The optimal usage of the ISCP by trainee and trainer

Published:November 10, 2021DOI:https://doi.org/10.1016/j.mpsur.2021.10.001

      Abstract

      The Intercollegiate Surgical Curriculum Programme (ISCP) provides the Curriculum with the specialty syllabus, trainee’s portfolio of activity, and the process and recording of assessment. It is an excellent resource and in order to gain the optimal benefit trainees and trainers are recommended to invest some time in navigating through the site and understand its functionality. The launch of the 2021 Surgical Curricula is an important change with the new assessment tool of the Multiple Consultant Report (MCR) and the trainee input with their self-assessment. The ISCP has incorporated the MCR assessment process (Generic Professional Capabilities and Capabilities in Practice) into the learning agreement structure such that the progression through to the higher-level outcome of the curriculum, defined as a day 1 consultant in a specialty, is enhanced by frequent and focussed feedback specific to the trainee. To achieve the optimal outcomes, it is important to have strong engagement with the ISCP and the useability has been enhanced to facilitate this.

      Keywords

      The Intercollegiate Surgical Curriculum Programme (ISCP) provides a system that enables surgical trainees and trainers to securely capture learning, teaching and feedback utilizing a variety of online educational tools. The programme site provides the curriculum incorporating the specialty syllabus through which a trainee should progress and provides the means for learning to be both recorded and assessed.
      The ISCP was launched in 2007 by the Joint Committee on Surgical Training (JCST). The JCST works on behalf of the four Surgical Royal Colleges of the UK and Ireland to develop, promote and ensure the highest possible standards of surgical training. The ISCP has evolved to be the platform to provide the necessary framework and the required tools to support training of surgeons to the standard required by the Royal Colleges of Surgeons and approved by the General Medical Council (GMC).
      From its inception, the ISCP has provided the curriculum for UK and Republic of Ireland surgical training. It covers all ten Specialist Advisory Committee (SAC) recognized surgical specialties (cardiothoracic surgery; general surgery; neurosurgery; oral & maxillofacial surgery; otolaryngology; paediatric surgery; plastic surgery; trauma and orthopaedic surgery; urology; and vascular surgery). It also includes the curriculum for Core Surgery for early years trainees. With all this information and instruction readily available, the ISCP can initially seem daunting. Trying to identify how and what to learn alongside working as a surgical trainee can seem a challenge, but spending time learning how to use the ISCP optimally enhances the training experience. As a trainee, incorporating the ISCP into the daily aspects of the job and motivating oneself to use it in a step-by-step manner, mirroring the training placement, is profoundly beneficial.
      From August this year (2021), all surgical specialty curricula have been published on the ISCP site after very extensive revision to meet the GMC standards of ‘Excellence by Design’. This describes the high-level outcomes which define the daily activities of the trained surgeon. These outcomes not only include knowledge, clinical and technical skills, but also the professional attributes defined in the GMC's Generic Professional Capabilities (GPCs). The assessment of trainee progression is underpinned by the Multiple Consultant Report (MCR) which is undertaken by at least 2 consultant trainers. With all the new curricula all starting this year the role of the ISCP is all the more important in outlining, delivering and recording these new outcome-based curricula.
      Oversight of the ISCP is provided by its management committee that allows for constructive dialogue with representative groups. Those represented include the SAC curriculum leads, including core surgery training, trainee organizations and specialty associations for surgical training, NHS employers, lead deans, lay/patient representatives, deaneries/HEE, statutory education bodies, educationalists, other medical royal colleges and medical educational bodies. All users should be confident that their views have been represented and the feedback they have provided has driven the ISCP development.

      Assessment

      The approach to assessment has been revised to move away from the granular approach of a range of work-place-based assessments. The high level activities expected of a day one consultant have been arranged into a series of Capabilities in Practice (CiP) which detail the knowledge, clinical and technical skills together with the relevant components of the GPCs. There are five shared CiPs across Core and all surgical specialty training:
      • Managing the outpatient clinic.
      • Managing in patients and ward rounds.
      • Managing the emergency take.
      • Managing the operating list.
      • Managing multidisciplinary team working.
      These are assessed globally to determine if the trainee has reached the curriculum-defined level for their stage of training. In Core training the expected levels relate to the level of supervision. By the end of training, the trainee should be considered competent in all five to be able to perform as a day one consultant. There are additional specialty-specific CiPs in cardiothoracic, paediatric and plastic surgery. Evidence for achieving CiPs can be supplemented by targeted work-place-based assessments in response to previous MCR feedback.
      The GPCs are arranged in nine domains with a number of subsections. Some are directly applicable for inclusion in the CiPs, e.g. professional knowledge and skills and values and behaviour are part of managing an outpatient clinic. Others are domains in their own right such as research, teaching, quality improvement and leadership. These are included both within assessment of the CiPs where relevant and as separate topics.
      The GPCs are:
      • Professional values and behaviours
      • Professional skills
        • Practical skills
        • Communication and interpersonal skills
        • Dealing with complexity and uncertainty
        • Clinical skills
      • Professional knowledge
      • Health promotion and illness prevention
      • Leadership and team working
      • Patient safety and quality improvement
        • Patient safety
        • Quality improvement
      • Safeguarding vulnerable groups
      • Education and training
      • Research and scholarship
      Each is supported by a series of descriptors which can be used to describe and highlight both good performance and areas where development is required.

