Mandatory Training Needs a Major Review N a Quiet Sunday Afternoon, I Decided and Prescriptive, Mandatory Learning

comment “The ‘corporate capture’ of healthcare weakens government’s integrity” DAVID OLIVER “I have a problem with breast cancer screening“ HELEN SALISBURY PLUS Freedom of speech and assisted dying; recycling in hospitals WOUNDED HEALER Clare Gerada Mandatory training needs a major review n a quiet Sunday afternoon, I decided and prescriptive, mandatory learning. Some could to update my compulsory online argue for merit in doing practical and non-clinical safeguarding training. Confronted by training online in one’s own time, although even photos of bruised children, tales of here learning is better done with room for discourse. Oabuse, and parental drug taking, I could Doctors are encouraged to reflect on their clinical bear no more. practice. Yet the current system leaves little time Who thought that such training should be done for true reflection, having become a largely solitary in sterile cyberspace, without discussion between activity more akin to rumination. peers? What with fire training, manual handling, Peer group learning (including supervision) allows and another dozen mandatory requirements, my doctors to explore the uncertainties of their work schedule is filled with having to “learn” what others and, importantly, the emotional impact of working decide is important for me to know to practise safely. so close to death, despair, and disability. It allows for The training is often described interchangeably cases to become real and for true learning to occur. as statutory and mandatory, yet these are different— Given the importance of some of the areas covered the former required by law, the latter determined by in the statutory and mandatory training and the the employer. scarcity of time for learning, it’s important to And it’s not clear who determines that the design a system that uses best evidence training is required—the Care Quality Commission, for learning. The lack of evidence for trusts, royal colleges, the GMC? For example, the the current approach leads me to CQC doesn’t have a list of mandatory training but suggest that the system of training does inspect against a set of subjects, and trusts requirements (including subjects, or practices can be marked down if not all staff content, duration, and format) needs a complete the training. fundamental review. Is it for revalidation? The GMC requires doctors to Clare Gerada is GP partner, Hurley Group, London judge for themselves how best to keep up to date, [email protected] whether evidence of training should be presented Cite this as: BMJ 2019;365:l1406 at appraisal, and how evidence of completion should be presented. The current suite of mandatory training has, in good faith, been deemed important by individuals Peer group or organisations. But it’s become at best a chore, an learning allows expensive tick box exercise. At worst, it contributes to high levels of mental distress in our profession. doctors to Delivery of much of the training also runs counter explore the to educational good practice. What’s apparent from uncertainties of educationists is that the best outcomes—behaviour their work and, change, educational impact, and improved patient importantly, care—are achieved through experiential, active learner, peer group learning. This is a long way from the emotional where we are now, with a focus on passive learners impact the bmj | 6 April 2019 21 PERSONAL VIEW We risk our careers if we discuss assisted dying with patients or colleagues Five anonymous palliative care doctors say that their professional association is stifling free speech and denying an informed debate e are five consultants; The assertion that between us we have 94 doctors in the years of consultant level UK might be experience in palliative called on to “kill” medicine. We share patients is blatant Wconcerns about the way that our specialty’s scaremongering medical colleges represent assisted dying in the media, including in this journal. being asked to “kill” patients. In our view, those at the APM. We have no reason to The Royal College of Physicians (RCP), after these assertions are indefensible and morally suspect that our colleagues are any less a recent survey of its members and fellows, repugnant interpretations of a reasonable sympathetic, compassionate, or proficient, adopted a neutral position on assisted dying. attempt by the college to use neutrality to than we are. We, however, disagree that Since the survey was announced, there has facilitate discussion about the topic. assisted dying is inherently a bad thing. We been an outpouring of strong opinions from We are unaware of any evidence that other believe it is our professional responsibility the officers and members of the Association jurisdictions that have legalised forms of to have an open discussion on the subject. for Palliative Medicine (APM). Most criticised assisted dying have seen a loss of public faith It’s important to do this as many of the dying the RCP for not following the APM’s absolute in the medical profession. There is also no people for whom we care have expressed a opposition to a change in UK law to allow for evidence that assisted dying is inconsistent wish that assisted dying be an option they some forms of assisted dying. Fortunately, with modern evidence based medicine. Most could access. The BMJ restored some balance by publishing importantly, the assertion that doctors in the We would like to tackle the charge that articles from Canadian physicians who have UK might be called on to “kill” patients is legalising assisted dying would lead to experience of providing assisted dying. blatant scaremongering. doctors being asked—possibly even forced Critics suggest that by taking a neutral by unspecified insidious means—to “kill” stance the college is opening the door to an Not inherently a bad thing patients. We believe that our colleagues, irreversible breakdown of medical standards We would like to open another side to this for whom we have enormous respect, have and public trust; is a dereliction of thousands discussion. As consultants in palliative failed to read and understand the terms of of years of Hippocratic practices; and—worst medicine, we undoubtedly see the same recent attempts to bring assisted dying to of all—that it would lead directly to doctors spectrum of patients and their carers as the UK, and are confusing “assisted dying” BMJ OPINION Richard Thorley Recycling in hospitals: The pollution of our oceans with plastics extensive, sterile procedures are performed, and the destruction of Earth’s forests to the volume of waste is even greater. couldn’t we do better? make paper based products have huge The packaging of medical supplies, implications for our planet and human just like the packaging of food and health. Recycling is no longer just an other commercial products, needs to be applaudable action; it is now expected slimmed down and, where possible, of us all. So why do we see so little of it in made of sustainable and recyclable hospitals? materials. But this won’t happen The healthcare environment has massive without incentives for manufacturers. potential to reduce waste and scale up When sourcing medical products, recycling. But while the rest of society has the environmental impact should be been relatively successful in trying to reduce considered alongside efficacy and cost. the amount of waste sent to landfill, there Typically, a ward treatment room will have has been little change to our practices separate bins for sharps, infectious waste, in hospitals. Recently, when I was in the clinical waste, and domestic items, but it’s process of inserting an intravenous cannula, rare to see a recycling bin too. Could we a patient commented on the amount of have them as well? Those materials that are packaging waste involved. When more already recyclable should be recycled; there 22 6 April 2019 | the bmj with “voluntary euthanasia.” An example is the ACUTE PERSPECTIVE David Oliver Falconer Commission which made it very clear that the act of dying would be at the competent patient’s repeated request, facilitated by a doctor writing It’s time to put a catch on the a prescription, for a lethal “draught” that would revolving door to the NHS lobby have to be taken by the conscious patient by his or her own hand. We challenge that this could be n January the chief digital officer tenders to be put out to “any qualified construed as “killing.” for NHS England, Juliet Bauer, provider”—to being chief executive We have tried in different ways to engender an left to take up a role at a Swedish of Care UK, “the largest provider of open and fair discussion about the subject with our digital start-up company. The private NHS services.” Mark Britnell specialist colleagues, in the hospices, hospitals, company, called Kry (Livi and Gary Belfield, who headed the and community settings in which we practise Iin the UK), has developed a video health department’s grandly named our craft. All of us have been stifled from talking consultation app and has partnered “world class commissioning,” moved about this topic. We believe that there are many general practices in England. to KPMG, which sells consultancy to more colleagues—especially trainees and early That same month the Financial the NHS. career consultants—who do not share the views Times reported that Bauer had written Monitor, the former regulator of of the officers of the APM, but we suspect they are a newspaper article extolling the foundation trusts, was headed by a inhibited from openly sharing their own views. virtues of Kry’s app without disclosing McKinsey consultant, David Bennett, that the company had already on one of the highest salaries in the No concession hired her (the piece was eventually NHS.

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