Post-COVID rehabilitation for IMT outpatient training: a quality improvement project demonstrating the benefit of protected clinic time

Abstract

Problem: Internal medicine trainees (IMTs) require training in outpatient settings to prepare for the medical registrar role, as well as it being a core competency. However, time in the outpatient environment is inconsistently allocated, and IMTs traditionally struggle to reach ARCP targets, let alone feel ready for registrar practice. COVID decimated outpatient training when outpatient services all but ceased and hospital doctors were required to staff inpatient wards with intense clinical pressures. A majority of IMTs at our hospital did not meet the requirements for outpatient clinic numbers by their Annual Review of Competence Progression (ARCP) in summer 2021. Aim: We sought to recover outpatient training for IMTs at Queen Elizabeth Hospital Woolwich, primarily through improving the number of clinics that IMTs attended in the year 2021–2022. We aimed to increase the rate of IMTs achieving 20 or more clinics (the curriculum target) each year to 100%. A secondary aim was to improve the quality of training, with the hope of elevating outpatient training above the low bar of pre-COVID levels. We then extended this project to subsequent years. Methods: We tackled this issue with QI methodology. Firstly we developed ideas for potential interventions through interviews with IMTs, supervisors, and other stakeholders, and refined these with a driver diagram. We carried out three PDSA cycles to examine the effect on IMT clinic numbers. We also assessed negative impacts of intervention with balance measures, and utility with process measures. Results: The biggest improvement in clinic attendance was seen with the introduction of a ‘clinic week’. Through funding granted in the HEE COVID recovery scheme, we were able to provide locum cover to facilitate a week off ward duties for each IMT, in order to attend clinics. Each IMT attended an average of 9.75 clinics per clinic week, almost half of the yearly requirement of 20 clinics in one week. Zero trainees reported that this impacted on their other training opportunities. 87.5% of trainees achieved ARCP clinic criteria in 2022, increased from less than 50% in 2021. All trainees felt that the clinic week improved the quality of their outpatient training. This suggests that allocated and protected time to attend outpatient clinics is an important tool in the provision of outpatient training for IMTs - and should be considered even outside of the post-COVID period of recovery. Indeed, the next stages of our project will be to extend this despite the loss of HEE COVID recovery funding.