Policy responses and statements

Name of organisation:

General Medical Council

Name of policy document:

Tomorrow's Doctors 2009 - a draft for consultation

Deadline for response:

27 March 2009

Background: The General Medical Council regulates undergraduate medical education. To do this, it sets down standards and ensures that those standards are met.

The GMC is revising 'Tomorrow’s Doctors', the standards for undergraduate medical education, and will publish a new edition in summer 2009. The document lists outcomes that graduates from UK medical schools must achieve in order to graduate, as well as standards for the delivery of teaching, learning and assessment.

The consultation will interest the public and patients who will be treated by tomorrow’s doctors; employers of doctors; teachers in medical education, doctors and students; medical schools and other organisations providing medical education and training.

COMMENTS ON
GENERAL MEDICAL COUNCIL
TOMORROW'S DOCTORS 2009 - A DRAFT FOR CONSULTATION

The Royal College of Physicians of Edinburgh is pleased to respond to the General Medical Council on the draft of Tomorrow's Doctors 2009.

General Comments

There was general agreement that this represents an improvement on the 2003 edition, and the College welcomes the emphasis on practical, experiential learning with the opportunity to develop the skills necessary to function effectively as a foundation doctor.  However, new material, with its accompanying justification should not (by implication) dominate the document.  It is important that existing requirements and outcomes carry appropriate weight.

Medical Schools should be supported in their development of new and innovative approaches to teaching medicine whilst ensuring that a common curriculum is delivered to agreed standards.

Domain 1: Patient safety

Students must be expected to have a continual awareness of the importance of patient safety.

Domain 2: Quality assurance, review and evaluation

The focus on quality assurance is understood, but it will result inevitably in an increasing burden of administration for hard pressed clinical staff.  See later comments about time in job plans.

Domain 4:  Student selection

A national system of Student Fitness to Practice procedures would reduce the chances of a student excluded from one medical school being allowed to commence medical studies at another UK university.

Domain 5: Design and delivery of curriculum, including assessment

The College agrees with the decision to drop from the new edition the absolute requirement to devote 25-30% of time to SSCs (para 65).  However, it is important to retain some element of choice and individual interest, and a minimum percentage should be considered to protect some discretionary learning.  SSCs are also useful for exploring different medical careers.

It is important to limit the demands for new/expanded core elements to avoid squeezing practical and problem solving skills out of the curriculum.

It is important for all students to have practical experience of applying their knowledge to patient care throughout their medical training (para 67); this will prepare them better to function with confidence as a Foundation Doctor.

All students must have opportunities to learn from other health and social care practitioners (para 83).  This will bring greater understanding of teamwork, authority and respect for colleagues and should be strengthened to make it less discretionary.  Learning from qualified health and social care practitioners may be more beneficial than shared learning in multi- disciplinary classes.  All teachers should be trained for their teaching responsibilities.

The document requires all clinical placements to be planned and structured and to be in a variety of healthcare environments (paras 84-7).  Whilst laudable, the NHS is far from able to guarantee this, and the GMC should require medical schools to be much clearer about their expectations of host hospitals.  At present, the outcomes and expected standards are too loosely defined.  Students must be able to undertake a wider range of tasks with greater confidence than at present at graduation, and structured clinical placements with adequate supervision are essential to this aim.

Students should have opportunities to interact with patients across the age spectrum in addition to diverse social, cultural and ethnic backgrounds (para 85).

There is widespread agreement that student assistantships are effective methods of preparing students for work as a pre-registration doctor, and the document should specify a minimum period (para 90).  This should be independent of shadowing, although a subsequent assistantship could be combined with a period of shadowing.  The curriculum should specify a steady increase in student responsibility (under supervision) throughout the course, particularly in the senior years when students should be considered part of the teams to which they are attached.  There is, of course, some concern about the logistics of delivering this opportunity to all medical students.

Shadowing of  foundation posts is also essential (para 91), and there should be greater national co-ordination of the time and length of shadowing, particularly as national recruitment will result in more students moving beyond their immediate medical school areas for their foundation years.  The GMC should be more prescriptive about the length and positioning of shadowing, using “must” or “will” rather than “should”.  Handover and induction are key patient safety issues and complement shadowing.

The GMC should not be prescriptive about electives.

The GMC should involve the employers and professional bodies in all reviews of standards as the needs of the NHS and medical practice will change.

Students will benefit from feedback from a range of assessors (medical and non-medical), but this must be coordinated and led by one individual (para 92).  All assessors should have easy access to and understanding of the standards and outcomes required.

