How would you improve the specialist training programme that produces many of our medical consultants?
When the Royal College of Physicians of Ireland (RCPI) commissioned leading Canadian physician Prof Kevin Imrie to answer this question, he went back to basics.
He asked whether the specialist training ensured that doctors had the necessary skills to do their work to the required standard.
Were they able to talk to their patients in a straightforward way? Were they able to work comfortably alongside colleagues?
The president-elect of the Royal College of Physicians and Surgeons of Canada presented his report to the college last week, saying he was impressed by the high quality of training he encountered during the seven-month review process.
The RCPI is home to six of the 13 postgraduate training bodies in Ireland and provides postgraduate training in hospitals to more than 1,200 doctors in 26 specialities including obstetrics and gynaecology, internal medicine, pathology, paediatrics and public health.
Prof Imrie says the college could take an international lead role by moving towards a model that puts greater focus on practical skills and competencies, rather than on the accumulation of knowledge for exam purposes.
Abrupt manner
Everyone knows the man who got 600 points in his Leaving Cert but has an abrupt manner with patients. Or the woman who consistently came top of her class in medicine but has problems doing a simple procedure.
“Historically we would have depended much more on what people knew – on exams that can measure knowledge – and that’s very important, but beyond knowledge we need to know that physicians are able to use that knowledge,” Prof Imrie says.
“We all know that you can have physicians who are very bright, but may not be very good communicators or may not be very good at working with other people, and the sense is that we like to assess people on those skills as well.”
He would like to see assessment being based on direct observation of trainees at work to see if they can do their work to the required standard.
After seven months studying the Irish healthcare system, he says he was struck by what was achieved with so little funding.
"I come from a system in Canada and north America where there are probably more resources available for medical education . . . so what impressed me in a very positive way was just how much is accomplished with relatively little here. Training takes place in hospital sites that are extremely busy."
Lengthy training
It can take about 15 years to become a specialist, starting with undergraduate medical school and completing an internship before going through basic and higher specialist training.
His review encourages the college to eliminate the time between entering postgraduate training and working as a specialist.
“There can be gaps, particularly between the basic specialist training and higher specialist training, and sometimes gaps between completing training and taking up a consultant post.”
He also says the college should strengthen its commitment to training doctors who can provide general care in broad specialities.
“In north America, we are very focused on specialists, and subspecialists. And that has the risk of fragmentation in care, particularly for older patients who may have multiple medical problems and may have to have multiple doctors.
“This leads to problems of different doctors prescribing medications that may be in conflict with each other or information getting lost between one clinician and another.”
Ireland is already good at generalism. “That’s one of the real strengths of the Irish system . . . the movement in other parts of the world has been to more subspecialisation and in cases where that’s happened, those systems are trying to change back to something that looks more like the model that you’ve got here.”
Better information
Other recommendations include making training structures more predictable for doctors by giving them better information about their rotations for the first few years of training.
The day is gone when medical training was for young single men who lived in hospitals for long periods.
“Now the medical workforce involves women and people with families and we have to recognise that reality, and make sure that the training is able to meet the needs of having a balanced family life because we want our physicians to be well and not burn out.”
But is it really possible for a non-consultant hospital doctor (NCHD) to have a good work-life balance? “Medicine is always going to be hard work, but yes, absolutely, because we need to have a medical workforce that is sustainable.
“We know that patient outcomes are better when they are cared for by healthcare professionals who are happy and valued in the workplace.”
He says doctors work as hard here as anywhere else and, on average, work more than the maximum hours prescribed under the European working time directive. “The system is working to adapt to being fully compliant with that directive, but that’s a difficult change.”
During his work on the review, he heard concern about the emigration of some of our best doctors. “It’s a complex manner. On the one hand, it is a compliment to the Irish training programme. And there is real value to people going away, late in their training, to gain skills and bring them back. But, on the other hand, there is a concern that fewer physicians are coming back. We want to ensure that Ireland is a great place to be a physician.”
Findings
Prof Imrie outlined his findings to Minister for Health
Leo Varadkar
last week and says the new Minister seems to be enthusiastic about implementing change.
RCPI president Prof John Crowe has also welcomed the findings, saying the college has already begun work on the recommendations.
Prof Imrie believes implementation of his report will help produce doctors who are not just bright and knowledgeable, but effective at communicating and working in teams.
“I do think it will be a medical workplace that’s more inviting and one that fewer physicians will be choosing to leave,” he says. “And with luck, a number who have left will choose to come back.”
