Virtual Continuity inLearning Programme –‘on-the-job’ learning forfoundation doctorsEleanor Wood, Academic Unit of Medical and Surgical Gastroenterology, HomertonUniversity Hospital NHS Foundation Trust, UK

INTRODUCTION

The cornerstone of a juniordoctor’s continuing medicaleducation is the patient

(journey).1 Traditionally,experience of the patient journey,from first presentation to finaldestination (be that discharge ordemise), has provided a stepwiseapproach to learning (Figure 1). Itis this continuity in learning thatnot only builds knowledge, but is

a prerequisite to the developmentof clinical judgement. This is theholy grail of medicine: a skill thatcannot be taught in lectures,acquired by reading textbooks oremulated by computer programs,and which sets apart fineclinicians from mediocre ones.

Thus, the traditional way inwhich doctors learn is at oddswith our current working practice.Continuity in learning from the

patient journey is being compro-mised by the implementation ofthe European Working TimeDirective (EWTD) and the Accred-itation Council for Graduate Med-ical Education (ACGME) residentduty hours restrictions, whichhave reduced junior doctors’working hours and have increasedshift work,1,2 and by the devel-opment of acute care units (ACU)and speciality-driven care. Here,in the UK, there is a real threat

The cornerstoneof a juniordoctor’scontinuingmedicaleducation isthe patient(journey)

Work-basedlearning

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that as a direct consequence ofthis, knowledge and clinicaljudgement will not be acquired byour junior doctors, and thus wewill fail to maintain our highstandard of doctor.

Although in the UK the intro-duction of the FoundationProgramme, a 2-year trainingprogramme that forms the bridgebetween medical school and spe-cialty or general practice training,and the completion of work-basedassessments offer learning oppor-tunities for junior doctors, lectureseries have been shown to bepoorly attended, and theprogramme was found to be overlybureaucratic.3 Moreover, despiterecognising the need for earlierexposure to patients, and theimportance of the patient journeyduring medical school training,this appears to be lost duringfoundation year 1 (FY1).4 Ibelieve that, as part of theprogramme, we need to be offer-ing dynamic ‘on-the-job’ learningthat supports the concept ofcontinuity in learning from thepatient journey, and will blendeducation with service delivery.

Although as a group, doctorsbemoan the loss of continuity incare (and therefore learning),there is little in the literaturedemonstrating either the actualextent of the loss or indeed anypractical solutions that mayovercome this perceived problem.

I hope to show the extent of theloss and to suggest a potentialsolution.

Is there continuity of care andthus learning for juniordoctors?Working at the coal face in a busydistrict general hospital led me to(anecdotally) identify three po-tential rate-limiting steps in thepatient journey (Figure 1). Duringmy 24-hour medical on-calls as aconsultant, I prospectively col-lected data pertaining to thesethree steps in the patient journeyof emergency medical admissions,by asking the following questions.

1. How many of the patientswere clerked by junior doctors(i.e. is junior doctor exposureto patients adequate)?

2. How many junior doctorspresented the patients theyhad clerked to the consultant

on the post-take ward round(such discussion and feedbackis an invaluable learningexperience)?

3. How many patients weretransferred to the clerkingdoctor’s home ward for ongo-ing care (allowing doctors tolearn from the results of theirinitial decisions and investi-gations)?

The results indicated that only4.4 per cent of patients (7 of158) were clerked by the mostjunior doctor (FY1), 62.9 per centof patients (66 of 105) werepresented by the clerking doctorand 12 per cent of patients (19 of158) were transferred to theclerking doctor’s home ward forongoing care. In conclusion,there does not appear to beadequate exposure to, or conti-nuity of care of, patients forjunior doctors, and thus thecontinuity in learning provided bythe patient journey is beinglost.5,6

VIRTUAL CONTINUITY INLEARNING PROGRAMME – APOTENTIAL SOLUTION

I have developed, and plan toimplement at the HomertonUniversity Hospital NHSFoundation Trust, in collaborationwith the Royal Free HampsteadNHS Trust, a Virtual Continuity inLearning Programme (VCLP) torecapture this lost knowledge(Figure 2). Utilising the virtualconsulting room (VcR; Figures 3

Clerking

Presentation toon-call Consultant

Response totreatment

PATIENT CLERKING & DIFFERENTIAL DIAGNOSIS

SIMPLE INVESTIGATIONS

REVIEW OF RESULTS

DIAGNOSIS

TREATMENT

RESPONSE TO TREATMENT

11

3

2

2

3

Learning via the patient journey –potential rate limiting steps

Figure 1. Stepwise approach to learning.

