Medical education and the service in which it is embedded are undergoing radical changes. A new postgraduate paediatric curriculum has been introduced in the United Kingdom, the content of which has been derived by the Royal College of Paediatric and Child Health (RCPCH) from Delphi consensus and documents such as Good medical practice.1 It is competency based and will enable trainees to progress according to their acquisition of these competences. Therefore, unlike the earlier time based curricula, the time to complete the curriculum may vary. As progress depends on competence, there is a greater emphasis on continuous assessment of performance. All these aspects bring with them challenges for those responsible for curriculum delivery.

RECRUITMENT

Recruitment is the first stage in the delivery of the curriculum and postgraduate selection practices have been widely criticised. Current research is exploring measures that may be more valid and reliable than the traditional methods. Recruitment based on competences has been found to be superior to the traditional structured interview2 and correlates well with performance.3 Although there are practical limitations to delivering this on a national scale, in 2008 the use of national standardised structured short-listing and interview was felt to be an improvement on the previous geographically variable processes. However, more work is needed in identifying appropriate selection methods.

ORGANISATION AND DELIVERY OF TRAINING PROGRAMMES

Although outcome based education places greater emphasis on the product rather than the process, it is important to examine the organisation and delivery of the curriculum, both key elements of curriculum design, which is the responsibility of the postgraduate deaneries. The RCPCH has produced a guidance document for deaneries on the structure and balance of posts within a programme that may best be able to deliver the necessary learning opportunities.4 However, inevitably, due to the differing service opportunities within deaneries, programmes will be constructed in different ways.

There is a wealth of literature on the organisation and delivery of curricula in the undergraduate domain but far less about the delivery of postgraduate curricula. Organisation of undergraduate teaching may vary between discrete blocks of information or be themed into broader categories, and delivery may vary from traditional lecture based through to problem based learning.5 There is considerable debate about the relative merits of the different methods. The advocates for problem based learning claim that case based integrated learning is more obviously clinically relevant and helps the learner to apply that knowledge at a later stage to clinical situations.6 However, it has been criticised for not guiding learners adequately and risking content gaps.5 The traditional approach has been criticised for delivering large amounts of knowledge but not ensuring it can be appropriately applied. More important, however, than the relative merits is the congruence of the whole package.7 The same argument is true for postgraduate education.

There is always an opportunity for teaching on almost any aspect of a clinical encounter: it is up to the trainer and trainee to seize it.8 Clinical training depends crucially on patient contact. Clinical reasoning depends on the development of “illness scripts” which are a memory bank of previous cases seen.9 These establish a basis for pattern recognition essential for future problem solving strategies; the more patient contacts, the richer the library of scripts. Analysis of these theories concentrates on diagnostic decision-making.10 Situated learning theory11 describes models of how professionals learn to apply technical knowledge within infinitely varied social contexts. By integrating these two theories one can begin to understand how the experienced clinician adapts clinical management plans according to the social context, a feature vitally important in paediatrics. Problem based learning focuses on enabling students to acquire functional organisation of these clinical scripts and emphasises the relevance of learning. Although little has been written about problem based learning in the postgraduate arena,12 13 much of work based teaching follows these problem based learning principles.

To consolidate the knowledge gained in these situations and to ensure a comprehensive delivery of the curriculum, it is essential to supplement this form of teaching with more formal learning opportunities. This can be with a teaching programme of lectures and seminars, or blended learning opportunities incorporating information technology, use of simulation and online learning. For those topics that are of crucial importance (eg, child protection) or those where local expertise may be lacking (eg, adolescent medicine) the RCPCH provides educational tools that can deliver these aspects of the curriculum.

The broad variety of teaching strategies that can be used to deliver the curriculum are summarised in table 1.

Despite this wide range of opportunities, there are also barriers to delivering workplace teaching with its distractions and competing priorities. Perhaps the greatest current concern relates to the implications of the European Working Time Directive (EWTD) regulations, enacted in UK law as the Working Time Regulations,14 which state that by 2009 doctors may work a maximum of 48 h. It has been suggested that if there are fewer than 10 doctors in a rota then service work will dominate training in a way that is educationally unacceptable.15 The effect of the number of doctors in a rota and the balance between acute and planned care is demonstrated in fig 1. As the number of hours is reduced, the planned and more formal structured learning opportunities are decreased. This is perhaps particularly challenging for those who are undertaking subspecialty training where their acute shifts are not in the subspecialty of their training and thus every reduction in hours reduces the exposure to subspecialty training opportunities. Many paediatric departments do not yet have plans in place for meeting the EWTD directive16 and the impact this may have on training is of concern.

