10. THE DELIVERY OF INTERMEDIATE LEVEL TRAINING [Annex C]
10.1 The principles of intermediate level training
This section describes the delivery of Intermediate Level training in the ST3-4, which is based on the principle of ‘spiral learning’ [see section 2.2.1]. Having gained knowledge of the principles underlying anaesthetic practice at Core Level, trainees are now introduced to more complex areas of practice.
This period of training will normally last twenty-four months. There are seven ‘essential units’ and three ‘optional units’. Each unit of training within the general duties group is a standalone unit and should be assessed accordingly.
The detailed learning outcomes and competences for these units of training are contained in Annex C.
10.2 Organisation of intermediate level training
10.2.1 Clinical units of training
The College recognises that some Schools of Anaesthesia may have difficulty in providing training in some special interest areas; nevertheless, every trainee must complete all core clinical learning outcomes for all the essential units and therefore suitable arrangements must be made by the School. Whilst it is accepted that not all trainees will gain clinical experience in the optional units, they must nevertheless acquire the relevant knowledge, so these topics should be included in teaching programmes or trainee self-directed learning.
With the exception of the general duties unit of training, it is recommended that trainees spend between four and twelve weeks in each unit of training; the exact time depends upon local arrangements and the constraints of the indicative two year time period.
All Schools should ensure that trainees are exposed to all the essential intermediate units of training during ST3-4. As for Core Level training, it is important that Schools ensure that their programmes of training are organised in a way that ensures all the learning outcomes are achieved within the identified time; these, along with all the competencies, are identified in detail in Annex C.
10.2.2 Dedicated blocks of training
The only stipulation for this is in ICM training; intermediate training in ICM must be in a three-month block [see section 10.2.5]. Trainees would also benefit from dedicated blocks of training in the more complex aspects of practice. The College recommends that Intermediate level training in cardiothoracic, neuro, paediatric anaesthesia and pain medicine is delivered in dedicated blocks of at least four weeks up to a maximum of three months. Trainees must undertake a minimum of twenty sessions to ensure all the core clinical learning outcomes for all non-ICM units are achieved.
10.2.3 Flexibility for ST4 and ST5
The College supports the concept of ‘spiral learning’, however it is recognised that due to geographical considerations and availability of some specialties within some Schools of Anaesthesia that spiral learning cannot be implemented across all units of training.
For those schools who are unable to implement spiral learning across all units of training, some flexibility is possible for ST4 and ST5. It is expected however, where possible, intermediate training will be delivered entirely within the indicative two year period for the intermediate level. For those Schools requesting flexibility in delivering ST4 and ST 5 training, the following rules apply:
- At least 6 months Higher training must be completed by the end of ST5
- All Intermediate essential units must be completed by the end of ST5
- The ILTC is only issued when all essential intermediate level units of training are completed and the Final FRCA is passed. For trainees who will not complete their intermediate essential units until ST5, the Intermediate Level Progress Report must be sent to the College at the end of ST4 and the ILTC completed when all essential intermediate units of training are completed.
- Trainees will still be required to pass the Final FRCA examination as a requirement to progress to ST5.
In exceptional circumstances, Schools may apply to the Chair of the Training Committee for prospective approval to defer a maximum of two intermediate essential units of training to ST5 for an individual trainee - in such cases the trainee must have passed the Final FRCA by the end of ST4. The Programme Director and Regional Adviser must apply in writing to the Chair of the Training Committee explaining why the trainee cannot complete the units of training within the intermediate phase of training and why they should be permitted to progress to ST5 with approval to defer. If approved, the Intermediate Level Progress Report must be sent to the College at the end of ST4 and the ILTC completed when all the essential intermediate units are completed. Deferred units must still be completed within the first six months of ST5.
10.2.4 Pain medicine training
Pain medicine is a compulsory part of intermediate level anaesthetic training; this should ideally be undertaken in a dedicated ‘block’.
10.2.5 Intensive care medicine training
Intermediate level intensive care training is mandatory for all trainees and is completed as a single 3 month block in ST3 or 4. Trainees who intend to complete additional ICM experience and competencies to complement advanced level training in specialty areas of anaesthetic practice, and are not following the dual CCTs programme, may complete their Higher level three month block of ICM in ST 3 or 4 (see section 10.2.5.1 below for more information).
