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What is expected from those involved in clinical attachments?

August 2006

Doctors
It is important for the doctor to ensure that they undertake a clinical attachment in the right specialty, rather than undertaking one for the sake of it. This will ensure that they get the maximum practical and educational benefits, and the most useful reference. However, general practice, general medicine, and accident and emergency are beneficial for all doctors. The purposes and goals for the clinical attachment should be agreed between the IMG and their supervising consultant at the outset and it is useful to review them at regular intervals throughout the attachment.

There are a number of practical points that doctors should adhere to, similar to if they were working. For example, be punctual, and if delayed or unavoidably detained always call to explain why. IMGs should be enthusiastic and show an interest in what they are doing. A good way to do this is by asking questions when appropriate. Furthermore, IMGs are in a good position to assist the clinical team by undertaking appropriate tasks. Doctors on attachment in primary care, who have permission to work may be offered note summarising work which may also help in understanding record keeping in the UK.

Supervisors
Each doctor undertaking a clinical attachment should have a named supervisor who is responsible for them. It is helpful for the supervisor to meet the doctor undertaking the clinical attachment in advance to discuss each other’s expectations of the attachment. An initial interview should cover:

• learning needs assessment including exploring previous experience
• goal setting
• ground rules (what is expected of the attached doctor and what can be expected of the supervising doctor and their team)
• clarification of education and training expectations
• a clear timetable

On-going timetables and feedback

• during the course of the attachment, the supervisor and the attached doctor should meet for a formal mid-attachment appraisal meeting: to review activities and goals, and to provide formative feedback.

End of the attachment

• there should be an exit interview and a written report on the attached doctor
• opportunities for on-going links with the clinical unit (such as attending clinical meetings) could be discussed.
• formative and summative assessments allow for realistic references.

Educational content
A well-structured clinical attachment should have a curriculum which leads to greater understanding of the NHS, including the relationship between primary and secondary care, and should conform to relevant educational standards. It may be helpful to draw up a personal development plan to ensure that the training needs are regularly monitored, and to ensure that each party knows what is expected of them. This may also help the supervisor when writing the doctor’s reference.

Generally speaking it is helpful for a doctor undertaking a clinical attachment to participate in the following:

• in a secondary care setting, to shadow junior doctors and other clinicians in the team, such as nurses and therapists, to see how the NHS works and how patients are managed.
• in a primary care setting to shadow GPs, primary care team members, receptionists and practice managers, to obtain an overall perspective of working in primary care
• participate in ward rounds, outpatient clinics, teaching sessions and surgeries. Present cases in different settings to enable them to demonstrate clinical knowledge
• in primary care, doctors should write up a chronic care case history on a patient, with management options and reflections on the case.
• observe consultations and participate in patient clerking, history taking and physical examinations (where appropriate and under supervision)
• attend clinical meetings
• develop knowledge of patient safety issues
• gain experience in clinical governance and the legal aspects of health care, by attending relevant meetings
• become aware of the expectations of the British patient, to enhance their clinical communication skills and learn as much as possible about the doctor-patient partnership
• appreciate the roles of teams, management and leadership in health care. Perhaps through attending wider trust meetings to better understand working as part of a team.
• the doctor should help out with clinical audits/research projects, and if possible conduct their own

Additional areas that may benefit a clinical attachee

• CV writing skills, how to complete application forms and interview preparation
• networking skills and their benefits
• career advice and jobsearch skills
• IT/library skills
• ethical issues (such as Good Medical Practice)
• management skills

Training and support for supervisors
Training for supervisors of clinical attachments should cover:

• clarification of purposes of clinical attachments
• definitions of what is a refugee/asylum seeker. Available from http://www.ind.homeoffice.gov.uk/documents/asylumpolicyinstructions/ - go there
• routes to registration with the GMC. Available from http://www.gmc-uk.org/doctors/before_you_apply/registration_factsheet.asp - go there
• legal aspects and access to patients
• checklist for initial interviews
• model timetable
• giving feedback; exit interviews
• model written reports.

These topics should be laid out simply to form an information pack, and the attached doctor, supervising doctor and their team (which includes staff from allied disciplines), should receive copies of the documents before the attachment begins.

Ongoing support for the supervising doctor must be available; specific arrangements will reflect local needs and facilities. There should also be a debriefing at the end of each attachment so that lessons can be learned and shared with others involved in attachments.

Evaluation and monitoring
Evaluation of the attachment by the attached doctor must be built in from the outset. It is key that the attached doctor evaluates the attachment with reference to the above standards, and that this is fed back to the supervising doctor and their Trust. Good practice dictates that the Report and assessment of the attached doctor by the supervisor always precedes the provision of feedback.

