START your engines please...

As a paediatric registrar in the final 12 months of training (and not infrequently wondering how in the world I got here), I found myself at the Royal College of General Practitioners last week faced with the prospect of the START assessment. “Not an exam!” I have repeatedly been told, but a formative assessment that should highlight areas requiring “development” before becoming a proper grown up consultant…

So, how indeed did I get here? For those who still have the START ahead, allow me to share with you some tips for preparation I picked up along the way:

What does START stand for?

It stands for Specialty Trainee Assessment for Readiness of Tenure. Someone was asked this in a previous sitting of START and didn’t remember it, so I made sure I knew. Yes, really.

When to do it?

It is suggested by the RCPCH1 that the optimal time for the START assessment to be taken is during ST7 year to gain enough experience as a senior registrar, but also to allow enough time to put into place the developments needed prior to CCT. Theoretically, however, it can be done at any time during level 3 (ST6-8) training.

At ST6 the thought of being a consultant would have sent me into a minor meltdown, and undoubtedly there would have been far too many areas highlighted requiring improvement. During ST7, I was doing a slightly random post which involved little “true” general paediatrics, but in all honesty, I forgot to apply due to a variety of personal reasons (including getting married). On reflection though, I felt that doing the START at the beginning of ST8 really wasn’t a bad thing for me. I was encouraged to behave in a more “consultant-y” manner towards the end of ST7, and subsequently did things like management courses, tricky child protection work, and run clinics independently almost by accident. Which I suppose a lot of other trainees also do anyway, so don’t panic if you missed the “ideal” time.

What is the assessment like?

The START is an OSCE-style assessment, consisting of 12 eight-minute stations with 4 minutes of preparation time before each to gather your thoughts, plus a 44-minute prep station for critically appraising a paper and doing a prescription task. This makes it one long assessment!

You are given scenarios at each station on a variety of things, mapped to broad themes (see RCPCH website for more details). The scenarios run like “professional conversations” with a consultant who is sat in the examination room, with you adopting the role of a new consultant. This is to make it feel less like an exam and more like a case-based discussion, and bear in mind that you are not expected to know everything that a very experienced consultant knows! There is a teaching scenario, and you can be thrown into a role play situation with two medical students present, which is kind of fun.

How do you prepare for it?

Unlike the MRCPCH part 2, there isn’t really a list of set topics that you can revise, as a lot of what is assessed fall into the category of “soft skills”, i.e. communication, dealing with conflict, teaching, managing teams. Saying that, the assessment is mapped to the Level 3 parts of the General curriculum, so I had a look through that and made sure I was fairly confident at dealing with whatever topics were ticked in the Level 3 column!

There are also some things that you can practice, e.g. prescribing controlled drugs; having a system on how to critically appraise a paper (in 20 or so minutes); revising competence (including Gillick and Fraser, those two old friends). I found the RCPCH e-learning for health modules2 surprisingly useful, especially the ones on legal aspects of adolescent health and the child protection level 3 modules, as safeguarding is a common theme.

I started preparing about a month before, but I know people who have used much less time to prepare (I’m sure they are far cleverer than me). Identifying areas you need to study/practice early is actually quite useful, as you can tailor your clinical workload (e.g. clinics, child protection work) to gain the relevant experience. I would recommend that you get a little study group together with other people doing the START at the same time. It’s really useful to practice scenarios as a group and bounce ideas off each other. As the assessment looms ever closer, it also helps to reduce levels of general panic. Plus, it’s a nice excuse to meet up for coffee- who says study sessions have to be in the confines of the workplace?!

What is it like on the day?

The START always takes place in the Royal College of General Practitioners, as it is one of the few places big enough to hold multiple rounds of START on the same day. It is a nice and shiny facility, a couple of minutes walk from Euston Square tube station. Prior to the assessment, you are given a little pep talk on how the START is not an exam, but should be seen as a learning opportunity. This is all very well, but in reality, there are buzzers going off between stations and assessors in rooms, so you cannot help but have sweaty palms as memories of medical school OSCEs come flooding back to you…

You are allowed to take a water bottle and a snack around with you, which I would highly recommend you do as there is no break in the relentless onslaught of scenarios. The 44-minute prep station for the critical appraisal and safe prescribing will allow you to have a little breather. Make sure you go to the toilet before you start as you won’t want to waste a precious second of your prep time!

What happens after?

After your last station, there is no great fanfare ending; you just get your things and head off. A bit of an anti-climax, I must admit, but my mental faculties were exhausted by then, so I just jumped on the next train back home.

Feedback from the assessment is not immediate; you have to wait 4-5 weeks, after which you receive feedback on your eportfolio and need to discuss it with your educational supervisor. I’m still waiting for this bit, so can’t comment just yet, although I would imagine it to involve a discussion on how to tackle the areas that need development prior to CCT.

So in summary…

As far as assessments go, the START is actually quite fair, and feels a lot more relevant than having to swallow Nelson’s textbook of Paediatrics. It is a fairly realistic way of assessing how you would act as a new consultant; after all, by the time we get to ST8, most of us are expected to behave like one anyway. And as there is no Pass/Fail element, some of the pressure is off. Just remember to smile!


Further Reading



Dr Darshana Bhattacharjee