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    Training, Supervision andCompetency in Gynaecological

    SurgeryDr Dina Bisson

    Consultant Obstetrician and Gynaecologist andTraining Programme Director for O & G

    Severn Institute, Bristol.

    26 April 2007RCOG

    London

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    Training

    Training refers to the acquisition ofknowledge, skills, and competencies as aresult of the teaching of vocational orpractical skills and knowledge that relatesto specific useful skills

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    Supervision

    Supervision means the act of watchingover the work or tasks of another who maylack full knowledge of the concept at hand.Supervision does not mean control ofanother but guidance in a work,

    professional or personal context.

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    Competency

    Competence is the ability to performsome 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 andprocedure

    Pre operative preparation

    Perform operation

    Deal with complications and post operativecare

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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 medicalregister in 2002

    Aware of changes to training and workingpractices

    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 & Gundergone radical change requiringinnovative 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 levelof 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

    RecognisesH

    igh 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 operativeprocedure

    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 ofTechnical Skill

    Developed byU

    niversity 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 ofWashington 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 validityVirtual reality simulators

    Predictive validity?

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    OSATS in real life

    Work Based assessments

    Opportunities for assessment every dayAssessments 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 FORTISSUE

    Frequently used unnecessary force ontissue or caused damage by inappropriate

    use of instruments

    Careful handling of tissuebut occasionally causes

    inadvertent damage

    Consistently handled tissues appropriatelywith minimal damage

    TIME & MOTION Many unnecessary moves. Frequently

    stopped operating or needed to discussnext move.

    Makes reasonable progress

    but some unnecessarymoves. Sound knowledgeof operation but slightly

    disjointed at times

    Economy of movement and maximum

    efficiency. Obviously planned course ofoperation with effortless flow from one

    move to the next.

    KNOWLEDGE /HANDLINGOFINSTRUMENTS

    Lack of knowledge of instruments Competent use of

    instruments butoccasionally awkward or

    tentative

    Fluid moves with instruments and no

    awkwardness and obvious familiarity withinstruments

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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 specificationfor 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 CompetentWorkforce

    Maintain Public Confidence


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