46746/0013987.pdf [Accessed 3 June 2014].

Weinstein, D. (2011) Ensuring an Effective Physician Workforce for the United States, Atlanta, GA: Josiah Macy Jr. Foundation. Available at: http://macyfoundation.org/docs/macy_pubs/JMF_GME_Conference2_Monograph(2).pdf [Accessed 3 June 2014].

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BSTDr Catherine Fleming (Chair)Dr Michael O’Neill (Chair)Prof Gaye CunnaneDr Dearbhla Kelly Mr Martin McCormackDr Keelin O’Donoghue

Content and MethodologyDr Deirdre Bennett (Chair)Dr Suzanne O’Sullivan (Chair)Ms Aileen BarrettDr Caitlin BegganDr Basil El NazirDr Sinead HartyDr Sean Kennelly Dr Jacinta MorganDr Elaine NearyDr Clare O’LoughlinDr Cecily Quinn

Hospital Accreditation Working GroupDr Una Geary (Chair)Dr Dubhfeasa Slattery (Chair)Dr Conal CunninghamMs Georgina FarrMs Annette Kelly Dr Sarah Moran Dr Michelle Murphy Dr Suzanne O’Sullivan Prof Arthur Tanner

Trainer Working GroupProf Suzanne Norris (Chair)Dr Michael O’Connell (Chair)Ms Aileen BarrettDr Tara CoughlanDr Orla CraigDr Suzanne DonnellyMs Georgina Farr

Postgraduate Training Working GroupDr Kieran O’Connor (Chair)Dr Anthony O’Regan (Chair)Prof Richard CostelloProf Garry CourtneyDr Clare FallonDr Donough HowardDr Sean Kennelly Dr Deirdre MulhollandDr Karl NeffDr Seamus O’Reilly Dr Eoin Storan Dr Catherine Wall

Trainee Working GroupDr Gráinne O’Kane (Chair)Prof Colm Bergin (Chair)Dr Jaspreet Bhangu Ms Siobhán CreatonDr Kara HeelanDr Eleanor HigginsMs Hadas Levy Dr Hugh O’ConnorDr Jane O’HalloranDr Douglas MulhollandDr Siobhán Neville

Workforce Planning Working GroupProf Eilis McGovern (Chair)Dr Barry White (Chair)Ms Louise Casey Dr Eibhlín ConnollyDr John FitzsimmonsDr Eleanor HigginsDr Howard JohnsonDr Mary KeoganDr Sally Ann LynchDr Paul McElwaineDr Diarmuid O’Shea

Appendix A: Working Group MembersThe recommendations provided by the working groups are internal reflections and reports. They informed Prof Imrie of each group’s views, but the recommendations made in the Imrie report were developed independent of the working groups and RCPI staff. In addition to the members listed below, the Imrie Review Group (Prof Colm Bergin, Dr Ann O’Shaughnessy and Mr Brian Costelloe) were members of each of the Working Groups.

Appendices

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Report of the National Joint Steering Group on the Working Hours of NCHDs (Hanly, 2001)1. Achieve reduction in working

hours in line with EWTD2. Medical Manpower • Increase the number of consultants to

create a consultant provided service • Appropriate medical manpower should

be agreed to ensure greater equilibrium in the NCHD/caonsultant ratio

• A service provided by tired doctors with lengthy on call commitments is unacceptable

• Shift working and / or different work attendance patterns will need to be extended

• Appropriate consultants should be on duty and supported by rostered NCHD staff working appropriate shift patterns

• Flexible working arrangements and more family friendly policies should be agreed in parallel to the extension of shift working where appropriate

3. Hospital Services • Greater consideration to the concept

of team working in all specialties • Consideration should be given

to the concentration and or redesignation of existing services

• Re-engineering of roles within the multi-disciplinary team

4. Training • All NCHDs should be in structured,

recognised training posts • Dedicated training should be ‘ring

fenced’ for NCHD training • Development of an employment and

training contract. This should clearly outline service responsibility and structured training time for each recognised post

• Revised work attendance patterns such as shift work should be flexible to facilitate attendance at designated training times

• A National Task Force should be established to plan, implement and monitor the introduction of the EWTD and concurrent changes

• National Task Force to provide robust central guidance and support through this process

• Local Working Groups (LWG) should be established in each hospital

• Consideration should be given to patient/public representation on this group

• A representative of the Primary Health Care Forum should be included on the hospital working party

• A conflict resolution and mediation facility should be made available to all hospitals engaged in the process from the National Task Force

• Consideration should be given to a national incentive and accreditation scheme for successful hospitals

• Consideration should be given to the extension of clinical budgeting to assist in the management of the NCHD resource

• Communications at national level between policy makers and service providers needs to be harmonic and coherent

• A national awareness and education programme should be devised to prepare the general public for this change

Medical Education in Ireland: A New Direction (Fottrel, 2006)Education Programme and Curriculum • Defined set of programme outcomes • Outlines of how programme outcomes are

to be achieved, defining core, optional and elective modules and programme regulations

• A curriculum for each module • Quality assurance mechanismsClinical Training • Introduction of a accreditation process

for clinical sites and a national register of sites accredited for clinical training

• Accredited sites should be entitled to access educational funding

Trends in Irish Reports1

1The recommendations included represent a selection of the recommendations made in the reports and, in some instances have been edited for the purposes of layout and brevity. For the full recommendations and context, please see the original reports.

