Higher specialty training in genitourinary medicine: A curriculum competencies-based approach

Introduction

Completion of higher specialty training in genitourinary medicine (GUM) is assessed against criteria defined in the Specialty Training Curriculum for Genitourinary Medicine in the United Kingdom. An updated curriculum was implemented in December 2016. This evaluation was based on the previous curriculum which was implemented in August 2010, ¹ and is hereafter referred to as the GUM curriculum.

The departments of Sexual Health and HIV Medicine at Guy’s and St Thomas’ NHS Foundation Trust (GSTFT), London, UK are responsible for providing GUM training that assists specialty trainees (StRs) in successfully meeting the requirements of the curriculum. Those requirements include competency in the management of genitourinary pathology such as genital ulcers, infestations and dermatoses, as well as the management of human immunodeficiency virus (HIV), and the provision of contraception.

The departments are jointly commissioned to provide GMC-approved higher specialty training for seven StRs. The clinics are based in the borough of Lambeth, which has the highest diagnosis rate for HIV, syphilis and gonorrhoea and one of the highest under 18 conception rates in London. ² They provide GUM outpatient services to over 55,000 patients per year and outpatient and inpatient HIV services to around 3500 patients. However, the pressure to deliver care with limited NHS resources can sometimes negatively impact on training, and this is a key challenge to address.

Prior to the introduction of the modular training programme, interventions to protect delivery of trainee education over service provision included:

Controlling the patient demand for walk-in services aiming to meet key performance indicators such as the 48-hour wait target. ³

Despite these changes, the annual GMC trainee feedback in March 2013 was poor with the department scoring red in two areas. A review of StR training was undertaken with the aim of ensuring that trainees had access to training opportunities identified in the curriculum and to improve their educational experience. A formalised approach to training delivery, by way of the GUM Registrar Training Streams (RTS)/modular training programme (Desai, M. The Clinicians’ Roster: Recommendations for Current and Future Considerations. Unpublished source 2014) (Table 1), was implemented on 10 December 2013. It divided the curriculum competencies into seven training modules to allow the StRs to rotate through each module. Trainees were involved in the development of the programme. Three HIV modules each of six month’s duration and four sexual health modules each of three month’s duration were designed. Apart from the six-month HIV inpatient module, trainees are encouraged to do mainly sexual health modules in ST3 and ST4 (the first two years of specialty training). This is to facilitate preparation for the Diploma in Genitourinary Medicine (London Society of Apothecaries) which trainees are expected to achieve by the end of ST4.

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Table 1.

Description of the seven streams in the Registrar Training Streams (RTS) programme.

Stream/clinical opportunities	Comments
Common components	Apply to all streams
Out-of-hours on-calls	1:7 on-calls evening and weekends for HIV wards and GUM in-patients
Common components	Apply to streams 2–7 only
Emergency HIV clinics	Five clinics distributed among all available StRs
General sexual health clinics	Mandatory Allocated to each StR such that he/she undertakes the equivalent of 7 clinical sessions per week
General HIV clinic	Mandatory one clinic per week
Stream 1 (HIV ward registrar)	6 months
HIV wards	Mandatory 3 months
Post-discharge clinic
Stream 2 (HIV registrar)	6 months
Specialist chest clinic	Supernumerary StR
HIV research clinic
Specialist young adult’s clinic	Supernumerary StR
Stream 3 (HIV registrar)	6 months
Antenatal HIV clinic	Supernumerary StR except when lead consultant is on leave
Hepatitis/HIV specialist co-infection clinic	Third to fifth calendar weeks Supernumerary StR
Specialist HIV treatment advice clinic	Third to fifth calendar week Supernumerary StR
HIV Neurocognitive assessment clinic	First and second calendar weeks Supernumerary StR
Stream 4 (SH registrar)	3 months
Gynaecology training	Mandatory Each component can be undertaken during the same 3-month period StR is essentially supernumerary as they do not provide a service
Pathology/laboratory training
Stream 5 (SH registrar)	3 months
Long-acting reversible contraception training clinic	Mandatory Supernumerary StR
Contraception clinic
Stream 6 (SH registrar)	3 months
Specialist gay men’s clinic	Supernumerary StR
Syphilis clinic	Mandatory
Stream 7 (SH registrar)	3 months
Genital dermatology clinic	Mandatory Supernumerary StR
Specialist complex female sexual health clinic	Supernumerary StR

HIV: human immunodeficiency virus; StR: specialty trainee; SH: sexual health.