For the evaluation to be complete, supervising doctors and their teams should have the opportunity to comment on their preparation for and involvement in the attachment, perhaps in the form of a written report. Exit interviews and mutual feedback are essential learning tools for both the supervisor and the doctor undertaking the clinical attachment. Some organisations recommend that the supervising doctor should write a report including:

• Education activities in which the doctor’s been involved
• Ability to discuss appropriate clinical care
• Professional relationships with patients, supervisor and other staff members
• Communication skills
• Attitudes – reliability, initiative and timekeeping

Medico-legal position
There are a number of requirements that should be fulfilled before a doctor can carry out a clinical attachment, including: Criminal Records Bureau check and occupational health check. These checks can take a considerable length of time and this should be taken into account by all involved in clinical attachments. Please note that required documentation can vary between trusts, with some also requiring a reference from a UK source. Some Medical Staffing Departments also provide contracts for clinical attachments that doctors must sign.

The Hospital Trust‘s risk management department and medical staffing department should be aware of the fact that attachments are taking place. It may also be able to facilitate the doctor in taking part in induction processes for the hospital.

Some individuals/organisations who are involved in clinical attachments have requested clear guidance about what an attached doctor should or should not be able to do on a clinical attachment. Whilst individual trusts are free to create guidance for their own staff, it is unfortunately not possible to do so in these guidelines. Instead, the following are a number of principles that should be considered:

• Indemnity

The supervising doctor is responsible for the actions of the attached doctor and they should check with their medical defence society regarding indemnity. It is important also for the supervisor to check the specific details of the employing authorities’ indemnity arrangements, specifically if there are any restrictions/limitations under their arrangements including whether or not it covers medical students/clinical attachments.

• Consent

Doctors undertaking clinical attachments are considered to have similar roles to senior medical students. Therefore, as with medical students, the patient must give free and informed consent to their involvement in training of any personnel, and must be aware that an attached doctor is not registered to practice in the UK. If they do not consent to be seen by an unregistered doctor their wishes must be respected.

• What can an attached doctor do?

It is important that the supervisor exercises judgment as to what the attached doctor is capable of doing whilst bearing in mind that the doctor is not registered with the GMC. The supervisor will retain ultimate clinical responsibility for patients and they will need to make a decision in light of the attached doctor’s experience, knowledge and skills. However, the overriding factor is that the doctor is not registered and therefore cannot do any more than is permitted of a medical student. Furthermore, the patient must always give their consent.

Generally speaking, talking to patients, taking histories and performing routine physical examinations are to be encouraged. Policies about what can and can’t be done vary from Trust to Trust, with some Trusts permitting doctors on clinical attachments to take blood under direct supervision and with the consultant’s permission. However, invasive procedures and intimate physical examinations should not be permitted.

The legal implications of increasing attached doctors' contact with patients
Due to the legal status of attached doctors (i.e. that they are not registered with the GMC and currently not indemnified by defence organisations, or by a medical school) it is unavoidable that they will have a fairly passive role. There is ample evidence that active engagement enhances learning, and in the clinical setting the number and range of patients encountered is highly correlated with learning and performance. Therefore, ways of increasing contact with patients during the clinical attachment need to be explored. With the advent of structured clinical attachments the medical defence organisations may be able to review their position, particularly where the attached doctors are entitled to GMC registration, having passed PLAB for example. It may also be possible for bodies running clinical attachment schemes to take out insurance to indemnify the attached doctors in the same way that medical students are insured by their medical school.

Note: The GMC plans to phase out limited registration by early 2007 which may have an impact on clinical attachments.

The abolition of limited registration is a major step in achieving a single approach to the registration of all fully qualified doctors. It will mean that there will no longer be a separate probationary period for international medical graduates.

The GMC will be implementing the changes once all the necessary pieces of legislation are in place, and will ensure that doctors, sponsors, employers and other relevant audiences receive full information about the implications of the abolition of limited registration, as soon as possible.

The GMC hopes abolition will be complete by the early part of next year, 2007. The legislation to abolish limited registration is part of a section 60 Order giving effect to a range of changes to medical regulation which will come into effect shortly. The Department of Health undertook a period of consultation (which closed on 31 January 2006) on the proposed legislation. Parliament has now approved the section 60 order and we await final approval from the Privy Council. The GMC will want to implement the changes as soon as possible thereafter but there will be some further work to be completed before they can do so.

International medical graduates who have completed an internship will be eligible to apply for full registration. They will no longer need to obtain an offer of employment in order to do so but they will need to satisfy a number of criteria before a grant of registration can be made.

There will be transitional arrangements which will allow doctors who hold limited registration at the time the changes come into effect to move to full registration. There will be no additional costs for doing so.

Please watch the GMC's website for further information: http://www.gmc-uk.org - go there