      Optimal ISCP usage by the trainee

      The site is now best accessed using Google Chrome or Microsoft Edge when using a Hospital access.
      Once registered the first action for the trainee is to set up their placement on the ISCP. The trainee needs to know their assigned educational supervisor (AES) and training programme director (TPD) whose role is to provide global objectives for the assigned post.

       Step 1: Creating personal development plans, self-assessment and transition

      Personal development plans (PDP) and self-assessment may previously have seemed like a tick-box exercise, but in the new curriculum it is necessary to engage with them fully to provide focus for upcoming rotations and allow you to maximize your training experience. By reviewing your specialty curriculum, your index procedures and critical conditions can be identified which will allow you to recognize gaps in your knowledge and seek appropriate opportunities to address this. It will also allow you to have more meaningful conversations with trainers as you will understand the areas in which you seek to improve and trainers can then help structure learning opportunities for you to address this. From a portfolio aspect, familiarizing yourself with the site first and clicking through to view what is where and what is actually available is always worthwhile. This will immensely improve efficiency when organizing meetings and uploading evidence.
      New to the 2021 surgical curriculum is the self-assessment, which is the trainee component of the MCR process. Research has shown that for outcomes-based curricula to be successful, learner engagement and self-directed assessment is vital to the process.
      • Iobst W.F.
      • Sherbino J.
      • Cate O.T.
      • et al.
      International CBME Collaborators
      Competency-based medical education in postgraduate medical education.
      This is an excellent tool which allows the trainee to reflect on their strengths and weaknesses and identify their own learning foci for the coming 3–6 months if completed thoroughly and honestly. It also serves as a useful resource when reviewing the MCR and trainees can compare their own reflections against the feedback from their trainers. This is hugely beneficial for trainees and enhances the number of opportunities for formal feedback to be given to the trainee. One of the most important aspects of self-reflection is to be able to recognize your optimal learning style and environment and so be able to work with your supervisors to facilitate this. At the first objective setting meeting, do not worry that the MCR outcomes along with the self-assessment are not incorporated into the learning agreement, but do provide reassurance to your trainers that they are completing the form appropriately (Figure 1).
      Figure 1
      Figure 1The first objective setting meeting.
      Once transitioned to the new curriculum and when the first MCR and self-assessment have been undertaken these are linked into the learning agreement and are visible to trainee and AES. It will therefore be easier to interpret the learning and development requirements and insert these into the next phase of the trainee learning agreement. These could be focused upon and so evidenced by aspects of the GPCs or the CiPs or trainees may look to use WBAs to evidence where suggested development from the MCR is appropriate (Figure 2).
      Figure 2
      Figure 2MCR is linked into the learning agreements.
      As a trainee, a trial self-assessment can be undertaken via the link (Trial MCR) on the top horizontal bar menu and while this is not saved within the ISCP, one can save the print PDF and upload this into other evidence within the portfolio. This self-assessment is encouraged prior to curriculum transition at present as you can assess your perceived level against the curriculum outcomes and also has the added benefit of being a gap analysis to show any COVID induced training deficit. At present for further support there are pop-up videos embedded into the ISCP explaining items such as the self-assessment and there are further supporting evidence on the JCST/ISCP You Tube site (https://www.youtube.com/channel/UCNFco9XJHPYs-ucDWcr5FkA).
      Since the new Curricula went live on the ISCP at the start of August 2021, when setting up a placement and learning agreement as a trainee you will be asked whether you want to switch to the 2021 curriculum. For the majority of trainees that will be a yes when progressing to the next year of training. The exceptions are the uncoupled CT2s and those entering their final year of SpR training, although the latter can discuss transition with their TPD. The rules on transition are found via the ISCP Curriculum pages (https://www.iscp.ac.uk/iscp/curriculum-2021/#heading_12).

