Participant Guidance Proof of concept study of the use of Competencies in Practice (CiPs) in internal medicine Contents What is the proof of concept study? The aim of the study Timeline What will I be expected to do in the study? Roles and Responsibilities Making entrustment decisions What are the Internal Medicine CiPs and how are they assessed? Other recommended support materials In addition to the contents of this guide the following materials are also available. We will be developing the FAQ section so please check our dedicated webpage throughout the process. eportfolio user guides eportfolio videos Frequently Asked Questions HELPDESK: support is available throughout the process from our dedicated team via curriculum@jrcptb.org.uk or 0203 075 1625 or 0203 075 1287
What is the proof of concept study? As you know the JRCPTB is currently developing the new internal medicine curriculum on behalf of the Federation of the Royal Colleges of Physicians. An integral part of this work involves the development of a supporting assessment system. The present curricula for physician training are based on achieving a large number of individual competencies that are assessed throughout training by a variety of different methods. An improved, more authentic, simplified and more easily deliverable system for assessing progress through the new curricula could be attained by centring the curriculum on a smaller number of outcomes rather than multiple detailed competencies. We propose to describe training outcomes as Competencies in Practice (CiPs) and have identified 14 CiPs for internal medicine (See table 1: The Internal Medicine CiPs) that collectively cover the key professional activities expected of a fully trained physician. Within each CiP we have described four levels at which a trainee may be judged to be performing (See table 1: The Internal Medicine CiPs). Ascribing a specific level to each CiP for each trainee will allow progress to be gauged and to relate progress to what tasks are actually performed in the clinical workplace and the level of supervision that the task must be performed under. This approach is not an alternative to competency-based education, but an evolution of that concept that can usefully translate competency into real life clinical practice. The successful implementation of an outcome-based model of training depends on the ability of supervisors to make judgements about a trainee s performance in relation to a number of broad, observable outcomes of relevance to the delivery of patient care. That is, judgements about what level the trainee is performing at in each of the 14 CiPs. We have currently called these judgements entrustment decisions. Full details of the CiPs and levels are provided below essentially, when a trainee is adjudged to be performing at level 4 for each of the 14 competencies in internal medicine, and to have completed other mandatory aspects of training (including specialty-specific CiPs), they will be considered to have fulfilled the requirements of the training programme. Given that this approach is significantly different from the current system, is currently largely conceptual, and may have significant impact on training and education practice, we wish to explore its feasibility and acceptability in the UK NHS setting in a controlled way before considering implementation and for that reason have entitled this study Proof of Concept. Our study has been sponsored by our partners Health Education England, NHS Education Scotland and the Wales Deanery. The aim of the study The study will explore: 1. Whether clinical and educational supervisors are able to make entrustment decisions, in a range of clinical specialties and learning environments, across the entire range of 14 different CiPs and four different performance levels. 2. What types and forms of evidence supervisors require, and trainees feel are necessary, to make such decisions.
3. Whether trainees and supervisors find the approach more or less acceptable than the current approach. Specifically is it more or less complex, more or less time consuming, and more or less fair. 4. Whether the currently proposed levels (1-4) are equally meaningful, useful and helpful for all of our proposed CiPs 5. Whether face-to-face training is perceived as helpful to participants. Timeline In order to make this as an authentic experience as possible we shall be asking the participants to complete their paperwork in July, post-arcp (where possible). This will enable us to consider the role of CiPs at a time when usual end of training year assessments are underway and trainee portfolios should be completely up to date. The summary timeline is as follows: Face to Face training sessions and electronic guidance materials released - June 2016. Trainees/Supervisors complete the forms and survey July 2016 Evaluation team consider the data - July to August 2016 Evaluation complete - October 2016 IMPORTANT: The proof of concept study is to be conducted entirely separately from the ARCP. Under no circumstances should the paperwork completed as part of the study be used to inform the ARCP process. Supporting materials In addition to the contents of this guide the following materials are also available on our dedicated webpage eportfolio user guides eportfolio videos Frequently Asked Questions HELPDESK: support is available throughout the process from our dedicated team via curriculum@jrcptb.org.uk or 0203 075 1625 or 0203 075 1287
