Foundation programme for newly qualified doctors
http://www.100md.com
《英国医生杂志》
Should improve specialist training in the UK but may lack capacity
Born of necessity, developed with remarkable consensus, and piloted successfully for a year, the United Kingdom's new foundation programme for medical graduates has been launched.1 The programme aims to ensure that all entrants to formal postgraduate specialist training have met the standards required to progress to that particular phase of lifelong learning.2 Opinions vary about the role of these reforms and their impact on the medical education system and workforce.
The programme focuses on performance in the workplace, rather than only knowledge and skills, largely in response to recent scandals that highlighted problems with clinical governance, professional teamwork, and practitioners' honesty. The core competencies required to complete the programme match those laid down by the General Medical Council in Good Medical Practice and reflect reasonable expectations of the ability of junior medical practitioners.3 Although the UK may be the first to formalise such a system, similar moves are being discussed in other places with similar systems of medical education and career progress.
The introduction of such programmes should not imply that medical schools are not doing their job. Medical education is a long process. In just four, five, or six years, medical schools are expected to cover the basic elements required for competent practice as a junior medical officer. The foundation programme is meant to ensure that these competences can be applied under supervision in the workplace. Learners learn more effectively when they are responsible for their actions, and it has always been the early hospital years that allowed graduates to develop the confidence to become competent practitioners. The weakness of the previous system has been the lack of time, resources, and expertise necessary to ensure that every junior hospital doctor reaches that point.
The new system aims to make every clinical experience a relevant, more standardised, better supported, and educationally valuable experience with specific and achievable learning objectives. Assessment will focus on practical aspects of medical work rather than examinations, and it will reward greater engagement by learners. The programme also brings new learning opportunities—such as posts in public health, primary care, and academia—where junior doctors can sample a broader range of options for hospital as well as non-hospital careers.
And the complete package includes bridges and shorter pathways to more advanced specialist training, removing at least some repetition of less valuable learning experiences, and recognising the more relevant and valuable placements that contribute to the achievement of specific career objectives. In summary, the foundation programme has the potential to provide a sound platform on which to build future medical careers more quickly and more flexibly.4
As usual, however, it is the implementation of these reforms that raises the most questions. Although the programme has enormous potential for success, the stakes are high, and failure may not be forgiven. One response to the global shortage of medical work-forces has been a rapid expansion of undergraduate medical education into new secondary and primary care facilities, where service loads are high and educational resources are stretched.5 This means that the foundation programme will be competing for learning opportunities with medical schools and even with specialty training programmes, and capacity may not be sufficient for all levels of education to expand quickly.
What will students and new doctors make of these reforms? Junior doctors might now be treated more like students, rather than junior professionals who are adult learners. Current students are reasonably concerned that there may be insufficient posts, diluted clinical experience, and the possibility that some may not achieve the required competences and be stranded without a traditional career.6 7 And, although there are advantages to identifying graduates who are unsuited to clinical careers at an early stage, will reasonable alternatives be available?
The likely success of the programme in moving medical graduates to a wider range of specialties, including those where the need is greatest, is hard to judge. Workforce trends are difficult to predict. The recent international downturn in demand for primary care and the more general specialties may not recover,8 9 trends towards subspecialisation in primary and tertiary care may continue, and new specialties will continue to emerge. Much of the programme's success in directing careers may depend on whether and to what extent learners have inspirational experiences in such areas of need, and on the tension created by pressure to ensure that core competencies are also achieved in more mainstream areas of medicine.
Furthermore, high quality teaching and learning do not happen by accident: a curriculum is initially no more than a document. Medical schools must engage with the foundation programme, helping to develop expertise in medical education and ensuring that the years spent as junior hospital doctors are part of a smooth transition for graduates. There will have to be rapid expansion in the number of medical graduates who have been taught to teach—those with formal training in methods of teaching and learning. Postgraduate training in medical education may have to become a formal requirement for at least some clinicians in each teaching facility, and medical education may develop into a formal postgraduate medical specialty. Lastly, the current difficult pathways for medical practitioners to gain formal educational qualifications may need to be simplified, with more flexible professional doctorates or membership courses.
