A step forward for education

Andrew Connolly, Chairman of the Medical Council of New Zealand, explains what the publication of the New Zealand Curriculum Framework for Prevocational Medical Training means for the country’s next generation of doctors

The recent release of the New Zealand Curriculum Framework for Prevocational Medical Training (NZCF) is possibly the biggest step forward in New Zealand medical education in the past two decades, bringing benefits to interns and patients alike. This is the first of a number of important changes being made to prevocational training for doctors.

Commenting in Medical Council News (July 2011), the then-chairperson of Council, Dr John Adams, following the release of a discussion paper on the Prevocational Training Requirements for Doctors in New Zealand, noted: “Personally, I’m very optimistic about this paper and the possible improvements it identifies that could be made to medical education. After over 20 years of reports and reviews, the paper begins the conversation about not whether, but about what and how change is to be implemented.”

Three years on, the foundations have been laid for comprehensive changes in prevocational medical training. Today the NZCF is on the verge of being implemented and builds on prior learning, experience, competencies, attitudes and behaviours acquired during medical school, particularly the trainee intern year.

The NZCF describes the learning outcomes to be substantively completed by the end of postgraduate year 1 (PGY1) and PGY2. These outcomes are to be achieved through clinical attachments, educational programmes and individual learning, in order to promote safe, quality healthcare.

The implementation of the NZCF will ensure that there are clear expectations for all involved in prevocational training with specific goals in each intern’s professional development plan, linked to the NZCF, allowing for a clear and common understanding of what needs to be achieved and assessed. When beginning new attachments, the NZCF provides a useful guide for discussing the learning opportunities that may be available from a given attachment. It will help to identify particular skills and procedures that may be learnt during the attachment and enable the trainee to plan in advance to achieve such training.

Learning outcomes are split into five sections:

• Communication
• Professionalism
• Clinical management
• Clinical problems and conditions
• Procedures and interventions.

Interns gaining provisional general registration and commencing PGY1 in November 2014 will be expected to begin the process of attaining the learning outcomes from the NZCF through a mix of clinical attachments, learning modules and individual learning. Interns will record the skills they gain in a skills log. There is opportunity for them to take into account prior learning from the trainee intern (TI) year. This is a high trust model, and progress with the attainment of skills will be discussed with supervisors, although there is no need for supervisors to sign off attainment.

E-portfolio

An additional key feature of changes to prevocational training will be the introduction of an e-portfolio for each intern to maintain a record of learning. The e-portfolio will help to track the progress made in each attachment and capture overall learning. The e-portfolio will store a range of information including the intern’s professional development plan (PDP), assessment reports, skills log, and CPD activities.

The e-portfolio will be owned by the intern, and will be accessible to the prevocational educational supervisor, and the clinical supervisor on each attachment. The e-portfolio will decrease the bureaucratic burden for interns and supervisors by making sure that information travels with the intern and is always available, and providing an easy electronic method of collecting reports and other records.

The PDP is a short planning document that will assist the intern and their supervisors to reflect on achievements to date, and identify areas that need to be focused on in future clinical attachments or through learning modules. It will help structure and focus individual learning.

The intern will enter goals in their PDP over the course of PGY1 and PGY2 with help from their supervisors. The goals are targeted around obtaining the learning outcomes in the NZCF, and include the areas for improvement identified through the end of attachment assessments. In PGY2 the goals can be targeted around the intern’s vocational aspirations.

Community-based experience

Changing models of care and a projected increase in the incidence of age-related and chronic conditions will result in a greater share of medical services needing to be provided in the community. Regardless of whether or not an intern is planning to undertake vocational training in general practice, gaining some experience in a community setting will be of benefit. In particular it will ensure they are fit for purpose by providing the opportunity to:

• practise triaging skills
• work with degrees of uncertainty
• understand the systems beyond the hospital boundary and the integration between primary and secondary care
• expose interns to the current and future possibilities for delivery of healthcare outside the hospital.

Council wants all interns to complete a community-based clinical attachment during PGY1/PGY2, and has approved a staged transition, commencing in November 2015, and requiring 100% compliance for all interns by November 2020. The community setting is designed to give interns a view of how medicine is (as well as could be) delivered outside the hospital setting. A community-based clinical attachment is defined as: “An educational experience in a Council accredited attachment led by a community focused specialist which involves the learner in caring for the patient and their illness in the context of the community and their family.” Features of the community attachment would usually include:

• the community management of medical illness and mental health, including early detection of disease, population health surveillance, acute and chronic care management
• the role of the vocational scope of general practice within the wider healthcare network – this would not usually include a hospital-based attachment, with the exception of those rural hospitals run predominantly by general practitioners.

General practice is expected to be the major setting for most community attachments but it would be detrimental to insist on it being compulsory: Council wants to see interns exposed to innovations such as integrated care or outreach attachments that are being established by some hospital-based specialists and services. This is not the same as going to a hospital-based specialist’s private rooms – this would not be an acceptable community attachment as it is simply replicating hospital outpatient work in a different setting.

This definition does not exclude a hospital-employed supervisor whose focus is in the community. Community exposure is relevant to all interns, and many will spend the entire clinical attachment in general practice, but Council’s decision allows for even greater variety and, therefore, we hope, greater progress in staffing, innovative clinical care, and most importantly improved patient care across the sector over time. There are potentially many important areas of practice in the community, such as a specific multidisciplinary approach to community child health that could potentially be lost if we made general practice compulsory.

What are the outcomes of the changes?

Although possibly difficult to quantify, the Council believes public health and safety will be improved in the long-term. Our specific objectives for these changes to prevocational training include:

• Improving the balance between service demands and training requirements
• Increasing the opportunity for interns to obtain the broad-based core competencies needed for medical practice in New Zealand
• Improving the vertical integration on the continuum of learning, and transition between medical school, prevocational training, and vocational training
• Increasing opportunities for interns to work in community-based and outpatient settings
• Improving the opportunity for PGY2s to extend competencies relevant to vocational training
• Increasing the opportunity for senior doctors to participate in the supervision and training of interns.

An evaluation programme is being undertaken, to consider whether the changes being put in place for prevocational training result in improved quality of training for interns, and to determine whether the objectives are met. More information about the changes Council is making to prevocational training is available at www.mcnz.org.nz.