School of Medicine Final Year HANDBOOK

2010/2011

FOREWORD FROM THE YEAR 5 DIRECTOR Dear Student Welcome to the final year. We are proud that you have successfully mastered the earlier years and are now ready for independent practice learning and to become professionally critically self-aware. As you are completing your undergraduate course you must also start preparing for your post-graduate education. This guide ensures that you have a complete overview of the year ahead and the nature and opportunities in prospect. Please take time to read this guide especially in the first few weeks. There will be many things that are new to you. Please read this InsertinPhoto Here with the Generic Programme handbook. guide conjunction We have attempted to ensure that all dates and arrangements are correct, however unforeseen circumstances do occur. For this reason please make sure your contact details with MBChB office are kept up to date at all times and that you read your emails on a frequent (even daily) basis. Changes to your activities and important deadlines will be notified through the email system. I wish you a happy and successful final year. Work hard but also have fun. This is just the start of the rest of your life! With best wishes,

Professor Richard D Griffiths Director of Final Year Professor of Medicine (Intensive Care) Contact Information: Professor R D Griffiths Email:

[email protected]

Final Year Contact: Rachel Dunbavin School of Medicine MBChB Office Cedar House Ashton Street L69 3GA Telephone: 0151 795 4359

E:Mail:

[email protected]

The MBChB Office in room G.15 of Cedar House is open from 10 a.m. to 4 p.m., Monday through Friday, and from 4 p.m. to 6:30 p.m. on Thursday evenings.

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Table of Contents (Jump to your page by pressing Ctrl + Click to follow the link) FOREWORD FROM THE YEAR 5 DIRECTOR ........................................................................................ 2 Contact Information: ....................................................................................................... 2 Overview of the Year...................................................................................................... 5 Aims and Outcomes of the Year .................................................................................... 5 A Note on Entry to Year Five.......................................................................................... 6 ATTENDANCE ..................................................................................................................................... 6 MITIGATING CIRCUMSTANCES .......................................................................................................... 7 STUDENT PERSONAL TUTOR/MENTORS ............................................................................................ 8 Clinical Psychology Advisory Service for Health Professional Students ......................... 8 YEAR 5 TIMETABLE 2010-11............................................................................................................... 9 Portfolio: what is it for? ................................................................................................. 10 Allocation of Fifth Year Attachments ............................................................................ 10 ASSESSMENT .................................................................................................................................... 13 Introduction to Assessment in Final year ...................................................................... 13 Review of Portfolio, PETA Process and Student Support ............................................. 14 Course Monitoring/Evaluation and Feedback ............................................................... 14 CHECKLIST OF REQUIREMENTS FOR FINAL YEAR............................................................................. 17 PETA Process in Summary .......................................................................................... 18 Advice to Students on the Preparation of the Portfolio for the Final Meeting: ............... 20 Registration of Portfolios for Graduation ...................................................................... 20 Procedure in the Event of a PETA Referral .................................................................. 21 External Examiner Review of a Failed PETA ............................................................................... 21 Definition of a Fail....................................................................................................................... 21 Appeals ....................................................................................................................................... 22 A Note on Requests by Future Employing Trusts for Final Year students to Attend Courses .... 22 Generic Descriptors of PETA Levels of Attainment ...................................................... 22 Mid Term Record Of In Training Assessment ............................................................................. 22 Final Professional Education & Training Appraisal ..................................................................... 24 GUIDANCE GIVEN TO SUPERVISORS ON THE FORMAT OF THE PETA MEETING ............................. 24 A Structured Approach to Discussing Cases in the Portfolio ........................................ 25 Evaluate the Clinical Management Skills as Appropriate for a House Officer ............... 25 COMPONENTS OF THE YEAR............................................................................................................ 27 1. WARD Care Attachments – F1 HO Shadowing Syllabus & PETA Objectives ........ 27 Expectations of the Student: ...................................................................................................... 28 Expectations of the Foundation Year Trainee: ........................................................................... 29 Expectations of the Consultant: ................................................................................................. 29 Final Year Students Prescribing During Shadowing (not applicable in A/E) ............................... 30 2. SAMP - Selectives In Advanced Medical Practice ................................................. 30 Illustrative example of a Selective in Advanced Medical Practice ............................................. 32 Expectations of the Student ....................................................................................................... 34 Expectations of the Clinical Supervisor (a named consultant): .................................................. 34 SAMP Critical Reviews – Requirements and Marking Criteria.................................................... 34 SAMP Assessment Form for Critical Review of Clinical Guideline or Legal/Ethical Dilemma .... 37 3. ACUTE Care Attachments: Emergency Medicine Syllabus and PETA Objectives ....................... 38 Aims ............................................................................................................................................ 38 Expectations of the Student ....................................................................................................... 39 Expectations of the Consultant Convenor and Consultant Supervisors ..................................... 40 Expectations of the Emergency Medicine Team ........................................................................ 41 4. Community-Orientated Medical Practice ............................................................... 44 Goals ........................................................................................................................................... 45 Objectives ................................................................................................................................... 45 Weekly Activities ........................................................................................................................ 48 Expectations of the Student ....................................................................................................... 51 Handbook Year 5 2010-2011

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Expectations of the GP Supervisor ............................................................................................. 52 OTHER GENERAL ACADEMIC ELEMENTS ......................................................................................... 53 Clinical Case Guidance – Using the C.A.R.E Approach ............................................... 53 Writing Case Reports .................................................................................................................. 53 Example of a Clinical Case Record .............................................................................................. 55 Clinical Science/Therapeutic Reports........................................................................... 57 Adverse Event/Critical Incident Report ......................................................................... 58 How to Record a Case on The Electronic Clinical Log ................................................. 60 Prescribing Skills.......................................................................................................... 61 Practical Prescribing Learning Objectives ................................................................................... 61 Building Your Own Formulary..................................................................................................... 62 Using Case Records & Case Log to Demonstrate Prescribing Skills ............................................ 63 Patient Safety Programme and Clinical Skills Record ................................................................. 64 Minimum Practical Skills to be Demonstrated During Final Year in Liverpool ........................... 64 Mini-CEX- Guidance for Use in Final Year ................................................................... 65 Advanced Life Support Training ................................................................................... 68 Medical Students‟ (Final Year) Simulation Course. ...................................................... 68 Competencies for the Care of the Acutely Ill ................................................................ 69 Erasmus Exchanges During Selectives In Advanced Medical Practice ........................ 72 The Duties of a Doctor Registered with the General Medical Council ........................... 73 The Duties of a Doctor Registered with the General Medical Council ........................... 73 PREPARING FOR YOUR FUTURE ....................................................................................................... 74 Applying for your Foundation Post ............................................................................... 74 Career Development .................................................................................................... 74 Final Year Resources ................................................................................................................... 76 REFERENCES AND LINKS .................................................................................................................. 77 The “Concern Form” – Concern about an MBChB Student ........................................................ 79 What happens to a concern form? ............................................................................................. 81 Notification of Concern .............................................................................................................. 82 STUDENT PROGRESS ........................................................................................................................ 83

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INTRODUCTION TO THE YEAR 5 PROGRAMME Overview of the Year In final year a portfolio is used for learning and assessment as a means to cement the professional culture and life-long learning. It is important that students learn to take control of their own learning and accept the professional responsibility that this brings including reflective practice and critical self-awareness. Students are prepared for Foundation training and achieve a satisfactory “fitness-to-practise” outcome as required by the GMC. The patient case reports are the main method of learning. A large proportion of clinical time during final year will be in the form of clinical shadowing either of F1 year house officers, F2 year senior house officers, intermediate specialty training grades or GP trainees. Students will be allocated a clinical supervisor who will be a consultant, specialist or general practitioner with whom they will agree how to achieve their learning objectives. The final year is designed and assessed to adapt students to postgraduate learning skills and identify and support any weak students over the course of the year, as they are prepared for practice. In particular portfolio learning and the PETA process are introduced in keeping with the principles of the Foundation years. It therefore combines elements of professional appraisal and professional assessment. There are five clinical attachments in final year, all must be completed: Acute CARE (EM)

Ward CARE (F1HO shadowing)

Community Oriented Medical Practice

Selective In Advanced Medical Practice

Selective In Advanced Medical Practice

Hospital Based 7 + 1 weeks

Hospital Based 7+1 weeks

In the Community 7+1 weeks

In a speciality 7+1 weeks

In a speciality 7+1 weeks

Seven weeks of each attachment are to be spent gaining intensive clinical experience. The eighth week of each attachment is for reflection and catch up time.

Aims and Outcomes of the Year The final year aims to encourage the development of the independent practitioner and to promote those attributes described by the Education Committee of the GMC. The five attachments allow students: To be prepared for entry to the Foundation years as a house officer (by completing an F1 shadowing attachment). To experience emergency and long-term care in the hospital and community (by completing Emergency Medicine (EM), ward and community attachments). To experience in depth possible career choices of clinical specialities (by completing two Selective in Advanced Medical Practice attachments). To establish a framework for quality of clinical care and critical self-awareness (yhrough applying the concepts of “Clinical Governance”). To establish the foundation for post-graduate learning (through the practical application of a reflective patient case-based Portfolio and associated PETA process).

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A Note on Entry to Year Five Entry to year five requires the satisfactory completion of all components of the course up to the end of Year 4, including Special Study Modules 1, 2, 3 and 4. If a student has failed SSM5 they must repeat the block (condensed into four weeks) either during the summer holiday at the end of Year 4 or at the end of the Year 5. WARNING Students who fail SSM6 must repeat at the end of Year 5. This may delay graduation by six months, until December. In exceptional circumstances students who have successfully re-sat SSM6 have received a temporary approval from previous Vice-chancellors and been able to commence F1 posts in August. This is an exceptional arrangement made by the Director of Medical Studies that is not guaranteed. Otherwise employment could be delayed by one year as is the case with other students who might fail to complete any final year attachments or requirements. Any student who has been instructed to re-write an SSM, (as opposed to those who must re-sit the whole block), must complete the re-write by August 31st for entry into year five. A satisfactory standard must be achieved in the fourth year examinations, if not in June by the re-sit in August. No student will progress into year five unless this has been achieved.

ATTENDANCE General information about the University‟s attendance policy may be found in the 201011MBChB Generic Handbook under the section Sickness Absence. The specific attendance policies of the MBChB programme can also be found in the generic handbook under the section Attendance Policy for the MBChB Programme. There you will find the procedures for self-certifying missed sessions due to illness, information about when a physician‟s note is necessary, and who to contact if you miss a compulsory session. It will also explain how to obtain pre-approval for missed sessions and explain the consequences of unauthorised absences. See also the generic programme handbook for 2010-11, section 2 under Implications of Non-Attendance. The final year is 40 weeks long. 35 weeks are spent on clinical attachment and 5 weeks are used for self-study and assessment. Full attendance is compulsory for the 35 weeks of clinical attachments and any PETA meetings. Leave should not be requested or taken during clinical attachments unless this is for sickness or unavoidable reasons. Any leave or absence must be notified and agreed with the clinical supervisor, sent in writing to the School Office and included in the portfolio. Holiday time is provided: on all national holidays, there is a Christmas break and time at the end of the year before graduation. A student may fail any PETA if attendance on an attachment has not been satisfactory. It is the student's responsibility to ensure that their attendance is recognised by their performance and involvement and an agreement reached with their supervisor how best this might be reached. If sickness occurs during a clinical attachment and the approved absence exceeds 2 weeks the student should arrange with the clinical supervisor to extend the attachment into the self-study week to avoid failure on this basis if at all possible. In final year a lack of professional attitude regarding managing attendance and time keeping can result in automatic failure. The supervisor's decision is final. Students demonstrate professionalism and their fitness to practise by appropriate management of absence due to illness or other reason. Sadly a number of students have failed final year because of a basic failure in taking a professional approach to attendance and failing to notify faculty of leave or sickness or simply failing to demonstrate to their supervisors their presence!

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MITIGATING CIRCUMSTANCES In respect to the MBChB programme, it has been agreed that the cases for mitigating circumstances should be provided on two separate occasions, and students will be notified at the appropriate time the dates by which these should be submitted. The first dates will refer to any mitigating circumstances which you feel may have impacted on your performance throughout the academic year. The second submission date will refer to any mitigating circumstances which you feel may have affected your performance during the examination period. You must submit mitigating circumstances at the appropriate time. Please note: A claim cannot be delayed, nor any evidence relating to it be delayed, on the grounds of sensitive personal family or cultural reasons. Please note that the following is generic information issued by the University and not all sections are relevant to medical students. All components of the programme have to be passed independently. Students sometimes perform more poorly in assessments (whether examinations or other types of assessments) than their previous performance or achievements would have predicted. Sometimes this poor performance can be attributed, or partially attributed, to particular circumstances beyond the control of the student. These circumstances are described as „mitigating circumstances‟ if they are accepted in mitigation of the poorer than expected performance. When a Board of Examiners accepts that there have been mitigating circumstances, it will usually not regard the student‟s poorer than expected performance at its face value in making decisions about the student‟s progress in studies or final degree classification. Where circumstances are accepted in mitigation of poorer than expected performance students may be allowed (where practicable) to retake the assessment as if it were a first attempt. Mitigating circumstances may, for example, include: Illness affecting the student. Bereavement. Serious illness affecting a close family member. Unforeseeable or unpreventable events. Independent documentary evidence, such as medical certificates, must be provided in all cases to verify mitigating circumstances. It is the responsibility of the student concerned to report all circumstances which s/he wishes to be taken into consideration to the nominated person in his/her department. Students should report such mitigating circumstances as soon as possible (normally within five working days) after the events under consideration occur, and no later than one week before the meeting of the Board of Examiners at which the assessment concerned will be considered. Mitigating circumstances should be reported using the form available at: http://www.liv.ac.uk/tqsd/pol_strat_cop/appl_for_cons_of_mitcirc.doc Full information on the Mitigating Circumstances Policy and the Mitigating Circumstances Guidelines for Students is available at: http://www.liv.ac.uk/tqsd/pol_strat_cop/index.htm

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STUDENT PERSONAL TUTOR/MENTORS University information on Personal Tutors can be found in the 2010-11 MBChB Generic Handbook under the section Support Services for Students. All students are allocated to a personal tutor at the beginning of the course. The personal tutor is appointed to act as a personal „mentor‟, to help and support students during their time in Liverpool. While a student may feel they do not need this personal tutor support, they still have the responsibility of staying in touch with their tutor throughout the 5-year programme, so that if difficulties arise the relationship is such that the personal tutor can provide support. Some students have found the personal tutor system to be invaluable if a crisis arises due to academic study, personal, or other difficulties. The Year Director is aware that students may need help at any stage during the programme, and it cannot be emphasised enough that the personal tutor should be regarded as their source of continuing support and help at all times. The School and University policy is to ensure that all students and tutors get to know one another.

Clinical Psychology Advisory Service for Health Professional Students Health professional students (medics, dentists and health science students) aim to maintain their well being and develop effective ways of coping during their training. However, it is common for students to develop concerns about their well being and coping at some time during their studies. To meet these needs it is important that students are able to access timely and appropriate help. The Advisory Service aims to provide professional and confidential support for health professional students with these concerns. Detailed Information about the service can be found at: http://www.liv.ac.uk/advisory/index.htm. Please take time to visit this website. Students can contact the Academic Sub-Dean, Dr. Lyn Williams, or the Senior Tutor, Dr. Vanessa Martlew, confidentially, prior to seeking referral. To arrange a meeting with either of these Advisors by contacting Mrs. Jane Goldberg at [email protected] or 0151 794 8756

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YEAR 5 TIMETABLE 2010-11 Groups

Weeks Date 31/08/2010 06/09/2010 13/09/2010 20/09/2010 27/09/2010 04/10/2010 11/10/2010 18/10/2010 25/10/2010 01/11/2010 08/11/2010 15/11/2010 22/11/2010 29/11/2010 06/12/2010 13/12/2010 20/12/2010 27/12/2010 04/01/2011 10/01/2011 17/01/2011 24/01/2011 31/01/2011 07/02/2011 14/02/2011 21/02/2011 28/02/2011 07/03/2011 14/03/2011 21/03/2011 28/03/2011 04/04/2011 11/04/2011 18/04/2011 25/04/2011 02/05/2011 09/05/2011 16/05/2011 23/05/2011 30/05/2011 06/06/2011 13/06/2011

A

B

C

Acute Ward COMP Acute Ward COMP Acute Ward COMP Acute Ward COMP Acute Ward COMP Acute Ward COMP Acute Ward COMP Self study and assessment period SAMP1 SAMP2 Acute SAMP1 SAMP2 Acute SAMP1 SAMP2 Acute SAMP1 SAMP2 Acute SAMP1 SAMP2 Acute SAMP1 SAMP2 Acute SAMP1 SAMP2 Acute Self study and assessment period Xmas Xmas Ward COMP SAMP1 Ward COMP SAMP1 Ward COMP SAMP1 Ward COMP SAMP1 Ward COMP SAMP1 Ward COMP SAMP1 Ward COMP SAMP1 Self study and assessment period COMP SAMP1 SAMP2 COMP SAMP1 SAMP2 COMP SAMP1 SAMP2 COMP SAMP1 SAMP2 COMP SAMP1 SAMP2 COMP SAMP1 SAMP2 COMP SAMP1 SAMP2 Self study and assessment period SAMP2 Acute Ward SAMP2 Acute Ward SAMP2 Acute Ward SAMP2 Acute Ward SAMP2 Acute Ward SAMP2 Acute Ward SAMP2 Acute Ward Week for external examiners meeting

D

E

SAMP1 SAMP1 SAMP1 SAMP1 SAMP1 SAMP1 SAMP1

SAMP2 SAMP2 SAMP2 SAMP2 SAMP2 SAMP2 SAMP2

Block 1

Ward Ward Ward Ward Ward Ward Ward

COMP COMP COMP COMP COMP COMP COMP

Block 2

SAMP2 SAMP2 SAMP2 SAMP2 SAMP2 SAMP2 SAMP2

Acute Acute Acute Acute Acute Acute Acute

Block 3

Acute Acute Acute Acute Acute Acute Acute

Ward Ward Ward Ward Ward Ward Ward

Block 4

COMP COMP COMP COMP COMP COMP COMP

SAMP1 SAMP1 SAMP1 SAMP1 SAMP1 SAMP1 SAMP1

Block 5

PLEASE NOTE Five by 8 week periods (7 weeks programme with 1 week self study) Group C allows ERASMUS exchange during SAMP There is no self study and assessment period at the end of Block 5. Completed Portfolios are to be handed in on Friday 10th June 2011

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Portfolio: what is it for? A portfolio contains evidence of the students work. Portfolios support active self-directed learning and foster a personal approach to professional development and the taking of responsibility for adult learning. The final year portfolio prepares students for post-graduate learning. It is central to a review or appraisal process that in Liverpool is called the Professional Education and Training Appraisal (PETA). Once graduated the completed portfolio will be the student‟s evidence to present at the first meeting at the start of the post graduate foundation years. This may be very relevant for those taking up a foundation post in hospitals away from Mersey that are not aware of our excellent graduates! The challenge in final year for the student is to develop their identity as an independent professional and take what they have learned into practice, apply their skills, learn to make decisions and evaluate their own performance. The aim is to not only develop professional “practice skills” but also “learning skills”. Specifically this means demonstrating critical self-awareness not only of appropriate professional practice but also of the personal approach to working and learning that underpins this practice. This is why the final year portfolio is an ongoing reflective record of professional achievement. Students must be encouraged to learn independently and be critical of their own and others‟ performances. They are expected to display a maturity of values and act professionally. Final year aims to prepare students for work in a hospital or in the community. Students must demonstrate in their professional practice and their portfolio, their awareness of their own strengths and weaknesses in final year by: Critically evaluating a patient‟s various problems with a relevant and appropriate history and examination. Showing logical reasoning and decision-making on options for management for common conditions. Maintaining requisite skills to undertake practical tasks in a safe and responsible manner. Prescribing safely while aware of risk and benefit. Evaluating the outcome and recognising when things do not go as planned. Recognising the uncommon and knowing when to seek help. Helping patients and relatives to deal with emotional distress. Working as an effective member of a team including taking leadership and sharing in decision-making. Communicating effectively with both patients and colleagues. Developing awareness of how to learn, identify and prioritise learning objectives and the study methods used to meet these objectives.