The success of the foundation programme, then, will require genuine academic development and support throughout the entire healthcare system, rather than in a relatively small number of elite teaching facilities.
Richard Hays, professor of medical education
School of Medicine, James Cook University, Queensland 4811, Australia (richard.hays@jcu.edu.au)
Competing interests: None declared.
References
National Health Service. Modernising medical careers: foundation programmes. www.mmc.nhs.uk/pages/foundation (accessed 25 Aug 2005).
Gallen D, Peile E. A firm foundation for senior house officers. BMJ 2004;328: 1390-1.
General Medical Council. Good medical practice. 3rd ed. London: GMC, 2001. www.gmc-uk.org/standards/good.htm (accessed 25 Aug 2005).
National Health Service. The rough guide to the foundation programme. London: Stationery Office, 2005. www.mmc.nhs.uk/download_files/The-Rough-Guide-to-the-Foundation-Programme.pdf (accessed 25 Aug 2005).
MacDonald J. A survey of staff attitudes to increasing medical undergraduate education in a district general hospital. Med Educ 2005;39: 668-74.
BBC News Online. Junior doctors' training revamped. http://news.bbc.co.uk/1/hi/health/4131420.stm (accessed 25 Aug 2005).
Junior doctors face unemployment. http://news.bbc.co.uk/1/hi/health/4720905.stm (accessed 25 Aug 2005).
Evans J, Lambert T, Goldacre M. GP recruitment and retention: a qualitative analysis of doctors' comments about training for and working in general practice. Occas Pap R Coll Gen Pract 2003;83(iii-vi): 1-33.
Schwartz MD, Basco WT, Grey MR, Elmore JG, Rubenstein A. Rekindling student interest in generalist careers. Ann Intern Med 205;142: 715-24.
Born of necessity, developed with remarkable consensus, and piloted successfully for a year, the United Kingdom's new foundation programme for medical graduates has been launched.1 The programme aims to ensure that all entrants to formal postgraduate specialist training have met the standards required to progress to that particular phase of lifelong learning.2 Opinions vary about the role of these reforms and their impact on the medical education system and workforce.
The programme focuses on performance in the workplace, rather than only knowledge and skills, largely in response to recent scandals that highlighted problems with clinical governance, professional teamwork, and practitioners' honesty. The core competencies required to complete the programme match those laid down by the General Medical Council in Good Medical Practice and reflect reasonable expectations of the ability of junior medical practitioners.3 Although the UK may be the first to formalise such a system, similar moves are being discussed in other places with similar systems of medical education and career progress.
The introduction of such programmes should not imply that medical schools are not doing their job. Medical education is a long process. In just four, five, or six years, medical schools are expected to cover the basic elements required for competent practice as a junior medical officer. The foundation programme is meant to ensure that these competences can be applied under supervision in the workplace. Learners learn more effectively when they are responsible for their actions, and it has always been the early hospital years that allowed graduates to develop the confidence to become competent practitioners. The weakness of the previous system has been the lack of time, resources, and expertise necessary to ensure that every junior hospital doctor reaches that point.
The new system aims to make every clinical experience a relevant, more standardised, better supported, and educationally valuable experience with specific and achievable learning objectives. Assessment will focus on practical aspects of medical work rather than examinations, and it will reward greater engagement by learners. The programme also brings new learning opportunities—such as posts in public health, primary care, and academia—where junior doctors can sample a broader range of options for hospital as well as non-hospital careers.