What will I be expected to do in the study? Participating trainees have been linked with their clinical and educational supervisors in the existing eportfolio. Each participating trainee will be required to attend one meeting with their educational supervisor. At these meetings they will discuss progress in relation to each CiP and agree a level at which they are currently performing. Newlydeveloped forms will be used by both the clinical and educational supervisors to rate the trainee s progress against 14 internal medicine CiPs, using a clearly defined framework of levels. 1. Before each meeting Trainees will a) Ensure that at least one clinical supervisor has completed an assessment of their performance using the new CiP Study Clinical Supervisor Report. b) Consider what evidence they need to provide to inform the decisions made about their performance at each CiP c) Complete a CiP Study Trainee Self-Assessment and indicate the level at which they feel that they are performing to inform the discussion with the educational supervisor. This form must be completed ahead of the meeting with the educational supervisor. Clinical Supervisors will a) Review the trainee s e-portfolio and consider their personal experience of the trainee. b) Complete a CiP Study Clinical Supervisor Report indicating what level they feel the trainee is performing at for each CiP. There is no requirement to discuss the completion of the report with the trainee, but its contents will be available to the trainee once the form is submitted. Educational Supervisors will a) Review the trainee s e-portfolio and consider the Clinical Supervisor report and trainee self-assessment that have been provided on the new forms. 2. During each meeting a) The educational supervisor trainee pairs will discuss progress and performance and agree and document a level of performance for each CiP on the CiP Study Educational Supervisor Report. Note: If there is disagreement between a trainee and educational supervisor about their level of performance, this will be specifically documented. 3. After each meeting a) Trainees, clinical and educational supervisors will complete a short evaluation questionnaire All participants will receive a letter confirming their participation upon receipt of the completed evaluation questionnaire.
Roles and Responsibilities Overview of the process CLINICAL SUPERVISOR Completes clinical supervisor report TRAINEE Completes self assessment form EDUCATIONAL SUPERVISOR Reviews completed clinical supervisor report, trainee self assessment form and eportfolio EDUCATIONAL SUPERVISOR AND TRAINEE Face to face meeting to discuss progress to inform final decision Trainees You will obviously be integral to the process! Trainees are asked to: familiarise themselves with the forms on the eportfolio consider what evidence you will use to inform the final entrustment decision made by your educational supervisor in a face to face discussion make a self-assessment of your level of performance using the CiP Study Trainee Self-Assessment form ensure that at least one of our recruited clinical supervisor fills in a form about you. Please note that there is no need to specifically link current evidence to the curriculum in this study as, in the future, each CiP will be an integral part of, and thus clearly link to, the curriculum. A key part of the study is to seek your views about the types and amount of evidence that you think it will be necessary for a trainee to present to enable entrustment decisions to be made. Remember that some of our current sources of evidence (for example, case based discussions) could eventually be regarded as unhelpful, or you may feel that other sources that we do not currently use could be included in the new system. This is for you to decide! This study relates only to internal medicine so please bear that in mind when considering your supporting evidence. Key deadlines: We will need your support in ensuring that your clinical supervisor(s) has completed their paperwork by Friday 15 July and that your educational supervisor has submitted their form by no later than Friday 29 July 2016. You will need to complete the self-assessment form prior to the meeting with your educational supervisor.
Clinical Supervisors (CS) As clinical supervisor you will have access to a new form which asks you to assign a level against each CiP. You will be required to provide a small amount of commentary to support each CiP and will be required to summarise the evidence you have used to make this judgment. A key part of the study is to seek your views about the types and amount of evidence that you think it will be necessary for a trainee to present to enable entrustment decisions to be made. Remember that some of our current sources of evidence ( for example, case based discussions) could eventually be regarded as unhelpful for some or all CiPs, or you may feel that other sources that we do not currently use could be included in the new system. This is for you to decide! This study relates only to internal medicine so please bear that in mind when considering your supporting evidence. Key Deadline: This form is the first step in the process so you must complete this by no later than Friday 15 July 2016. Educational Supervisor (ES) The educational supervisor is ultimately responsible for making the final entrustment decision about the doctor in training, awarding a level for each of the 14 CiPs. What tools can be used? We suggest three key sources of information that you can use to inform your entrustment decision. 1. New CiP Study Clinical Supervisor Report: you will have at least one new clinical supervisor report available for your trainee. In this report the clinical supervisor will have rated the trainee against each CiP, noting additional comments, feedback and detailing the evidence used to inform their rating. 2. Existing trainee portfolio: as now, you will have access to completed WPBAs and other evidence to inform your final decision. Bear in mind however, that the type and volume of portfolio material could be different were this system to be introduced into real practice. We need you to consider what will the minimum level of information you feel you would require in the future will be. 3. Face to face meeting: all educational supervisors must finally meet with their trainee to discuss progress, their self-assessment and discuss evidence the trainee believes supports attainment of particular levels. A key part of the study is to seek your views about the types and amount of evidence that you think it will be necessary for a trainee to present to enable entrustment decisions to be made. Remember that some of our current sources of evidence ( for example, case based discussions) could eventually be regarded as unhelpful for some or all CiPs, or you may feel that other sources that we do not currently use could be included in the new system. This is for you to decide! This study relates only to internal medicine so please bear that in mind when considering your supporting evidence. Key Deadline: The final version of the Educational Supervisor report must be submitted on the eportfolio by Friday 29 July.
