ACUTE MEDICINE HIGHER TRAINING PROGRAMME StR HANDBOOK WALES DEANERY
WELCOME! CROESO Acute medicine is a vibrant, rewarding, and rapidly developing medical speciality, concerned with the assessment, diagnosis and management of adults presenting to secondary care with acute medical illness. It also involves the management of busy acute medical units (AMUs) to ensure they deliver high-quality, efficient and patientcentred care. This handbook provides an overview of the Acute Medicine Specialist Training scheme and details the essential information required for trainees. The Welsh Higher Training Programme in Acute Medicine fulfils all the recommendations of the Royal College of Physicians and GMC for accreditation in this speciality and aims to offer the highest quality training in hospitals situated throughout Wales. The four-year programme is designed to provide trainees with a Certificate of Completion of Training (CCT) in Acute Internal Medicine (AIM) with the option of extending training to a fifth year in General internal Medicine (GIM), or to dually accredit in another speciality. Core trainees from both Core Medical Training (CMT) and Acute Care Common Stem (ACCS) are eligible to apply for the Acute Medicine StR programme. We hope you enjoy your time in Wales and look forward to working with you. Note: If you spot any errors, omissions, contradictions, or if any updates are needed please contact Dr Nia Rathbone (Nia.Rathbone@Wales.nhs.uk) or Dr Aled Huws (Aled.Huws@Wales.nhs.uk). The definitive guides for training and curriculum matters remain the Gold Guide and the speciality curricula. 2
CONTENTS Acute Medicine Training Overview......5 Wales Deanery...6 Acute Medicine Specialist Training Committee (STC)...7 Wales Higher Training Programme in Acute Medicine....8 Entry Criteria.......8 Training Programme General Comments....... 8 Postgraduate Training Pathway........8 Speciality Experience......11 ST placements...12 Sample Rotations........13 Hospitals participating in training...14 Acute Consultants / Associate Specialists in Wales......15 Educational and Clinical Supervisors...16 Educational supervisors...16 Clinical supervisors...17 Patient safety concerns...17 Undermining/bullying...17 Specialist Skill......18 Curricula...19 E-portfolio (JRCPTB)...20 Key points...21 Overview of AIM training requirements 22 Overview of GIM training requirements......22 Work Based Placed Assessments (WBPAs)...25 Supervised Learning Events (SLEs)...25 Mini-clinical evaluation exercise (mini-cex)...25 Case-based discussion (CbD)...25 Direct observation of procedural skills (DOPS)...25 Acute care assessment tool (ACAT)...25 Multi-source feedback (MSF)...26 Patient survey...26 Audit Assessment...26 3
Quality Improvement Project Assessment Tool...26 Teaching observation...26 Multiple consultant report (MCR)...27 Audits...27 Firth calculator...27 Personal library........28 Training quality surveys.......28 Annual calendar...28 Training days and leave...29 Acute Medicine Summer School...29 Welsh Acute Physicians Society (WAPS).29 GIM Training...29 Study Leave...30 Annual leave...30 Speciality Certificate Examination (SCE)...31 Annual Review of Competence Progression (ARCP)...34 Principal ARCP outcomes...35 Penultimate Year Assessment (PYA)...36 Completion of training...37 Out of Programme (OOP) requests...38 Acting up as a consultant (AUC)...39 Flexible / Less Than Full Time Training (LTFT)...40 Professional Support Unit (PSU)...40 Useful training related websites...41 Society for Acute Medicine....41 Journals...41 Other societies and organisations...41 Useful training resources...42 Appendix 1: AIM/GIM ARCP Checklist.43 Appendix 2: GIM PYA Checklist.44 4
Acute Medicine Training Overview Acute Internal Medicine (AIM) was formally recognised as a speciality in 2009, having previously been a subspeciality of General Internal Medicine (GIM). This was in response to the growing need for a senior medical presence supervising acute medical takes within an Acute Medical Unit (AMU) environment and has resulted in a massive expansion of Consultant Acute Physicians along with the development of Acute Medicine training programmes. Over recent years, the Wales Deanery has expanded the number of training posts in this evolving field in recognition of the increasing number of appointments of Acute Physicians nationally. In Wales we currently have 13 training posts of 4 years duration with the option of dual accreditation. Entry to the Acute Medicine training programme can either be from Core Medical Training (CMT) or Acute Care Common Stem (ACCS). Our training programme is exciting and varied. The experience it offers is unique as it allows rotation through many different specialties at registrar level in a variety of work settings and intensities. It also offers the opportunity for trainees to develop their own area of interest or special skill whilst satisfying the core curriculum requirements. AIM is a hospital-based speciality, with the majority of the work involving care of medical patients around the time of admission to hospital. The spectrum of clinical problems encountered in the AMU is very wide, and this variability enables trainees to become experts in assessment, investigation, diagnosis and management across multiple disciplines. The posts are a mixture of AMU, ambulatory care, elderly medicine, respiratory, cardiology and intensive care medicine rotations. Training concentrates on the recognition and management of medical emergencies, the development of acute medical services and the acquisition of skills in leadership and management of the AMU as a whole. The requirement to obtain an additional specialist skill or interest during higher training enables acute medicine trainees to pursue a professional qualification, diagnostic skill or research interest that will enhance their clinical practice. These interests can be maintained throughout their career as an Acute Physician, adding another dimension to the speciality. 5
Wales Deanery http://www.walesdeanery.org/ The aim of the Wales Deanery is to commission, quality assure and support the education and training of trainees in Wales. The Deanery manages out of programme experience, flexible or less than full time training, inter-deanery transfers and ARCPs in conjunction with the Acute Medicine STCs. There are several important people within the Deanery who will monitor and help support your training: Acute Internal Medicine (AIM) Trudy McMullin E-mail: McmullinT@cf.ac.uk Telephone number: 02920 687483 General Internal Medicine (GIM) Robert McGowan E-mail: McGowanR@cardiff.ac.uk Telephone number: 02920 687588 Speciality Training Manager Hilary Williams E-mail: williamsh3@cf.ac.uk Telephone number: 02920 687444 6
