The Royal College of
Anaesthetists
Curriculum for a
CCT in Anaesthetics
Edition 2
August 2010
Version 1.2
Preface
This, the 2nd
edition of The CCT in Anaesthetics, replaces The CCT in Anaesthetics Edition 1 dated 26 January
2007...
The next point of contact is the College Tutor of the department in which the trainee is working. If the
College Tutor is ...
Table of Contents
Preface 2
Table of contents 4
Executive summary 8
1. Introduction 12
1.1 Aim 12
1.2 The scope of anaesth...
3.10 Military service 34
4. Simulation technology for learning in anaesthesia 35
4.1 Context 35
4.2 Application in trainin...
10. The Delivery of Basic Level Training 52
10.1 The principles of basic level training 52
10.1.1 The basis of anaesthetic...
13.7 Anaesthesia in developing countries 74
13.7.1 Requirements for consideration 75
13.7.2 Requirements on return to the ...
Annex G Training and teaching, academic and research [including audit] and
management for anaesthesia, pain medicine and i...
Executive Summary
This document identifies the aims and objectives, content, experiences, outcomes and processes of
postgr...
that spring from these personal and professional qualities of work are specifically identified in the
assessment system.
D...
evaluate trainee progress and to provide evidence to the Annual Review of Competence Progression [ARCP]
panels.
The Fellow...
Achieving the CCT
As previously stated in ‘duration of training’, the training programme is divided into four distinct pha...
1. Introduction
1.1 Aim
This document identifies the aims and objectives, content, experiences, outcomes and processes of
...
The CCT programme is thus designed to meet the diverse service needs of the NHS. By way of illustration,
there were 501 co...
The curriculum revision process began with development of a task list of capabilities expected at the end of
each of the f...
The previous editors of the CCT in Anaesthetics and those who edited the Northern Schools of
Anaesthesia Training Manual i...
Advisory Group, the IBTICM, the Faculty of Pain Medicine and the AAGBI. The Committee is always
pleased to receive comment...
• To assist colleagues in decisions about the suitability of surgery in difficult situations
• Provide teaching to less ex...
2. Principles of the training programme
2.1 Underlying principles
The principles of the UK CCT in Anaesthetics training pr...
2.2.3 Experiential Learning [See Appendix 5 – RCoA Clinical Assessment Strategy]
Much of the learning is service-based and...
2.2.5 Teaching and Training; Academic and Research; Management
These are considered essential elements of the training pro...
It is important to ensure that the attached sessions have relevance to the unit[s] of training [and Level] that
individual...
the “Gold Guide”7
. In addition, one of the College Bernard Johnson Advisers provides strategic advice to the
RCoA on the ...
2.9 Schools of Anaesthesia
Schools of Anaesthesia are responsible, on behalf of the Deanery, for the delivery of a GMC app...
Schools usually have between five and ten hospitals, including a tertiary specialist centre, providing
training. Occasiona...
• Schools of Anaesthesia in conjunction with local Specialty Training Committee are responsible for:
o The administrative ...
• A suitably equipped teaching area and a private study area
• An appropriate rest area whilst on shifts
2.13 Equipment an...
• Paediatric resuscitation guidelines [Resuscitation Council (UK)]
2.13.2 Simulating critical incidents and equipment fail...
3. Entry to and progression through training
3.1 Progression through the CCT programme
3.1.1 Indicative duration
To obtain...
3.2.2 ACCS entry
• ACCS training is a three year programme of training in anaesthesia, acute medicine, emergency
medicine ...
• Trainees from the Republic of Ireland: Trainees entering ST year 3 who completed their basic level
training in the Repub...
Transitional arrangements have been agreed with the GMC for those trainees who were appointed to a
CCT programme in Anaest...
where their primary medical qualification was obtained17
[A certificate is required from the
GMC as proof – Article 3(3) c...
• Locum Appointments for Training [LAT]: 18
o A LAT post can count towards a CCT if it covers a clearly identifiable porti...
All trainees are required to register for training with the College’s Training Department as soon as possible
after appoin...
4. Simulation technology for learning in anaesthesia
4.1 Context
The use of a wide range of methods to translate and deliv...
National Association of Medical Simulators]20
] within the faculty of clinical and educational supervisors and
other educa...
5. Human factors in clinical practice
The curriculum requires trainees to demonstrate comprehensive knowledge of many aspe...
6. Clinical supervision
The definitions of supervision described below have been developed from a consideration of the
pro...
this will depend on the combination of the trainee's grade, the nature of the clinical work and the
layout of the hospital...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
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The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
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The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
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The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
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The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
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The commitment to all aspects of professionalism should be ...
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The commitment to all aspects of professionalism should be ...
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The commitment to all aspects of professionalism should be ...
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The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
The commitment to all aspects of professionalism should be ...
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  1. 1. The Royal College of Anaesthetists Curriculum for a CCT in Anaesthetics Edition 2 August 2010 Version 1.2
  2. 2. Preface This, the 2nd edition of The CCT in Anaesthetics, replaces The CCT in Anaesthetics Edition 1 dated 26 January 2007. It has been totally rewritten to align with Standards for Curricula and Assessment, PMETB, London, 2008. The opportunity has been taken to introduce new units of training and to revise or merge others to reflect changes in anaesthetic practice and service needs. In 2007 the titles of trainees changed with the introduction of Modernising Medical Careers [MMC] and they changed again in 2008. The term Specialty Registrar [StR] is used throughout this curriculum to encompass trainees who may still be in Fixed Term Specialty Training Appointments [FTSTA] and those with contracts as Core Trainees [CT] and Specialist Registrars [SpR]. StR1 = CT1 = FTSTA 1 StR2 = CT2 = FTSTA 2 StR3 = SpR1 = FTSTA 3 StR4 = SpR2 StR5 = SpR3 StR6 = SpR4 StR7 = SpR5 Abbreviations A list of commonly used abbreviations is provided in annexes B, C, D and E Trainee Registration All trainees are required to register with the College’s Training Department as soon as possible after starting their training. Copies of the Annual Review of Competence Progression [ARCP] and any correspondence related to their individual training are held at the College. A Certificate of Completion of Training [CCT] date is estimated, usually on entry to Specialty Training [ST] year 5. This is altered if the necessary competencies and assessments [including examinations] are not obtained or other circumstances prevail [such as sick leave or maternity leave] by the expected date. There are distinct benefits for trainees who register with the College. They are: • Access to the College’s trainee e-portfolio • Access to e-Learning for anaesthesia • Access to training programme advice from the Medical Secretaries and training administrators Advice The first point of contact for information concerning a trainee’s training or career planning is this curriculum in conjunction with Guidance for Trainers, Regulations for FRCA Examinations and Guidance on Preparation for the FRCA Examinations. The latter documents are available on the training and examination pages of the College website www.rcoa.ac.uk . 2
  3. 3. The next point of contact is the College Tutor of the department in which the trainee is working. If the College Tutor is unable to give the necessary guidance then the Regional Adviser should be asked for advice. Only if the College Tutor or Regional Adviser cannot help should a trainee contact the College’s Training Department for advice because inevitably the Training Department will have no knowledge of the trainee’s personal circumstances. 3
  4. 4. Table of Contents Preface 2 Table of contents 4 Executive summary 8 1. Introduction 12 1.1 Aim 12 1.2 The scope of anaesthetic practice 12 1.3 Curriculum design and development 13 1.4 Structure of the curriculum document 16 2. Principles of the training programme 18 2.1 Underlying principles 18 2.2 Training concepts 18 2.3 Training environments 20 2.4 Trainers 20 2.5 Minimum number of recommended training sessions 20 2.6 Out of hours commitments 21 2.7 Less than full time trainees [LTFT] 21 2.8 Supervision 22 2.9 Schools of Anaesthesia 23 2.10 Specialty advisory committees 23 2.11 Responsibility for training in the workplace 24 2.12 Accommodation for training and trainees 25 2.13 Equipment and safety guidance 26 3. Entry to and progression through training 28 3.1 Progression through the CCT programme 28 3.2 Entry to basic level training 28 3.2.1 Direct entry 28 3.2.2 Acute Care Common Stem [ACCS] entry 29 3.3 Entry to intermediate level training 29 3.4 Progression to higher and advanced special interest level training 30 3.5 Progression through higher/advanced training to the recommendation of the award of a CCT/CESR[CP] 30 3.6 Examinations and the award of a CCT 30 3.6.1 Transitional arrangements for transfer from the 2007 curriculum 31 3.6.2 CCT versus CESR[CP] 31 3.7 Re-entering training after a break 32 3.8 Principles for approving previous training and experience 32 3.9 Trainee registration 34 4
  5. 5. 3.10 Military service 34 4. Simulation technology for learning in anaesthesia 35 4.1 Context 35 4.2 Application in training 35 4.3 Implementation 35 4.4 Application in assessment 36 5. Human factors in clinical practice 37 6. Clinical supervision 38 6.1 Clinical supervision: the obligation to patients 38 6.2 Grades of clinical supervision 38 6.3 Clinical supervision by consultants 39 6.4 Clinical supervision by specialty doctors 39 6.5 Clinical supervision of one trainee by another 40 6.6 Clinical teaching and supervision 40 7. The trainee in difficulty 41 8. Assessment 42 8.1 Evidence for the annual review of competence progression 42 8.2 RCoA Fellowship examinations 42 8.2.1 Tests of knowledge for the award of a CCT 42 8.2.2 RCoA Fellowship 42 8.3 Workplace based assessments 43 8.3.1 Choosing appropriate assessment instruments 43 8.3.2 Available methodologies 43 8.3.3 How many workplace-based assessments 43 8.3.4 The Annual Review of Competence Progression 44 8.4 The workplace based assessments 45 8.4.1 The DOPS, A-CEX and ALMAT 45 8.4.2 CBD 46 8.4.3 Simulation based assessment 46 8.4.4 Logbook and portfolio 46 8.4.5 Evidence of participation and attendance at training events 47 8.4.6 An independent appraisal 47 8.5 Appeals against assessment 47 8.5.1 Unsatisfactory workplace based assessment 47 8.5.2 Failure of FRCA examinations 47 8.6 Assessors 48 8.6.1 Workplace assessors 48 8.6.2 FRCA examiners 48 9. Training documentation 49 9.1 RCoA recommendations for portfolios and logbooks 49 9.1.1 Portfolios 49 9.1.2 Logbooks, diaries and other records 49 9.2 Data protection 50 9.2.1 Use of patient ID in logbooks 50 9.3 Documentation of training 50 9.3.1 The trainee’s responsibilities 50 9.3.2 The School’s responsibilities 51 5
  6. 6. 10. The Delivery of Basic Level Training 52 10.1 The principles of basic level training 52 10.1.1 The basis of anaesthetic practice 52 10.1.2 Basic anaesthetic training 53 10.2 Organisation of basic level training 54 10.2.1 Clinical units of training 54 10.2.2 Assessments 54 10.2.3 ACCS 55 10.2.4 Pain medicine training 55 10.3 Progression to intermediate level training 55 11. The Delivery of Intermediate Level Training 57 11.1 The principles of intermediate level training 57 11.2 Organisation of intermediate level training 58 11.2.1 Clinical units of training 58 11.2.2 Dedicated blocks of training 58 11.2.3 Deferral of essential intermediate units of training 58 11.2.4 Pain medicine training 59 11.2.5 Intensive care medicine training 59 11.2.6 Service commitment to ICM and obstetrics 61 11.2.7 Professionalism and common competences in medical practice 61 11.2.8 Teaching and Training; Academic and Research; Management 61 11.2.9 Assessments 61 11.3 Intermediate level section of the curriculum 62 11.4 Progression to higher/advanced level training 62 12. The Delivery of Higher/Advanced Level Training 64 12.1 The principles of higher/advanced level training 64 12.2 Organisation of higher/advanced level training 66 12.2.1 Clinical units of training 66 12.2.2 Advanced level training 67 12.2.3 Deferral of essential intermediate units of training 67 12.2.4 Pain medicine training 67 12.2.5 Intensive care medicine training 68 12.2.6 Service commitment to ICM and obstetrics 69 12.2.7 Professionalism and common competences 70 12.2.8 Assessments 70 12.3 Recommendation to the General Medical Council [GMC] for the award of a Certificate of Completion of Training [CCT] or Certificate of Eligibility for Specialist Registration [Combined Programmes] [CESR[CP]] 71 13. Out of programme 73 13.1 Out of programme clinical experience [OOPE] 73 13.2 Out of programme training [OOPT] 73 13.3 Out of programme experience for research [OOPR] 74 13.4 In and out of programme experience for education and management 74 13.5 Applying for OOPT and OOPR 74 13.6 Secondment between schools and deaneries 74 6
