Public Health Medicine Training: How Should We Train the Trainers?*

Dr Arun Midha^*, Mrs Kathryn Redway^†, Dr. Hilary Fielder^*, Professor Stephen Palmer^*, Dr. Cerilan Rogers^*, Dr. Dorothy Wright^‡, ^* Division of Public Health, University of Wales College of Medicine, ^†Henwick Old Farm, Thatcham Kent, ^‡Morgannwg, Health Authority, 41 High Street, Swansea

Abstract - In the United Kingdom, a qualified medical doctor needs to undertake a five year training programme to reach Consultant status (Medical Specialists in a particular area such as public health, surgery, obstetrics etc.) During this period of training they are known as 'Specialist Registrars'. Consultants in Public Health Medicine have a key training role acting as Trainers assisting these Specialist Registrars to acquire epidemiological public health skills necessary to attain Consultant status. In addition to formal Public Health Medicine training, Trainers have a pastoral role that can mean that they need to be sensitive to the emotional needs of their Specialist Registrars. Praising or reprimanding adults is not an easy task and few people are trained for it. In this training role, Consultants themselves need to be equipped to undertake this effectively. The 'Wales' training model, developed by the Faculty of Public Health Medicine in Wales, has sought to address this need and could be replicated to train Trainers in other medical specialties and in other parts of the world.

Key words: Trainer training.

   A prospective public health medicine consultant in the United Kingdom, in common with other medical specialities, must complete a five-year training program as a specialist registrar. These physicians are already qualified as medical practitioners, often having further post-graduate qualifications and substantial clinical experience. During the training period the special registrar is guided and supported by consultants. In the United Kingdom, the Faculty of Public Health Medicine identifies six broad training areas: health information, preventive medicine, health promotion and environmental health, management of health services and teaching and research.¹ The Record of In-service Training and Assessment² includes 17 competencies that reflect these training areas and specialist registrars must be able to demonstrate that they have acquired the skills and knowledge to apply them before becoming a consultant. In each of the five years of training the specialist registrar and his/her trainers agree on a number of competencies to be achieved that year. The training program reviews these locally on a quarterly and annual basis.

The Consultant as Lead Trainer/Academic Trainer

    A key training role of a consultant in public health medicine is to act as either a lead trainer or academic trainer for specialist registrars in achieving the competencies required to apply for consultant status. The lead trainer in conjunction with the specialist registrar should identify perceived learning needs and agree on priorities. The lead trainer also ensures that the specialist registrar is undertaking specific tasks that relate to the attainment of competencies and provides frequent feedback to monitor progress on attainment during the five year training program. Apart from a lead trainer, specialist registrars are allocated an academic trainer who is normally a consultant holding an academic appointment in the University Department of Epidemiology and Public Health who assists the specialist registrar in identifying his or her academic learning needs. They also provide supervision and support for the duration of the training program to ensure attainment of the academic requirements as laid down by the Faculty of Public Health Medicine.

    In addition to formal public health medicine training, both types of trainers have a pastoral role and need to be sensitive to the emotional needs of their specialist registrars. Those special registrars who have just changed career and direction, those who have been uprooted and whose family lives, as a result, are being disrupted and, those who find that expert skills of another discipline are now largely obsolete, all need support. Praising or reprimanding adults is not an easy task and few people are trained for it. These skills are difficult to develop because they are, by and large, qualitative in nature as opposed to the more quantitative, more measurable epidemiological public health science skills.

    Although the Faculty of Public Health Medicine in the United Kingdom requires that training programs provide "training the trainer" training courses to assist consultants in developing these qualitative skills, there is no formal guidance on how this training should be done.¹ The Public Health Medicine training scheme in Wales has developed a model for trainer training consisting of a workshop held over two days. The program has two clearly identified aims: to help trainers to learn about and acquire interpersonal skills that can be used in pastoral and professional roles; and to be confident with the skills and techniques offered in the program so that they become part of the trainers’ working practices.

Workshops to 'train the trainer'

    The first component of the workshop concentrates on skills building. The skills building activities are directed at learning to set objectives, giving and receiving feedback, and conducting a performance appraisal using a mix of case studies and, discussions. It also covers the annual assessment process and examinations. The second component helps the participant develop an action plan about how to use their newly acquired skills to support training, focusing particularly on how they could assist a specialist registrar who was experiencing difficulties either professionally or personally.

