Trainee-led initiatives in prevocational training - HETI

I am the Program Manager with CETI's General Medical Training Unit.It's one of the great bits of my job to support the NSW JMO Forum.1

The Forum is a trainee‐representative advisory subcommittee of theNSW Prevocational Training Council. It is composed of elected traineerepresentatives from the 15 training networks that make up theprevocational training program in NSW and the ACT.Each year each network elects a new PGY1 representative, who willserve on the Forum for two years. We also elect rural reps from themajor rural training sites in NSW, making about 34 or 35 reps. Abouthalf of the Forum is new each year, and half are carrying on from theprevious year, and this system provides both a regular flow of newideas and a degree of continuity.2

The basic message of our presentation today is simple: JMOs are adultlearners and enthusiastic employees who have the interest,involvement, ideas and innocence required to attempt innovations inmedical education and training. It makes good sense pedagogically andadministratively to give them a leading role in shaping the system inwhich they will learn and work.I am sure that most of you are already acting on this knowledge insome ways, but there are also plenty of forces in the system thatoperate against trainee‐led initiatives. Two JMO Forum representativesare going to give you brief examples of ways in which trainee‐ledprojects can offer the system new and better ways of doing things,achieving results that would be difficult to reach by other means.3

The JMO forum as a whole identified the lack of a consistent statewide educationprocess. As seen by the graphic formal teaching varied widely not only acroos the 15prevocational networks in NSW but from hospital to hospital. and over the last two yearsthere has been a sustained and concerted effort by the trainees to address a few keyareas. this from a ground up driven process which thanks to the wholehearted and inmany cases overwhelming support from DPETs and JMO managersAddit:Of the 27 hospitals represented here•Average teaching hours per week = 1.5–24 hospitals have 1 hour per week–17 hospitals have >1 hour per week• 49% (22/45) are pager protected5

Rather than refer to an expert panel with a multitude of committees which is probablythe more politically correct and academically rigorous way of doing it … the JMOs in theEducation working group went away and came up with what we as Junior Doctors feltwas of most value in each topic6

In some ways we were like charging horses with blinkers – quite oblivious to the ruffledfeathers or the potential fallout8

11 out of 15 had implementedAccording to the JMO respondents, of the 11 hospitals in this poll that had implementedthe series 10 had done so effectively and was well received. Obviously this is a smallsample and its early days given the proposal was sent out at the end of last year.We are hoping to repeat the 2010 survey with a much larger number of hospitalssurveyed later next year.This is not to say this is a perfect system –one of the common criticisms is that there istoo much expected from each teaching session than can be adequately deliveredWhat it is, is a prime example9

In 2011 our focus changed to address the oft neglected part of the ACFJD10

So why bother with trainee led initiavesWell theres the chance to play god –create tomorrows achievers in your own image13

Thanks Vikas. I’d like to tell you about two more projects that the members of the JMOForum has been involved with. The first occurred at a local health network level wherethe JMO Forum was asked to get involved with the NSW Health Services ImprovementBranch Acute Care Taskforce who were particularly looking at JMO Handover. Dr HamishDunn has already discussed the content of the findings in another presentation at thisevent.16

In the following year the JMO Forum undertook a statewide audit of handover, thedetails of which you can see on the slide and the results of which have been used byNSW Health to focus handover improvement across the state. The point being that therewas no possible way this audit could have been conducted without JMO buy‐in andownership. This was acknowledged by NSW Health.17

The second project was devised and executed by the Careers working party of the JMOForum who have compiled a Doctors GPS guidebook to navigating specialty training. Intheir own time the working party members contacted all relevant specialty colleges andhave put together a one stop shop information resource for interns and residents for allmajor specialty pathways. This publication is in final draft and will be published andreviewed biannually as an official NSW Health CETI publication.18

There are numerous other JMO led projects out there which I don’t have time to tell youabout and which I’m sure many of you are involved in. The key point I would like toreiterate is that these projects are the result of volunteer time and energy and peoplewho believe in what they are trying to do. They only earn a budget as a result of theirquality and utility. They are owned by the JMOs who seek input, feedback and supportas needed from people who believe that they have something valuable to offer.20