  7. 7. 13.7 Anaesthesia in developing countries 74 13.7.1 Requirements for consideration 75 13.7.2 Requirements on return to the UK 76 14 Completion of training 77 14.1 Request to complete training as a locum consultant 77 14.2 Leaving the training grade 77 14.3 Applying for a consultant post 77 15. Equality and Diversity 78 Table 1 Consultant post vacancies 2008.........................................................................................................14 Table 2 Questions for ARCP panels.................................................................................................................46 Table 3 Domains of Good Medical Practice...................................................................................................46 Table 4 CanMEDS categories for the role of the doctorCa005 Physician Competency Framework...............87 Table 5 CanMEDs categories for professionalism..........................................................................................88 Appendix 1 Curriculum working group membership 80 Appendix 2 Management of sickness, parental and maternity leave 81 Appendix 3 Criteria for the appointment of trainers 83 Appendix 4 CanMEDS classifications 86 Appendix 5 RCoA Clinical Assessment Strategy for assessment leading to the CCT/CESR[CP] in anaesthetics 88 Appendix 6 Anaesthesia List Management Assessment Tool 102 Appendix 7 Anaesthetic Non-technical Skills [ANTS] behavioural marker system for anaesthesia 103 Appendix 8 An assessment manifesto 104 Appendix 9 Guidelines for trainees who have not passed the basic or intermediate assessment of knowledge 106 Appendix 10 RCoA Logbook summary 108 Annex A Professionalism in medical practice Annex B Basic level training Annex C Intermediate level training Annex D Higher level training Annex E Advanced level training Annex F Intensive Care Medicine 7
  8. 8. Annex G Training and teaching, academic and research [including audit] and management for anaesthesia, pain medicine and intensive care medicine Approvals Date Version Description GMC Approval 25 Feb 2010 1 First submission Conditional Approval 28 Apr 2010 1.1 Update submission – response to conditions Approved 02 Jul 2010 1.2 Minor change update 8
  9. 9. Executive Summary This document identifies the aims and objectives, content, experiences, outcomes and processes of postgraduate specialist training leading to a Certificate of Completion of Training [CCT] in anaesthetics. It defines the structure and expected methods of learning, teaching, feedback and supervision. It sets out what knowledge, skills, attitudes and behaviours the trainee will have to achieve. These are identified as learning outcomes that are specific enough to be a precise guide for trainers and trainees. A system of assessments is used to monitor trainee progress through the stages of training. Method of development This curriculum was developed from the previous anaesthetic curriculum [CCT in Anaesthetics, Edition 1: dated April 2009] by a process of expert consultation. Principal amongst those consulted were: the associations and groups devoted to the practice of specialised anaesthesia; College Tutors and Regional Advisers [RA] of the RCoA; anaesthetic and critical care clinical directors; other management representatives; anaesthetic trainees; representatives of patients. The General Medical Council [GMC] guidance on Good Medical Practice [GMP] was used in the development of curriculum items and assessments at all stages of the programme. Delivery Anaesthesia is a craft specialty and, as a result, much of the education and training is acquired through experiential learning and reflective practice with trainers [including consultants, SAS doctors and more experienced trainees] and with their clinical and educational supervisors in the clinical areas of work. In addition, aspects of the curriculum are formally taught in the workplace using a variety of different formats including lectures, tutorials and seminars by consultants, SAS and trainees in anaesthetics, critical care and pain medicine, by e-learning and personal study. The instructional arrangements are coordinated within twenty-nine Schools of Anaesthesia, with the learning in each specialist area overseen by consultants with special experience in that subject. Aim This programme leads to the award of a CCT in anaesthetics that entitles admission to the Specialist Register. Its aim is to produce well-trained, high quality clinicians, with the broad range of clinical leadership and management skills and professional attitudes necessary to meet the diverse needs of the modern National Health Service [NHS] and who can embark upon safe, independent practice as consultant anaesthetists in the United Kingdom [UK]. Organisation of the curriculum The objectives of training are grouped into four stages of learning. Within these, they are organised by surgical sub-specialty or anaesthetic focus. In addition there are a group of general outcomes that are not specific to any particular clinical training. These are listed separately as ‘Professionalism and Common Competencies in medical practice’. The objectives are divided into two categories representing knowledge and skill. Values and behaviours relating to practice are separately listed but the knowledge and behaviours 9
  10. 10. that spring from these personal and professional qualities of work are specifically identified in the assessment system. Duration of training Indicative duration: To obtain a CCT in anaesthetics a trainee has to follow a competency based Specialty Training [ST] programme covering four stages of learning in anaesthesia, intensive care medicine and pain medicine. These are: • Basic level, which will normally last two years [CT years 1 and 2] • Intermediate level, which will normally last two years [ST years 3 and 4] • Higher and advanced levels, which will normally last three years [ST years 5 to 7] At current levels of clinical experience, which are restricted to 48 hours per week, it is unlikely that the necessary outcomes can be achieved at an adequate level of performance in less time than the seven years identified. Underlying principles The principles of the UK CCT training programme in anaesthetics leading to a CCT are that it: • Is outcome based • Is planned and managed • Does not jeopardize safe practice • Is delivered by appropriately trained and appointed trainers • Allows time for study • Includes core professional aspects of medical practice that are essential in the training of all doctors • Meets the service needs of the NHS • Is prepared with input from the representatives of patients • Accommodates the specific career needs of the individual trainee • Is evaluated • Is subject to review and revision Assessment The Royal College of Anaesthetists [RCoA] has developed an integrated set of workplace-based assessments [WPBA], which are to be used throughout the entire postgraduate training programme. They are blueprinted against, and support, the curriculum and every learning outcome that is identified in the curriculum is matched to at least one possible assessment. WPBAs must only be undertaken by those who are appropriately trained; if they are performed by others than consultants in anaesthesia, intensive care and pain medicine, a consultant must take ultimate responsibility for the assessment outcome. The assessment system is available for download from the RCoA website. It is also available in paper format from the College, for which a charge is made on application. Assessments take place by means of the formal RCoA Fellowship examinations, by WPBAs in the course of day-to-day clinical practice and, where appropriate, using simulation. These assessments are used to 10
  11. 11. evaluate trainee progress and to provide evidence to the Annual Review of Competence Progression [ARCP] panels. The Fellowship of the Royal College of Anaesthetists [FRCA] examination is a two-part “high-stakes” national assessment. Its major focus is on the knowledge required for practice but the oral and objectively structured clinical examination [OSCE] elements of the examination allow testing of decision-making, understanding of procedure and practical elements [including the use of simulation for assessment]. Possession of the Primary FRCA [or a GMC approved equivalent] is a mandatory requirement for entry into the ST year 3, as is the Final FRCA [or a GMC approved equivalent examination] for entry into ST year 5. The WPBAs sample the syllabus for each unit of training and are used as evidence of progression. The assessments should relate specifically to the trainees current unit[s] of training. Successful completion of the assessments themselves do not guarantee progression but are taken into consideration when determining whether trainees have achieved the minimum clinical learning outcome[s] defined for that unit of training. The tools used are: • Anaesthetic Clinical Evaluation Exercise [A-CEX] • Anaesthetic List/Clinic/Ward Management Assessment Tool [ALMAT*] • Acute Care Assessment Tool for ICM [ICM-ACAT] • Direct Observation of Procedural Skills [DOPS] • Case Based Discussion [CBD] • Multi-Source Feedback [MSF] • Clinical Supervisors end of unit Assessment Form [CSAF] [*Note, this assessment should use the A-CEX form, which allows for a single case, or a list etc, to be assessed.] The A-CEX, DOPS and CBD are directed principally towards recording proficiency in the individual competencies required for clinical practice. The ALMAT/ICM-ACAT and the CSAF look formally at the way these abilities are put together to undertake safe and effective day-to-day clinical practice. The MSF and the CSAF are particularly useful in terms of gathering information about the trainee’s professional demeanour, communication skills and ability to cooperate within a team; all consultant and SAS trainers are expected to feedback comments to inform the CSAF outcome for the individual units of training. Performance in the A-CEX, ALMAT, ICM-ACAT, DOPS and CBD is rated satisfactory or unsatisfactory on each occasion and it is not expected that all will be ‘passed’. Trainees will need to have undertaken sufficient assessments and have shown sufficient progress to show their Educational Supervisor, and therefore the ARCP panel, that they are suitable for the next stage of training. MSF and CSAFs are not graded. These assessments will be evidence to the Educational Supervisor and ARCP panel that the trainee’s performance meets the requirements of professionalism and good medical practice. They are measures of the trainee’s behaviour. It must be remembered that some trainees may be so deficient in these areas that their overall practice will be unacceptable despite excellent performance in tests of knowledge and skill. 11
  12. 12. Achieving the CCT As previously stated in ‘duration of training’, the training programme is divided into four distinct phases. Each requires the trainee to achieve set milestones and pass the essential units of training [the core competencies required for a CCT] in order to progress from one training year to the next. These milestones are: • Initial assessment of competence [First 6 months]; • Initial assessment of competence in obstetric anaesthesia [within first 2 years]; • Primary FRCA examination [in years 1 and 2]; • Basic level training certificate [end of year 2]; • Final FRCA examination [in years 3 and 4]; • Intermediate level training certificate [end of year 4]; • Complete Higher and advanced essential units of training; and • Advanced special interest units of training relevant to ultimate area of practice. To successfully pass the basic level, trainees must achieve all the competencies in the basis of anaesthetic practice units of training [see section 10.1.1] and all the competences in the basic anaesthesia units of training [see section 10.1.2]. The basic level training certificate is awarded on successful completion of the initial assessments of competence, the Primary FRCA examination [or an approved equivalent] and all the basic level units of training [see section 10.3]. This allows the trainee to competitively apply for an ST year 3 post through national competition. Once appointed to ST year 3, the trainee must pass all the essential units of training for the intermediate level [see section 11.1]. The trainee must also successfully pass the Final FRCA examination [or an approved equivalent]. Once completing the essential units of training and passing the Final FRCA examination, the trainee is issued with the intermediate level training certificate which allows the trainee to progress to ST year 5 [see section 11.4]. There are optional units available at the intermediate level if there is available time in the trainees training programme. To progress from ST year 5 to the award of a CCT, the trainee must successfully complete the essential units of training [see section 12.1]. There are optional units of training available and can count towards the required essential general duties units of training [see section 12.1]. The advanced level of training requires trainees to finish their last year of training preparing for consultant practice in a District General Hospital or a tertiary centre [eg, a cardiothoracic centre]. The trainee must complete at least one advanced unit of training over 1 year or 2 units of training over 6 months per unit of training [see section 12.1 and 12.2]. This programme produces anaesthetists who are able to provide the services required by the NHS outlined in section 1.2. 12
