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In their accompanying article [1], Paul et al. present information concerning the number of training opportunities for trainee anaesthetists in their hospital between 1999 and 2009. Their principal conclusion is that for all grades of trainee as a single group, they find no evidence that the European Working Time Directive [2] adversely affected training opportunities in their hospital, in terms of supervised time over this period. It is possible that without the Directive, which has been a Regulation (the EWTR) since its delayed implementation in 2009, trainee service workload might have expanded uncontrolled, to the point that training itself was placed under threat. It is also possible that were it not for the EWTR, their department might now have many more discrete training opportunities than in 1999. Be that as it may, their data do support their conclusions. Of more interest to educationalists, indeed to the public, is the implicit suggestion that the quality of training during these training opportunities is also unchanged. However, Paul et al.’s study did not set out to quantify the quality or efficacy of the training opportunities they documented.

There have been numerous developments in postgraduate medical education since 1999 [3]. There has been an increasing emphasis on the documentation of performance, the provision of effective feedback, the creation of Schools in Deaneries and the approval of posts and programmes against General Medical Council (GMC) standards [4]. What has been the effect of these developments? There have been many opportunities created for quality improvement and increased efficiency in the delivery of training, both in the working environment and away from it. Examples of this are the involvement of trainees and trainers from all crafts in the local architecture of their training environment; something of a tradition for UK anaesthesia [5–7]. Other developments such as trainee/trainer surveys, an emphasis on faculty development, and the recognition of the potential offered by simulated practice, have all created the prospect of improved educational governance [8]. The proposal that these changes may have offset, and possibly more than compensated for, any negative impact of the EWTR (if there has been a negative impact) has sufficient face validity that it merits further academic enquiry.

Patient safety is the first domain in the GMC’s standards for training which are described in their 2011 document The Trainee Doctor [4]. The GMC requires that the “…supervision of trainees must be consistent with the delivery of high-quality, safe patient care”. The impact of non-technical skills and human factors on the curriculum for anaesthesia training in the UK is already measurable [9, 10]. The effect of the World Health Organization’s Surgical Safety Checklist in the UK is becoming more tangible as providers of surgical services implement the detail of these guidelines, for example, team briefing at the start of lists and marking the site of regional blockade [11, 12]. These developments are becoming a daily part of the experience of UK anaesthetists in training. Building the principles that underlie these initiatives into the development of medical professionalism in anaesthetists in training is likely to lead to improved patient care [9, 13].

And what of experience? The ubiquitous proposal that ‘experience’ is a fundamental component of achieving proficient practice has compelling face validity, but is it true? Byrne’s recent editorial [14] in this journal has eruditely drawn attention to the academic basis of what surgeons have been asserting for some time [15]. Byrne argues that apprentiship training enhanced by appropriately designed and assessed simulated practice is valuable. With reference to cognitive psychology, he proposes that, “… the function of an expert in any field is largely dependent on [the development of] schemata”, which are internal representations of the world around us [16]. He describes the development and purpose of ‘schemata’ in detail and relates their development to ‘deliberate practice’ [17–19] and ‘reflection in action’ [20], providing evidence that effective schemata may take 10 years to establish. It is logical to conclude from this that the maintenance of the number of attachments to which trainees have access each week is not, on its own, a measure of the educational impact of the EWTR, nor is it likely that this is true of any single initiative.

Moving on then to the content of effective apprentiship in UK anaesthesia training since the introduction of the EWTR. It is worth considering the outcomes we should expect from the modern training attachment, regardless of how many are delivered per week. Stahl and Davies consider this using the concept of the ‘realm of influence’ of medical education [21]. Indeed, how do we know that the ultimate influence of a module in a training programme improves patient outcomes? In developing the concept, Stahl and Davies build on the idea of mastery (achieving long-term retention of knowledge, skills and beliefs with associated worthwhile and long-lasting behavioural change [22]) as opposed to learning. They observe that few studies in medical education have attempted this assessment and fewer still have demonstrated a positive effect of an educational initiative on patient outcome [21]. Stahl and Davis cite Kirkpatrick and Kirkpatrick when advocating four levels for evaluating the success of education [23]. Phillips’s work [24] is used to build on this using his proposal of a fifth level titled ‘return on education’ which, in this context, means maximising the impact on improved patient care [21]. Prospective consideration should therefore be given to how to deliver this fifth level when setting learning outcomes for an educational initiative or module.

Schuwirth and van der Vleuten have suggested that medical education must adapt to society’s changing attitudes [25] towards medical care and the working environment. Citing the EWTR alongside growing patient awareness of physicians’ role in medical education, they ask that assessment and educational research standards are raised. They express concern about alleged negative attitudes to assessment amongst trainers and trainees, adding that a cultural shift is required to deliver increased standards. So, whilst we still don’t know if the quality of training opportunities has been preserved or enhanced in Paul et al.’s department (and it’s likely that they have), it’s important to consider those factors that may have impacted on their quality over the last decade. It is likely that educational standards have been improved, at least in terms of consistency. We support Schuwirth and van der Vleuten and believe that those involved in research into postgraduate anaesthetic training must now not only start to describe meaningful outcomes worthy of enquiry, but also find ways of encouraging those involved to go on and undertake the necessary research itself.

