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??Special Feature
HIGHER TRAINING AND CONTINUING MEDICAL EDUCATION IN RADIATION ONCOLOGY IN THE UNITED KINGDOM RICHARD G. B. EVANS, M.B.,
FRCR
Faculty of Clinical Oncology, The Royal College of Radiologists
sible for the award of higher degrees which, in general, recognize scientific endeavour by the individual. The Royal College of Radiologists considers that a minimum of 5 years’ training, in both clinical radiology and clinical oncology, is necessary before appointment to a Consultant post. This training should consist of an initial three years of basic training, be followed by two or more years of higher training.
INTRODUCTION The Medical Act of 1858 stated “. . . it is expedient that persons requiring medical aid should be enabled to distinguish qualified from unqualified practitioners.” The General Medical Council was established to undertake the role of supervising undergraduate education, and those who meet the necessary requirements and who after completing satisfactorily a 12 month period of general clinical training (the pre-registration year) are statutorily entitled to full registration with all its privileges including the right to engage immediately in independent practice. In today’s educational terms, however, they would not be regarded as qualified for anything other than further professional training in the specialty or specialties of their choice. The GMC has made it clear that “the principal objective of basic medical education (the under-graduate course and the year of general clinical training) is not to train specialists in any field of medicine but to provide all doctors by the time of full registration with a knowledge, skills and attitudes which will provide a firm basis for future vocational training.” Today, the “qualified” doctor is one who is fully trained, whether in, for example, general practice, community medicine or in a hospital-based clinical specialty. A variety of arrangements exist for specialist training under the auspices of the Royal Colleges and Faculties which are the bodies principally responsible for the provision and moderation of training, and the obtaining of additional qualifications awarded by these bodies plays a significant part in relation to such training. Some qualifications, such as membership of the Royal College of Physicians (MRCP) or Fellowship of the Royal College of Surgeons (FRCS), enable a doctor to embark upon higher specialist training with a view to securing accreditation or its equivalent. Others, such as membership of the Royal College of Pathologists (MRCPath), are awarded at or close to the completion of specialist training. Universities are respon-
POST-FRCR OR HIGHER TRAINING IN CLINICAL ONCOLOGY In 1989 a working party of the Education Board was set up to advise on how this should be achieved. Introduction The time between passing the final fellowship examination and obtaining a consultant appointment has lengthened over recent years and few senior registrar appointments are now made without the FRCR. The average time in post for a senior registrar in clinical oncology is now 3.3 years and the overall total time spent in training posts is now 6-7 years. The main elements that are desirable in post-FRCR training are as follows: General clinical experience. After 3-4 years of general radiotherapy training under supervision and culminating in success at the final FRCR examination, a general level of clinical competence should be assumed. Because of the varying pattern of training in different departments, however, it is possible that gaps may exist in the experience of individual trainees. These should be identified by the regional post-graduate adviser or the College tutor and the deficiency made up in the post-fellowship period. Site specialization. There is an increasing trend for site specialization to occur among surgeons and medical oncologists and an appropriately high degree of specialization
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should be expected of clinical oncologists to keep them abreast of developments in specialized areas of expertise. This is likely to be increasingly important as multi-disciplinary teams are developed and where the clinical oncologist will need to make a full contribution on the basis of up-to-date specialist knowledge. There is considerable fear that specialization at senior registrar level will reduce trainees’ options in applying for jobs outside the field that they have studied. It is to be hoped that site specialization experience is considered as an introduction in methodology of management that is applicable not only to the site under consideration but to others, and that this should make candidates more, rather than less, acceptable even though the post for which they are applying is intended to provide specialization in a different area. Recommendation. It is recommended that one year of post-fellowship training is spent on attachment to a team that provides site specialization experience. This will usually mean attendance at joint clinics and involvement in development and review of protocols appropriate to that site. Implementation. On passing the FRCR or appointment to senior registrar post a trainee should be able to discuss with the regional post-graduate adviser or College tutor what facilities are available for developing site specialization experience. If facilities do not exist within the trainee’s center it should be the responsibility of the tutor or adviser to arrange for the trainee to attend another department in the region to gain the necessary experience. The College is to maintain a central register of units where special experience can be gained so that this information can be made available, both to trainees and to regional post-graduate advisers and College tutors. Research experience. Departments of clinical oncology provide the largest body of clinicians able to provide nonsurgical oncology care and are well organized to do so in numerous large regional centers. Developments in cancer care over the next 20 years are likely to come from advances in many disciplines; these include molecular biology, genetics and immunology. While radiotherapists will always be called upon to provide expertise in the delivery of ionizing radiation, they will be left completely behind unless the specialty is research based and can take advantage of, and integrate with, new developments in tumor biology. For this reason it is considered essential that trainees in clinical oncology are able to develop experience of research methods. Senior Registrars are currently allowed in their contract to have one day free each week to pursue research interests but because of service needs and the low priority that research is given in many departments there are very few who are able to take advantage of this. 1. Recommendations.