  13. 13. 1. Introduction 1.1 Aim This document identifies the aims and objectives, content, experiences, outcomes and processes of postgraduate specialist training leading to a CCT in Anaesthetics. It defines the structure and expected methods of learning, teaching, feedback and supervision. It sets out what knowledge, skills, attitudes and behaviours the trainee will achieve. These are identified as learning outcomes that are specific enough to be a precise guide for trainers and trainees. A system of assessments is used to monitor the trainee’s progress through the stages of training. 1.2 The scope of anaesthetic practice Anaesthetists form the largest single hospital medical specialty and their skills are used in all aspects of patient care. Whilst the perioperative anaesthetic care of the surgical patient is the core of specialty work [and this includes all types of surgery from simple body surface surgery in adults to the most complex surgery in patients of all ages, including the pre-mature newborn] many anaesthetists have a much wider scope of practice which may include: • The preoperative preparation of surgical patients • The resuscitation and stabilization of patients in the Emergency Department • Pain relief in labour and obstetric anaesthesia • Intensive care medicine • Transport of acutely ill and injured patients • Pre-hospital emergency care • Pain medicine including: o The relief of post-operative pain o Acute pain medicine and the management of acute teams o Chronic and cancer pain management • The provision of sedation and anaesthesia for patients undergoing various procedures outside the operating theatre. Examples of this include different endoscopic procedures, interventional radiology and dental surgery [this list is not exclusive] Anaesthetists are also widely involved in teaching and training undergraduates, postgraduates, nurses and paramedics. In addition they are involved in the leadership and/or management of hospitals and the various departments in which they play a major role such as: • Intensive and acute care services • Pain management services • Emergency services • Day surgery • Operating theatres and recovery units 13
  14. 14. The CCT programme is thus designed to meet the diverse service needs of the NHS. By way of illustration, there were 501 consultant anaesthetist posts advertised in the BMJ in 2008 and the table below identifies the breadth of post advertised [information from Dr Paul Spargo]: Table 1 Consultant post vacancies 2008 Area of interest in consultant anaesthetist posts advertised Number [%] General duties posts General anaesthesia 156 (31) General anaesthesia + an interest in: Intensive Care Medicine Chronic Pain Orthopaedics [including trauma] Miscellaneous [includes paediatrics, obstetrics and other special interest areas] 81 [16] 32 [6] 17 [3] 83 [17] Posts with principle commitment to a special interest Obstetric anaesthesia 42 [8] Cardiac / Cardio-thoracic / Cardiac ICM 25 [5] Paediatric anaesthesia [tertiary unit] 24 [5] Neuroanaesthesia [+/- Neuro-critical care] 20 [4] Paediatric Intensive Care Medicine 13 [3] Intensive Care Medicine 8 [2] During the course of anaesthetic training, trainees will develop particular interests within the specialty and in ST years 5-7 these will be reflected in their choice of optional units of training at the higher and advanced level. At the end of training most anaesthetists will have gained experience and expertise in some special interest areas of practice, along with the general training that is common to all. The design of this curriculum reflects and facilitates this diversity. 1.3 Curriculum design and development This curriculum represents a complete revision and rewrite of the previous curriculum documents [Edition 2 January 2007] taking into account guidance from the following two authorities: a. The General Medical Council [GMC] has developed and published a schedule of seventeen specific standards with which a postgraduate medical curriculum must comply. The RCoA fully accepts these as representing good practice in curriculum and assessment development and has been able to abide by them. b. The NHS Litigation Authority [NHSLA] is a Special Health Authority responsible for handling negligence claims made against NHS bodies in England1 . The NHSLA has published standards expected of Trusts. For training these emphasise the need for appropriate supervision and assessment, and the documentation of competencies. To assist employers, the curriculum defines the competencies that have to be achieved and completed satisfactorily at each stage of training. Importantly, this Edition includes reference to minimum clinical learning outcomes that all trainees must achieve before progression to the next stage of training. 1 The Welsh Risk Pool and the Scottish Clinical Negligence and Other Risks (Non-Clinical) Indemnity Scheme (CNORIS) fulfil similar roles to the NHSLA. In Northern Ireland each Trust has its own risk assessment and negligence scheme. 14
  15. 15. The curriculum revision process began with development of a task list of capabilities expected at the end of each of the four stages of training i.e: • Introductory and basic level • Intermediate level • Higher level • Advanced level These were then expanded to include a series of discrete units of training many of which follow through all four levels listed above [as in the previous edition of the curriculum]. Broad general learning outcomes, were then set at a level of detail that describes useful, complete, elements for each unit of training. These are then followed by core learning outcomes; these must be attained before a trainee can progress further in training. Attainment, or not, of these outcomes can be observed and rated by means of the assessment systems described in Section 8. 1.3.1 The development process The content of the anaesthetic competency curriculum was established in a protracted developmental programme within one school of anaesthesia in the early 1990s. The process involved about sixty anaesthetists who met in two workshops and from this developed a task list that identified all the training items required in the anaesthetic specialist training programme; this curriculum was subsequently adapted and updated. This latest curriculum has been developed from these previous anaesthetic curricula2 by a process of expert consultation, led by a working party that reported to the RCoA Training Committee and Council. Principal amongst those consulted were: the associations and groups devoted to the practice of specialised anaesthesia; College Tutors and RAs of the RCoA; anaesthetic and critical care clinical directors; and other management representatives; anaesthetic trainees; representatives of patients. [Full membership as listed in Appendix 1] The GMC guidance on GMP was used in the development of the curriculum items and assessments at all stages of the programme. The task lists, outcomes and assessments have been developed by anaesthetists with experience and specialist knowledge in all areas of anaesthetic, intensive care and pain medicine practice. All review groups included trainees and patient representatives. In addition to the specialty specific competencies there is a section of generic professional and ‘common competencies’, which have been developed using GMP and from competencies from the Academy of Medical Royal Colleges [AMRoC] namely those on Medical Leadership3 and Common Competences4 frameworks. There have been three iterations of information between the editors and the specialist groups providing advice. The complete document has been reviewed and re-edited following feedback from the national Schools of Anaesthesia who in turn sought the comments of their representatives from the Postgraduate Deans. The Lead Dean for Anaesthesia is a member of the Training Committee to which each stage of the development has been presented. 1.3.2 Acknowledgements The Royal College of Anaesthetists acknowledges the wide support that it has received from groups and individuals in the development of this programme of Competency Based Training. In particular: 2 The CCT in Anaesthetics, Edition 1, Royal College of Anaesthetists, August 2007 3 Academy of Medical Royal Colleges. Medical Leadership Curriculum. 2009 4 Academy of Medical Royal Colleges. Common Competences Framework for Doctors. August 2009 15
  16. 16. The previous editors of the CCT in Anaesthetics and those who edited the Northern Schools of Anaesthesia Training Manual in 1996 The Intercollegiate Board for Training in Intensive Care Medicine [IBTICM] The Faculty of Pain Medicine of the Royal College of Anaesthetists [FPMRCoA] The RCoA Advisory Boards for Northern Ireland, Scotland and Wales The Patient Liaison Group of the Royal College of Anaesthetists The Trainee Advisory Group of the Royal College of Anaesthetists The Group of Anaesthetists in Training, Association of Anaesthetists of Great Britain and Ireland [AAGBI] The Lead Dean for Anaesthesia The following Specialist Societies, Associations and organisations: Age Anaesthesia Association Anaesthetic Research Society Anaesthetists in Management Association of Burns and Reconstructive Anaesthetists Association for Low Flow Anaesthesia Association of Anaesthetists of Great Britain and Ireland [AAGBI] Association of Cardiothoracic Anaesthetists Association of Dental Anaesthetists Association of Paediatric Anaesthetists of Great Britain and Ireland British Association of Day Surgery British Association of Immediate Care British Malignant Hyperthermia Association British Medical Acupuncture Society British Ophthalmic Anaesthesia Society British Society of Orthopaedic Anaesthesia Difficult Airway Society Emergency Medical Retrieval Service European Society for Regional Anaesthesia Group of Anaesthetists in Training Intensive Care Society Neuroanaesthesia Society of Great Britain and Ireland National Institute for Academic Anaesthesia Obstetric Anaesthetists’ Association Paediatric Intensive Care Society Plastic Surgery and Burns Anaesthetists Resuscitation Council Society for Education in Anaesthesia UK Society for Computing and Technology in Anaesthesia Society for Intravenous Anaesthesia Vascular Anaesthesia Society 1.3.3 RCoA Training Committee The RCoA Training Committee is responsible for submitting the curriculum to the GMC. It consists of members of College Council, the Bernard Johnson Advisers for less than full-time trainees and overseas trainees, the Lead Dean for anaesthesia, and representatives from England, Northern Ireland, Scotland and Wales, the Regional Advisers, College Tutors, the RCoA Patient Liaison Group, the RCoA Trainee 16
