UK anaesthetic training and the law of unintended consequences. Cause for concern?

Robert Merton identified several mechanisms by which the actual effects of behaviour may deviate from the intended ones [1]. These have collectively become known as ‘the law of unintended consequences’ which more generally states that the actions of people, and especially of government, always have effects that are unanticipated or unintended [2]. Recent changes within the National Health Service (NHS) seem to confirm this with an unexpected and potentially undesirable effect on anaesthetic training. In 1996, higher specialist training in the UK changed fundamentally with the introduction of a unified training grade. Before this date, trainees arranged their own training by applying for a series of posts and an apprenticeship system formed the basis of learning [3]. In response to a requirement to bring British postgraduate medical education in line with European practice (EEC Directive 93/16/EEC), structured Specialist Registrar (SpR) training programmes leading to the award of a certificate of completion of specialist training (CCST) were introduced. Before April 1996 the Specialist Training Authority (STA) had accepted the proposals of the Royal College of Anaesthetists (RCA) for a six-year programme of training, comprising two years of Senior House Officer (SHO) and four years of SpR training. The speciality of anaesthesia was one of the first to submit a programme of training that complied with the recommendation of the Calman report that training should be completed in seven years following full registration with the General Medical Council (GMC) [4]. Most trainees were spending a year in another speciality, so a six-year programme of anaesthetic training was proposed. In 1998 the RCA applied to the STA to increase the SpR training programme from four to five years. The drive for the change was the observation that, since the inception of the six year programme, the majority of trainees were extending their anaesthetic training by spending time in ‘unapproved’ posts, such as fellowships in specialist units, abroad or in research. Another concern was that the caseload of trainees had fallen so much that training in the management of uncommon conditions or infrequent adverse events had become more difficult to acquire. In-depth subspecialty training could not easily be provided in an SpR programme of four years’ duration. The UK training programme was comparatively long but it was acknowledged that, unlike in the UK, many overseas programmes do not prepare trainees for independent practice. In Canada and the USA for example, further fellowship training in a subspecialty may be required and in Europe many doctors spend some time in specialist posts following completion of their training with a gradation of responsibilities which are not equivalent to the newly appointed UK consultant. Learning in the professions has always been based on the apprenticeship model: ‘learning to be the professional by practising the profession under conditions of supervision and careful selection of appropriate levels of independent responsibility and experience’ [3]. The term apprenticeship may be inadequate; supervision and careful selection of what trainees do is a start, but there is a need for critical reflection on practice – the kind of professional discourse that goes on between a good supervisor and trainee. The relationship is more than simply that of the master and apprentice; it is a professional one, since medicine requires doctors to exercise judgement in unique, complex and uncertain situations. Schön coined the term ‘professional artistry’ to describe this kind of competence, also noting that it often becomes intuitive or unconscious [5]. The interpretation of the Calman reforms and the manner of their implementation together with other parallel changes such as reduced junior doctors’ hours and the introduction of clinical governance have placed this approach to training under threat [3]. The ‘supply’ model of learning has developed. Training events (induction programmes, learning agreements, assessments, appraisals and teaching) have become separated from clinical practice, and training goals are defined and monitored, overlooking the fact that much apprenticeship learning is undefinable and unmeasurable. More emphasis is laid on the skills of the teacher to teach rather than the learner to learn. Furthermore, the separation of the funding and organisation of training from service conflicts with the need to integrate learning and clinical practice [3]. Following the Calman reforms, it was intended that the shortened time for training would be compensated by its increased focus. The approach to training became more technical with the emphasis on measurement, routines and protocols with a philosophy that knowledge is graspable and permanent [5]. Of course, technical procedures have to be mastered but the skills have to be used with wisdom in situations of uncertainty. Anaesthetists must be able to deal with the unpredictable. When the length of the training programme was increased, the STA required it to be ‘competency based’ [6]. This was partly an acknowledgement that the final part of the Fellowship of the Royal College of Anaesthetists (FRCA) or equivalent is acquired relatively early in SpR training. With the introduction of the unified training grade, even the hurdle of the Senior Registrar interview had been removed. An additional impetus was the introduction of the Clinical Negligence Scheme for Trusts (CNST) in 1999 to assist in managing their clinical negligence liability. The RCA published detailed training manuals [6], the underlying principle being the need to document ‘competence’ in terms of knowledge, skills and attitudes at a level commensurate with the stage of training. There are many different approaches to the assessment of competency. They include task-based or behaviourist approaches on the one hand, or the assessment of more general and transferable attributes on the other with integrated competency or ‘performance’ combining the best aspects of both methods [7]. But practical clinical competency assessment is very difficult to perform well [8]. There is a temptation to adopt a reductionist model [9] with practice divided into parts that can be taught, learnt and assessed, and to assume that when someone acquires all the ‘parts’ they somehow acquire the ‘whole’. But the whole is greater than the sum of the parts; in order to take account of the judgement necessary in specific but infinitely varying situations there must be regular observation, discussion and reflection on practice with the trainee. So competence is much more than the accumulation of competencies. Even the term ‘competence’ may be insufficient and in today's complex world we must educate not merely for competence but for ‘capability’– the extent to which individuals can adapt to change, generate new knowledge and continue to improve their performance. Education for capability should focus on the process of learning and avoid goals with a rigid and prescriptive content [10]. Many consultants are ill-prepared for the role of educational supervisor and the formal assessment of competency is uncharted territory for them. So far, there has been little in the way of allocation of time and resources to redress this. There is a genuine fear of the consequences of ‘getting it wrong’. As a result, most have adopted a rather task-based approach that underestimates