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