11. THE DELIVERY OF HIGHER/ADVANCED LEVEL TRAINING [Annex D/E]
The intention of the RCoA is to allow trainees, as far as possible, to achieve their career aspirations. However it is recognised that training opportunities must balance anticipated career vacancies. For this reason trainees should maintain flexibility in their choices. Higher training permits this, whilst also allowing the trainee to develop a special interest area which will be carried on in the advanced year of practice.
11.1 The principles of Higher/Advanced level training
This section describes the delivery of Higher and Advanced Level training in ST5-7, which is based on the principle of ‘spiral learning’ [see section 2.2.1]. The delivery of Higher and Advanced training varies according to the ability of School programmes to deliver the essential Higher units of training to all its trainees, whilst also accommodating individual trainees’ advanced unit[s] requirement to fit their chosen special interest area. It is therefore feasible for a trainee to complete an advanced unit of training for a period of six to twelve months in ST6 before completing all the essential higher units of training at ST7. If specific advanced units of training are over-subscribed, it will be left to the TPD, in conjunction with the School Training Committee to determine how the opportunities will be allocated in a transparent and fair way.
The aim of higher and advanced training is to allow the trainees to become expert and therefore more independent in all areas of clinical practice, by requiring less consultant guidance and supervision. By the end of advanced training this process will be complete for the areas of anaesthetic practice in which trainees aspire to work.
The curriculum is such that no trainee will be competent to practice independently in all special interest areas of anaesthetics, intensive care and pain medicine at the end of seven years of training. Nevertheless, each trainee’s individual programme of training must be able to provide the necessary mix of essential and optional units of training to suit the aspirations of both the trainee [leading to their CCT in Anaesthetics] and the NHS without compromising patient safety.
This period of training normally lasts thirty-six months. Trainees are expected to complete an indicative twelve months higher level general duties, during which they must complete at least nine of the units listed in the essential block including the mandatory units of ‘airway management’, ‘perioperative medicine’ and ‘management of respiratory and cardiac arrest,’ as they are generic to all anaesthetic practice. The other units should be relevant to the trainee’s special interest area and this may include time from an optional higher unit of training as identified in Annex D. It is therefore essential that trainees consider what special interest area of practice they intend to pursue early, as this should inform their choice of units completed within higher general duties.
The duration of general duties training may be reduced to an indicative 6 months with prospective approval of the Chair of the Training Committee. Trainees who complete the reduced period of 6 months must complete five of the 13 units listed, of which three must be the mandatory units. The remaining indicative six months would consist of activities such as research, academic, management, education or specialising in a specific general duties specialty, for example vascular surgery. It is important that trainees still complete a balanced programme if they complete only six month of higher level general duties.
All the optional higher units except pain medicine contribute to the general duties requirements. Anaesthesia in developing countries can count for a maximum of 6 of the 12 months for general duties; military anaesthesia and remote and rural each can count for a maximum of 3 months. Only one of these options can be counted towards the general duties requirements.
In addition to general duties, there are four other essential clinical higher units [ICM, cardiac, neuro and paediatrics]. ICM must be a dedicated 3 month block and each of the remaining essential units and the optional higher unit of pain medicine should be in blocks of at least four weeks consisting of a minimum of twenty sessions. The exact time will depend upon individual School programmes, speed of competence acquisition and trainee aspirations. The combined total duration for each essential unit, except general duties, across the intermediate and higher levels should not exceed six months.
The detailed learning outcomes and competences for these units of training are contained in Annex D and E.
11.2 Organisation of higher/advanced level training
11.2.1 Clinical units of training
The College recognises that some Schools of Anaesthesia may have difficulty in providing training in some special interest areas; however every trainee must complete all core clinical learning outcomes for all the ‘essential units’. For ICM, trainees must achieve the attainment levels as defined in Annex F.
