New education method or tool
Open Access

It’s time to train… How we combine high quality Urological training with service provision in a busy DGH setting

Mamoon Siraj[1], Rono Mukherjee[1], Margaret Lyttle[1]

Institution: 1. Mid Cheshire Hospitals HNS Foundation Trust
Corresponding Author: Ms Margaret Lyttle ([email protected])
Categories: Educational Strategies, Postgraduate (including Speciality Training)
Published Date: 05/04/2018

Abstract

Introduction: With constrained training time, we must look for and optimise the educational opportunities within the “service” element of our workload. We proposed that In Patient referrals be used as educational cases.

Methods: We reviewed these referrals over 5 years (2013-2017) and mapped the referrals against the curricula for Core Surgical Training (CST) and General Practice Trainees (GP).

Results: Curriculum mapping against the Urology components of the curricula for GP found all but one of the topics was addressed. For CST all topics were covered. The topics mapped against the curricula were common reasons for referral, therefore we expect that even in a short attachment a Trainee could see most if not all of these.

Conclusion: On average, 0.69 referrals were received per day. Therefore one training case takes relatively little time and should be achievable by even the busiest Trainers and Trainees.

We demonstrate that using inpatient referrals from other teams as an educational resource effectively covers the breadth of the Urology components of both GP and CST curricula. We propose that this approach could be usefully employed by other units and specialities

Keywords: Postgraduate medical education; curriculum mapping; Urology

Introduction

A challenge faced by trainers and Trainees alike is how to balance the demands of service that is needed to maintain safe and effective patient care, yet still provide time for high quality training. Service pressures are often exacerbated by rota gaps (Temple, 2010), endemic within the NHS at the present time. The British Medical Association survey from 2017 found around two thirds of hospital doctors had experienced rota gaps in the previous 12 months with 68% of hospital doctors and 48% of General Practitioners reporting vacancies in their departments and practices (Tonkin, 2017).

The lack of training time is particularly acute in short attachments for Trainees - typically 4 months for General Practice (GP) trainees and 6 months for Core Surgical Trainees (CST). The Trainer must also be aware of the potential for differing educational needs in different groups of trainees. It can therefore be difficult to provide a single educational intervention that is beneficial to all Trainees. We propose a potential solution to these challenges that we found in Urology but the solution could also be applicable to other specialities.

Methods

We started by reviewing the day to day work of the Department to see how we could improve training without any significant additional time commitment from either Trainee or Trainer. We noted that referrals from other teams within the hospital (In Patient Consultant to Consultant referrals) were often reviewed by the Trainer alone. This was often an ad-hoc activity squeezed in between other commitments.  It was suggested that if the Trainer reviewed the referrals immediately after the morning ward round, taking the CST/GP Trainee(s) along, these cases would provide a mix of common urological complaints along with occasional more unusual cases. We proposed that these referrals would be treated as educational resources and Trainees encouraged to reflect on these cases and also to submit Workplace Based Assessments based upon them.  In order to confirm the educational merit of this approach, we retrospectively reviewed these referrals going back 5 years (January 2013- December 2017 inclusive) and mapped the reason(s) for referral against the curricula for CST and GP.

Results

Over the 5 year period (January 2013- February 2017) there were 1060 Consultant to Consultant referrals made to our Urology Department (in a District General Hospital) covering a total of 1268 Urological complaints. This averages 0.69 referrals per day.

The GP curriculum (RCGP) relating to Urology is covered in section 3.07 Men’s Health. The topics included are erectile dysfunction, Prostate Specific Antigen (PSA), prostate cancer, suspected malignancy and testicular lumps. When the main reason(s) for referral were mapped against these curriculum items, we found all but one of the topics, erectile dysfunction, was addressed. Thirty one (2.9%) referrals related to elevated PSA/ suspected prostate cancer and 58 (5.4%) to metastatic prostate cancer. Overall 186 (17.5%) of referrals related to suspected cancer, including prostate, renal, bladder, upper tract transitional cell carcinoma, testicular cancer and penile cancer. This demonstrates that even in a District General Hospital setting, we see rare pathology that covers the scope of Urological Oncology. Fifteen (1.4%) referrals were regarding scrotal or testicular swelling, pain or lump.