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• Medical schools should enter into overall governance agreements with clinical sites for the provision of such clinical education and training services

• Medical schools to influence how clinical training funding is allocated

• Medical schools and clinical sites or networks must introduce conjoint management, administration and logistical structures

• The number of joint education/healthcare academic clinician appointments should be increased in line with international norms

Oversight of Medical Education • A shared oversight model be established • Strategic national policy issues should

be addressed and direction established within the shared oversight

• This model should consist of an interdepartmental steering group on medical education and a national medical education consultative body

Preparing Ireland’s Doctors to meet the Health Needs of the 21st Century (Buttimer, 2006)Priority Recommendations • A robust governance structure capable

of driving forward the major reforms proposed in Ireland’s medical education and training system in a co-ordinated manner

• Independent, expert evaluation of the training value of NCHD posts

• Legislation to assign appropriate medical education and training functions to the HSE and, where appropriate, the Medical and Dental Councils

• Development of financial/information systems and information communications technology (ICT) infrastructure to generate an evidence-base to underpin and support implementation of the recommendations in the Report

• Graduate retention measures, including the implementation of the National Flexible Training Strategy and an increase in consultant numbers

• Systematic annual workforce planning exercises to identify the appropriate numbers required at various levels of training in each specialty and subspecialty based on the staffing needs of the service

• Ongoing cooperation, collaboration and liaison between all the key stakeholders.

• Detailed assessment of, and agreement on, the resource requirements needed to implement these recommendations, where such costings are not currently available

• Implementation of the Training Principles to be Incorporated into New Working Arrangements for Doctors in Training

Training Bodies • Introducing a module on the health of

doctors including caring for colleagues and caring for self, possibly as part of the generic management module

• Including the development and implementation of confidentiality protocols in their curricula

• Providing for assessment and retraining after a long illness

• Developing career support for trainees who are unlikely to progress in a specialty so that they may transfer their competencies to another specialty.

• Publish, in conjunction with HSE-MET, the numbers to be accepted onto each training programme

Other Notable Recommendations • Increase consultant numbers with a

corresponding decrease in the numbers of doctors in training in particular at SHO and Registrar level which can lead to a more streamlined career path

• HSE-MET should promote family-friendly policies, including flexible training

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• The Medical Council, the HSE and the Training Bodies should hold trainers and trainees accountable for the delivery of their contractual and training contract responsibilities.

• Employers should ensure that service demands are not met from allocated training time. Equally, however, Training Bodies, employers and the Medical Council should ensure that trainers and trainees deliver their contractual obligations

Strategic Review of Medical Training and Career Structure (MacCraith, 2013/ 2014)Interim Recommendations (2013) 1. Interim measures be identified by the

HSE, employers and the training bodies with a view to protecting training time for both trainees and trainers

2. In relation to non-core task allocation, the Working Group recommends that a national implementation plan should be put in place by the HSE to progress this matter

3. Specialties that have not already done so should urgently review their programmes in line with international norms

4. That all newly-appointed trainees are informed in advance of their placement/locations for the first two years of a training scheme

5. Explore the implementation of a couple matching/family-friendly initiative

6. Review the funding mechanism to address disparities affecting certain trainees/specialties

7. Streamline process to reduce paperwork burden

8. Measures to improve communication be rolled out on a consistent basis by the HSE and hospital managements

9. Improve feedback loop between HSE-MET and the training bodies to support career planning

Strategic Review of Medical Education and Career Structure (2014) 1. Address the barrier caused by the variation

in rates of remuneration between new entrant Consultants and their established peers that have emerged since 2012. It further recommends that the relevant parties explore options to advance a more differentiated Consultant career structure (i.e. clinical service provision, clinical leadership and management, clinical research, academic, quality improvement and other roles)

2. Development and introduction of a system of accountable personal development/work planning for all Consultants, aligned with professional competence schemes, as appropriate

3. More individually-tailored time commitments should be made available, and facilitated where possible, for both new and existing Consultant posts

4. Personal development/work planning process for Consultants outlined in Recommendation 2 above, should include an outline of the resources required to achieve the service and personal objectives set out in the plan