Allocation of Fifth Year Attachments Because the allocation to Foundation Year 1 posts is undertaken nationally, students will not know which hospital in which they will spend their F1 year by the time they start fifth year and therefore the Ward Care placement may not be in that hospital. To give students the best opportunity, however, the first two choices for Foundation Year 1 jobs that students give at the end of 4th year will be allocated to Ward Care and Acute Care as far as is possible. The location of your Ward Care attachment determines your timetable for final year, i.e.,: if your Ward Care attachment is in September, you are in group B, and your attachments will follow the rotation order:

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Attachment 1: Ward Care Attachment 2: SAMP1 Attachment 3: Community Oriented Medical Practice Attachment 4: SAMP2 Attachment 5: Acute Care (See timetable for details of other rotations) WARD CARE ATTACHMENTS The Ward Care attachment aims to prepare you for the F1 year. You will shadow a Foundation Year Doctor who may be in the hospital where you intend to apply for your F1 post. Arrangements for application to F1 posts however will take place during final year. Using your preferences as defined at the end of fourth year where each student intends to apply for their F1 post, your placement on Ward Care attachment for final year will be finalised. There is no facility to shadow GP F1; however those foundation posts that include a GP rotation are met by the opportunities provided in the final year Community Oriented Medical Practice (COMP) attachment. 3 ACUTE CARE ATTACHMENTS The location of your Ward Care attachment determines your timetable for final year. Therefore students in group A who will shadow a F1 in session 3 will complete their Acute Care attachment in Session 1, and so on. The School of Medicine will allocate where possible in one of the two hospital choices chosen at the end of 4th year to enable them to gain experience in a different hospital. Each Emergency Medicine (EM formally A+E) department has a convenor for final year to whom the student should report on the first day of the attachment: Arrowe Park Chester RLBUHT UH Aintree Warrington Whiston Southport Blackpool

Mark Buchanan Steve Moore Lawrence Jaffey John Hollingsworth Rachel Wallis Sarah Graham Charlie Scott Nigel Kidner

The RLBUHT and UH Aintree have limited paediatric facilities, therefore students doing Acute attachments at these hospitals will spend some time at Alder Hey. The convenor there is Barbara Phillips. SAMP ATTACHMENTS Students will select two 7 week options drawn from a list of available attachments. Most placements are available only at certain times during the year, as indicated on each SAMP proposal. Some SAMPs may be open to only one student at a time, whilst others will offer a programme for several students. In all cases the specialist: student ratio is 1:1; students will follow individualised programmes. If the student is due to undertake a SAMP during session 1 (groups D and E), s/he should make his/her choice in July. Subsequent SAMP choices will be open for selection at the start of the previous session (i.e. for session 2 SAMP should be chosen at start of session 1 etc). SAMPs are not SSMs and students cannot make their own arrangements but can encourage new SAMPs to be offered. Any SAMP offered must be available for any student to choose. The supervisor must also be registered for the PETA process (automatic for all of our local teaching Trusts). They are not electives and it is not possible to undertake out of region or overseas SAMPs except within the Agreements of the ERASMUS programme. COMMUNITY ORIENTED MEDICAL PRACTICE ATTACHMENT (COMP) This is a 7 week attachment in General Practice, which includes 1 full day per week in CCT.

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Students may be placed in the Merseyside area or Llandudno. Students are asked to indicate their preference of location. These preferences are considered but cannot always be guaranteed. Please be aware that for most students, GP practices are outside Liverpool city centre and some travelling will be required. Llandudno/North Wales There are 20 students per block who will be placed in North Wales. Fully serviced self-catering accommodation is provided for students free of charge throughout the attachment. The accommodation is near Llandudno town centre and is available from Sunday – Thursday each week. There may be a limited number of places that enable students to stay for the total 7 weeks without having to return to Liverpool. This is a popular attachment, with excellent teaching facilities and various opportunities for outdoor activities in the area. Students are welcome to apply with a group of up to 12 friends. ERASMUS SAMP Erasmus is part of the Socrates European exchange programme. Students who are accepted to take part in the programme will be automatically allocated to group C for final year so that exchanges can take place for a continuous period of 16 weeks during sessions 3 and 4. Agreements currently exist with the following Institutes to take Liverpool students: Karolinska Institutet University of Maastricht Universitaet Ulm Universite d‟Angers Linkoping Universitet Universidad de Salamanca University of Pavia University of Vienna

-Stockholm, Sweden. - Maastricht, Netherlands. - Ulm, Germany. - Angers, France. - Linkoping, Sweden. - Salamanca, Spain. - Pavia, Italy. - Vienna, Austria

The Erasmus co-ordinator is Rev Dr . David Taylor (email: [email protected]). Selection for Erasmus exchange occurs in 4th year. Further details are available at the back of this guide (see section entitled Erasmus Exchanges During Selectives In Advanced Medical Practice).

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ASSESSMENT General information regarding the assessments for the MBChB Programme can be found in the Programme Specification Document, located here: http://www.liv.ac.uk/sme/current-students/programme-specifications.htm The University Code of Practice on Assessment can be found here: http://www.liv.ac.uk/tqsd/pol_strat_cop/cop_assess/cop_assess.doc

Introduction to Assessment in Final year During final year assessment hinges on the learning portfolio and Professional Education and Training Appraisal (PETA). In signing the final PETA form, the clinical supervisor certifies that the student has attended a clinical placement and achieved the appropriate skills and knowledge and also has the appropriate professional attitudes to enter at F1 level within that clinical discipline. Students are expected to make a record of their achievements - the portfolio. The portfolio is a collection of evidence that learning has taken place, and with the case reports it is a reflective record of achievements. Similarly students should record their weaknesses and explain how these have been addressed. Within the portfolio students should write about three clinical case reports (or equivalent reports) per week; these should demonstrate consideration of the learning objectives. Brief details of the cases must also be entered onto the electronic clinical computer case log. It is advised that students maintain this on a regular basis and complete the computer logging in time to print out a record to be filed in their portfolio before each PETA meeting. The learning objectives on each attachment PETA form dictate the basis for all student “learning targets”. Such targets should be recorded on the first PETA meeting Learning Objective Sheet and students must use their portfolio to manage their learning and provide proof of their progress and accomplishments: Supervisors use the portfolio to monitor student progress, act as an agreed record of set learning objectives and to inform their assessment of the student. They also record their comments on the student‟s progress and accomplishments in readiness for F1 training. Students should maintain a skills log within the PSP programme and build a personal formulary to demonstrate progress. They should record any achievements, and details of any courses or meetings attended; presentations made or articles they have published should also be included in the portfolio. Material that is not the student‟s work should be excluded. Before each PETA assessment the students should ensure that their portfolios are in order and that they have included evidence that course requirements have been satisfied (attendance records etc.) An agreed record of the PETA interview and its conclusions should be kept in the portfolio. Any concerns should be documented at that time. Students should be able to demonstrate progress and achievement of the learning objectives for each attachment by discussing the evidence in their portfolio with their consultant supervisor at each PETA meeting. Please remember to forward the following to the undergraduate coordinators: week 1 PETA learning objective sheet by the end of week 1, mid-term PETA form by the end of week 4 and the final PETA forms by the end of week 7.

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IMPORTANT TO NOTE: Without exception, all work that contributes to a student‟s PETA assessment must be completed by the end of EACH eight-week period. If PETA forms are not registered in the MBChB office within one week of completion of each attachment students will have failed an attachment unless they have an agreement with their supervisor for any delay and notified the MBChB Office. The completed Portfolio must be handed in on Friday 10th June 2011, in order that students may graduate in July 2011. Completed Portfolios will not be accepted before or after this date.

Review of Portfolio, PETA Process and Student Support After two attachments have been completed a formal review or moderation process occurs. Each year the exact format is confirmed with the external examiners and occurs sometime in late February or early March (date to be confirmed). It is likely to follow the established format used successfully in the last few years where a team of examiners review the portfolios and interview a selection of students. The formal interview will follow a similar process to a final PETA review. Students will be called to participate based upon a number of criteria that are established in discussion with the external examiners. These can change but may include; students failing to complete or return PETA documents or not logged cases electronically, students who have had problems in the fourth year or with the examinations, students who have graded borderline or lower at any mid or final PETA meetings, students who have had any problem of attendance, behaviour or attitude. In addition a proportion of students may be selected at random from the year such that more than 10% of the year is reviewed.

Your attendance is mandatory and takes precedent over all other arrangements. As the selection process is broad, it is expected that the majority of students called for review are completely satisfactory. Indeed, previous reviews confirm this to be the case. However there are a few students who find the final year process a challenge and may need extra support. Although the review process may seem intimidating it is designed to be supportive and identify any weaknesses while there is still time to offer a remedy so that graduation can be successful. Detailed instructions are provided to students on what to expect. The examiners are asked to take a supportive and diagnostic approach to student learning and make constructive recommendations where they see weaknesses.

Course Monitoring/Evaluation and Feedback At the end of each attachment, students will be asked to complete an evaluation form. Through student feedback, the School of Medicine will monitor resource provision, supervision, teaching and clinical opportunities provided. The forms are available on the School of Medicine‟s website. At the end of the year, every student will also be asked to complete a formal feedback questionnaire. Please be constructive in your comments for these evaluations and be assured they are independently and confidentially managed: Your feedback is invaluable for students in the next cohort whose course may be adapted according to your recommendations. First PETA Meeting - Learning Objective Sheet During the first week of an attachment, learning objectives are set for later review. Learning Objectives can be concerned with: Knowledge, Skills or Values. Students must record on this sheet each learning objective and how its completion will be documented in the learning portfolio. i.e. using particular patient case records or the clinical skills card, for example. Remember to note patient case numbers in the evidence provided section. The sheet must be forwarded to the undergraduate co-ordinators at the end of the first week. CARE Clinical Case Records (see later for detail) During each 7-week attachment the student is expected to document the care of 3 patients per week to a total of 18 “cases” (16 case reports + 2 Clinical Science). Students should choose cases which best reflect the experience they have gained when meeting the learning objectives, as documented on the Attachment Learning Summary Sheet. Students‟ clinical case records are the main learning tool in fifth year and are the method by which the student demonstrates progress through final year for assessment purposes. Each case should require significant background reading. Three of these cases must be selected and used by students to summarise their progress on the Attachment Learning Summary Sheet prior to the Final PETA meeting. Handbook Year 5 2010-2011

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Clinical Science (therapeutic) Reports (see later for detail) In all placements, but particularly in SAMPs it is not possible to express learning simply in case reports. To encourage reflection on the basic sciences (e.g. of physiology, biochemistry, pathology, the behavioural sciences or pharmacology and therapeutics) and to meet a particular learning objective a Clinical Science report should be used. Complete at least 2 additional to replace 2 Clinical Case reports. In some placements up to 6 Clinical Science reports may be appropriate in place of case reports. Adverse Event/Critical Incident Report (see later for details) At least two analyses of actual or potential adverse events should be evaluated using the special forms. These are similar to IR1 reporting forms used within the NHS. Attachment Learning Summary Sheet Prior to their FINAL PETA meeting students must use this sheet to summarise both what they did and what they feel they have achieved during an attachment. As part of this summary they must select three portfolio cases of which they are most proud to illustrate how their professional practice has developed during the attachment. This learning summary sheet and the learning objective summary sheet are key resources for supervisors to refer to as they undertake their final review of a student‟s progress during the FINAL PETA meeting. The learning summary sheet should be a personal critical self-review of work and learning to date which may be referred to at any point during final year. GMC Clinical Skills Record & Patient Safety Programme (PSP) The GMC have published and will be implementing Tomorrows Doctors 2009 during the academic year 2010-2011. Please read this important booklet as it defines the competencies you are expected to achieve during your undergraduate training. Look at Appendix 1 – Practical Procedure For Graduates. Many of these skills you will have obtained in previous years. One of the purposes of the Patient Safety Programme (PSP) is to ensure that you are competent to undertake these skills when you become an F1. Whilst a final year student you must not undertake any skill unsupervised. However the PSP booklet enables you to record satisfactory completion of the various tasks up to 5 times. Please ensure that this part of the PSP logbook is completed so that you can show it to your ward sister when you start as an F1. This confirms the skills in which you are competent and do not need further supervision: for example, if you have only undertaken a male catherisation on a single patient whilst in final year, as an F1, you should not catheterise a man unsupervised without being supervised on 4 more occasions. If you have undertaken any practical procedures during the final which are not detailed in the PSP logbook please add them to the blank practical skills page. Patient Safety Programme (PSP) This programme has been designed to ensure that you are competent and confident to undertake basic clinical tasks when you become an F1. This year there are 5 parts to the programme; medicines management, practical skills, oxygen management, blood product transfusion and death certification. Each component has the same structure: firstly an on-line computer based knowledge test, secondly a practical skills session and finally the opportunity for you to undertake and record the practical skill on real patients. It is hoped you will satisfactorily achieve the supervised skill on 5 patients. However if you do not achieve this, it will not mean you cannot qualify; however you will have to demonstrate that you are competent in each skill as detailed by the GMC Tomorrow‟s Doctors 2009. Clinical Feedback Form During an attachment students are part of a clinical team. The purpose of this form is for a peer of the student who has worked most closely with them during an attachment (i.e. F1 or F2 Trainee), to record their view on the student‟s knowledge, skills and behaviour. The form must be completed and returned to the student’s supervisor prior to the Final PETA meeting. Senior Nurse Feedback Form (ACUTE, WARD and SAMP 1 & 2 only) During an attachment students will work closely with nursing staff. The purpose of this form is for the nurse to communicate the student‟s strengths and weaknesses, achievements and future Handbook Year 5 2010-2011

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practical targets to the student and their supervisor , in preparation for F1 training. The form must be completed and returned to the student’s supervisor prior to the Final PETA meeting. Mini-CX Practice (see later section for detail) To develop experience we introduced the mini clinical examination format (Mini-CX) to ward and acute care so that students may practice such an assessment format that they will use in their Foundation years. Students should arrange at least one attempt in both Ward and Acute Care. Electronic Log Print Outs It is a requirement of the portfolio of clinical achievement that students show evidence of clinical practice. The electronic clinical log is an important part of that record. The information held in the log enables the Director of Final Year to track the experience of all students and to observe the clinical opportunities that are arising at the many clinical sites. It is important that students maintain their electronic record on a frequent basis (preferably weekly) to enable the School of Medicine to monitor their clinical progress through the year. Information on how to log a case electronically via the web can be found towards the end of this handbook. Both the electronic log and the paper portfolio are the student‟s proof of contemporary clinical training (the electronic log records the date of entry) and should be shown as evidence of progression as the basis for discussion at each of the three PETA meetings a student has during an attachment. A printout of all the cases they have seen for each attachment should be stored in the portfolio and must be reviewed at PETA meetings. SAMP Review During “Selective in Advanced Medical Practice” attachments (SAMPs), students will be required to produce two (maximum 2500 word - short journal article length) concise critical analysis reviews of either current clinical guidelines or clinical dilemmas. A review of a guideline should follow a standard structure of introduction to include the aims and objectives of the review, followed by an update section that discusses the guideline in the light of current literature, and finishes with a revised guideline and applied conclusion section. There may be no change in the guideline but the evidence for the status quo must be established. A review of a clinical dilemma can follow a similar format where the introduction establishes the questions or arguments that are to be addressed; the middle section reviews the current literature that supports the various arguments and a conclusion that summarises the current positions. Illustrative cases may be included. Concise reviews are favoured and they must not be lengthy dissertations nor detract from the clinical case learning. These must be completed within the time frame of the clinical 7 weeks of a SAMP and are assessed by the clinical supervisor. A grade will be awarded using a criterion based approach, and the mark sheet is in the portfolio. The PETA for the SAMP must include the grade awarded for the critical review. Any critical review given a fail mark must have been independently second marked. Students are therefore strongly recommended to complete their critical review in the first five weeks of the attachment to allow sufficient time for assessment. Personal Formulary Students must review their practical prescribing skills in all attachments during final year. They are expected to build their own personal formulary. This year a required list of drugs has been included. The drugs in this required formulary have been defined by F1s as those drugs they are expected to be able to initiate for a patient admitted as an emergency; for instance in heart failure. These drugs are listed in the final year portfolio and you are expected to become very familiar with them. Students must be able to show evidence of their knowledge and skills in prescribing in their personal portfolio and computer log. More information on personal formulary can be found later in this handbook. Student Referral Protocol Form The PETA referral form is used when a supervisor wishes to refer a student after either Mid Term or Final PETA meetings. A copy of this form and the procedure used for its completion is held in the student's portfolio. Students will be given a replacement copy of the referral form by School Office, if they are referred. The form itself is a means through which a student and supervisor can initially state their respective concerns formally to the Director of Final Year.

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CHECKLIST OF REQUIREMENTS FOR FINAL YEAR The Portfolio is a requirement for qualification and must be available for review by supervisors and the year director or external examiners on request. It is your passport to graduation and required for entry to foundation years. At a minimum it must contain: Five satisfactory Final PETA forms Completed clinical cases or other reports (18 per attachment) May include 2-3 clinical science/therapeutic reports Adverse event/critical incident reports (2 per attachment) Learning objective summary form (1 per attachment) Attachment Learning summary form (1 per attachment) Clinical Feedback form (1 per attachment) Nurse Feedback form (1 per attachment) Two satisfactory completed SAMP critical reviews PSP booklet with clinical skills record A personal formulary Evidence of clinical activities (Minimum 90 case summaries and 5 computer case log print outs) Evidence of any approved absence/notification of sickness Evidence of career planning Curriculum vitae Failure to meet all course requirements will mean that graduation is deferred until the requirements have been met. Students must: Achieve a satisfactory attendance on all clinical attachments as agreed with supervisor (in excess of 90%), and have lodged details of any absences with the School Office. Any absences should also be recorded in the portfolio. Students MUST hand in their portfolios to their supervisor prior to each PETA meeting, which occur in week one, four and eight of an attachment. Additionally at each PETA meeting students must have up-to date 1) Portfolio of cases & other reports 2) Clinical Skills Record in PSP 3) Learning Objective Summary Sheet 4) Clinical Feedback Form (Final PETA only) 5) Nurse Feedback Form (Final PETA only) 6) Attachment Learning Summary Sheet (Final PETA only) 7) Clinical log printout 8) Personal Formulary Five satisfactory Final PETA forms must get to the School Office by the following dates at the latest: for session 1, by 22nd October 2010 for session 2, by 17th December 2010 for session 3, by 25th February 2011 for session 4, by 22nd April 2011 for session 5, by 10th June 2011 (note 7 weeks only) Students who fail to meet these deadlines without informing the MBChB office with a satisfactory explanation will have their studies suspended immediately. They will be unable to continue their placements and graduation will be delayed and they will be unable to enter foundation years. Handbook Year 5 2010-2011

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Students must provisionally register with The School of Medicine office by 22nd April 2011 and complete the “Intention to Graduate Form” if they wish to graduate on time. Students must register the completed portfolio with five satisfactory PETA forms with the School Office at least three weeks before graduation (10th June 2011).