Acute Medicine Specialist Training Committee (STC) The main role of the STC is to organise the speciality training programme in Wales. It consists of Acute Medicine consultants from each of the Health Boards within Wales, consultants from the specialties through which our trainees rotate along with a trainee representative. A Chair and a Training Programme Director (TPD) oversee the STC. TPDs are responsible for managing the speciality training programme including recruitment, placements and ARCPs. They also assist the Deanery with managing trainees in difficulty. Acute Medicine STC Chair Dr Nia Rathbone Consultant Acute Physician Royal Glamorgan Hospital, Llantrisant E-mail: Nia.Rathbone@Wales.nhs.uk Training Programme Director (TPD) Dr Tom Cozens Consultant Acute Physician Royal Gwent Hospital, Newport E-mail: Thomas.Cozens@Wales.nhs.uk StR Trainee Representative Appointed on annual basis 7
Wales Higher Training Programme in Acute Medicine Entry Criteria Entry into Acute Medicine higher speciality training is possible following successful completion of both a Foundation Programme and a Core Training programme - either Core Medical Training (CMT) or Acute Care Common Stem (ACCS). The minimum experience in CMT posts in Medicine is 24 months or 24-36 months in ACCS posts of which at least 12 months must include the care of acute medical inpatients. Full membership of the Royal College of Physicians (MRCP) is a minimum educational requirement for entry to the programme at ST3 grade. The other qualities considered essential or desirable are detailed in the ST3 Acute Internal Medicine Person Specification, which can be found via the following link: http://www.st3recruitment.org.uk/specialties/acute-internal-medicine.html Postgraduate Training Pathway The following diagrams illustrate the different postgraduate training pathways in Acute Internal Medicine leading to single or dual CCT: 8
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The following diagram shows an example programme for dual CCT in ICM and AIM: 10
Specialty Experience The program has been constructed to ensure exposure to specialities relevant to Acute Medicine. Training includes time on AMU and Ambulatory Care as well as attachments in other relevant specialties, with a focus on managerial AMU experience towards the end of higher specialist training. The trainees will gain experience in the following fields: Acute Internal Medicine, including experience working in o Acute Medical Units (AMUs) = Medical Admissions Units (MAUs) or Clinical Decisions Units (CDUs) o Ambulatory care (AECU or MDUs) o Acute non-selected takes Cardiology Critical Care (ITU, HDU, CCU) General Internal Medicine including acute non-selected takes (minimum 4 months): o Respiratory Medicine o Care of the Elderly Out Patient experience o Rapid Access Medical outpatient clinics / Hot Clinics o Acute Medicine review clinics o Speciality based clinics - Cardiology, Respiratory Medicine, and Medicine for the Elderly The final year of training should include at least 6 months experience within an Acute Medical Unit that is led by an Acute Physician. This should include training in management and leadership skills as well as taking a more senior, but supervised, role within the running of the acute medical take. Throughout training the trainee should be aware of the need to acquire a special competency or skill that is specifically relevant to Acute Internal Medicine. Acquisition of one of these competencies is a mandatory part of training and trainees should review with their educational supervisor as early as possible in their training which of these would be most relevant for their career development, and sustainable in the long term. This is detailed in the Specialist Skill chapter on page 18 of this handbook. The trainee will be required to take part in organised, relevant courses particularly those which form part of the Core Curriculum, and the regional GIM Training sessions. The trainee will be expected to keep abreast of current developments within the speciality, to practice evidence-based medicine and to help to change practice within the department where appropriate. Computer literacy is essential in order to ensure effective audit of all clinical / managerial aspects of the work of the department. 11
ST Placements Each clinical placement usually commences in the first week of August each year. However, should a trainee leave the programme outside this changeover interval, the start date of a newly appointed ST3 may be brought forward or delayed to match the timing of the vacancy left by the departing trainee. The trainee will be placed in one LHB (usually one hospital) for the whole year though trainees may rotate between specialties at various intervals throughout the year. Most trainees rotate to North Wales for at least one year of their training. The TPD will endeavour to inform trainees of as many of their future placements with as much advance notice as is reasonably possible. It may occasionally be possible, if circumstances permit, to inform some trainees of their placements for the entire 4/5 year training programme though this has to date proved difficult given the fluctuating number and staggered CCT dates of trainees, as well as the expanding number of hospitals participating in training over recent years. Trainees will usually rotate through ICU/Cardiology in the early part of training. Those trainees rotating through North Wales will usually do so in the earlier years of their training. The final year is usually in South Wales and should include at least 6 months experience within an AMU led by an Acute Physician. Thus, there will be a degree of certainty about where the trainee will be geographically located for the duration of their training although this is not totally guaranteed. A Survival Guide to Cardiology & ICU has been produced by one of the current trainees and contains invaluable tips and practical advice to help prepare trainees for what is often regarded as a rather daunting year. This handout, along with a host of other useful documents, will be given to trainees at the beginning of their training and can be accessed via the WAPS cloud account. If