The GMC has asked whether medical schools should use pooled question banks for examinations.  This brings to the fore the issue of a nationally agreed assessment system to give the public confidence in the output from all medical schools.  National modules could form part of every medical school exam structure, retaining some local flexibility in line with individual courses.  Ensuring consistent standards for medical graduates is important for patients, employers and for young doctors applying for future training posts competitively. External examiners alone are not in a position to calibrate outputs properly (even to a minimum level) from different medical schools, although their reports should receive a formal response and be retained as part of the internal quality control record. 

There should be no compensatory mechanism to allow students to graduate without demonstrating competence in all outcomes (para 98).  However, the number and variety of outcomes in “Tomorrow’s Doctors” is such that, inevitably, some will fail one or more assessments.  A set of core competences as an absolute minimum may be more realistically achievable and useful in terms of patient safety.

The College agrees that information about students with particular difficulties on graduation should be communicated to their Foundation Programme Directors.  This would be to the benefit of students providing resolved issues were not allowed to “tarnish” their record (para 102).

Domain 6: Support and development of students, teachers and local faculty

Doctors with teaching responsibilities must have time allocated in their job plans (para 109).

Education and training opportunities for all teachers should adopt a ‘core and options’ approach to avoid duplication in training courses aimed separately at undergraduate and postgraduate level (para 128).  Teachers should deliver the curricula but have local discretion over style and mode of teaching to retain motivation and benefit from their experience.

Domain 8: Educational resources and capacity.

Paragraph 141 should be expanded to require host hospitals to ensure consultants with education and clinical supervision and assessment responsibilities for undergraduate students have time allocated within the job plans.  See also paragraph 109 above.

Domain 9: Outcomes

The overarching outcome (para 150) should precede the 3 sub-areas, which should also be re-ordered to ensure that the doctor as practitioner is listed first (para 156-163).

Comments on outcomes for the doctor as a practitioner include:

• Students should have an awareness of public health aspects in addition to the focus on individual patient care.
• There should be more explicit reference to students having an understanding of the overriding importance of patient safety.
• Students should be capable of assessing and recognising severely ill patients and the need for immediate emergency care.  Some hospitals use the ALERT course during assistantships or shadowing.
• There should be explicit references to developing empathy with patients (in addition to the theoretical psychological and social understanding listed in the doctor as a scholar and scientist).

Para 158 (diagnose and manage clinical presentations) would benefit from adding:

• the ability to create a problem list and co-ordinate their daily work
• the ability to undertake a functional assessment of the patient to ascertain the impact of their disease
• an awareness of the importance of patient choice as students synthesise a full assessment of the patients problems (para 158 e)
• reference to the importance of uncertainty and risk when supporting patient choice
• an understanding of chronic and multiple problems in addition to acute single disease issues

Box I:  Practical procedures for graduates

This includes several practical procedures that are the subject of work-based assessment for Foundation Doctors.  However, the College agrees that they are appropriate for undergraduate learning.  The list need not be exhaustive and would perhaps benefit from more regular review than the GMC full guidance.  Comments include:

• consider adding the ability to use routine cognitive assessment, given the ageing population and the rising prevalence of dementia
• consider adding something specific on patient to patient transmission of infection to complement the sections on infection risk in practical procedures
• the references to glucose monitoring may be outdated or impractical given hospital policies and new technology

Comments on the doctor as a scholar and scientist include:

• Para 153 refers to the importance of psychological and sociological factors that contribute to illness.  Given the known positive effect of work on health, it would be helpful to strengthen the need for students to understand fully the impact of employment status on health.
• Students must appreciate that science will change during their working lives and their thinking needs to accommodate change.  Strengthening careers advice and offering SSCs may motivate greater appreciation of the need to understand and retain basic science.

Comments on the doctor as a professional include:

• Para 168b refers to an understanding of the framework within which medicine is practised in the UK.  The College believes it is important that newly qualified doctors understand their responsibilities as valued employees of the NHS.

Comments on the doctor as a professional are variable and the College considers that leadership should be incorporated into the doctor as a professional.  All doctors will assume leadership roles in some situations, albeit this will be relatively infrequent for new graduates. 

Privacy issues

The College accepts the value of retaining and sharing information (with appropriate safeguards) about student performance and conduct both for patient safety reasons and to target appropriate support for the benefit of the student.

Other Comments

Tracking the performance of Foundation Doctors through FY1, including their success following the foundation programme, would provide medical schools with valuable feedback on their students.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[27 March 2009]