  17. 17. Advisory Group, the IBTICM, the Faculty of Pain Medicine and the AAGBI. The Committee is always pleased to receive comments on this training programme from both trainers and trainees. These should be addressed to the Medical Secretary of the RCoA Training Committee at medsec@rcoa.ac.uk 1.3.4 Ongoing curriculum review The curriculum is reviewed regularly with an implementation date for any changes being not less than six months after their publication date. Minor changes are inserted in the on-line manuals immediately and are collectively submitted to GMC for approval once a year. Major changes, such as a new unit of training, are submitted to GMC for approval as and when necessary and are inserted into the curriculum when approval has been granted. Summaries of changes are listed on the training pages of the College website as they occur. Occasionally the Training Committee has to take decisions that may affect the immediate interpretation or application of specific items in this manual. These will be published in Guidance for Trainers and, if necessary, earlier by a ‘Training Programme Update’ circular to all RAs and Deputy Regional Advisers [DRAs], College Tutors, Training Programme Directors [TPDs], as well as being published on the College website. 1.4 Structure of the curriculum manual The structure of the anaesthetics training programme is set out in this manual and includes the programme rules, learning outcomes [including minimum learning outcomes for progression where appropriate], level of knowledge, skills, and required attitudes and behaviours for each unit of training. The learning outcomes for knowledge and practical skills that relate to the technical performance of anaesthesia are defined for each unit of training. The related assessments are at the end of each section of training. The learning outcomes that relate to the general skills of medical practice as related to anaesthesia, critical care and pain medicine are placed in a separate section called ‘Professionalism and common competencies of medical practice’ [Annex A]. These should be followed throughout practice, both during training and post-CCT: they do not relate to particular stages of training. As a result the College considers that it is not appropriate to write specific competencies for these in the different stages of training, instead they are all embedded within the clinical units of training. The Section below [1.4.1 Values and behaviours of practice] provides further detail. In addition, there is a further section [Annex G] that identifies additional skills required for teaching, research methodology and management. The commitment to all aspects of professionalism should be demonstrated throughout training. As trainees reach their final years in training, particularly at the advanced level, the College expects trainees to demonstrate aspects of medical leadership and management, teaching and training that will benefit both patients and the organisations for which they work. Specific generic descriptors include: • Show the decision making and organizational skills required of an anaesthetist to manage busy operating sessions that involve patients having complex surgery and ensuring that the care delivered is safe and timely, benefiting both the patient and the organisation • Gain maturity in understanding the importance of utilising the time allocated to clinical sessions effectively, whilst not compromising safety 17
  18. 18. • To assist colleagues in decisions about the suitability of surgery in difficult situations • Provide teaching to less experienced colleagues of all grades • Gain the necessary maturity to guide the choice of audit cycles in developing practice 1.4.1 Values and behaviours of practice There is always a difficulty dealing with the affective competencies for learning. Conventionally they are listed along with the cognitive and psychomotor competencies. They cannot however be conveniently and usefully dealt with in this way. In the first place they do not relate to a particular stage of training or placement; “shows respect for the opinions of others” is a general quality of practice that must be developed throughout practice and followed at all times. A curriculum in terms of competencies or learning outcomes has the property that each statement describes how the learner will behave when that learning step has been taken. Behaviour will demonstrate new qualities that can be traced back to the learning. The affective competencies cannot be directly observed in this way; they are exhibited by means of actions. In this manual the affective competencies are listed in a separate section as ‘professional attitudes and behaviours’. The taxonomy used for these is the CANMEDS classification that was developed by the Royal College of Physicians and Surgeons of Canada [See Appendix 4]. Additional information has been incorporated from the GMC guidance ‘Good Medical Practice’ and from Anaesthetic Non-Technical Skills [ANTS] [See Appendix 7]. All the assessment methods described in this document have responses that map to all these qualities of practice [See Section 8]. In summary, the values and behaviours of practice may be evident as skills or knowledge, and may be assessed directly using the assessment system. Many, however, do not manifest themselves except in the performance of another competence; the mark-sheets have been developed to allow identification of these traits. For ease of use, there are six annexes [B-G], which contain all the units of training for each level, guidance for the examinations and, within the Basic Level section, the initial assessment of competence [IAC] and the initial assessment of competence in obstetric anaesthesia [IACOA]. 18
  19. 19. 2. Principles of the training programme 2.1 Underlying principles The principles of the UK CCT in Anaesthetics training programme are that it: • Is outcome based (the essential units of training are the core competencies required of all trainees) • Is planned and managed • Does not jeopardize safe practice • Is delivered by appropriately trained and appointed trainers • Allows time for study • Includes core professional aspects of medical practice, that are essential in the training of all doctors • Meets the service needs of the NHS • Is prepared with input from the representatives of patients • Accommodates the specific career needs of the individual trainee • Is evaluated • Is subject to review and revision 2.2 Training concepts 2.2.1 “Spiral” learning The training programme is based on this concept which ensures that the basic principles learnt and understood are repeated, expanded and further elucidated as time in training progresses; this also applies to the acquisition of skills, attitudes and behaviours. To facilitate this, the programme is divided into basic, intermediate, higher and advanced levels, each consisting of a core of essential units of training (these units form the core competencies for anaesthetists on achieving the CCT) to which the trainees return at each level, as well as specialist areas of practice which are introduced from the Intermediate Level onwards. The outcome is such that mastery of the specialty to the level required to commence independent practice in a specific post is achieved by the end of training as knowledge, skills, attitudes and behaviours metaphorically spiral upwards. 2.2.2 Broad-based flexible training The CCT programme is constructed so that all anaesthetists have the same core skills. In the latter years of training flexibility is introduced so that individual career aspirations can be met by providing dedicated periods of advanced level special interest training. This also allows the needs of the NHS to be met with a short lead-in time; for example, if there is a sudden reduction in requirement for cardiac anaesthetists and an increases need for specialists in pain medicine, the lead time to effect this would be only two years [See Table 1, page 13, for further information on the current needs of the NHS]. Because all anaesthetists have a common broad-based training up to higher and advanced special interest level this allows someone to be redirected with a minimum of retraining to meet changing workforce needs. 19
  20. 20. 2.2.3 Experiential Learning [See Appendix 5 – RCoA Clinical Assessment Strategy] Much of the learning is service-based and, for its effectiveness, depends upon its context within clinical practice. Research has shown that performance improves with practice and that up to 200 iterations of a procedure may be required for the learner to approach the standard of performance demonstrated by a truly expert practitioner. Analysis of learning curves reveals that 70 to 80% of this performance is achieved after 30 iterations. There are many reasons why trainees may not be able to achieve 30 performances of a technique and there is no expectation that all elements of the curriculum will be learned to that level of skill. It is important to understand that many repeats of techniques are required for mastery and that the RCoA WPBA system does not require performance to this level, except those related to the advanced level units of training chosen by the individual trainee. The need for repetitions in training is an important determinant of the duration of training. The authors of this curriculum believe that current levels of experience of about 2500 to 3000 cases overall during training are such that mastery can only be achieved in a limited range of the listed outcomes beyond intermediate level training. The suggested length of placements in the training programme are such that there is reasonable opportunity for trainees to become expert in the key competencies in their chosen special interest areas of practice on which the safety of practice depends at CCT. 2.2.4 Common competencies of medical practice required by all doctors The trainee must also develop general professional knowledge, skills, attitudes and behaviours required of all doctors. It is the view of the College that they should be developed and followed throughout practice, both during training and post-CCT. Thus, the professional attitudes, behaviours and common competencies listed are those expected of all doctors throughout their professional practice and, as a result, there are no changes to the competencies over the years of training; inevitably some of the descriptors are more specific to the specialty of anaesthesia, critical care and pain medicine. Whilst this section identifies the specific professionalism and common competencies expected throughout training, they are also embedded in the clinical units of training at all levels, principally as demonstrated within skills though, where more appropriate, they have been listed within the knowledge sections; as such, they will be expected to be included within the assessments of clinical training. Twelve domains have been identified covering professionalism and common competencies. These are as follows:  Domain 1: Professional attitudes and behaviours  Domain 2: Clinical Practice  Domain 3: Team working  Domain 4: Leadership  Domain 5: Innovation  Domain 6: Management  Domain 7: Education  Domain 8: Safety in Clinical Practice  Domain 9: Medical ethics and confidentiality  Domain 10: Relationships with patients  Domain 11: Legal framework for practice  Domain 12: Information Technology 20
  21. 21. 2.2.5 Teaching and Training; Academic and Research; Management These are considered essential elements of the training programme. Trainees require a clear understanding of the principles of adult learning and how they can use these to be effect in their years of training, not only for their own learning but also in the teaching of others. Academic enquiry is also considered important in the practice of anaesthesia, critical care and pain medicine and the competencies identified must be embedded into the CCT programme of all trainees. Finally, a clear understanding of healthcare management is essential for all doctors who aspire to work in the NHS; again there are clear competencies that develop over the indicative seven year training programme. Further, there is the opportunity to undertake advanced training in one of these disciplines for trainees with a specific interest; the competencies and learning outcomes have been clearly identified and are included within this section [Annex G] though they must not detract from the acquisition of essential advanced clinical skills. More guidance is given on this in section 11.2.8 2.3 Training environments The training of anaesthetists will occur in UK posts and programmes approved by the GMC, or in other posts and programmes for which prospective approval has been given. Departments in which training occurs must comply with the regulations and recommendations of the relevant national Departments of Health, GMC, the RCoA, FPMRCoA and the IBTICM. From time to time, the RCoA, FPMRCoA, IBTICM and AAGBI issue guidance on standards of practice, which must be adhered to by departments in which training occurs.5 2.4 Trainers Doctors responsible for training have to comply with the GMC generic standards for training6 . The RCoA’s Criteria for the Appointment of Trainers are at Appendix 3. 2.5 Minimum number of recommended training sessions On average a minimum of three supervised sessions per week [spread over a three to six month cycle] is required to ensure the adequate delivery of workplace based learning necessary to allow the majority of trainees to progress through to a CCT within the seven year indicative length of the programme; this figure is based on many years of experience of assessing training programmes. To ensure patient safety, trainees new to the specialty must, at all times, be directly supervised until they have passed the Initial Assessment of Competence [IAC] [see more detail about this in Section 6] and then appropriate level of supervision for the trainees level and competence; this is also the case for those new to specialist areas of practice; these concentrated periods of supervision will be essential to ensure that most trainees are able to complete all the minimum learning outcomes in, what is, a very full programme of training. It is accepted that there may be variation from week to week depending on local work patterns and structure of individual school programmes of training. 5 Good Practice, The Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland, Third Edition 2006: Guidelines for the Provision of Anaesthetic Services, Royal College of Anaesthetists, 2009. 6 Generic standards for training. General Medical Council. April 2010 21
