Ruchi Sinnatamby – Series 2 – Teaching Hospitals

[00:00:00] Cheryl: Welcome to the podcast from Cambridge University Medical Education Group, or CUMEG for short. This is a podcast from the University of Cambridge Clinical School, focusing on medical education. We discuss a range of topics that medical educators are dealing with. I'm your host, Cheryl France, Head of CUMEG.

Today I would like to introduce Dr Ruchi Sinnatamby. Ruchi is a consultant radiologist at Cambridge University Hospital's NHS Foundation Trust, which is also known as Addenbrookes.

In addition, Ruchi is the Clinical Sub Dean at the University of Cambridge Clinical School. Ruchi's role as Clinical Sub Dean is to foster the links between the University and Cambridge University Hospital's NHS Foundation Trust.

Welcome, Ruchi. It's wonderful to have you with us today.

[00:00:55] Ruchi: Thank you, Cheryl. It's lovely to be here. I'm looking forward to our chat.

[00:00:59] Cheryl: I am too. I think it would be great for us to just start out, if you'd be kind enough to kind of tell us a little bit more about your background and your current roles.

[00:01:08] Ruchi: Thank you.

So as you said, I'm Clinical Sub Dean for Cambridge University Hospitals. We call it CUH here. In addition, I am Director of Studies for clinical medical students at one of the colleges here, that's Murray Edwards College which is one of one of only two colleges for women here at Cambridge. And I was previously Vice President of Murray Edwards College up until last year.

 I also act as an exam review officer for the university, which means I adjudicate on student appeals over our final, end of year examinations. But interestingly, because of conflicts of interests, we can only adjudicate on exams in subjects other than our own, which means that I review appeals for things like law or anthropology. Lots of interesting other subjects, but not medicine.

[00:02:04] Cheryl: That is really fascinating. Quite a range of roles. My goodness.

Thank you so much for taking the time to be here today because obviously, you are very busy. And I could almost interview you on each of those roles because they sound so interesting and dynamic all in their own right.

[00:02:23] Ruchi: Thank you, Cheryl.

I suspect you probably want to know a little bit more about the sub dean role as we're focusing on undergraduate medical education.

[00:02:32] Cheryl: I do actually.

So I think it would be really interesting to understand more about the relationship between clinical schools and teaching hospitals.

[00:02:42] Ruchi: Okay. So, in my role as Sub Dean, I think it's fair to say there are three main areas that I cover, and the first is, as you say, a crucial one of liaison between the hospital and the university.

I also oversee the finance that the hospital gets for clinical student placements. And that means looking both at allocation of finance and transparency of spending of what we call the tariff finance, and I can explain what tariff is a little bit later.

And the third is quality assurance of all of the undergraduate education that's delivered within the hospital. Now part of that includes, and this is a new aspect reporting to the hospital board of governors. So that they get an understanding of the educational component that's being delivered within the hospital.

 As clinical sub dean, I'm a member of the senior leadership, what we call the core deanery team. i.e. Cabinet that administers the undergraduate medical education course here at Cambridge. And as part of quality assurance, I also undertake education appraisals for our senior teaching officers.

And for the hospital, I act as a representative on interview appointment panels for new consultants. Now, this is health service consultants, where I look to represent undergraduate education and make sure that our new consultant appointments are made to people who have an interest in delivering education, because after all, they're coming to work at a teaching hospital.

[00:04:34] Cheryl: Yeah. That's quite interesting.

 

So there's quite a lot that you are doing not only with the clinical school, but at the hospital facing side of things in order to ensure the smooth working.

[00:04:45] Ruchi: Absolutely, and actually, my day job, my clinical job is 90% of my role, so my clinical sub dean role is effectively or contractually one day a week.

So most of it's the day job, which is as a specialist in breast cancer imaging and breast screening.

[00:05:05] Cheryl: Okay. Oh, that's quite interesting. So, one day a week

[00:05:10] Ruchi: That's kind of nominally how the sort of contract is drawn up in practice, it's pretty pervasive.

[00:05:18] Cheryl: I'm sure it is. And I'm sure, you know, bits of things happen throughout the week that you wouldn't even recognize have happened just to ensure that the smooth working relationship occurs.

Would that be correct?

[00:05:29] Ruchi: Absolutely. And I think one of the things I really love about it is the education aspect to my job is very wide ranging and it's what keeps my interest fresh in, you know, a long-term clinical career where I think you find that a lot of clinicians, particularly in teaching hospitals, become very specialized.

So although I'm a clinical radiologist, the vast majority of my clinical job is, as I said, doing breast imaging and having a much wider ranging portfolio of education keeps my interest, keeps me fresh helps me enjoy my job greatly.

