Queensland Supervisor Training Workshop Part 2 Overview of

Queensland Supervisor Training Workshop Part 2 Overview of supervision and 2012 FP Focus on stage 1 & 2

What makes for effective supervision?

Source: Tim S: Understanding Medical Education Evidence, Theory and Practice: United States: Wiley-Blackwell; 2010.

Source: Tim S: Understanding Medical Education Evidence, Theory and Practice: United States: Wiley-Blackwell; 2010.

Good and bad RANZCP supervisors? Type Good supervisors Supportive • • • Educative • • • Managerial • • • Poor supervisor Care about the trainee and supervision • Supportive and empathetic, providing counsel but never therapy • Honest, understanding, approachable and • flexible in their approach. Losing temper, shouting and being abusive, no warmth in interaction Trying to engage the trainee in therapy Fixed, rigid, perfectionistic and eccentric. A role model who maintains the supervisortrainee hierarchy Answering trainee questions and providing their reasoning Allows trainee autonomy and independence, but with a watchful eye Providing continuous constructive feedback Able to place clinical issues in the broader social, political and historical context. • • Poor or out of date clinical skills Too much responsibility too early Little clinical guidance Praise / positive feedback and criticism given without direction for improvement. Hands on with patients Aware of training requirements Takes responsibility for trainee clinical decisions. • • • Not on ward Unaware of training requirements Politically out of date. Source: Chur-Hansen A, Mc. Lean S: Trainee psychiatrists' views about their supervisors and supervision. Australas Psychiatry 2007, 15(4): 269272.

What do RANZCP trainees value in supervision? A 2009 survey of SA trainees identified the following factors as being valued by trainees: 1. Protected time and space 2. General support and guidance 3. Observed interviews 4. Exam preparation. Aspects of supervision generating negative feedback included: 1. Lack of structure 2. Lack of set time 3. Lack of flexibility 4. Too didactic an approach 5. Frequent changes of supervisor. Note that supervisors value the importance of different factors, and express conflicting frustrations. Source: Luffingham M: Clinical supervision: which components are most valued by trainees? Australas Psychiatry 2009, 17(6): 511. Chur-Hansen A, Mc. Lean S: Trainee psychiatrists' views about their supervisors and supervision. Australas Psychiatry 2007, 15(4): 269272.

Techniques as a Supervisor § Modeling skills § Feedback § Advice or direction (early and struggling) § Didactic teaching (esp. first years)

Techniques as a Supervisor § Allowing ventilation – catharsis § Support and empathy § Guided problem-solving § Socratic questioning § Problem-based learning

How to stop supervision becoming therapy? § Be alert to dynamics and process issues § Talk frankly about supervision not being the same as therapy if you become aware of the problem § Re-direct content to less personal areas – presentations, interviews, knowledge-base etc § Discuss with Chief Training Supervisor / Director of Training § Encourage trainee to get own personal therapy (when relevant)

Key changes that came with the CBFP Copyright © 2015 The Royal College of Physicians and Surgeons of Canada. http: //www. royalcollege. ca/rcsite/canmeds-framework-e. Reproduced with Permission.

11 Key changes that came with the CBFP WORKPLACE-BASED ASSESSMENTS § Structured workplacebased assessments § Written feedback FEEDBACK AND GRADING ARE MORE FORMALISED CLEARER STANDARDS § More training resources for supervisors § More guidance about the standards expected in each Stage of training

12

13 What are Formative & Summative Assessments? Formative Summative Assessment for learning Assessment of learning Immediate feedback Evaluates trainee’s learning at a particular point Feedback identifies strengths Feedback: Pass/fail / Percentage Feedback highlights areas for improvement Must pass to progress Feedback typically delayed Ways to improve performance outlined Exams, Psychotherapies, Scholarly Project, ITAs

14 Formative assessment – Work based Assessments WBAs § Used formative assessment of competencies, NEVER as a mechanism to ‘mark’ or ‘pass/fail’ § Provide the trainee with timely, meaningful and effective feedback § Supervisors will use a minimum of 3 WBAs to inform their assessment of each EPA* § Trainees are responsible for arranging WBAs with a supervisor § Multiple tools are available: Cb. D), Mini-CEX, OCA), PP and DOPS.

15 Formative assessment – Work based Assessments WBAs § Completion of three WBAs does not infer that the professional activity is entrustable. § More than three WBAs may be required for the trainee to demonstrate they are functioning at an appropriate level for the EPA to be awarded. § Supervisors may need to educate trainees about the entrustment process if under pressure to sign-off on an EPA based on WBAs completed by other supervisors or after completion of three WBAs.

16 Entrustable Professional Activities (EPAs) • Summative assessments used to assess competence of the trainee to perform specialised, professional activities or tasks with distant (reactive) supervision at the appropriate standard for the training Stage. • Certifies that trainees are attaining the necessary knowledge, skills and attitudes that are embedded in the Fellowship competencies.