PETA Process in Summary Week 1: Week 3 or 4: Week 7: Week 8:

Start of clinical attachment: “setting the learning agenda” Mid term PETA progress meeting End of clinical attachment, handing in of portfolio to supervisor and final PETA assessment Completion of any extra work or outstanding appraisals

Week 1 PETA: Setting the Learning Agenda During the first week of the attachment students settle into their daily routine and meet with their supervisors for the first time. Prior to this meeting (and subsequent PETA meetings) students should hand in their portfolio to the supervisor or designated representative i.e. Registrar or Clinical Secretary. Using the Student’s Portfolio Supervisors should:  review the pre-set learning objectives held in the portfolio on the MID and FINAL PETA forms.  consider any pertinent information i.e. previous attachment(s) learning objective forms, end of attachment summary sheets and portfolio cases. Additionally a student may have been referred during their last attachment and the referral form from the Director of Final Year may have to be considered when setting learning objectives.  discuss with their team which learning objectives to set for the student. Learning objectives may range from those that may be informally held, to the more pertinent which will need to be included by the student on their learning objectives form and subsequently in their portfolio. During their meeting, the student and supervisor should discuss the broad aims of the attachment and agree what could, should and must be achieved in the forthcoming weeks, as well as how achievement of learning objectives can be demonstrated practically and recorded in the learning portfolio by the student in preparation for PETA assessment. Agreement on attendance must be formalised. A timetable is helpful. Week 1: Outcomes  Specific Clinical skills to be acquired, as well as personal formulary entries necessary to demonstrate pharmaceutical knowledge, are all agreed.  Specific portfolio cases to meet learning objectives are agreed and a copy forwarded to School Office via the undergraduate co-ordinators. NB Students should be encouraged to select portfolio cases to meet learning objectives. It is best practice to require students to complete one agreed clinical case a week and demonstrate their growing critical selfawareness, professional manner and overall clinical competency, by selecting the two remaining cases per week themselves.  Student and Supervisor agree who will complete Significant Other and Nurse Feedback forms. It is the student’s responsibility to distribute these forms and inform these individuals of what is required of them.  Student and supervisor complete the Attachment Learning Objective Sheet. This is then forwarded to School Office via the undergraduate co-ordinators. Handbook Year 5 2010-2011

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Weeks 1 to 3 Students complete 3 portfolio cases per week and log them Students maintain their personal formulary Students maintain their clinical skills record Supervisors observe students and obtain informal feedback from clinical team concerning their progress Week 3 or 4 Mid Term PETA Meeting During either week 3 or week 4 a MID PETA meeting is held between the supervisor and student. Once again, students should hand their portfolio into their supervisor, or the agreed representative, prior to this meeting. The supervisor should then discuss progress with medical and nursing staff and review the student‟s portfolio prior to the PETA meeting. The attachment learning objective sheet must be used to aid their analysis and highlight areas that need further discussion with the student. Portfolios should also be checked to ensure they are up to date. A brief outline of the necessary documentation a student must have up to date can be found on the front sheet of the attachment PETA forms, Mid and Final. Adequate time for PETA meetings must be allowed. This will vary with the circumstances, but a full examination and discussion of the portfolio evidence by both supervisor and student must be undertaken for the student‟s progress towards F1 training to be assessed and reflected upon fully. Consequently it is expected that PETA meetings should last not less than forty minutes. A list of generic PETA descriptors for students and supervisors can be found in the next section of this guide. Supervisors are asked to identify a second reviewer when they are unsure about a particular student's performance. During the PETA meeting supervisors should review the student's progress towards objectives, recognise strengths and confer support and encouragement while also identifying weaknesses. No student should fail a final PETA without receiving a warning at the mid PETA if the reason for failure arose during the first four weeks. In particular, professional attitudes should be discussed if such a warning is received. The supervisor should use all available information, including feedback from other members of the medical or nursing staff in these situations and, in particular, attendance must be monitored and discussed if necessary. Week 4: Outcomes A mid-point PETA form must be signed in the 4th week. If there is cause for concern on any issue, the student and supervisor should discuss and plan remedial action together to be documented on the PETA form at this stage. In this case, no contact with the School Office is necessary. However, if its use is deemed necessary by a supervisor, the PETA referral form should be forwarded to the Director of Final Year via School Office. The student should retain a copy of signed PETA form. The Learning Objectives Form in the student‟s portfolios should be revised as necessary. Agreement between supervisors and students concerning who will complete the Nurse Feedback Sheet as well as the Clinical Feedback Form, must be reached and the relevant forms issued no later than Week 4 in readiness for Final PETA review in week 8. Weeks 4 to 7/8: Students complete 3 portfolio cases per week and log them Students maintain their personal formulary Students maintain their clinical skills record

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Supervisors observe students and obtain informal feedback from clinical team concerning their progress Week 7-8: Students complete their Attachment Learning summary forms, ensure their portfolios are up to date in preparation for their PETA assessment and hand them in to their supervisor (or nominated representative) before the meeting takes place. Nurse Feedback Form is completed and returned to the student‟s supervisor Clinical Feedback form is completed and returned to the student‟s supervisor. A full review of the student‟s portfolio is undertaken Week 7 End (or during Week eight) The FINAL PETA meeting occurs, the attainment of objectives is discussed, achievements confirmed and any continuing weaknesses are highlighted. A student fails the attachment if they continue to demonstrate an unsatisfactory performance following the fourth week interview despite a warning. In some circumstances, unsatisfactory performance may only become evident after the second interview and be a reason for failure, but every effort should be made to inform the student promptly. In all circumstances the student must be informed of the reasons for an unsatisfactory report.

Advice to Students on the Preparation of the Portfolio for the Final Meeting: It is important to ensure that your portfolios are in a format that will assist supervisors and reviewers. In the PETA folder for each attachment section there are two sheets; one is the copy of the learning objectives defined at the beginning and the second is the attachment summary sheet with free flowing text on what you was done and achieved during that attachment. This at first may seem difficult, but think about the following points. You are trying to summarise what you have done and learnt. Number the case summaries and use the case numbers in the summary text so that your supervisor can find the case. Explain where your range of cases demonstrates your experience and support the final PETA form conclusions. For instance during ACUTE certain cases might have improved your skills of triaging patients or dealing with children. During shadowing certain cases might have illustrated what is required in preparation for discharge. Where do the cases and formulary show your understanding of practical prescribing? Where do the cases show demonstration of best evidence practice in your evaluation? Describe where you have learnt from adverse events occurring in patient care? Think about how your skills have advanced or where your weaknesses were improved. Have you recognised good and bad practice in professional behaviour or communication? How would you describe what you have learnt? In what ways has your attitude or professional confidence changed? Finally identify three cases from each of your three attachments that you are most proud of. Say why in your summary and place these three cases at the front of each section and identify them accordingly.

Registration of Portfolios for Graduation By the end of the 4th attachment (by 22nd April 2011) all students who expect to be able to graduate will be required to provisionally register with School Office the completeness of their

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portfolio for graduation subject to satisfactory completion in the remaining attachment. They sign the “Intention to Graduate Form”. Students who fail to meet the April deadline will be unable to graduate in July. The next opportunity to graduate will be December, but students will have to defer the beginning of their F1 posts by one year (see later). It is a student's responsibility to ensure that a completed portfolio (record of achievement) is registered in the School Office at least three weeks before the date of graduation (10th June 2011 with graduation during week commencing 18thJuly 2011). CHECK DATES nearer the time on the School office notices. Students who have failed attachments will not be able to graduate in July, but must submit their portfolios for review and register their requirement for continuation of study.

Procedure in the Event of a PETA Referral The PETA referral form is used when a supervisor wishes to refer a student at either Mid Term or Final PETA meetings. A copy of this form and the procedure used for its completion is held in the student's portfolio. Students will be given a replacement copy of the referral form by School Office, if they are referred. The form itself is a means through which a student and supervisor can initially state their concerns formally to the Director of Final Year. Any student who is referred must make an immediate appointment to see the Director of Final Year and ensure all documentation is provided. In exceptional circumstances the supervisor may have felt unable to arrive at a decision regarding the student. The Year Director will interview the student to receive mitigating circumstances and examine the portfolio and computer case log as evidence of the student's achievements. An allowance for sickness or approved leave will be considered if this is the only reason for failure and where this absence had been correctly notified to the School Office. Additional written evidence from the supervisor will also be examined. If the student's portfolio of achievement, electronic case log and his or her own contemporaneous self-assessment is unable to refute the PETA, a failure will be confirmed. If the correct processes have been followed and PETA interviews complete then a failed decision is final. The Director of Final Year has the authority to recommend performance if sufficient evidence of achievement is presented. will arrange the review. In the rare circumstance that either the Medical studies was the supervisor for the student, the Dean will process

a review of fail or borderline The Director of Medical studies Year Director or a Director of establish an alternative review

External Examiner Review of a Failed PETA In the eighth week of the last attachment the two external examiners meet and will examine the portfolios of any student failing a PETA. They may require the student to attend for interview. They will consider the reason for deferral of any student and this may mean that graduation will be delayed.

Definition of a Fail A student will fail a clinical attachment in the event that: a) They achieve less than the satisfactory clinical attendance as agreed with supervisor, any leave or sickness having been correctly agreed and recorded. In the event of legitimate absence from the clinical attachments (for instance due to sickness) a minimum attendance of 90% in the year is required and no more than 2 weeks missed absence in any one Handbook Year 5 2010-2011

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attachment. Poor attendance, lateness and tardiness will not be tolerated. The supervisor is required to automatically fail any student who shows lack of professionalism over attendance and timekeeping. b) An unprofessional attitude or behaviour continues to be displayed following a warning. c) The student is awarded a fail mark for a critical review (SAMP). d) The student fails to achieve an overall satisfactory clinical standard for the objectives agreed within each PETA or fails to complete components of that attachment. e) The student fails to complete each PETA process in the required consecutive time frame as explained in the final year handbook.

Appeals A fail alone is not sufficient grounds for appeal. If however a student feels that a PETA has been unfair, unjust or incomplete they should in the first instance discuss this with the Year Director.

A Note on Requests by Future Employing Trusts for Final Year students to Attend Courses In the Mersey Deanery, all employing trusts appreciate that Liverpool graduates are fully prepared for F1 posts. However for students applying out of region, their future employer is often unaware of the preparedness of our students and instead may request new F1 to attend lengthy shadowing placements despite these being within term time. Liverpool students must complete their course if they wish to graduate and must politely point out that their own course is still running and that their future employer has no right to encroach on their time. In exceptional circumstances we are prepared through negotiation with the Year Director to allow a 1 week leave specifically for orientation if it is confirmed that it is not possible to arrange it after portfolio hand-in.

Generic Descriptors of PETA Levels of Attainment The following describes the levels of attainment used for grading at mid-term and end PETA assessment. The grading is intended to be supportive so that all students may achieve a final pass if performance is COMPETENT. The overwhelming majority of students are expected to achieve at least a grade of 3 with many achieving levels much higher. However some students may require extra support or further study to reach minimum level of competence. Please note that if supervisors have particular concerns during an attachment about the poor performance of any student, they are advised to undertake all assessments with a clinical colleague, and write carefully and in detail.

Mid Term Record Of In Training Assessment 5 More Than Competent: This is an Outstanding Student This grade identifies a student who demonstrates a mastery of that knowledge, skill or attitude that merits special recognition significantly beyond that of a good or average student. There is a personal confidence and maturity of professional practice that is well beyond the minimum that we require for a F1 house officer. The student must exhibit initiative, independence, and responsibility fully aware of best evidence practice. Their professional attitude to patients, colleagues and other team members is exemplary. They demonstrate critical professional reflection on their own and the practice of others to avoid adverse events. Attendance is beyond reproach and the portfolio is a joy to behold.

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4 More Than Competent: An Above Average Student The student demonstrates development towards a complete and satisfactory mastery of the knowledge, skills and attitudes one would require of a F1 house officer. The student demonstrates a personal confidence and understanding of their strengths and weaknesses. The student shows individual responsibility and is developing professional independence in their knowledge and practice. Follows best evidence practice for common disorders. Exceeds the minimum requirement of the attachment in terms of quality of cases seen, or procedures and tasks undertaken. Has a good professional attitude with patients, colleagues and other team members. Can reflect on their practice and learning and can recognise adverse events. Attendance record is good and the portfolio and electronic log are well maintained. 3 Competent: Basic Competence Assured, The Student is Performing at a Level “Fit to Enter Practice” at F1. (The minimum acceptable pass level for FINAL PETA meeting) The student demonstrates a basic mastery of the knowledge, skills and attitudes one would wish to see in a F1 house officer. The student is aware of the strengths and weaknesses and any gaps do not give great cause for concern. The student can safely and appropriately start practice at this level. With help and support the student is starting to develop individual responsibility and will apply best evidence practice for common disorders. The student has an acceptable professional attitude with patients, colleagues and other team members. The student completes the minimum requirements of the attachment in terms of case seen or procedures and tasks undertaken. Attendance has been satisfactory. The portfolio is regularly maintained to the required level. 2 Not Yet Competent: There is Some “Cause for Concern” This student needs to demonstrate improvement. Although the student is able to demonstrate most of the aspects there are some weaknesses in the knowledge, skills or attitudes required that give “cause for concern” regarding their “fitness to practice” independently. This grade should also be awarded if immaturity of professional practice or attitude is evident and the student is unable to recognise bad practice. This grade may be applied if attendance has been less than satisfactory or the minimum number of case records or clinical tasks required have not been completed (see PETA form top sheet) This grade should be used supportively at the MID PETA and be accompanied by recommendations for remedial action between the student and supervisor. This grade is fully consistent with a student being passed competent and “fit to enter practice” at the final PETA if they are able to demonstrate an improvement in the item(s) under assessment. However this is only an acceptable grading for the MID PETA meeting, and immediate referral should occur if a student continues to be appraised at this level at the FINAL PETA meeting. 1 Not Yet Competent: Not Ready to Enter Practice Referral for review by the Director of Final Year We would expect few students (if any) to demonstrate this grade; however it must be applied if there is clear evidence that can be documented in the referral form. This grade goes well beyond being a „cause for concern‟. The student is showing no development towards a mastery of the knowledge, skills or attitudes required of a house officer. The student appears unable to recognise their weakness and is not developing any individual responsibility. The student demonstrates bad professional skills or attitude towards patients or other health care workers. The student is dangerous. The student appears unable to recognise their weakness and shows no individual responsibility. Attendance is poor and the student has failed to seek permission for any absence. The portfolio is not maintained, the case records are incomplete and below the minimum number required. Evidence of practice is not recorded on the electronic log. Any student whose performance is deemed to be in this category must be referred to the Director of Final Year immediately whether at mid or final PETA.

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Final Professional Education & Training Appraisal Pass Grading: Satisfactory Completion of a Clinical Attachment This is awarded for all students who demonstrate competence at grade 3 and above at the final meeting. Within the separate items on the form one or two items graded at 2 is allowable for early attachments as long as improvement has been demonstrated and that the overall grade is 3. Recommendations how to correct weaknesses must be given to the student. Attendance must have been satisfactory and the portfolio and other tasks required complete and up to date. This satisfactory pass grade must only be awarded if there is no doubt or continued cause for concern. Fail Grading: Referral to Director of Final Year This is required for any student graded not yet competent (1) at any time and any student graded not yet competent (2) at the mid-term PETA and who subsequently fails to improve by the Final PETA and continues to demonstrate unacceptable behaviour in practice, attitude or presents an incomplete portfolio. The student must not be passed if “cause for concern” remains. Please note that poor professional attitude to attendance requires an automatic referral. The PETA referral form is used for this process and should be completed in the presence of the student and where possible contain the views of the student. It is forwarded to the Director of Final Year by the supervisor once the student has responded to their concerns (24 hours is recommended). The Director will review all available information. Where the PETA process has been followed correctly and there is evidence of unacceptable performance the decision of the supervisors will normally be upheld and arrangements made for the student to undertake further study. Very occasionally the supervisor may feel they are unable to decide on a student borderline between grade 2 & 3 and refer. In this situation the fail decision may be reversed. However this situation should be normally be avoided where possible by involving another local assessor. Regardless of the outcome of a referral both the supervisor of the student during their next attachment (if progression is possible in light of referral) and the referring supervisor, will receive notification of the outcome of the referral from the Director of Final year.

GUIDANCE GIVEN TO SUPERVISORS ON THE FORMAT OF THE PETA MEETING Obtain sight of the student portfolio before the PETA meeting. Read through the portfolio, using student‟s learning summary sheets and patient case summaries to identify and select issues for discussion. Seek specific feedback from other medical and nursing staff, in particular the clinical feedback and nurse feedback forms. Confirm your knowledge of student attendance, participation, clinical work, communication and attitude. Choose a relaxed and non-threatening, confidential environment and ensure that the time is committed and free from interruptions. Ask the student about the attachment in general and whether they have had the opportunity to complete what has been agreed. Examine their timetable and review what they did on call, shadowing, or other. Discuss their attendance and if there have been problems this must be discussed in the context of professional responsibility. Any student who shows persistent poor attendance must be warned and referred to the Director of Final Year and cannot achieve a satisfactory completion of the attachment. Check for completed electronic case log printout. Unless the student is in a particularly remote attachment there can be no excuses. Check progress in Clinical Skills log Check progress towards completing a personal formulary appropriate for a F1HO Check that all that is included in the portfolio is the student‟s own work and that which is required by the attachments. The portfolio is not to become a collection of printed texts or Handbook Year 5 2010-2011

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additional student notes. The student should be gently advised to file these in an accompanying folder separate from the portfolio. We want quality not weight! Look at the patient cases. Briefly scan through and check that all 18 patient case summaries (or clinical science reports) are complete. If they are incomplete require a valid explanation and mark accordingly. In particular check that the cases are not simple cases stories but meet the requirements of the CARE plan process with analysis, rational treatment plans and evaluation. Remember: - every case demands comments in the reflection section. Ask the student to explain why they have chosen certain particular cases. What they are most proud of and where they show contribution to the PETA objectives?

A Structured Approach to Discussing Cases in the Portfolio The following structure asks questions under the broad headings that refer to the GMC "attributes of the independent practitioner" and has been used by the external examiners in their independent reviews. It has been found more helpful if you ask the student to identify a case they are most proud of and wish to discuss rather than stumbling through a case the student only half remembers. A weak student will become evident during this process. Remember students must select three patient cases and highlight key areas of achievement and future need for their Final PETA meeting. In discussion draw upon physical and psychological problems, and test their application and knowledge of the physical, behavioural, and epidemiological sciences. Expect a clear summary and concise analysis of the problems and differential diagnoses. They should be able to interpret the results and explain the management. Link this with the personal formulary if appropriate and discuss. Make sure that the case is evaluated and that the student knows how and why the final diagnosis is arrived and can explain and justify the management plan in terms of best current guidance. If the progress or management did not go as planned or an adverse event occurred this must be discussed.