  22. 22. It is important to ensure that the attached sessions have relevance to the unit[s] of training [and Level] that individual trainees are undertaking at the time; the concept of a ‘balanced programme of training’ is essential. It is therefore acceptable, for example, to count two accompanied sessions in ITU, coinciding with a day of on call for ITU, if the trainee is on a dedicated ICM block; it is not appropriate if they are providing essentially service cover for ICM for the day, whilst undertaking an anaesthetic unit of training as the accompanied teaching sessions should be in this area of practice. 2.6 Out of hours commitments Out of hours work for trainees largely involves providing services for emergencies and, compared with elective work, makes different demands on the anaesthetist. There are several reasons for trainees to undertake out of hours work. It provides: • An opportunity to experience and develop clinical decision making, with the inevitable reduction in out-of-hours facilities, under distant supervision • An opportunity to learn when to seek advice and appreciating that, when learning new aspects of emergency work as trainees, they require close clinical supervision • A reflection of professional anaesthetic practice, as in most hospitals patients are admitted 24 hours a day, seven days a week, so requiring dedicated out-of-hours emergency facilities; there is thus a service commitment Occasionally, there may be a unit of training, where out of hours work is not required; this will be the exception. For units of training where out of hours work is required [the majority], trainees should not work more onerously than 1:8 to ensure that they can meet the many training outcomes that are gained during normal working hours, in addition to those gained out of hours. The College does recognise that there are occasions when additional out of hours work is required due to local circumstances; when this occurs, it should be for short periods only otherwise there will be an adverse impact on the trainees progression through the programme making it is almost certain that training time will have to be extended to ensure the learning outcomes are met. Local trainers, in conjunction with their Clinical Directors [CD], must recognise this consequence if excessive out of hours commitments [i.e. more onerous than 1 in 8 for more than the occasional week] are placed above training requirements. Finally, it is important to ensure that any new aspects of emergency work are undertaken initially with close clinical supervision. For trainees unable to undertake out of hours work due to illness or other debilitating circumstances, the College Tutor, RA, TPD and Medical Secretary will determine whether it is possible to obtain all the essential learning outcomes and, if so, if extra training time is required. This may involve extending the period of training for a specific unit[s] and/or the whole programme. Trainees are advised to discuss the potential consequences of an inability to perform out of hours work as soon as practicable, as it may have a major impact on the training programme leading to the award of a CCT, including failure to complete a CCT programme. 2.7 Less than full-time [LTFT] trainees After appointment in open competition any trainee, with Deanery agreed eligibility, can request to train less than full time. The training programme will be delivered on a pro rata basis for those who are eligible and have Deanery support. Each region has a LTFT training adviser who works with the RA and the local Deanery to ensure that the needs of those trainees are met. General advice on LTFT training is contained in 22
  23. 23. the “Gold Guide”7 . In addition, one of the College Bernard Johnson Advisers provides strategic advice to the RCoA on the needs of part time trainees; he/she is also a member of the RCoA Training Committee and can be contacted via training@rcoa.ac.uk. Finally, the European Medical Directive states that: “Member States may authorise part-time training under conditions laid down by the competent authorities; those authorities shall ensure that the overall duration, level and quality of training is not lower than that of continuous full-time training.”8 This is interpreted to mean that LTFT trainees should, pro rata, undertake the same out-of-hours work as full-time trainees, including weekend on-call duties. 2.8 Supervision As it may be as little as five minutes between a problem developing and the patient suffering serious permanent injury in anaesthesia, it is necessary for consultants and trainees to work more closely together in clinical practice than is the case in most other specialties. The expectation is that anaesthesia will, only exceptionally rarely, add to the serious morbidity and mortality attendant upon the interventions for which the anaesthesia is being provided. With some estimates of death due solely to anaesthetic mishap being less than one in a million in UK practice, it is clear that the activities of learners present a major threat to the levels of safety. Anaesthetists are very ‘risk averse’ and strict supervision of learners is embedded in their practice, and in their teaching. 2.8.1 Clinical supervision Every trainee must, at all times, be responsible to a nominated consultant, be that undertaking routine lists without direct consultant supervision, or emergency on call duties. The consultant must be available to advise and assist the trainee as appropriate. Sometimes this will require the consultant’s immediate presence but on many occasions less direct involvement will be needed. Supervision is a professional function of consultants and they must be able to decide what is appropriate for each circumstance in consultation with the trainee. The safety of an individual hospital’s supervision arrangements is the concern of the local department in conjunction with the hospital management; it is necessary for them to agree local standards and protocols that take account of their particular circumstances. [Section 6 details the definitions of the different levels of supervision that local departments must consider; they have been developed from a consideration of the professional responsibilities of medical practitioners to patient safety.] 2.8.2 Educational supervision Every trainee must have a nominated educational supervisor to oversee their individual learning. The College recommends that an educational supervisor is responsible for a maximum of four trainees. [See also 2.11]. 7 A Reference Guide for Postgraduate Specialty Training in the UK. Modernising Medical Careers. Fourth edition June 2010.[Gold Guide][sections 6.47-6.57] 8 Article 22(a) of Directive 2005/36/EC of the European Parliament and of the Council of 7 September 2005 on the recognition of professional qualifications 23
  24. 24. 2.9 Schools of Anaesthesia Schools of Anaesthesia are responsible, on behalf of the Deanery, for the delivery of a GMC approved programme of postgraduate education in anaesthesia, intensive care and pain medicine. There may be separate Schools for the ACCS training, although many such programmes fall within the remit of Schools of Anaesthesia. The School should provide educational leadership and governance, ensuring appropriate structures are in place to deliver training to the standards required by the GMC. All hospitals in the UK that provide training belong to a School. Schools are normally within Deanery boundaries, but a small number involve more than one Deanery. In some cases, there is more than one School per Deanery. It is important to note that the current twenty-nine Schools of Anaesthesia are not a homogenous group. Training nationally is based upon the CCT in Anaesthetics curriculum as provided by the RCoA, but there is flexibility to allow local organisation of training. This flexibility means Schools may have different structures extending from the personnel involved to the amount and type of paperwork used by the Schools. There are several different leadership/management roles in a School of Anaesthesia, the majority of which are carried out by consultant anaesthetists. A particular School may or may not have all of these areas of specific responsibility; • Head of School [HoS]: appointed by the Deanery with RCoA input • Regional Adviser [RA]: appointed by the College with Deanery input [note some RAs are also HoS] • RAs may also be appointed for ICM [RAICM] and Pain Medicine [RAPM] by the College with Deanery input • DRAs may be appointed in large schools appointed by the College with Deanery input • Training Programme Director [TPD]: Deanery appointment o TPDs may also be appointed for ICM and ACCS o Deputy TPDs may be responsible for a specific part of the anaesthetic training programme e.g. core trainees • College Tutors: within each Trust; joint appointment by College, Trust and Deanery • Board Tutors for ICM • Local Pain Medicine Educational Supervisors There are variable secretarial and administrative staffing structures between Deaneries, as there is in the management structure of Schools. More information about individual Schools can be obtained from their local Deanery. In addition, many Schools of Anaesthesia now have dedicated websites. 2.10 Speciality Advisory Committees The majority of Deaneries have Speciality Advisory Committees [sometimes known as Training Committees]. These are usually chaired by the RA and should include the College Tutor[s] from each hospital, as well as a LTFT training adviser, the TPDs, HoS and trainee representative. Duties include overseeing the training programme, ensuring standards of training are maintained and resolving any local training issues. 24
  25. 25. Schools usually have between five and ten hospitals, including a tertiary specialist centre, providing training. Occasionally a Deanery may divide training by geography [e.g. North and South Schools], which facilitates administration and reduces travelling for trainees. Together, hospitals within a School can normally provide all the essential units of training required to achieve a CCT in Anaesthetics. District general hospitals can offer a wide range of experience and training, whilst the more specialist area of anaesthesia for cardiac, thoracic, neuro and paediatric surgery may take place in a tertiary referral centre. Occasionally secondments are required outside the School in order to obtain these specialist areas of training. Single speciality hospitals may complement the overall provision of training within a particular School. The TPD must organise rotations in such a way that all trainees are exposed to all the essential units of the training programme at an appropriate stage to allow the completion of competencies/minimum clinical learning outcomes and progression towards the CCT. Schools, until now, have had their own unique paperwork advising their trainees as to what is required to progress through the curriculum. The curriculum and its assessment are the responsibility of the RCoA; standard ‘paper’ forms for assessment have now been developed by the College to mirror those in development in the e-portfolio and are available on the website. The School is responsible on behalf of the Deanery for recruitment to the training programme, including shortlisting and interviewing; with the move towards national recruitment this is expected to change between 2010 and 2012 [details of changes will be placed on the website and all those involved with training will be notified individually]. Schools are also responsible for ensuring the ARCP occurs, and those with their own web sites may develop their own methods of communication with their trainees. Quality assurance is an increasingly important role for the School. Schools are involved in approving study leave and providing access to relevant educational courses for their own trainees. 2.11 Responsibility for training in the workplace Competency based training relies on WPBAs made during clinical service. The responsibility for the organisation, monitoring and efficacy of this training and assessment is shared by a variety of authorities: • The GMC is responsible for approving programmes of training and training capacity • The RCoA is responsible for: o Advising the GMC on the competencies/learning outcomes in training o Advising the Postgraduate Deans on the arrangements for organising and monitoring the in- service training provided by schools of anaesthesia and hospitals o Funding the Bernard Johnson Advisers who provide advice on equality and diversity issues within training programmes o Evaluating the training of individual trainees and recommending them to the GMC for the award of CCTs • The Postgraduate Dean is responsible: oTo the GMC for the quality management of the training programme oFor the overall training arrangements in each Trust. The Clinical Tutor/Director of Medical Education acts as the Dean’s officer within the trust and has overall responsibility for the educational environment oFor ensuring that the ARCP process is organised correctly 25
