Self assessment and laboratory training

Dear Colleague,

Following the Trainers and Trainees meeting I have given further thought to the issue of a taught programme. The main aim of this programme was to prepare trainees for the self-assessment questions. Observations from the RITA suggested that reflective writing in relation to learning events were not truly reflective. They were mainly a regurgitation of the "knowledge" base with little critical appraisal of the evidence or any national guidance that may have been quoted. This makes undertaking the RITAs difficult. Despite these anxieties it is important that I stick to the principle of adult self directed learning and also make sure that I do not leave an albatross for my successors neck. Hence:

1. I have appended a set of 4 self-assessment essays to guide your self-directed learning. You can direct your learning individually or indeed discuss your answers with your peers or trainers. Also included is an optional essay which you can submitt to myself and Richard Quinton (one HARD copy to each of us) before 2nd February 2008. The winner will be notified at their post-RITA review meeting and the prize will be formally handed to them at the T&T meeting in June 2008. This is good for the CV.

2. I have appended a document providing guidance on laboratory training.

3. In next years RITAs the panels will be marking the reflective cases/writing much harder looking for critical appraisal skills, etc.

4. Given time issues I have abandoned the proposal of circulating self-assessment MCQs.

Kindest of regards,
Shaz.
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Self Assessment Essay Questions

Essay 1

A 55 year-old man with a history of paroxysmal AF treated with amiodarone for the last year is referred to you with the following TFTs, TSH less than 0.01 mU/l; fT4 56pmol/l; fT3 22pmol/l. He is thyrotoxic on examination. In no more than 500 words discuss how you would manage him.

A 25 year old woman presents with lethargy, change of voice and leg cramps. Her biochemistry is TSH= 206mU/l, FT4=6pmol/l, FT3=3.7pmol/l. What is the diagnosis, how are you going to treat her? Explain the FT4 and FT3 levels. What information does this patient need to know about her prognosis and ongoing treatment? Restrict your answers to no more than 500 words.

Essay 2

A 32 year-old man with a past history of hypertension treated with bendrofluazide is referred to you by his GP to rule out an endocrine cause. The GP does not think the patient is cushingoid and has already undertaken 2 24-hour urine cortisol measurements which were normal. In no more than 1000 words, discuss adrenal hypertension in relation to this case.

Essay 3

A GP has been struggling with the diabetic control of a 56 year old Caucasian man with Type 2 DM for 5 years, HbA1c 9%, BMI 32 kg/m², waist circumference 96 cm, well controlled BP and lipids. He is on top dose Metformin, gliclazide and was intolerant of rosiglitazone. Orlistat has been ineffective. The GP was wondering what therapeutic options are or would be available for this patient. In no more than 1000 words, discuss novel therapies for the treatment of Type 2 Diabetes in relation to this patient.

Essay 4

A 32 year old woman with a five history of Type 1 DM, background retinopathy and poor hospital attendance attends out-patients following a GP referral because of an eGFR of 29. The GP has advised her she has stage 4 kidney failure and she is very worried. Her HbA1c is 8.5% on bd Novomix 30, LDL-cholesterol is 3.2 and BP is 134/84 mmHg. Her GP advises you these results are typical of her repeat measures over the last year and her creatinine has varied between 120 and 140 micromole/l in the last 18-months. No urine results are available. In no more than 1000 words, discuss how you would manage this lady.

PRIZE ESSAY-If you wish to apply for the best Essay prize for the year submit this essay. In no more than 1000 words, describe the management of patients receiving chronic glucocorticoid replacement therapy, in relation to the available published data and reflect upon any ongoing controversies in the accepted “best practice” for monitoring therapy.

Laboratory Training

To function effectively as a Consultant specialising in Diabetes & Endocrinology it is essential that trainees experience training in laboratory medicine. The curriculum is a little “fuzzy” on this issue, hence the need for this guidance. A number of training units already provide multidisciplinary opportunities to interact with a biochemist, but it is important to arrange exposure to laboratory medicine during each unit attachment backed up by background reading. It is important to cover the following topics:

HbA1c assay measurement, cv, standardisation

Glucose measurements in the lab and meters with causes of errors

Hormone assay methods – Immunometric, RIA, ELISA, Chromatography; Reasons for variability and errors, e.g. hook effect, protein binding

Pitfalls in autoAb measuring, e.g. TBII, thyroid, adrenal

Pitfalls in measuring or assessing the following hormones or endocrine axis – TSH, fT4, fT4, thyroglobulin, total thyroid hormones; Prolactin; Cortisol, ACTH; PTH, calcitonin, calcium, vitamin D; Water & electrolyte handling; electrolytes, osmolality, ADH; GH, IGF1; LH, FSH, Testosterone, SHBG, E2; Renin, aldosterone, PRA; Catecholamines

Out of Programme Experience/Research

Dear Colleague,

I have forwarded some important information regarding Out of Programme
Experience/Research. Any proposed experienec/research abroad needs
careful planning with atleast 6-month notice to myself.

