The Final year Phase 3

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The Final year - Phase 3
Professional Education Training Appraisal
(PETA)

• The clinical apprenticeship
• Towards clinical governance and the independent
  practitioner

Professor R D Griffiths, Professor of Medicine
(Intensive Care) Director of Final Year
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Final year - Aims

• To be prepared for Foundation training as a house
  officer for either hospital or community
• To experience in practice emergency and long-term
  care in the hospital and community
• To experience in depth possible career choices of
  clinical specialities
• To establish a framework for quality of clinical
  care
• To establish the foundation for post-graduate
  learning, assessment and critical self-awareness

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Critical self-awareness is key to fitness to
practice

• The individual responsibility to reflect
  question
• What they know they know
• How they do things
• How they behave
• Distinct from the traditional student
• Others take responsibility for what they know
• Knowledge sampled once only in exams
• Rarely check how they do things
• Presented unquestioned role models of behaviour

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Moving from a student to a professional fit to
practice
They should learn to know what they know and can
do safely, rather than have others tell them what
they know
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Overview of year (5 x 7 weeks)

• Acute Care
• A/E shift working, SHO shadowing, emergencies,
  acute admissions and initial managements
• Ward Care
• F1HO shadowing in future hospital ( post)
• Continued care through to discharge
• Community Orientated Medical Practice (COMP)
• Preventive and continued acute and chronic care
• Clinical responsibilities of GP and other
  services
• Selectives in Advanced Medical Practice (SAMP)
• TWO specialist options to aid career plans

Seven weeks full attendance at each attachment is
required for clinical experience. The eighth
week of each attachment is available for self
study and outstanding meetings. This is not be
available for the final attachment.
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Timetable by groups for final year
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GMC Tommorrows doctors 2002

• Students must receive regular and consistent
  information about their development and progress.
  
• Clinical logbooks and personal portfolios, which
  allow students to identify strengths and
  weaknesses and to focus their learning
  appropriately, can provide such information.
• Using these will emphasise the importance of
  maintaining a portfolio of evidence of
  achievement, which will be necessary once they
  have become doctors and licence to practise is
  regularly revalidated

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Clinical case reports

• Collect information
• Summarise Key features of history and examination
• Analyse
• Problem list/differential diagnoses, working
  diagnosis
• Investigations results that discriminate or
  guide
• Rationalise
• Treatment plan, prescribing, advice, etc.
• Evaluate
• review, monitor progress/complications etc

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Clinical case reports
Evaluate

• Review the working diagnosis
• Monitoring the disease, progress and treatment?
• Match care to good practice and best evidence
  guideline?
• Briefly mention the key features of any current
  guideline that apply to this case.
• Describe any problems, adverse events
• explain why these might have occurred
• how they could have been prevented?
• List any family or social implications?

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Reflection
Reflection
Describe - your thoughts on what you have
learned, where you have struggled, how you could
improve next time.

• Say how this case has helped you achieve your
  learning objectives?
• What new knowledge and skills have you learned
  from this experience?
• What should you learn more about?
• Have your professional attitudes been affected by
  this case? How will this influence your behaviour
  in the future?
• What have been your strengths in dealing with
  this case? Could you have done better?

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What goes wrong - the student?

• Superficial clerking, diagnosis and treatment
• Traditionalist view (record what seen without
  thinking), no summarising and analysis
• Often just a single diagnosis no problem list
• Thought process is lacking. Investigations lack
  focus
• No clear management plan or merely a prescription
• No attempt at evaluation, critical analysis of
  case or discussion of good evidence and bad
  practice
• Apparent no background reading
• The Student is unable to reflect on their
  learning
• The case experience fades and learning lost
• because the process was not followed in depth

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When it goes right - the student

• Have to work hard but it is worthwhile
• Makes all the learning real and have meaning
• two to three hours of reading for each case
• I feel more confident that if I dont know
  something it is OK to admit it and feel confident
  that I have the ability to find out
• I didnt find it difficult being reflective
  about myself in a case because I have no problems
  criticising myself or being honest about
  something I could not do, or a patient I found
  irritating

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What goes wrong - the supervisor?