Making entrustment decisions The new Internal Medicine curriculum is based around 14 competencies in practice (CiP) that we expect all doctors to have demonstrated and be trusted to be able to undertake by the time they complete their CCT. This aims to replace the large number of tick box competencies in the current GIM and CMT curricula. It is fundamentally based on the judgement of clinical and educational supervisors, informed by the evidence a trainee collects in their eportfolio. The new model of assessment will require educational supervisors to make a summative educational judgement on how the doctor in training is progressing with their training against each of these 14 competencies in practice (CiP). These judgements will be used to inform the ARCP. The decision making process at an ARCP records educational progress and should never replace the day to day decisions about a trainee s ability to deliver the service. Levels of Performance As outlined in the section What are the CiPs and how are they assessed? each CiP must be considered at four levels; level 1, level 2, level 3 and level 4. Level descriptors CiPs 1-9 are clinical in nature and the following level descriptors apply: Level 1: Observations of the activity no execution Level 2: Trusted to act with close supervision Level 3: Trusted to act with supervision available quickly Level 4: Trusted to act unsupervised (with clinical oversight within training) CiPs 10-14 are non-clinical and have different descriptors: Level 1: No or limited knowledge or experience Level 2: Knowledge but limited experience, trusted to act with close supervision Level 3: Knowledge and experience, trusted to act with guidance available Level 4: Experienced and trusted to level of independent practice Level 1 It is likely that Level 1 will have been achieved during Foundation training. However, in some cases supervisors may consider that a trainee would benefit from observing an activity before being able to act under supervision. Please note; level 1 should only be awarded where it genuinely reflects the level of supervision required. It should not be used where there is insufficient evidence or the activity has not been observed. In these circumstances the option of insufficient evidence / not observed should be selected on the report. Level 2 At the start of Internal Medicine it is expected that most trainees will be trusted to act with close or direct supervision, in accordance with the context in which they are working.
For example, a trainee may undertake a ward round without direct supervision but would be limited to what decisions and actions they could take without confirming with a doctor at a higher level. Conversely, direct supervision may be required for breaking bad news Level 3 This level applies when the trainee is trusted to undertake an activity not under close supervision but with supervision available quickly. Examples might include running an out-patient clinic with the consultant in the next room only discussing cases with them at the end of the afternoon, or running an acute take overnight with a consultant available for regular post-take ward rounds but on-call from home. It is important that a clear decision has been made that a doctor is trusted to undertake this activity and this is documented during their training. This is a positive decision by a supervisor that they can move, and practice to level 3, rather than at level 2 where they require close supervision at all times. Level 4 The final level is level 4. Essentially level 4 means the clinical or educational supervisor is satisfied that the doctor in training can act unsupervised, based on their judgements of the trainee s performance and eportfolio evidence. It is only when level 4 has been reached in all 14 competencies in practice that a doctor can complete training and receive a CCT. While they remain in a training programme they are still under clinical supervisor oversight as is the situation now. A level 4 decision is a very important summative decision; the supervisor is saying that in their professional judgement they are now trusted to undertake this activity at the level of a CCT. Appendix 1 outlines the grid detailing expected level by stage of training, against each of the CiPs. What are the Internal Medicine CiPs and how are they assessed? Each of the 14 CiPs are shown in table 1 and are key outcomes we expect doctors in training to demonstrate while moving through their training. In table 1 note that each of the 14 CiPs has a number a title a bulleted list of key tasks or behaviours that inform the achievement of that outcome, a reminder of the level descriptors and the expected level at different stages of training a list of the type of evidence that may have been collected in the eportfolio which could supplement decisions made by the clinical and educational supervisor based on observation of how the doctor has worked in the workplace. The clinical and educational supervisors are asked to make a judgement as to what level the trainee is performing at for each CiP. Even where the trainee is making satisfactory progress, there is still an opportunity to reflect development
needs. In the event the trainee is not at the level expected for their stage of training it is essential to document what level they are at, and why the expected level has not been reached. To further assist decision making Appendix 1 summarises the expected levels for trainees for each CiP that we would normally expect a trainee to have achieved by their year (or stage) of training ie ST1-ST7. It would be quite usual for trainees to achieve a 3 or a 4 earlier than predicted in this grid. However any trainee achieving a 3 or 4 later than predicted in this grid would normally have specific developmental requirements and should be listed in the comments box on the form. Please refer to table 1 for the CiP descriptors, levels and suggested evidence.