Evaluate the Clinical Management Skills as Appropriate for a House Officer:Collecting information. First page. How well do they summarise the salient features of the history and examination? Have they got the key features of the case important in diagnosis and management? See how they have recorded information. Discuss difficulties of getting the full story and communication with patients and whether they can reflect on their skills. Analysis of the case. First page, bottom. Do they list the actual problems and make a differential diagnosis and not simply a single diagnosis. Question their knowledge, interpretation of evidence, reasoning and judgement applied to clinical problem solving. Can they discuss the pathophysiology and how diagnoses are established? Ask on application of timely investigations and seek justification. Rational Therapy: Top of the second page of the case summary. From this case question their planning and implementing treatment strategies and their practical application of skills. Do they understand the practical detail of management? Address the risk-benefit of treatments and prescribing. Discuss what needs to be said to the patient or relatives. Evaluation: Middle section. Are they able to discuss the outcome of a case? How was the final diagnosis established? What is the long-term prognosis and what follow up is required? Discuss patient education, illness prevention or risk identification. Was the student aware of any adverse events? From a case chosen by the student question depth of specialist knowledge acquired about a particular diagnosis. When discussing the three cases use the following points to address the GMC professional behaviour, attitudes and duties, otherwise seek additional cases to cover these issues. Get the student to discuss a case that did not go as planned or where there was a complication, adverse event or where the student felt the management or communication could have been better. They should have completed an adverse event report. Ask the student to identify an example of difficult decisions, good application of the doctor-patient relationship or where they saw a poor example of professional practice or attitude. Honesty Handbook Year 5 2010-2011

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and respect for patients and their dignity should be discussed. Explore what they understand by working as team and illustrate different kinds of responsibility. Ask the student to select a case from the portfolio that brings out ethical or legal issue. Were they involved with difficult ethical decisions such as death and sickness certifications and consent to therapy, post-mortem or research. From the case discussed earlier see how the student understands efficient use of resources/investigation. Did the student encounter a case where they felt there was economic or practical constraint on provision of care? Reflection on case learning outcome & professional development: Look at the case summaries you have discussed with the student. Do they show a critical awareness of their professional learning and practice? Discuss educational skills and their ability to reflect on their experience. Read out what they have written and get the student to explain how this case has helped them and what it has encouraged them to do further. Complete the rest of the requirements of the PETA form. This will vary with the different attachments and the supervisors will have different mechanisms to confirm this. For instance there may be a SAMP report upon which to comment. Discuss the question they addressed and explore their critical thinking and analysis of the published research with regard to application in practice. Did they arrive at any recommendations? Award a grade but also write specific comments in each of the PETA boxes making sure that the student understands what you are saying. If you are pleased say so. Give specific praise if justified. Identify where matters have improved from the midterm PETA. If not, identify the weaknesses that have not improved. Are these sufficient to require referral to the Director of Final Year or has the student achieved an acceptable standard? If you have any constructive comments or anxieties to pass on to the next supervisor please write these in the section at the bottom. This might include a particular recommendation. Always make sure the student fully understands your concerns. Supervisor and student sign full signatures. Make sure the form has the student name at the top! Top copy is sent/taken by student to the School Office/Sub-Deans Office. The middle copy is kept by supervisor/clinical sub-dean and the bottom copy kept by student in portfolio. Please make sure all three copies are legible. After you have signed their form ask the student if they had any constructive comments they would directly like to make to the supervisors about how the attachment could be improved. Remind them that they are required to make a confidential feedback to the School Office using the SIFT attachment feedback forms that are on the web.

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COMPONENTS OF THE YEAR 1. WARD Care Attachments – F1 HO Shadowing Syllabus & PETA Objectives The GMC recommends that you should have spent part of your final undergraduate year shadowing an F1 pre-registration house physician or surgeon. The final year allows you to do this for a full seven weeks. During shadowing attachments in the fifth year students are expected to work as an integral member of the firm. They should assist the F1 and be fully involved in patient care and management plans. Since students may shadow a post in a hospital similar to where they will be a F1, their learning agenda includes becoming familiar with the functioning of the hospital, its formulary and protocols, post-graduate training opportunities, computer and communications systems. General Aims At the end of the attachment the student should have realised the pressures and responsibilities involved in ward care and decision making during the F1 year. They should have demonstrated: That they are independently able to work at a level at which it is appropriate to start their F1 training year. That they can work as a team member and understand the workings of a hospital from the perspective of the F1. Learning Environment You will have the opportunity to observe and participate in a wide range of clinical tasks and patient management activities in the real clinical environment. You will observe and be involved in the management of conditions as they occur on the ward to which the student is attached. You should be expected to explain cases in which they have been involved, and talk through all aspects of patient management with the F1 and consultant educational supervisor. You should work independently but with supervision so as to experience a sense of the level of responsibility involved in the F1 job. During your time on the ward, you will be integrated into the multi-disciplinary team, and so will have the opportunity to learn about the responsibilities and role of a F1 as an integral member of a firm. During the first week of the Ward Care attachment consultant supervisors should ask a senior nurse to monitor and provide feedback on the student‟s ability to work as part of a team. A feedback form is included in the student portfolio and this should be completed and filed in the portfolio before the final PETA meeting and portfolio review. Specific Aims You should observe and practice the processes of patient care during your stay on the ward incorporating these into your learning objectives, including: Receiving new patients to the ward History taking Physical and psychological examinations Ordering and conducting investigations Interpreting results of investigations and tests Diagnosis Formulation of patient management plans Initiation of treatment Prescribing and administering drugs and therapeutics Monitoring patient response to treatment Reviewing the management of the patient Handbook Year 5 2010-2011

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Deciding when and how to stop treatment Referral/ discharge Communication with family Communication with GP/ social services Role of outpatients/ review clinic After-care and follow-up Public health issues/ disease follow-up Undertaking these tasks is dependent on the level of student supervision and specific limitations on what a student can and cannot do. See next section. Expectations On the advice of the Clinical Sub-Dean and to suit specific local requirements the student would normally shadow the F1 in the post they first expect to occupy. However currently, until Foundation posts are organised earlier than is currently occurring nationally, this is not feasible. If practical, the student should take the opportunity to acquaint themselves with some aspects of the second post, but this is not mandatory. The skills you are learning are generic and it should not matter which post you actually shadow. In addition to shadowing during the routine daytime hours, you will have some on-call duties in order to experience the particular pattern of F1 working. In addition to the Clinical and Communication Skills support at the University, students are expected to attend any formal F1 teaching sessions at the hospital. Students will have full access to Education Centres and other learning resources at hospitals.

Expectations of the Student: Attend the ward on a daily basis to match the daytime hours of the F1 with a number of oncall periods as agreed with the consultant supervisor. Demonstrate a professional attitude and respect to fellow health care professionals, patients and colleagues. Join the F1 in their routine for the seven weeks. Under direction from the F1 or senior share with the F1 all the tasks of the day working as a team. However under no circumstances must they deputise for the absence of the F1 under these arrangements. The student is responsible through the F1 to the consultant for all their actions regarding patients within that medical team. Decide upon their competence to perform a task and confirm this with the F1 by agreement. This will depend upon the individual‟s personal experience and the decision of whichever qualified practitioner is supervising. Liverpool medical students have received considerable formal clinical skill training. At all levels of professional training however this is a matter of judgement that is a shared responsibility between the trainee and trainer. If in doubt, medical students should always adopt caution and accept the role of observer if required. All qualified practitioners should similarly reflect upon their own experience and only undertake a task for which they feel competent so as to minimise patient risk. There are certain tasks that will require close observation by a competent qualified professional when first undertaken. The student must ensure that the F1 has confirmed such arrangements. For example students may have been trained in passing a urinary catheter in the skills laboratory but to become professionally competent in this skill they must be supervised in their clinical demonstration of this task a number of times. Under close direction of the F1 or senior, clerk, examine and order investigations and initiate therapy. At all times actions will require confirmation with the F1 or senior qualified practitioner. Writing in hospital notes, completing request forms, prescriptions and discharge letters can be filled out by the student but must be signed by the F1 once checked. Demonstrate practical prescribing under supervision. Students may fill out but cannot sign fluid or prescription forms. Students may administer injections but only under direct and close observation by a qualified practitioner (doctor or nurse) with responsibility for supervision remaining with the F1 or senior medical practitioner. Handbook Year 5 2010-2011

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Accept that in all matters the decision of the F1 or supervising qualified practitioner is final. They must not argue or dispute actions or judgements in front of patients or impede the F1 in their work. If however they believe a decision to be wrong or harmful to the patient it is their duty to bring this to the attention of a senior qualified practitioner and to be able to justify the assertion. On business ward rounds and consultant meetings students should take responsibility to present and discuss the patients for which they have been caring. Briefly document within their portfolio using the CARE plan the management through to discharge of three cases per week that best illustrate the experience they have gained. Maintain the computer case-log. Maintain their log of skills attained Attend F1 teaching and audit. Actively participate in the PETA and reflect on their professional development in the portfolio.

Expectations of the Foundation Year Trainee: Share their experience of the post with the student and allocate tasks for them to undertake. With due regard to patient safety liaise with the senior nursing staff to ensure adequate student supervision and monitoring. Assume direct responsibility at all times for the student during clinical activities but expect the student to show professional judgement as to their own competence and ability. The F1 should remain within a reasonable physical distance from the student. It is acceptable to supervise the student dealing with another patient on the same ward, but not acceptable to send the student as their deputy to see a patient on another ward unless this is in close proximity. The F1 must not leave responsibility for supervision to another health professional without their full agreement. Not to leave the student to undertake a task that s/he does not feel competent to undertake. The F1 must not allow the student to deputise for a task unless they are confident of the student's competence and are able to provide supervision. The F1 by agreement may allow supervision by another qualified practitioner so long as they feel happy to supervise the student in that task. However the F1 through their consultant remains responsible for the student's actions. Expect the student to show professional courtesy at all times, to respect the role of the F1 and expect the student to assist them in their work (at the discretion of the F1). Use best judgement to protect the rights and safety of the patients in their care as they undertake their obligation to pass on their knowledge and skills. Report promptly to the consultant poor attendance, and any unprofessional behaviour by the student or hazardous situation that arises. Provide constructive feedback to the student and the consultant to assist assessment.

Expectations of the Consultant: Undertake three meetings for the PETA process to provide feedback to the student on clinical performance and professional behaviour and make the final PETA assessment. Student and consultant should sign the Mid and Final PETA forms. A copy retained by the student with the top copy returned by the student to the School Office. Institute a mechanism that monitors the student‟s attendance. Recognise a poorly performing student and provide guidance and support. Facilitate the working arrangements of the team for this period so that the F1 has sufficient time to manage the shadowing activities. Support and reinforce the learning of the F1 and shadow. Allow the student to take on the roles of the F1 where appropriate. Encourage an environment where there is a willingness to provide adequate supervision for the student. Encourage nursing staff and other health care professional to work with the student as they would any junior doctor, and include them as a member of the team. Specific Learning Objectives for Ward Care Attachments Handbook Year 5 2010-2011

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During the first meeting with supervisors, students should consider the PETA form contained in their portfolio, should agree on a timetable and decide upon specific activities that will help to achieve the PETA objectives. The portfolio contains a mid-term PETA to be signed by the supervisor and the student during the 4th week of the attachment, and a final PETA to be signed during the seventh or eighth week. One copy of each PETA should be sent to the School of Medicine as soon as it is complete, one copy to be retained in the portfolio.

Final Year Students Prescribing During Shadowing (not applicable in A/E) Students may write up drugs for patients but not sign the prescription. The legal responsibility for checking that the drugs have been written up correctly is entirely that of the supervising doctor who signs the prescription. Under no circumstances may a student write up a prescription for controlled drugs. These have to be written up and signed by a fully qualified doctor. The following sections have been ratified by local Hospital Trusts. A student can: Under close direction of the F1 or senior, clerk, examine and order investigations and initiate therapy. At all times actions will require confirmation with the F1 or senior qualified practitioner. Writing in hospital notes, completing request forms, prescriptions and discharge letters can be filled out by the student but must be signed by the F1 once checked Demonstrate practical prescribing under supervision. Students may fill out but cannot sign fluid or prescription forms. Students may administer injections but only under direct and close supervision by a qualified practitioner (doctor or nurse) with responsibility for supervision remaining with the F1 or senior medical practitioner

Under no circumstances may a final year student deputise for absence of the F1. 2. SAMP - Selectives In Advanced Medical Practice The overall goal of a SAMP is to promote the science and art of a particular clinical area. They provide students with the opportunity to take responsibility for clinical, administrative, management and professional activities in a given specialist area of medicine. SAMPs are intended to provide clinical teaching and learning opportunities that are different from the previous teaching in years 1 – 4 and are at a greater depth and allow some insight into future career possibilities. It is also an opportunity for students to explore the scientific basis of a speciality. A proportion of the learning objectives for each SAMP must be in the basic sciences. General Aims At the end of the attachment the student should have: Studied in depth a specialist area of clinical practice. Explored future career pathways. Engaged in teamwork, and experienced management in the NHS. Carried out a critical review of a chosen topic. Located the specialist area within the wider health care context. Identified key social and public health responsibilities related to that area of clinical practice. Identified and integrated basic science knowledge and clinical skills within the specialist environment. Specific Learning Objectives These are different for each SAMP. An example of a proposed SAMP in ICU is printed on the next two pages; this includes site details and specific learning objectives. A proposal for each SAMP option is displayed on the student web listed by specialty. Handbook Year 5 2010-2011

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Erasmus Selective In Advanced Medical Practice Several students are involved each year in the Erasmus exchange programme. They will go abroad for an Erasmus SAMP during sessions 3 and 4 of final year. The portfolio requirements and SAMP report however are the same.

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Illustrative example of a Selective in Advanced Medical Practice SECTION A: 1. Speciality Title/Aim: A Career Selective in Critical Care Medicine The student will develop particular skills in the identification and management of the critically ill patient. 2.

Consultant Name(s):

Professor R D Griffiths, Dr T Hankin, Mr P Nee, Dr F Andrews, Dr J Wood, Dr T Mahambry, Dr P Jeanrenaud, Dr K Sim. 3. No. of SAMPS Offered: (for each session, the number of SAMPs offered should be indicated in the box provided) Session 1 2 Session 2 2 Session 3 2 Session 4 2 Session 5 2 4.

Contact details and meeting point for student(s)

Intensive Care Unit, ward 4E Whiston Hospital ICU tel: 0151 430 1581, ICU Cons Sec tel: 0151 430 1421 5.

Site Information:

Whiston Hospital is a busy district general hospital serving some 350,000. The adult critical care department includes intensive care and high dependency beds. The consultants have a background in Medicine, Anaesthesia or Emergency Medicine. Junior staffs are involved in multidisciplinary rotations including the Acute Care Common Stem Training (ACCS).

SECTION B: The general objectives of any SAMP attachment are: To provide an in depth clinical practice experience that allows the student to collect and analyse information, rationalise treatment decisions and evaluates the outcome. To aid future career decisions To review the scientific basis for the speciality To provide an opportunity for students to engage in teamwork, and experience patient and service management in the NHS. To enable students to carry out a critical review of an aspect of a clinical area. To enable students to locate a particular specialist area within the wider health care context. To enable students to identify key social and public health responsibilities related to a particular area of clinical practice. Specific areas of interest for this speciality 1. Clinicial Problems -Hypotension/shock -Respiratory Failure -Confusion and CNS Failure Handbook Year 5 2010-2011

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-Oliguria and acute renal failure -Fever and sepsis 2. SPECIALIST INVESTIGATIONS & TREATMENTS -Monitoring circulation and use of inotropes -Monitoring respiration and ventilatory support -Electrolyte management and renal support -Nutrition support -Sedation, coma and brain death 3. SPECIALIST PRACTICAL PROCEDURES & SKILLS -Identification of the at risk patient -Central lines, haemodynamic measurement -Airway management -Mechanical ventilation and weaning -Nutrition and fluids 4. BASIC SCIENCE TOPICS FOR THE SPECIALITY -Circulatory control, determinants of cardiac output -Principles of oxygen transport, delivery and mechanisms of compensation - Pathophysiology of shock -Mechanisms and control of normal breathing at rest and exercise -Ventilation, perfusion, gas exchange and respiration. 5. POSSIBLE TOPICS FOR CRITICAL REVIEW (Best practice/best evidence/ clinical guide-line/ legal issue/ ethical dilemma) -Update from a selection of current management guidelines -Organ donation -Not for resuscitation orders -Withdrawing support -Communication with relatives Sections 6 & 7 briefly list specialist activities in which students may be involved whilst on attachment: 6. CLINICAL OPPORTUNITIES: -Twice daily consultant working ward rounds -Weekly Friday clinical team review and case audit meeting -Daily F2 shadowing and 1 night per week -Consultant, Registrar, F2 or Clinical Nurse Practitioner shadowing on ward visits, either referral or follow-up -Monthly ICU rehab clinic 7. MEETINGS/ ACADEMIC OPPORTUNITIES/ OTHER ACTIVITIES AND RESPONSIBILITIES: -The student will attend post-graduate meetings within the Trust -Take responsibility under supervision to implement protocol based tasks within their level of experience - Witness communication skills, doctor-relative, doctor-patient, multidisciplinary, team working. - Examine the activity descriptors and their role in audit of ICU performance - Provide discharge detail and undertake POST-ICU patient review.

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Expectations of the Student Attend the specialist service or team on a daily basis and join the trainees and consultants in the specialist activities. Identify at the first PETA meeting with the consultant a number of specific specialist learning objectives, some of which must be in the basic applied sciences. Demonstrate through discussion knowledge and application of these specialist topics. Undertake clinical or management tasks where appropriate but only consistent with their confidence and competence to perform a task. Assist with clerking, examination and investigations. Assist with treatment. Demonstrate practical prescribing and therapeutics under supervision On business ward rounds and consultant meetings you will take responsibility to present and discuss the patients they have been caring for. Briefly document within the portfolio using the CARE plan the management through to discharge of three cases per week that illustrate the depth of experience they have gained. To demonstrate the breadth of experience, complete the details in the computer clinical log of all cases in which they have been personally involved. Identify adverse events Maintain a log of skills attained Attend specialist meetings and at least one audit meeting. Identify a topic for critical review to contribute to the specialist team learning. This can be either a current management protocol or an ethical dilemma. Present the review in written form and where possible as a presentation to the team. Actively participate in the PETA and reflect on their professional development in their portfolio.

Expectations of the Clinical Supervisor (a named consultant): Undertake the three meetings for the PETA process and provide positive feedback to the student on clinical performance and professional behaviour and make the final assessment. Institute a mechanism that monitors student attendance. Regularly review the progress of the student's portfolio including the clinical case log and document this at the third PETA meeting. Recognise a poor-performing student and provide guidance and support if performance or attendance is below expected at the mid-PETA meeting. Facilitate the working arrangements of the team for this period so that the F2 or specialist registrar has sufficient time to encourage learning and provide supervision. Encourage the student to be a member of the team and allow the student to take on tasks that contribute to the team activities. Identify at the first PETA meeting with the student a number of specific specialist learning objectives, some of which must be in the basic applied sciences. Foster an environment that requires the student to demonstrate through discussion knowledge and application of these specialist topics. Supervise and assess the 2500 word critical review, and where possible, ensure that an opportunity is provided for the student to present their report to the clinical team.

SAMP Critical Reviews – Requirements and Marking Criteria Students should write a concise report of between 2000 and 2,500 words (maximum) which is either: An up to date critical review of a clinically relevant best practice guideline. OR A critical discussion of a relevant clinical/legal/ethical dilemma.

