CETI’s principles of network training and prevocational network reform

1. My name is Craig Bingham, and I support the Prevocational Training Council of NSW as
the Program Coordinator. I am going to present some information about the current
state of the training program and then I’m going to hand over to Ros who will outline
some of our future plans.
Like other programs in Australia, CETI’s prevocational program is growing rapidly to take
in the increasing number of medical graduates. You have already heard from Claire
Blizard about the amazing number of new training positions that have been accredited
this year.
As many of you already know because you participated in the process, last year CETI
commissioned an external review of the prevocational program. The review team did a
great job, and it provided us with a report that has guided our thinking about the best
way forward.
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2. The external review panel found “an extraordinary level of commitment of individuals
and institutions at all levels to prevocational training.”
The panel then made recommendations for how we might get even more out of juice
out of the orange. Broadly, it recommended that we develop a clearer model of what we
were teaching in the prevocational program and how we were teaching it, tying that
model to the Australian Curriculum Framework for Junior Doctors and to an improved
assessment process.
It also made recommendations towards rejuvenating the networked system of training
to ensure that governance was transparent, that all stakeholders were engaged, that
funding flowed smoothly and that access to training opportunities in NSW was
equitable.
In response to the review, we are working on new models that Ros will present shortly.
I want to show you a snapshot of the system as it is, using data gathered from the
reports provided to CETI every half year by Directors of Prevocational Education and
Training.
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3. The DPET reports originated as funding and expenditure reports, but I think their more
useful role is the information they give us about how prevocational training is actually
proceeding at different sites across the state.
When I started as Program Coordinator at the end of 2008, reporting was about 50%.
We worked on improving the quality of the reporting template, tried to ask better
questions, prefilling the form where possible, chasing reports pretty hard, and closing
the feedback loop by reporting back to DPETs on what we found. With the goodwill of
DPETs and JMO Managers, this got reporting rates above 80%.
Recently, there have been a lot of changes keeping us all busy, with IMET moving into
CETI and the AHSs morphing into LHNs and then LHDs. I hope this is the reason for a
temporary blip in reporting, and that the reporting rate for Jan‐Jun 2011, reports being
collected now, will be back above 80%.
The data I’m going to show you now come from July 2009 to December 2010 (the light
green bars), and will be published in more detail soon.
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4. DPETs report trouble getting and using their prevocational training grant, but most
spend money anyway. Each financial year, expenditure equivalent to 80% of training
grants allocation is reported. This leaves 20% unaccounted for, which is not a good
result, and the accounting for the money that is spent is sometimes vague and difficult
to check.
Some of the problems in funding distribution and reporting are indicative of a more
general problem in the system.
In any event, the prevocational training grants are only a subsidy to the health districts,
which are expected to provide other funds for prevocational training, not least by paying
a DPET’s salary.
90% of DPETs report that their health service gives them funded time to perform their
duties — but this means that 10% do not.
80% report that their health service gives them funded administrative support, but only
11% report that an education support officer or DPET assistant is funded. This means
that most administrative support is provided by the JMO Management Unit. The
external review recommended that the role of the JMO Manager in prevocational
training should be more clearly defined, and this is something CETI is very happy to
explore in cooperation with health district administrations.
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5. So far the DPET reports have not answered the questions above, but I hope they will in
future, because it would be very useful in workforce planning to know more clearly what
trainee progression and retention is really like. For example, some sites appear to have
big troubles keeping PGY2s until the end of the year, but others have no problem at all. It
would be good to know more about this, which is why we have added these questions
to the reporting template.
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6. Frequency: The typical approach is one one‐hour lecture per week, plus term‐specific
teaching. Nearly as many sites report holding two or more sessions a week, sometimes
to give JMOs a choice of when to attend. Some DPETs organise distinct programs for
PGY1s and PGY2s; others, particularly at smaller sites, conduct a combined program.
About a third of DPETs report difficulties associated with delivering the education
program, such as: finding speakers, getting JMOs to attend, protecting the JMOs time for
attendance and finding time to plan the program.