[00:06:17] Cheryl: I bet it does. I think it's that interest, and it sounds fascinating, all the different hats that you wear, you know, just at the introduction, telling us all these different roles, it sounds fascinating and nice to dip your toe into different aspects.

[00:06:31] Ruchi: Absolutely. As long as it's not jack of all trades and master of none, it's more a portfolio career.

[00:06:36] Cheryl: Okay. That's fair enough. That's fair enough.

So can we just dive a little bit deeper into the aspect of the relationship between the clinical school and the hospital. So, you talked about there's a liaison role, there's a finance role, and there's a quality assurance role.

Would you mind telling us a little bit more about each of those?

[00:06:57] Ruchi: Yes. But maybe it's helpful to kind of understand. The role that hospitals play in undergraduate education and in particular, how? So CUH, Cambridge University Hospitals is the major partner trust for the clinical school. And just winding back a little, so our students spend three years doing the preclinical part of their education.

So down in the town, in university, where it’s lecture based and seminar based and supervision based, but it's very theoretical. And then from years four to six, they come up here based at the clinical school to undertake their clinical education.

Now in those three years, it works out to roughly half of that time is spent at the hospital here at CUH or Addenbrookes Hospital, as you call it. And the other half of their time is spent either in our regional partner trusts, all over East Anglia or in general practice or doing public health or psychiatry, other forms of clinical education.

So half of their time is spent here Addenbrookes. Now what does that mean? Some of that is going to be what we call the core component of learning medicine and surgery. Some of that, particularly in year five, is doing placements in specialist areas. Students will have specialist experience in regional hospitals as well. But what we at CUH provide is access to tertiary referral experience. So things like specialist neurosurgery, specialist plastic surgery, oncology where patients are referred in from all over the region for access and treatment and facilities that are only available here in Cambridge.

The other aspect of the learning here in Cambridge, is a lot of communication skills teaching is delivered here, and also the practical skills. So, things like learning to take blood, learning to do lumber punctures, all the sort of hands-on practical skills as well as the learning how to examine patients and make diagnoses and learning about treatments.

[00:09:32] Cheryl: So everything you've just said, sounds like it's quite a big teaching hospital, and I presume we really need that because here at the university we potentially have 900 students coming through the hospital and as the major provider for the training. How does that work in practice?

[00:09:53] Ruchi: Okay, so that is a good question.

So, you're right. Addenbrookes is a very large teaching hospital. It's got around 1,100 beds. It serves the local population in Cambridge, but it also has referrals regionally, nationally, and internationally.

And yes, 300 students in each year. Around 900 students in total is a lot of students. I think it's important to establish that, or to note, that the majority of teaching and supervision of experience of students on placement is delivered by health service staff rather than university staff. So that's one factor to consider.

And the other thing is to recognize that because of that, there is always an element of tension between the desire to deliver education and the concern about possible impact on service delivery. So for example, you might find that if you have students with you in clinic, there might be a concern that the time taken to supervise students, explain conditions to students; might impact on the numbers of students a clinician can see within an outpatient session. So those are all things to balance.

But moving away from that a little bit perhaps it would help to explain how the funding works.

[00:11:28] Cheryl: I think that would be really helpful because clearly there, you talked about that tension, that it's important to be able to have that time to explain. But clearly the clinician needs the time. So is there funding to give extra time or how does the funding work?

[00:11:43] Ruchi: Okay, so that's a good question. Perhaps the first place to start is to think about how medical students are funded in total within the UK.

So there are two components to funding. The first component goes to the university, and part of that is contributed by student fees, but the majority of that component, comes from the government and the funding that goes to the university is there to provide obviously salaries for university staff, but a lot of it goes in administration and infrastructure delivery of assessments and exams. For example, delivery of lectures, things like that.

Then the second component, goes towards funding placements, and that's called tariff. Now all of tariff comes from the government, from the National Health Service, and it's delivered via health service education boards. Now here in the UK here in England that structure is called Health Education England, and Health Education England has a number of regional establishments. And those here in Cambridge, we are funded by Health Education East of England, and they pay the hospitals to provide placement experience. And this means that tariff is equitable or equal across all providers. So, you know, we talked about students having placements in general practice and in regional hospitals and in psychiatry and in acute teaching trusts like ours here at Addenbrookes.

So the funding is roughly equitable and its decided with a formula which works on student numbers, so it's per head and the length of time they spend on placement. So remember I said all of the students will spend roughly 50% of their time here, at Addenbrookes. So a substantial amount of tariff comes to the hospital to deliver that amount of payment.