Table 1: The Internal Medicine CiPs CiP 1 CiP 2 Managing an acute unselected take demonstrates behaviour appropriately with regard to patients demonstrates behaviour appropriately with regard to clinical and other professional colleagues demonstrates effective consultation skills including challenging circumstances demonstrates ability to negotiate shared decision making demonstrates effective clinical leadership accurate diagnosis of patients presenting on an acute unselected take over a standard shift appropriate management of acute problems in patients presenting on an acute unselected take over a standard shift appropriate liaison with specialty services when required Level 1: Observations of the activity no execution (expected at Foundation level) Level 2: Trusted to act with close supervision ST1 Level 3: Trusted to act with supervision available quickly ST3 Level 4: Trusted to act unsupervised (with clinical oversight within training) ST6 CiP Study Clinical Supervisor Report MSF CbD ACAT Logbook of cases Simulation training with assessment (eg IMPACT) Managing an acute specialty related take demonstrates behaviour appropriately with regard to patients demonstrates behaviour appropriately with regard to clinical and other professional colleagues demonstrates effective consultation skills including challenging circumstances demonstrates ability to negotiate shared decision making demonstrates effective clinical leadership appropriate continuing management of acute medical illness in patients admitted to hospital on an acute unselected take or selected take Level 1: Observations of the activity no execution (expected at Foundation level) Level 2: Trusted to act with close supervision ST1 Level 3: Trusted to act with supervision available quickly ST3 Level 4: Trusted to act unsupervised (with clinical oversight within training) ST6 CiP Study Clinical Supervisor Report MSF CbD ACAT Logbook of cases Simulation training with assessment (eg IMPACT)
CiP 3 CiP 4 Providing continuity of care to medical in-patients, including management of comorbidities and cognitive impairment demonstrates behaviour appropriately with regard to patients demonstrates behaviour appropriately with regard to clinical and other professional colleagues demonstrates effective consultation skills including challenging circumstances identifies and manages barriers to communication (eg cognitive impairment, speech and hearing problems, capacity issues) demonstrates ability to negotiate shared decision making appropriate liaison with other specialty services when required appropriate management of comorbidities in medial inpatients (unselected take, selected acute take or specialty admissions) demonstrates awareness of the quality of patient experience Level 1: Observations of the activity no execution (expected at Foundation level) Level 2: Trusted to act with close supervision ST1 Level 3: Trusted to act with supervision available quickly ST3 Level 4: Trusted to act unsupervised (with clinical oversight within training) ST6 CiP Study Clinical Supervisor Report MSF ACAT Mini-CEX DOPS MRCP(UK) Managing patients in an outpatient clinic, ambulatory or community setting, including management of long term conditions demonstrates behaviour appropriately with regard to patients demonstrates behaviour appropriately with regard to clinical and other professional colleagues demonstrates effective consultation skills including challenging circumstances accurate diagnosis and appropriate comprehensive management of patients referred to an outpatient clinic, ambulatory or community setting appropriate management of comorbidities in an outpatient clinic appropriate management of comorbidities in ambulatory or community setting Level 1: Observations of the activity no execution (expected at Foundation level) Level 2: Trusted to act with close supervision ST1 Level 3: Trusted to act with supervision available quickly ST3 Level 4: Trusted to act unsupervised (with clinical oversight within training) ST6 CiP Study Clinical Supervisor Report ACAT mini-cex Patient survey Letters generated at OP clinics
CiP 5 CiP 6 CiP 7 Managing medical problems in patients in other specialties and special cases demonstrates effective consultation skills including challenging circumstances management of medical problems in inpatients under the care of other specialties appropriate and timely liaison with other medical specialty services when required Level 1: Observations of the activity no execution (expected at Foundation level) Level 2: Trusted to act with close supervision ST1 Level 3: Trusted to act with supervision available quickly ST3 Level 4: Trusted to act unsupervised (with clinical oversight within training) ST6 CiP Study Clinical Supervisors Report ACAT CbD MRCP(UK) Managing a multi-disciplinary team including effective discharge planning demonstrates behaviour appropriately with regard