ENT trainees are fully registered doctors who have responsibilities to comply with the requirements of Good Medical Practice. This includes ensuring that they put the interests of their patients at the heart of their practice. This duty is complementary to their development into independent specialists in otolaryngology. All good doctors want to do what is right for patients, and that includes ensuring that they are treated safely with risk being kept to an absolute minimum during treatment. The old maxim ‘First do no harm’ is as true today as it was when first introduced.
One of the reasons the Postgraduate Medical Education Training Board [now incorporated into the General Medical Council (GMC)] was created was to attempt to ensure that doctors are trained to the correct standard and that the training could be monitored and trainees assessed to ensure competence had been achieved. The driving force behind this was to make sure that patients were treated safely and that the catastrophic failures in patient safety as seen in the Bristol heart scandal, Alder Hey and the Shipman case were not repeated.
The curriculum for ENT training develops doctors to become competent in the management of a wide range of relevant clinical conditions as well as in professional and leadership skills (this aspect is generic to all surgical specialities). The self evident aim is to produce a competent, and thus safe, ENT surgeon.
In the context of patient safety we need to consider the responsibilities of the trainee, the supervisor, the training programme, as well as external agencies such as the Specialist Advisory Committee (SAC) and the GMC.
As described above, ENT trainees are registered doctors who have a duty to maintain their skills as practising doctors and it is their responsibility and not that of their supervisor or programme director to ensure this is the case.
Trainees should ensure that all the mandatory requirements required of them by their employers are complied with. Participating in well organised induction programmes, handover, mandatory training, governance procedures and audit meetings will all ensure that they are working within the safety framework expected by their employers. It is important to develop the skills of reflection so that one can learn from clinical experience. Increasingly trusts expect all staff to participate in serious untoward incidents (SUIs) with an emphasis on constructive learning.
Specifically trainees need to develop their competences within the framework of the syllabus, which includes professional and leadership skills. There are some safety related courses which are mandatory within training such as Advanced Trauma Life Support and laser safety courses. It is a mandatory requirement that users of lasers must attend a laser safety course to ensure safe use of potentially dangerous medical equipment.
It is therefore no surprise that many such safety related courses are compulsory during training, and the drive towards simulation based training (now incorporated into the syllabus) is based on the premise that this will improve patient safety.
Undoubtedly the most important role of the supervisor (which really includes all consultants with whom trainees work) in this context is in setting an example of how to behave within a working environment with patients and all colleagues. Consultants should not underestimate how the way they practise has a powerful influence on trainees. This is known as the ‘hidden curriculum’. It is what made the old apprentice based training so good when trainees worked with positive role models and so bad when the reverse was the case. Trainees will learn much more effectively when working within a supportive training environment which includes working in departments where consultants put patient safety at the heart of their practice. A happy, functional department will be a much safer environment to work in than a dysfunctional department .
So excellent educational supervisors will not just have done the correct educational courses but will be excellent clinicians and role models. This will include operative and clinical excellence as well as being effective participants in audit and governance. They will respect their trainees, treat them fairly and help them reflect on aspects of their practice that have gone well and not so well.
“There is little doubt that the most important influences in ensuring patients are treated safely by trainees are the attitudes and responsibilities of the trainee doctor and the example set by their consultant supervisors in the workplace.”
Practically speaking, educational supervision requires trainers to ensure there is adequate and appropriate supervision in the workplace. It is worthwhile noting that the Joint Committee on Surgical Training (JCST) survey of trainees includes questions regarding supervision of trainees in theatre, clinic and on ward rounds, as these are viewed as key quality indicators of good educational supervision (and thus patient safety). It is interesting that the JCST survey shows that consultants perform worst overall in the indicator for supervision on ward rounds, something that needs to be improved as we move towards the requirement for a more consultant delivered service (http://www.jcst.org/quality_assurance/index_html).
The training programme and the deanery
Deaneries are responsible for the professional development of trainees. This will include speciality specific training (e.g. temporal bone courses) which will aid patient safety by developing competence but also more generic training which helps with team working, communication etc. Human Factors training is now embedded within training programmes, quite correctly.
Training programme directors have a key role in overseeing a trainee’s development. They are in the best position to identify placements best suited to a trainee’s needs. They have a pivotal role in identifying trainees who may be struggling both with specific competences and more general professional skills related to patient safety. Deaneries have programmes in place to support struggling trainees that can make a real difference to their development.
As part of the quality assurance role of deaneries they will ensure that training environments are safe, by ensuring adequate supervision, handover, induction etc. They do this by regular surveys of trainees and visits to departments. Registrars should always have dedicated consultant cover at all times, both in elective and more importantly emergency work, in the units in which they work. If deaneries feel that patient safety is being compromised within a unit, then approval for training can be withdrawn, although this usually only happens after an agreed action plan has not been implemented.
The role of the SAC
The role of the SAC is to set standards and work with deaneries to ensure training programmes enable standards to be met and the curriculum to be delivered. The SAC develops the curriculum which ultimately assures that an ENT surgeon is safe and competent. The SAC liaison member (LM) for each deanery plays an important role in ensuring programmes meet essential criteria which ensures, as much as possible, that training environments are safe. They contribute to the annual report submitted by the JCST to the GMC. So for example a LM may identify a unit that does not have dedicated consultant cover for registrars at weekends, and report back to the SAC and deaneries, helping to develop a remedial action plan.
The GMC is the body ultimately responsible for ensuring training happens in a safe environment. They charge deaneries to quality assure training and the SACs to write appropriate curricula. They take the survey of trainees seriously and patient safety issues can be reported via the survey directly to the GMC. The Francis report places a responsibility on trainees and medical students to report patient safety concerns. One development to be implemented soon is accrediting trainers to ensure training is delivered by properly trained and supported supervisors (http://www.gmc-uk.org/Approving_ trainers_implementation_plan_Aug_12. pdf_49544894.pdf). This will be managed by deaneries and many of you will be going through the process of becoming accredited as trainers. The regulator has sweeping powers to withdraw training from units that do not comply with standards which includes standards for patient safety.
Ensuring patients are treated safely is the reason for having a structured training programme with a defined end point of training. However there is little doubt that the most important influences in ensuring patients are treated safely by trainees are the attitudes and responsibilities of the trainee doctor and the example set by their consultant supervisors in the workplace.
1. Huitt W. Maslow’s Hierarchy of needs. Educational Psychology Interactive. Valdosta, GA, Valdosta State University; 2004 (http://chiron.valdosta.edu/ whuitt/col/regsys/maslow.html).
Declaration of Competing Interests: None declared.