• Only a traditional clerking is expected?
• Have not bothered to read the new guidance.
• Believe they know better.
• May not understand adult learning?
• Fails to stimulate higher skills of critical
  analysis and evaluation.
• Do not allow a student to admit ignorance
• Do not realise what they have long forgotten!
• Do not discuss cases or ignore the portfolio

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In defence of your supervisors?

• Teaching is not their only job!
• Most love it or like it, some just accept a few
  hate it.
• They are all busy with increasing pressures
• Are only human
• Cross section of views, ages and experience!
• Can make mistakes but dont like acknowledging
  this
• Have been trained in a different system
• Believe in themselves
• Do not realise what the GMC expects for tomorrows
  doctors

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How can you make sure it works?

• Grow up and take charge of your learning
• motivation is your responsibility now
• Do your clinical work, cases and reading
• This is traditional medicine, the more you do the
  more you know and the better you are.
• Discuss aspects of your case with whoever is
  involved
• Use your skills of PBL in analysis and case
  synthesis
• Do not expect too much everywhere is different!
• Make sure you arrange all your meetings.
• Your consultants/GP are very busy people.
• If your consultant takes a superficial view of
  your portfolio or completely ignores your cases
  tell me!

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The portfolio
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The Liverpool portfolio

• 18 Completed clinical cases or other reports per
  attachment
• Must include at least two clinical
  science/therapeutic reports
• COMP includes 1 communication case study
• Occasional extra sheet e.g. for a guideline
• 2 Adverse event/critical incident reports per
  attachment
• Electronic log printout (contract with faculty)
• Clinical skills record card ALS certificate
• Personal prescribing formulary
• PETA folders from each attachment
• PETA learning Objective
• Nurse and Junior Medical Feedback
• Mid-point PETA
• Final PETA
• Reflective Summary sheet
• SAMP critical reviews x 2 (2500 words)
• CV and Other evidence of learning
• Evidence of approved absence
• But NOT loads of other printed material!

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Electronic Clinical Log

• Students evidence with Medical school of
  clinical work
• Has been simplified from previous years
• Record ALL portfolio cases only
• Log contemporaneously (as is practical)
• Have printout ready for Final PETA meeting

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Personal formulary

• Link the cases you see to the drugs that are
  prescribed
• Involve yourself in prescribing, administration
• Identify risks and benefits
• Handbook on practical prescribing
• Read and work through scenarios on the web
• Build your own personal formulary
• Outline template on web
• maintain this in portfolio (written or printed)
• Optional electronically log drugs
• Present for discussion at PETA reviews

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Assessment

• Entry to final year on completion 4th year exams
• Five sequential PETA processes
• (Professional Education Training Appraisal)
• May include specific requirements
• Completed Portfolio
• Professional approach to
• Attendance, sickness, leave
• conduct

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Elements of the assessment

• Professional Education Training Appraisal -
  PETA
• Consultant/supervisor expert report (11)
• Five sequential assessments
• Portfolio
• evidence of clinical practice
• Summary of objectives achievements
• cases, reports, logs etc.
• Electronic case log personal formulary
• Responsibility resides with the student
• Externally validated

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Professional Education Training Appraisal

• Meeting 1 First PETA Week 1
• Orientation Introductions
• Review and agree learning objectives
• Set timetable and attendance requirements
• Meeting 2 - Mid-point PETA Week 4 or 5
• Review of portfolio
• Reflect and discuss personal progress
• Advice or warning given
• Mid-point PETA signed and returned to MBChB
  office
• Meeting 3 - Final PETA Week 7 or 8
• Final review of portfolio
• Discussion of progress and achievements
• Final PETA signed and returned to MBChB office
• PETA forms must be countersigned by Clinical
  Sub-Deans offices/COMP

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P.E.T.A process

• Relaxed non-threatening, supportive discussion of
  progress
• Centred around portfolio but also other
  information
• Initial meeting
• Discuss opportunities, students requirements,
  weaknesses, agree timetable, book meetings
• Agree and complete learning objective sheet
• Mid term final meeting
• Use the Portfolio as evidence
• Combination of checking and in depth discussion
• Based on the GMC attributes of the independent
  practitioner

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Attachment objectives

• First PETA meeting
• Be proactive and discuss what you have done and
  now wish to achieve
• List out the things you want to do learn about
• Discuss how to do this and who will help
• Agree with supervisor your targets
• Knowledge
• Skills (practical, prescribing etc)
• Timescales
• Attendance
• Important to make this meeting work
• it is the basis on how you should be assessed
• If you ignore it the final PETA meeting is harder

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Structured PETA approach

• Student select cases for discussion
• Or identify issues from cases to support
  achievements
• Evaluate clinical management skills
• Collecting information, Analysis of the case
• Rational therapy, Evaluation
• Professional Behaviour, attitudes and duties
• Adverse events
• Examples of good and bad practice
• Ethical, legal, economic/practical constraints
• Reflection critical self awareness
• Each case
• Whole attachment summary sheet

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How do I know how I am doing?