  26. 26. • Schools of Anaesthesia in conjunction with local Specialty Training Committee are responsible for: o The administrative organisation of trainee placements/rotations in the training programme o Monitoring the training programme o Providing Annual Reports to the Postgraduate Dean o The administrative organisation of ARCPs o Working with CDs to ensure satisfactory local arrangements are in place to ensure in-service training is delivered in accordance with the principles adopted by the DH [in regard to rota compliance], the GMC, the RCoA and the Postgraduate Dean • TPDs organise the rotations to ensure that all units of training are covered • RAs are responsible for representing the policies and views of the College in all relevant matters within their region • College Tutors are responsible, ultimately, for the overall training and assessment arrangements in their hospitals9 , working in conjunction with the individual educational supervisors. • Educational Supervisors are responsible for ensuring an individual trainee has an agreed educational plan, that this is delivered, that the appropriate assessments are carried out and that the trainee receives regular educational and workplace appraisals • Clinical Supervisors are trainers who are selected and appropriately trained to be responsible for overseeing a specified trainee’s clinical work and providing constructive feedback during a training placement; in anaesthetic training, Clinical Supervisors will normally be the lead for specific units of training. Some training schemes appoint an Educational Supervisor for each placement; if this is in a hospital that only delivers one unit of training, the roles of Clinical and Educational Supervisor may be merged10 . • Consultant/SAS trainers: All consultants/SAS anaesthetists who have any contact with trainees [which includes providing senior support and cover for out of hours duties] have a responsibility for providing appropriate training, supervision and assessment. They should comply with the Deanery requirements. 2.12 Accommodation for training and trainees Any hospital with trainees must have appropriate accommodation to support training and education; this may be in the Department of Anaesthesia or elsewhere in the hospital e.g. the Postgraduate Teaching Centre. This accommodation should include: • A focal point for the anaesthetic staff to meet so that effective service and training can be co- ordinated and optimal opportunities provided for gaining experience and teaching • Adequate accommodation for trainers and teachers in which to prepare their work • A private area where confidential activities such as assessment, appraisal, counselling and mentoring can occur • A secure storage facility for confidential training records • A reference library where trainees have ready access to bench books [or an electronic equivalent] and where they can access information, including electronic resources, at any time • Access for trainees to IT equipment such that they can carry out basic tasks on a computer, including the preparation of audio-visual presentations; access to the internet is recognised as an essential adjunct to learning 9 See also The Regional Advisers’ Handbook, 1998 and The College Tutor - Roles and Responsibilities, 2002 10 Quality framework operational guide. GMC April 2010. 26
  27. 27. • A suitably equipped teaching area and a private study area • An appropriate rest area whilst on shifts 2.13 Equipment and safety guidance Anaesthesia is high risk and special measures must be taken at all times to minimise the possibility of mishaps. The preoccupation of anaesthetists with safety dates from long before the recent development of a focus on safety in medical practice. During five decades of practice routines, protocols and equipment design that help ensure safe practice have been incorporated into the fabric of anaesthetic practice and are constantly emphasised to each new generation of anaesthetists. Specific competencies relating to patient safety are included in every section of the anaesthesia learning. There is therefore no specific section of learning devoted to safety. Specific factors encountered by trainees which affect safety include: • RCoA/AAGBI guidance: From time to time the College will issue guidance or instructions on the use of key protocols and equipment by trainees. These will be prompted by safety requirements, often arising from critical incidents, and will normally be promulgated immediately by e-mail or letter to all RAs and College Tutors, and then included in the next edition of Guidance for Trainers. In addition, the AAGBI produce regular guidelines on safety issues, which are also highly relevant to training environs and patient safety in general. • Monitoring standards: Trainees should not be required to deliver anaesthesia without using monitoring equipment which complies with the recommended minimum monitoring standard current at that time. the most recent standards are those defined in: o Recommendations for Standards of Monitoring during Anaesthesia and Recovery, 4th Edition 2007, Association of Anaesthetists of Great Britain and Ireland o Good Practice, a guide for departments of anaesthesia, critical care and pain management Third Edition 2006, Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland • Skilled Assistance: Trainees must have dedicated qualified assistance wherever anaesthesia is administered as defined in: The Anaesthesia Team, Revised Edition 2005, Association of Anaesthetists of Great Britain and Ireland. 2.13.1 Key protocols It is recommended that the protocols listed below should be displayed or be immediately available in all locations where anaesthesia is delivered. • Adult resuscitation guidelines [Resuscitation Council (UK)] • Anaesthetic machine checklist [AAGBI] • Failed intubation and ventilation drill [Protocols for this should be determined locally] • Management of anaphylaxis [AAGBI and/or Resuscitation Council (UK)] • Guidelines for the Management of Severe Local Anaesthetic Toxicity [AAGBI] • Management of malignant hyperthermia [AAGBI] • Management of peri-arrest arrhythmias [Resuscitation Council (UK)] 27
  28. 28. • Paediatric resuscitation guidelines [Resuscitation Council (UK)] 2.13.2 Simulating critical incidents and equipment failure It is a necessary part of trainees’ development that they should gain the confidence to handle critical incidents and equipment failure. Trainees should be made aware that in the event of a mishap it should not be presumed that the equipment is in the same state as when checked before the start of the list. In no circumstances, however, is it acceptable for an anaesthetist to interfere with an anaesthetic machine during a procedure with an anaesthetised patient for the sole purpose of testing the reactions of a trainee. Training for these eventualities is appropriate in simulated situations, without a patient being present, or in verbal discussion. 28
  29. 29. 3. Entry to and progression through training 3.1 Progression through the CCT programme 3.1.1 Indicative duration To obtain a CCT in anaesthetics a trainee has to follow a competency based programme of training covering basic, intermediate and higher/advanced special interest levels of training in anaesthesia, intensive care and pain medicine. Anaesthetic training has been uncoupled since 2008, such that trainees in their first two years [Basic Level training] are called Core Trainees [CT]. The indicative duration of CCT training is seven years, of which: • Basic level will normally last two years [CT years 1 and 2] • Intermediate level will normally last two years [ST years 3 and 4] • Higher and advanced level will normally last three years [ST years 5, 6 and 7] Progression through the training programme will be determined by the rate at which trainees achieve the necessary competencies/minimum learning outcomes; this will also determine the duration. Trainees should understand that progression is not just about competence achievement, but also the experience that underpins competence in clinical practice. 3.1.2 Minimum duration In current practice the indicative and minimum times for completing training are similar. Though this anaesthetic training programme is designed around a schedule of competencies, and is monitored by acquisition of these rather than be the time spent in training, it is unlikely that a trainee will be able to complete the programme to a satisfactory standard in less than the seven years. This is because research has demonstrated that about 30 repetitions of all major competencies are required in order to achieve outcomes that are 80% as good as those of a ‘proficient’ practitioner in the procedure. Trainees currently undertake some 2500 procedures in the course of seven years practice; a rough calculation shows that about 80 major procedures can be brought to the level of having experience of 30 iterations in seven years of training The implication is that completing the competence schedule with sufficient iterations of its major components to achieve 80% of expert performance within seven years is an achievable target [See Appendix 5]. It is unlikely that sufficient experience can be achieved in less than seven years and if the caseload of trainees falls it will be necessary to reconsider whether all the required outcomes can be met in the time available. 3.2 Entry to basic level training 3.2.1 Direct entry Direct entry to Basic Level Training [CT years 1 and 2] is by competitive selection under nationally agreed arrangements. 29
  30. 30. 3.2.2 ACCS entry • ACCS training is a three year programme of training in anaesthesia, acute medicine, emergency medicine and ICM. As such it is accepted by the GMC as an element of the relevant specialty curricula for the four specialty CCT programmes. • Entry to ACCS training will be by competitive application under nationally agreed arrangements. • The duration and content of each ACCS specialty module may vary between Deaneries. The three year anaesthetic ACCS training is made up of two years of the ‘generic’ ACCS training followed by one year of specialty specific training; for anaesthetic ACCS trainees, the specialty specific training will be in anaesthetics. • The minimum learning outcomes for the anaesthesia section of the ‘generic’ ACCS are derived from the first six months of training, principally those in the Basis of Anaesthetic Practice section. • For anaesthetics, the combined ACCS and one year specialty specific training learning outcomes will total the Basic Level anaesthetic competencies plus augmented learning outcomes derived from the acute and emergency medicine training. • Trainees must successfully complete all the core assessments in the ACCS and anaesthetics programmes to pass the ACCS element of training. • The trainee must achieve all the basic level requirements by the end of the three years of ACCS [anaesthetics] training to be eligible to apply for ST 3 in anaesthetics; all ACCS trainees who are appointed to a StR 3 post in anaesthetics will follow the anaesthetics higher speciality training defined in this curriculum leading to a CCT. • ACCS [anaesthetics] trainees should be encouraged to pass the FRCA Primary MCQ Examination of knowledge before completing the ACCS ‘generic’ training. 3.3 Entry to intermediate level training Entry to Intermediate Level training [ST years 3 and 4] is by competitive selection under nationally agreed arrangements. All trainees progressing to ST 3 are required to have the Basic Level Training Certificate [BLTC] before they can commence their intermediate level training. The BLTC confirms the trainee has: • Achieved the IAC and the initial assessment of competence in obstetric anaesthesia; • Successfully completed all the basic level units of training in anaesthetics and ICM by attaining all the core clinical leaning outcomes; • Passed the primary FRCA examination or GMC approved equivalent [or hold an exempting qualification] [see Examination regulations for a full list11 ]; and • Attained all the competencies identified in the Basic level Common Competencies as detailed in Annex B. The following are acceptable alternatives to the BLTC: 11 Primary and Final FRCA Examination Regulations. Royal College of Anaesthetists. August 2009 30
