Career advice- the role of appraisal

Department of Surgical Paediatrics, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK

The purpose of this article is to discuss the benefits of and to illustrate a framework for appraisal. The place of career advice in this process is mentioned, as is a brief discussion on assessment. From the point of view of the individual doctor, information to help him/her choose an appropriate career path should be readily available. It is more likely that a doctor will perform well throughout their career if in a career or occupation that suits them.

The traditional methods of obtaining careers advice have been rather haphazard. Studies indicate that career choice is often made relatively early in clinical undergraduate experience that presumably reflects the ‘surgical role model’ that undergraduates experience. In other cases a doctor’s career path is influenced either positively or negatively by examination results. A pre-registration house officer might have decided on a career in a particular speciality branch based on experience (either positive or negative) as a student, or as a house officer and discussions with peer groups may also play a part in deciding on the future career path. In some cases, a junior doctor may be fortunate in having a consultant mentor with whom they are able to discuss these issues. Moreover, with access to the necessary facts, ‘market opportunities’ may also influence the decision.

The four Scottish Deaneries have agreed on uniform documentation for the educational supervision of pre-registration house officers (PRHOs). All PRHO’s have access to an educational supervisor during their pre-registration year. There is explicit reference to careers advice contained in the documentation covering this process. Thus, from an early stage, there is at least the possibility of objective careers advice for a junior doctor. In addition, it is usual for the PRHO to take part in an educational programme during the 6-month house job that will include in it some general aspect of career guidance appropriate to their stage of training.

Once the individual enters the senior house officer (SHO) grade, the availability of career advice is less certain. A doctor who is on a Basic Surgical or Medical Training Scheme (BST/BMT) or General Practice Vocational Training Scheme (GPVTS) is expected to have regular contact with a trainer for assessment. That should provide the opportunity for career advice. All SHOs in surgical posts should be registered with a College, maintain a logbook and have assessment forms completed.

However, for those SHOs who do not form part of a BST scheme the method of career advice becomes rather more haphazard and opportunistic. It is under these circumstances that the role of a mentor becomes much more important.

There is concern about the progress of SHOs who are not on a designated training programme. As a result, it has been proposed that whatever the stage of training, SHOs will have a portfolio (The SCPMDE SHO Portfolio & Record of In-Service Training & Achievement), which will contain a Record of In-service Training Assessments (RITA). This information will be held by both the trainee and by the Scottish Council for Postgraduate Medical and Dental Education (SCPMDE), and should benefit both parties, as it will allow the trainee’s progress to be monitored. This should mean that there is less chance of the trainee drifting without a clearly defined career goal. The complementary part of this plan is that the SHOs will have regular appraisals that will both inform the RITA process and allow for corrective action by the trainer (and trainee) if career progress is going adrift.

An illustration of this type of appraisal and career information guidance is published annually by the West Midlands Deanery. This details the possibilities of promotion from SHO to specialist registrar (SpR) in the previous 12 months, the overall planning for specialties, and indicates local and national sources of advice. Copies of this document can be obtained from Miss Jane Harris, Postgraduate Medical and Dental Education, 27 Highfield Road, Edgbaston, Birmingham B15 3DP.

Since the introduction of the Specialist Registrar (SpR) grade, there has been an obligation on the part of consultant trainers to provide higher specialist trainees with regular appraisals and assessment of progress. This is laid down in the Orange Book on SpR training (A Guide to Specialist Registrar Training; Feb 1998: p47).

Appraisals are important throughout the course of the SpR’s training, but they are particularly important at the early stages where it may become apparent to all concerned that the trainee has made or is in danger of continuing a poor career choice. It is at this stage when a trainee will benefit from an objective look at their progress and the choices facing them. There is a specific opportunity to direct subspecialty choices through the RITA process (see below). However, in most cases, the SpR has already made significant career choices and is happy with their decision. While some sub-speciality career advice may be necessary, on the whole career advice will be a matter of fine-tuning.

The purpose behind appraisal for medical staff under training is to set goals for training. In this context, it is inevitable that career options will be discussed.

The concept of appraisal is not new although it has only recently been introduced into medicine. There is often confusion between assessment and appraisal. There can be a degree of overlap between the two processes, but the emphasis for trainees must be on goal setting, especially in the first instance.

The difference between assessment and appraisal has been summarised thus: “Ticking boxes set by others” (Assessment) and “Ticking boxes that I have helped to set myself” (Appraisal).

It is important that trainers undertaking assessment and appraisal have themselves the appropriate training. Courses are available through the Royal College of Surgeons of Edinburgh and the SCPMDE. It should also be recognised that the process of assessment and appraisal can apply to all grades in medicine from PRHOs through SHOs, SpRs, and non-consultant career grades to consultants and is the cornerstone of continuing professional development (CPD).

Assessment can best be described as an objective, standard-setting exercise and will often be an element of performance review in the process. It should be objective, dispassionate and unbiased.

Summative assessment is a regulatory process and involves the judgement of progress in knowledge, attitudes and skills according to external standards, which are set by peer groups or according to norms and criteria. The results of this process are in the public domain. Examinations are an obvious example, e.g. MRCS and Specialty Fellowship examinations. Another example is the form that is completed at the end of a trainee’s attachment to a unit in a training rotation. The JCHST form and the Record of In-Training Assessment (RITA) are examples of this type of assessment record for SpRs. SHOs on BST rotations have similar forms (see below).

A - initiated on appointment to SpR rank; B - amendments to RITA A; C - satisfactory progress in programme; D - directed training required but counting towards CCST; E -specialist training arrested and directed training instituted; F - out of programme experience; G -completion of specialist training.