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The SAMP reports are NOT SSM projects. They only form a small part of the SAMP and must not detract from the clinical case report learning All SAMP reports must follow a standard structure: Guideline review: Section 1: Introduction and background to include the aims and objectives of the review. Section 2: Discussion of the guideline in the light of current literature. Section 3: Revised guideline and applied conclusion section. There may be no change in the guideline but the evidence for the status quo must be established. OR Review of a clinical (legal/ethical) dilemma: Section 1: Introduction and background establishes the questions or arguments that are to be addressed, Section 2: Review of the current literature that supports the various arguments Section 3: Conclusion that summarises the current positions. Illustrative cases may be included. . Reports must have been assessed by the clinical supervisor within the time frame of the clinical 7 weeks of a SAMP. Students are therefore strongly recommended to complete their critical review in the first five weeks of the attachment to allow sufficient time for assessment. Grades will be based on the marking criteria described overleaf, the minimum grade is 0, the maximum is 9. A mark of zero will be given for any section not done. Any critical review graded a fail (0-4) must be independently second marked before the end of the eighth week of the attachment. The PETA for the SAMP (which must be submitted to the School of Medicine by the end of the 8th week) must include the grade awarded for the critical review. The critical review assessment form is shown overleaf. Assessors will award a mark of either zero, 1, 2 or 3 for each section of the review.

Total grade to be stated on the final SAMP PETA: 0-4 = Fail, 5, 6, 7 = Pass 8-9 = Pass with Merit Oral Presentation of SAMP Reports Though not linked to final year assessments, students may be encouraged to present a version of their SAMP report to the supervising consultant and specialist team. One of the aims of writing the report is that the student should contribute to the body of knowledge in that field. Written Work Students are required to type or word process SAMP critical reviews. They must be concise documents and not lengthy dissertations. Quality is not measured by size but reasoned content. Written reviews must adhere to the following guidelines. Length 2,000 – 2,500 words maximum, excluding references and figures. Typestyle “Times” style typeface with 12 point pitch. Spacing 1.5 line spacing should be used. Margins Margins at a minimum of 40mm for the left hand margin and 25mm for the right hand margin. Referencing Vancouver style referencing must be used e.g.,: (1) Articles in Journals Handbook Year 5 2010-2011

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You CH, Lee RY, Menguy R. Electrogastrographic study of patients with unexplained nausea, bloating and vomiting. Gastroenterology 1980 Aug; 79(2): 311-4 (2)

Personal Author of a Book Colson JH, Armour WJ. Sports injuries and their treatment, 2nd rev ed. London: S Paul, 1986.

Numbered references should be positioned at the end of the work and reference numbers in the text. Page numbers Pages should be numbered consecutively and the position of page numbers should be consistent throughout. Diagrams

Diagrams and illustrations should be placed as near to the relevant text as possible.

Computing facilities In the event of any problems accessing computing facilities, you should contact the School Office AS SOON AS POSSIBLE. Critical reviews must be assessed by the end of any SAMP attachment. It is advised that work is completed and ready for marking by your supervisor by the end of the 5th week at the latest.

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SAMP Assessment Form for Critical Review of Clinical Guideline or of a Legal/Ethical Dilemma Student name:

Date:

Title of review:

signed:

Report Section

Section 1 Guideline review Introduction and background, includes aims and objectives of the review. OR Review of a clinical (legal/ethical) dilemma: Establishes the questions or arguments that are to be addressed.

Descriptors

Assess ment scale

Towards Merit As satisfactory, but research and review is more extensive and draws upon key journal references.

3

Guideline review Update section, discusses the guideline in the light of current literature.

Grade:

/3

Comments

Satisfactory Summarises background information to establish the reason for the review and the question to be addressed.

2

Unacceptable Unable to identify the main issues of the review. Unfocused collection of past references from books.

1

No work submitted for this section.

Section 2

Grade awarded/ Comments

0

Towards Merit As satisfactory, but can support arguments/ implications from cited new evidence.

3

Grade:

/3

Comments Satisfactory Demonstrates analysis of recent literature and draws together main implications/ discusses main arguments.

2

OR Review of a clinical (legal/ethical) dilemma: Reviews the current literature that supports the various arguments.

Unacceptable Limited analysis of any new literature, unable to draw together main implications/ discusses main arguments.

1

No work submitted for this section.

Section 3 Guideline review Revised guideline and applied conclusion section. There may be no change in guideline, but evidence for status quo must be established. OR Review of a clinical (legal/ethical) dilemma: Conclusion that summarises the current positions.

0

Towards Merit As satisfactory but has a more cogent argument and discusses the limitations of any new recommendations. OR competently summarises and/or discusses the current position. Satisfactory Presents a coherent concluding argument for and against the status quo and presents a proposal for best practice. OR Clearly summarises the current position. Unacceptable An incoherent conclusion that lacks evidence of structured thought. No clear proposal for best practice presented OR Current position not summarised

3

Grade:

/3

Comments

2

1

No work submitted for this section. 0 TOTAL GRADE:

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3.

ACUTE Care Attachments: Emergency Medicine Syllabus and PETA Objectives Convenors:

Dr. Sarah Graham - EM Consultant, Whiston Hospital Dr. Charlotte Doughty - EM Consultant, Arrowe Park Hospital

Aims General Aim To gain competency in the care of the undifferentiated patient and the acutely ill or injured adult or child. Specific Aims At the end of the attachment you should understand the principal functions of the accident and emergency department. Students should be able to: Appreciate the acute management required for the: - Relief of suffering - Resuscitation of vital functions - Prevention of deterioration of the patient Perform basic and advanced life support Evaluate the undifferentiated patient Understand the immediate management of the undifferentiated patient Develop a differential diagnosis relevant to the patient‟s chief complaint Consider potentially serious conditions consistent with the chief complaint Discuss the options for treatment of patients presenting with common emergencies and demonstrate acute prescribing. Evaluate the special needs of elderly patients presenting to the EM department. Evaluate the special needs of children presenting to the EM department. Demonstrate an awareness of public health issues in emergency medicine Demonstrate an awareness of multidisciplinary team working The accident and emergency department provides educational opportunities 24 hours a day. The student will experience out of hours work and „shift work‟. A base in the accident and emergency environment also affords access to other clinical areas where delivery of care continues during the early hours following admission to hospital. The acute care module provides an opportunity to EVALUATE, SYNTHESISE and APPLY the fund of knowledge acquired in previous levels of the medical course in a realistic situation. Learning Environment In this module, students will observe and participate in the management of patients attending the accident and emergency department. Students will observe and practise the processes of patient care during the first 24 hours following presentation, including: Preparation to receive patients The triage process Immediate life-saving interventions Targeted History and focused examination Utility of monitoring in the emergency department Handbook Year 5 2010-2011

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Utility and interpretation of special tests Initiation of treatment and monitoring the response to treatment Referral/disposal Ambulatory care/review clinic You should attend at relevant procedures carried out by experienced members of the Nursing and Professions Allied to Medicine (PAM) staff such as: Triage, assessment of pain relief needs, recording observations, monitoring patients Recording the electrocardiograph Nasogastric intubation Urinary catheterisation Application of plaster casts Wound closure, dressings and splints Exposing and developing radiographs Physiotherapy interventions in the EM department In addition you should follow the progress of selected patients after admission to hospital In this module you will concentrate on the first 24 hours definitive care during which the patient is stabilised and early diagnostic and therapeutic interventions are initiated.

Expectations of the Student Students cannot act as completely independent practitioners in the AED, however they are expected to demonstrate independence of thought and mastery of personal skills under supervision. All patients must be seen and examined by trained staff members. All procedures and interventions will be supervised and all investigations agreed by trained staff members. Trained staff will implement action after discussion with the student. STUDENTS ARE EXPECTED TO: Attend the EM department in accordance with their roster. departmental co-ordinator of any absences due to illness.

Students should inform their

Daily shadow staff in the EM department who are familiar with your learning objectives. Attend the resuscitation room, trauma room, major treatment and minor treatment areas. Timetables should be agreed with the consultant supervisor at the first PETA meeting. Attend relevant procedures carried out by experienced members of the nursing and other staff (including Professions Allied to Medicine). Attend review clinics and observation ward rounds in the EM department as applicable. Attend any formal teaching sessions as applicable Attend the ICU/HDU/CCU and acute admissions wards - to enable follow up of patients during the first 24 hours of admission Spend 1/2 day or 1 day as an observer with an ambulance team to promote an understanding of `the patient journey‟. This will be arranged during the attachment. Students will be expected to conform with the Ambulance Service requirements of an observer to ensure their personal safety. Write in the clinical notes. Trained staff will countersign all clinical records written by the student. Students CANNOT prescribe or gain patient consent. Evaluate patients and derive a plan for initial management, further investigation, treatment and disposition in accordance with the available guidelines. Students CANNOT treat or discharge Handbook Year 5 2010-2011

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patients independently. Demonstrate knowledge of practical and safe emergency prescribing. Students may fill out prescriptions under supervision but CANNOT sign prescriptions. Briefly document within their portfolio, using the CARE plan, the initial management of three cases per week that illustrate the depth of experience they have gained. To document the evidence of the breadth of their experience they must complete the details in the computer clinical log of all cases with whom they have had some personal involvement (see section on computer log). Maintain a log of skills attained on the clinical skills record card in the portfolio. Act in a mature and professional manner at all times, observe local departmental guidelines on how to conduct themselves. Be presentable and identifiable at all times. Actively participate in the PETA process and in particular identify specific learning objectives at their first PETA meeting with their supervisor. Maintain a clinical log-book and update their clinical skills log and case reports prior to their PETA meetings. Use common sense!

Expectations of the Consultant Convenor and Consultant Supervisors Each EM Department will have a convenor in overall charge of the attachment. In addition each student will be allocated a named consultant supervisor who will take ultimate responsibility for their education. In the absence of the named supervisor, another consultant or designated deputy may deputise, however the named supervisor must deal with all borderline students concerning their assessments, and must sign or countersign all PETAs. THE CONSULTANT CONVENOR IS EXPECTED TO: Be aware of the names and arrival dates of students in the department Prepare in advance. Ensure that there is available for each student: 1. 2. 3. 4.

Timetable, including „shifts‟ to avoid overcrowding by students Hard copy orientation material, ‟who‟s who in the department‟ etc Advice on etiquette, dress code etc Provide copies of the EM learning objective syllabus where necessary

Meet and greet the students on day 1 in the department. Provide a person to undertake a guided tour of the department. Provide an induction to the Department. Ensure that junior doctors and others who may be asked to provide educational input are familiar with the students‟ objectives Be supportive of students and facilitate their learning experience in the EMD. Arrange and participate in small group discussion of cases seen. Students should present a case from their portfolio, and may lead the discussion. Ensure that they are familiar with the PETA process.

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THE CONSULTANT SUPERVISOR OR DEPUTY SHOULD: Meet with students on at least three occasions during their attachments 1. At the beginning to discuss objectives and timetable 2. In the 4th week for the mid-term PETA 3. In the seventh/eighth week for final PETA assessment Ensure that students work only under supervision and undertake only those clinical tasks, which are appropriate to their role. Monitor student attendance in the EMD, no formal signing in should take place, however students are expected to attend at least 90% of the time and complete work which demonstrates that they have treated the attachment as a professional training position. Recognise poorly performing students and offer guidance and support. Get feedback from other staff as to how well students are performing Meet with any student demonstrating cause for concern at the mid-term PETA meeting and conduct this student‟s final PETA assessment in person. Be familiar with the structure of the undergraduate curriculum, copies of the undergraduate handbook are available from the School of Medicine office. Be familiar with the suggested syllabus for the EM attachment. Be aware of the scoring system for final assessment and the appropriate action in cases of unsuccessful completion of the attachment. Liaise with the Convenor in case of poorly performing students.

Expectations of the Emergency Medicine Team The EM team refers to all doctors, PAMs (professions allied to medicine – eg: Pharmacist/ OT/ Social Worker), and nurses - in the EMD. THE EM TEAM ARE EXPECTED TO: Be introduced to the student during the introductory week. Welcome students as colleagues, and encourage their attendance at regular in-department weekly teaching, and other EMD training or management activities. Be aware of the syllabus for the EM attachment. Be aware of the clinical skills students are required to gain competency in. Ensure that the student has exposure to the wide variety of pathologies presenting to the EM department and how they are managed. Allow the student to observe and assist at practical procedures, eg: urethral catheterisation. Supervise students for procedures where this is necessary, e.g.,: IV cannulation, wound dressing, bandaging etc. Ensure that students get exposure to normal working practices of the department. This will include supervision by nursing staff during some procedures in addition to doctor supervised activities, such as ward round on the short stay ward, and follow up clinics. Be supportive of students and facilitate their learning experiences in the EMD. Ensure that students work only under supervision and undertake only those clinical tasks, which are appropriate to their role. Review clinical record entries made by students for patients they have seen. Assist students in identifying areas for independent study. Handbook Year 5 2010-2011

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Facilitate medical student follow-up of patients admitted through the EMD. Give feedback to the tutors regarding student‟s progress. Acute Care Attachment Specific Objectives A full list of specific aims and objectives to help students define their learning objectives is available and should be made available to students at the beginning of the attachment. This is a summary of the main aims and objectives. By the end of seven weeks, the student should have demonstrated that s/he is able to: develop a differential diagnosis relevant to the patient‟s chief complaint; consider potentially serious conditions consistent with the chief complaint; consider factors in history, examination and special tests relevant to the classification of disease by severity; demonstrate a knowledge of how symptoms and signs of disease may be modified by: Age Comorbid factors Compensatory mechanisms Prescribed drugs Intoxicants Time since onset Prior treatment S/he should be able to discuss the options for treatment of patients presenting with common emergencies including: Acute medical emergencies Acute abdominal pain Traumatic conditions - wounds, burns and skeletal injury Infectious diseases - Meningococcal disease, pneumonia, urinary tract infection Complications of early pregnancy (Special arrangements at RLUH/UHA) Acute psychiatric emergencies (acute confusional states and assessment of suicide risk) S/he should be able to evaluate the special needs of elderly patients presenting to the EM department. S/he should be able to evaluate the special needs of children presenting to the EM department. Note: Since the Royal Liverpool University Hospital and Aintree EM departments do not see children, students who are on attachment at those hospitals will go to Alder Hey EM for one week to get experience of paediatric emergency medicine. Students should be able to demonstrate an awareness of public health issues in emergency medicine. Specific Aims - 4 Skill Areas 1. 2. 3. 4.

Attention will be focused on: The evaluation of undifferentiated patients with the objective of identifying serious pathology. The development of a knowledge of emergency prescribing. The development of practical and clinical skills using your clinical skills record card as a guide. The development of your communication skills. (Demonstrate competence in communication in supervised encounters).

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Paediatric Syllabus The paediatric syllabus includes: the teaching of practical skills specific to children, recognition of the sick child, an understanding of prescribing for children, an understanding of the importance of child abuse, an understanding of common emergencies in children, knowledge of the special requirements of children within EM dept, an appreciation of the legal aspects of treating children in EM dept Case Records for Acute Care Attachments The following clinical processes should be included in the cases: 1. Critical cardiac ischaemia (USA or AMI) 2. Respiratory emergency 3. Trauma resuscitation with ATLS protocol 4. Head injury (minor or major) 5. Use of observation ward 6. ITU admission of an A&E patient 7. Management of an orthopaedic injury 8. Poisoning (overdose) 9. Appropriate use of diagnostic imaging 10. Antibiotic treatment or prophylaxis 11. A “risk management” case (complaint, missed finding, identify where process could be improved) 12. The multidisciplinary approach to patient care 13. A hand injury 14. A soft tissue injury 15. Attempted suicide 16. Acute confusional state

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4. Community-Orientated Medical Practice Unit Director Professor M Lloyd Williams, Email: [email protected] Deputy Director Dr Sian White, Email: [email protected] Unit Administrator Chris Johnson Tel: 0151 795 4361 Email: [email protected] Community Studies Secretary Rachael Carr Tel: 0151 795 4350 Email: [email protected] Fax: 0151 795 4349

Internet website: http://www.liv.ac.uk/csunit Further Contact Details: Liverpool Clinical Tutors Dr Christine Thomas:

[email protected]

Dr Jane Brocki: Dr Andrew Cavadino:

[email protected] [email protected]

Llandudno Clinical Tutor Dr Julia Riley:

[email protected]

Llandudno Administrator Glenys Pardanjac Tel: 01492 871477

Abbreviations used in the text: ANC CDM CHS CSRC Com.Skills DN G.P. GP HA H.P. HV IHD IT PCEC

Ante-natal Clinic Chronic Disease Management Child Health Surveillance Clinical Skills Resource Centre Communication Skills District Nurse General Practice General Practitioner Health Authority Health Promotion Health Visitor Ischaemic Heart Disease Information Technology Primary Care Education Centre

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PCT PD PH PN Pr. Act. PETA UCCT

Primary Care Trust Personal Development Public Health Practice Nurse Practice Activities Professional Educational and Training Appraisal University Community Clinical Teacher

In the Community, you will work with, and under the guidance of a General Practitioner and his/her team. There will be 8 weeks of compulsory community activity including 1 week of reflective learning. The main aim of this component is to encourage the development of an independent practitioner. The three main goals, and the educational objectives required to achieve these goals are outlined below. Goals 1. Demonstrate awareness of opportunities and inequalities in Community Health Care delivery 2. Demonstrate competency in clinical and communication skills

3. Demonstrate maturity of personal and professional values

Objectives Identify local issues Review the effectiveness of local health care Demonstrate effective consultation skills Consolidate previously learned practical skills Evaluate patients' problems critically and holistically Show logical reasoning when making clinical and non-clinical management decisions Apply effective communication with patients, relatives and colleagues Practice team skills including taking leadership and sharing in decision-making. Acquire new clinical skills whenever possible Apply educational principles with patients and colleagues Implement the principles of self-awareness and self-criticism in clinical and non-clinical situations

Weekly Activities Summary (see contents page for abbreviations) You will achieve the educational objectives by It is important to remember successfully completing a number of weekly that, at the end of each activity, activities both inside and outside the practice. you still have to formulate learning objectives. In Practice four ½ days minimum per week, for example comprised of: “ I am a GP”….............................(at least) ½ day each week Practice Related Activities ……… 3 sessions per week Outside Practice CCT ……. ……………..1 full day Personal Development 3 sessions per week Backup session ½ day each week

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The backup session -this time can be used to collect additional information on patients you have seen in surgery or clinic. It may also be used for any additional activities such as visiting a hospice or spending time with a social worker (remember Personal Safety if visiting outside agencies) An example (actual days may be different according to placement) of a full week‟s Activities is presented in the following table:-

Monday

Tuesday

Pr.Activity

Pr.Activity

Wednesday

“ I am a GP”

Pr.Activity

Backup session

Thursday

PD

UCCT

PD as directed by UCCT

Friday

UCCT

PD

You must keep a portfolio of learning. This will be a record of learning objectives and what you have done about them, tasks accomplished, skills re-visited and a written summary of at least 16 patient encounters. Also 2 significant events and 2 clinical science/therapeutics reflections should be recorded. Your portfolio will be assessed by your GP on week 4, and at the end of the attachment.

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In Practice Activities – 4 sessions each week (Please see Contents page for abbreviations)

Performance will be assessed weekly

Session 1

1/2 day each week doing a GP’s work, shadowed by a G.P. *

You may also have “on-call” commitments with your GP on this day

Morning consultation sessions Dictate/ write referral letters when required Use Practice method of reviewing incoming post/ investigation results/ prioritising actions Use Practice method of issuing repeat prescriptions House visits with GP(remember for personal safety another student should be with you if you are visiting an outside agency) Give telephone advice when required

Sessions 2, 3 and 4

Chronic Disease Management & Health Promotion activities Using the practice protocol, run as many of the following practice clinics as possible shadowed by the PHCT member who normally runs the clinic. Asthma/ Diabetes/ IHD/ Lipids/ BP/ smoking CHS/ ANC/ PN clinic/ DN clinic/ Travel Vacc./ Imms/ Diet/ Cx cytol. The PHCT member who has supervised you running a clinic will be asked to complete the Communication Skills Assessment form. You and the GP supervisor will use this to help in the completion of your final PETA

All clinical and management decisions must be discussed and agreed with the supervising GP or his/ her deputy before any action is taken.