The CST curriculum is modular (ISCP, 2017). As well as technical skills and procedures the CST curriculum lists only 4 knowledge domains, namely acute testicular pain, urinary retention, ureteric colic and obstructive uropathy.  We also reviewed the “requirement to meet the ST3 in Urology” list of topics that is included in the CST curriculum and also the Urology Curriculum (ISCP 2015, updated 2016) as this outlines the knowledge Trainees entering Speciality Urology Training from Core training would be expected to have. This covers urinary tract calculi, functional Urology (including lower urinary tract symptoms, urinary tract obstruction, acute urinary retention and and chronic urinary retention), urinary tract infection (including epidymitis and scrotal abscess), Urological Oncology, treatment of renal failure, testicular pain and swelling. As the Urology curriculum included all of the core curriculum topics we mapped the referrals against the criteria to meet the ST3 in Urology topics as we felt this would be more comprehensive.   Stone disease accounted for 68 (6.4%) of referrals, including staghorn calculi and bladder calculi. Functional urology referrals were 533 (50.3%) of the total. Urinary tract infection prompted 191 (18.0%) referrals. Acute Kidney injury/ obstructive nephropathy was the reason for referral in 24 (2.3%) cases, however a further 134 (12.6%) referrals were for hydronephrosis and 23 (2.2%) for high pressure chronic retention of urine. Referrals regarding Urological Oncology and testicular pain and swelling are detailed previously.

The topics mapped against both curricula were the commoner reasons for referral; therefore we expect that even in a short attachment (4 months for GP, 6 months for CST) a Trainee could see most if not all of these.

Discussion

Finding a balance between the time required for the increasingly formal educational requirements of Trainees and the increasing workload resulting from a healthcare system under pressure is a challenge faced by many Trainers. Doctors of all grades and specialities face increased service commitment and increasingly our Trainees find their training time compressed by rota gaps and the requirement to cover these (Temple, 2010). Professor Sir John Temple’s report comments that “in the NHS, training and the delivery of patient care are inextricably linked. It is recognised that the majority of training should take place in a service environment”. The recommendations from this report include ensuring that service delivery explicitly supports training, making every moment count (meaning planned training and a focus on the needs of the Trainee) and a recommendation that Trainer and Trainees “must use the learning opportunities in every clinical situation” (Temple, 2010). We believe our model fits with these principles.

When rota gaps and service pressures factors combine with annual or study leave, out-of-hours shifts and compensatory rest, a Trainer and Trainee may not see as much of each other as would be optimal for training. Our proposal does not attempt to substitute for a well-structured job plan for Trainees and protected training time but it does encourage a mind-set that regardless of other pressures, a brief period of time should be allocated in the daily routine of the Department to focus on training. We chose the In Patient referrals as they were relatively quick to see (on average, 0.69 referrals were received per day) and changed daily (unlike some inpatients). We also felt that if individuals were allowed to choose an educational case from the inpatient/ clinic/ theatre list, personal favourite topics of the Trainer or subjects were the Trainee already felt confident in his/her knowledge may predominate, particularly if a Trainee felt that an workplace based assessment would follow and wanted to “perform” and score well in this. The referral system we describe prevents these biases and largely covers the breadth of the curricula. It of course goes without saying, that all other educational opportunities remained open to the Trainees. The referral reviews were simply a brief focused intervention in order to ensure that for at least one activity per day, CST/ GP education was highlighted as a priority for the department and the Trainee and were additional to the other timetabled activity of the Trainee (on call, clinic, flexible cystoscopy list or theatre list). One potential disadvantage of this system is that depending on what time of day the referrals are received, the Trainee(s) may not have prior knowledge of the topic and therefore do not have the opportunity to do preparatory study. Depending on the personality and preferred learning style of the Trainee, this could potentially cause anxiety and be sub-optimal for knowledge retention.