to patients demonstrates behaviour appropriately with regard to clinical and other professional colleagues demonstrates effective consultation skills including challenging circumstances demonstrates effective clinical leadership demonstrates ability to work well in a multi-disciplinary team, in all relevant roles Effectively estimates length of stay Identifies appropriate discharge plan Recognise the importance of prompt and accurate information sharing with primary care team following hospital discharge Level 1: Observations of the activity no execution (expected at Foundation level) Level 2: Trusted to act with close supervision ST1 Level 3: Trusted to act with supervision available quickly ST3 Level 4: Trusted to act unsupervised (with clinical oversight within training) ST6 CiP Study Clinical Supervisor Report MSF ACAT Discharge summaries Delivering effective resuscitation and managing the acutely deteriorating patient competence in assessment and resuscitation able to promptly assess the acutely deteriorating patient, including those who are shocked or unconscious effective participation in decision making with regard to resuscitation decisions Level 1: Observations of the activity no execution (expected at Foundation level) Level 2: Trusted to act with close supervision ST1 Level 3: Trusted to act with supervision available quickly ST3 Level 4: Trusted to act unsupervised (with clinical oversight within training) ST6 CiP Study Clinical Supervisor Report DOPS ACAT
CiP 8 CiP 9 CiP 10 MSF ALS certificate Logbook of cases Reflection Simulation training with assessment (eg IMPACT) Managing end of life and palliative care skills demonstrates behaviour appropriately with regard to patients demonstrates behaviour appropriately with regard to clinical and other professional colleagues demonstrates effective consultation skills including challenging circumstances delivers appropriate palliative care and end of life care Level 1: Observations of the activity no execution (expected at Foundation level) Level 2: Trusted to act with close supervision ST1 Level 3: Trusted to act with supervision available quickly ST3 Level 4: Trusted to act unsupervised (with clinical oversight within training) ST6 CiP Study Clinical Supervisor Report CbD Mini-CEX MSF MRCP (UK) Regional teaching Reflection Achieving procedural skills Please see the curricula/arcp decision aids for procedures required in accordance with stage of training CMT Curriculum / CMT Decision Aid GIM Curriculum / GIM Decision Aid For each procedure: Able to outline the indications for the procedures and take consent Evidence of aseptic technique and safe use of analgesia and local anaesthetics Evidence of safe learning in clinical skills lab/simulation before performing procedures clinically Level 1: Observations of the activity no execution (expected at Foundation level) Level 2: Trusted to act with close supervision ST1 Level 3: Trusted to act with supervision available quickly ST3 Level 4: Trusted to act unsupervised (with clinical oversight within training) ST6 CiP Study Clinical Supervisor Report DOPS Is focussed on patient safety and delivers effective quality improvement in patient care raises concerns including errors, serious incidents and adverse events (including never events )
shares good practice appropriately demonstrates the delivery of quality improvement Level 1: No or limited knowledge or experience (expected at Foundation level) Level 2: Knowledge but limited experience, trusted to act with close supervision ST1 Level 3: Knowledge and experience, trusted to act with guidance available ST2 Level 4: Experienced and trusted to level of independent practice ST6 CiP Study Clinical Supervisor Report QIPAT / AA CbD Mini-CEX MSF TO Participation in / leading quality improvement project Reflection on complaints and compliments Record of attendance at clinical governance meetings and committees CiP 11 Carrying out research and managing data appropriately CiP 12 demonstrates behaviour appropriately with regard to managing clinical information/data demonstrates understanding of principles of research and academic writing demonstrates ability to carry out critical appraisal of the literature understanding of public health epidemiology and global health patterns Follows guidelines on ethical conduct in research and consent for research Level 1: No or limited knowledge or experience (expected at Foundation level) Level 2: Knowledge but limited experience, trusted to act with close supervision ST3 Level 3: Knowledge and experience, trusted to act with guidance available ST5 Level 4: Experienced and trusted to level of independent practice ST7 CiP Study Clinical Supervisor Report GCP certificate Attendance at regional teaching Quality improvement project / critical analysis of data Poster presentations Journal club reports Higher degrees Supervision of trainee undertaking a project Acting as a clinical teacher and clinical supervisor ability and experience of teaching and training medical students, junior doctors and other health care professionals including: - delivering teaching and training sessions - effective assessment of performance - giving effective feedback able to supervise less experienced trainees in their clinical assessment and management of patients able to supervise less experienced trainees in carrying out appropriate practical