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Outside Practice Activities – 2.5 days (5 sessions) (Please see Contents page for abbreviations) 2 sessions Personal Development - “Time to think” Preparation for weekly activities IT/ Library/ Reflection 1 session Personal development ( as directed by UCCT) Preparing case for presentation/other tasks for CCT day 2 session Full Day Release - CCT During the day a variety of topics will be covered including: Reflection

Performance will be assessed weekly

Therapeutics Significant event analysis/defensive medicine Sickness Certification Medico legal/Ethical Issues Stress Management Careers/personal development

During these sessions the following communication skills will be addressed Counselling Motivational interviewing Handling emotions Telephone consultations Handling complaints/conflict On one of the CCT days you will have the opportunity to work with an actor and practice your consultation skills. During this session you will both receive and give feedback to other students in the group on these consultation skills and will have an opportunity to practice strategies for dealing with different situations. You are required to produce reflective detailed case presentations on powerpoint to present to the group for discussion. In addition you will be required to prepare for each CCT day.

Full Attendance at UCCT sessions is compulsory

Weekly Activities In the first week, you will be expected to acclimatise very quickly. Your GP and Practice Manager will have a 7 week timetable for you, with in- and outside practice activities planned in advance, and you need to sit down with them to make sure that you all agree on your responsibilities. You need to make yourself as available and accessible as necessary, and meet the team as soon as possible. You will need to obtain from the practice one example of a significant/critical event analysis which they have carried out in the past year or one which you have been involved with in the practice, to take to the second UCCT session. Straight away, you also need to familiarise yourself with the following: -

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The staff

Administrative

Clinical Diagnostic equipment

The premises

Patient management protocols

Reception procedures

Letter format

Times of surgery/ clinic sessions IT system

Review systems for mail, hospital and lab.reports, etc Routines for disposal of sharps/ waste

Record keeping

Repeat prescription routines

As soon as possible, you need to become familiar with clinical matters. It will NOT be sufficient in your first week to simply sit in with your GP and your other supervisors to observe what happens. Your GPs have been advised that you are expected to take an active, full participatory role in surgeries, clinics and all other practice activities from your first week. In this way, you can quickly learn the routines and protocols by doing rather than just watching. For at least one 1/2 day each week, you will carry out the duties of your GP, doing his/ her work. Your GP will shadow you throughout the day. You will take the lead role in all of the GP’s daily activities. In the first week only, you might take it in turns During two more half-day sessions, you will be expected to with your supervisor to take the lead role in either a health promotion or disease see patients so that you prevention clinic or a patient education clinic. can see each his/her consultation technique. In the second week, on your “1/2 day as a GP” you should aim to see about 6 patients in each consultation session, and your GP will have patients booked to see you at approximately ½-hour intervals. The same situation applies in clinics. You have to talk with whoever normally runs the clinic and find out their normal schedule. When you are running a clinic, the patient numbers should be reduced slightly, to facilitate your learning.

You need to do the consultations and make decisions. Your GP/ PHCT member is shadowing you, but you need to discuss with him/ her any management decisions, and they must sign any necessary certificates you decide to issue.

In subsequent weeks, you will gradually increase the numbers of patients that you see in both surgery and clinic sessions. This will be determined between yourself and your GP/ PHCT member.

NB At the end of each “1/2 day as a GP” and each clinic, you should have identified a number of learning objectives from every patient encounter. You must attend to these in greater detail than in previous years. In total, you will have completed at least 16 reflections on your personal medical practice. In addition you should write up two Significant Events/Adverse Events/Critical Events and either two Clinical Science reports or two therapeutic reports. So in total there should be 20 case studies/reports in your portfolio. Keep them in the portfolio for presentation in feedback sessions to your GPs. Your “Personal Development” sessions can be used for private study, to prepare your weekly activities, to use the practice IT system and Library, and to reflect on your work and its outcome in terms of patient management.

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Remember that there is one session – Back-up time - available for completion of in- or outside practice activities, writing up cases studies

Teaching Activities CCT Day Release weekly activities are dependent upon the area in which you are located in the Community. Students working in the Merseyside area and peripheral hospitals will have the day based at the University; sessions in Llandudno take place on a Thursday. All outside-practice sessions:– as part of your personal and professional development it is useful to document and reflect on any additional outside activities and keep this with your portfolio. You must keep your PETA assessment form in a safe place. It must be presented, with all your other PETA forms to the appropriate University authorities on request before graduation.

Please remember that you are a student medical practitioner. At all times, therefore, you must conform to the standards and values expected of the profession.

Assessment in the Community You must obtain a Professional Educational and Training Appraisal (PETA) certificate for each of the five programmes of the year. The PETA forms are a collection of professional statements confirming your “fitness to practice”. In the Community, assessment is both formative and summative Formative assessment is continual, and based on:Observation by your supervisor (General Practitioner or deputy) during your clinical attachment Review at intervals of your record of achievements – a portfolio - by your Supervisor Full attendance at Community Clinical Teaching days Summative assessment:Only if you have fulfilled the aims and goals of the attachment, and achieved the agreed specific learning objectives will a PETA certificate be signed by your GP Supervisor at the end of your attachment Your final year requires you to practice as an individual with hands on experience working as a clinical "apprentice". Your learning in the Community will be helped by, and assessed, using your portfolio. The portfolio will cover all in-practice and outside practice activities, and include  an electronic log-diary of all patients seen in the General Practice setting.  a written summary of: 16 case reports 2 significant event analyses 2 clinical science reports/therapeutic reports  tasks accomplished  skills re-visited,  new skills acquired  a record of learning objectives and what you have done about them, The parameters used for assessment will be those indicated on the PETA form in the handbook. Your portfolio will be assessed by your GP on week 4 and at the end of the attachment. Time should be set aside to do the assessment and give you feedback on your performance. Please take your portfolio to your GP attachment each week as your GP may want to check on your progress. Handbook Year 5 2010-2011

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In the 6th week one of the practice staff will be asked by the GP to complete the General Practice Communication Assessment form. You should then discuss the assessment with your GP before he/she completes your final PETA In the event of poor performance, your GP will contact the Community Studies Unit Administrator as soon as possible. Thus if there is any concern early on, it is feasible to try to address this appropriately before the final PETA is due. If after consultation it is felt that your overall performance is not satisfactory you will be referred to the Director of Final Year for a final decision. Any absences from General Practice must be notified to the Community Studies Unit secretary. Satisfactory assessment will ensure that you receive your PETA form. Your Final PETA will also need to be countersigned by your UCCT as well as your GP to confirm attendance and full participation in activities as directed by UCCTs and demonstration of competent communication skills. Expectations of the Student Attend the General Practice surgery, University Community Clinical Teaching Sessions and any other organised activities in accordance with their timetable. Under supervision from their GP the student will undertake the daily activities of a GP. This will include consulting in surgery, answering queries, repeat prescribing, reading and actioning clinical letters and inputting data on to the computer, telephone consultations, home visits, attending team management and clinical meetings. By the end of the attachment they should understand the day to day running of a Primary Care, its organisation, team work and how management decisions are made. During all patient interactions the student should demonstrate competent communication skills When consulting with patients the student should take a relevant history and examination of the patient. Formulate differential diagnosis and management plan. The patient should then be presented to the GP supervisor. Following agreement from the GP supervisor the student should order any investigations and initiate therapy (the GP must sign the prescription) and make any referrals. All consultations should be recorded on the computer system in the appropriate format. Throughout this process the student should recognise the limitations of their personal knowledge It is important to make arrangements for any follow-up or safety netting Part of the consultation involves the ability to review previous diagnoses and management in light of best evidence and show awareness of good practice and perform a medication review. They need to be aware of the principles of repeat prescribing The student should understand and apply recognised principles of health screening and be able to manage a health promotion/disease prevention activity in practice During the attachment the student will run a chronic disease clinic. They will review the patient and their condition and identify and initiate any management changes. They must be able to prescribe appropriately in acute and chronic situations(students can not sign prescriptions) Demonstrate competent communication skills with colleagues and peers to facilitate good team work Be aware of adverse events and how the practice monitor and manage any significant events that come to light. They should understand the principles and responsibilities of “on call” and “out of hours” services and how it applies to their GP surgery Maintain a log of skills attained Continue to develop their personal prescribing formulary Handbook Year 5 2010-2011

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Actively participate with their GP supervisor in their PETA and reflect on their professional development in the portfolio. Demonstrate a mature and professional attitude at all times, both in practice and during University teaching sessions. Present patients during University teaching sessions, as agreed with their Community Clinical Teacher, and demonstrate their reflection on the case Undertake any preparatory work for University teaching sessions Expectations of the GP Supervisor Undertake the three meetings for the PETA process and provide formative feedback to the student on clinical performance, communication skills and professional behaviour and make the final assessment. Inform the Community Studies Unit secretary of any absences Regularly review the progress of the student's portfolio including the clinical case log and document this at the third PETA meeting. Get feedback from other members of the health care team to help inform the PETA process Recognise a poor-performing student and provide guidance and support if performance or attendance is below expected at the mid-PETA meeting. Provide the student with a clear timetable of their activities Provide a fully equipped clinical room with access to computer records in which the student can consult with patients on their own, before presenting the case to the GP supervisor Encourage and supervise students learning from patients Encourage all the Primary Health Care Team to work with and include the student as a member of the team.

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OTHER GENERAL ACADEMIC ELEMENTS Clinical Case Guidance – Using the C.A.R.E Approach Clinical case reports are the main learning method that a student demonstrates progress through final year: clinical case management is central to final year and the PETA assessment. It is also how you will continue learning through the rest of your professional life. Do not take this activity lightly. It is not simply about documenting what happens but a much higher intellectual activity by which you are stimulated to think and read around the subject. To make the most of the case for your learning you should expect to spend at least two hours on reading or research around the subject. When permitted you should write in the hospital/clinic notes. However each week at least three cases should also be included in your portfolio. The case report does not simply document the initial clinical feature of the case and its diagnosis, in final year more time should be spent on the patient centred management, practical prescribing and evaluation of progress and outcome. You should not only consider the outcome, but what were the risks and complications of the problem and its treatment. There are enough pre-printed case report forms provided in your learning portfolio to last the year. It is not necessary to type up your reports but please write clearly and legibly. You may write in note form as you would in the medical notes where this is appropriate, and so long as the meaning is clear to a supervisor or external examiner. It should NOT be necessary to add additional sheets. Writing Case Reports The method you use follows a logical cycle similar to that used in research. We have called it the CARE plan. It stands for Collect case information, Analyse and investigate, Rationalise treatment options and Evaluate the outcomes. The evaluation phase comes in two parts, the first asks you to reflect on the use of best evidence with a view to improving patient care. The second asks you to reflect on where the case fits into your existing learning plan by requiring you document what existing learning objectives you have meet, as well as new ones you have identified, as a result of your involvement with the case With this process you will learn how to diagnose and manage a particular problem, taking into account the circumstances of the individual, evaluate (audit) your care of the patient in the light of current evidence, as well manage and document your professional development towards F1 training.

Collect Collect

Evaluate

Reflect

Analyse

Rationalise

During each Clinical attachment it is expected that you document the clerking and management of at least 3 patients per week. The precise format may vary whether you are F1 shadowing, in A/E or in the community or a specialist selective. In some SAMPs, particularly in laboratory or diagnostic services some variation in approach is permitted. Clinical Science reports can be used as alternatives for some learning objectives. When you choose the cases you should ensure you have completed the core cases and revisited those that you have perhaps considered in less depth. The core cases provide a useful framework but you should not exclusively study cases from this list, particularly when you are in specialist areas. Your aim is to show a breadth of experience and the following rules should apply.

a) When choosing each case to write up, pick those that illustrate how you have addressed a learning objective for that attachment.

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b) Use the cases to demonstrate practical prescribing or a new procedure. In each clinical area demonstrate by choice of the cases issues of prescribing in different settings (acute, maintenance, discharge etc).

c) Use the cases to illustrate different processes of care applied to the case. This is particularly important in the community where the case management may reflect prevention. Collect Case Information: History and examination reported only as brief notes of the key features sufficient to describe the case. By intention the space is limited so that it forces you to get used to summarising the key points. Of course we encourage you to do a full clerking elsewhere when appropriate and permitted write this in the hospital/clinic notes; however we wish you to list the key features only in the portfolio. Analyse: Define the clinical problems and list reasonable differential diagnoses for each problem. List the initial investigations and the subsequent investigations to confirm your analysis. Present (or order) discriminating investigations in a realistic sequence. List key investigation results that confirm diagnosis and guide management Explain any abnormal results and implications for treatment. Provide a working diagnosis (or rarely diagnoses). Rational Therapy: Describe a rational treatment plan for this patient. Immediate therapy and the information you will communicate to the patient. What procedures need to be performed? Who else needs to be informed? Where will the patient be nursed, special instructions? List the drugs prescribed, the doses and route, and any interactions or precautions. Is the patient at any risk? Explain the plans for follow-up. To whom was care handed over? What is the indication for discharge? Describe any long term therapy and communication. Evaluation: Reflection on Practice and the Use of Best Evidence This section is about the patient. It is very important and you should spend time reading up. Review the working diagnosis in the light of investigations and progress. List what should be done to monitor the disease, progress and treatment? Did the care follow a good practice and best evidence guideline? Briefly mention the key features of any current guideline that apply to this case. You may include copies of such guidelines in your portfolio next to the case if you wish. Describe any problems or complications (adverse events) and explain why these might have occurred or how they could have been prevented (risk management)? List any family or social implications? Reflection on Learning – Meeting and Identifying Learning Objectives This is about what YOU achieved towards meeting your learning objectives and not about the patient or the case. This section asks you to make connections between your current circumstances, past experiences and future intentions: - think about what you have done and leaned. You may find this difficult at first but for you, your supervisor or any external assessor, this section must show how you are managing your learning from professional practice. How has being involved in this case related to your PETA learning objectives? What are you proud of? What have you learned from this experience, knowledge and skills? Handbook Year 5 2010-2011

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What you should now learn more about? Have your professional attitudes been affected by this case? How will this influence your behaviour in the future? What have been your strengths in dealing with this case? Could you have done better?

Example of a Clinical Case Record This is only an illustration of one type of format. Do not necessarily copy this layout slavishly rather follow the spirit of the instructions presented earlier. Sometimes information normally written in one section is more appropriate in another depending on the nature of the case. A good case is not measured by the amount of words, rather by one that shows evidence of higher level thinking, thorough analysis and reason with careful evaluation showing background reading. What we call “joined up thinking”. Finally what is most important is for you to know what you have learnt. This is why the “reflection section” comes at the end to say what you have learnt. Collect Case Information 67 old female. SOB 3 days. Fever, cough, green sputum, wheeze. Chronic "asthma", smokes 15 per day. No previous admissions Ventolin and Becotide inhalers from GP over last two years. Sleeps flat normally until this illness. Usually no problem with household tasks and shopping Flight of stairs OK slowly, SOB on hills since 1 year. Always thin but noted more weight loss over last year Lives with Husband age 71, mild CVA 1 year ago. O/E Talking sentences, but SOB at rest, RR 26, T 38.7 HR 110 Not clinically cyanosed, satn 89% in Air Some Wheeze, barrel Chest, Thin Green sputum, no clubbing Dull with bronchial breathing L base Not in heart failure, BP 140/85, SR Nil else, No masses, No lymphadenopathy, breast/thyroid OK, not anaemic Analysis 1. SOB, Fever, cough, chest signs => Pneumonia or infective bronchitis Sputum C+S, CXR, Blood culture, FBC, Blood gases, clotted blood for serology (atypical pneumonia screen) 2. Weight loss => Emphysema, occult malignancy, hyperthyroidism As above plus U/E, Glucose, Thyroid function, Liver function, dietary history. Initial Results: WBC 13.2, neutrophilia, CXR = emphysema and L lower lobe consolidation Working Diagnosis: Pneumonia and emphysema Rational Therapy Admit to medical admissions unit, Face mask oxygen to saturation 91-95%, (inspired oxygen of 0.4 to 0.6) TPR chart, PEFR chart IVI 1 litre 0.9% saline/24hrs and free oral fluids Ampicillin 500mg 6 hrly IV for 7 days, Clarithromycin 500mg 12hrly IV for 7 days Nebulised salbutamol 5mg 4hrly and as per PEFR Next day some response to antibiotics with T 37.6 more tachypneoa, RR 32 increase wheeze, prolonged expiration and using accessory muscle. Well saturated, blood gases not hypoxic, no CO2 retention. CXR consolidation L lower zone but more hyper-expanded lung fields. Handbook Year 5 2010-2011

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Worsening asthma. Not drinking Neb salbutamol 5mg hourly for three hours and if improving 4 hrly Possibly add ipratropium bromide 0.5mg nebulised to salbutamol regimen Hydrocortisone 100mg IV 6hrly for 24hrs IVI 2 litres/24hrs alternate 0.9% saline and 5% dextrose Prednisolone 60mg orally daily for 2 weeks. (Consider IV aminophylline or salbutamol ?) (Remember to put these drugs in personal formulary as appropriate, read up about their pharmacology and the risks and benefits of their use) Evaluation Diagnosis confirmed. TFTs normal, No evidence of occult maligancy, dietary history consistent with weightloss secondary to severe emphysema. 48hrs Sputum culture shows Haemophilus Influenzea sensitive to ampicillin but resistant to clarythromycin. Clarythromycin stopped and continue with ampicillin for 7 days. Amoxycillin 500mg orally 8 hrly to complete course once pyrexia settled, clinically improving and taking oral diet.

a) b) c) d)

e) f)

Additional points to include: Did we follow hospital antibiotic policy? British Thoracic Society guidelines? Drug interactions and risks e.g. using aminophylline when on clarythromycin Were there any unexpected problems or complications? Was the deterioration we saw consistent with the natural history of the illness or because we failed to appreciate the severity of the asthma on admission and under treated? Discharge medications, follow up? GP letter Information to patient and relatives.

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Clinical Science/Therapeutic Reports The Clinical Science report form is an occasional alternative to clinical case reports. In each attachment there are likely to be at least two learning objectives (but in some more) that are better suited to this format of reporting. They should require a similar amount of background reading (about 2 hours) to complete. They will be useful to describe aspects of clinical physiology and treatment, or pathophysiology and treatment, or examples of pharmacology and therapeutics. The following headings appear on the forms: 1. Define the problem & clinical significance This replaces the history and examination and allows you wide scope. For instance septic shock may be the pathological scenario.

2. Explain the clinical expression in terms of physiological and pathophysiological processes Discuss and explain the clinical signs in terms of pathological mechanisms.For instance explain why you get a distributive shock and vasodilation or why coagulation gets disturbed, or why renal failure occurs, or why hypoxia occurs, why is there a lactic acidosis.

3. Describe the underlying pathological mechanisms and /or mechanisms of pharmacological intervention Describe the pathological processes that are amenable to therapy and mechanisms of action of any therapeutic options. For instance you could discuss early goal directed fluid resuscitation, inotrope physiology, or antibiotics, or activated protein C or steroids…. 4. Describe Practical therapeutic options identifying benefits and risks Outline the practical aspects of what can be done and outline the risks and benefits, early and later management. 5. Key Practice Points Any key guidelines or important practice points. There are guidelines for handling severe sepsis. 6. Reflection on your learning outcome – meeting and identifying new learning objectives As for clinical case reports.