5. Reconfiguration of hospital services should be used as an opportunity to address the barrier of the unattractiveness of the working environment in some Level 2 and Level 3 hospitals

6. With regard to improving clarity around availability of Consultant posts by specialty and location, the Working Group recommends that more centralised and coordinated workforce planning and better matching of new posts to service requirements and existing trainee capacity

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Forum Retaining Medical Talent: Implementation Plan (Retention Steering Group, 2013)1. HSE MET 1.1 Develop a Workforce Planning Structure 1.2 Develop Structured connected workforce plan • Define and agree the governance

structure for the workforce planning function in the Irish Health Service

• Develop structured, connected workforce planning. Limited to identifying and defining numbers and grades of personnel – starting with Consultants

1.3 Improve Information Exchange through the NCHD Database

1.4 Coordinated approach to communication with trainers /trainees from PGTB and MET

1.5 Explore the viability of increasing the number of Richard Steevens scholarships

2. HSE HR Directorate 2.1 Recognise the need for flexible working

options for doctors in training and combat negative perceptions of working flexibly. Develop an updated policy on flexible working for trainees

2.2 Medical Workforce Substitution 2.3 Review critical tasks interns undertake at night

– e.g. ECGs, first dose antibiotic etc and liaise with National Director of Medical Education Director of Nursing and Midwifery Services to discuss a national approach and best practice

2.4 Explore the introduction of proleptic appointments

2.5 Improved communication from HSE corporate to NCHD

2.6 Review the Consultant appointment process • Map process and identify

duplications & inefficiencies • Appointments aligned to service need • Data on competition ratios 2.6 Development of the Consultant role

2.7 Consider the viability of establishing emergency team to cover during teaching time (undisturbed and bleep free)

3. HSE – Quality & Patient Safety Directorate 3.1 Facilitate the requirement for doctors in

training to access training body information by providing access to training body websites/emails/e-portfolios in the hospital sites

4. Postgraduate Training Bodies 4.1 Review the length of the specialty

training programmes 4.2 Development of a policy on

recognition of training experience5. Clinical Director Programme 5.1 Explore the introduction of individual

or “Chief Resident” in hospital responsible for coordinating training

6. Trainees 6.1 NCHDs having a greater voice

in hospital management through membership on hospital committees

6.2 Start developing training guidelines, in line with EWTD requirements, to protect standard of training (e.g. Post take ward rounds, minimum exposure time to trainers, etc.)

7. Forum of Irish Postgraduate Medical Training Bodies

7.1 Develop a nation-wide career advice structure for medical students, interns and doctors in training programmes which will provide essential information to doctors regarding career paths

7.2 Develop a formal mentoring scheme for doctors in training to provide support on career progression

7.3 Develop a structured system that formally reviews the training environment provided by consultants to whom doctors in training are assigned

7.4 Improve Training Site Regulations • Introduce stricter regulations regarding

what constitutes a training site.

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• Hospitals which do not/cannot support training subject to evaluation by the PGTB and should not be assigned trainees at that site until improvement plan is in place and progress is made

7.5 Postgraduate Training Bodies to develop a communication strategy aimed at junior doctors. The communication strategy to consider the following:

• Feedback sessions with trainees and training bodies (Trainee Forum)

• Involve trainees at all levels of PGTB activity 7.6 Introduction of compulsory reporting to

PGTB on absences at education sessions due to non-release and feedback to hospitals

7.7 Improved communication between hospitals and PGTB on training rotations

7.8 Formalise NCHD Input into Clinical Programmes

• Postgraduate trainee representatives to sit on the Clinical Advisory Groups

7.9 Single Point of Responsibility for Training within a Hospital

Report of the Basic Specialist Training Strategic Review Group (Keane, 2014)1. BST Vision 1.1 Programme Duration • The three programmes in GIM, Paediatrics

and Histopathology should remain as two-year programmes except in exceptional circumstances. All trainees should attempt their MRCPI within the two years and a third year provided for trainees who are unsuccessful and therefore are ineligible to apply for HST posts

• A full proposal for the additional third year, including eligibility and application criteria will be need to be developed for the three programmes

• The BST Programme in Obstetrics and Gynaecology should become a three-year programme as per IMC requirements

1.2 Programme Structure • To introduce a ‘hub and spoke’ model for

all four programmes with the number of ‘spokes’ dependent on the programme size

• Training requirements and accreditation criteria for all hospitals providing basic specialist training should be reviewed by the Hospital Inspections Committee in 2014 and a set of quality assurance criteria defined

• The number of GIM schemes should be reduced from 19 to 6 using a ‘hub and spoke’ model. The implementation group should explore the feasibility of linking the hubs to the new hospital networks; however this may not necessarily provide the most feasible format for amalgamating the existing schemes within the defined criteria for accreditation of training sites