Regards,
Shaz.

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25 May 2007

Letter to all Programme Directors and STC Chairs


Dear Colleagues

Re: PMETB prospective approval of time spent out of programme

PMETB have recently changed their regulations surrounding out of programme experience. From 1 January 2007, all training outside the UK, which is to be part of a rotational programme, and count towards the award of a CCT, will require prospective approval from PMETB.

Background
The legislation establishing PMETB makes it clear that PMETB may approve training outside the UK towards the award of a CCT. To count towards CCT training, the post must be part of an approved CCT specialty training programme, be supervised, and have prospective PMETB approval. These regulations are a change to the current process so the following information will give advice on the process of approval, should a trainee wish to apply for prospective approval to have time spent out of programme count towards their CCT date.

If a trainee has received prospective approval for the out of programme experience (OOPE) / research (OOPR) from the College / Faculty or the deanery prior to 31 December 2006, then this approval will be honoured. If trainees have received retrospective approval for the out of programme experience prior to 31 December 2006, this approval will be honoured. PMETB may seek verification of this when the trainee applies for their CCT.

From 1 January 2007, to prospectively approve a post outside the UK
PMETB have said that they will prospectively approve, towards a CCT, training outside the UK in the following circumstances:

• On receipt of a formal application for approval from a deanery for inclusion in a CCT training programme.
• Inclusion of the post in a training programme which has the explicit support of the relevant royal college representative(s). Local college representatives must act according to the national policy of their respective royal college and should seek advice from the college where necessary to ensure consistency of standards across the UK.
• The application describes the process the deanery used to select the post/programme.
• The dean confirms that the training meets PMETB standards.
• The dean confirms that the post is subject to similar deanery-managed quality control processes as UK posts.
• If the quality control processes are different, the deanery provides a description with the application.
• For training in another EEA Member State, the Dean confirms that the post is approved for training in that specialty by that Member State confirmed by a statement/certificate from the relevant European member states’ competent authority.

Transitional arrangements
PMETB issued some further guidance on 16 April 2007 which has extended the time for transitional arrangements. All retrospective recognition of previous overseas training or retrospective recognition for OOPEs / OOPRs that did not receive prospective approval from the Colleges / Faculties will be stopping on 31 July 2007.

If there are any trainees that you are aware of that are currently out of programme and did not seek prospective approval for their OOPE / OOPR, prior to 31 December 2006, they are advised to contact their College / Faculty to seek clarification as to their processes for seeking retrospective recognition.

There will be some doctors who have applied for SpR training programmes with overseas training at basic, and some at higher specialist training level, who have the required entry criteria. Some may have been granted approval for these posts by the relevant College or Faculty but if they have not been appointed to a Specialist Registrar programme by 1 January 2007 and not been given retrospective approval by 31 July 2007 for this training, then these posts cannot be credited towards the award of a CCT. If this happened in the future then such doctors may be eligible for specialist registration at the end of their training through the Article 14 route but could not be awarded a CCT because they have not completed a full UK specialty training programme in PMETB approved posts and programmes.

For the award of a CCT
So that PMETB can decide whether to award a CCT it will require evidence of successful completion of the entire specialist training programme when it undertakes its usual checks on an application. PMETB will require evidence of the date of appointment to the CCT programme. Trainees who have undertaken prospectively approved overseas training as part of their CCT programme will need to be able to provide the necessary evidence demonstrating progression in their training such as trainers’ reports, assessments etc., the same as for those in UK training.

Northern Deanery arrangements
An information sheet detailing the Northern Deanery process for seeking approval from PMETB is attached at appendix 1.

Timeframe
We will add this information to the PIMD website and trainees will be able to download details of the process. As we are unsure of the length of time that PMETB require to approve each application we would urge you and your trainees to start this process well in advance of the proposed out of programme experience / research. We would advise trainees to start this process at least 6 months before they plan to leave the programme.