• Your PETA interview should tell you
• In addition all PETA items will be graded
• Supervisors will be required to place you within
  one of the overall grades
• Competency Grade 3 or above for passing
• 4 5 more than competent
• Grades 2 Not yet competent
• Implies improvement possible to 3
• Grade 1 Not yet competent
• Not yet ready to enter practice

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Student responsibility

• Ensure assessment complete within each attachment
• SAMPs reviews completed in time
• To ensure PETA forms completed and returned to
  MBChB office via Clinical Sub-Dean (or other
  local arrangement e.g. COMP)
• Any exceptional leave is approved
• Provisionally register in April (end of 4th)
• Register completed portfolio in MBChB office end
  5th block which is usually about 2-3 weeks before
  graduation date.
• Be available to meet external examiners as
  required
• Either during course or a few days after handing
  in portfolios.

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Attendance requirements

• Course time 40/48 weeks (5 x 8),
• Mandatory Clinical attendance 35 weeks (5 x 7)
• Holiday in this time is not allowed
• 1 week at end of each attachments 5 weeks
• To use as self-study time, preparation
  assessment
• To use for catch up for sick leave/absence
• Not vacation time but may be off campus
• Holiday national days (e.g 4 d at Easter)
• 2 wk Xmas, 6 weeks around graduation (june/july).
• A confirmed attendance is a GMC requirement for
  graduation. Be warned !

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What happens if ?

• Your attendance is poor and get referred
• You fail and have to re-do
• You do not do all your cases and get PETA
  referred
• You fail and have to re-do
• You do all your cases but very superficially, do
  little learning but still manage to get your PETA
  signed OK because you consultant was not vigilant
• You pass that attachment but may get caught the
  next one! Supervisors have been warned to be
  vigilant
• You will join the ranks of second class doctors
  as in the past able to pass exams but doomed to
  crap on society and be shown up by your better
  colleagues in due course.

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What happens if a PETA not satisfactory?

• Referral for review
• Interview with Director Phase 3
• will examine evidence and other opinions
• Appeal only on basis of contrary evidence
• Poor professional attitude / attendance will fail
• Each of the five PETA attachment are complete in
  themselves
• Attachment may be repeated (once)
• Graduation deferred until five satisfactory PETAs.

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External Evaluation

• Two external examiners ( some internals)
• March Portfolio Moderation Review process
• May be one of the following
• Selected students required to attend for detailed
  interview much like a final PETA meeting.
• Criteria based upon performance, attendance and
  completion of process including returning forms.
• Some years all portfolios taken in for grading
• June - Review decisions to defer graduation
• all failed PETAs reviewed with portfolios
• Students must be available to attend if requested

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External Examiners comments

• Very supportive of learning process and
  experience of the students
• Improvement on traditional approach of both
  learning and the assessment
• Concerns
• some students did not try or appeared to
  misunderstand process
• some supervisors did not try or appeared to
  misunderstand process
• Quality assurance process
• you may have some final PETAs with two assessors.
• Diagnostic and supportive feedback
• Greatly impressed by this course and the
  appraisal process.have created a model which
  other universities should follow

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How well do our students do?
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What must I remember?

• When you get the Final year guide READ it
• Final year is no easy ride but hard work
• Very high standard of your predecessors
• Make the system work for YOU
• Book your PETA meetings well in advance
• Agree your objectives at the beginning
• If having problems talk with your supervisor
  early
• Summarise your achievements at the end
• Check HepB, Rubella TB status and make sure
  documentary evidence up to date.

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And finally

• What is important is not what they know,
• or what they think you know
• but what YOU know you know.
• The most important message for the rest of your
  life is.

To have fun