• As part of the core training requirements, a number of criteria need to be clearly defined, including the level of care provided at training sites, availability of ‘unselected take’. The Group recommends that all trainees will be required to spend at least six months in a peripheral hospital with on-call requirements and ‘unselected take’

• Hospital Inspections should include an inspection of all sites providing basic specialist training in an equivalent standard-setting exercise to that of higher specialist training

2. Programme Governance & Support • The Associate Dean/National Specialty

Director (Histopathology) roles and responsibilities should be clearly defined with a maximum term of office of three years

• For larger programmes (GIM/O&G), the Associate Deans/NSD should be supported in their roles by a ‘hub coordinator’ who will report directly to the Associate Dean/NSD and coordinate post allocations for that hub in conjunction with RCPI Medical Training. The term of office for these posts should be no more than three years

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• In larger teaching hospitals a ‘group training lead’ may be required to coordinate local training activities and support the hub coordinator. This role may be undertaken by a local trainer and while the post may be rotated annually, the term of office for any one group training lead should be no more than three years

• Hub coordinators and/or group training leads should have a forum to develop a programme of teaching activities that may then be implemented in each local clinical site

• All hospitals should have a designated ‘SHO Coordinator’ – a nominated point of local contact for both trainees and trainers – with a term of office of no more than three years

• All posts should have clearly defined ‘job descriptions’ and funding for these posts/roles will be required. The implementation group should explore a funding model that is sustainable and reflects the responsibilities aligned with each post. Protected time may be required for Associate Dean/NSD roles, hub coordinators and group training leads

3. Recruitment • Applications: all trainees should have the

option to apply to one, some or all schemes • Interviews: Move to a national interview

process whereby each candidate is interviewed once and the interview score is used for all matching purposes

• All interview centres to be provided with administrative support by RCPI

• Short-listing/interview criteria need to be more clearly defined and should be explicitly available to all candidates

• Allocation (Matching): this process should be done by RCPI as one score should make the process more straightforward

• Post allocations: Schemes to provide rotations for the entire two-year programme where possible. Once a candidate has been allocated to a rotation within a scheme, it should not be changed without

consultation with the training body • Post-match: The post-match process should

be phased out (it is acknowledge by the group that service demands will need to be met and it may not be possible to do so in 2014 without the post-match process). While still in place, all post-match applicants should be required to meet the same shortlisting and interview criteria as training programme candidates

• Where unfilled training posts are subsequently filled by non-trainees, these doctors may be awarded credit for a training year if they complete all training requirements and are deemed to be eligible for a training post. They may then be admitted to RCPI training programme

• All of these recommendations will require significant collaboration and communication between RCPI’s Medical Training Department and the HSE’s Medical Manpower Departments

4. Certification • Trainees should be automatically

awarded a BST certificate on successful completion of the programme

• All trainees must attempt the MRCPI (GIM & Paediatrics) within the two years of the BST programme

• Trainees in O&G will be required to attempt the MRCOG within the three years of the BST programme from 2014

• End of year assessments should occur at the end of year

• ALL posts to be signed off at the end of the post • Further ePortfolio developments to ensure ease

of access and sign-off for trainers and trainees5. Trainer Engagement in the Training

and Assessment Process • The implementation group should work closely

with the Continuous Improvement Project leads and Vice Dean to develop a comprehensive and effective plan to improve communication with trainers and thereby improve their engagement in the training processes

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• The Trainer Competency Framework developed in 2013 should be embedded in a performance management process for trainers with all expectations and roles clearly defined and monitored

• The Trainer Matrix – including requirements for trainers to contribute to interviews and examinations – should be reviewed in conjunction with the CIP

• The Group recommends that Associate Dean/NSD, hub coordinator and group training lead roles all include an element of peer support training

• All BST trainers must apply to RCPI for trainer status if not already registered as a HST trainer and the same minimum requirements should apply to both e.g. new trainers must complete the RCPI Essential Skills course prior to becoming a trainer

• Further ePortfolio and assessment training is required for new and existing trainers – the implementation group should work with the Assessment Strategy project lead to develop a communications plan for any changes implemented in assessment practices

• A formal mentoring programme has been recommended by both internal and external stakeholders. Formal mentoring training needs to be developed for interested trainers

6. Trainee Engagement in the training and Assessment Process

• College should develop a clear and defined plan for gathering trainee feedback and implementing changes, working with trainee representatives to improve the quality of the training programme

• Formal mentoring has been mooted by trainee groups previously and the Group is in favour of developing a formal mentoring programme with specific minimum criteria and training for all mentors

7. Mentoring Programme • Implementation group to work with the

Medical Training Department and Continuous Improvement. Project leads to develop a formal mentoring programme using international best-practice guidelines and research to inform the programme structure