Out of programme for research
In addition, PMETB have issued guidance on OOPR. The time spent out of programme will be recognised towards the award of a CCT, when the approved curriculum includes research as an optional element. If research is part of the PMETB approved CCT curriculum requirements, the run through training programme should reflect this. Therefore, if research is in a programme, which should be based on an approved curriculum, then trainees may undertake this research and no further approval need be sought from PMETB.

If research is part of the PMETB approved CCT curriculum requirements, but the run through training programme does not offer the possibility of a period of research, prospective approval for individual OOPR posts should be sought from PMETB by the postgraduate deanery. This process is similar to the OOPE process outlined above:

• A formal covering letter from the deanery to PMETB seeking prospective approval of the OOPR post and confirming that this post has deanery support. PMETB cannot accept applications from individual trainees or Colleges/ SACs / Faculties.
• Confirmation that the OOPR post has the explicit written support of the relevant royal medical college representative(s). Local college representatives must act in accordance with the national policy of their college and should seek advice where necessary from their college to ensure consistent standards across the UK
• A statement from the competent authority in the country where the OOPR will take place which details the purpose and structure of the post to the satisfaction of the Deanery and the College.
• If the documentation outlined in point 3 above is not provided, then a brief description of the OOPR post which covers the following points: a) where the OOPR is based, b) the structure of the OOPR, c) the educational goals and characteristics of the OOPR, and d) confirmation that the post is subject to quality management in line with PMETB requirements.

What if research is not a requirement of the curriculum?
If a period of research is not a requirement of the approved CCT curriculum, but trainees still wish to undertake it, it is still possible to do so as out of programme experience. This is permissible provided that it has the approval of the postgraduate dean. Time in these posts will not be counted towards the award of a CCT, however, and therefore such posts do not need PMETB approval.

Further information
Links to their full guidance can be found in appendix 1.

If you have received applications from trainees recently for support for an out of programme experience you must alert them to these new processes. These are significant changes to the way out of programme experience is currently approved and no doubt the exact process will become clearer once we have undertaken the first few applications. If you have any questions about this process, please contact Sarah Beecroft sarah.beecroft@ncl.ac.uk.

Yours sincerely

D G Smith
Acting postgraduate Dean

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Out of Programme Experience (OOPE)/ Out of Programme Research (OOPR) Procedure
Should a trainee be considering time spent out of programme they must discuss this with their training programme director to ensure that the proposed post meets the educational needs of the trainee.

PMETB have introduced new regulations surrounding OOPE/OOPR from 1 January 2007, therefore, once a post has been applied for and offered to the trainee, the trainee must inform the Northern Deanery so that a prospective approval application can be made to PMETB.

It is recommended that this process is started 6 months prior to the proposed OOPE/OOPR. The trainee must submit an application for OOPE/OOPR to the Specialty Programme Coordinator (please see website for contact details) for their specialty. If the following information is not included in the Deanery OOPE/OOPR form the trainee must submit:

1. An up to date CV
2. Offer letter for the OOPE/OOPR
3. Letter of support from the Programme Director
4. Educational contract or details of the research project
5. Timetable (for OOPE only)
6. Name of supervisor for the OOPE/OOPR
7. Confirmation that the OOPE/OOPR post has the explicit written support of the relevant royal medical college representative(s).
8. A statement from the competent authority in the country where the OOPE/OOPR will take place which details the purpose and structure of the post to the satisfaction of the Deanery and the College.

• If the trainee is unable to obtain requirement 8, they must submit a brief description of the OOPE/OOPR post which covers the following points: a) where the OOPE/OOPR is based, b) the structure of the OOPE/OOPR, c) the educational goals and characteristics of the OOPE/OOPR, and d) confirmation that the post is subject to quality management in line with PMETB requirements.
  

It is the responsibility of the trainee to ensure full supporting documentation is sent to the deanery.

Once a complete application is received this will be submitted to the Postgraduate Dean for approval. The Postgraduate Dean will seek prospective approval of the OOPE/OOPR from PMETB and will confirm that the post has Deanery support.

Once the post has received approval from PMETB the trainee will receive confirmation from the Specialty Programme Coordinator, usually via email. This will be copied to the Deanery Human Resources Department, who will write to you informing you of Deanery approval and HR arrangements; they will also inform the Trust and the Programme Director that the trainees’ application for OOPE/OOPR has been successful.

It will be the trainees’ responsibility to inform their Royal College/Faculty of PMETB approval.

PMETB are insistent that applications must come from the Deanery. This is to maintain consistency with PMETB policy for holding the Deaneries responsible for local level quality management of education and training.

Trainees are therefore advised to liaise with their Specialty Programme Coordinator to co-ordinate their applications for approval.