And the complete package includes bridges and shorter pathways to more advanced specialist training, removing at least some repetition of less valuable learning experiences, and recognising the more relevant and valuable placements that contribute to the achievement of specific career objectives. In summary, the foundation programme has the potential to provide a sound platform on which to build future medical careers more quickly and more flexibly.4
As usual, however, it is the implementation of these reforms that raises the most questions. Although the programme has enormous potential for success, the stakes are high, and failure may not be forgiven. One response to the global shortage of medical work-forces has been a rapid expansion of undergraduate medical education into new secondary and primary care facilities, where service loads are high and educational resources are stretched.5 This means that the foundation programme will be competing for learning opportunities with medical schools and even with specialty training programmes, and capacity may not be sufficient for all levels of education to expand quickly.
What will students and new doctors make of these reforms? Junior doctors might now be treated more like students, rather than junior professionals who are adult learners. Current students are reasonably concerned that there may be insufficient posts, diluted clinical experience, and the possibility that some may not achieve the required competences and be stranded without a traditional career.6 7 And, although there are advantages to identifying graduates who are unsuited to clinical careers at an early stage, will reasonable alternatives be available?
The likely success of the programme in moving medical graduates to a wider range of specialties, including those where the need is greatest, is hard to judge. Workforce trends are difficult to predict. The recent international downturn in demand for primary care and the more general specialties may not recover,8 9 trends towards subspecialisation in primary and tertiary care may continue, and new specialties will continue to emerge. Much of the programme's success in directing careers may depend on whether and to what extent learners have inspirational experiences in such areas of need, and on the tension created by pressure to ensure that core competencies are also achieved in more mainstream areas of medicine.
Furthermore, high quality teaching and learning do not happen by accident: a curriculum is initially no more than a document. Medical schools must engage with the foundation programme, helping to develop expertise in medical education and ensuring that the years spent as junior hospital doctors are part of a smooth transition for graduates. There will have to be rapid expansion in the number of medical graduates who have been taught to teach—those with formal training in methods of teaching and learning. Postgraduate training in medical education may have to become a formal requirement for at least some clinicians in each teaching facility, and medical education may develop into a formal postgraduate medical specialty. Lastly, the current difficult pathways for medical practitioners to gain formal educational qualifications may need to be simplified, with more flexible professional doctorates or membership courses.
The success of the foundation programme, then, will require genuine academic development and support throughout the entire healthcare system, rather than in a relatively small number of elite teaching facilities.
Richard Hays, professor of medical education
School of Medicine, James Cook University, Queensland 4811, Australia (richard.hays@jcu.edu.au)
Competing interests: None declared.
References
National Health Service. Modernising medical careers: foundation programmes. www.mmc.nhs.uk/pages/foundation (accessed 25 Aug 2005).
Gallen D, Peile E. A firm foundation for senior house officers. BMJ 2004;328: 1390-1.
General Medical Council. Good medical practice. 3rd ed. London: GMC, 2001. www.gmc-uk.org/standards/good.htm (accessed 25 Aug 2005).
National Health Service. The rough guide to the foundation programme. London: Stationery Office, 2005. www.mmc.nhs.uk/download_files/The-Rough-Guide-to-the-Foundation-Programme.pdf (accessed 25 Aug 2005).
MacDonald J. A survey of staff attitudes to increasing medical undergraduate education in a district general hospital. Med Educ 2005;39: 668-74.
BBC News Online. Junior doctors' training revamped. http://news.bbc.co.uk/1/hi/health/4131420.stm (accessed 25 Aug 2005).
Junior doctors face unemployment. http://news.bbc.co.uk/1/hi/health/4720905.stm (accessed 25 Aug 2005).
Evans J, Lambert T, Goldacre M. GP recruitment and retention: a qualitative analysis of doctors' comments about training for and working in general practice. Occas Pap R Coll Gen Pract 2003;83(iii-vi): 1-33.
Schwartz MD, Basco WT, Grey MR, Elmore JG, Rubenstein A. Rekindling student interest in generalist careers. Ann Intern Med 205;142: 715-24.