It is recommended that the minimum research experience for a senior registrar is that
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the 1 day a week specified in their contract for research should be protected for that purpose. A program of research should be agreed prospectively with their regional post-graduate adviser or College tutor and that this should be annually reviewed. Implementation. For those who wish to gain greater research experience, opportunities need to be made available for them to spend a year or more free of clinical duties during which more intensive research can be pursued. The post-graduate adviser or College tutor should be aware of what posts are available and this would be greatly assisted by a central register held at the College. survey of trainees in clinical oncology has shown that the majority would favor a period of research during their training. Administration/management. It is becoming increasingly important for trainees and new consultants in clinical oncology to have experience in administration and management. Most regions provide a 1 week course in management and it is recommended that all senior registrars in clinical oncology should attend one of these courses. During their training they should also have experience of sitting on their unit or divisional management committee and on committees relevant to equipment provision. Experience should also be gained in management of junior staff rotas and in organization of educational activities such as journal clubs and invitation of speakers to their departments. There should also be an opportunity to become involved in audit both of activity and performance within a radiotherapy department. Continuing education. Post-FRCR trainees, like consultants, need the opportunity to continue post-graduate education and each training department should have a program of post-graduate meetings and lectures that a trainee should be involved in planning. Department should also be active in encouraging trainees to attend post-graduate courses and symposia to enhance specialist expertise. Conclusion The main recommendations of this report are that site specialization and research experience should be made an important part of post-FRCR training. This should be implemented and monitored through the regional postgraduate advisers and college tutors in each training department. The College has a role in making sure that established consultants and members of appointments committees are aware of the desirability of such training. It also has a role in maintaining a register of units where specialist experience can be obtained and a register of available fulltime research posts. Monitoring of post-FRCR training is being done through regular College visits to training departments and inspecting specific posts offering postFRCR specialist training.
Continuing medical education in radiation oncology in the UK 0
The working party concludes by advising that the College should also institute mechanisms whereby Regional Post-Graduate Advisers and College Tutors can report centrally on the implementation of these proposals. Accreditation Application for a Certificate of Accreditation may be made by holders of the FRCR on completion 5 years of recognized training. Not less than 4 years should be spent in full time clinical work, of which at least 1 year should be at senior registrar or equivalent grade. Full time research, experience in related clinical fields, or time spent gaining specialist experience is encouraged but may not necessarily be counted wholly toward the accreditation period. Approval by the Royal College of Radiologists should be obtained prospectively if accreditation is to sought for such experience. It is strongly recommended that such plans are discussed with the head of department and regional postgraduate education adviser before any such scheme is started. Specialist registration The General Medical Council, accepting that the public need and desire some way of recognizing those members of the profession with particular skills, has, on the advice of the appropriate college or faculty, identified individuals, should they so wish, who have satisfactorily completed their higher training by the addition to the register of the letter T with an indication as to the specialty in brackets, for example, T (Rad). The GMC has not indicated that this recognition of skills will be time-limited, but the Royal College of Obstetricians and Gynecologists, the Royal College of Psychiatrists and the Faculty of Clinical Radiology of the Royal College of Radiologists have produced reports of working parties on continuing medical education that have also considered the associated issues of reaccreditation and recertification of specialist qualifications. The education board of the Faculty of Clinical Oncology has convened a similar working party on CME because it was felt that the Faculty should adopt a pro-active approach and not wait until CME became a GMC requirement.
