4 Teaching and Learning
4.1 How the Neurosurgery curriculum is delivered
The curriculum is used to help design training programmes locally that ensure all trainees can develop the necessary skills and knowledge in a variety of settings and situations. The curriculum is designed to ensure it can be applied in a flexible manner, meeting service needs as well as supporting each trainee’s own tailored learning and development plan. The requirements for curriculum delivery have not changed as a result of this new curriculum. All training must comply with the GMC requirements presented in Promoting excellence: standards for medical education and training6 (2017). This stipulates that all training must comply with the following ten standards:
Theme 1: learning environment and culture
S1.1 The learning environment is safe for patients and supportive for learners and educators. The culture is caring, compassionate and provides a good standard of care and experience for patients, carers and families.
S1.2 The learning environment and organisational culture value and support education and training, so that learners are able to demonstrate what is expected in Good Medical Practice and to achieve the learning outcomes required by their curriculum.
Theme 2: educational governance and leadership
S2.1 The educational governance system continuously improves the quality and outcomes of education and training by measuring performance against the standards, demonstrating accountability and responding when standards are not being met.
S2.2 The educational and clinical governance systems are integrated, allowing organisations to address concerns about patient safety, the standard of care, and the standard of education and training.
S2.3 The educational governance system makes sure that education and training is fair and is based on the principles of equality and diversity.
Theme 3: supporting learners
S3.1 Learners receive educational and pastoral support to be able to demonstrate what is expected in Good Medical Practice, and to achieve the learning outcomes required by their curriculum.
Theme 4: supporting educators
S4.1 Educators are selected, inducted, trained, and appraised to reflect their education and training responsibilities.
S4.2 Educators receive the support, resources and time to meet their education and training responsibilities.
Theme 5: developing and implementing curricula and assessments
S5.1 Medical school curricula and assessments are developed and implemented so that medical students are able to achieve the learning outcomes required for graduates.
S5.2 Postgraduate curricula and assessments are implemented so that doctors in training are able to demonstrate what is expected in Good Medical Practice, and to achieve the learning outcomes required by their curriculum.
It is the responsibility of Health Education England (HEE) and its Local Offices, NHS Education for Scotland (NES), Health Education and Improvement Wales (HEIW), the Northern Ireland Medical and Dental Training Agency (NIMDTA) and the Health Service Executive (HSE) in the Republic of Ireland to ensure compliance with these standards. Training delivery must also comply with the latest edition of the Gold Guide. Appendix 7 outlines the quality management arrangements for the curriculum.
4.2 Learning opportunities
A variety of educational approaches will be used by education providers to help trainees develop the knowledge, clinical and technical skills, professional judgement, values and behaviours required by the curriculum. Taken together, these educational approaches ensure that the CiPs and GPCs are taught appropriately in order that the purpose of the curriculum is met. These educational approaches divide into three areas:
- Self-directed learning
- Learning from practice
- Learning from formal situations
4.2.1 Self-directed learning
The curriculum is trainee-led and self-directed learning is encouraged. Trainees are expected to take a proactive approach to learning and development and towards working as members of a multi-professional team. Trainees are encouraged to establish study groups, journal clubs and conduct peer reviews. They should take the opportunity of learning with peers at a local level through postgraduate teaching and discussion sessions, and nationally through courses and electronic resources. Trainees are expected to undertake personal study in addition to attending formal and informal teaching. This includes using study materials and publications and reflective practice. Trainees are expected to use the developmental feedback they get from their trainers in learning agreement meetings and from assessments to focus further research and practice.
Reflective practice is an important part of self-directed learning and of continuing professional development. It is an educational exercise that enables trainees to explore, with rigour, the complexities and underpinning elements of their actions in order to refine and improve them. Reflection in the oral form is very much an activity that surgeons engage in and find useful and developmental. Writing reflectively adds more to the oral process by deepening the understanding of practice. Written reflection offers different benefits to oral reflection which include: a record for later review, a reference point to demonstrate development and a starting point for shared discussion. Whatever the modality of reflection, it is important that it takes place and that there is a record of it having taken place, whether or not the specific subject or content of the reflection is recorded7. Self-directed learning permits development in all five CiPs and the GPCs, especially when there is effective reflection on all aspects of learning at the centre of self-directed learning.
