MB O'Neill¹, B Freyne¹, AJ Nicholson^2
1Mayo General Hospital, Castlebar, Co Mayo
²Children’s University Hospital, Temple St, Dublin 1

Abstract

This study of paediatric trainees, who were awarded their CSCST from 2005 to 2010, evaluated their training experience and assessed whether the curriculum goals were achieved. From an incomplete database 23 (57.7%) graduates based in Ireland and 3(19%) based abroad responded. Twenty one (81%) of respondents were currently working in Ireland as consultants, 20(80%) had a post membership qualification and 23 (92%) had travelled abroad for fellowships. Positive experiences included clinical training (44%), positive role models (44%), quality of the training days (52%).Negative experiences included lack of protected time for research (52%), excessive clinical service (28%), and poor monitoring of trainers (20%). Mean Likert scores for curriculum competencies were clinical care 4.9, clinical knowledge 5, application of evidence 3.7, academic supervisor skills3.3, knowledge of public health 3.2, health economics 2.2, and healthcare systems modification 2.3. The curriculum deficiencies can be addressed through the diploma in Leadership and Quality in Healthcare which has been developed by the Health Service Executive and the College of Physicians but an adequate database of graduates needs to be maintained.

Introduction

The establishment of the Higher Specialist Training (HST) program in paediatrics, in 1999, marked a transition from individual self directed training in paediatrics to a formal process with the establishment of a defined curriculum, structured training and assessment. The first Specialist Paediatric Registrars (SPR) who completed the full 5 years of training received their certificates of satisfactory completion of specialist training (CSCST) in the Higher Specialist Training (HST) in General Paediatrics in 2005.While trainees in program reported favourably on their experiences¹ this study was under taken to assess graduates perceptions on the achievement of curriculum goals, and their views on the training experience inclusive of the strengths and weaknesses.

Methods

A mixed model questionnaire was constructed to survey graduates of the Higher Specialist Training Program in General Paediatrics. Closed questions elicited demographic information and quantified the training process. Likert scales were designed to encompass four levels of certainty; definitely, probably,possibly and not at all. There were six possible choice boxes (cuing at 1 not at all and 6 definitely) which encompassed intermediate scores as required. An example of the question structure can be seen in Figure 1.They assessed the graduates perceptions of competency in the 7 core elements of the paediatric HST curriculum which include clinical care, ethical and legal knowledge, application of evidence to practice, ability to supervise, and undertake research, have appropriate knowledge in the areas of public health, health economics, and healthcare systems. Open questions were utilized to assess perceived strengths and weaknesses of the program. The questionnaire was tested for internal validity by piloting it amongst colleagues who had completed the specialist paediatric registrar (SpR) program and also currently enrolled trainees.

Data from the Royal College of Physicians in Ireland (RCPI) indicated that 87 paediatric SPRs were awarded their CSCST between 2005 and 2010. We utilized the trainee e-mail addresses that were available from the RCPI to survey the SPRs however the database was not current with failure to deliver rate of e-mail delivery in 21 (24.1%) .We were unable to determine the number of email addresses that were both current and active. Consequently from the database the authors defined a convenience sample of graduates where their current location was known with a degree of certainty or to whom the initial e-mail sent was delivered. For 87 graduates, 60 addresses were deemed reliable, 44 (73.3%) located in Ireland and 16 (26.7%) abroad however 4 doctors, based in Ireland, were on maternity leave therefore 56 doctors were surveyed by post and by email. Quantitative data was analyzed using SPSS 14.0 for word. Qualitative data was analyzed using the framework approach until data saturation was reached.

Results

Responses of graduates based in Ireland were 23(57.5%) and from abroad were 3(19%). The male: female ratio was 3:1. Each graduate year was represented with a minimum of 3 to a maximum of 6 responses. All respondents, with 1 exception, had attended medical school in Ireland. The mean time spent in the training program was 5.2 years, range 5 -7 years.

Twenty (80%) graduates completed a post membership qualification. Eleven identified barriers which prevented completion in the allotted time which were related to family circumstances (5), lack of resources (4), clinical workload (3), attainment of permanent consultancy prior to finishing (2) and relocation (1). Twenty three 23 (92%) travelled overseas for fellowships, including 4 who completed dual fellowships. Twenty one fellowships were in a chosen in paediatric subspecialties and 2 in general paediatrics. Fellowships locations were Canada (11), United Kingdom (6), USA (5), Australia (3) and France (1). Fourteen fellowships were research and clinical with 9 being clinical. Twenty one (81%) respondents were currently in Consultant posts which included General Paediatrics 7, Community Paediatrics 2, and subspecialist practice inclusive of , Endocrinology 3, Respiratory 3, Neonatology 2, Gastroenterology 2, Intensive Care 1, Neurodevelopment 1. It emerged in qualitative analysis that the most common reason people diverted from their proposed career plan was availability of an alternative consultancy and that quality of life issues pushed people away from jobs in tertiary referral centers.

The beliefs related to curriculum competency are outlined in Table 1. Qualitative themes related by the trainees were classified as either positive or negative. Positive qualitative themes were the clinical competency gained through training in Ireland for 44%, the exposure to excellent role models for 44%, the quality of the SPR training days for 52%, the recognition that overseas fellowships were important for 40%, and the attempts to standardize the assessment process for 22%. The negative themes included, lack of protected time for study and research for 52%, excessive clinical service provision for 28%, poor monitoring of trainers for 20%, mismatch between clinical rotations and career goal of the trainee for 16%, and a lack of management training for 12%.

Discussion

This study evaluated the perceptions of graduates of the HST program in General Paediatrics as they related to the achievement of the curriculum goals and their views on the strengths and weaknesses of the program. Such views are important as the trainees are the future leaders of paediatrics in Ireland and their insights should be drivers for change². Positive findings include the achievement of the curriculum goals as they relate to clinical practice which is also reflected in the qualitative themes. This is similar to the Canadian experience where 96% of paediatricians felt they were adequately or very well trained³. The negative findings suggest that curriculum goals are not being achieved in areas of health policy, public health and healthcare modification. These deficiencies may be relevant to other postgraduate training bodies and could be addressed by online educational modules. The diploma in Leadership and Quality in Healthcare developed by the Health Service Executive and the Royal College of Physicians of Ireland could also address these deficiencies. The curriculum for training must also reflect potential future megatrends, a process undertaken by the American Academy of Paediatrics⁴, if trainees are to be adequately prepared for their professional careers.

The inadequacy of time for study and research cited by trainees highlights a central dilemma of training where there is the need for appropriate ‘down time’ for reflection and the consolidation of learning⁵. The development of a paediatric faculty educational leadership committee would provide a mechanism to disseminate and educate on issues of educational innovation to trainees and trainers⁶. Consultants undertaking this role would have to be supported with a reduction in their clinical commitment. A major weakness of this survey is the absence of an adequate database through which all graduates could have been contacted which may has implications for the retention of paediatric trainees as once gone from the scheme they may be unaware of the job opportunities available for them. The M:F response rate is at variance with the HST program in paediatrics where the M:F is 1:2 suggesting that the low female response rate may be related to the absence of an appropriate database. Many of the respondents, of this survey, are currently working in Ireland as consultants, and incorporating their views into future changes to the paediatric training program needs to be considered as their insights can lead to improved training.

Correspondence: MB O'Neill
Paediatric Department, Mayo General Hospital, Castlebar, Co Mayo
Email: [email protected]

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