Virtual Continuity in Learning Programme

ON

CALL

LOST CONTINUITY

= LOST KNOWLEDGE

Patient -> Clerking Dr’s ward

Specialist wards / ACU / EWTD / shifts

Virtual Continuity in learning programme

12%

88%

KNOWLEDGE

Foundation Programme

Figure 2. Virtual Continuity in Learning Programme.

Continuity inlearning from

the patientjourney is being

compromised

234 � Blackwell Publishing Ltd 2009. THE CLINICAL TEACHER 2009; 6: 233–236

and 4),7–9 demonstrated at theAssociation for Medical Educationin Europe exhibition in 2006(http://www.ucl.ac.uk/medicalschool/current-students/learning-resources/Virtual-consulting-room-demo/), theelectronic patient record (EpR)and case-based discussion (CbD)work-based assessments (Fig-ure 5), the programme will bringtogether the actual and virtualpatient journey to provide on-the-job learning for foundationdoctors.

The VcR is an intranet-basedguidance application providingdirect access to specialist knowl-edge. With the help of 250 healthcare professionals at the RoyalFree Hampstead NHS Trust, thepatient journeys component hasbeen developed by translatingmedical knowledge from horizon-tal prose to electronic algorithmsin order to represent the rationalprocesses used by specialistswhen making clinical decisions. Itcontains over 370 patient jour-neys, and over 1400 hyperlinkedscreens, across all specialities(medicine and surgery) from firstpresentation to final destination,spanning primary and secondarycare. Each patient journey startswith a symptom, a sign or adisease: a graphical root-and-branch structure, embedded

with decision nodes, allows theuser to navigate along individualpathways. Progress through theclinical flow chart is designed tosimulate the ‘what next?’ ques-tions asked by users. Rolling thecursor over a relevant node ex-poses evidence-based backgroundtext. When the cursor is movedfrom the node, the associatedinformation disappears, thusdisentangling process fromknowledge.7 A student version iscurrently available to all RoyalFree and University CollegeMedical School students.

Previous studies utilising theVcR within the accident andemergency (A&E) department,medical wards and primary carehave demonstrated educationalbenefit, support of clinical deci-sion making and the potential toimprove patient care. Specifically,55.3 per cent of users (21 of 38)and 52.6 per cent of users (20 of38) reported improved knowledgeand support of clinical decisionmaking, respectively, within theA&E department: of junior doc-tors’ on the medical wards, use ofthe VcR in 94 per cent of cases(46 of 49) improved their knowl-edge, and in 88 per cent of cases(43 of 49) supported clinicaldecision making; of GP users,88 per cent (15 of 17) found it tobe a good learning tool, and41 per cent (7 of 17) agreed thatuse of the patient journeys im-proved patient care.7–9

VIRTUAL CONTINUITY INLEARNING PROGRAMME –METHOD

Together with the HomertonHospital’s Foundation Programmedirector, we will be recruiting 62Foundation Year 1 and 2 doctorsto participate in a 6-month studydesigned to assess whether the

Figure 3. The Virtual Consulting Room homepage (Reproduced with the permission of UniversityCollege London Biomedica (UCLB) & Royal Free Hampstead NHS Trust).

Figure 4. The Virtual Consulting Room – ‘Jaundice patient journey’, with background text exposed

after placing the cursor over the alarm features decision node (Reproduced with the permission of

University College London Biomedica (UCLB) & Royal Free Hampstead NHS Trust).