4.2.2 Learning from clinical practice
Surgical learning is largely experiential in nature with any interaction in the workplace having the potential to become a learning episode. The workplace provides learning opportunities on a daily basis for surgical trainees, based on what they see and what they do. Trainees are placed in clinical placements. determined locally by Training Programme Directors (TPDs) that provide teaching and learning opportunities. The placements must be in units that are able to provide sufficient clinical resource and have sufficient trainer capacity.
While in the workplace, trainees are involved in supervised clinical practice, primarily in a hospital environment in wards, clinics or theatre. There are strong links to practitioners working in primary care and training environments may include private settings and, where available for training, a variety of community settings where the necessary facilities and governance arrangements are in place. The trainee role in these contexts determines the nature of the learning experience.
Learning begins with observation of a trainer (not necessarily a doctor) and progresses to assisting a trainer; the trainer assisting/supervising the trainee and then the trainee managing a case independently but with access to their supervisor. The level of supervision changes in line with the trainee’s progression through the phases of the curriculum. As training progresses, trainees should have the opportunity for increased autonomy, consistent with safe and effective care for the patient. Typically, there should be a gradual reduction in the level of supervision required and an increase in the complexity of cases managed until the level of competence for independent practice is acquired.
The CiPs are best taught, particularly in the early phases of training, by a specifically selected trainer directly watching and supervising while the trainee carries out the activity. This type of training is known as Professionalised Training and requires more time (and so, consequently, a reduced clinical workload) than conventional methods. It permits more thorough teaching, more rapid achievement of skill and earlier recognition of difficulties. Continuous systematic feedback and reflection are integral to learning from clinical practice. The CiP and GPC descriptors through the MCR assessment provide detailed feedback and identify specific, timely and relevant goals for development through training. Education providers should make every attempt to ensure that each trainee has exposure to Professionalised Training appropriate to their phase of progression through the curriculum. It is recommended that this be one session per week per trainee in the early years. Trainees are required to keep a surgical logbook to support their reflection and the assessment of their operative skills.
4.2.3 Learning from formal situations
Learning from clinical practice is supplemented by an educational programme of courses and teaching sessions arranged at local, regional and national levels. These should be mapped to the CiPs, GPCs and the Neurosurgery syllabus and may include a mixture of formal talks including attendance at national conferences relevant to the specialty, small group discussion, case review and morbidity and mortality meetings, literature review and skills teaching. A list of recommended courses for trainees is given in appendix 5.
Teaching in formal situations often involves the use of simulation. In this context simulation can be any reproduction or approximation of a real event, process, or set of conditions or problems e.g. taking a history in clinic, performing a procedure or managing post-operative care. Trainees have the opportunity of learning in the same way as they would in the real situation but in a patient-free environment. Simulation can be used for the development of both individuals and teams. The realism of the simulation may reflect the environment in which simulation takes place, the instruments used or the emotional and behavioural features of the real situation. Simulation training does not necessarily depend on the use of expensive equipment or complex environments e.g. it may only require a suturing aid or a role play with scenarios.
Simulation training has several purposes:
- supporting learning and keeping up to date
- addressing specific learning needs
- situational awareness of human factors which can influence people and their behaviour
- enabling the refining or exploration of practice in a patient-safe environment
- promoting the development of excellence
- improving patient care.
The use of simulation in surgical training is part of a blended approach to managing teaching and learning concurrent with supervised clinical practice. The use of simulation on its own cannot replace supervised clinical practice and experience or authorise a doctor to practice unsupervised. Provision of feedback and performance debriefing are integral and essential parts of simulation-based training. Simulation training broadly follows the same pattern of learning opportunities offering insight into the development of technical skills, team-working, leadership, judgement and professionalism. Education providers should use all teaching methods available, including simulation teaching, to ensure that the full breadth of the syllabus is covered. Where there is a need for specific intensive courses to meet specific learning outcomes, there may be a number of equivalent providers.