    The workshops begin with a session on how a trainer should set appropriate learning objectives for their specialist registrars. Since specialist registrars have to undergo a process of a formal annual appraisal, the need not only to set objectives but also to ensure that these can be readily tested is an essential prerequisite. In pairs, a trainer pretends to be a specialist registrar and selects what he or she would study in a given year. The Faculty's Record of In-Service Training and Assessment on "Core Competencies" is used as a basis for agreement.² The application of SMART criteria (specific, measurable, achievable, realistic and time-bound) is useful in this context.³ Good regular communication is essential between the trainer and specialist registrar, as is trust, particularly in terms of discussing potentially sensitive issues such as the specialist registrar's abilities and learning gaps. By setting objectives, with regular and frequent review and feedback those experiencing training overload can be assisted and those who lack enthusiasm can be motivated. The trainer must have a good feel for when and how to encourage a poorly motivated specialist registrar or restrain an unrealistically enthusiastic one.

    Methods of giving and receiving feedback are also discussed. Providing feedback has long been recognised as an essential component of effective learning.⁴ The importance of catching deterioration in performance at as early stage as possible is discussed and the possible reasons for this deterioration is examined. Are there for example, signals that could be recognised early on preventing a worsening situation? Examples of signals could include a failure to meet agreed objectives, a failure to attend pre-arranged meetings with trainers or to meet specified deadlines. According to Handy⁵, feedback should be given as soon as possible after a learning opportunity. Clearly, specialist registrars cannot learn unless feedback is both regular and frequent. Some trainers felt that some personal matters should be referred elsewhere while others considered that they should try to see if they themselves could help.

    The workshop addresses the specific skill of communication (the ability to listen and respond effectively) using the concept of transactional analysis.⁶ Berne suggests that when we communicate with another adult, we do so in one of three ego states as a parent, adult or child. In the parent ego state we would speak in dogmatic, autocratic terms. Berne subdivides this state into: i) critical parent behaviour where a more critical, moralising approach is used and, ii) nurturing parent behaviour where a protective, sympathetic more comforting approach is adopted. Adult behaviour responses can be either: (i) judgmental for example, "I would not do this if I were you"; (ii) interpretative expressed with questions like: "You feel you would be happier if you just escape to…"; (iii) supportive by offering real help; (iv) probing, for example asking "Why do you think you are frustrated with the work you have on right now?" or, (v) understanding, reflecting back to people what they have just said. Child behaviour consists of impulsiveness, inquisitiveness and curiosity. It would also express itself through behaviour that was self-centred, self indulgent and rebellious. In the context of the training process, a trainer would aim to communicate with his or her specialist registrar in an adult mode most of the time. However, if the specialist registrar feels frustrated or over extended he or she might adopt the "child ego state" – for example – "I am angry, I cannot do this, or help me, show me how". Some trainers could occasionally retreat to a parent mode and treat the specialist registrar as a child, responding with words like "That’s not right. I told you this before." The workshop uses a short exercise in the form of a "How do we respond?" questionnaire which is based on Berne's work to illustrate how well or badly they communicate and how influenced they are by their own preconceived ideas. It was interesting that in the workshops, trainers tended to use probing frequently, when some situations may benefit from an evaluating, more expediting, more direct, or more urgent response. The exploration of different styles of responses might well achieve better results.

    The next session focuses on the annual performance appraisal. According to Stewart⁷, appraisal is used for three main purposes: remedial (concerned with putting right things that are going wrong), maintenance (concerned with encouraging the person being appraised to continue those things he or she is doing well) and, development (concerned with what the person being appraised needs to do next). In essence, a performance appraisal consists of two people who meet and agree on answers to the following questions: ' What did we set out to do doing the last training period?, Did we do it?, What are we going to do next, and how will we know if we have done it?'⁷ It allows the trainer and specialist registrar to review past performance and plan future training. Trainers are paired into academic or lead trainer and the specialist registrar. They each have a briefing sheet that the other does not see. Each illustrates a case study, where there is a difficulty either in personality or with the learning side of the training. Trainer and specialist registrar have a maximum of 45 minutes to conduct their appraisal and agree on a course of action. An example of a case study is given in Figure 1.

    The workshops finally analyse, step-by-step, the behaviours and techniques explored in the previous sessions and discuss how each trainer could transfer and use these skills with their specialist registrars.

Outcomes

    On the whole, every experience - listening, responding, appraising - was seen as useful in giving trainers the tools to train specialist registrars more effectively. Comments such as 'There is a need to establish a philosophy which is about "adult-adult" learning, that is reflective, not damaging through service and academic sides', 'There needs to be "ground rules" about constructive criticism', and 'We should treat specialist registrars as we would like to be treated ourselves' were reflective of the trainers' views on how best to manage their own specialist registrars.

    One of the main outcomes of the workshops was a view that a project-based approach to learning encouraged creativity and a questioning attitude in specialist registrars. In this approach, the lead trainer identifies a number of projects. The specialist registrar would be expected to prioritise these and the academic trainer would assist in writing a protocol for each project, identifying learning objectives. At the end of each individual project, there would be a structured process review against set learning objectives between the specialist registrar, the lead trainer and the academic trainer (Figure 2).