CiP 13 CiP 14 procedures able to act a Clinical Supervisor to the standard required by the GMC Level 1: No or limited knowledge or experience (expected at Foundation level) Level 2: Knowledge but limited experience, trusted to act with close supervision ST1 Level 3: Knowledge and experience, trusted to act with guidance available ST3 Level 4: Experienced and trusted to level of independent practice ST7 CiP Study Clinical Supervisor Report MSF TO Observe undertaking a mini-cex on a trainee Education course such as doctors as educators etc Dealing with ethical and legal issues related to specialty clinical practice demonstrates behaviour with regard to professional regulatory bodies remains up to date and fit to practise demonstrates ability to offer apology or explanation when appropriate understands the safeguarding of vulnerable groups demonstrates ability to lead the clinical team in ensuring that medical legal factors are considered openly and consistently Level 1: No or limited knowledge or experience (expected at Foundation level) Level 2: Knowledge but limited experience, trusted to act with close supervision ST1 Level 3: Knowledge and experience, trusted to act with guidance available ST2 Level 4: Experienced and trusted to level of independent practice ST7 CiP Study Clinical Supervisor Report CbD DOPS Mini-CEX MSF MRCP(UK) Reflective writing ALS certificate End of life care and capacity assessment e-learning / course with assessment The ability to successfully function within NHS organisational and management systems demonstrates behaviour appropriately with regard to managers and to management requests demonstrates ability to respond appropriately to complaints demonstrates effective clinical leadership demonstrates promotion of an open and transparent culture Level 1: No or limited knowledge or experience (expected at Foundation level) Level 2: Knowledge but limited experience, trusted to act with close supervision ST2 Level 3: Knowledge and experience, trusted to act with guidance available ST3 Level 4: Experienced and trusted to level of independent practice ST6 CiP Study Clinical Supervisor Report QIPAT / AA
MSF CbD Lead role in governance structures Management course with practical application observed KEY AA Audit assessment ACAT Acute care assessment tool ALS Advanced Life Support CbD Case-based discussion ES Educational supervisor GCP Good Clinical Practice IMPACT Ill Medical Patients' Acute Care and Treatment MCR Multiple consultant report Mini-CEX Mini-clinical evaluation exercise MRCP Membership of the Royal Colleges of Physicians MSF Multi source feedback QIPAT Quality improvement project assessment tool TO Teaching observation
Appendix 1 Outline grid of the proposed Internal Medicine Curriculum (V19) SELECTION PYA Internal Medicine Internal Medicine + Specialty Training level ST1 ST2 ST3 ST4 ST5 ST6 ST7 Ambulatory Focus Inpatients Acute care SPECIALTY care/opd Level to be achieved by end of training year: Level 2: Acting with close supervision, Level 3: Acting with supervision available quickly, Level 4: Acting unsupervised (but still with consultant oversight) 1. Managing acute unselected take 2. Managing an acute specialty-related take 3. Providing continuity of care to medical in-patients 4. Managing outpatients with long term conditions 5. Managing medical problems in patients in other specialties and special cases 6. Managing an MDT including discharge planning 7. Delivering effective resuscitation and managing the deteriorating patient 8. Managing end of life and palliative care skills 9. Delivering effective quality improvements in patient care 10. Carrying out research and managing data appropriately 11. Acting as a clinical teacher and clinical supervisor 12. Dealing with ethico-legal issues 13. Working with NHS systems 14. Achieving procedural skills Learning should include: Assessment must include: Minimum 4/12 Geriatrics 12/12 acute take (Year 3) Minimum 4/12 AMU Minimum 4/12 ITU/HDU Minimum 100 clinics (at least 40 in year 2), can be community based Clinical improvement project MRCP(UK) Minimum of 1 year of contributing to acute take (unselected or within specialty) with ongoing in-patient responsibility. Minimum of 3/12 in final year Outpatient clinics in one of more specialties other than main specialty Clinical improvement project Evidence of generic capabilities and internal medicine within 2 years of CST SCE/KBA in main specialty