trainees step out of programme for any reason, it is anticipated that they will return to the rotation they left. If a grace period is required, trainees may need to go back to the beginning of their rotation. It is very important for trainees to arrange a meeting with their educational supervisor within the first couple of weeks of their first rotation to discuss their personal development plan and educational needs for that year this should be recorded on an induction appraisal form on the NHS e-portfolio. The StR s weekly timetable will vary significantly with each placement. It is acknowledged by the STC that the trainees are entitled to one protected session per week for specialist skill / service improvement / admin. The following table shows sample training rotations (5-year, for those aiming for dual accreditation with GIM). Please note: these examples are meant only as a guide to illustrate the usual locations and sequence of the rotations. The actual rotations allocated by the TPD will depend on placement availability, service demand and training needs of the individual. 12
Trainee 1 Trainee 2 Trainee 3 Trainee 4 Year 1 - ST3 UHW Cardiology ICU UHW ICU Cardiology Princess of Wales CDU Stroke Wrexham Maelor MAU Year 2 ST4 Royal Glamorgan AECU Resp 4/12 COTE 2/12 Royal Glamorgan Resp 4/12 COTE 2/12 AECU UHW Cardiology ICU UHW ICU Cardiology Sample Rotations: Year 3 ST5 Princess of Wales CDU Stroke Princess of Wales Stroke CDU Royal Glamorgan Resp 4/12 COTE 4/12 AECU Royal Glamorgan AECU Resp 4/12 COTE 2/12 Year 4 ST6 Ysbyty Glan Clwyd MAU Royal Gwent MAU Ysbyty Gwynedd MAU Nevill Hall MAU Year 5 ST7 Royal Gwent MAU Nevill Hall MAU Prince Charles CDU Princess of Wales Stroke CDU 13
Hospitals participating in training Training is provided in 9 hospitals in 5 Health Boards across Wales. The post holder will be required to work at any of the following Health Boards in Wales: Abertawe Bro Morgannwg University Health Board Aneurin Bevan Health Board Betsi Cadwaladr University Health Board Cardiff and Vale University Health Board Cwm Taf Health Board Hospital Speciality / Experience Clinical Placement Coordinators - *May 2016 Ysbyty Gwynedd, Bangor AMU Dr Chris Subbe Ysbyty Glan Clwyd, Rhyl Wrexham Maelor Hospital, Wrexham Nevill Hall Hospital, Abergavenny Royal Gwent Hospital, Newport Princess of Wales Hospital, Bridgend Royal Glamorgan Hospital, Llantrisant Prince Charles Hospital, Merthyr Tydfil University Hospital of Wales, Cardiff AMU, A&E Majors, AMU, MDU MAU MAU CDU Stroke Medicine / COTE AECU (Ambulatory Care) AMU Respiratory COTE CDU, MDU ICU Cardiology Dr Hari Nair Dr Sarah Dyer Dr Matt Brouns Dr Tom Cozens Dr John Hounsell Dr Harish Bhat (Stroke) Dr Les Ala / Dr Chris Hodcroft Dr Amit Benjamin (Resp) Dr Biswas (COTE) Dr Aled Huws Dr Chris Hingston (ICU) Dr Richard Wheeler (Cardio) * Note: The list of Clinical Placement Coordinators (CPC) is subject to change. Trainees will be informed of their CPC by the TPD upon commencing each placement. 14
Acute Consultants / Associate Specialists in Wales Note: This list is subject to change. Updated 31/8/15. Royal Gwent Hospital (RGH), Newport: o Hannah Brothers o Tom Cozens o Paul Mizen o Llifon Edwards o Haris Saleem o Emma Mason o Ferran Cavalle o Anna Lewis Nevill Hall Hospital (NHH), Abergavenny: o Matt Brouns Ysbyty Ystrad Fawr (YYF), Ystrad Mynach: o Mohamed Adlan University Hospital of Wales (UHW), Cardiff: o Dave Thomas o Anil Kumar University Hospital Llandough (UHL), Cardiff: o Ahmed Osman o Anna De Lloyd o Nolan Arulraj Princess of Wales Hospital (POW), Bridgend: o John Hounsell Royal Glamorgan Hospital (RGL), Llantrisant: o Les Ala o Nia Rathbone o Chris Hodcroft o Kate Speed o Nerys Conway o Atul Kalhan o Eugene Tabiowo Prince Charles Hospital (PCH), Merthyr Tydfil o Mohamed Hassan o Mark Stephens o Aled Huws o Vikas Lodhi o Joanne Morris Morriston Hospital (MH), Swansea (not currently participating in ST training): o Steve Lennox 15
o Ali Al Hassani Ysbyty Gwynedd (YG), Bangor o Hassan Mohammed o Anwar Khan o Chris Subbe Ysbyty Glan Clwyd (YGC), Rhyl o Aye Nyunt o Hari Nair o Atanu Basu o Sarah Davies Wrexham Maelor Hospital (WMH), Wrexham o Sarah Dyer o James Kilbane Educational & Clinical Supervisors Each trainee will have two nominated supervisors who will be named at the beginning of their rotation; one clinical placement coordinator (who will change with the various placements listed on page 14) and one educational supervisor (who should remain the same for the entire training). Note: there will be a number of clinical supervisors within each post but only one clinical placement coordinator. Educational supervisors It is your responsibility to arrange regular meetings with your educational supervisor (ES) and ensure the e-portfolio is up to date and reviewed. If you have difficulty arranging meetings with your educational or clinical placement coordinator (CPC) or have any other concerns you should speak with your TPD. You should have four meetings with your ES during each placement, with documentation completed on the e-portfolio: 1. Induction appraisal within initial 4 weeks of the post 2. Mid-point review (optional but recommended) 3. ES report / review (prior to ARCP) 4. End of attachment appraisal end of July prior to rotation to next post A formal process of appraisals and reviews underpins training. This process ensures adequate supervision during training, provides continuity between posts and different supervisors and is one of the main ways of providing feedback to trainees. All appraisals should be recorded in the eportfolio. For those who are dually accrediting, it is important to look at and complete your training requirements for both AIM and GIM this includes audits, SLEs and attendance at training days. 16