• Mentoring training should be provided to all potential mentors and the list of trained mentors available to trainees

8. ‘Run through training’, Continuous Training and Cross-Training Credit

• The Group is not in favour of establishing ‘run-through training’ for medical specialties at this time

• Matching of BST exit criteria with HST entry criteria

• Cross-training credit should be fully explored by the Forum and credit awarded where trainees apply to related specialties and disciplines, either internally or externally

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Lancet: Health Professionals for a New Century (Frenk, 2014) - InternationalInstructional Reforms1. Adopt a competency-based curricula2. Promote inter-professional and

trans-professional education3. Exploitation of the power of

information technology for learning4. Harness global resources and adapt locally 5. Strengthening of educational resource6. Promotion of a ‘new professionalism’7. Establish joint planning mechanisms Institutional Reform8. Expansion from academic centres

to academic systems9. Link through networks, alliances, and consortia10. The nurturing of a culture of critical inquiry

Macy Foundation: Ensuring an Effective Physician Workforce for the United States (Weinstein, 2011) - United States of AmericaA. Governance:1. An independent review of

governance and financing2. Enable GME redesign through

accreditation policy3. Ensure adequate numbers and

distribution of physicians4. Provide trainees with needed skills sets through

innovative training approaches and sites5. Ensure a workforce of sufficient

size and specialty mixB. Content and format:1. Greater accountability through public

representation and public reporting2. Greater relevance through broadening

sites and content of training and requiring inter-professional education

3. Greater efficiency through adopting a competency based approach, and eliminating non educational experiences and redundancies in training

4. Greater flexibility to individualize training for different career goals

5. Greater research base to improve and evaluate training

The Future of Medical Education in Canada (Health Canada, 2012) - Canada1. Ensure the right mix, distribution and number

of physicians to meet societal needs2. Cultivate societal accountability

through experience in diverse learning and work environments

3. Create positive and supportive learning and work environments

4. Integrate competency-based curricula in postgraduate programs

5. Ensure effective integration and transitions along the educational continuum

6. Implement effective assessment systems7. Develop, support, and recognize clinical teachers8. Foster leadership development9. Establish effective collaborative

governance in PGME10. Align accreditation standards

Shape of Training: Securing the future of excellent patient care (Greenaway, 2013) - United Kingdom1. Appropriate organisations must make

sure postgraduate medical education and training enhances its response to changing demographics and patient needs

2. Appropriate organisations should identify more ways of involving patients in educating and training doctors

3. Appropriate organisations must provide clear advice to potential and current medical students about what they should expect from a medical career

4. Medical schools, along with other appropriate organisations, must make sure medical graduates at the point of registration can work safely in a clinical role suitable to their

Trends in International Reports2

2The recommendations included represent a selection of the recommendations made in the reports and, in some instances have been edited for the purposes of layout and brevity. For the full recommendations and context, please see the original reports.

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competence level, and have experience of and insights into patient needs

5. Full registration should move to the point of graduation from medical school, subject to the necessary legislation being approved by Parliament and education, legal, and regulatory measures are in place to assure patients and employers that doctors are fit to practice.

6. Appropriate organisations must introduce a generic capabilities framework for curricula for postgraduate training based on good medical practice that covers, for example communications, leadership, and quality improvement and safety

7. Appropriate organisations must introduce processes, including assessments that allow doctors to progress at an appropriate pace through training within the overall timeframe of the training programme

8. Appropriate organisations, including employers, must introduce longer placements for doctors in training to work in teams and with supervisors including putting in place apprenticeship arrangements

9. Training should be limited to places that provide high quality training and supervision, and that are approved and quality assured by the GMC

10. Postgraduate training must be structured within broad specialty areas based on patient care themes and defined by common clinical objectives.

11. Appropriate organisations, working with employers, must review the content of postgraduate curricula, how doctors are assessed and how they progress through training to make sure the postgraduate training structure is fit to deliver the broader specialty training that includes generic capabilities, transferable competencies and more patient and employer involvement

12. All doctors must be able to manage acutely ill patients with multiple co-morbidities within their broad specialty areas, and most doctors will continue to maintain these skills in their future careers

13. Appropriate organisations, including employers, must consider how training arrangements will be coordinated to meet local needs while maintaining UK-wide standards

14. Appropriate organisations, including postgraduate research and funding bodies, must support a flexible approach to clinical academic training

15. Appropriate organisations, including employers, must structure CPD within a professional framework to meet patient and service needs, including mechanisms for all doctors to have access, opportunity, and time to carry out the CPD agreed though job planning and appraisal

16. Appropriate organisations, including employers, should develop credentialed programmes for some specialty and all subspecialty training, which will be approved, regulated and quality assured by the GMC