The programmewill bringtogether theactual andvirtual patientjourney

� Blackwell Publishing Ltd 2009. THE CLINICAL TEACHER 2009; 6: 233–236 235

introduction of the VCLPenhances the learning process. Inthe first phase of the study thedoctors will act as their owncontrols, completing 3 CbDassessments in the usual way.After completion of a question-naire they will then be issued withpasswords for the Virtual Con-sulting Room (VcR) and be askedto record the hospital number ofinteresting patients that theyclerk whilst on-call but subse-quently do not continue to carefor. Using these actual patients,they will be asked to use EpRwhich will provide a dischargesummary (including diagnoses),blood, histopathology, imagingand endoscopy results, and withthis information be invited toenter the VcR to follow the rele-vant virtual (simulated) patientjourney prior to completing allsubsequent CbD assessments.They will be able to marry theiractual patient results with stagesin the virtual journey to learn notonly how and why specialistsmake decisions but also the evi-dence behind these decisions andother related areas. Use of the VcRwill be monitored by web-trackingsoftware to provide quantitativedata and further qualitative datawill be obtained on conclusion ofthe study when Foundation

doctors complete a further ques-tionnaire and participate in focusgroups.

Expected educational outcomesand projected benefits topostgraduate clinical educationI anticipate, although clearly thisis the focus of the research, thatimplementation of the VCLP willhave similar benefits to thoseseen with utilisation of the VcR,and in so doing provide effective‘on-the-job’ learning for Founda-tion doctors thus improving theirknowledge, clinical decision-making skills and clinical judge-ment. Enhancing the quality ofpostgraduate clinical education inthis way will ultimately enhancepatient care (this will be thesubject of future research shouldthe VCLP be proven to be benefi-cial in this study).

SummaryWith the decline of physicalcontinuity of care, I support thedevelopment of virtual continuityof care in the form of the VCLPdescribed above. I anticipatethat, should the proposed studybe successful, the VCLP, theunderlying principles of which arein keeping with recent sugges-tions for reform,10 could beincorporated into or parallel the

foundation programme, ensuringthat continuity of care, and thuslearning, is sustained forfoundation doctors.

REFERENCES

1. Tsouroufli M, Payne H. Consultant

medical trainers, modernising

medical careers (MMC) and the

European time directive (EWTD):

tensions and challenges in a

changing medical education

context. BMC Med Educ 2008;8:31.

2. Irani JL, Mello MM, Ashley SW, Whang

EE, Zinner MJ, Breen E. Surgical resi-

dents’ perceptions of the effects of

the ACGME duty hour requirements

1 year after implementation. Surgery

2005;138:246–253.

3. O’Brien M, Brown J, Ryland I, Shaw

N, Chapman T, Gillies R, Graham D.

Exploring the views of second-year

Foundation Programme doctors and

their educational supervisors during

a deanery-wide pilot Foundation

Programme. Postgrad Med J

2006;82:813–816.

4. Muir F. Placing the patient at the

core of teaching. Med Teach

2007;29:258–260.

5. Chow J, Wood E. Provision of learning

opportunities for Foundation Year 1

doctors in a district general hospital.

Abstract 4AA ⁄ P6, Association for

Medical Education in Europe (AMEE) &

Association for the Study of Medical

Education (ASME, UK) 2008.

6. Wood E. Is there continuity in

learning for junior doctors? Abstract

9C ⁄ SC4, Association for Medical

Education in Europe (AMEE) &

Association for the Study of Medical

Education (ASME, UK) 2008.

7. Wood E, Berlingieri P, Whitwell K,

Rayne T, Dearden J, Epstein O. The

Accident and Emergency department

Virtual Consulting Room. Telemed J E

Health 2006;12:521–527.

8. Wood E, Rankin A, Berlingieri P,

Epstein O. The Junior Doctor’s Virtual

Consulting Room. J Telemed Telecare

2007;13(S1):65–67.

9. Berlingieri P, Wood E, Rayne T,

Kwong W, Norris D, Linehan J,

Epstein O. The Virtual Consulting

Room: an intuitive solution to

bridge the eternal divide between

primary and secondary care. J Tele-

med Telecare 2007;13(S1):5–7.

10. Hirsh DA, Ogur B, Thibault GE, Cox M.

‘‘Continuity’’ as an organizing

principle for clinical education

reform. N Engl J Med 2007;356:

858–866.

Figure 5. The Virtual Continuity in Learning Programme utilises the virtual consulting room, elec-

tronic patient record and case-based discussion work-based assessments (virtual consulting room

image reproduced with the permission of University College London Biomedica (UCLB) & Royal Free

Hampstead NHS Trust).

Enhancing thequality of

postgraduateclinical

education inthis way will

ultimatelyenhance patient

care

236 � Blackwell Publishing Ltd 2009. THE CLINICAL TEACHER 2009; 6: 233–236