The supervisor s main responsibilities are to use e-portfolio evidence such as outcomes of assessments, reflections and personal development plans to inform appraisal meetings. They are also expected to update the trainee s record of progress through the curriculum, write end-of-attachment appraisals and supervisor s reports. Clinical supervisors Clinical supervisors (CS) are responsible for overseeing your day-to-day clinical work, such as inpatient work and outpatient clinics, and providing constructive feedback during a training placement. Your ES will also seek feedback about your progress and performance from your CPC or CS this will be recorded in your multiple consultant reports (MCRs). In some cases your CPC will also be your ES i.e. the roles will be merged. All elements of work in training posts must be supervised with the level of supervision varying depending on the experience of the trainee and the clinical exposure and case mix undertaken. Outpatient and referral supervision must routinely include the opportunity to personally discuss all cases if required. It is required that the clinical supervisor devotes at least one hour per week in their timetable per trainee for this work. As training progresses the trainee should have the opportunity for increasing autonomy, consistent with safe and effective care for the patient. Any concerns or problems (either personal or related to your job) that you experience during your placement can be discussed with your clinical placement coordinator or educational supervisor or any other member of the department you feel comfortable approaching. If there are any issues with your placement or job plan, you should approach your CP/CPC as the first point of contact, who will then inform your ED who will in turn contact the TPD. If you do not feel comfortable discussing or are unable to resolve any concerns raised you are welcome to contact the TPD directly. There is also in each hospital a tutor of the Royal College of Physicians, who is available for discussion. Patient safety concerns Any concerns you have relating to patient safety should be discussed with either your clinical placement coordinator or educational supervisor. If these concerns potentially relate to your supervisors they should be discussed with the head of department or local clinical director. Undermining / bullying If you encounter or witness any undermining or bullying during your placements you should discuss this with either your clinical placement coordinator or educational supervisor. If you feel this involves your supervisors you can discuss this with the TPD. 17
Specialist Skill The development of an additional skill or qualification is a mandatory requirement of training in Acute Medicine. This specialist skill must be acquired before the date of the trainees CCT. For some trainees, this may be a procedural skill or a practical interest such as echocardiography, ultrasonography or scoping; while for others it may be an academic interest where they ll gain a qualification in healthcare management, leadership or medical education, or it could be developing an interest in another medical field such as stroke, intensive care medicine or medical toxicology. Some may choose to undertake a serious bit of medical research during their training years. Note: Please refer to the corresponding section in the AIM curriculum for a more exhaustive list of the types of specialist skills that may be acquired by trainees. The new Specialist Skill section on the SAM website also has a comprehensive list and detailed information on 23 possible options for specialist skill: https://www.jrcptb.org.uk/specialities/acute-medicine http://www.acutemedicine.org.uk/what-we-do/training-and-education/skills/ In considering which specialist skill to develop, the trainee should consider how the acquisition of the skill may benefit the delivery of the Acute Medicine service overall. Choice of skill should take place as early in Acute Internal Medicine training as is possible. The skill should be one that can be used and developed throughout the physician s career. We try to accommodate the trainees choice of special skill and the sooner the decision is made the sooner we will be able to support this choice. However, if there is specific skill desired by the trainee before application but falls outside the options listed on the SAM website, trainees are encouraged to contact the programme director as early as possible. It is recommended that a trainee should choose only ONE specialist skill in which to achieve competence. It is not anticipated that any trainee should be trying to adopt extensive experience in multiple skills during the training programme. Whichever specialist skill the trainee chooses there must be robust arrangements for training, assessment of competence, and maintenance of competence as defined by the relevant authority for each skill (e.g. BSE for echocardiography or JAG for endoscopy). It is important that an individual trainee recognises that continued exposure to and practise of a procedural skill is the only way to sustain competence in that skill. The choice of procedural skill should therefore be made whilst taking into account which is most likely to be required by the health service after training is complete. Discussion with the programme director or Educational Supervisor is recommended when making this decision. 18
Curricula Both the AIM and GIM curricula along with respective ARCP decision aids are available on the JRCPTB website http://www.jrcptb.org.uk/specialties or accessible through links on your e-portfolio. These documents outline the competencies required to achieve your CCT, including the requirements for assessments and progress at each stage of your training. It is important to ensure that evidence of your training is uploaded to your e- portfolio on a regular basis, with adequate linking between your assessments or reflections and relevant parts of the curriculum (NB: you can link to more than one part of your curriculum). AIM Curriculum AIM curriculum 2009 (amended 2012) & decision aid (revised November 2014) http://www.jrcptb.org.uk/specialities/acute-medicine The AIM curriculum has been designed to enable StRs on completion of CCT to apply for Acute Medicine consultant posts armed with competencies for the delivery of high quality medical care to acutely ill patients and also the managerial skills required to run AMUs. The curriculum emphasises the skills and competencies that must be acquired in the acute medical settings but also reflects those that are relevant to the inpatient and outpatient settings including ambulatory care. Specific competencies in the management of patients requiring level 2 care are also mandatory for trainees undertaking training in AIM. It also details how these competencies will be assessed as a trainee progresses through the syllabus. GIM Curriculum GIM curriculum 2009 (amended 2012) & decision aid (revised November 2014) http://www.jrcptb.org.uk/specialties/general-internal-medicine-gim Within the GIM curriculum there is an emphasis on the training of physicians with the ability to investigate, treat and diagnose patients with chronic medical symptoms, with the provision of high quality review skills for inpatients and outpatients fulfilling the requirement of consultant-led continuity of care. While these attributes are not emphasised in the AIM curriculum it is clear that these are competencies that must be acquired for those pursuing a dual CCT in AIM and GIM. It is recognised that there is a hierarchy of competencies within each curriculum. It is expected that the breadth and depth of evidence presented for the emergency presentations, top symptom presentations and procedures will be greater than that for the common competencies and the other important presentations which should be sampled to a lesser extent i.e. work place assessment evidence is not required for all of these competencies. However, there must be evidence of engagement with that section of the curriculum. 19