17. Appropriate organisations should review barriers faced by doctors outside of training who want to enter a formal training programme or access credentialed programmes

18. Appropriate organisations should put in place broad specialty training

19. There should be immediate consideration to set up a UK-wide Delivery Group to take forward the recommendations in this report and to identify which organisations should lead on specific actions

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Review of International TrainingArea UK US Australia Denmark Canada

Duration of Training

• Foundation /Core Training: (BST equivalent – include internship) 2 year foundation 2 year core training (CT1 +CT2 – StR grade)

• Specialty Training (HST equivalent): (Dual Training available) minimum 4 years

• Residency (BST equivalent) includes 1 year internship

• Fellowship (HST) 1-3 years depending on the specialty

• Basic Prep Training 3 years in duration (after internship).

• Advanced specialist Training 3 + years (HST)

• One year of internship is mandatory (Basic Clinical Training)

• 4 – 5 years of specialist training. There are 38 different specialties to choose from

• No internshipSpecialties typically 5 yearsMedicine and Paediatrics 3 years core training– followed by 1-3 years of subspecialty specified rotations per year• Fellowship training (optional)

Rotations • Rotation Core Training: 3 – 4 rotations per year (Experience in 6 specialties)

• Rotation Specialist Training: Year 1: District General Hospital (DGH) Year 2 – 3: Split between DGH and Tertiary centres (in one year or 6 month posts). Last 2 years – Advanced specialist area modules. In exceptional circumstances will allow all training in one centre

Sample Residency: Blocks of weeks (e.g Cleveland Clinic)• Inpatient Internal

Medicine 8 weeks• ICU 6 weeks• Ambulatory Internal

Medicine 12 weeks• Elective 14 weeks• Night Float 6 weeks• Consults 2 weeks• Research 4 weeks Fellowship• Rotation: Regional and

specialty dependent

• Basic Prep Training Rotations: 3-6 months. Sample Australian Training Rotation http://www.racp.edu.au/page/btp

• Advanced Training : 6 – 12 months rotations – sample rotation medical oncology - http://www.racp.edu.au/page/specialty/medical-oncology

• The internship is split into two 6-month positions, the first usually being in a hospital, and the second often (80%) being in primary care/family medicine.

• Specialist: At least two training institutions for at least 12 months each within one’s own specialty. Individual employment period vary between 3 and 36 months

Rotations determined by the programmes run by the 17 university PGME offices and accredited by the Royal College of Physicians and Surgeons of Canada. Example: McGill Residency Program, Montreal - Internal Medicine Specialties (e.g. cardiology, gastroenterology):• 3 years core training• 2+ years specialty training

(e.g. gastroenterology)• Fellowship training (optional)• Residents are paid but are

full-time university students and pay school fees

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Area UK US Australia Denmark Canada

Exams • Core Training required to progress: MRCP (UK) MRCPUK Completion of all parts of the MRCP (UK) examination is a mandatory requirement for entry into ST3 in all medical specialties

• Specialty Certificate Examinations (SCEs)

• Fitness to practice exams: Trainees must pass the USMLE Step 3 or COMPLEX Level 3 in order to be state-certified for practice of medicine.

• USMLE Step 3 and COMPLEX Level 3 cover clinical thinking and clinical management. USMLE has multiple-choice test items and computer based case simulations.

• Specialty Board exams. Example Pediatrics Board examination

• To progress to fellowship trainees must have completed a residency and are board eligible or board certified

• The PREP Basic Training program has two summative assessments: the Written Examination and the Clinical Examination.

• These two examinations occur in the 3rd year of training to determine eligibility for progression to Advanced Training.

• The Written Examination may be attempted if a trainee has completed the full-time equivalent of 24 months of basic training before the beginning of the clinical year in which the exam is held.

• The written examination is analogous to the MRCP Part 1 and 2 (written) exams in the United Kingdom and Ireland. The Clinical Examination may be attempted following success in the Written Examination.

There does not appear to be any examination after medical school. You do however have a number of courses to complete: http://www.esgo.org/ENYGO/Pages/TrainingOpportunities.aspx?country=Denmark

Each resident’s training is monitored by a system of feedback and in-training evaluations. It is expected that there is a multi-facetted system of evaluation determined by the program should include in-training examinations and direct observation of clinical skills and may include other evaluations

Assessment Assessment:• Induction Appraisal• Mid-point Review• Review of ePortfolio

Workplace-based assessments and progress through the curriculum can be reviewed

• End of Attachment Appraisal: curriculum progress reviewed

• The curriculum is competency based per residency programme as opposed to a national framework: http://my.clevelandclinic.org/locations_directions/regional-locations/fairview-hospital/about/internal-med-curriculum.aspx