  31. 31. • Trainees from the Republic of Ireland: Trainees entering ST year 3 who completed their basic level training in the Republic of Ireland should possess a Certificate of Basic Training issued by the College of Anaesthetists of Ireland. • Specialty Doctors [SDs] and Staff and Associate Specialist [SAS] grades: SDs and SAS grades returning to training without a BLTC may be assessed individually by the local RA prior to applying for intermediate level training. If appropriate the RA will issue the Confirmation of Basic Level Equivalence Certificate in lieu of the BLTC; they will also need to be in possession of the Primary FRCA or exempting qualification 3.4 Progression to higher and advanced special interest level training Before progressing to Higher and Advanced Special Interest Level training [ST year 5 and beyond] trainees must have an Intermediate Level Training Certificate [ILTC] and supporting records of satisfactory WPBAs. The ILTC [indicating deferrals where relevant12 ] must be signed by the RCoA RA [or deputy] and College Tutor [or another designated consultant]. SDs and SAS grades returning to training who do not have an ILTC will be assessed individually by the local RA prior to applying for Higher Level training; if appropriate, the RA will issue in the Confirmation of Intermediate Level Competences Certificate in lieu of the ILTC; possession of the Final FRCA or equivalent is an essential requirement. 3.5 Progression through higher/advanced training to the recommendation of the award of a CCT/CESR[CP] The College wishes to allow trainees to achieve their career aspirations; however, it is recognised that training opportunities must be balanced against anticipated career vacancies. For this reason trainees should recognise the need to maintain flexibility in their choices; higher/advanced training permits this to a greater degree. If a specific training placement is over-subscribed, it will up to the TPD and local SAC to determine how this is best managed. Once all the agreed learning outcomes are completed satisfactorily for higher/advanced training and the RITA G/ARCP Outcome 6 has been received, the College will formally recommend to the GMC the award of a CCT or CESR[CP]. 3.6 Examinations and the award of a CCT The RCoA FRCA examinations are imbedded in the CCT programme and approved by the GMC. It is a legal requirement that for the award of a CCT, the GMC must approve the curriculum, programmes and the assessment system13 . Trainees who possess passes in non-GMC approved examinations in lieu of the approved examinations will not be eligible for a CCT but will be eligible for a CESR[CP]. [For additional information, see section 8.2] 3.6.1 Transitional arrangements for transfer from the 2007 Curriculum 12 Arrangements exist for individual Schools of Anaesthesia to defer specific intermediate level Units of Training to StR year 5. See Section 11.2.3 for more details. 13 Section 34I of the Medical Act 1983 31
  32. 32. Transitional arrangements have been agreed with the GMC for those trainees who were appointed to a CCT programme in Anaesthetics under the PMETB approved 2007 curriculum and transfer to the 2010 GMC approved curriculum. For trainees who have completed the Irish examination in lieu of the respective UK examination by the date of transfer to this curriculum, the examination will be recognised for the award of a CCT. For those trainees who have only partly completed a component part of the Irish examination, for example the MCQ of the Primary, there are two options: • Complete the Irish examination and proceed with the training programme for the award of a CESR[CP]; or • Complete the RCoA examination [within the rules for number of permitted attempts] Any trainee eligible for a CCT who after transferring to this curriculum, completes a non GMC approved examination will lose their eligibility for a CCT and will be eligible for a CESR[CP] instead. Those trainees who remain on the 2007 curriculum are not affected. 3.6.2 CCT versus CESR[CP] The CCT and the CESR[CP] are two recognised routes for specialist registration. To be a substantive consultant in the NHS, the legal requirement is that the individual is on the specialist register and does not stipulate that the individual must have a CCT14 . The CCT is awarded to those trainees who have completed a GMC approved CCT training programme in its entirety15 as opposed to the CESR[CP] which is awarded to a trainee who completed a component of their training outside of the approved programme. For example, the test of knowledge. Citizens of the European Union (citizens of member states) have acquired rights which are defined in the Treaties of the European Union which includes freedom of movement between member states and freedom to provide a service. To be able to exercise these rights as an anaesthetist in another member state, the CCT and CESR[CP] holders must satisfy the following criteria: • Must be a citizen of a European Union state; or • Has EU community rights (eg a spouse of an EU national); and • Primary medical degree from a recognised European Union medical school16 Additionally for both CCT and CESR holders: • If the individual is an EU national or has EU community rights, and has worked for 3 out of the last 5 years as a specialist in the UK then this can be recognised in Europe regardless of 14 Section 4(b) of SI1996/0701 The National Health Service (Appointment of Consultants) Regulations 1996 15 Section 34K of the Medical Act 1983 16 Article 24 of Directive 2005/36/EC of the European Parliament and of the Council of 7 September 2005 on the recognition of professional qualifications 32
  33. 33. where their primary medical qualification was obtained17 [A certificate is required from the GMC as proof – Article 3(3) compliancy certificate] For those who do not meet this criterion, the individual will be required to be assessed through the European State’s equivalence process. 3.7 Re-entering training after a break Applications from doctors who want to re-enter training after a break will be dealt with in accordance with the procedures and person specifications of the national recruitment programme. For those who have continued to practise anaesthesia [for instance as SDs or SAS grades] the point of re- entry will depend on the level of previous training and subsequent experience. Eligibility for a CCT or CESR[CP] will be confirmed by the Training Department and will be based on a case by case basis. 3.7.1 Re-orientation/Phased return Trainees returning to the specialty after a substantial break will require a period of re-orientation through a phased return programme. This will vary with the length of the break and the nature of any medical work the trainee has been engaged in during the interim. The Postgraduate Dean, through the School of Anaesthesia/Local Specialty Training Committee, should ask the appropriate College Tutor to monitor the trainee’s induction and progress and in the light of that to make recommendations about the requirements for their future training programme. Advice may be sought from the RCoA Training Committee. 3.8 Principles for approving previous training and experience In a competency based training programme previous training and experience obtained outside a standard training programme may be accepted by the Deanery [subject to confirmation by the College] when an applicant is appointed to a GMC approved training programme at CT 2 or higher. The duration of previous training and experience that can be accepted will be defined by the national person specification relevant to the year of entry. Trainees appointed to the anaesthetics programme above CT1 will normally only be eligible for the CESR[CP]. Special provisions exist for EU trainees to be eligible for a CCT. The College will confirm whether the trainee is on the CCT or CESR[CP] route when they register with the College in accordance with GMC rules. 3.8.1 Types of posts where approval of training in the UK and EU might be sought • Fixed Term Training posts Normally a maximum of two years in FTSTA and/or FTTA posts can be credited towards CT 1-2 and ST 3-4 of the CCT programme. Such trainees will join at an appropriate point in the anaesthetic CCT programme determined by the competencies achieved in earlier training 17 Article 23, paragraph 1 of Directive 2005/36/EC 33
  34. 34. • Locum Appointments for Training [LAT]: 18 o A LAT post can count towards a CCT if it covers a clearly identifiable portion of the approved training programme specified in this curriculum, has been correctly delivered and assessed and it is properly documented. o If a doctor is appointed to a relevant specialty training programme through open competition, the documented competencies achieved during a LAT[s] may be taken into account by the TPD when determining the year of entry. o The GMC does not have limits on the maximum time spent in LATs except that they can only count towards a CCT if the doctor subsequently enters an approved training programme. Deaneries should keep a careful record of these appointments on the trainee’s file. A doctor cannot obtain a CCT with only LAT appointments; they can, however, use LATs towards their Certificate of Eligibility for Specialist Registration [CESR] application. • Locum Appointments for Service [LAS]: cannot count towards CCT training but may count as experience towards a CESR. • Training in another European Union [EU] state: Prospectively approved and documented training in another EU state may be accepted on the same basis as UK approved training, subject to certain conditions. Advice on this can be obtained from the College, at training@rcoa.ac.uk, and the PMETB website www.pmetb.org.uk. Finally, it is important to note that it is essential that time spent in FTSTA, FTTA or LAT posts is properly documented and the relevant competencies assessed to the standards specified in this manual, if they are to be recognised towards a CCT, as it is for all LAS experience that may be used in a CESR submission. 3.8.2 Unapproved training and experience Training and/or experience gained outside the UK and EU, and experience and/or unapproved training obtained within the UK and EU, may be accepted by a deanery as proof of competencies when an applicant is appointed to a GMC approved training programme at CT 2 or higher. Under GMC rules, final acceptance of this previous training is a college responsibility if the trainee is seeking the CESR[CP]. The duration of previous training and experience that can be accepted will be defined by the national person specification relevant to the year of entry. Time spent in unapproved training and service posts must be properly documented and the relevant competencies assessed to the standards specified in this curriculum, if they are to be recognised towards a CESR application [note: such time will not be eligible to be counted towards training for a CCT; advice on this can be obtained from the College at training@rcoa.ac.uk, and the GMC at www.gmc- uk.org. The responsibility for proving that the necessary competencies have been achieved to the standards defined in this curriculum rests with the trainee. 3.8.3 Recognition of higher and advanced level training This can only be obtained with prospective approval; the rules for the prospective recognition of higher and advanced level training in unapproved posts in the UK or abroad, i.e. Out of Programme Training [OOPT], are described in Section 13. 3.9 Trainee registration 18 Gold Guide Sections 5.37 to 5.40 34
  35. 35. All trainees are required to register for training with the College’s Training Department as soon as possible after appointment to any training post. Copies of the ARCP Outcome forms and any correspondence related to their individual training are held at the College. A CCT date is estimated, usually on entry to ST year 5. This is altered if the necessary competences are not obtained or other circumstances prevail [such as sick leave or maternity leave] by the expected date. 3.10 Military service Military trainees are normally attached to Schools of Anaesthesia and are trained in the same manner as civilian trainees. All military medical education is commissioned by the Defence Postgraduate Dean on behalf of the Defence Medical Services and all military trainees are required to achieve the same level of competence as other trainees to be awarded a CCT. Due to the nature of military service, military trainees may be deployed away from their training rotations as required by the Ministry of Defence. It is recognised that there are training opportunities for trainees while deployed on operations [e.g. open hostilities and peacekeeping]; the learning outcomes have been formalised in the military unit of training and they can form part of Higher Level general duties training. The military unit of training can only account for three months of the total indicative six months higher level general duties required for ST years 5-7. Only one deployment will count and any additional time deployed beyond three months will extend the calculated CCT date. Deployment time will not count towards the allowable twelve months overseas out of programme training [OOPT] in ST years 5-7 of the anaesthetics programme. Trainees should discuss overseas OOPT opportunities with the Tri-services RA before applying for such a placement. For OOPT see section 13. Other opportunities for training recognition while on deployment may materialise over time. The College will examine all requests for training recognition through the Training Committee however, such requests for additional training recognition must be approved by the Tri-services Deanery first. This is to ensure that the proposed training meets with the requirements of the curriculum and benefits all defence anaesthesia trainees. 35