So how does that translate to individuals looking after students? Well something we do here, Addenbrookes, which I think is relatively unique, is that every single consultant, so NHS consultant rather than university consultant that works at Addenbrookes has a small proportion of their salary that comes straight, or is accountable to undergraduate education and is paid by tariff. Now it's only a small fraction of the time, but that is to recognize the fact that they work in a teaching hospital and it's to accommodate what we call ‘on the job teaching.’ So if you have a student with you on the ward or in clinic, while you are doing your regular day job, a proportion of that funding will make up part of your pay.

Additionally, and this is something that I have worked very hard to establish here at Cambridge, is that we have a number of individuals who provide what we call over and above teaching contributions. So they may be running student selected components, they may be delivering seminars, they may be specialty leads, looking after the organization of all of the teaching in that particular area, and they have their time recognized specifically by direct tariff funding.

[00:15:36] Cheryl: So they'll have more time.

[00:15:37] Ruchi: They will have more time allocated. Or more funded time allocated.

Now, how that translates will depend on the service delivery within their own department. But it, the idea is not necessarily to pay an individual more than their peers, but to be able to buy time out for that consultant to deliver the education we require to look after the students. That's the theory, at any rate, it is quite a complex equation and my goal is transparency of tariff spending. Let's just say we are working towards that goal. We haven't quite reached that yet.

[00:16:17] Cheryl: Well, it's very complex and it's because as you say, some people might be giving more time and it's important to recognize that.

[00:16:25] Ruchi: I think so. And I think it is also important to recognize why NHS consultants are so keen to help us with their teaching. I think education is really prioritized by many, many, well, I would say the vast majority of people working in a teaching hospital because it is incredibly rewarding and it goes back to what I was saying about the educational component of my job. It's what keeps it interesting and fresh and you get so much more out of it.

It's not just about pay though. And I think we also need to think about how we reward our health service consultants for teaching. And some of that is about recognition of titles. Now that's always a slightly tricky issue. So in Cambridge we have so people who are NHS employed but do a lot of teaching can apply for affiliated titles within the university. So they have a title, for example, an affiliated assistant professor, and crucially they can then get access to library access and access to journals.

[00:17:50] Cheryl: Which is quite important

[00:17:51] Ruchi: and things like that, which is quite important. The other thing that we try and provide is faculty development for people who are involved in teaching.

So that can be courses and qualifications postgraduate medical education certificates, diplomas, master's programs, et cetera. We get health service consultants involved in delivering exams and things like that. And I know that sounds like more work, but people really, really want the opportunity to examine for finals exams and to play a part in helping students graduate and become the doctors of tomorrow.

I think every single consultant working in the hospital recognizes that if we don't do a good job educating our students, we will not be growing the junior doctors of tomorrow, the people that will work with us on our teams and ultimately replace us when we want to hang up past stethoscopes.

[00:18:53] Cheryl: I would agree with that, and I think it's really important to recognize that it's not just the funding. The idea of titles is important, but really you highlighted that idea of extra training, the ability to get different certificates, to have a whole new skillset that others may not be able to get, and I think that's really, really important.

The other thing I'm just going to highlight here, because it's very unique to England is when you're talking about hospital consultants, we're talking about the most senior doctors at a hospital. So, they're the ones that have been through specialist training and are specialists in their field; the consultants.

[00:19:31] Ruchi: Absolutely. So here in England, the term consultant, physician, surgeon, et cetera, et cetera, the consultant that's your sort of final career grade within the NHS structure.

[00:19:45] Cheryl: Yeah, I just wanted to highlight that.

[00:19:47] Ruchi: Senior hospital doctor, your final destination.

[00:19:50] Cheryl: and the ones that we want teaching our students because they're the ones who have the specialist skills and have had years of training themselves.

[00:19:58] Ruchi: Absolutely. But I also think it's very important to recognize that our junior doctors, so that the people who are training and along the road to becoming consultants have a really important part to play in educating our students as well, and they are really keen and helpful. So one thing we haven't talked about is the regular bedside teaching that the medical students have in the hospitals in the form of clinical supervision groups.

So clinical supervision groups are small groups of students, say between five to eight students at a time, and they are overseen by a junior hospital doctor consistent across a long period of time. So ideally over that student, the year for that student and they take them round, giving them bedside teaching, practical teaching with patients on clinical signs and differential diagnoses and treatments.

It's a very important educational relationship. It's also a very highly prized and valued construct, both for the students and for the junior doctors doing that work.