The PREP program utilises formative and summative assessments to assess and guide a learner’s training. Formative Assessment tools• Mini-CEX• Learning Needs Analysis• Professional Qualities Reflection

Formative Assessment of competence among trainees. Online portfolio documents trainees training

Evaluation/Certification• In-training evaluations (ITER) o

At the end of each rotation o Trainees typically cannot access their rotation evaluation until the complete an evaluation of the teaching faculty and the rotation itself • Final in-training evaluation (FITER)

• FITER content includes written/oral exams, ITERs, feedback, Scholarly projects, OSCEs

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Area UK US Australia Denmark Canada

Protected Time

Education Supervisor: duties will normally occupy approximately one hour of protected time per trainee, per week. For details, see guidance in London Deanery Professional Development Framework for Supervisors: http://faculty.londondeanery.ac.uk/professional-development-framework-for-supervisors/Professional%20Development%20Framework%202012

Appears to be more cultural as the consultant contracts are academic and clinical and can use the academic time to carry out training.

There is currently a demand for more protected time. Training is largely dependent on the local providers and there is little consistency in the contribution of trainers.

The majority of training takes place as part of clinical commitments with the aim of meeting competencies as set out by specialist specific curricula. Additional general and specialty specific mandatory courses are required in order to meet theoretical education requriements. It is unclear to what extent there is protected time to attend these courses.

There is protected study leave, but is variable and determined by the regional education programme providers.Commonly, one half day per week is protected for educational activities and a second half day may be protected for a longitudinal continuity experience. Trainees may have as much as 1 year of paid protected time to pursue research or other academic skill development

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Area UK US Australia Denmark Canada

Governance • GMC/PMETB - Regulate all stages of doctors’ training and professional development in the UK, set and monitor standards for all postgraduate medical training. Responsible for the organization and delivery of Postgraduate Medical Education Training which devolves responsibility for local training to the Deaneries

• The Colleges, Faculties and specialty associations have responsibility and ownership of the curriculum and assessment system for each specialty and sub-specialty.

• Deaneries responsible for local training.

• CMT Programme/ Director Head of School coordinates the Training Programme

• Educational supervisor - Responsible for the overall supervision and management of a specified trainee’s educational progress

• Clinical Supervisor: Responsible for overseeing a specified trainee’s clinical work and providing constructive feedback during a training placement.

• Residency and Fellowship programmes are accredited by the ACGME.

• The curricula are approved by ACGME with input from the Medical Boards.

• Trainees are evaluated and certified on the basis of licencing exams (USMLE, implemented by FSMB & NDME) and the Specialty Board Exams (overseen by Specialty Boards).

• Residency programmes can be based at either a university or a community hospital site. The university-based sites are more research and academically focused, whereas community-based sites provide two streams of postgraduate training: one that produces graduates who will likely go on to subspecialise and work in academic environment and a second stream who will likely practice more clinically-based medicine.

• Postgraduate training programmes in the US are accredited by the ACGME. Each specialty has a specific Residency Review Committee. This Residency Review Committee is responsible for setting programme requirements, the objectives of training as well as accrediting residency programmes in the US.

• Australian Medical Council, Medical Board of Australia, Royal Australian College of Physicians

• All providers of specialist medical education must be accredited by the Australian Medical Council (AMC)

• The Royal Australasian College of Physicians (RACP) is a not-for-profit professional organisation responsible for training, education, and representing over 13,500 physicians and paediatricians and 5,000 trainees in 25 medical specialties in Australia and New Zealand.

• Health funding in Australia is provided jointly by the federal (central) government and six state and two territory governments. Funding from the federal government provides for university based medical education and general practice postgraduate training. State and territory

• Governments fund postgraduate specialist training and provide funding for a public hospital system.

• The Danish Health and Medicines Authority (Danish: Sundhedsstyrelsen) is a state-owned entity in Denmark sorting under the Ministry of Health

• The National Board of Health approves each position for postgraduate training.

• Regional councils on postgraduate medical training for each of Denmark’s three regions (Northern, Southern, Eastern). A secretariat for postgraduate medical training serves each council.

• Denmark’s national authorities approve specialties and certify medical specialists.

• http://www.euro.who.int/__data/assets/pdf_file/0004/160519/e96442.pdf Overview of Health system structure see page 21

• 17 Postgraduate Medical education offices run by the Universities and accredited by the Royal College of Physicians and Surgeons of Canada

• Postgraduate Deans for Medical Education

• Residency Program Committee• Programme Director – meets

each trainee twice a year and chairs the residency program committee

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Area UK US Australia Denmark Canada

Trends / Reports

Securing the Future of Excellent Patient Care: http://www.shapeoftraining.co.uk/static/documents/content/Shape_of_training_FINAL_Report.pdf_53977887.pdf

ACGME Data Resource Book - Academic Year 2011 - 2012 https://www.acgme.org/acgmeweb/Portals/0/PFAssets/PublicationsBooks/2011-

• Review of the Accreditation Standards for Specialist Medical Education and Continuing Professional Development Programs http://www.amc.org.au/images/Accreditation/2013-standards-sme-consultation-20130825.pdf

• AMC Accreditation standards: www.amc.org.au/index.php/ar/sme.