E-portfolio (JRCPTB) Trainees are required to register for specialist training with JRCPTB at the start of their training programmes. Enrolment with JRCPTB is mandatory and has an enrolment fee, which can either be paid to the JRCPTB with an upfront one off payment of 845 (tax deductible) in 2016, or as instalments of 169 per annum paid alongside collegiate membership. The maximum duration of payment is 5 years (even if you take longer to complete your training). Trainees can enrol online at https://www.jrcptb.org.uk On enrolling with JRCPTB trainees will be given access to the e-portfolio. https://www.nhseportfolios.org This web-based e-portfolio is where trainees should record their assessments, appraisals, reflections on learning experiences, acquisition of competencies and progress through training. It allows evidence to be built up to inform decisions on a trainee s progress and provides tools to support trainees education and development. Note: the JRCPTB will not provide a paper-based alternative to the e-portfolio. It is important to become familiar with the different components of the e-portfolio early in your training, as it provides evidence of adequate progression, assessed at your annual ARCP. It includes a record of meetings with your educational supervisor, Clinical supervisor, examination and certificates, personal library (80MB limit), workplace based assessments (WPBAs) / Supervised Learning Events (SLEs) with links to your curriculum and Annual Review of Competence Progression (ARCP) outcomes. It is primarily the trainee s responsibility to ensure the e-portfolio is kept up to date though supervisors also have access to shared parts of the portfolio and have a responsibility to record appraisal outcomes and sign off the record of competence. The trainee must also arrange assessments and ensure they are recorded, prepare drafts of appraisal forms, maintain their personal development plan, record their reflections on learning and record their progress through the curriculum. If you have any difficulties in engaging your ES in the e-portfolio you must inform the TPD immediately it will not be accepted as a reason for incomplete information provided at your ARCPs. 20
E-Portfolio - Key points Ensure that all of your personal details including e-mail address are kept up to date within the Profile section. You should complete a PDP (personal development plan) at the start of each clinical attachment and prior to your ARCP to outline your objectives for your next placement (this information will be used to plan the rotation) Each review meeting and report entered by your ES must include that it covers both Acute Medicine & GIM (if working towards dual accreditation) You should review the decision aids for both Acute Medicine & GIM at the start of each placement so that you are aware of your requirements for the forthcoming year this includes the appropriate number of SLEs Your e-portfolio and assessments should be updated regularly throughout the year and linked to the relevant parts of the curriculum. The number of times an SLE can be linked to curriculum competencies is limited to eight for each ACAT and two for CbD & mini-cexs Your ES should sign off the different components of your curriculum. This can be very time consuming but can now be done as a group sign off or sampling of the curriculum rather that exhaustively sign off every competence. It is worth using the Royal College of Physicians diary to record your CPD activity an annual summary can be uploaded as a PDF to your personal library (it is also recommended at your GIM PYA) Courses etc can only be validated if certificates are uploaded to your e-portfolio (this usually requires completion of feedback) Any absences from work should be recorded on your e-portfolio. You will be required to complete a trainee absence form, sent to you by the deanery, ahead of your ARCP every year. Your TPD should be notified of periods > 2 weeks, which may potentially require an extension to your CCT date. The assessments required for stage of the training programme is summarised in the AIM and GIM decision aids (see links in Curricula chapter). An overview is provided below, however this is not exhaustive: 21
Overview of AIM training requirements 1. Educational Supervisor (ES) report to cover training year since last ARCP 2. 4-6 Multiple Consultant Report (MCR) must be completed annually each MCR must be completed by either the trainee s clinical supervisor / clinical placement coordinator or consultants who the trainee has regular working contact with (not consultants that trainees have fleeting contact with e.g. on-call). For dual accrediting trainees, 2 MCRs must include feedback on GIM clinical abilities. Summary of the MCR and any actions resulting to be recorded in ES report 3. Specialist Certificate Exam (SCE) AIM SCE usually taken in years 3 or 4 and achieved by CCT 4. Valid ALS throughout training (these are valid for 4 years) evidenced in the Certificate and Exams section of your e-portfolio. 5. Supervised Learning Events (SLEs) - Minimum of 10 SLEs (ACATs, CbDs and mini CEX) per year of training to include a minimum of 6 ACATs SLEs should be performed proportionately throughout each training year by a number of different assessors across the breadth of the curriculum. Structured feedback should be given to aid the trainee s personal development 6. Multi-source feedback (MSF) - Minimum of 12 raters including 3 consultants and a mixture of other staff (medical and non-medical) Replies should be received within 3 months for a valid MSF. If significant concerns are raised then arrangements should be made for a repeat MSF. An MSF should be completed per year. Don t forget your self-assessment! 