Attendance: is generally high for PGY1s and falls away for PGY2s, but it is worth noting
that at many training sites attendance by PGY2s continues to be above 80%, which
suggests that in the right environment and with the right content, PGY2 trainees will
come.
A change over the last year is that an increasing number of DPETs are successfully using
the JMO Forum’s unified lecture series as a guide in the preparation of their education
programs. We will hear more about the lecture series later, from Ros and also from the
JMO Forum.
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7. All training sites are required to run continuous evaluation of their training terms using
feedback from JMOs, collected in term evaluation forms. The graphs show the response
rates reported by DPETs. At more than a third of sites, DPETs report that term
evaluations are completed by fewer than half the JMOs. On the other hand, nearly as
many DPETs report receiving term evaluations from more than 80% of JMOs, which
shows that it is possible to collect this information if the system is set up for it.
CETI hopes that in future we can move to a online system that collects both the JMOs’
performance assessments and their term evaluations. If we can collect good assessment
and evaluation data, and make these data available more rapidly and consistently to all
stakeholders, we will be in a better position to identify strong and weak points in the
state’s prevocational program.
CETI’s recommended term evaluation form is available at
www.ceti.nsw.gov.au/prevocational#trainers.
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8. Here I have listed most but not all DPET activities. They are busy people. Some wear out.

From July 2009 to December 2010, eight of 51 hospital DPETs retired and were replaced:
an annual turnover rate of 10%. We also had two new hospital sites appoint DPETs, and
this year, we have seven new general practice DPETs overseeing GP training terms.
Whenever a new DPET is appointed, CETI supplies them with a DPET guide, the
Superguide, the Trainee in Difficulty handbook, the ACF, the Doctor’s Compass, and
whatever else we can give them. The DPET guide is getting a bit old now, and a
thoroughly revised edition will appear before the end of the year.
Written advice is all very well, but yesterday evening we had a DPET induction session,
which was a chance for new DPETs to gather a bit of potted wisdom from their more
experienced colleagues. One of the important purposes of this Forum is to help connect
new DPETs to their colleagues in the prevocational program.
Because the DPET role is so important, CETI’s accreditation standards require that DPETs
undergo an annual performance review by their Director of Medical Services and the
General Clinical Training Committee. According to the DPET reports, only a bit more than
half are actually having an annual performance review.
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9. In all the activities listed above, the DPET reports record a tremendous amount of effort
and creativity by DPETs, JMO Managers, committee members, supervisors and trainees in
pursuit of improved education. But I think it is fair to say that the picture is highly
variable, with some sites and networks showing high levels of engagement, others less
so.
So, before I hand over to Ros, what do the DPET reports tell us about DPET attitudes to
the networked training system they work in? We asked DPETs for their response to some
key propositions in the July‐December 2010 reports. I only have data from 19
respondents, but I think it tells us something.
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10. Sixteen of nineteen DPETs agreed or strongly agreed that rotations through networks
enhance training opportunities, and three were neutral or had no opinion. So we have
strong support for the basic concept of network training.
And most DPETs surveyed, with a little bit of fence‐sitting but no disagreement, agreed
that general practice rotations and rural rotations were valuable in prevocational
training, which was also reassuring.
Then we have a series of propositions for which there is clear majority support, but
some minority dissent. Most think the network committee is an effective forum for
deciding issues that arise between training sites in the network, but a few did not.
Similarly with the idea that the education and welfare of trainees is coordinated at a
network level ...
... that it is clear in the network system who is managing each trainee...
... and that rotation of trainees takes into account the workforce needs of all.
When asked to consider whether the network model is effective across health service
boundaries, the most common response was neutral/no opinion, with nearly equal
numbers in agreement or disagreement. Most networks necessarily cross these
boundaries, so clearly we have to work harder at the communications with health
district executives to ensure that we have their support for the training networks.
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11. Opinion was pretty evenly divided too, on the statement “the network system works to
the advantage of the largest sites in the network”.