[00:21:14] Cheryl: Absolutely. And here in this region, we train those junior doctors to work with the students, don't we? To provide some extra training to help them to understand how students learn and how they can train.

[00:21:27] Ruchi: Absolutely. They have very important faculty development themselves, and there is a wonderful program to train those junior doctors to teach effectively, and it's a very popular program and there are more junior doctors who want to become clinical supervisors than physicians available quite frequently.

[00:21:53] Cheryl: And that's wonderful to know that we've got this infrastructure, so you've got the junior doctors training some of our students as well as the most senior doctors training our students. There's funding around that to help support that. But just as important, there's extra training available and other titles and options to recognize that, that training, would that be fair?

[00:22:17] Ruchi: Absolutely. Absolutely.

[00:22:18] Cheryl: Okay. No, it's quite complex. So I think your role must be very interesting in that you are helping to manage all those different complex levels.

So, you've got that liaison between the university and the hospital but also within the hospital, all those different levels, and ensuring that the training's happening across different specialties as well as within those different levels of doctor training.

[00:22:49] Ruchi: Absolutely; and making sure that all of the doctors who are involved in delivering student education are happy, that they have what they need to be able to deliver that education, whether that's time, that is always the sticking point, or facilities, et cetera. So it comes back to being able to draw on the money that is coming into the hospital to be able to resource the teaching.

That's not always easy because we talked about the components of tariff that are going to salary, but a lot of tariff will go to help with the hospital infrastructure because literally having footfall of students going through the place using consumables, masks, gloves, et cetera, et cetera, that all takes money as well. And so a lot of tariff goes in to help with that as well. And also, things like IT licenses a lot of stuff that you don't think about.

[00:23:48] Cheryl: That's really important. And you're right, there's lots of extra bits that you need to consider.

So you've talked about lots of different teaching at different levels. It sounds quite a bit that students are getting.

Is there anything that we've left out?

[00:24:05] Ruchi: Two things come to mind, Cheryl.

So one is a very important part of our course, which we call the CPCs, which are the Clinical Pathological Conferences, and they're designed to replicate an important facet of how we deliver healthcare, which is our multidisciplinary team meetings. So, in a CPC, you have specialists in a particular area. So for example, I'll tell you about the CPC we run for breast cancer, where you have a breast surgeon and a breast imaging consultant, someone like me and a breast pathologist, and we discuss cases and how each of our disciplines contributes to working up the effect diagnosis and treatment for a patient. And we also have genetic specialists come into that CPC as well thinking about inherited breast cancer.

So these are sessions that we provide across each of the major disease presentations. And the contributors to these CPC’s are, some of them are university consultants, but a lot of them are NHS Health Service consultants, and the idea is students listen to us discussing the cases, and it's also interactive as well. So these regular CPCs are a very important part of how we deliver education here at Addenbrookes.

The other thing that we also need to think about is the delivery of assessments. So, the exams occur here within our clinical skills unit at Addenbrookes. So, some of the exam administration is covered by the university, but a lot of the exam delivery is done by Health Service consultants, from Cambridge and also from our regional partner trusts.

So I hope I'm giving you a flavour of how much interdependence and cooperation and working together, team working, goes on to deliver a really complex package of medical education.

[00:26:22] Cheryl: It is complex. I mean, what you've described today has been fascinating. It's been really interesting to understand all the different levels, how intricate that relationship is, but also how rich it is. It sounds like the students have some fantastic opportunities to learn from different specialties.

[00:26:45] Ruchi: Absolutely, and I think I'm biased, but I think it's an amazing course and a very, I think picking up on your word, rich and diverse educationally diverse course.

One thing we didn't talk about is the students’ selected components. So this is where students can choose something they want to explore in greater detail. And we offer a real wealth of stuff here at Addenbrookes, because of our tertiary service provision. So, students might choose to be attached to one of our transplant surgeons or complex ear, nose and throat or plastics or really niche specialist oncology provision and they can do projects, et cetera. And that is an incredible opportunity to work with very specialist services to foster an interest and develop an interest and maybe do a project as well.

[00:27:44] Cheryl: That is interesting. I can imagine from a student's perspective; how do you choose? It does sound like there's some wonderful opportunities there.

I think the other thing before we wrap up, I'd like to just touch on, because you did mention this at the beginning, is the quality assurance aspect of training and helping students to learn. How does that work in practice?

[00:28:06] Ruchi: Absolutely. So quality assurance is really important and this is something that's grown and developed over the course of my tenure as clinical sub dean.