7. A Patient Survey should be completed in the first two years and another in the last two years e.g. during years 2 and 4 (i.e. ST4 and ST6). 8. AIM Audit or AIM Quality Improvement projects 4 before CCT one of which must complete the loop. Ideally a Quality Improvement assessment (QIPAT) or Audit assessment should be performed 9. Teaching observation 1 before PYA 10. Signed off for: common competencies, emergency presentations, top presentations & other important presentations. One assessment in each major domain should be covered during your placement 11. Common competencies - Confirmation by educational supervisor that level 3 or 4 achieved. Ten do not require linked evidence unless concerns are identified. Evidence of engagement with 75% of remaining competencies to be determined by sampling and level achieved recorded in the ES report 22
12. Emergency presentations Evidence of engagement required for all 4 emergency presentations by end of AIM training. ES to confirm level achieved and complete rating for each presentation. Evidence to include ACATs, mini-cexs and CbDs 13. Top presentations. Evidence of engagement required for all top presentations by end of AIM training. Level achieved to be determined by sampling and recorded in ES report 14. Practical procedures - summative DOPS evidence required for each of the following: a. Clinically independent by completion of ST3 for: i. Central venous cannulation (by femoral approach as a minimum) with ultrasound guidance where appropriate* ii. Abdominal paracentesis* iii. DC cardioversion iv. Knee aspiration b. Clinically independent by completion of year 3 AIM for: i. Intercostal drainage (1) Pneumothorax insertion using Seldinger technique* ii. Intercostal drainage (2) Pleural Effusion using Seldinger technique following ultrasound guidance* iii. By PYA: signed off for CVP line insertion, intercostal drain insertion using ultrasound c. Clinically independent by PYA for: i. Arterial line d. Competent in skills lab by PYA for (these have been removed from the curriculum though there may be a delay until the decision aid is updated): i. Temporary cardiac pacing via transvenous route* ii. Sengstaken- Blakemore Tube insertion* Summative sign off for routine procedures to be undertaken on one occasion with one assessor to confirm clinical independence. Summative DOPS sign off for potentially life threatening procedures (marked with asterisk) to be undertaken on at least two occasions with two different assessors (one assessor per occasion) 15. Clinical activity - Annual Summary of Training Calculator uploaded to your personal library: a. Acute take: 1250 patients seen before CCT b. Ambulatory Care: 300 new patients seen before CCT 16. Clinical experience with relevant competencies in AMU, Cardiovascular medicine, Respiratory Medicine, Geriatric Medicine, Intensive Care Medicine Specialist Skill training 17. Teaching satisfactory record of teaching attendance (should be specified at induction but evidence of attendance at a minimum of 70% of deanery training days 23
should be achieved) with 100 hours external AIM teaching (including regional teaching days) before CCT Overview of GIM training requirements For dually accrediting trainees - as per AIM requirements except: / in addition to AIM requirements 1. GIM Audit or GIM Quality Improvement projects Need to have lead one before CCT one of which must complete the loop. Quality Improvement assessment tool (QIPAT) or Audit assessment (AA) to be performed 2. Multiple Consultant Reports (MCR) of the 4-6 MCRs that must be completed annually, 2 MCRs must include feedback on GIM clinical abilities for dual accrediting trainees 3. Clinical activity: o GIM Acute Take: 1000 patients seen before CCT o Outpatients clinics (or equivalent): 186 clinics performed before CCT (approximately 1500 outpatients) Please note: AIM trainees dually accrediting with GIM can count new ambulatory care patient contact experience as outpatients for the GIM curriculum. Each SLEs can be linked to both AIM and GIM curriculums i.e. the SLEs do not need to be duplicated for the purposes of satisfying both curriculum requirements. Similarly, though the absolute number required for each curriculum differs, the same patient contact experience can be counted towards the clinical activity requirements for both curriculums. 24
Workplace-based Assessments (WPBAs) The various workplace based assessment methods are described below. More information about these methods including guidance for trainees and assessors is available in the eportfolio and on the JRCPTB website www.jrcptb.org.uk. These assessment tools are available online in the eportfolio and assessments should be recorded in the trainee s eportfolio. Printable versions of some of the forms can be found in the document library on this website. http://www.jrcptb.org.uk/assessment/workplace-based-assessment Supervised Learning Events (SLEs) Trainees should aim for at least 10 SLEs (ACATs, CbDs and mini CEX) - to include a minimum of 6 ACATs. SLEs should be performed proportionately throughout each training year by a number of different assessors across the breadth of the curriculum. Structured feedback should be given to aid the trainee s personal development mini-clinical Evaluation Exercise (mini-cex) This supervised learning event tool evaluates a clinical encounter with a patient to provide feedback on skills essential for good clinical care such as history taking, examination and clinical reasoning. The trainee receives immediate feedback to aid learning. It can be used at any time and in any setting when there is a trainee and patient interaction and an assessor is available. Case-based Discussion (CbD) The CbD is a tool for supervised learning events based on a trainee's management of a patient and provides feedback on clinical reasoning, decision-making and application of medical knowledge in relation to patient care. It also serves as a method to document conversations about, and presentations of, cases by trainees. The CbD should focus on a written record (such as written case notes, out-patient letter, discharge summary). A typical encounter might be when presenting newly referred patients in the outpatient department. Direct Observation of Procedural Skills (DOPS) A DOPS is an assessment tool designed to evaluate the performance of a trainee in undertaking a practical procedure, against a structured checklist. The trainee receives immediate feedback to identify strengths and areas for development. DOPS have been separated into two categories for routine and life-threatening procedures, with a clear differentiation of formative and summative sign off. Formative DOPS for routine and potentially life threatening procedures should be undertaken before doing a summative DOPS and can be undertake as many times as the trainee and their supervisor feel is necessary. Summative DOPS should be undertaken as follows: Acute Care Assessment Tool (ACAT) The ACAT is designed to be used for supervised learning events on the acute medical take (but may be on a ward round or covering a day's management of admissions and 25