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Adverse Event/Critical Incident Report You should be critically aware of all aspects of practice going on around you. Fortunately you may rarely see serious adverse events, but there are many situations where a critical eye will disclose potential adverse events or critical incidents. Find these near misses and use these to learn how to avoid them. A useful exercise is to work through a prescription chart of a patient on many drugs and see if you can detect any potential interactions that could lead to adverse events. This would be particularly useful to do in primary care or whenever the patient is already on medication when admitted to hospital. Don‟t forget an adverse event can include an omission of a recommended treatment (e.g. failure to give DVT prophylaxis). Other examples of “failures” are given on the next page. The reverse side of the form has these same reminders. Guidance Notes: Use this form to document any adverse event or critical incidents that you encounter during your final year placements. Whether minor errors (omissions or commission) or serious events/incident they are all good learning opportunities. You must learn how to reduce or avoid adverse events and reduce and manage critical incidents. The trust the public has in doctors is central to Medical Professionalism and that includes the skills to protect our patients. Collect a number of these forms (at least 2 per attachment) and use them as discussion points during PETA meetings to demonstrate your ability to recognise and manage such events. This form does not replace the Trust‟s IR1 incident reporting system. Please identify if you know that this was also completed.

Simplified Incident Categories Clinical Incident: any occurrence related to a patient‟s clinical management which did or could have resulted in harm to the patient; this includes near misses. Specific therapeutic errors are identified separately. Therapeutic error: a specific medication error in prescribing that did or could have resulted in harm to the patient including near misses. Therapeutic adverse event: a side effect or complication of treatment that may or may not have been the result of a prescribing error. Other incidents: any near misses, equipment defects/failures, communication problems. Do not report on accidents, fire or security incidents unless they reflect poor care that could have harmed the patient.

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Below is an outline of the headings you will see on the form: 1. Define the event/incident Clinical incident (inc near miss)

Other incident

Location______________________ Therapeutic error (inc near miss)

Therapeutic adverse event

Trust‟s IR1 form

2. Explain what happened, what was being done OR how it was recognised 3. Outline extent of injury/ill health OR risk of injury/ill health 4. Describe immediate action taken OR should be taken (treatment or change of treatment) 5. Describe what action needs to be taken to prevent similar events re-occurring (refer to guidelines/standards) 6. Reflection: what have you learnt from this event? What is the impact on your practice?

Examples of general incidents (Disciplines may have more specific examples e.g. in obstetrics or anaesthesia) Failure to diagnose or delay in diagnosis or wrong diagnosis Failure to recognise complication of treatment Failure/delay in admission/referral/operating/treating Intra-operative complication Failure of screening/monitoring/delivery in obstetrics Failure to warn/consent Failure to order correct investigations/xray Failure to interpret investigation correctly Failure to act on abnormal results Problems with interventions/lines/infusions Lack of facilities or equipment Equipment failure/malfunction Self-harm (e.g. needle stick) Injury or harm to others by patient Unexpected death

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How to Record a Case on The Electronic Clinical Log The electronic logging is being simplified at the request of the students. Log every case for which the full CARE cycle has been followed and are going in your portfolio as the written evidence of practice. You should log cases once a week. You must provide an up-to-date print out of your clinical log at each PETA meeting. By the end of the year you must have 5 clinical log printouts summarising the cases filed in your portfolio. You can access the clinical log from any computer with internet access using the address: www.clinicallog.liv.ac.uk. From here you can choose to log a case or review a case history. Log a case: There are 5 pages to fill in to log a case. Use the “NEXT” and “BACK” buttons to alter information before you log the case. Remember to indicate which attachment you are on at the time of logging. Page 1 – allows you to record the patient‟s details Page 2 – you should indicate the diagnosis/ Read code Page 3 – lets you record information about your attachment and drugs prescribed and risk of treatment. This section will also link into the personal formulary section of the clinical log book. Page 4 – allows you to review the information entered for this case to check it is correct Review a case: Here there are three viewing options, you can also sort the information you have selected by various criteria (sort by date seen, alphabetically etc). Use summary view to view the cases you‟ve selected. Use print view to print a hard copy for your portfolio. You can change your password on the clinical log menu, you can also select which are the cases to be included in the paper portfolio. Remember the electronic case logging is YOUR evidence to the supervisor and the Director of Studies for final year that you are seeing patients. You will discuss you cases with your supervisor at your PETA meetings; the Director of Final Year, however, reviews periodically what, how and when students are seeing patients. (Every piece of data entry is date recorded).

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Prescribing Skills You should review your practical prescribing skills in all attachments during final year. You must include evidence of your knowledge and skill in prescribing in your portfolio and computer log. Details of the drugs that have been prescribed by your supervisor/ your HO/ another doctor must be recorded for each case you are involved in. You are expected to build your own personal formulary, which should cover at least 90% of the drugs or classes of drugs in the provided list. Worked example of documentation: Drug Name (proper name): Diclofenac BNF section: 10.1.1 Typical Dose (with units): 50mg x 3 daily Special instructions: Take with food Indications for use: Inflammatory pain, renal colic Mode of elimination: renal excretion, many are metabolised by the liver first 3 important issues you would tell the patient about the drug: write them down as you would say to the patient

List up to 3 drugs which significantly interact with this class and state what action you would take

Class: NSAID Route: oral Mode of action: Inhibitor of cyclooxygenase / prostaglandin Common Side effects: Indigestion, rashes, peripheral oedema

1. May cause tummy ulcers. 2. In someone with asthma, it may make you more wheezy 3. Long term use has been associated with an increased risk of heart attacks and stroke 1. Warfarin 2. Lithium

Never use together Ensure lithium dose is checked after starting Diclofenac

3. Consider the risk benefit for those patients in whom you have seen this drug prescribed

Practical Prescribing Learning Objectives Knowledge Knowledge of and ability to use information resources BNF, data sheets Drug information bulletins Pharmacists Pharmaceutical promotional materials Enhanced knowledge of preferred drugs and limited number of alternatives Use of generic names Regulations around prescribing

Skills The process of rational prescribing Definition of problem (diagnosis if possible!) Define therapeutic objective (patient reassurance, symptom relief, curative, preventative)Define appropriateness of prescribing to meet this objective Handbook Year 5 2010-2011

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Drug selection from formulary (effectiveness, safety cost convenience) Tailoring therapy for the patient (Appropriateness of drug choice in the light of previous experience, contraindications, allergies, other illness or medication, dose etc). Prescribing for children and the elderly, for pregnant or breast feeding women, and for patients with renal and hepatic impairment Writing a prescription safely (hospital inpatient, outpatient and community) Legible, precise Controlled drugs Monitoring the success or otherwise of the treatment (as appropriate) Keeping up to date – sources Incorporating new drugs, dropping/modifying older choices Clinical governance and prescribing in hospital and the community

Attitudes At each stage - Involving patients in the prescribing decisions Does the patient want a treatment? Potential benefits? Potential hazards? Instructing the patient on how to use the treatment Enhancing concordance Balanced approach to prescribing - Risk v benefit

Building Your Own Formulary During final year, you are expected to build your own formulary. It will be the basis of your prescribing for the rest of your professional life, with regular amendments as useful new drugs appear and as your experience grows. How do I develop a personal formulary? You should develop your personal formulary partly by consulting your colleagues, partly using your own experience. As a new doctor, your choice of drug may not be available in a hospital or prescribed commonly in a practice. However, it is almost certain that a drug closely similar to one in the formulary will be included. Therefore in developing your own formulary, as well as identifying a drug, you need to think about how it acts, what class it comes from (betablocker, cephalosporin etc) which will usually enable you to deal easily with other drugs from that class. As well as formularies, you may find key evidence based guidelines or protocols that you want to apply that have drug recommendations.

Selecting a drug and building a personal formulary Drugs to be familiar with: Your first choice (no more than 60-70, often only one representative of a class e.g. betablockers) Second choices (100-150 Drugs occasionally used; need to look them up.) Defining suitable drugs Efficacy/effectiveness – What are the indications for this drug? Do you know the evidence for this drug in that indication? Safety – What are the major adverse effects of this drug and what are the major possible interactions? Cost Handbook Year 5 2010-2011

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Convenience Balancing acts/ Risk-benefit: Consider the suitability of this drug for the patients in whom you have seen it used.Is it effective? safe? Or was there a better alternative? Make a list for each first line drug and include this in your portfolio cases. Dose (for each indication), Formulation, Frequency of administration You should document details of personal formulary drugs in the portfolio section: “Personal Formulary” or electronic formulary. You should gradually remove and add drugs from your portfolio formulary so that eventually you have a list of the 60 / 70 drugs, which you have found most useful. Formularies should be discussed with supervisors at each PETA meeting.

Using Case Records & Case Log to Demonstrate Prescribing Skills In your writing up of at least three cases per week, you must include space that includes the basis of a practical prescribing. The computer case log will include fields to record drug names In your case report, document: A working diagnosis (not necessarily the final diagnosis) The therapeutic aim (e.g. relief of symptoms, lower blood pressure etc) Any non-pharmacological treatment for this patient? Any pharmacological treatment? For each drug, write a sample prescription, listing: Patient identifiers Name of drug(s) Formulation (tablet, inhaler etc) Dose Proposed duration of therapy (or next review date if indefinite) Also detail any follow up/monitoring arrangement that may be appropriate.What will you explain to the patient? e.g., Hypertension Lower the blood pressure and hence risk of cardiovascular event Exercise more, stop smoking, avoid high salt intake. Make sure you choose cases to illustrate a broad spread of prescribing that should be include: -

Emergency prescribing Initial therapy Acute maintenance therapy Ward single dose, Ward new course of therapy, Ward continued therapy GP acute (new treatment course) GP chronic (long term therapy) Hospital discharge including information to the GP, Examples of multiple drug therapies, identify risks and possible interactions

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Patient Safety Programme and Clinical Skills Record In Tomorrow‟s Doctor 2003 and the revision 2009, the GMC states that certain skills may be required from the first day of the pre-registration year. They should not be undertaken without proper training; therefore students should ensure that they maintain a record and clinical log to demonstrate development of at least the following skills during final year.

Minimum Practical Skills to be Demonstrated During Final Year in Liverpool a. b. c. d.

e.

f. g. h. i. j. k. l. m.

n. o. p. q. r.

s.

Discuss procedures with patient (as when obtaining valid consent) Calculate drug dosage accurately Write a prescription Procedures involving veins Venepuncture Insert cannula into peripheral vein Give intravenous injections Mix and inject drugs into intravenous bag Use a pump to give drug treatment Blood transfusion and precautions Injections Give intramuscular injections Give subcutaneous injections Arterial blood sampling Suturing & local anaesthesia Perform an ECG Interpret an ECG Basic cardiopulmonary resuscitation Perform basic respiratory function tests Administer oxygen therapy safely Correct use of a nebuliser/ inhaled medicinal devices Gastrointestinal Insert nasogastric tube Rectal examination including protoscopy Bladder catheterisation (male & female) Observe a lumbar puncture (for diagnostic purposes) Nutritional assessment Administration of insulin Infection control How to collect a mid-stream urine sample Nose and throat swabs Blood culture Control of haemorrhage Using superficial pressure Using specific pressure points Using a tourniquet

In addition, students should demonstrate development of the specific skills relevant to each attachment

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Mini-CEX- Guidance for Use in Final Year Short clinical examinations called Mini-CEX are a feature of the Foundation program portfolio. This preparatory exercise will help you to prepare for postgraduate portfolio learning and assessment. It is expected that all students attempt two Mini-CEXs in ward and Acute EM attachments - one just prior to your Mid-PETA, in week 4, and one prior to your Final-PETA, in week 7. There will be a space for the grade to be recorded on your PETA forms, but for the present you should keep completed forms in your portfolio until after your Final-PETA. After which you should return them along with your completed Final-PETA form to the School of Medicine. Note: To help the process the Mini-CEX form exactly mirrors the one used by the foundation programme. Please leave the space which asks for your GMC number blank and write your name at the top of the form where it asks for “Doctors” name. What is the Mini-CEX? Mini-CEX is designed to provide feedback on skills essential to the provision of good clinical care by observing an actual clinical encounter. In keeping with the Foundation programme quality improvement assessment model, strengths, areas for development and agreed action points should be identified following each Mini-CEX encounter. The Mini-CEX form samples a range of areas within the Foundation curriculum and can be mapped to Good Medical Practice, but was designed originally by the American Board of Internal Medicine. Who should you ask to assess you? In Foundation years you will need to get at least 6 different doctors (experienced SpRs, Specialist Associate/Staff Grades, consultants or GPs) to assess you by the end of your rotation. In final year, during the first week PETA meeting, you should try and agree with your consultant supervisor who will complete the Mini-CEX with you prior to the Mid and Final PETA‟s, as well as which one of the six foundation curriculum areas you will address. You should briefly record this information on your Learning Objective PETA sheet and address the outcomes of Mini-CEX assessments during subsequent PETA meetings. The six main foundation curriculum areas are 1) airway, 2) breathing, 3) circulation, 4) neurological, 5) psychological/behavioural and 6) pain. For more information please refer to the foundation curriculum document at: www.mmc.nhs.uk/curriculum. Your supervising consultant should try and complete a Mini-CEX with you prior to your FinalPETA. Prior to your Mid-PETA during your Ward attachment you should try to get the F1 Trainee you shadow to complete a Mini-CEX with you. What should you be assessed doing? Mini – CEX is suitable for use in a community-based, out-patient, in-patient or acute care setting. It is designed to provide feedback that should be of help to you. Therefore you should be assessed undertaking the actual clinical encounters which will be normally expected of you when you begin postgraduate training, such as clerking in a new patient. When should you use mini-CEX? Mini-CEX can be used at any time of the day or night, whenever you have a clinical interaction with a patient and a potential assessor is available. So you could ask your consultant supervisor to let you review the last patient on a ward round, or ask a SHO to let you see the next patient to come into A&E. How should it work? The observed process should take no longer than 15 minutes. Do what you would normally do in the situation. This is not meant to be a „long case‟ examination taking hours. Your assessor should then provide some immediate feedback which should take no longer than 5 minutes. You can then address any learning outcomes in subsequent portfolio cases as well as during PETA meetings in week 4 and 7.

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What next? You should score your satisfaction with the process at the bottom. Remember this is about your satisfaction with the MINI-CEX process, not with how you have done on this occasion.

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FY

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Advanced Life Support Training Accreditation in ALS will be provided through courses funded by your future employers and organised through the resuscitation training at Aintree. You will be given this opportunity at some time during the final year. You will be excused from other activities and YOU MUST ATTEND your allocated time slot. The curriculum prescribed by the Resuscitation Council (UK) for ALS accreditation involves you revisiting and revising resuscitation skills already covered in the undergraduate clinical skills programme, there will also be a number of new skills introduced and developed. ALS in perspective Causes and prevention of cardiac arrest* Risks to rescuers* Airways management* Rhythm recognition and monitoring* Defibrillation* Drugs and drug delivery* Cardiac arrest in special circumstances Peri-arrest algorithms and pacing Post resuscitation care Ethical and legal aspects of resuscitation Bereavement Assessment of knowledge and skills (*Previously covered in undergraduate course)

Medical Students’ (Final Year) Simulation Course. Dr Arpan Guha , Consultant in Intensive Care, Royal Liverpool University Hospital Introduction: This is a course designed to reinforce the ABC approach to acute medical problems using a simulated clinical environment. Students will undergo a combined workshop/lecture/simulated scenario teaching. Students will be able to put into practice their clinical team skills and learn in a realistic clinical environment. Additionally, team-working skills and crisis management techniques will be discussed. Venue: Cheshire and Merseyside Simulation Centre, University Hospital Aintree, Liverpool . Course duration: 1 day Course content: Students will be able to actually experience patho-physiology of different acute conditions on the simulator, as well as the effect of interventions. Course material: Handbook Year 5 2010-2011

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A handout will be available covering the various topics. Additional reading resources, both printed and web-based, will be suggested. Course tutors: Tutors will be drawn from Consultants and senior trainees from acute disciplines, as well as senior nurses. Programme The programme starts with registration at 8.30 am, and consists of presentations and clinical scenarios. The course will finish by 5 pm.

Competencies for the Care of the Acutely Ill To be achieved by medical students by the time of graduation The following core set represents the knowledge and skills for acute patient management in which all students should gain competency. Those in normal type reflect essential competencies, and those in italics indicate optional competencies. Airway and Oxygenation Describes the signs of airway obstruction Demonstrates safe use of simple airway manoeuvres/adjuncts (head-tilt, chin lift, suction, Guedel, naso-pharangeal airway) Describes the indications and rationale for safe oxygen therapy in the critically ill patient Describes the principles of controlled oxygen therapy in the patient with chronic obstructive pulmonary disease (emphasising the importance of alleviating life threatening hypoxia) Demonstrates basic treatment for simulated choking Demonstrates safe and effective use of laryngeal mask airway Describes the indications for and method of needle or surgical crycothyroidotomy Demonstrates safe and effective endotracheal intubation Breathing and Ventilation Demonstrates a systematic clinical assessment of breathing and oxygenation Describes the common causes of breathlessness Describes the clinical signs and treatment of a tension pneumothorax Demonstrates effective bag-valve-mask ventilation Demonstrates effective mouth-mask-ventilation Demonstrates effective expired air ventilation without adjuncts Describes the indications for invasive mechanical ventilation Describes how to manage hypercapnic respiratory failure Circulation Describes the clinical features of shock Describes potentially reversible causes of a cardiac arrest Demonstrates the immediate management of a simulated witnessed in-hospital cardiac arrest Describes how to recognise and treat common peri-arrest arrhythmias Demonstrates peripheral venous cannulation including attention to patient comfort and infection control Demonstrates effective external chest compressions Describes effective fluid resuscitation Describes control of external haemorrhage Handbook Year 5 2010-2011

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Recognises cardiac arrest rhythms (VF, pulseless VT, PEA and asystole) Demonstrates safe and effective use of an automated external defibrillator Demonstrates safe and effective use of a non-automated external defibrillation Describes alternatives to peripheral venous access Describes the indications, risks and safe administration of blood products Describes the indications for central venous catheterisation Confusion and Coma Describes the common causes of altered consciousness Demonstrates a systematic approach to the assessment of the acutely ill patient with altered consciousness Describes how to recognise and initiate treatment of status epilepticus Demonstrates the recovery position Drugs, Therapeutics and Protocols Describes how to recognise and initiate treatment for an acute attack of asthma Describes how to recognise and initiate treatment for diabetic emergencies Describes how to recognise and initiate treatment for acute heart failure Describes how to recognise and initiate treatment for an anaphylactic reaction Describes the causes, presentations and treatment of oliguria Describes the indications and dosages of drugs used in the management of a cardiac arrest Describes how to recognise and initiate resuscitation of a patient with an acute abdomen Describes how to recognise and initiate treatment for meningococcal septicaemia Describes how to recognise and initiate treatment for a pneumonia Describes how to recognise and initiate treatment for common drug overdoses Describes how to recognise and initiate treatment for acute coronary syndromes Describes how to recognise and initiate treatment for an acute exacerbation of chronic obstructive pulmonary disease Describes the common causes and treatment of life threatening hypo-/hyper-natraemia and kalaemia Describes the role of vasoactive drugs in treatment of the shocked patient Clinical Examination, Monitoring and Investigations Describes normal physiological ranges for basic vital signs including pulse, blood pressure, SpO2, respiratory rate, urine output and body temperature Demonstrates a systematic approach to the clinical assessment and timely management of the critically ill patient Demonstrates safe handling and disposal of sharps and clinical waste Demonstrates a systematic approach to 3- and 12-lead ECG interpretation, recognising common and important abnormalities Demonstrates a systematic approach to chest X ray interpretation recognising common and life threatening abnormalities Measures arterial blood pressure correctly using a manual method Describes the importance of repeated and timely reassessment of the acutely ill patient Demonstrates/describes how to obtain an arterial blood gas Describes a systematic approach to arterial blood gas analysis Describes the principles and limitations of pulse oximetry Demonstrates the rationale use of common laboratory tests and investigations in the critically ill patient Demonstrates/describes how to perform urinary catheterisation Describes the pathophysiological processes underlying critical illness Describes the indications and complications of arterial line insertion Describes the principles and limitations of central venous pressure monitoring Describes the principles and limitations of invasive arterial pressure monitoring

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Team-Working, Organisation and Communication Describes/demonstrates how to recognise one‟s own limitations and when to call for help Describes/demonstrates the principles of breaking bad news Describes how to deal with the personal emotional issues surrounding critical incidents, breaking bad news, post-incident stress etc. Describes/demonstrates the principles of good communication skills Demonstrates the ability to work as part of a multi-professional team Demonstrates the ability to extract and critically appraise literature Demonstrates good time keeping, punctuality Describes the role of early warning scoring systems and/or ICU outreach Patient and Societal Needs Describes the importance of and methods for achieving adequate pain control Demonstrates respect for patient dignity Describes key aspects of in-patient safety Describes the ethical and legal implications of attempting/not attempting resuscitation Describes the principles of consent in the acutely ill patient Trauma Describes the principles of recognition and initial management of patients with suspected spinal injuries Describes or demonstrates a systematic approach to the assessment and immediate treatment of the victim of trauma Equipment Demonstrates how to correctly set up an intravenous infusion Demonstrates how to correctly prepare and give an intravenous drug Demonstrates how to correctly set up and administer high flow and controlled oxygen therapy Demonstrates how to set up and use an oxygen/air driven nebuliser and describes indications for use of either device Describes how to set up, insert and manage a chest drain Infection and Inflammation Adheres to the basic principles of infection control measures including handwashing Describes the recognition and immediate resuscitation of a patient with sepsis Describes a rational approach to antibiotic prescribing in the patient with sepsis Taken from: Perkins GD, Barrett H, Bullock I, Gabbott DA, Nolan JP, Mitchell S, Short A, Smith CM, Smith GB, Todd S, Bion JF. The Acute Care Undergraduate Teaching (ACUTE) Initiative: consensus development of core competencies in acute care for undergraduates in the United Kingdom . Intensive Care Med (2005) 31:1627–1633 Developed using a modified Delphi survey and consensus meetings through a multidisciplinary collaboration of health care professionals and funded by the resuscitation council incorporating the views of 359 professionals.

