Trainee Led Initiatives

Trainee led initiatives
in Pre-Vocational
Training

I am the Program Manager with CETI's General Medical Training Unit.

It's one of the great bits of my job to support the NSW JMO Forum.

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The Forum is a trainee‐representative advisory subcommittee of the
NSW Prevocational Training Council. It is composed of elected trainee
representatives from the 15 training networks that make up the
prevocational training program in NSW and the ACT.

Each year each network elects a new PGY1 representative, who will
serve on the Forum for two years. We also elect rural reps from the
major rural training sites in NSW, making about 34 or 35 reps. About
half of the Forum is new each year, and half are carrying on from the
previous year, and this system provides both a regular flow of new
ideas and a degree of continuity.

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The basic message of our presentation today is simple: JMOs are adult
learners and enthusiastic employees who have the interest,
involvement, ideas and innocence required to attempt innovations in
medical education and training. It makes good sense pedagogically and
administratively to give them a leading role in shaping the system in
which they will learn and work.

I am sure that most of you are already acting on this knowledge in
some ways, but there are also plenty of forces in the system that
operate against trainee‐led initiatives. Two JMO Forum representatives
are going to give you brief examples of ways in which trainee‐led
projects can offer the system new and better ways of doing things,
achieving results that would be difficult to reach by other means.

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The JMO forum as a whole identified the lack of a consistent statewide education
process. As seen by the graphic formal teaching varied widely not only acroos the 15
prevocational networks in NSW but from hospital to hospital. and over the last two years
there has been a sustained and concerted effort by the trainees to address a few key
areas. this from a ground up driven process which thanks to the wholehearted and in
many cases overwhelming support from DPETs and JMO managers

Addit:
Of the 27 hospitals represented here
•Average teaching hours per week = 1.5
–24 hospitals have 1 hour per week
–17 hospitals have >1 hour per week
• 49% (22/45) are pager protected

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Rather than refer to an expert panel with a multitude of committees which is probably
the more politically correct and academically rigorous way of doing it … the JMOs in the
Education working group went away and came up with what we as Junior Doctors felt
was of most value in each topic

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In some ways we were like charging horses with blinkers – quite oblivious to the ruffled
feathers or the potential fallout

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11 out of 15 had implemented
According to the JMO respondents, of the 11 hospitals in this poll that had implemented
the series 10 had done so effectively and was well received. Obviously this is a small
sample and its early days given the proposal was sent out at the end of last year.
We are hoping to repeat the 2010 survey with a much larger number of hospitals
surveyed later next year.
This is not to say this is a perfect system – one of the common criticisms is that there is
too much expected from each teaching session than can be adequately delivered
What it is, is a prime example

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In 2011 our focus changed to address the oft neglected part of the ACFJD

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So why bother with trainee led initiaves
Well theres the chance to play god – create tomorrows achievers in your own image

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Thanks Vikas. I’d like to tell you about two more projects that the members of the JMO
Forum has been involved with. The first occurred at a local health network level where
the JMO Forum was asked to get involved with the NSW Health Services Improvement
Branch Acute Care Taskforce who were particularly looking at JMO Handover. Dr Hamish
Dunn has already discussed the content of the findings in another presentation at this
event.

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In the following year the JMO Forum undertook a statewide audit of handover, the
details of which you can see on the slide and the results of which have been used by
NSW Health to focus handover improvement across the state. The point being that there
was no possible way this audit could have been conducted without JMO buy‐in and
ownership. This was acknowledged by NSW Health.

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The second project was devised and executed by the Careers working party of the JMO
Forum who have compiled a Doctors GPS guidebook to navigating specialty training. In
their own time the working party members contacted all relevant specialty colleges and
have put together a one stop shop information resource for interns and residents for all
major specialty pathways. This publication is in final draft and will be published and
reviewed biannually as an official NSW Health CETI publication.

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There are numerous other JMO led projects out there which I don’t have time to tell you
about and which I’m sure many of you are involved in. The key point I would like to
reiterate is that these projects are the result of volunteer time and energy and people
who believe in what they are trying to do. They only earn a budget as a result of their
quality and utility. They are owned by the JMOs who seek input, feedback and support
as needed from people who believe that they have something valuable to offer.