ward work). The ACAT looks at clinical assessment and management, decision-making, team working, time management, record keeping and handover for the whole time period and multiple patients. There should be a minimum of 5 cases for an ACAT assessment. Multi-source feedback (MSF) This tool is a method of assessing generic skills such as communication, leadership, team working, reliability etc, across the domains of Good Medical Practice. This provides objective systematic collection and feedback of performance data on a trainee, derived from a number of colleagues. Raters' are individuals with whom the trainee works, and includes doctors, administration staff, and other allied professionals. The trainee will not see the individual responses by raters, feedback is given to the trainee by the Educational Supervisor. Trainees are also required to complete a self-assessment form. If significant concerns are raised then arrangements should be made for a repeat MSF Patient Survey (PS) Patient Survey address issues, including behaviour of the doctor and effectiveness of the consultation, which are important to patients. It is intended to assess the trainee's performance in areas such as interpersonal skills, communication skills and professionalism by concentrating solely on their performance during one consultation. Patient survey guidance, survey forms and summary forms are available in the assessment section of the JRCPTB website. The summary form must be completed and signed off by your ES and then uploaded to your personal library as evidence. Audit Assessment (AA) The Audit Assessment tool is designed to assess a trainee's competence in completing an audit. The Audit Assessment can be based on review of audit documentation or on a presentation of the audit at a meeting. If possible the trainee should be assessed on the same audit by more than one assessor Quality improvement project assessment tool (QIPAT) The QIP Assessment tool is designed to assess a trainee's competence in completing a quality improvement project. The trainee should be given immediate feedback to identify strengths and areas for development. All workplace-based assessments are intended primarily to support learning so this feedback is very important. The QIP Assessment can be based on review of QIP documentation OR on a presentation of the QIP at a meeting. If possible the trainee should be assessed on the same QIP by more than one assessor. Assessors can be any doctor with suitable experience - for trainees in higher speciality training this is likely to be consultants. Teaching Observation (TO) The Teaching Observation is designed to provide structured, formative feedback to trainees on their competence at teaching. The Teaching Observation can be based on any instance of formalised teaching by the trainee which has been observed by the assessor. The process should be trainee-led (identifying appropriate teaching sessions and assessors) and one TO should be completed before PYA in AIM & GIM 26
Multiple Consultant Report (MCR) The Multiple Consultant Report (MCR) was introduced in 2013 and is designed to capture the views of consultant supervisors on a trainee's clinical performance. It must be completed by a minimum of 4 consultants (maximum of six) or associate specialists / speciality doctors (not trainees) who are able to provide feedback on a trainee's clinical performance. Educational supervisors should not be asked to complete an MCR for their own trainees as they will complete the ES report. Note these are different to MSF assessments. Each MCR form is completed by a single consultant who should either be the trainee s clinical supervisor (or clinical placement coordinator) or a consultant who the trainee has regular working contact with and not a consultant who the trainee may have fleeting contact with e.g. on-call. For dual accrediting trainees with GIM, 2 MCRs must include feedback on GIM clinical abilities. A summary of the MCR and any actions resulting is to be recorded in the ES s report. Therefore if four MCRs are required, four consultants should complete a form each resulting in four MCR forms. The MCRs will be automatically collated and summarised in the MCR Year Summary Sheet that will inform the ES report at the end of the training year. The MCR requests feedback on clinical performance and must be completed in addition to the Multi Source Feedback (MSF) tool. The same consultant may be approached to complete both forms. Out of programme trainees are also advised to complete these reports. Trainees who are less than full time should complete the number of MCRs pro rata following discussion with their education supervisor. Further information is available in the assessment section of the JRCPTB website. Audits AIM trainees are required to complete four audits or quality improvement projects (QIP) prior to CCT (one per year), one of which must complete the loop. These should be uploaded to the personal library. An audit assessment tool or QIPAT assesses a trainee s competency in completing an audit / QIP and must be completed after review of the documentation or presentation at a meeting. Those trainees dually accrediting with GIM are also required to complete a single GIM audit / QIP prior to CCT (and complete an audit assessment tool). Ideally an audit should be commenced near the start of the placement so there is an opportunity to perform a second/further cycle later in the year. Involvement in a local service development is also equally acceptable. Annual Summary of Training Calculator This calculator calculates your acute medical and outpatient experience. It is available for download from the GIM section of the Wales deanery website (see below link), with an alternative version downloadable from the GIM section of the JRCPTB website: https://www.walesdeanery.org/specialties/general-internal-medicine 27