We proposed the timing as the end of the ward round as this allows the team to review new admissions, identify potentially deteriorating patients and identify discharges early yet still provide a fixed time when the team is together and avoids the risk that the training becomes overlooked when individuals get caught up with other activity (such as clinics or theatre over running).We feel that the addition of (on average) 1 extra patient at the end of a ward round should be achievable by even the busiest Trainers and Trainees.

Within the referrals, common complaints repeat but these can still have educational merit by increasing the depth of knowledge in common presenting complaints. Also a single presenting complaint may lead to a variety of different discussions. If we take haematuria as an example, this could lead to discussions on “red flag” symptoms, bladder cancer, renal cancer, prostate cancer, urinary tract stones, coagulopathy, urinary tract infections, interstitial cystitis, Nephrological causes of haematuria, the basic science of testing strips and the limitations of these, Uro-Radiology, and the role of the Multi-Disciplinary Team (MDT) in diagnosis and management.

Erectile dysfunction is the sole Urological topic not covered from GP curriculum by the referrals. A possible explanation for this may be that this complaint may not be volunteered by the patient or specifically asked about by their doctors who admitted them for another complaint. An alternative explanation may be that even if disclosed or identified, erectile dysfunction is not considered an acute problem or serious enough to warrant in patient assessment. As this is the only topic not covered from the GP curriculum, it is straightforward to compensate for this by timetabling the GP trainee to attend the erectile dysfunction clinic. This is supported by the GP curriculum which advises trainees in secondary care placements to “take the opportunity during your hospital-based placements to attend outpatient clinics in specialities directly relevant to men’s health such as Urology”. Meanwhile, the CST may benefit more from being scheduled to an additional endoscopy or theatre list to learn the technical skills that their syllabus includes (Supra-pubic catheterisation, flexible cystoscopy, rigid cystoscopy, bladder biopsy and cystodiathermy, retrograde urethrogram, retrograde insertion of ureteric stent, exploration of scrotum, excision of epidymal cyst and circumcision).

Potentially, other units may experience a different mix of referrals, however we feel that this would be unlikely as the referrals are unscreened from in-patients in other specialities and although we report our experience in a District General Hospital, we do not believe the case mix of these referrals would be substantially different in any other type of hospital. In larger hospitals, it is possible that the volume of referrals may be higher (and anecdotally this is our experience). It may therefore be necessary to be more selective as to which case or cases are focused upon as educational rather than service activity. In this case both Trainer and Trainee should be mindful of the potential for case bias according to personal favourites or existing strengths discussed above.

Conclusion

With constrained training time for both Trainer and Trainee, it is important to look for and make the most of educational opportunities within the “service” element of our workload. We demonstrate that using inpatient referrals from other teams as an educational resource takes relatively little time but effectively covers the breadth of the Urology knowledge components of the curricula for both General Practice and Core Surgical Training. We propose that this approach could be usefully employed by other units and specialities provided that teams are mindful of the curriculum requirements of their Trainees and quality assure the process by curriculum mapping or feedback from Trainers and Trainees.

Take Home Messages

  1. For your own Departments, consider how best to fit educational interventions into the daily routine of the team. Could a small change in routine provide a big improvement in Training?
  2. Highlighting that a particular case will be the basis for teaching/training focuses the attention of both Trainer and Trainee.
  3. Different Trainees will have different educational needs – an awareness of the differing curricula for different Trainees (dependant on speciality and seniority) is essential to provide appropriate training.
  4. Encourage reflection by Trainees and submission of workplace based assessments.
  5. Small focused “doses” of daily educational focus may be more accessible and achievable for both Trainer and Trainees, particularly in times of service pressure and rota gaps.

Notes On Contributors

Mr Mamoon Siraj is a Consultant Urological Surgeon with particular interests in stone disease and endourology. He has a wealth of training experience both in the Operating Theatre and on wards and in clinics. He is a Clinical Supervisor for Urology Speciality Trainees.