There have been many opinions expressed in the medical literature asserting an adverse impact on training from the EWTR, but equally as often these are rebutted [26, 27]. These exchanges suggest that we should go back to basics and study the professional skills of the medical educator, review what it is that works (what’s formative) and attempt to establish whether ‘mastery’ as the pinnacle of professionalism leads to reliable judgements of the qualities of the evolving professionals (the trainees) by faculty (the supervisors) [28–30]. Consultants of the baby boomer generation (b. 1946–1955) may bemoan the changing landscape and reminisce fondly about the way they worked and learnt 30 years ago. However, some things remain the same and are rightly regarded as important. New trainees in anaesthesia continue to experience a structured and supervised initial training period, largely delivered by senior staff. This intense period of one-to-one teaching is key to developing safe and effective practice and the importance of good role models cannot be over-emphasised [29]. One-to-one teaching in the clinical environment is regarded as normal practice in anaesthesia and remains a large component of how trainees learn. The Royal College of Anaesthetists continues to set the standard for attachments in clinical practice at a minimum of three sessions of direct consultant supervision per trainee per week. It expects trainees to receive this throughout their training, giving regular opportunity for discussion, debate and feedback on individual practice. Paul et al.’s data show that they achieved this standard. However, we still know relatively little about the quality of such learning opportunities [28, 30].

The reduction in hours has inevitably meant a reduction in total caseload but it’s difficult to compare these two groups’ caseloads objectively, if only because before the mid-1990s, most of us did not collect details of cases completed nor of the level of supervision of each case. The baby boomers usually expected to train for at least 10 years post-qualification, including a one-year, non-anaesthetic SHO post before starting anaesthetics and at least three years spent as a Senior Registrar – the later years characterised by a heavy service workload, nominally supervised but largely autonomous – before taking up a consultant post. From our personal experience, the average hours worked during the 1980s were around 100 per week. A full-time anaesthetic trainee today can plan to gain the Certificate of Completion of Training (CCT) nine years post-qualification [10]. Today’s Core Trainees, having completed their Foundation Programme, would have to work a further 18 years to clock up the same number of contracted hours that the baby boomers did 25 years ago. Previous publications have described this problem in reference to specialist areas [31]. Factors other than the EWTR may also have had an impact, including the overall increase in both consultant and trainee numbers.”

Service reconfiguration has also changed trainees’ experiences and these effects are more difficult to evaluate. Pre-operative assessment used to be done the night before surgery at the end of a full day spent in theatre. Whilst sometimes daunting to start seeing patients at 7pm, they were usually in a bed, with notes and results, and one could spend as long as needed assessing the patient and discussing the anaesthetic plan. This aspect of clinical practice has virtually disappeared and been replaced by nurse-led pre-operative assessment with admission on the day of surgery. Conceding that there is an administrative benefit to these new arrangements, do these changes matter educationally? Postoperative analgesia is another area where clinical practice has changed so much that trainees are no longer able to follow up patients after a shift. How do trainees learn about the efficacy or otherwise of their peri-operative plans when many patients go home within a few hours of their procedure?

Different generational attitudes towards careers also affects the delivery of education. Clark described how ‘generation Y’ (b. 1981–2000) has different aspirations to ‘baby boomers’, for example, greater expectations for a life outside work. The EWTR has not been a universal success in that respect. Shift working has disadvantages and, initially, poor design of work patterns was not uncommon following the EWTR’s introduction, which will have impacted on the nature of theatre attachments and other learning opportunities. There is also increasing dislike amongst graduates to working patterns involving unsocial hours, something that cannot be avoided in anaesthesic training.

Whatever the EWTR’s advantages or disadvantages, there is no realistic prospect of turning back the clock. Nor is there an appetite to do so outside the medical profession: a recent report from the House of Commons Health Committee states: “We do not feel any rose tinted nostalgia for a system which used to rely on over-tired and under-trained junior doctors …it is possible to reconcile reasonable hours for junior doctors with high quality training and, most importantly, high standards of care for patients” [32]. The Academy of Medical Royal Colleges agrees [33].

Our personal experience of preparing candidates for Final FRCA over the last 20 years suggests that our trainees are intelligent, well-motivated and knowledgeable. They are perfectly capable of delivering excellent care as consultants and need to be encouraged to aspire to that excellence as a core component of their professional behaviours. Perhaps more of a challenge is persuading them and us that the systems in which we work also need our input and enthusiasm to deliver and support a learning environment with better measures of learning outcomes whose ‘realm of influence’ extends through behavioural change to demonstrably improved patient outcomes. Paul et al.’s paper establishes that in their department the potential opportunity to do so has been undiminished since the introduction of the EWTR, at least in terms of the frequency of ‘the attachment’. What’s needed now to benchmark UK anaesthesia educational practice is a programme of research to evaluate formally the success of our apprentiship model. Because today’s anaesthetic educational environment is not better, not worse, just different, Kirkpatrick and Phillips’s proposed approach to evaluating educational success is a credible basis for such an assessment. We suggest that it is now important to engage with their fifth level of assessment of the impact of education – to test whether or not the ‘realm of influence’ of education extends as far as the improvement of patient outcomes.

Competing interests

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CMSC is an Associate Postgraduate Dean in the East Midlands Healthcare Workforce Deanery (EMHWD), and AEC is President of the Society for Education in Anaesthesia (UK). The views expressed here do not necessarily represent those of either body. No external funding declared.

References

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  2. Competing interests
  3. References