http://www.jrcptb.org.uk/specialties/general-internal-medicine-gim It should be updated annually and uploaded to your personal library. The AIM decision aid stipulates that 1250 acute take patients and 300 new Ambulatory care patients should be seen prior to CCT, whilst the GIM decision aid states that 1000 patients should be seen on the acute intake and 186 outpatient clinics attended (approx 1500 outpatients) before a trainees CCT date. Personal library This section of the e-portfolio allows you to upload electronic documents to provide evidence of your training (ALS/SCE/CPD certificates, audits etc). You can upload any file type, however it is limited to 80MB of space. The files can be organised into folders & subfolders. Training quality surveys The national GMC training survey serves to monitor the quality of medical education and training in the UK. In addition an online placement survey is sent out towards the end of each rotation. Completion is a mandatory requirement of training and allows the quality and balance of the training rotations to be maintained. Annual calendar February: AIM Trainee Survey March : ST Applications April: ST3 Interviews May: Society for Acute Medicine Spring Conference May: Spring Meeting of the Society of Physicians in Wales (Portmeirion) May: AIM ARCPs May/June : Acute Medicine Summer School May/June: Welsh Acute Physicians Society Spring Symposium June: Society of Acute Medicine Benchmarking Audit (SAMBA) June/July: Acute Medicine Awareness Week September: Society for Acute Medicine International Conference September: GIM ARCPs October: Welsh Acute Physicians Society Autumn Symposium November: Society of Physicians of Wales and Royal College of Physicians Joint Update in General and Acute Medicine (Cardiff) 28
Training days and leave Acute Medicine Summer School The Acute Medicine Summer School is an annual training week arranged for Acute Medicine trainees and is held alternately between North and South Wales, usually at a rural hotel location. It provides a varied programme of activities including service improvement workshops, video simulation sessions on emergency clinical scenarios, practical procedure workshops, debates on contentious clinical issues, a journal club, guideline updates and a number of talks by distinguished local and national speakers on a range of different topics. One of the training days is a national Acute Medicine Symposium organised by WAPS. Attendance is mandatory and it is the responsibility of the trainee to ensure that any oncall commitments are swapped to allow attendance. Any difficulty in obtaining leave for the mandatory training week should be reported to the TPD as soon as possible. Welsh Acute Physicians Society (WAPS) The recently formed Welsh Acute Physicians' Society is dedicated to furthering Acute Medicine and supporting trainees in Wales. The group was set up predominantly by a group of acute medicine trainees to raise the profile of the speciality across Wales but is open to all those with an interest in acute medical care and education. The society organises educational events such as the Acute Medicine Symposium, which provides 6 CPD points. Trainees joining the training programme will automatically gain membership to this society and free entry to all symposiums. GIM Training Several GIM core curriculum training courses are available each year, with dates advertised in your e-portfolio. The mandatory GIM core curriculum training days required for CCT are: Core Management & Leadership Training Teaching Techniques Communication Skills Medical Law Assessing Trainees Medical Ethics Trainees are also required to attend at least 3 GIM generic curriculum regional StR teaching days (around 4 per year). These courses are arranged by the deanery and take 29
place in South Wales with video link available to North Wales trainees. You may need to contact the organisers to find out dates and get onto email lists. If the trainee does not comply with the minimum attendance percentage of 70%, they will obtain an unsatisfactory ARCP outcome. Currently the North Wales days are organised by Dr. Ben Thomas or Dr. David Glover in Wrexham Maelor Hospital. Booking contact: 01978 727123 or Email: deborah.bevan@new-tr.wales.nhs.uk The South Wales teaching days are managed by Dr Aled Roberts (STC Chair) & Dr Biju Mohamed (TPD). Any enquiries, should be directed to Dr Roberts Email: aled.roberts2@wales.nhs.uk) or Dr Mohamed biju.mohamed@wales.nhs.uk GIM courses are advertised on the e-portfolio and RCP / Wales deanery website. For full information on dates or to book your place on the training days, please contact Miss Ceri Cook at the Wales Deanery: E-mail: McGowanR@cardiff.ac.ukTel no: 02920 687588 You are required to provide evidence of 100 hours of external GIM CPD points prior to your CCT. We advise registering for the RCP CPD diary a summary of your CPD for each year can be uploaded to your personal library as a PDF (this is also recommendation at your GIM PYA). Study Leave The Wales Deanery defines the study leave budget annually (currently capped at around 800 per trainee). Each specialist trainee is entitled to 30 days study leave per annum. Attendance at ARCPs and core curriculum for specialist trainees is mandatory and therefore not deducted from your annual study leave. All study leave must be requested and authorised using the INTREPID 10 online system. This database keeps a record of all leave taken throughout your training and remaining study leave budget available. Study leave will be granted at the discretion of your departmental leave coordinator. Most hospitals require a minimum of 6 weeks notice to allow cancellation of outpatient clinics and other clinical commitments, although this can vary between different Health Boards (this should be discussed at your local induction meeting). Annual leave Trainees in their first five years of NHS employment are entitled 27 days of annual leave, increasing to 32 days thereafter. Similar to study leave, at least 6 weeks notice is often required to allow cancellation of your clinical commitments. The process for gaining annual leave will vary between Health Boards and should be discussed at your local induction meeting at the start of your placement. 30