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The leader by McDonagh regarding outpatient training for rheumatology specialist registrars is a timely and important commentary.1 Having done most of my training in the United Kingdom, for the past two years I have spent time at the University of Toronto, Division of Rheumatology. This experience provides some observations that are relevant to the current debate.
It is impossible to avoid the differences in the organisation of health services and postgraduate medical education in the UK and Canada. These have a significant impact on training. The NHS is consultant-led with a high dependency on doctors at the senior house officer and registrar grades to provide the service. Many outpatients are therefore seen by doctors who may have little or no previous experience in rheumatology. Because of the pressure of numbers and resultant time constraints mistakes in management as well as potentially unnecessary follow ups can go unchecked. The Canadian health care system is consultant-based. Specialists work on a fee for service basis and are required to see each patient. Clinics are organised in proportion to the number of patients the specialist can see. Not all clinics are training clinics, the “service only” clinics do not have trainees in attendance. At the training clinics, patient numbers are reduced to allow the specialist time to review the case. Postgraduate training programmes are university rather than hospital-based. All residents and their salaries are assigned to the university associate dean of postgraduate education. The allocation of “student trainees” and their remuneration budgets are then made to training sites based on their ability to provide an educational programme. In return, the training site gets prestige as well as a measure of service from the student trainees. The major implication of such a switch is the transfer of additional service obligation to the consultant. This, in turn, may be delivered by the consultant or by clinical associates appointed for this purpose.
This framework enables adequate time to be set aside for one to one teaching at the clinics. The content of such teaching evolves through the period of time the trainee is with the consultant. Early on it focuses on history and examination skills. Later, as competence develops, more time is spent on management and related issues. Observation of the consultant-patient interaction is also a key area that is both possible and extremely instructive in this setting. Some clinics also arrange post-clinic rounds. This enables full and detailed discussion of a few cases by trainees and staff. Teaching seminars can also be made more relevant to the outpatient clinic by adopting a problem-based learning approach,2 this learning exercise can easily be geared towards everyday clinic decisions and conduct.
Pressure to provide a service is a major obstacle to maximising the training potential of clinics. However, conversion of specialist registrars (and senior house officers!) to a student trainee role would, in many hospitals, lead to chaos in the outpatient service, the demands on which continue to rise inexorably.3 One starting point would be for consultants with a trainee to designate one session a week as a “training clinic”. This should be a regular commitment not just confined to the first few weeks of the post. Such a clinic would have a smaller number of patients with protected time for teaching. For consultants with a large clinical service dependent on doctors in training grades, this would provide a mechanism by which training and teaching in the outpatient setting could begin and gradually evolve with time. This could be coupled with departmental clinic rounds and a problem-based learning approach for teaching seminars. Incentives to provide such training will be necessary to balance the pressures of service. The paradigm shift in funding discussed above would change the status of trainees from apprenticeship to studentship and would be a major incentive to change the service: education ratio of posts to one in which education is favoured.
In Toronto the opportunities to learn in the outpatient clinic are considerable. The current pressure of service within the NHS needs to be resolved to allow trainees the time and space to learn from their trainer. While a paradigm shift in the overall structure is necessary to realign service and education, introduction of the “training clinic” model would be possible within the current structure. l agree with Dr McDonagh that we need to comprehensively re-think how we use the outpatient clinic to its maximum potential for the training of rheumatologists in the UK.
I am indebted to Dr Dafna Gladman, Director of Postgraduate Training Program in Rheumatology, University of Toronto and Dr Murray Urowitz, Associate Dean of Postgraduate Education, University of Toronto for their helpful discussion of this subject.
I wish to thank Dr Bruce for sharing his recent experience of rheumatology training in North America and providing an evidence base for future discussion of this theme. He illustrates that quality training can develop in the outpatient setting and suggests a realistic starting point for NHS rheumatology outpatient services with a weekly “training clinic”. The issues of service demands, remuneration, and responsibility are appropriately highlighted. I would actively encourage further sharing of such experiences and ideas and would hope that future “teaching the teacher” courses will cover such training in the outpatient setting specifically.