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

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

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.

Competency

Competence is the ability to perform some task

Unconscious incompetence Conscious incompetence Conscious competence Unconscious competence

Domains of Learning

Knowledge Exams – MRCOG

Skills Surgical skills

Attitudes TO2

Gynaecological Surgery

Selection of appropriate patient and procedure

Pre operative preparation Perform operation Deal with complications and post

operative care

Competency in Obstetric Practice

Decision Making Communication with patient Communication with team Practical skills

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

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

Recent Training

EWTD/ Shift working Protected teaching and study leave Cancellation of lists Fewer “routine” cases Laparoscopic techniques Senior trainees need experience

Historical Supervision

Apprenticeship/ Firm structure Generalists Time expired senior registrars

Current Supervision

No firm structure/ lack of continuity Registrars less experienced Lists cancelled if no supervision Specialisation

Historical Competence

No test to pass Longer/Time based training Competence assumed FRCS

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

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.

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

New Curriculum

Defines knowledge and skills Courses to attend Methods of assessment

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

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?

Competency Based Assessments

CbD Mini CEX OSATS

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

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

Mini CEX in gynaecological surgery

Taking consent Pre operative assessment Post operative review Explaining results

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

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

OSATS in O & G

Simulation Reproducible “blind” assessors Feasible Valid

?face validity Virtual reality simulators Predictive validity?

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

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

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

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

Advanced Training Skills Modules

Benign Abdominal Gynaecology Surgery

Vaginal Gynaecology Surgery Hysteroscopic Surgery Laparoscopic Gynaecology Surgery

ATSM

Curriculum Defined Methods of assessment Completion of module signed off ?may be part of future person

specification for consultant posts

Assessment of Consultant Practice

Annual Appraisal Record of Adverse Incidents Complication Rates Use of Assessment Methods Evidence of Competency

Conclusion

Changes in Working Practices Focussed Training Curriculum Well Defined Supervision Evidence Based Competency

Conclusion

Ensure Competent Workforce Maintain Public Confidence