the complexity of the professional task – an almost ‘NVQ approach’ [8, 11]. The assessment of ‘knowledge and skills’ is easier and more tangible, with other aspects of professional behaviour that are much more subjective taking second place. For the majority of trainees, assessment should be a positive experience – a non-threatening opportunity to demonstrate how much and in what ways they have benefited from their training. However, for the poorly performing doctor there are potentially serious consequences with delays to training or even the termination of training, so methods of assessment need to be objective, reliable and valid. Methods to judge performance in a more systematic way have been described but are not yet widely employed [12-14]. Paradoxically, the introduction of competency-based training may have added to the uncertainties of trainees. A much needed expansion of both consultant and trainee numbers has compounded the problem. In the absence of a ‘firm’ structure a trainee may work with the same consultant infrequently and may not be in a position to demonstrate how they are progressing [12]. Consequently, the trainee or trainer may be unsure who is best placed to undertake an assessment and consultants may be reluctant to ‘sign off’ a trainee. Daily in-service assessments are a way round this problem but are not widely used at present and there is little information on whether they correlate with other measures of clinical performance [15]. Rotations have led to trainees spending relatively short periods in a single hospital and have further added to this problem. The time-based structure to the training programme and the need for trainees to support rotas place constraints on the ability of a department or school of anaesthesia to allow key units of training to be repeated. The New Deal was introduced in the UK in 1991 with the aim of reducing junior doctors’ hours of work to an average maximum of 56 h. The European Working Time Directive (EWTD) became obligatory for junior doctors from August 1st 2004 [16]. The SIMAP ruling meant that all time spent in the hospital, whether working or resting, counts as working time so that resident on-call rotas have become non-viable [17]. Shift patterns of work with a shorter maximum duty period, usually of 13 h, have replaced traditional on-call rotas. The inevitable effect is a reduction in the number of daytime hours worked. The need for service provision in Intensive Care and Obstetric Units (in excess of the time allocated for ‘training’) has not altered and the time spent in theatre has been shortened. Already there is evidence that there has been a reduction in the number of weekly training lists and the number of cases done [18]. There are contractual obligations for trainees to keep diaries of their hours and financial penalties are incurred by Trusts if working patterns are non-compliant. Staying on to help out, to finish a case or simply for interest is less of an option. Certainly there is great confusion over whether these are permissible. The new work-sensitive consultant contract allows out-of-hours work by consultants to be recognised. Delays to its implementation have meant that consultant work patterns have remained largely unchanged. Theatre re-organisation to enable the more efficient use of operating time during the evenings and weekends has been slow. The net effect is that new opportunities for supervised training and to perform competency assessment ‘out-of-hours’ have not been realised. Trainees on rotations often have to travel considerable distances and journey frequency has been increased by the introduction of shorter shift periods. Shift working brings fragmentation and reduced continuity of care. Night shift working upsets the normal circadian rhythm, exacerbating fatigue [19]. Strategies for the organisation of shifts and for lessening their impact are not widely known in medical circles [20]. Some trainees perceive that both their quality of life and their training have been harmed [21]. The quality of training may not necessarily be harmed by the introduction of shifts but one cannot help feeling that in the UK it might have been. Formal training sessions and ‘apprenticeship-style’ learning must take place during fewer day-time hours and compete with heavy service demands. There is no clear evidence that the actual or perceived quality of training is better or worse in a shift system compared to an on-call system but a well structured and supervised working environment may compensate for a reduction in day-time hours or a high work intensity [22, 23]. Increasing the number of doctors who contribute to a shift allows them to do night duty less frequently and increases their presence during the day. Blocks of nights are preferable as they can be interspersed with longer periods of day-time training. However, they are unpopular because they are inflexible and come round relatively frequently. In the UK the number of trainees available to support a shift is barely adequate in most hospitals, night duty is frequent and daytime presence is decreased commensurately. The minimum number to run a robust full shift with prospective cover is usually eight at Senior House Officer level and more may be required at SpR level [24]. The planned restructuring of the training grades with the introduction of Foundation Programmes and the ‘run-through’ training grade has created further uncertainty. But there are also opportunities here. The Postgraduate Medical Education and Training Board (PMETB) has adopted a set of principles that will form the basis for assessment in postgraduate medical education in the UK. Not least among these is that ‘there will be resources sufficient to support assessment’ [25]. The European Commission has recently initiated consultation on possible amendments to the EWTD. In practice this means that if a third category of time is recognised – the inactive part of on-call time – resident on-call duties might be resumed [26]. Finally, the ‘Hospital at Night’ project and the new consultant contract will encourage the movement of a significant amount of work into the extended day [27]. These may facilitate the swing of the pendulum in favour of apprenticeship learning and education for capability. ‘Despite the pressure of reduced time for training, apprenticeship learning should not be neglected in favour of more formal teaching. Instead, it should be enhanced and concentrated, by setting aside time for feedback and supervision, as well as exploiting every opportunity for training on the job. There is no better way of realising the full potential of the trainee and passing on the wisdom of clinical experience’ [28]. The challenges facing postgraduate medical education will not be resolved by formal approaches to education. Informal approaches still have their merits. While experience does not simply equal learning, perhaps it is time to bring back the apprentice [29]. SpRs reaching CCST today are probably no more or less prepared for the role of consultant than their Senior Registrar predecessors [3, 28]. What has changed is the level of uncertainty brought on by constant changes to training and the wider NHS. We must restore stability and preserve the professionalism that is ebbing from our working lives as a result of the law of unintended consequences. I am grateful for the advice of Dr Ian Lewis and Professor Colin Coles in the preparation of this manuscript.

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