By the time this editorial reaches print the early effects of the implementation of the European Working Time Directive (EWTD) will be apparent. Concern has been expressed regarding the impact of the EWTD on patient care and training.1 The time frame in which this will be felt is unclear but it is likely that any impact on patient safety will be appreciated first. Trainees have been raising concerns about the potential impact of the EWTD for some time.1–3 If problems do arise then NHS trusts and doctors will have to work together to find solutions rapidly.
The option of derogation (postponement of the deadline for full EWTD compliance) has been offered to individual trusts by the Department of Health, however, applications from medical specialties within trusts have been relatively uncommon. The aim of derogation was to allow further time to achieve full implementation of the EWTD. For many units it seems that sufficient numbers of trainees are not currently available to construct compliant rotas that fulfil out-of-hours commitments while also enabling wards to be appropriately staffed during the working day.
With concerns for patient safety foremost in doctors’ minds, it might seem an odd time for the Trainees Committee (TC) of the Royal College of Physicians (RCP) to release a detailed document containing recommendations to improve the quality of physician training in the UK. On the contrary, the TC feel it is of the utmost importance that high-quality training is maintained at all times, and that this is vital for patient safety. The EWTD provides the perfect stimulus for reviewing how service and training interact and how the latter can be improved.
There is an urgent need to focus on the adequacy of the future consultants to be produced in every specialty. We must all decide whether or not we feel these consultants are going to be adequately trained, and whether current training is long enough. These decisions are set against a background of certain groups openly stating that new Certificate of Completion of Training holders are not as well equipped to serve the NHS when compared to those achieving entry to the specialist register in the past. Interestingly, these comments were made before the implementation of the EWTD, which has further reduced training experience.4
The TC feels that plentiful learning opportunities present themselves to trainees each day, and that trainees and trainers alike need to be more efficient at recognising and benefiting from each potential learning event. The aim of the recommendations contained within the TC's document is to improve training in the limited time available in current programmes. Some of these improvements will require a greater time commitment from supervisors and this must be properly timetabled and planned with an allocated fraction of a programmed activity for each clinically or educationally supervised trainee. However, many of the suggestions have more to do with modifying attitudes, expectations, strategies and quality control with existing time and resources.
The ward round is a perfect example of a missed learning opportunity. With the pressure of time and service the ‘teaching’ ward round has gradually been replaced by a ‘business’ round. This affords trainees less time to present cases (perfect preparation for the PACES examination) and fewer opportunities for discussion. Perhaps it is more appropriate for these discussions to take place at the end of the round, away from patient areas. In any event it is important that more is made of the learning opportunities generated by the ward round than is currently realised by the occasional case-based discussion or use of the acute care assessment tool. Time following ward rounds should be set aside to facilitate less formal but important discussions of cases that can educate trainees from foundation to senior specialty level and beyond.
It is necessary to become more intelligent about training organisation and integration with service commitments of a modern NHS trust to ensure trainees are sufficiently educated in the time available. The full document entitled Achieving the highest standards of training for physicians is available online at www.rcplondon.ac.uk/about-the-college/committees/trainees/documents/training-doc.pdf, and any comments and suggestions are welcome.
- © 2009 Royal College of Physicians