Evaluation of Workshops 

   Formal scientific evaluation of such educational interventions is difficult. However, in general, evaluation of any training should not be considered as a one-time event. Rather, it should be considered in terms of a cyclical process whereby information is fed back to inform and enhance the content of future training. Evaluation of the training program was undertaken by two questionnaires; the first completed at the end of the workshop and the second after 12 months had elapsed. The first questionnaire was completed by 38 of 40 consultants (95% response rate). On a Likert scale ranging through very good, good, satisfactory, poor and extremely poor, 65% of respondents thought the content was very good and 35% that it was good. 81% of respondents thought the teaching quality was very good and 19% thought it was good. These are necessarily value judgements but these are people who have experienced many years of teaching, who know the aims of the course and could judge if it was appropriate for their needs in order to meet the aims.

    After 12 months, the second questionnaire was sent out to all trainers to identify if they had had an opportunity to use the skills and techniques gained on the course and, also if they had found that the skills learned had made it easier to set objectives, give or receive feedback and undertake a performance appraisal. Thirty-one evaluation forms were returned (response rate 81%). Consultants were asked if they had had an opportunity of setting objectives, giving and receiving feedback or carrying out a performance appraisal for specialist registrars. 39% (12) of Consultants said that they had had an opportunity to set objectives for their specialist registrars. This was disappointing given that one of the reasons for consultants attending the course was to develop skills that they needed as part of their role as a trainer. Of these, 3 said that the skills learned on the course had made this task easier, 7 relatively easier and 2 said that the course had made in neither more or less easy. In terms of giving and receiving feedback, 77% (24) indicated that they had had an opportunity of using the skills learned in the course. Of these, 4 had found this task easier, 15 relatively easier and 5 neither more nor less easy. Finally, for performance appraisal, only 16% (5) had had an opportunity of carrying out a performance appraisal with a specialist registrar. Of these 3 had found the skills learned in the course made it relatively easier to carry out this task while 2 had found it neither more nor less easy. There were two main reasons for the relatively small percentage of consultants having had the opportunity to set objectives, give and receive feedback or carry out a performance appraisal. First, a number of consultants attending the workshops were relatively new in post. The Faculty of Public Health Medicine has introduced a rule that while allowing a consultant to undertake training to enable them to act as trainers, it does not allow them to take up a formal trainer's role for two years. Secondly, at the time of the workshops the scheme in Wales was relatively low on specialist registrars and so some consultants had not been allocated Specialist Registrars to train.

Conclusion

    Training the trainer is important for the education of future consultants. However, we found that trainers in Wales, while knowledgeable about public health as a science, often were not equipped to guide specialist registrars through the learning process. The workshops have been run in Wales on four separate occasions and we have been able to train 40 public health medicine consultants who now can act as trainers in Wales. Although the training in public health medicine includes training in managerial theories and skills, the role of the trainer involves different skills with a subtle blend of management, mentoring, advocacy and teaching. These workshops aim to give a framework to ensure that trainers are equipped - or at least are confident with particular techniques and tools that enable them to impart their knowledge. Clearly, personalities can cause difficulties but with the appropriate training of consultants the scheme can ensure that, once a specialist registrar is accepted in to a training scheme, the trainer can help him/her achieve the competencies and complete their training successfully. In addition, the techniques used in these workshops might be applicable to trainers in other health professions and with small adjustments, be suitable for use in other countries.

References

1. Faculty of Public Health Medicine of the Royal Colleges of Physicians of the United Kingdom (1996a).     Handbook on training and the examination for membership. The Faculty, London.

2. Faculty of Public Health Medicine (1996b). Record of in-service training and assessment. The Faculty, London.

3. Drucker P (1954). The practice of management. New York, Harper.

4. Turney C (1984) (Ed). 'Skills of supervision'. Sydney. University of Sydney press.

5. Handy C B (1993). Understanding Organisations 4^th Edition London Penguin.

6. Berne E (1967). Games people play: the psychology of human relationships. Harmondsworth: Penguin.

7. Stewart A M (1992). 'Making performance appraisal work'. In D M Stewart: 'Handbook of Management Skills' 2^nd Edition Aldershot Gower.

Reference:

Midha A, Redway K, Fielder H, Palmer S, Rogers C, Wright D. Public health medicine training: How should we train the trainers? Med Educ Online [serial online] 2000;5:2. Available from URL http://www.med-ed-online.org.

Correspondence to:

Dr Arun Midha, Division of Public Health, University of Wales College of Medicine, Heath Park, Cardiff. Telephone 029 20 742249, email MidhaAD@Cardiff.ac.United Kingdom