Trainees following the single CCT in either anaesthetics or ICM may apply competitively for appointment to the dual CCTs programme before the end of ST5. ICM trainees applying for entry to the anaesthetics programme at ST3 must meet the anaesthesia experience requirements as defined in the national person specifications for entry to ST3 anaesthesia. Eligibility for the CCT in anaesthetics will depend on where and when the anaesthesia training/experience was obtained. [See section 3.7.1 for CCT versus CESR[CP].
10.2.5.1 ICM flexibility for non-Dual CCT trainees
Trainees are expected to complete 3 months ICM in ST3/4 and another 3 months in ST 5/6. For trainees undertaking additional ICM experience to complement advanced training in specialty areas of anaesthetic practice, schools may allow the 3 months ICM usually completed in ST5/6 to be completed in ST3/4. In such circumstances, the following rules apply:
- The School of Anaesthesia may decide whether this flexibility is available within the programme;
- Prospective approval to complete the 6 months Intermediate and Higher ICM in ST3/4 must be obtained from the Regional Adviser for Anaesthesia;
- Any trainee who decides not to complete additional ICM after completing the 6 month Intermediate and Higher ICM block in ST3/4 must undertake another 3 month attachment in ICM in ST5/6/7 to complete their spiral learning.
10.2.6 Service commitment to ICM and obstetrics
In many hospitals anaesthetic trainees provide out of hours cover to intensive care units and obstetrics. Whilst these provide valuable training and experience, it must not be to the detriment of anaesthetic training; trainees must receive a balanced programme of training over their five higher specialty training years. It is up to individual Schools, normally via their STCs, to ensure the College recommendations for training are met.
Service commitment to ICM: the College recommends that trainees must spend no more than a total of 6 months when all time spent in ICM duties is considered in their indicative two years of intermediate level training undertaking day time ICM duties [this is to include their three month dedicated block], to ensure they achieve their other anaesthetic competencies.
Service commitment to obstetrics: the College recommends that no more than a third of service commitments in their indicative two years are dedicated to obstetric anaesthetic services.
The College expects trainees to develop their skills in emergency anaesthesia in all disciplines, as detailed in the core clinical outcomes of the essential units of training in Annex C. Trainees’ exposure to emergency anaesthesia should not be compromised as a consequence of service commitments to ICM and obstetric anaesthesia. ‘Sign off’ confirming adequate exposure to emergency anaesthesia related to that particular area of the curriculum is necessary on the Completion of Unit of Training form.
10.2.7 Professionalism and common competences of medical practice
In addition to the clinical units of training, trainees must continue to demonstrate commitment to professionalism [Annex A]. As for Core Level training, these competencies should be assessed in the course of clinical practice and are identified within the clinical units of training [see section 7].10.2.8 Teaching and Training; Academic and Research; Quality Improvement and Management (Annex G)
As in Core Level training, important competencies are identified in these more generic aspects of practice; it is expected that they will be achieved in the course of a trainee’s day to day clinical practice and preparation for the Final FRCA examination. Departments of Anaesthesia should have a comprehensive educational programme that allows trainees to develop the competencies identified in the Education and Academic and Research section. It is also essential that trainees have access to teaching of applied basic sciences that underpin safe practice of anaesthesia.
See Section 7 for information on assessment in the training programme.
10.3 Progression to higher/advanced level training
To complete intermediate level training successfully, the trainee must achieve all the specified core clinical learning outcomes and pass the Final FRCA. The emphasis when confirming satisfactory completion of intermediate level training is on competence, not time. When signing the Intermediate Level Training Certificate trainers, in conjunction with educational supervisors, must be satisfied that the trainee has obtained the required intermediate level core clinical learning outcomes in anaesthesia and ICM and not that they have just completed two years of training. If the College Tutor feels unable to sign the Intermediate Level Training Certificate within the ‘normal’ two years, the trainee must spend more time in training [see section 10.2.3].
In order to progress from intermediate to the second 6 months of higher/advanced level training the trainee must have:
- Completed all the essential intermediate units of training as evidenced by the ‘Completion of Unit of Training ’ for each
- Demonstrated appropriate professionalism and common competencies;
- Passed the RCoA Final FRCA;
- Been issued with the Intermediate Level Training Certificate