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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. 




                                                                                             1
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. 




                                                                                         2
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.




                                                                                            3
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.




                                                                                               4
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.




                                                                                               5
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. 




                                                                                            6
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.




                                                                                              7
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. 




                                                                                             8
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.




                                                                                             8
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.




                                                                                           9
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.




                                                                                            9
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




                                                                                                       10
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. 




                                                                                            11
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.




                                                                                             11
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.




                                                                                             12
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.




                                                                                              13
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.




                                                                                     14
We have no specific plans for reform of term specific teaching at this stage. It is a rich 
source of learning for trainees.




                                                                                              15
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.  




                                                                                            16
Simulation and workshops will be supported more strongly by CETI in future, through 
the Centre for Teaching and Learning.




                                                                                       17
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. 




                                                                                               18
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.




                                                                                               19
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. 




                                                                                               20
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.




                                                                                          21
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.




                                                                                               22
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.




                                                                                             23
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.    




                                                                                                 24
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.




                                                                                               25
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 




                                                                                         26
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.




                                                                                           26

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