Colloboration, mentoring and empowering JMOs can only result in good. Even projectswhich fail will ensure some kind of learning outcome for those involved. It is imperativethat the idea of initiative, ownership and leadership is not lost in the JMO experience.JMOs have spent years being trained to identify problems and work towards solutions.Its their day to day job. And they should be doing it outside of the clinical arena in orderto become competent professionals.21

Too often we see the expectation of sudden gravitas and knowledge from a clinicalperspective in the transition from ‘subservient’ resident to ‘in charge’ registrar. Thesame applies to education and training. Unless junior doctors are encouraged toinnovate, to question, to look for better ways of doing things at local and system levelsthe future looks bleak. We need to create leaders and change drivers for the future now–otherwise there will be no one to sit in the seats you now occupy 20 or 30 years fromnow. Sometimes ‘consultation’ is a dirty word. It just means there was a JMO in theroom. If you have access to them, find out what they actually are thinking and involvethem. They may surprise you. If they complain or raise issues –make them part of theteam to fix it, even better make them lead the team with your backing. Eg Rosteringworking groups22

JMOs are a widely untapped resource for quality change and innovation. We areconstantly being chided for our lack of interprofessionalism and encouraged to workbetter and more closely with other staff. Shouldn’t the same hold true at a healthsystem level? JMOs working with Unit Managers and Directors of Education, collegerepresentatives, medical education officers, medical superintendents. The goals arecommon, so the tracks should stop running in parallel and start to converge.23

Thanks Lucy. In pursuing their projects, the JMO Forum members are learning leadershipskills, communication skills, professional practice skills. NSW Health runs a number ofleadership programs for clinicians, but I think the JMO Forum is one of the bestleadership programs yet devised. They are learning how the health system works andhow it can be to positively influenced. As they learn, they are helping to build the futurestrength of education and training in health. This works because the system has25

1 Made space for trainees to talk2 Given permission for trainees to act3 Adopted an expectation that trainee representatives will be trainee activists.Are there risks associated with this process?26

‐ Risk of revolution? Will trainees forget who is in charge? Not likely.Endorsement and support by senior clinicians tends to be one of the first things traineesseek for their projects, as it is essential if they are going to get past square one.Rather than revolution, I wonder about the opposite risk ‐‐ that if we don't encouragetrainees to innovate, initiate and lead, we may develop a medical workforce that is toopassive in the face of accelerating change, and not sufficiently adapted to the idea thatthey have to make things better for themselves and their patients through their owninitiatives.27

‐ Risk of patient harm? We haven't seen this ‐ most education and training projects areone or two steps removed from patient care, leaving plenty of room for review by seniorclinicians before there could be any unintended negative consequences.28

‐ The biggest risk that I have seen with trainee‐led initiatives is that there will beinadvertent miscommunication, because trainees are not fully aware of thelabyrinthine depths of the system in which they work, and they are not practiseddiplomats. Wording, timing, tone and address all matter.‐ There is a risk that JMOs will put people offside because they have not used the rightchannel or the right language, or kissed the right hand. There is sometimes a role forpeople (like me, and the Chair of the Prevocational Training Council, and directors oftraining) in providing an interpreter service that helps translate between the systemand the JMOs, so that their big ideas are not misconstrued or lost.29

So, if there is time, here are my three final tips:Subtle differences in organisation and expectations can lead toprofoundly different outcomes. For example, two years ago the thenchair of the JMO Forum reorganised the forum into working groups,each one with a specific focus and a project to complete within theyear. This created an expectation on every forum member that theywould get something done at the meetings, not just meet and talk.What has resulted has been a flowering of trainee creativity.Committees with trainee representation need to expect traineeactivism: don’t just ‘tick the box’ by having some trainees show up tothe committee; raise the expectation that trainees will be activemembers. Give them jobs to do, don’t just ask them to be there. Thismakes being on the committee so much more worthwhile that itmakes it much easier to get trainee involvement.Build links between trainees and higher levels of the system: In NSW,CETI advertises the existence of the JMO Forum to other NSW Healthorganisations as a resource that can help solve problems they areworking on. It can really work well to link the trainee representatives30

to the higher‐level change agencies in the system. This union of shopfloor and boardroom can make proposed changes more realistic andincrease stakeholder engagement.30