Supervision is fundamental in the delivery of safe and effective training. It takes advantage of the experience, knowledge and skills of expert clinicians and ensures interaction between an experienced clinician and a trainee. The ultimate responsibility for the quality of patient care and the quality of training lies with the supervisor. Supervision is designed to ensure the safety of the patient by encouraging safe and effective practice and professional conduct. A number of people from a range of professional groups are involved in teaching and training with subject areas of the curriculum being taught by staff with relevant specialist expertise and knowledge. Those involved in the supervision of trainees must have the relevant qualifications, experience and training to undertake the role. Specialist skills and knowledge are usually taught by consultants and senior trainees whereas the more generic aspects of practice can also be taught by the wider multidisciplinary team (MDT).
The key roles involved in teaching and learning are the Training Programme Director, Assigned Educational Supervisor, Clinical Supervisor, Assessor and Trainee. Their responsibilities are described in appendix 6 and further information is given in the Gold Guide.
In the UK, the GMC’s process for the recognition and approval of trainers8 enables Deaneries/HEE Local Offices to formally recognise AESs and Clinical Supervisors (CSs) and ensure they meet the specified criteria. Trainees must be placed in approved placements that meet the required training and educational standards of the curriculum. In each placement, trainees have a named AES and one or more CS, responsible for overseeing their education. Depending on local arrangements these roles may be combined into a single role of AES.
All elements of work in training posts must be supervised. The level of supervision varies according to the experience of the trainee, the clinical exposure and the case mix undertaken. As training progresses trainees should have the opportunity for increased autonomy, consistent with safe and effective care for the patient. Achievement of supervision level IV in any of the five CiPs indicates that a trainee is able to work at an independent level, with advice from their trainer at this level being equivalent to a consultant receiving advice from senior colleagues within an MDT. However, within the context of a training system trainees are always under the educational and clinical governance structures of the Health Service.
4.4 Supporting feedback and reflection
Effective feedback is known to enhance learning, and combining self-reflection7 with feedback promotes deeper learning. Trainees are encouraged to seek feedback on all they do, either informally, through verbal feedback at the end of a learning event, or formally through workplace-based assessments (WBAs). The MCR and use of the CiP and GPC descriptors provide regular opportunities for detailed and specific feedback. Trainee self-assessment provides a regular opportunity for focused and structured reflection and development of self-directed goals for learning as well as developing these goals through dialogue with trainers. All the assessments in the curriculum are designed to include a feedback element as well as to identify concerns in multiple ways:
- Learning agreement: appraisal meetings with the AES at the beginning, middle and end of each placement
- WBA: immediate verbal dialogue after a learning episode
- CBD: meeting with a consultant trainer to discuss the management of a patient case
- MSF: meeting with the AES to discuss the trainee’s self-assessment and team views
- MCR (mid-point formative): meeting with the AES or CS to discuss the trainee’s self-assessment and CSs’ views on CiPs
- MCR (final formative, contributing to the AES’s summative Report): meeting with the AES or CS to discuss the trainee’s self-assessment and CSs’ views on CiPs
- Formal examinations: summative feedback on key areas of knowledge and skills
- ARCP: a feedback meeting with the TPD or their representative following an ARCP.
Constructive feedback is expected to include three elements i) a reflection on performance ii) identification of the trainee’s achievements, challenges and aspirations and iii) an action plan.
4.5 Academic training
All trainees are required to satisfy the learning outcomes in domain 9 of the GPC framework: Capabilities in research and scholarship. Trainees are encouraged to participate in clinical research and collaborative trials to achieve these outcomes, as well as in journal clubs, literature review and systematic review and to make a major contribution to the publication of novel findings in peer reviewed journals. An understanding of the principles of research, its interpretation and safe implementation of evidenced-based new methods, processes and techniques is essential for the modern, progressive practice of Neurosurgery and in the interests of patients and the service.
Some trainees choose to take time out of training for a formal period of research, as specified in the Gold Guide. For the majority, this leads to the award of a higher degree in an area related to their chosen specialty. Some also choose to focus a significant part of their training time on academic medicine, but need to complete all the essential elements of the Neurosurgery curriculum satisfactorily in order to achieve certification. The rate of progression through the clinical component of their training is determined by the ARCP process to ensure that all clinical requirements are met in keeping with the curriculum. Arrangements for academic training differ in detail across the nations of the UK and Republic of Ireland. Details of arrangements can be found on the webpages of the relevant National Health Education body.
Promoting excellence: standards for medical education and training
Improving feedback and reflection to improve learning. A practical guide for trainees and trainers
GMC recognition and approval of trainers