Note: All StRs undertake out-of-hours duties for HIV wards and emergency referrals to HIV and Sexual Health; Each stream is undertaken for a maximum of six months, except when gynaecology training and laboratory/pathology training have been successfully completed in the same three-month period; StRs can undertake the equivalent of one specialist clinic for 12 months in the final year to develop a specialist interest.

The aim of the RTS was to assure equality of clinical opportunities for StRs to:

Complete core competencies of the GUM Curriculum in a timely manner in relation to expectations of the Annual Review of Competence Progression.

Methods

In 2015, a purposive sample of StRs and trainers were consulted about the utility of available clinical opportunities in attaining curriculum competencies. The trainers’ perspectives were obtained from two faculty members, including an educational supervisor. After excluding trainees who had undertaken less than three months of the RTS programme, or were on long-term/maternity leave, six StRs were sampled. Each of the competencies in the genitourinary medicine 2010 curriculum has four levels of attainment called level descriptors. Trainees must achieve all four levels to be certified as competent in that area of the curriculum. An example of this is displayed in Table 2.

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Table 2.

The four levels of attainment for the valid consent competency¹.

Level descriptor
1	Understands that consent should be sought ideally by the person undertaking a procedure and if not by someone competent to undertake the procedure.Understand consent as a process.Ensures always to check for consent for the most simple and non-invasive processes – e.g. history taking. Understands the concept of ‘implicit consent’.Obtains consent for straightforward treatments that he/she is competent to undertake with appropriate regard for patient's autonomy.
2	Able to explain complex treatments meaningfully in layman's terms and thereby to obtain appropriate consent.Responds appropriately when a patient declines consent even when the procedure would on balance of probability benefit the patient.
3	Obtains consent in ‘grey-area’ situations where the best option for the patient is not clear.
4	Obtains consent in all situations even when there are problems of communication and capacity.

The two faculty members reviewed the four level descriptors for each competence, upon which they agreed the ‘usefulness’ conferred by the quantity and quality of the learning provided by the overall programme or each specific clinical opportunity. Data were gathered using a 44 × 18 matrix to provide the ‘expected usefulness’ of the overall programme and the 18 individual clinical opportunities in attaining each of the 44 competencies. A section of the matrix is shown in Table 3.

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Table 3.

Sample of 44 × 18 matrix (two competencies are displayed) where usefulness is quantified using a Likert-type scale.

Sexual health competency	General GUM	AFC	FRC	GD	LARC	WR	Lab	Syphilis	Gynae	EC	ANC	TB	YAC	HIV wards	CTU	Hep	TAC	General HIV	Median score
1. Sexual and medical history	4	4	4	4	3	4	2	3	3	2	3	2	3	2	2	3	3	3	3
2. Ethical research	3	3	2	1	2	3	2	3	2	1	3	2	3	2	4	2	3	4	2.5

Note: 0 = not at all useful, 1= slightly useful, 2= quite useful, 3= very useful, 4= extremely useful.

AFC: after five clinic (LGBT clinic); FRC: female referral clinic; GD: genital dermatology clinic; LARC: long acting reversible contraception clinic, WR: Walworth Road community sexual health clinic; Lab: laboratory; Gynae: gynaecology; EC: HIV emergency clinic; ANC: HIV antenatal clinic, TB: HIV/tuberculosis clinic; YAC: HIV young adult clinic; CTU: HIV clinical trials unit; hep: Hepatitis clinic; TAC: treatment advice clinic; HIV: human immunodeficiency virus; LGBT: lesbian, gay, bisexual, and transgender.

The StRs were also asked to rate the usefulness of the overall programme in attaining each of the 44 competencies. Usefulness was quantified using a Likert-type scale: 0 = not at all useful, 1= slightly useful, 2= quite useful, 3 = very useful and 4 = extremely useful. The median was calculated for the usefulness of the overall programme for each competency. They were asked to complete a semi-structured, electronically-administered survey (Google® forms).