The statement “the network system works to the advantage of the smallest sites in the
network” was the only proposition which drew more disagreement than agreement. And
this is concerning, because one of the hopes of the network system is that it will help
develop the workforce and training capacity of smaller sites.
A closer look at the survey responses suggested a divide in attitudes between DPETs at
smaller sites and larger sites, with the smaller sites less likely to find the network
processes effective. Large sites tend to think the system favours smaller sites, but the
smaller sites don’t necessarily agree!
The prevocational training program is about developing good doctors for the benefit of
the State as a whole, and training networks are a sound approach to achieving that aim.
I’m going to hand over to Ros now, who will talk about how we plan to realise more of
the potential of networked training.
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12. So, what’s the picture? Generally, there are high levels of engagement by DPETs and JMO
Managers, demonstrated in a wide range of training and development activity on behalf of
prevocational trainees. But we’re not here to rest on our laurels. Where is the room for
improvement?
One: there are tensions within some networks that we would like to reduce.
Two: the external review found that implementation of the ACFJD is not strong. People are not
clear exactly what they are doing with it, and there is as yet no strong mapping of training to the
ACF, so we don’t really know how well we are covering the curriculum or where the gaps are.
Three: As we reported at this Forum last year, our current assessment process is not as effective
as we would like. It underreports underperformance, doesn’t provide enough specific feedback
to trainees to help them visualise what better performance would be, and doesn’t give us
enough information about strengths and weaknesses in the training program.
The Prevocational Training Council was very pleased to receive the external review report on the
program. We have taken its recommendations on board and developed a response that we hope
provides a blueprint for the future. It was a big review, and I can’t give you our detailed
response to every recommendation here. I want to concentrate on the major directions, which
can be described in two parts:
1. Developing a learning model for the program that integrates work, training and assessment
2. Tuning in the network model to deliver excellence in training
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13. A learning model should begin with some basic principles of adult learning, all of which
have direct implications for how we manage the prevocational program.
Adults are internally motivated and self‐directed. This means:
Trainees have primary responsibility for the direction and pace of their own learning.
The program facilitates ‐learning, but it is appropriate for trainees to manage many
aspects of their training personally.
The program should place the curriculum and all resources necessary to plan adequate
training into the hands of trainees as well as supervisors, directors of training and
administrators. Trainees and their organisations should play a role in structuring the
program. It is in pursuit of this principle that CETI supports the JMO Forum and
encourages it
Adults bring life experiences and knowledge to learning experiences
The previous experience and existing knowledge of trainees can be used to enrich
learning opportunities.
Teachers should take the time to establish what trainees already know as the starting
point for teaching.
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14. Trainees can play an important role as teachers themselves.
Adults are goal oriented, relevancy oriented and practical
Above all, this means that learning on‐the‐job is central to prevocational training.
Lectures should focus on the practical aspects of the subject, and opportunities for
teaching and learning have to be integrated into clinical practice at patient encounters,
ward rounds and ward handovers, and when clinical procedures are being performed.
Trainees are more motivated to learn when they see that the lesson will help them reach
their personal objectives.
Assessment should be meaningful and rewarding. The outcomes of successful learning
(including registration, and career progression) should be explicit. Advancement should
be linked to the achievement of goals.
The system’s goals for training (safety, efficiency, etc) need to be made relevant to
trainees.
Adult learners like to be respected
Trainees should be treated with the respect they are expected to show to others.
Trainees should be integrated into mutually supportive clinical teams.
Procedural fairness should be demonstrated in all decisions affecting trainees.
All learners benefit from feedback
Learners should expect feedback about their strengths and areas for improvement.
Providing feedback is necessary for developing confident and competent clinicians.
Providing feedback can ameliorate uncertainty and stress in trainees.
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15. It is also useful to think of the learning cycle as modelled by Kolb. Applied learning
requires trainee doctors to move through the complete cycle — they need to
conceptualise, experiment, do and review — but what is interesting is that different
people naturally pick different starting points in the cycle. Some are concrete thinkers,
and have to get their hands on first. Others like to start from reflective observation,
others prefer to begin with a text and abstract knowledge, and others are
experimenters.