Mr Rono Mukherjee is a Consultant Urological Surgeon. He is Clinical Lead and Educational Lead for the Department. He is an Assigned Educational Supervisor for Foundation Year doctors and for Urology Speciality Trainees. He sits on the Health Education North West ARCP panel for Urology.

Ms Margaret Lyttle is a Consultant Urological Surgeon with interests in Female and Functional Urology and Medical Education. She is a member of AMEE and has presented at the AMEE conference and published on Medial Education topics. She is a Clinical Supervisor for GP trainees and Urology Speciality Trainees.

Acknowledgements

Bibliography/References

ISCP (2016). Educating the surgeons of the future. Intercollegiate Surgical Curriculum Programme; [accessed 3 Feb 2018]. https://www.iscp.ac.uk/static/public/syllabus/syllabus_u_2016.pdf

ISCP (2017). Educating the surgeons of the future. Intercollegiate Surgical Curriculum Programme; [accessed 3 Feb 2018]. https://www.iscp.ac.uk/static/public/syllabus/syllabus_core_2017.pdf

RCGP (2018). Royal College of General Practioners; [accessed 3 Feb 2018]; http://www.rcgp.org.uk/training-exams/gp-curriculum-overview/online-curriculum.aspx

Temple J. (2010). Time for training. A review of the impact of the European Working Time Directive on the quality of training. NHS; https://www.hee.nhs.uk/sites/default/files/documents/Time%20for%20training%20report_0.pdf

Tonkin (2017). British Medical Association; [accessed 3 Feb 2018]. https://www.bma.org.uk/news/2017/june/incidences-of-rota-gaps-surge

Appendices

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Reviews

Please Login or Register an Account before submitting a Review

Ken Masters - (17/09/2019) Panel Member Icon
/
The paper deals with combining high-quality Urological training with service provision in a busy DGH setting.

The paper is interesting, but does need some work:

• There is very little idea of the context in which this is set. The paper speaks only of the Department, but no name (although named as Urology in the Results) and no name of the institution. (The reader can possibly work it out from the authors’ designations, but it should be stated explicitly in the Introduction (or at least the Methods) in order to avoid possible misunderstandings) Also, there is no information about the size and other activities of the department.
• In the Results, the numbers and percentages are given in the textual paragraph. This makes reading and comparison really difficult. It would make the paper much easier to read if these statistics and the mapping were placed into a table or two.
• The paper is a useful lead-in for a project, but as a lead-in only, and, unfortunately, it fails to deliver on the title. The title promises a paper on “How we combine high quality Urological training with service provision” The phrase “high quality training” implies that some form of evaluation of the training was performed, and the quality was found to be high. But this is not the case, and there is no form of training evaluation at all. The paper really only identifies and then maps the training areas to the curriculum, so the title should reflect that.

Minor issues:
• “It of course goes without saying,…” If something goes without saying, then it probably does not need to be said. Either it needs to be said, or it does not. In this case, it probably does need to be said, so the first part of that sentence should be deleted.
• “Trainers” and “Trainees” should be written with small (lowercase) letters.
• Some of the sentences ramble a little, and some punctuation is a little loose. This could be tightened somewhat.

So, an interesting start to a project, but does need to have some areas strengthened. Also, at least some form of evaluation (even piloting) should be performed to have some sense of success or failure, otherwise the paper is really “we mapped things we normally do to the curriculum.”

Possible Conflict of Interest:

For transparency, I am an Associate Editor of MedEdPublish. However I have posted this review as a member of the review panel with relevant expertise and so this review represents a personal, not institutional, opinion.

Trevor Gibbs - (23/06/2018) Panel Member Icon
/
Quite an interesting paper to read and one that starts to address the balance and the opportunities that urological referrals create in the training atmosphere.
It is interesting to note from this paper that the material for training is there and the cases match the training needs. I felt however that this was just the start of a bigger piee of research. Just because the material is there doesn't guarantee effective training. Perhaps the paper could have been expanded and I feel made more useful, by looking at how these referral are used in training, what forms of educational interventions are helpful , how we assess the trainees in this area etc.