       Step 2: Identifying supervisors, setting your learning agreement and optimizing feedback

      Usually, an educational supervisor will be allocated to you prior to commencing the rotation; however, do your research! If there is a particular consultant whose field of work interests you and so believe would be beneficial to your career pathway, approaching them first to enquire if they have the time to supervise you is proactive and is likely to be more useful in the long term. You only get out of your training what you put in, and early recognition that your trainers have their own work commitments and other trainees apart from yourself is vital. Trainers are there to help and guide you, but they are not there to identify your own learning objectives and create the perfect environment for you to achieve your learning goals. It is vital to be motivated to find appropriate learning opportunities and discuss these with your trainer to maximize each interaction both in clinical and non-clinical situations. Trainee motivation has been demonstrated to positively correlate with performance and continuation of training/study, but it is also associated with driving a deeper reflection in learning and in turn fostering further study.
      • Kusurkar R.A.
      • Ten Cate T.J.
      • Van Asperen M.
      • Croiset G.
      Motivation as an independent and a dependent variable in medical education: a review of the literature.
      ,
      • Kusurkar R.A.
      • Ten Cate T.J.
      • Vos C.M.
      • Westers P.
      • Croiset G.
      How motivation affects academic performance: a structural equation modelling analysis.
      A clinical supervisor may be assigned to you, but with the new 2021 curriculum, multiple clinical supervisors can be listed and it is the responsibility of the trainee to select their lead clinical supervisor (CS). This new role carries great responsibility and spending the time selecting a trainer who is able to coordinate the MCR and with whom you work closely will only benefit your training. Your decision on the lead clinical supervisor can be ratified with your AES at the initial objective setting meeting, and at the same time you, as the trainee, will select the clinical supervisors for the placement all of whom can then feedback on your progression utilizing the MCR. The clinical supervisors can be changed during the placement or additional supervisors can be added if they have a specific interaction or viewpoint that can be reflected in the MCR.
      The credibility of the feedback provider and positive framing of feedback have both been shown to be independent factors in improving student satisfaction with feedback
      • van de Ridder J.M.
      • Berk F.C.
      • Stokking K.M.
      • Ten Cate O.T.
      Feedback providers' credibility impacts students' satisfaction with feedback and delayed performance.
      ,
      • Duijn C.C.
      • Welink L.S.
      • Mandoki M.
      • Ten Cate O.T.
      • Kremer W.D.
      • Bok H.G.
      Am I ready for it? Students' perceptions of meaningful feedback on entrustable professional activities.
      and the MCR highlights this effectively. This new tool aims to optimize both the quality and breadth of formal feedback that trainees receive from their clinical supervisors by delivering specific information regarding the trainee's performance compared with the standards outlined in the GPCs and CiPs. Both strengths and areas for improvement are commented and reflected upon which can then be used, in conjunction with the self-assessment, to shape the following 3–6 months.

       Step 3: Meeting the clinical components of the curriculum

      As a surgical trainee, it can be tempting to view the operating theatre as the only area to acquire skill and knowledge, especially as a junior trainee. Early recognition that there are lots of opportunities to learn and meet curriculum objectives outside of the operating theatre and by lots of different members of the team will make training less stressful and will enrich it greatly.
      In the 2021 surgical curriculum, a minimum number of work-based assessments (WBAs) is no longer required. This is a great improvement and should change the way in which you view WBAs as they are no longer a hoop to jump through and instead can be viewed as a valuable part of the learning experience. When completing any WBA, whether that be focusing on a procedural case or discussing a clinical scenario, it is vital to focus on one or two specific learning points instead of the whole experience. By tackling it this way, the task is no longer overwhelming and it allows you to elaborate on specific areas which in turn makes for more meaningful reflection. Focusing on only a few points per WBA will also allow you to identify your own weaknesses alongside gaps in your knowledge which, when discussed with your supervisor, can form the basis for further development and discussion to help broaden your knowledge.
      The new curriculum moves away from linking WBAs to ‘syllabus topics’ and instead focuses on what the trainee needs to demonstrate to show scope of practice for certification through the use of index procedures and critical conditions. Index procedures are defined by the ISCP as being ‘the common and important operations central to each specialty’, representing a breadth of practice and conferring importance for patient safety. These index procedures are documented and assessed through procedure-based assessments (PBAs). Critical conditions are defined as those conditions ‘where a misdiagnosis could be associated with devastating consequences for life or limb’. These are documented and assessed through the utilization of case-based discussions (CBDs) and clinical evaluation exercises (CEXs). These index procedures and critical conditions are then tabulated with a corresponding level of competence (see Figure 3) which allows trainees to map their progress and for supervisors to provide holistic feedback relevant to the trainee's stage in training.
      Figure 3
      Figure 3Table of WBAs for certification as on ISCP website.