17 Entrustable Professional Activities (EPAs) • Progression through training requires trainees to be entrusted to perform specific EPAs to an appropriate standard for the stage of training • Successful completion of EPAs within a term does not infer that the term will be passed on the ITA. Make sure trainees are aware that these are separate processes, particularly if you are working to address concerns more generally about performance.

18 Summative Assessment –Entrustable Professional Activities (EPAs) • A minimum of 2 EPAs required to be assessed and entrusted for every 6 month FTE rotation • Trainees must be entrusted with all mandatory EPAs for a stage before progressing to the next stage of the Fellowship Program • Fellowship EPAs across all Stages DO NOT have to be signed off by a supervisor who has a Certificate in the respective area of practice; however, supervisors must be accredited and current

19 The Stage 1 First 6 Months FTE Exception Rule • A trainee in the first 6 -month FTE rotation of Stage 1 may conditionally pass that ITA Report, and therefore the corresponding rotation, before achieving two of the mandatory Stage 1 EPAs in cases where: ▫ the supervisor indicates a ‘pass’ on the ITA Report ▫ the trainee has undertaken the required minimum of formative WBAs for the rotation. ▫ Trainee must complete mandatory WBA (OCA) • Cannot be applied in any other stage or rotation

20 EPA Deadlines: • Stage 1 EPAs must be achieved by the time the trainee has completed 18 months’ FTE accredited training in Stage 1 • Stage 2 EPAs* must be achieved by the time the trainee has completed 36 months’ FTE accredited training in Stage 2 • Stage 3 EPAs must be achieved by the time the trainee has completed 36 months’ FTE accredited training in Stage 3. • Failure to achieve the mandatory EPAs by the time requirements above will result in a requirement for the trainee to show cause to the Committee for Training (CFT) as to why they should be able to continue towards Fellowship as set out in the Failure to Progress Policy and Procedure.

21 EPA Deadlines: • It is not possible to transition to Stage 3 of training at 36 -months if the trainee only completes the minimum required EPAs per term • Completing the minimum requirements will leave the trainee with 8 -10 EPAs to complete between 3036 months • Trainees should be encouraged and supported to complete at least 4 EPAs and no less than 3 EPAs during each term of Stage 2.

22 Workplace-based Assessments (WBAs) Mini-CEX Mini Clinical Evaluation Exercise (briefly observed clinical tasks) Cb. D Case-based Discussion (detailed case discussions with supervisor) PP Professional Presentation OCA Observed Clinical Activity (a full 50 minute assessment with structured feedback and clear standards) DOPS Direct Observation of Procedural Skills (e. g psychotherapy, ECT, supervision, physical examination) Ø Highly recommended that trainees experience these tools early in their training Ø At least 3 of these will determine if an EPA is achieved

23 Case-based Discussion (Cb. D) • The trainee presents the relevant aspects of the case (15 -20 minutes) • The assessor prompts on further discussion points • Feedback occurs immediately • Followed by discussion and reflection • Cb. D completed in one 60 minute supervision session or less

24 Examples of Stage 1 Cb. D’s: • • • Mental health legislation Safe Prescribing Multicultural skills Consumer / Carer/ NGO Risk assessment

25 CBD Video examples Video 1 Video 2

26 Mini-Clinical Evaluation Exercise (mini-CEX) • Focused clinical interaction lasting between 15 -25 minutes • Feedback session occurs immediately, should be constructive and suggest areas that were good and suggestions for improvement, ideas to gain further experience and skill • Session and feedback 30 – 40 minutes

27 ‘Formative’ Mini-CEX vs ‘Summative’ OSCE: • Some similarity to certain clinical OSCE stations but not the same • Prior to conducting each Mini-Clinical Evaluation Exercise, the trainee and supervisor should determine together which of the assessment criteria to focus on during the formative assessment. • The feedback should focus on the agreed specific clinical tasks rather than on the trainee’s general performance

28 Mini-CEX DVD

29 Professional Presentation (PP) • Where and when? o Journal clubs o Case presentations o Grand Round presentations o Teaching medical students (didactic presentation) o In-service presentations o Wider options may be possible for more senior trainees • Presentation typically at least 30 minutes • Supervisor must attend for it to be used as a WBA

30 Professional Presentation (PP) • Assessment criteria • Trainee and supervisor determine assessment criteria to be considered during the PP Feedback should occur immediately after the presentation • o o o Introduction of the topic or issue Context of information and material used Analysis and critique Presentation and delivery Responses to questions Quality of educational content

Level of Performance End Stage 1 q Low level of independence q High level of supervision q Completes straightforward tasks

32 Stage 1 § Minimum 12 months FTE accredited training in approved Adult Psychiatry training post, 6 months of this time must be completed in an acute setting Supervision § § Minimum 4 hours per week 2 hours individual per week outside ward rounds & case review WBAs are often completed during supervision EPAs assessed at basic level