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Figure 1

SpR rotas involving full shifts (with kind permission of Professor Roy Pounder).

ASSESSMENT

The training programme is based on three levels of training and at each stage progress is assessed by a range of different assessment tools (fig 2). The assessment strategy17 outlines those assessments expected. These not only meet the Postgraduate Medical Education and Training Board’s (PMETB) principles for assessment18 but also use the utility model,19 which takes into account the five variables: reliability, validity, educational impact, acceptability and cost. These variables are weighted dependant on the context and purpose of the assessment. In line with good practice in assessment,20 the evidence from the workplace and examinations is triangulated to make an overall judgement about a trainee’s fitness to practice and this information is submitted to the Annual Review of Competency Panel (ARCP) who following the guidance21 approve the progress of the trainee. Educational supervisors, who have a role in ensuring trainees set appropriate learning objectives for their placements, also have the responsibility for collating the evidence that trainees have met these objectives as demonstrated by their assessments.

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Figure 2

RCPCH assessment road map. CBD, case based discussion; mini CeX, mini-clinical evaluation exercise; MSF, multi-source feedback; SAIL, Sheffield Assessment Instrument of Letters; SHEFFPAT, Sheffield Patient Assessment Tool.

The MRCPCH examination is a crucial requirement for progress between the first and second levels of training. Trainees need to be supported to acquire the skills necessary to pass the examination and also encouraged to take it when they are deemed to be ready so as not to unduly delay their progress through training. Before the introduction of the Foundation Programme, the average trainee could be expected to pass part 1 MRCPCH 26 months after starting their first hospital post and pass part 2 23 months later. Trainees are now expected to complete part 1 MRCPCH after 12–24 months of specialty training and part 2 after 24–36 months of specialty training. Educational supervisors will need to ensure that trainees are on target to meet these requirements.

Trainees will also need to complete a variety of workplace assessments including the mini-clinical evaluation exercise (min CeX), case based discussion (CBD), directly observed procedural skills (DOPS), Sheffield Assessment Instrument of Letters (SAIL) and a parent MSF (SHEFFPAT). Some of these instruments have been validated in the paediatric setting22^–25 and evidence is available from other specialties on others.26 27

However, there remain challenges in the delivery of these assessments. Firstly, the trainees and trainers need to have confidence in the tools used. Evaluation of multi-source feedback (MSF) in paediatrics23 28 confirms that trainees are concerned that the information received could be influenced by the assessors chosen and data do show that there is a difference between the scores of raters from different professional groups (Archer et al. Assuring validity of multi-source feedback in a national programme (submitted for publication)).29 Trainers are concerned that the instrument may not be sufficiently sensitive to identify at an early stage those trainees in difficulty. The RCPCH is therefore producing additional guidance on both of these aspects.

Two other reported obstacles are insufficient training of trainers in the use of the assessment tools and inadequate time to undertake the assessments. Further training resources are being developed and there is ongoing evaluation of the time taken to complete the assessments. Information to date suggests that it takes on average 6 min to complete the MSF form,22 27 25 min for the mini-CeX including feedback and the duration of the procedure for DOPS plus an additional third for feedback.27

QUALITY ASSURANCE

Standards for training having been established, it is essential that the professionals and public alike can be reassured that the outcome will be a highly competent paediatrician no matter in which part of the country they trained. PMETB, which has the statutory responsibility for quality assuring training, has developed a quality assurance framework29 which combines a number of methods for evaluating training programmes including inspection visits, which in the past, when conducted by the RCPCH, were very effective in highlighting good practice and stimulating improvement.30 However, these are time consuming and are to be supplemented by other data including trainee and trainer reports and deanery self-reporting. With the ever changing environments in which training is delivered, it will be essential that these systems for monitoring the quality of that training are sufficiently sensitive to ensure that a high quality is maintained.

CONCLUSION

There are many challenges in the implementation of a new curriculum. The success is likely to depend not only on the motivation, expertise and enthusiasm of all those involved but also the provision of adequate resources to support the faculty responsible for its delivery. While the newly developed deanery postgraduate schools will play a crucial role in this, we all have a responsibility to the public and our doctors in training to ensure that those resources are provided.