So when I started, we were not doing formal quality assurance for Addenbrookes, the major teaching hospital, and we brought that in. So there are many facets to quality assurance, but essentially how it's done is once a year that a team comes to perform a QA visit, and that team comes from the university. So these are my colleagues around the cabinet table in the deanery come to visit me as clinical sub dean, but also the major players within the hospital. So at the QA visit will be the chief finance officer, the medical director. And so the chief executive or their representative, together with the lead specialist, lead teachers.

So over the years we've developed a number of key performance indicators (KPIs) to help have some objective measurement of quality assurance. So they could be things like, you know what percentage of teaching sessions get cancelled. Now, nobody wants to cancel teaching sessions, but a transplant surgeon who's due to give a seminar on liver disease may be called away because a donor has come up and they're able to perform an operation and you know, clearly things like that, but that's not ideal for the students. So how many cancelled sessions are rearranged within a certain time limit? That one of our KPIs. And looking at satisfaction for student induction and end of placement assessments.

So we have some numerical KPIs that we return to the clinical school that we're judged against, but the other aspect of quality assurance is looking at the tariff funding and can the finance department of the hospital account for the money that they're getting from the government to provide education?

A third very important aspect is student feedback. What do students really think about how they are experiencing placements in the hospital?

So all those aspects are gone into, in great detail once a year. So we, from the hospital side provide a QA document to submit to the university and then the university review that document and come and visit the hospital providers. And then there's a discussion and then another document comes out of it. So quite formal really, but very important.

[00:30:52] Cheryl: Yes. That is important because I think you learn from these sorts of experiences and you can improve things or things that are going really well, others could learn from.

[00:31:02] Ruchi: Absolutely. So, yes, two important things. One is to learn how to do things better, but the other thing is to recognize and applaud things that are going well, and I think that last thing is really important for busy health service professionals who, well we talked about the impact on their time and the impact on their service, and I think it's very important to recognize that, and applaud them for things that are going well.

[00:31:30] Cheryl: I agree. I agree. I think that we all need to be applauded for what goes well a little bit more, so I think that's wonderful to hear that that is part of the process.

[00:31:40] Ruchi: Absolutely.

[00:31:40] Cheryl: And how the relationship can work, so that's wonderful to understand.

Wow. This has been really, really interesting to speak to you today.

You've been a fountain of knowledge and really complex topic. You know, we talk about oh, a relationship between a university and a teaching hospital. It doesn't sound like it's going to be that complex, but there are so many, I'd almost say, layers that we've pulled apart to understand in more detail. So thank you because it's been really interesting to listen to that today.

I think from my perspective, we've talked about quite a bit. Would you have any top things that you would say, you know what? I think listeners should take away these top tips from today's discussion.

[00:32:26] Ruchi: Absolutely. So I think the first thing I would say, my first take home message, as you say, is that, is to stress the importance of that close relationship between the placement provider i.e the hospital, health service employed deliverers and the university. And so, my role as sub dean is to broker that relationship, which is why I think it's really important that I have a seat within the cabinet and I know what's going on and, and help put the case for each half of that equation.

The second really important thing, I think, is how vital it is to recognize the contributions provided by those health service staff. Now, we've touched quite a bit on the money, but I think that's the most thorny and difficult side of it, and the reality is for the majority of health service staff are delivering the education, money is either not forthcoming or not a big factor. So what's really, really important is to rather than the cash, concentrate on the cache or what else we can give those very important health service professionals. So the titles, the faculty development, the reinforcing what they do and helping them do it better by providing them with away days and educational development and giving them access to journals and libraries and research contributions and things like that.

Finally, I think the last thing we discussed, quality assurance. How it's very important to make sure that both sides in the equation can be transparent about measuring and investigating the fact that they're doing what they're meant to be doing. I.e. how is the service provider, the hospital, fulfilling the curricular outcomes for the students and being how we can look at whether or not they're doing a good job in providing the education needed for those students.

[00:34:43] Cheryl: Excellent. Thank you so much. That was a brilliant summary to a very complex conversation today, so I really appreciate you being here today.

Ruchi, thank you once again for such an interesting discussion.

[00:34:56] Ruchi: Thank you, Cheryl. That was my pleasure.

[00:35:00] Cheryl: If listeners are interested in learning more about the working relationship between clinical schools and teaching hospitals, please contact us via the CUMEG website.

You'll also find our other podcasts on the website www.CUMEG.cam.ac.uk or look for us wherever you get your podcast.

We are grateful to you, our listeners. Thank you for taking the time out of your busy schedules to listen to us today. If you'd like to hear more from this and our previous series, please like and subscribe to our podcasts.

Until next time, I'm your host, Cheryl France. Thank you again for listening.[00:35:00]