The Malta Foundation Programme: one year on – Part II

by Tonio Piscopo & Kevin Cassar

Continued from Issue 2/11

3. Assessment

Assessment of trainees is another major change brought about by the foundation programme.  Whereas prior to the introduction of the programme, trainees were given full registration with the Medical Council of Malta without any formal assessment, trainees are now assessed repeatedly during the two years using different assessment tools and by several different assessors.  In order to implement these changes over 250 assessors received training in the assessment tools by the Malta Foundation School.  The tools include mini-Clinical Examination (mini-CEX) which assesses the trainee’s interaction with a patient, Direct Observation of Procedural Skills (DOPS) which assesses the trainee’s competence in performing a procedure, Case-Based discussion (CBD) which assesses the trainee’s management, documentation and professionalism, and multisource feedback (MSF) which is a 360 degree assessment by at least 10 individuals with whom the trainee works.

Trainees are obliged to complete at least 20 of these assessments during the year.  Introducing this intensity of assessment was of course a major challenge and the considerable number of assessments raised some concerns about whether this was feasible, particularly as no formal assessments of trainees had been carried out in the past.  The first year has shown us that our misgivings were unfounded.  For 86 trainees, between July 2009 and July 2010, no less than 2317 MSFs, 516 CBDs, 1117 DOPS, and 501 mini-CEXs were carried out.  These are huge numbers of assessments and achieving these numbers was only possible through the cooperation and efforts of a significant number of people, not least by the Consultant body.  Indeed our records indicate that 72% of all CBDs and 23% of all mini-CEXs were carried out by consultants.  The UK’s Postgraduate Medical Education Training Board (PMETB) survey of 2009 reported that in the UK only 46% of CBDs are carried out by consultants.  This indicates that consultant involvement in the assessment of our trainees is far higher than it is in the UK.  It also indicates that consultants are making a very major contribution not only to the training of foundation doctors but also to their assessments.

4. Trainee Support

A trainee support team (TST) has been set up within the Malta Foundation School under the direction of Dr Etienne Muscat.  The aim of the TST is to provide junior doctors enrolled in the Foundation Programme with access to a system that can assist them with issues that are hindering them in their training and, by extrapolation, in their expected maturation into independent, reliable and safe doctors. The concerns raised with the TST may include deficiencies of knowledge, clinical skills, professionalism, behaviour, substance abuse, and mental health and may be raised by the doctor or supervisor.  Prior to the setting up of this team, Dr Etienne Muscat visited the Trainee Support Unit at East Midlands Foundation Schools in the UK to witness first hand the functioning of the unit. The role of the team set up locally is to assess trainees who are experiencing difficulties to try and establish the cause of the problems and to provide the support required. During the first year of the foundation programme 11 trainees were assessed, 9 at FY1 and 2 at FY2 level. Interventions in these trainees included referral for clinical psychology evaluation, counselling therapy service, referral for independent psychiatric board evaluation, and referral for careers counselling.

5. Careers Advice

Dr Pierre Ellul is responsible for provision of careers advice to foundation doctors.  The role of Careers advice is to organise careers workshops, to support the development of taster weeks, to provide doctors with careers information, and to hold careers planning meetings with trainees as required.  Last year all FY2 trainees were offered Windmills Careers Day. Dr Pierre Ellul had received training in delivery of this careers workshop and delivered the workshops together with UK trainers.  The feedback from our trainees on this workshop was excellent.

6. Feedback

Throughout the year the trainees’ feedback on various aspects of their training has been sought.  This includes feedback about the lecture programme as well as their rotations.  End-of-post questionnaires are conducted anonymously using an on-line survey.  94% of trainees stated that they were satisfied or highly satisfied with the clinical skills acquired during their assignment (Figure 1).  95% reported that they frequently, regularly or sometimes received feedback (Figure 2) which the majority (93%) found useful (Figure 3).  Feedback from trainees also indicates that only a small minority of trainees were dissatisfied or very dissatisfied with the training provided by their clinical supervisor (15.9%) with the majority being very satisfied or satisfied.

7. Recruitment

The second objective of the foundation programme was to improve the retention rate of medical graduates within the service.  In 2007, only 63.6% of graduates from the University of Malta were recruited to the local health service.  The figure in 2008 was slightly better at 71.4%.  The introduction of the foundation programme resulted not only in an improvement in retention of local graduates but also attracted foreign graduates to join the programme.  In 2010, 84.2% of University of Malta graduates joined the Malta foundation programme together with 8 foreign graduates.  As a result the total number of doctors recruited in 2010 reached almost 95% of the number of students graduating from the University of Malta (Table 1).  The application process for entry into the Foundation programme in July 2011 has been completed.  For the first time the number of doctors recruited (88) exceeds the total number of final year medical students at the University of Malta (76).   This indicates that this second objective has definitely been reached.

Table 1: Number of doctors recruited into national health service.

Conclusions

The setting up of the foundation programme has resulted in major changes in the training of ‘houseofficers’.  It has provided a structured programme with good quality training, supervision and assessment.  The number of doctors recruited to the service has increased steadily and is expected to continue to increase.  This will not only improve the service but also the quality of training through increased educational opportunities and better distribution of workload.

The results obtained however do not allow for complacency.  There are major challenges ahead, not least the impending full implementation of the European Working Time Directive, increasing numbers of medical students at the University of Malta, increasing competition for posts from other EU nationals, increased demand on educational resources, and of course need for more basic specialist training posts for the increasing number of doctors.

The successful introduction of the Foundation programme in Malta is an example of how co-operation between all stakeholders together with the hard work of clinical and administrative staff can lead to major improvements in training standards and the rapid acquisition of a common goal.

Figure 1: Responses to question “Are you satisfied with the clinical skills acquired during this assignment?”

Figure 2: Responses to “Did you receive feedback about your performance during this assignment?”

Figure 3: Responses to “Was the feedback you received useful?”