CONTINUING
MEDICAL
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Patients and their families are increasingly concerned about standards of care in medicine as a whole, in oncology as a specialty and in the practice of individual oncologists. There is also increasing political interest, and an attempt to make members of the medical profession more accountable, in managerial and financial terms, for their style of practice. When resources are finite and demands virtually limitless priorities have to be determined to secure value for money. Audit of clinical practice has now become mandatory in hospitals and continuing medical education is a necessary consequence of deficiencies or weakness revealed by audit. UK government views of CME The attitude of the government to CME was expressed by the Secretary of State for Health in his address to the Joint Meeting on Postgraduate Medical Education on 6 July 1990 when he accepted the recommendations for the future structure of post graduate medical education and continuing medical education made by the Expert Advisory Group established by the Chief Medical Officer. A number of important themes emerged: i. CME will not be entirely subservient to the demands of the service. ii. There must be comprehensive programs for CME devised by regional health authorities. ... 111. CME programs must take account of the results of medical audit. iv. The system for delivery of CME should be part of the managerial structure, with clearly defined objectives, proper lines of accountability and budget holders, the funding disentangled from the current monetary headings and made explicit. V. Standards of CME should be monitored. vi. Standards of training for trainers should be recognized and met. vii. The postgraduate dean will act as director of postgraduate medical education in a region. Among the key tasks will be to ensure that: there are facilities of sufficient quality available for CME to be carried out; to ensure that the education is of sufficient quality; to secure positive links between the results of medical audit and educational programs.
EDUCATION
Definition Continuing medical education contains all those educational activities that relate to improving medical care, which occur after qualification and are not specifically directed toward passing examinations or fulfilling vocational or specialist training requirements. The pursuit of continuing education is the mark of a professional person. A medical career is a long one and CME is necessary to ensure the best quality of patient care by keeping up one’s knowledge base, practicing old skills and learning new ones.
Current extent of CME in oncology Many oncologists already perceive the importance of CME and approach this in various ways: regular reading of journals and text books; attendance and participation in postgraduate training activities for junior staff, attendance at specific CME activities organized locally or nationally by the College or at the College’s advanced oncology meetings or annual scientific meetings; attendance at educational activities organized by other bodies such as learned associations, universities, pharmaceutical companies, in this country or abroad. Much of the value of such personally planned CME may be criticized on
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educational grounds as opportunistic and ad hoc, not thematic or systematic, not conforming with the well-established principles and practices of adult learning. Principles of CME
Continuing medical education should be based on the well-established educational principles of adult learning, The topic should be relevant to clinical practice, and dealt with in small groups in an interactive way using experience as a basis for learning. The topics chosen should meet the needs of the participant, these being assessed as objectively as possible. Topics high in interest but low in relevance, presented in a didactic form in large lecture theatres at central venues chosen by meetings organizers on the basis of perceived rather than demonstrated needs of the participants, are unlikely to produce the incremental improvement in knowledge and skills of practical value in direct patient care. The proper strategy necessary to plan an effective CME program consists of five steps. The setting of aims: an aim should be a statement of general intent, for example, all participants in this CME activity will at the end of it be able to manage effectively a patient with bulky metastatic germ cell tumor of the testis. ii. A needs assessments: an individual oncologist’s needs or the needs of a group of oncologists, measured by the discrepancy between the current stage of knowledge, skills, attitude, performance within the facilities available, and the desirable ones. ... 111. The setting of objectives: Objectives should be reasonably specific consisting of much narrower statements of what a particular participant will be able to do on completion of the program. iv. Choice of methods: whereas immediate highly informed teaching in the presentation of a clinical program is the ideal, it is unlikely to occur and therefore impossible to plan. The next best is to postpone teaching on such clinical issues to a future, but not distant, programmed meeting, after all parties have had an opportunity to prepare their contributions. 1.
V.
The most convenient and economical teaching venue for participants and employers is as local as possible. If CME is to become a mandatory and more frequent activity, funding may not permit much travelling to distant venues. Local activities such as small seminars, workshops, and discussion groups close to the workplace are much more likely to meet the needs of busy clinicians and ensure attendance. Evaluation: The results of traditional educational practice in medicine are usually assessed by the degree of contentment of the participants rather than by specific assessment of measured changes in knowledge, skills, and attitudes which are fed back to the participants to allow comparison with colleagues.
If it is agreed that this model of good educational practice is sound, then it may be argued that most educational activities undertaken locally or centrally by the Royal College of Radiologists and other bodies fall very far short of this ideal at the present time. If an attempt is to be made to meet such educational criteria, then the college will have to develop an expertise in the principles of adult medical education to enable it to set national standards and to assess the value of CME provided locally and, perhaps most importantly, to organize “teaching of teachers.” CONCLUSIONS Continuing medical education has always been an important feature of a medical career and rightly so. The major change is that new procedures are now to be introduced to organize, monitor, and fund CME. Although as yet, it is not intended that CME become a mandatory requirement of employing authorities. The Royal College of Radiologists and its Faculty of Clinical Oncology must become outspoken champions of CME to ensure that it is undertaken by its members to a proper extent, to ensure that it is properly funded without detriment to clinical services and to ensure that the College and Faculty develop sufficient expertise in the principles and practice of CME to set appropriately informed standards.