• A Strategic Study of Postgraduate Medical Training: Baseline Report March 2011: http://www.hwa.gov.au/sites/uploads/hwa-postgraduate-medical-training-study-010611_0.pdf

Postgraduate Medical Training in Denmark - status and future perspectives http://sundhedsstyrelsen.dk/publ/Publ2012/EFUA/Laeger/SummaryPostgradMedTraining.pdf

Building on Values: The Future of Health Care in Canada http://publications.gc.ca/collections/Collection/CP32-85-2002E.pdfA Collective Vision for Postgraduate Medical Education in Canada:http://www.afmc.ca/future-of-medical-education-in-canada/postgraduate-project/pdf/FMEC_PG_Final-Report_EN.pdf

Generalist vs. specialist

• The Shape of Training Review, led by David Greenaway, is considering what changes might need to be made to postgraduate medical training to ensure that the UK is able to meet the needs of patients and the health service in the future.

• The review is examining five areas: balance of the medical workforce; flexibility of training; breadth and scope of training; balance between service and training; and needs of the patient.

• The vast majority of time spent in residency education is in inpatient, often critical care, settings. When it comes to residency, most of what trainees see is hospitalized patients with a lot of subspecialty-focused issues. http://newsatjama.jama.com/2013/06/26/too-few-generalist-physicians-doesnt-necessarily-mean-too-many-specialists/

Multiple specialisations and subspecialisations are possible, but this is associated with increases in training time.

The Danish Commission on Medical Specialists has recommend that there be less subspecialisation. Previous supbspecialties have been converted to independent specialties, merged with other subspecialties, or abolished. This change was arried out in order to address concerns that the increased specialisation was affecting the quality of general medical competencies.

There has been a continued trend towards increased specialisation in Canada. This has led to efforts to restrict the proliferation of new subspecialties, the deployment of the new program of areas of added competence, as well as a 2013 task force on generalism:http://www.royalcollege.ca/portal/page/portal/rc/common/documents/advocacy/ccc_task_force_report_july_2013_e.pdf

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Area UK US Australia Denmark Canada

Research • Essential component of training (most trainees undertake a period of out of programme research). Specialty training is combined with academic research.

• Academic Integrated pathways: Academic training can be pursued throughout the clinical training pathway. Fellowships and research grants are offered by various funders.

Research years that may last from one to four years if a Ph.D. degree is pursued. Research is encouraged

Academic research fellowships in Australia is you apply to the universities same way as you would in Ireland to do a PHD.

The Postgraduate medical training programme adopted in 2003 made research training mandatory for all specialties but the Danish Commission on Medical Specialists have proposed a 12 week research training module

Research projects are highly recommended but not mandatory in all programs.Protected time for research is typically available during the program.Residents who opt not to participate in research will be required to complete academic work in other fields like education or quality assurance.

References • Royal College of Physicians: http://www.rcplondon.ac.uk/ • The Shape of Training Review: http://www.shapeoftraining.co.uk/static/documents/content/Shape_of_training_FINAL_Report.pdf_53977887.pdf

• ACGME Data Resource Book - Academic Year 2011 - 2012: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/PublicationsBooks/2011-2012_ACGME_DATABOOK_DOCUMENT_Final.pdf

• Sample O&G residency program at Johns Hopkins: http://www.hopkinsmedicine.org/gynecology_obstetrics/education/residency_program/residency_training.html

• Australian Medical Council: http://www.amc.org.au/

• Royal College of Physicians Australia: http://www.racp.edu.au/

• Australian Health Practitioner regulation agency: http://www.ahpra.gov.au/

• Postgraduate Medical Trianing in Denmark: http://sundhedsstyrelsen.dk/publ/Publ2012/EFUA/Laeger/SummaryPostgradMedTraining.pdf

• Sample Clinical Genetics: https://www.eshg.org/fileadmin/www.eshg.org/documents/curricula/curriculum_DK-en.pdf

• Move to Competency Based Assessment: http://www.ijme.net/archive/2/competency-based-postgraduate-medical-training.pdf

• McGill Postgraduate Medical Education residency programme: http://www.medicine.mcgill.ca/postgrad/programs.htm

• CanMed 2015: http://www.royalcollege.ca/portal/page/portal/rc/canmeds/canmeds2015

• Building on Values: The Future of Health Care in Canada http://publications.gc.ca/collections/Collection/CP32-85-2002E.pdf