Should applications be made to the deanery Human Resources Department, they will refer the trainee to the Specialty Training Team, so that PMETB approval can be sought.

Retrospective approval for the OOPE / OOPR is essential after completion of the time out of programme, demonstrating evidence of completion of the expected competencies.

Full details of the PMETB guidance can be found on their website:

OOPE: http://www.pmetb.org.uk/fileadmin/user/Policy/Policy_Statements/Prospective_approval_of_overseas_posts_-_Guidance_2_Oct_06.pdf

OOPR: http://www.pmetb.org.uk/fileadmin/user/QA/Post_and_programme_approval/PMETB_guidance_on_research_approval.pdf

Specialty Training Team April 2007

APPLICATION FOR OUT OF PROGRAMME EXPERIENCE (OOPE)/OUT OF PROGRAMME RESEARCH (OOPR)

PERSONAL DETAILS

NAME: ______________________________________________

SPECIALTY: ______________________________________________

HOSPITAL: _______________________________________________

(At time of Leave)

CCT DATE: ___________________

PROPOSED OOPE/OOPR DETAILS

POST/RESEARCH:

____________________________________________________________

________________________________________________________________________________________________________________________

AIMS AND OBJECTIVES OF TIME OUT:

____________________________________________________________

________________________________________________________________________________________________________________________

OOPE/OOPR is funded by_______________________________________

Correspondence address whilst on OOPE/OOPR, including emails/phone number ____________________________________________________________

____________________________________________________________

PROPOSED DATES:

From: _________________________To:_______________________

CONSULTANT SUPERVISOR (Prior to Leave):

Name: _____________________________________________________

ROYAL COLLEGE APPROVAL

Training Approval has been granted by the Royal College/Faculty of __________________________________

Yes/No (Please delete as applicable)

Please indicate the amount of time, which has been approved towards your CCT:

Years: ____________ Months: ___________

My CCT date will not/will be deferred by ____________ years / months

The new CCT date will approximately be ______________________

The minimum requirement here is three months must count towards your CCT date / training (only exception being Nephrology and Gastroenterology). Approval will only be granted by the Postgraduate Dean if this is stipulated clearly in the letter of support from the Royal College or STC Chair.

PROGRAMME DIRECTOR APPROVAL

Please note this OOPE/OOPR Application Form will not be approved without your Speciality Programme Directors Signature below:

Programme Director Name: ____________________________________

Please confirm that the OOPE/OOPR is relevant to this trainee’s level of training and experience and will provide training specified in the curriculum relating to: ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

______________________________________________________________________________________________________________________________________________________

Programme Director Signature: __________________ Date: ______

Trainees: UK and overseas

I understand, in order to return to the rotation, that I will require full medical and employment clearances

Trainees Signature: ___________________________ Date: _____

PLEASE RETURN THIS FORM TO YOUR SPECIALTY PROGRAMME COORDINATOR AT THE PIMD

Insulin Infusion Pump Course: 29 - 30 Nov 2007

INSULIN INFUSION PUMP COURSE

Thursday 29 and Friday 30 November 2007

Academic Centre, The James Cook University Hospital,
Marton Road, Middlesbrough, TS4 3BW
www.conferencessouthtees.co.uk

An essential two-day programme for medical staff working with Insulin Infusion Pumps. The course offers the opportunity of a ‘practical hands on approach’ to using Insulin Infusion Pumps with topics including:
Starting insulin infusion pumps ¬ patient experiences on pump therapy ¬ carbohydrate counting ¬ rationale and evidence base for pump therapy ¬ basal and bolus rates ¬ paediatrics ¬ special situations ¬ hypoglycaemia/ hyperglycaemia/ sick day rules and inpatient care

A conference dinner will form part of the learning about estimation of carbohydrate intake which we encourage all members to attend and is included in the delegate fee.

Course fee: £225 per delegate

To register for the Insulin Infusion Pump Course, please complete the following and return to the address below:

Title……… First Name……………………Last Name…………………………………..….

Job title .....……………………………….... Hospital …..……………..……………..………

Address for correspondence ....…………………………………………..…………………...

………………………………………......………………………….............................................

Email………………………………............. Telephone…………………………………….

¨ I enclose a cheque for £225 payable to ‘South Tees Hospitals NHS Trust’

¨ I wish to be invoiced please state address……………………………………………….

…………………………………………………………………….............................................

Conferences and Courses Department
Academic Centre, The James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW Telephone: 01642 282534, Email: nicky.skippon@stees.nhs.uk