       Step 4: The ‘other bits’: research, audit, presentations

      The tasks of audit, research and publications can seem daunting and are often an afterthought for trainees, remembered just in time for the annual review of competencies for progression (ARCP). As such, they are often viewed as arduous instead of recognized as an opportunity for all trainees to develop their portfolio, learn different skills and improve the field in which they work. These projects provide trainees with the chance to undertake more self-directed learning in an area that interests them. Seeking out these projects as individuals, instead of waiting for trainers to hand tasks down to trainees, will allow trainees to identify what the department/surgical field needs and action on it. Identifying a project you actually care about will also make the task more enjoyable and you are more likely to complete it and be successful in publication, presentation and may even be able to invoke change from your work.

       Step 5: End of rotation/year reports and the ARCP

      As the final step in a rotation, it is easy to regard these meetings as just the gateway to the next phase in training. With the new 2021 curriculum, these meetings are now excellently based to be more than just a step and instead provide another opportunity for formal feedback for the trainee. It is vital to plan and organize these meetings with your trainer early and attend the meeting with your action plan prepared. Trainees should engage in honest reflection with their trainer, discussing both strengths and weaknesses displayed relevant to each of the GPCs and CiPs. By following this structure as a trainee, the MCR can also be incorporated into the discussion as it follows the same framework. This then allows these meetings to be a more enriching learning opportunity with the possibility to outline new goals for the coming rotation based on the experience of the past placement.
      The ARCP provides trainees with the chance to review the skills and knowledge they have acquired over the last year alongside being another formal opportunity for feedback not just from local supervisors, but from those at deanery and school level. From the trainee perspective the most important aspect is to have all the evidence from their training year complete and available to be viewed in the appropriate sections of the ISCP and hopefully show how the learning agreement has been undertaken and the objectives achieved. By entering into these meetings with a clear action plan, supervisors at all levels can provide focused feedback relevant to your training goals and also provide guidance for the next phase of training. These meetings also provide an opportunity for trainees to feedback on the ISCP and training programme and should be utilized as a chance for growth and improvement. Do remember, however, that the Gold Guide training manual makes it clear that the ARCP should occur without the trainee being present and so the decision is made on the evidence within the ISCP and so this should be clearly signposted for the deanery.
      It is easy to be overwhelmed by the ISCP and as such not utilize it optimally. As a surgical trainee, it can be hard to be thorough and organized with your portfolio, but by treating ISCP as integral to the learning process, it is easier and more enriching. The new 2021 curriculum brings the focus back to learning and removes barriers to allow trainees to view tasks as more than just tick-box exercises. Organization on the part of the trainee, however, is still vital and daily engagement with the ISCP is needed for success. Treating the ISCP as part of your daily learning will allow you to identify gaps in your knowledge and your CV, enabling you to address these gaps swiftly and then have more meaningful interaction with your trainers. The refocus of the ISCP on trainees is evident in the new curriculum and as such should impact positively on trainees but it remains true that you only get out, what you put in.