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Erasmus Exchanges During Selectives In Advanced Medical Practice Co-ordinator: Dr. David Taylor (Deputy Director of Medical Studies) A few students are involved in the SOCRATES/ERASMUS exchange programme. These students will go abroad for their SAMPs. In exchange, students from the Medical Faculty‟s partner institutes in Europe (in Sweden, the Netherlands, Germany, Spain, Austria and France) will complete clinical attachments here. Depending on their level of competence they will be offered 4th year rotations or final year SAMP choices. General Aims To provide an advanced attachment in a chosen area of clinical practice in a European country. To provide information about career paths as appropriate. To provide an opportunity for you to engage in team-work, and review management structures in the Health Care system of the country visited. To enable you to carry out a critical review of an aspect of the chosen clinical area. To enable you to locate a particular specialist area within the wider health care context. To enable you to identify key social and public health responsibilities related to that area of clinical practice. To enable you to identify and integrate medical science and clinical skills within a specialist environment. For you to experience “hands on” a speciality as it is practised abroad. To enable you to build critical analysis skills through comparisons of practice in Europe and in the UK. Specific Learning Objectives for ERASUMUS SAMPS If a partner institute abroad offers an ERASMUS attachment in a particular speciality the specific learning objectives as defined by a local SAMP provider for that area of clinical speciality will be used by a student on that attachment should the European provider not submit their own. Outgoing Liverpool Students Students going out from Liverpool will be allocated to group C during 5th (final) year, so that the European exchanges can take place for a continuous period between the beginning of January to the week ending April 2010. Exact dates will be known once arrangements are in place. This is a total of 16 weeks. You should list five options for study and this will be sent to the partner institution. The partner Institution will then choose TWO options, each of 8 weeks duration, which they feel able to provide the visiting student. During the 8 week period, there will be a 7-week period for clinical specialist practice and one week for the student to undertake self-study and assessment. The specialist: student ratio will be 1:1, with a specialist supervisor named for each student if possible. You are required to maintain your portfolio and produce two 2500 word critical reviews on subjects appropriate to your attachments consistent with other Liverpool students taking a home based SAMP.

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The Duties of a Doctor Registered with the General Medical Council Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and you must: Make the care of your patient your first concern Protect and promote the health of patients and the public Provide a good standard of practice and care o Keep your professional knowledge and skills up to date o Recognise and work within the limits of your competence o Work with colleagues in the ways that best serve patients'

interests Treat patients as individuals and respect their dignity o Treat patients politely and considerately o Respect patients' right to confidentiality

Work in partnership with patients o Listen to patients and respond to their concerns and

preferences o Give patients the information they want or need in a way they

can understand o Respect patients' right to reach decisions with you about their

treatment and care o Support patients in caring for themselves to improve and

maintain their health Be honest and open and act with integrity o Act without delay if you have good reason to believe that you

or a colleague may be putting patients at risk o Never discriminate unfairly against patients or colleagues o Never abuse your patients' trust in you or the public's trust in

the profession. You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.

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PREPARING FOR YOUR FUTURE Applying for your Foundation Post Please refer to the following website for information regarding applying for your F1 post: http://www.foundationprogramme.nhs.uk/pages/home/how-to-apply

Career Development The Careers Adviser based within the School of Medical Education, Christine Waddelove, is available to help with information, advice and guidance regarding your future career in medicine. A dedicated website has been developed for undergraduate medical students at www.liverpool.ac.uk/medcareers which provides lots of useful information and links to help in your career planning. A new website has also been developed by the NHS for medical students and junior doctors to help them with career planning www.medicalcareers.nhs.uk During your final year you will have to make a number of careers related decisions such as choice of Foundation School, NHS Trust and even rotations. You will all be required to complete the online UK Foundation Application Form and in order to help you with this process a number of workshops, talks and information will be organised. Chris Waddelove is located in 4.04 Cedar House, or can be contacted via email at [email protected]. There are four activities that you will be required to undertake as part of your final year portfolio which will help you to prepare for future career decisions. Activity 1 Career Management Skills Audit Career management is more than just thinking about the specialty you want to pursue in medicine. It also involves exploring your wider career aspirations, your strengths and weaknesses and the kind of work/life balance you want for your future. Career management skills are those you will need to help you to survive and succeed in a constantly changing and challenging work environment. They are different from the skills that you will develop in becoming a „good doctor‟ but can be just as important in helping to ensure that you make the right choices throughout your medical career. Career Management Skills have been defined as: • Self awareness – being able to identify your skills, values, interests and personal attributes • Self promotion – being able to define and promote your skills such as on a CV or interview • Being able to explore and create opportunities and therefore able to investigate and seize opportunities and get that sought after position • Action plan - being able to plan a course of action • Networking – awareness of the importance of developing a network of contacts • Matching and decision making - being able to align potential opportunities • Political awareness - keeping up-to-date with trends and developments in the world of medicine and in the NHS • Coping with uncertainty - being able to adapt goals in the light of changing circumstances • Self confidence – having an underlying confidence in own abilities Handbook Year 5 2010-2011

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(Adapted from Hawkins P, Skills for Graduates in the 21st Century, Association for Graduate Recruiters) You will undertake a careers management skills audit and the results should give you an idea of how well developed your career management skills are which ones you may still need to develop further. It would be useful to do this exercise at the start of the 5th year and then again near the end to see if you have been able to develop certain skills further and whether you need to focus on any particular career management skills during your foundation training. Activity 2 Careers Section In the future you may well be asked to bring your portfolio to a selection centre. Many deaneries have a „portfolio assessment‟ station as part of recruitment process for a number of specialties. It is never too early to think of the types of documents that you would include in this portfolio as they would not want you to bring a portfolio containing everything that you have done – you will need to be selective and consider the types of information they may want to see. This activity involves you Inserting appropriate careers related documents into the careers section Developing an index or contents page of the documents within the careers sections Reflecting on a number of questions regarding how you might develop the careers section in foundation It is hoped that this activity will also help you to complete your Foundation Application form. Appropriate information can include extracurricular activities, courses, audits, research or teaching that you have been involved with as well as other activities that you have undertaken to help with your career planning and development e.g. self assessment exercises such as Sci59. A proportion of applicants are asked for evidence to verify their answers and if you have the evidence already in your portfolio it will be helpful.

Activity 3 Informational Interviewing One of the ways that can help you to clarify what different specialties involve is to try and speak to doctors working in certain areas. In order for you to understand more about certain specialties we are asking you to complete three interviews with doctors in your attachment areas and then complete the reflective log. You can access an electronic copy of the reflective log on VITAL if you wish. The interview and log should be completed as follows: One by the end of the second attachment One by the end of the third attachment One by the end of the final attachment Guidance is given in your portfolio on how to set up an interview and also on the sorts of questions that you may wish to consider asking. This process will help to explore different specialties, help to clarify your career goals and identify your strengths and weaknesses which should help you with your career decision making process in the future.

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Activity 4 Curriculum Vitae (CV) Although you may not need a CV for the actual foundation programme application, a good curriculum vitae (CV) is essential for your successful progression up the professional ladder. It is also a good idea to give any referees that you may have a copy of your CV so that they know some details about your experiences and qualifications. In order to assess what your CV should contain and how that information should be displayed, you need to first understand the function of a CV. Put simply; a CV is a marketing tool. The biggest mistake that many people make when it comes to their CV is that they simply list information without giving any thought to how relevant the information is, and what impact the information will have on the person reading it. While your CV does contain facts about your academic and professional past, you need to make sure that you are assessing the relevance of each achievement rather than simply listing things as they happened. As such, your primary goal is to present those hard-earned credentials in a clear and concise manner, such that the reader can immediately be impressed with you. Please check the medical careers website at www.liverpool.ac.uk/medcareers for detailed information on how to complete a CV and some sample 5th year CVs.

Final Year Resources General Medical Council. The New Doctor. London: GMC; September 2009. This booklet describes the training of and duties of Pre-Registration House Officers. On-line version also available: www.gmc.uk.org BNF. British National Formulary, resource for prescribing. You should buy your own copy or use copies from post-graduate resource libraries. The on-line version WeBNF is very user-friendly: http://www.bnf.org.uk/index.html Drug info zone is another useful on-line tool: http://www.medicines.org.uk/ Final Year Virtual Resource Centre. School of Medicine Final Year resource, contains online version of this study guide, links to clinical log, BNF, and information about SAMP choices.

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REFERENCES AND LINKS Students are expected to know and comply with University policy and with specific MBChB programme policies and procedures. Please refer to the 2010-11 MBChB Generic Handbook for all policy issues. Certain items in the generic handbook which may be of particular interest are listed below. For your convenience, in cases where the generic handbook refers readers to another document or site, references to those links are also below. Generic Handbook Chapter & Supporting Web Pages Annual Declaration of Criminal Record and Student Agreement/ Conditions of Training Concern Forms

Criminal Record Background Checks Disabilities and Language Difficulties Fitness to Practise Procedure

Health Screening and Immunisation Implications of Non-Attendance

Mitigating Circumstances

Handbook Chapter 2: Important Information for All Students Forms are available on VITAL for each year under Course Admin and Handbooks

Posted on VITAL for each year under Course Administration and at the back of this handbook Generic Handbook Chapter 2: Important Information for All Students Generic Handbook Chapter 6: Support Services for Students www.liv.ac.uk/studentsupport/disability/index.htm Generic Handbook Chapter 2: Important Information for All Students: http://www.liv.ac.uk/students/exams/results/progress_of_student s.pdf http://www.liv.ac.uk/students/student-administrationcentre/policies-procedures/fitness-to-practise.htm Generic Handbook Section 2: Important Information for Students: Health Issues for Medical Students Generic Handbook Chapter 2: Important Information for All Students http://www.liv.ac.uk/students/exams/results/progress_of_students.pdf Generic Handbook Chapter 2: Attendance Policy for the MBChB Programme Generic Handbook Chapter 2: Important Information for All Students http://www.liv.ac.uk/tqsd/pol_strat_cop/index.htm

Needlesticks/ Post Exposure Policy Plagiarism, Collusion and Fabrication of Data

Student Progress

Forms are available on VITAL for each year under Course Administration Generic Handbook Section 2: Important information for Students: Health and Safety Generic Handbook Chapter 2: Important Information for All Students http://www.liv.ac.uk/tqsd/pol_strat_cop/index.htm

Generic Handbook Chapter 2: Important Information for All Students http://www.liv.ac.uk/students/exams/results/progress_of_students.pdf

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Plagiarism, Collusion and Fabrication of Data

Generic Handbook Chapter 2: Important Information for All Students http://www.liv.ac.uk/tqsd/pol_strat_cop/index.htm http://www.liv.ac.uk/tqsd/pol_strat_cop/plagiarismgl.pdf

Student Progress

Generic Handbook Chapter 2: Important Information for All Students http://www.liv.ac.uk/sas/administration/progress_of_students.pdf.

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The “Concern Form” – Concern about an MBChB Student Before completion of the form, the person who notifies should, were possible, speak to the student. These forms, once completed, are confidential. The information will only be disclosed to those concerned with the undergraduate course who have a direct need to know. From time to time staff who come into contact with MBChB students may have concerns about individual students. Such concerns vary from students who are withdrawn and about whom a member of staff is worried, to students whose attitude or behaviour is rude or inappropriate. The “concern form” offers staff the opportunity to “flag” such students to the welfare system. We do not expect major concerns to be highlighted in this way. We anticipate that if there is a potentially serious problem staff will contact us by telephone, email or letter as happens at present. Concern forms for an individual student will be collated and if there appears to be a persistent or consistent problem the student will be asked to see the appropriate member of the course team. This method of reporting from a wide variety of areas will enable the School of Medicine to monitor students who are causing concern much more effectively. Completed forms will not be accepted unless they are signed by the completer. However reporters may ask to have their identity withheld from the student if it is felt that disclosure may cause irreparable damage to their professional relationship with the student in question. Forms should be submitted to the MBChB Office. On receipt they will forward a copy of the form to the relevant Year Director who will decide whether the student needs to be seen (by either themselves of one of the MBChB academic team) to discuss the nature of the concern, or referred immediately to the Fitness to Practise committee or that the form be filed with no action. Students will be informed of the receipt of a form. If a form is issued in a Trust or GP practice the relevant Clinical Sub Dean will be informed. Regardless of this decision and the outcome of any discussions – all forms will be retained on the student file and will be kept during their entire academic career with the Medical School. If a student disagrees with any part of the form they may summarise their argument to be filed with the form. The Student‟s Personal Tutor will be notified that a form has been raised but will not receive a copy without the written permission of the student. This process is intended to be supportive to students. Our aim is to help those who are in difficulty. As you will see the following areas are outlined on the form: Professionalism Professionalism includes appropriate dress, language, behaviour, reliability and teamwork. Any student who is rude, aggressive or unpleasant to staff should be reported using a form. Administrative and support staff often encounter this sort of behaviour which may not be exhibited to teaching staff. Multiple instances will lead us to call students in for a discussion.

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Any instances of inappropriate attitude, physical violence or aggression, any conduct that brings the University, Medical School or NHS Trust into disrepute, misuse of University or Trust property or name, bullying or harassment should be notified to an academic sub-dean immediately. Poor academic performance Students who are struggling on the course, whose communication skills are causing concern, or whose knowledge seems to be lacking. These may be students whose attendance is poor, but equally may be those who are working hard but have academic difficulties. Suspected misuse of alcohol/drugs Students who persistently do not attend until mid-morning, who appear hung-over, or who are frequently injured may have problems with alcohol or illegal drugs. Staff may not wish to talk to students about this, so a report may be a route by which the School can help students when a problem is suspected. Other There may be a general concern that a student appears unhappy or unduly anxious or unwell. Any concern that a member of staff has will be treated confidentially and with sensitivity to the student. We now have well over 1000 MBChB students. This means that we cannot know each of them individually. Concerns which you have may well alert us to a problem of which we were previously unaware. Concerns expressed by other students Students who have concerns about colleagues can either fill in one of these forms or ask a trusted member of staff to complete a form, confidentially, on their behalf.

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What happens to a concern form?

If from a Concern form received by Undergraduate Office Trust/GP confirm CSD is aware Form copied – copy placed Receipt acknowledged Student informed on student personal file to staff member of receipt Form logged onto database (“reporter”) and checked for threshold reached Year director or deputy course director notified No Form noted only

Student seen (fact finding not disciplinary) student can see form maintaining reporter anonymity if requested

Welfare

Threshol d of 3 forms reached?

Yes (cc to year director)

Fitness to Practice Committee

Caution Established School, Faculty and University disciplinary procedures

1. Note for file (student may add their own version of events if they wish) 2. Letter to student 3. Letter to “reporter” and CSD if relevant 4. Personal tutor informed (copy of form with student‟s permission)

Welfare o Through the established system of student personal tutors o Through Deputy Course Directors/Academic Sub-Dean o Established counselling and psychological support both from the SME and through University routes o Access to independent local psychologists and psychiatric care outside the Mersey area o Rehabilitation and support networks accessible through the SME welfare structure and via local NHS partners

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MBChB A100, A101 Programme School of Medicine

Notification of Concern Student Name: (block capitals) Location: (name of hospital, GP practice etc)

Year of Study:

1

2

3

4

5

Please note nature of concern and attach further information if necessary: 1. Professionalism (e.g. teamwork, dress, attitude, communication)

2. Poor academic performance/communication

3. Suspected misuse of alcohol/drugs

4. Other

Report from: (block capitals)

Date:

Telephone Number:

Email:

Context in which this student has come to your attention, e.g. PBL facilitator, personal tutor

Signature:……………………………………………………(this form MUST be signed to be actioned – see over) Do you wish to withhold your identity from the student? O Reason?................................................................................................................……………… ……………………….. Please return to The MBChB Office, Cedar House, University of Liverpool Medical School, Liverpool L69 3GA For office use Noted by year director:………………………………..signed………………………………………… date………….…….Action Required:……………………………………………………………………… …………………………………………………………………………………………………………

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STUDENT PROGRESS The University monitors and reviews a student's progress in their studies. A student's personal tutor may be used as the first point of contact with a student whose progress is giving cause for concern. Progress Panels, acting on behalf of Boards of Examiners may conduct reviews of students‟ progress and investigate the reasons for any lack of progress and the student may be interviewed. Where a student‟s progress has not been satisfactory the Board of Examiners may decide, either in mid-session or at the end of each session that s/he is required to terminate their studies. Students may appeal against a decision made by the Board of Examiners to terminate their studies or to have been deemed withdrawn to the Faculty Progress Committee. The student would be entitled to attend the meeting of the Faculty Progress Committee and they may be accompanied by a friend or tutor. Further details may be found in the document „Guide on the Progress of Students on Taught Programmes of Study‟ which can be viewed on the web at: http://www.liv.ac.uk/students/exams/results/progress_of_students.pdf Progression Review in the School of Medicine will be performed twice per year. Academic staff will review each student‟s progression by examining their attendance records and relevant evidence of academic progress (e.g., progress toward completion of case presentations, clinical log-book, in-course assignments, etc.), feedback from academic and clinical staff, and any other academic components necessary to judge progress. Students will be invited to discuss any concerns raised by progression review.

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