Formative assessment concentrates on the learner and his educational needs. It attempts to measure progress in the three educational domains of knowledge, behaviours and attitudes, and skills. If records are kept of this progress, they are usually confidential and often held by the trainee; this often is part of an appraisal.

On the other hand, appraisal is usually a one-to-one discussion between the trainer and a trainee about goals to be set or those that have been achieved. It should be a two-way communication that is informal, non-threatening, and confidential. The main aim of appraisal is to encourage and support the trainee. It is designed to help fine-tune the training to the particular needs of individual trainees. Topics covered during appraisal may be personal and confidential thus, the content of the appraisal is not open to scrutiny, unless agreed to by the trainee. However, in the vast majority of cases, the process of appraisal will merely cover the trainees’ progress in their chosen speciality. In this context, appraisal may well be the vehicle for career advice.

Appraisal is a very useful training tool for both the trainer and trainee, with the roles and responsibilities clearly outlined at the start of the job in the shape of a job plan. It is essential that an individual consultant in the team be appointed as the educational supervisor responsible for junior staff and for ensuring that assessment and appraisals are carried out.

Using appraisal methods, the trainer is able to set some educational goals in discussion with the trainee. If both trainee and trainer agree the goals, then it is more likely that they will be achieved by the end of the trainee’s attachment.

The trainee will find it useful to have his roles and responsibilities clearly outlined at the start of the job. By discussing educational goals with the trainer, it is likely that the trainee will take responsibility for achieving these goals himself/herself.

The trainer should not use appraisal to discipline the trainee. Issues of discipline may be discussed during an appraisal, but only if the trainee has prior knowledge of the problem and the purpose of discussing them is to consider any educational issues that have arisen as a result. There are three types of appraisal and these are outlined below.

This should be carried out as close as possible to the start of the job. Ideally, the consultant should notify the trainee before he starts that an appraisal will be carried out within the first week. The purpose of the appraisal should be explained very clearly as some trainees might find this a threatening process. It is helpful to stress that appraisals are confidential and that the only items discussed outwith the appraisal process are those that are agreed during appraisal.

It is useful to have a framework for conducting an appraisal. This helps ensure a successful conclusion of the process.

Background: It is helpful for the trainee to bring an up-to-date copy of his or her curriculum vitae, and log book. The discussion with the trainee should commence by discussing aspects of these documents and the short and long-term goals.

Opportunity: The trainer should bring a copy of the departmental timetable as well as any departmental protocols. It is also helpful to have an idea of the training timetable, which includes such items as tutorials, inter-departmental teaching meetings, morbidity and mortality meetings and clinical-pathological conferences.

Goals: The first appraisal should establish and set out the educational goals of the trainee. It is essential that the goals are simple and attainable. This will allow the trainee to have a sense of achievement when he/she achieves the goals. In turn, this will stimulate him/her to set and achieve further goals.

Evaluation: It is usually fairly straightforward to identify whether the goals set out have been achieved particularly, if they have been well established at the first appraisal. If the goals have not been reached, the evaluation process will help to determine why this has not occurred. This is best done at the mid-term appraisal.

Rescue: If a goal is not achieved, it may have a negative effect on further efforts; this is particularly true for educational goals. At the time of the first appraisal this possibility needs to be discussed with the trainee, including any apportioning of blame which will give the trainee a degree of reassurance should the goals not be realised for reasons that are beyond their control.

Deal: This is the contract between the trainer and the trainee. It comes at the end of appraisal when the goals have been set and agreed by both parties. This may be in written form, and available for inspection by other parties. Alternatively, it may be in the form of a “verbal agreement”. It is helpful to be explicit about this as it ensures that both the trainer and the trainee are committed to achieving the educational goals (Bulstrode and Hunt, 1998).

It is important that this has a high priority, as the mid-term appraisal is essential for ensuring that the educational goals are on target for achievement. It is an opportunity for giving positive feedback and for restating the goals and the deal. It is also an opportunity for the trainee to realise that the goals are achievable. In the instances where targets are not being met, it is an opportunity to examine why this has happened and to provide support and guidance, as appropriate.

In most surgical specialties there is an assessment form that must be completed at the end of an attachment. It is useful to discuss this form with the trainee at the final appraisal. The SpR is required to sign the form before it is submitted to the appropriate Specialty Training Committee.

In addition to completing the assessment form, the final appraisal is an opportunity for the trainee to consider the next set of educational goals based on his/her immediate past experience. It is a further opportunity for career advice.

Appraisal is a very useful tool for both the trainer and the trainee. It helps to set up a good working relationship that encourages the development of mutual respect and ensures that educational objectives are set.

The Royal College of Surgeons of Edinburgh conducts courses on training skills for consultants (the “Educating Consultants” course), which explore the process of appraisal in greater depth. In addition, the SCPMDE conducts the “Supporting Clinicians on Training in Scotland” (SCOTS) course which deals with similar topics.

1. The Specialist Registrar Handbook, John Gatrell and Tony White, Oxford: Radcliffe Medical Press, 1999
2. A Guide to Specialist Registrar Training. Department of Health. February, 1998
3. Educating Consultants Course Manual, Victoria Hunt and Christopher J Bulstrode, 1998; Sumit: Oxford

Correspondence: Professor G Youngson, Convenor of Training Advisory Group, Royal College of Surgeons of Edinburgh, Nicolson Street, Edinburgh EH8 9DW, UK

EDUCATION SECTION

Career advice - the role of appraisal