The prevocational program has to provide resources and a safe framework to
accommodate all these learning styles.
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16. So, our model for learning in the prevocational program considers six modes of learning.
All of these are important, but the essential core, represented by the biggest segment, is
supervised clinical work.
Then we have term‐specific teaching, the network lecture series, simulation and
workshops, elearning and self‐directed learning.
Each of these learning modes is obviously interdependent, but they have specific
features which have to be managed and developed if we are to achieve the optimal
result.
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17. Points to make here:
The external review suggested that assessment needed to be better linked to work,
curriculum and learning outcomes. We are working on this, as some of you who
attended the assessment workshop yesterday will be aware.
Term objectives are yet to be comprehensively mapped to the ACFJD, and this is
something we need each training site to work on.
JMO Forum is working on the idea of a skills audit tool (something simpler than a
journal), designed to self‐record progress in clinical work.
We wrote the Superguide in part to encourage supervisors to make more use of the
teaching opportunities in their clinical day.
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18. We have no specific plans for reform of term specific teaching at this stage. It is a rich
source of learning for trainees.
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19. JMO Forum proposals for a unified lecture series chimed in nicely with the external
review’s recommendations for a more coordinated approach to education. The
Prevocational Training Council endorses the principles underlying the JMO Forum’s
proposal and has commended it to the networks – not necessarily for adoption outright,
but for consideration and inspiration. All networks should coordinate the lectures given
to prevocational trainees to ensure:
‐‐ that important topics are dealt with early
‐‐ that trainees do not miss lectures or duplicate lectures when they go on rotation.
How closely participation in lectures should be monitored is a difficult question.
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20. Simulation and workshops will be supported more strongly by CETI in future, through
the Centre for Teaching and Learning.
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21. eLearning is something on which CETI has made a rather slow start, but it is now much
more strongly resourced for this purpose.
Some of you attended the online learning workshop yesterday, and I hope to see CETI
taking a leading role in this mode of learning.
Employed correctly, online learning is a support and extension to other modes of
learning. It is seldom a replacement for supervised clinical experience, but it can lay the
groundwork for hands‐on experience, it can be enriching, and it can be fun. We need to
move beyond online learning as quizzes with a computer and start to embrace the
socially interactive and creative possibilities.
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22. In an important sense, all the learning that a trainee doctor undertakes is self‐directed,
but we mention it here as a separate mode of learning to acknowledge its importance
and to remind us all that the primary responsibility for learning rests with the individual
– we hope within a supportive environment.
DPETs have a role to assess the level of engagement that trainees are bringing to their
own education and to build a learning culture in the clinical environment that supports
lifelong learning.
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23. Now, if these elements can be thought of as combining to produce a learning model,
what sort of model is it, and what implications does it have for how we organise the
prevocational program?
One way of representing the model is as a learning spiral. Through spiralling over the
clinical ground through term after term, trainees acquire higher levels of learning.
Clinical judgement, professional behaviour and good communication become hardwired
through repeated and extended experience. As they repeat and extend their experience,
the number of entrustable professional activities – that is, clinical responsibilities that
they can perform independently – increases.
Each term imparts particular knowledge, skills and attitudes, but broadening clinical
judgement and integrating the spectrum of clinical competencies is largely achieved
through the accumulation of experience, reinforced and extended by the other learning
modes.
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24. Another way of visualising the learning model is as a partnership, with different
elements of learning managed by trainees, term supervisors, DPETs and training sites,
networks and CETI.
Because of its complexity, it has to be a cooperative and communicative system. I want
now to focus on the requirements as viewed at the training site and network level.
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25. No single facility can provide the full range of experiences required by prevocational
trainees, and facilities are organised into networks that cooperate to deliver training.
From an educational perspective, a network should be capable of delivering all the
elements of the learning model.
An ideal network, then, can deliver the curriculum of the ACF, provide sufficient core
terms, an appropriate mix of specialty terms and a range of clinical settings and patient
types. It needs supervisors who understand the importance of teaching, active
supervision and meaningful appraisal and assessment. The culture should be very
supportive of education and training.