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Colloboration, mentoring and empowering JMOs can only result in good. Even projects
which fail will ensure some kind of learning outcome for those involved. It is imperative
that the idea of initiative, ownership and leadership is not lost in the JMO experience.
JMOs have spent years being trained to identify problems and work towards solutions.
Its their day to day job. And they should be doing it outside of the clinical arena in order
to become competent professionals.

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Too often we see the expectation of sudden gravitas and knowledge from a clinical
perspective in the transition from ‘subservient’ resident to ‘in charge’ registrar. The
same applies to education and training. Unless junior doctors are encouraged to
innovate, to question, to look for better ways of doing things at local and system levels
the future looks bleak. We need to create leaders and change drivers for the future now
– otherwise there will be no one to sit in the seats you now occupy 20 or 30 years from
now. Sometimes ‘consultation’ is a dirty word. It just means there was a JMO in the
room. If you have access to them, find out what they actually are thinking and involve
them. They may surprise you. If they complain or raise issues – make them part of the
team to fix it, even better make them lead the team with your backing. Eg Rostering
working groups

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JMOs are a widely untapped resource for quality change and innovation. We are
constantly being chided for our lack of interprofessionalism and encouraged to work
better and more closely with other staff. Shouldn’t the same hold true at a health
system level? JMOs working with Unit Managers and Directors of Education, college
representatives, medical education officers, medical superintendents. The goals are
common, so the tracks should stop running in parallel and start to converge.

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Thanks Lucy. In pursuing their projects, the JMO Forum members are learning leadership
skills, communication skills, professional practice skills. NSW Health runs a number of
leadership programs for clinicians, but I think the JMO Forum is one of the best
leadership programs yet devised. They are learning how the health system works and
how it can be to positively influenced. As they learn, they are helping to build the future
strength of education and training in health. This works because the system has

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1 Made space for trainees to talk

2 Given permission for trainees to act

3 Adopted an expectation that trainee representatives will be trainee activists.

Are there risks associated with this process?

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‐ Risk of revolution? Will trainees forget who is in charge? Not likely.

Endorsement and support by senior clinicians tends to be one of the first things trainees
seek for their projects, as it is essential if they are going to get past square one.

Rather than revolution, I wonder about the opposite risk ‐‐ that if we don't encourage
trainees to innovate, initiate and lead, we may develop a medical workforce that is too
passive in the face of accelerating change, and not sufficiently adapted to the idea that
they have to make things better for themselves and their patients through their own
initiatives.

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‐ Risk of patient harm? We haven't seen this ‐ most education and training projects are
one or two steps removed from patient care, leaving plenty of room for review by senior
clinicians before there could be any unintended negative consequences.

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‐ The biggest risk that I have seen with trainee‐led initiatives is that there will be
inadvertent miscommunication, because trainees are not fully aware of the
labyrinthine depths of the system in which they work, and they are not practised
diplomats. Wording, timing, tone and address all matter.

‐ There is a risk that JMOs will put people offside because they have not used the right
channel or the right language, or kissed the right hand. There is sometimes a role for
people (like me, and the Chair of the Prevocational Training Council, and directors of
training) in providing an interpreter service that helps translate between the system
and the JMOs, so that their big ideas are not misconstrued or lost.

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So, if there is time, here are my three final tips:
Subtle differences in organisation and expectations can lead to
profoundly different outcomes. For example, two years ago the then
chair of the JMO Forum reorganised the forum into working groups,
each one with a specific focus and a project to complete within the
year. This created an expectation on every forum member that they
would get something done at the meetings, not just meet and talk.
What has resulted has been a flowering of trainee creativity.
Committees with trainee representation need to expect trainee
activism: don’t just ‘tick the box’ by having some trainees show up to
the committee; raise the expectation that trainees will be active
members. Give them jobs to do, don’t just ask them to be there. This
makes being on the committee so much more worthwhile that it
makes it much easier to get trainee involvement.
Build links between trainees and higher levels of the system: In NSW,
CETI advertises the existence of the JMO Forum to other NSW Health
organisations as a resource that can help solve problems they are
working on. It can really work well to link the trainee representatives

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to the higher‐level change agencies in the system. This union of shop
floor and boardroom can make proposed changes more realistic and
increase stakeholder engagement.

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Trainee Led Initiatives

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