Now I know what I don't know: how to reform the foundation years to fit 21st-century medicine

Editor – Laura Watts makes some good points in her critique of the UK Foundation Programme (Clin Med April 2013 pp163–5). Her proposal that there should be more flexibility in the choice of placements in the second year, to allow better preparation for subsequent specialty applications, is already in place in the West Midlands, where all foundation year (FY) doctors select their second year programme during March of their FY1 year and compete for popular rotations through evidence of their engagement in the programme in their e-portfolios.¹ In 2012 and 2013, all 570 FY1 doctors in the West Midlands deanery responded to a survey on the principal and the process of this system. Two-thirds consistently state that they prefer this uncoupled 2-year programme to a fixed 2-year programme.

The shortcomings Watts describes of the original assessment system in the Foundation Programme are well documented in the literature and have actually been addressed in the 2012 curriculum.² While it is true that the workplace assessments formerly used as ‘evidence of competence’ have been renamed as supervised learning events (SLEs), more importantly their function has been completely changed, so that they are now only used formatively for teaching and the ‘results’ of SLEs are disregarded in judging a trainee's suitability to progress. The trainees must still engage in SLEs, using them to seek teaching on their weaker topics, but progression is now judged by reviews of their workplace performance. Performance is what they actually do and is different from competence (what they can do), and reflects much more accurately how skilled they are clinically than the much derided ‘assessment of competence’ using miniCEX and CbD. True performance assessment of interpersonal and communication skill, professionalism and teamworking, using multi source feedback, has for long been the most valued assessment tool in the Foundation Programme. From August 2012, trainees’ overall clinical performance is also assessed in each foundation placement by the placement supervision group (PSG), which pools views from seasoned observers, including consultants, senior specialty trainees and specialist nurses, to add weight to the clinical supervisor's end of placement report. This group review reflects the ‘local faculty group’ model, increasingly popular as a clinical assessment process in specialty programmes, and which also relies on true performance assessment.

Specialty curricula leads on from the Foundation Programme and we may well see such assessment changes arriving in core medical training (CMT) and other specialty curricula before long in order to address widespread unease about the unreliability and bureaucratic burden of the competence assessment tools we are currently required to use in CMT.

• © 2013 Royal College of Physicians