      Optimal ISCP usage by the trainer

      For a trainer the ISCP is the best resource for information and guidance on the delivery of their specialty curriculum, and similarly to the trainee, the more time that a trainer invests into the ISCP the greater its benefit as a resource it becomes. Few people are aware of the ability to assign a secretary to be able to administer your account upon your behalf, but if you go to the dashboard then you can open that list of secretaries and if you are yet to nominate you will be directed to contact the ISCP helpdesk.
      At this point it is important to highlight the availability of the ISCP helpdesk, accessible 9am–5pm Monday to Friday by phone (020 7869 6299) or e-mail ( [email protected] ), with the aim to respond on-line within 24hours if during normal working hours. It is staffed by the JCST team and will be able to resolve or source the answers to allow optimal delivery of training and potentiate your usability of the ISCP as a trainer.
      Taking you back to the dashboard, this where a trainer arrives after the home page sign-in and provides the trainer with alerts, warnings and notices. The alerts, which are under a red band, represent a required action such as the validation of a work-based assessment, if a trainer had not alternatively followed the direct link sent via e-mail. Similarly, this is where the links to required MCR inputs will appear, though these also will be sent directly, with a link, via e-mail to mark the start of the 2-week MCR feedback window. At present when entering the dashboard site, the trainer will also have the imbedded pop-up video explaining the transferring/transition to the 2021 curriculum.
      With the 2021 curriculum the number of work-based assessments required by the trainee is reduced, as no longer will a deanery be requiring evidence of a specified number of WBAs over the course of an annual training placement. The procedure-based assessments are to be undertaken for index procedures for a specialty, and while the numbers and range of requirements may vary between the specialty, they are all clearly documented in Appendix 4 of the respective curriculum. Once successfully validated, these PBAS will be recorded within the trainee's WBAs for certification page (Figure 3) and also within the trainer area of the ISCP where the free text within the trainer feedback is analysed. To optimize the trainee experience it is good practice to provide clear, well-explained feedback that matches and reinforces the verbal feedback within a case and is developmental to the next time the trainee would undertake this.
      For the critical conditions (listed within Appendix 3 of the respective curriculum) which are felt to be of significant importance for patient safety and to demonstrate a safe breadth of practice, the trainee should undertake a CBD CEX to level 4. This very focussed assessment is also a certification requirement and so if the trainee is felt not to have displayed the required level the feedback should be clear with suggestions for development.
      In the dashboard, warnings may appear under a yellow band that represents a recommended action, and the notices are under a blue band indicating for information only. It is within this section that messages can be accessed where again notifications and reminders for WBAs occur and links to learning agreement sign-offs or to ARCP comments can be found. The colour code system is also used for the single trainee placement bar where a traffic light code is used to highlight where access or submission to the ISCP is not up to date (amber) or significantly outdated (red), so that it is easier to understand the status of trainee interaction.
      For both trainee and trainer, the largest component change within the ISCP arising from the 2021 is the MCR and its role in trainee assessment. As trainers, the MCR is utilizing the Professional judgement of a group of clinicians to feedback on and generate development, by utilizing clinical entrustment, in the progression of a trainee through to the higher-level outcome of being able to work at the level of a day 1 consultant. The process is that the trainee chooses a lead clinical supervisor and a further group of clinical supervisors for a placement; these decisions are confirmed by the assigned educational supervisor at the objective setting meeting.
      If nominated as a lead clinical supervisor, the trainer will be notified by message and e-mail that they can start the MCR process. Before the midpoint of the post they will arrange a meeting of, where possible, all the clinical supervisors (either face to face or on a virtual platform) to discuss a trainee, from a clinical perspective and ideally with the knowledge of their learning objectives for the placement. It will be very important as a supervisor to know where the trainee is in the training pathway and so know the critical progression points with the indicative CiP levels for their phase of training. The lead CS will record the opinions of the group within the MCR in which the GPCs and the CiPs have equal weighting. The default setting of the GPCs is ‘appropriate for phase’ (of training), but if it is felt development is required then the GMC written descriptors can be chosen or free text used. The CiPs are assessed by supervision levels with level IV being that of the day 1 consultant, and so if the adjudged entrustment is less than this, descriptors would be used for showing how development would be achieved. A maximum of five feedback points would be used per CiP, but it is important that where appropriate these include recognition of the aspects in which a trainee performs well.
      The MCR report will be created within the ISCP and clinical supervisors will be notified by e-mail that they have a 2-week opportunity to pass comment if they had been unable to attend the discussion or add to the feedback. Once all have commented or 2 weeks have passed, the AES will themselves pass comment on the MCR, highlighting where appropriate, evidence within the curriculum. Once signed off, the MCR will be viewable by the trainee and along with the self-assessment embedded into the next learning agreement meeting. It is at this stage that the lead CS should meet with the trainee to compare the MCR and self-assessment.
      If utilizing the trial MCR, and this will remain accessible until the end of the transition zone in July 2023, then when preparing to print the MCR, the print PDF feature can be utilized to save the MCR.
      For trainers, other than the introduction of the lead CS, the educational roles are unchanged and through the ‘my trainees’ section each trainee within each designated role can be found. Where the trainee has moved to a 2021 curriculum, this will be represented by a purple box:
      Image 1
      For a trainer, historical trainee links are stored for each role and again via the dashboard, in the ‘my roles’ section. Each section, such as educational supervisor, will have the names of all supervisees since the trainer joined the ISCP.
      While the main aim of the ISCP is to ensure that training is optimal and that the trainees are progressing, there is the option for a trainer to record their activity and also calculate a trainer's level of interaction with respect to trainee progression.
      The trainer area has been developed with the Faculty of Surgical Trainers who have provided a trainer dashboard that highlights activity as an effective and/or excellent trainer, and the site can also be utilized to provide recognition to the GMC in order to validate the role as a trainer. Within this trainer area there is also the option through the assessment of summaries to look at the quality of feedback and developmental advice being given within the WBAs and learning agreement.
      In summary, for both trainee and trainers the ISCP is an excellent resource, but to optimize the activity undertaken, especially with respect to the new curriculum, the advice would be to explore the site and learn to use the optimal resource to provide the trainee the best learning environment possible.

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