  36. 36. 4. Simulation technology for learning in anaesthesia 4.1 Context The use of a wide range of methods to translate and deliver a curriculum is an effective and high quality strategy that is recommended to all involved in postgraduate medical education and training. Provision of, and access to, the current range of simulation resources is increasing rapidly across the UK although it is not yet comprehensive. Competence is described within the curriculum at all levels of training in anaesthesia and demonstration of attainment is required by the GMC while ensuring patient safety remains paramount. The historical reliance upon workplace-based learning is being compromised further by decreasing hours spent in the clinical setting. These and other factors combine to encourage the use of simulation to enhance learning in anaesthesia. 4.2 Application in Training A diverse spectrum of simple to sophisticated simulation-based educational techniques may be used to assist the anaesthetist develop the attributes required for working safely and efficiently within complex and sometimes stressful socio-technical environments. In particular, effective use of simulation will help: • Acquisition and application of knowledge. • Train and ingrain new skills: learning routines and steps that together comprise a complex skill. • Reinforce drills: teach and test the learners response to specific critical incidents [this specific area is identified in the detailed units of training sections [all levels] where this use is considered appropriate]. • Develop professional behaviour and the set of non-technical skills which support delivery of expert anaesthetic practice, especially in the context of working within multi-professional teams and a variety of clinical environments. 4.3 Implementation The RCoA does not require that training in anaesthesia includes experience of learning with simulators. However, the proliferation of availability of part-task and medium fidelity simulation-based educational technologies within hospitals and higher education institutes means that most Anaesthetic Departments will soon have access to some form of simulation-based resource which can be used to enhance clinical training as outlined above The implementation of simulation based training, integrated within the existing clinical training programmes, will require development of faculty who are capable of delivering these training elements whilst making optimal use of the resources available. The RCoA therefore encourages the development of generic competencies for educators [described by the Academy of Medical Educators]19 and specific skills for simulation-based training [described by the Association for Simulated Practice in Healthcare [previously 19 http://www.medicaleducators.org/ 36
  37. 37. National Association of Medical Simulators]20 ] within the faculty of clinical and educational supervisors and other educators who support local training programmes. There are a number of simulation centres in the UK that deliver simulation training for anaesthetists and multi-professional teams and these include focus on the delivery of human factors training [see Section 5]. Schools of Anaesthesia are encouraged to establish links with such centres where possible to ascertain the best approach for local integration and application of simulation-based education within individual training programmes. 4.4 Application in Assessment Simulation is used as a validated assessment tool in the OSCE section of the Primary FRCA Examination for assessing a candidate’s response to specific critical incidents and to assess key communication skills. Similarly in the workplace mid-fidelity simulators are being used more widely to support the initial assessment of competence in techniques such as rapid sequence induction [RSI] and the failed intubation drill, as well as teaching and assessing competence in general anaesthesia for caesarean section prior to commencing on call duties in the Obstetric Unit. The use of simulation for high stakes assessment is currently limited by level of fidelity, a relative lack of evidence for validity of this form of assessment, and restricted availability of appropriate facilities for this purpose. The introduction by NCAS of simulator-based assessment of anaesthetists identified as having difficulties in practice is likely to increase attention on the role of simulation in training and assessment. As robust data becomes more available, it is clear that simulated experiences may provide a surrogate of clinical evidence for continuing progression through a programme of training and beyond. 20 http://www.namsonline.com/ 37
  38. 38. 5. Human factors in clinical practice The curriculum requires trainees to demonstrate comprehensive knowledge of many aspects of managing safety. The majority of adverse events are avoidable and are frequently caused by human factors. Human factors theory focuses on a range of topics associated with human abilities, behaviours and limitations in the context of workplace safety. Knowledge of human factors can be applied to influence the design of systems, tasks, equipment etc to make allowances for human capability in complex working environments. At a personal level, human factors theory can be translated into the non-technical skills [NTS], which complement individual technical skills, to facilitate safe and efficient performance of tasks. NTS are cognitive, social and personal skills such as: • Effective communication • Team working • Leadership • Decision making • Situation awareness • Stress management Good practitioners employ these skills to achieve consistently high performance and they are accepted as intrinsic to safe clinical practice. NTS can be taught, practised and assessed in the workplace alongside the ability to apply knowledge and perform technical skills. Previous curricula have not specified ways of doing this, which is addressed in this edition. The application of behavioural rating NTS systems can be used on an individual basis to observe and give structured feedback for training or assessment purposes. This may be especially important for those trainees found to be having difficulties in clinical practice, who frequently will have identifiable problems with specific non-technical skills. The Anaesthetic Non-Technical Skills [ANTS] taxonomy is one such system that has been developed for assessing this area of practice [See Appendix 7]. Better insight into the development of NTS at an individual level is associated with gaining insight into becoming an effective team member in the workplace. As team working is key to successful leadership and management in anaesthesia, intensive care and pain medicine, the ability to observe and feedback on NTS demonstrated by team members from other disciplines and professions is a valuable attribute. This is a characteristic described within teams working within other high reliability domains such as aviation and the nuclear or oil industry, which employ similar, but more generic, behavioural rating systems to help train and debrief team performances. 38
  39. 39. 6. Clinical supervision The definitions of supervision described below have been developed from a consideration of the professional responsibilities of medical practitioners to patient safety. 6.1 Clinical supervision: the obligation to patients Every patient requiring anaesthesia [including pre and post-operative care], intensive care and pain medicine must be cared for under the direction of an appropriate named consultant. On some occasions, consultants will themselves carry out the clinical aspects of the work; on other occasions, when appropriate, trainees or Specialty Doctors21 may provide direct care provided they have the appropriate competencies, without direct consultant supervision. To ensure the safety of patients, a trainee must be responsible to, and subject to, clinical supervision by a designated consultant at all times. This includes those occasions during elective, urgent and emergency work when the trainee, as part of their training, is deemed competent to make decisions without immediate reference to a more senior clinician. Trainees must be encouraged to seek advice and/or assistance as early as possible whenever they are concerned about patient management. This applies both in and out of hours. At all stages of training, a supervisor must respond with appropriate support to a request for assistance from a trainee. Patient safety must never be compromised. Every doctor should be prepared and able to oversee the work of less experienced colleagues and must make sure that medical and dental students and qualified doctors in training are properly supervised.22 Thus, there is an expectation that more senior trainees will provide appropriate levels of supervision to their more junior colleagues at times. 6.2 Grades of clinical supervision Clinical supervision of daytime and out of hours duties for anaesthesia [including pre and post-operative care], intensive care and pain management falls into two categories: direct and indirect: Direct supervision: This means the trainee is working directly with a supervisor senior to themselves who is actually with the trainee or can be present within seconds. This proximity maintains patient safety but, when appropriate, allows a trainee to work with a degree of independence that allows them to develop confidence. Indirect supervision: Indirect supervision falls into three categories: local, distant and remote sites: • Local supervision: This means that the supervisor is on the same geographical site, is immediately available for advice and is able to be with the trainee within 10 minutes of being called. The actual permitted time [which may be less than 10 minutes] and/or ‘distance separation’ of the supervisor from the trainee [e.g. in a nearby theatre with another trainee, doing administrative tasks, on the ICU, in a meeting etc] should be determined locally to maintain acceptable levels of patient safety; 21 Specialty Doctor includes Staff and Associate Specialist [SAS] grade. 22 Good medical practice, GMC 13 November 2006, paragraph 17: Teaching and training, appraising and assessing 39
  40. 40. this will depend on the combination of the trainee's grade, the nature of the clinical work and the layout of the hospital. • Distant supervision: This means the supervisor is available rapidly for advice but is off the hospital site and/or separated from the trainee by over 10 minutes. The maximum time or ‘distance separation’ permitted will depend upon the combination of the trainee's grade, the nature of the clinical work, local geography and traffic conditions. Since this is a quality of care, patient safety and risk management issue, the details should be determined in individual cases by the Clinical Director. Frequently used guidelines are consultant availability on site within 30 minutes or a travelling distance of less than 10 miles. Support for trainees during distant supervision is one of the factors that must be considered by the Deanery and the GMC when determining the grade and number of trainees who can be trained at any given hospital. Distant supervision requires that: o The trainee and supervisor agree that it is appropriate for the trainee o The trainee knows the limitations within which he/she can work o The trainee is capable of managing the possible complications of any procedure he/she might reasonably be expected to undertake until help arrives • Supervision in remote sites: The RCoA defines a remote site as any location where general or regional anaesthesia is administered away from the main theatre suite and/or anaesthetic department and in which it cannot be guaranteed that the help of another anaesthetist will be available. This may be either within or away from the base hospital. The relative isolation may be created by horizontal [e.g. corridors and roads] or vertical [e.g. stairs and lift] separation, by locked doors, local traffic conditions or by a combination of factors. Supervision in a remote site is a special example of distant supervision. Trainees would normally be expected to have successfully completed the relevant higher units of training before working in remote site and should be permitted to only if: o The trainee is judged by the Clinical Director in conjunction with the College Tutor/Educational Supervisor to possess the knowledge, skills, professional judgement and experience which is required to undertake such duties o A consultant is available to provide advice or help for the trainee throughout the period that the trainee is anaesthetising in a remote site o Skilled assistance for the trainee anaesthetist is available in the remote site at all times o The anaesthetic equipment and monitoring complies with the current recommended guidelines and standards appropriate to the work being performed in the remote site o The trainee has the confidence to work at the proposed level of supervision 6.3 Clinical supervision by consultants All operating lists, regular sessions in obstetrics, intensive care medicine, pain medicine, radiology, ECT and other ‘remote site locations’ should be allocated to a named consultant or Specialty Doctor. It is accepted that absences [holiday, study leave, professional leave or sickness] will occur. However, when such absences occur and a trainee undertakes a list, there must be an arrangement to provide direct or indirect [as appropriate] consultant supervision for the trainee e.g. using a “starred consultant” system, developed in many Departments of Anaesthesia. 6.4 Clinical supervision by Specialty Doctors When clinical supervision of a trainee is being provided by a Specialty Doctor, the trainee must always have unimpeded access to an identified Consultant [e.g. the “starred consultant”]. 40

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