Facilities require appropriate amenities, access to internet‐based learning, and
simulation facilities.
The benefit of training in both metro and rural settings, and large and small facilities is
largely understood, and the tyranny of distance is partly mitigated by a culture of
excellent cooperation between facilities, streamlining the number of health districts
involved and maintaining excellent links with vocational training programs.
Network governance principles which empower cooperative planning for the allocation,
education and training of trainees are essential.
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26. In relation to network governance, I want to introduce the consultation draft of new
terms of reference for network committees. The new terms of reference are more
explicit about the level of coordination and cooperation required in training networks.
They propose that the committee needs to negotiate explicit agreements between
network partners covering aspects of trainee management that have been contentious
in some networks.
Existing network committees are encouraged to consider and comment on these new
terms of reference, because we would like to implement them for next year.
We hope that this will eliminate some of the dissonance that occasionally mars the
smooth running of the program for the trainees.
The new principles and terms of reference have identified effective lines of reporting to
both CETI and the LHD, which could only improve executive sponsorship of the
prevocational training networks.
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27. While everyone involved in prevocational training is deeply committed to the best
outcome for our trainees, it is acknowledged that it requires considerable ingenuity to
achieve win: win for all trainees and facilities in a network. There are many examples of
how well this can be done.
We have tried to capture this in a transparent way: All trainees in the network should
have the same opportunity of access for allocation to specific terms.
We cannot assume that rural and regional recruited prevocational trainees will pursue a
generalist career — indeed, they may wish to pursue their vocational interest and then
return to regional specialist practice. This is a desirable outcome, and training networks
should facilitate this where possible. Recruitment to the regional facility is preferential,
but term allocation encourages equal opportunity. Of course, not all trainees can be
allocated to their first preferences. The way preferences are managed is up to the
Network, usually through flexible negotiating.
Leave management also requires an explicit understanding within the Network, both in
the management of planned and unplanned leave. A network accord about how leave
will be managed is best achieved before the completion of recruitment, to ensure that
sufficient baseline numbers are employed to meet all needs.
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28. The education and training program very clearly needs to be coordinated by the
Network. Having the same lecture over repeated terms at a secondment hospital is
almost as significant a waste of critical training time as missing major, core topics .
Detect, ALS and specific communication courses such as breaking bed news need to be
orchestrated by the network. Difficulties in local expertise can have several technological
solutions.
The welfare of all trainees must be a shared responsibility across the network, requiring
good communication and handover at all levels of prevocational support staff and
another routine agenda item for close attention at network meetings.
Working closely and cooperatively together at network level is the only way to deliver
the best training opportunities and workforce effectiveness.
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29. Summing up:
The external review recommended a more coherent approach to prevocational training,
and the Training Council agrees with this aim.
We do have a learning model, and we are working on improved implementation. We are
investigating assessment and self‐assessment to deliver better assessment forms and
processes. We are developing elearning and related online systems in assessment and
evaluation to support the good work that is being done in the networks. Producing
the Superguide was a step forward, and we intend, as well as continuing to promote
Teaching on the Run, to use the Superguide as the text behind workshops in
supervisor training. CETI also now has dedicated staff and funding for the
development of simulation training.
So we think CETI and the networks can deliver all the elements of the learning model.
Some networks are currently missing elements (eg, no network lecture series, no rural
terms or no GP terms). We hope networks will “self‐review” and (with CETI’s help)
work to gain some of these desirable elements.
Some network relations and governance can be improved, enhancing cooperation to
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30. deliver better individual training opportunities. To this end, we are developing new
principles of network training and new terms of reference for network committees
that we want networks to consider.
The new terms of reference are more explicit about the level of coordination and
cooperation required in training networks. A consultation draft will be coming to you
soon.
‐ We hope that the new terms of reference will provide grounds for agreement and help
to overcome some of the dissonance in the system. I think it is reasonable to hope
that we will make good speed on the road ahead. Thank you.
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