For each competence, the ratings of the trainers and trainees were compared. Where both groups rated the usefulness of the overall RTS programme as ≥3 (very useful), the conclusion was that the programme is ‘sufficiently useful’ for meeting that competence. Where a lone group or both groups attributed a rating <3, this identified curriculum competencies for which the programme is ‘insufficiently useful’.

Where fewer than 50% of clinical opportunities were rated as at least very useful in meeting a specific competency, a qualitative review was undertaken to determine those clinical opportunities that would be considered as ‘critical’ for attaining specific competencies. Content analysis of the StR responses was undertaken in the semi-structured survey, which coded responses as being supportive or non-supportive of a given clinical opportunity. The net weighting of supportive versus non-supportive comments was triangulated against the faculty’s view of a clinical opportunity expectation to be ‘critical’. This was used to categorise the quality of learning offered by each clinical opportunity as ‘high’ or ‘low’.

The annual GMC survey was completed by all trainees in the department and allowed trainee satisfaction to be measured to a national standard.

Results

Six StRs represented the experienced curriculum perspective, providing a 100% response rate. The cumulative duration of higher specialist training was 15 completed years with a median of 3 completed years per StR (range: 1–3 years). Data gathered using the 44 × 18 matrix provided the ‘expected usefulness’ of the overall programme and the 18 individual clinical opportunities in attaining the 44 competencies. Table 3 gives an example of two of the curriculum competencies, and how scoring of the existing clinical opportunities helps demonstrate their usefulness in achieving these competencies. For example, based on median scores given by the StRs, the available clinical opportunities were very useful in achieving the sexual and medical history curriculum component, but only ‘quite useful’ in achieving the ethical research curriculum component. On triangulation of these scores with the qualitative review and the trainer review, it was determined that achieving the descriptors for the ethical research curriculum component would need to be done through non-clinical opportunities, e.g. active involvement in a research project and formal courses or informal study. As a result of this finding, routine cover of the research clinics by StRs was removed from the RTS programme.

GMC survey

Prior to the implementation of RTS, the GMC training survey score in 2013 was poor with one green (highest quartile scoring) and two red flags (lowest quartile scoring). Since the introduction of the RTS, we have seen a steady improvement in the score: two green in 2014, six green in 2015 and nine green in 2016 (Figure 1). In the 2015 GMC survey, GUM training at GSTFT gained the highest number of green flags gained by any GUM training programme in London and the South East. Aspects of training that were rated as excellent included clinical supervision, induction, experience, workload and educational supervision.

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Figure 1.

Summary of GMC training survey results in relation to introduction of RTS. GMC: General Medical Council; RTS: Registrar Training Streams.

Discussion

The results highlight that delivering a training programme that focuses on meeting competencies appears to significantly enhance trainee satisfaction on a background of rising clinical activity and a changing service delivery model.

The results support formalisation of non-clinical training opportunities to attain certain curriculum competencies (e.g. research and management). Time and resources for these could be achieved by reviewing non-mandatory clinical opportunities. For mandatory training requirements deemed to be of low quality, efforts should focus on defining a clinical opportunity that would better meet the needs of StRs.

The results of the 2016 GMC survey demonstrate that this programme has achieved excellence in postgraduate medical education training for trainee satisfaction. Overall, the curriculum competencies-based approach to training offers a focused and objective approach to resolve the conflict of training and service provision.

Limitations

Only six StRs were included in this analysis. We may have underrepresented negative views, as our study did not take into consideration the views of all the trainers. We recommend that if this model is used, it should be followed by a focus group to discuss findings and recommendations.

It is noteworthy that trainee satisfaction occurred in the setting of increasing clinical pressures within the services including rising clinical activity and changes in clinical service delivery with real-time consultant support and improved nurse delivered models in both the GUM and HIV departments.

We have shown that despite increasing patient activity, implementing a training programme that focuses on delivering curriculum competencies and maximising efficiency of learning opportunities appears to improve training and increase trainee satisfaction. We propose that the curriculum competencies-based approach to training is a valuable approach that could be equally suitable for other post graduate medical education training programmes.