33 Stage 1 EPAs 2 Mandatory EPAs* 1. Use of an antipsychotic medication in a patient with schizophrenia/psychosis. 2. Providing psychoeducation to a patient and their family and/or carers about a major mental illness *Trainees still required to complete 2 EPAs in every rotation (exemption in 1 st rotation)

34 § In addition to the mandatory EPAs for Stage 1, trainees in Stage 1 are eligible to be entrusted with any or all of the five Stage 2 General Psychiatry EPAs and the Stage 2 Psychotherapy EPAs § The Stage 2 are assessed at the competence standard expected of Stage 2 (proficient) § Trainees must have support of Director of Training to complete any other stage 2 EPAs

Level of Performance End Stage 2 q Proficient

36 Stage 2 § Minimum 24 months FTE accredited training in an approved training program Supervision § § § Minimum 4 hours/week for 40 weeks annually 1 hour/week individual supervision of clinical work For every rotation in Stage 2, a minimum of 2 EPAs are assessed and entrusted at a proficient level

37 Mandatory areas of practice Stage 2 Consultation-Liaison (6 months FTE) EPAs: § Care for a patient with delirium § Manage clinically significant psychological distress in the context of a patients medical illness in the general hospital Child & Adolescent (6 months FTE) EPAs: § Develop a management plan for an adolescent where school attendance is at risk § Clinical assessment of a pre-pubertal child

38 Mandatory Stage 2 EPAs • Addiction Psychiatry EPAs ▫ Management of intoxication and withdrawal ▫ Co-morbid mental health and substance use problems • Psychiatry of Old Age EPAs ▫ Behavioural and psychological symptoms in dementia (BPSD) ▫ The appropriate use of antidepressants and antipsychotics in patients aged 75 years and over (or under 75 with excessive frailty)

39 Stage 2 Mandatory EPAs (General) To be attained by the end of Stage 2 ▫ Demonstrating proficiency in all the expected tasks associated with prescription, administration and monitoring of ECT ▫ The application and use of the Mental Health Act ▫ Assessment and management of risk of harm to self and others ▫ Assess & manage adults with cultural and linguistic diversity

40 ELECTIVE EPAs • Please note that if a trainee is in an elective term i. e. Adult psychiatry, Forensic, Indigenous mental health – The EPAs for these rotations then become mandatory. • This requirement often catches trainees in their first Adult term of Stage 2 who mistakenly thing that the S 2 -GEN EPAs are equivalent.

PSYCHOTHERAPY Stage 2 EPAs § Therapeutic alliance (EPA 2) § Supportive psychotherapy (EPA 3) § CBT: Anxiety management (EPA 4) § 2 out of 3 to be entrusted by end of stage 2 § The remaining EPA must be attained by the end of Stage 3 - still assessed at proficient standard and does not contribute to the minimum 2 EPAs per term

42 Psychotherapy written case • These CBD discussions with Psychotherapy supervisor are held early, mid and later phases of treatment and must be submitted to the college at the time of case submission. • Do not need to be co-signed by the principal supervisor

Summative Assessments • • • ITAs MCQ exam Essay-style OSCE Psychotherapy written case Scholarly project

44 When is the written MCQ exam sat? • Trainees are eligible to apply after completing 6 month FTE accredited training • Trainees should plan to sit the multiple choice exam during Stage 2. • The exam is computer based • The MCQ exam should be passed by 36 months FTE accredited training.

45 When is the written essay exam sat? • Trainees are eligible to apply to sit the exam after 18 months FTE accredited training • It is recommended that this is sat in Stage 3. • The essay exam should be passed by 60 months (full-time equivalent) of training.

46 Correlation with Clinical Examinations neither the MCQ nor the Essay- style examination is a barrier to a trainee’s eligibility for the clinical examinations; however, the MCQ deadline for completion occurs earlier than those of the clinical examinations. Correlation with Certificate of Advanced Training Programs The Essay-style examination is not a barrier to a trainee’s eligibility to be accepted into a Certificate of Advanced Training Program *.

47 OCSE Objective Structured Clinical Examination ▫ The OSCE examination may be attempted once the trainee has successfully completed Stage 2. ▫ It will be assessed at the standard of a Junior Consultant.

48 OSCE As of April 2018 the distribution of stations for the OSCE exam is as follows: • Eight (8) short stations – 10 mins / 1 examiner • Two bye stations – both 10 mins, both inactive, total 100 mins • Three (3) long stations – 20 mins / 2 examiners • Two bye stations – both 20 mins – one bye may be active or inactive, the second bye will be inactive, total 100 mins

49 Psychotherapy written case • Long psychotherapy intervention (approx. 1 year or 40 sessions) • Can be submitted for assessment during any stage of training • Assessed at the standard of a junior consultant • Includes both the provision of psychotherapy and the writing and submission of a case report

• BREAK – 15 MINUTES