At the higher level of training the emphasis increasingly moves to the trainee working with local or distant supervision as their clinical acumen and skills mature. Clearly, within the time available, not all special interests can be covered but it is expected that trainees in ST 6 and 7 will demonstrate competence in a wide area of practice.
11.2.2 Advanced level training
Advanced level training is designed to provide special interest area training for independent consultant practice to meet the demands of the NHS. Advanced training is limited to a maximum of an indicative twelve months either in one area of interest or two special interest areas each lasting an indicative six months. In their advanced unit[s] of training, trainees are encouraged to experience a wide range of clinical experiences across their chosen special interest area and this should include the option of working in more than one hospital within and outside of the School, including out of programme opportunities. Trainees who intend to obtain a post in a non-specialist hospital, without a commitment to ICM, should complete six months to a year of advanced general duties incorporating the appropriate units of training to suit their aspirations for independent consultant practice – for some, a combination of units from the general duties list plus six months advanced obstetrics training might be a suitable combination. As in other hospital-based specialties, there are a very small number of ‘super-specialist’ consultant anaesthetist posts each year [e.g. paediatric cardiac anaesthesia]; pre-CCT training for such posts has to be arranged on an individual trainee basis in conjunction with the Chair of the Training Committee to ensure it complies with the requirements of a training programme leading to a CCT [See section 12 for further details].
11.2.3 Pain medicine training
Pain Medicine clinicians do not have the expertise for the diagnosis of all the painful conditions that can, or should, be referred to the Pain Medicine Service. Their skills and training are best placed in the broader field of symptomatic pain management. It is recognised that some examination and diagnostic skills are core to training in Pain Medicine, such as examination of the musculoskeletal and peripheral neurological systems and the making of common musculoskeletal diagnoses, but it is not expected that the Pain Medicine trainee would develop diagnostic skills in all conditions referred to the Pain Service.
The Higher and Advanced Pain Medicine trainee must acquire an understanding of their own limitations in this respect and recognise the importance of referral back to primary, or onward to secondary, care. The acquisition of this judgement and its medico-legal implications are an important part of training.
It is recognised that diagnostic and examination skills may develop further after training, or as expertise and interest evolve in a subspecialty area of Pain Medicine e.g. pelvic pain, visceral pain or headache.
18.104.22.168 Pain medicine skill maintenance
Trainees who do not intend to pursue a special interest in pain medicine at the higher and advanced level are encouraged to complement their anaesthetic practice by maintaining their acute pain skills by participating in acute pain ward rounds in ST5-7 .
22.214.171.124 Higher level training
This is an optional higher unit of training and allows the trainee to examine and develop career aspirations in pain medicine. It is essential for all trainees who wish to progress to Advanced pain medicine training. In addition, the College and the FPM recommend that trainees considering a future consultant post with an interest in acute pain medicine undertake Higher level pain training as a minimum.
126.96.36.199 Advanced level training
Advanced pain medicine training should be delivered in a designated multi-disciplinary specialist centre offering a comprehensive range of management options, under the supervision of the RAPM and LPMESs. Trainees will normally spend twelve months in this dedicated advanced unit of training in addition to the time spent in core, intermediate and higher training. From advanced pain medicine training the trainee is expected to gain mastery in safe and effective pain medicine, the wider aspects of the management and progression of a pain medicine patient caseload, and the skills of audit/quality improvement, teaching and supervision, research and business management. Advanced pain medicine training is considered the minimum required for those aiming for a consultant appointment with sessions in pain medicine. In addition, the FPM recommend that all those who are appointed as Lead for Acute Pain Services should have completed this advanced unit of training in pain medicine. Subspecialty areas of pain medicine are described in the advanced pain medicine curriculum (Annex E). Advice should be taken from the RAPM as to where these training opportunities are available and the scheduling of such subspecialty training. Whilst it is recognised that a non-pain medicine out of hours commitment is often undertaken during the period of advanced pain medicine training, it should not occur more than 7 nights in an 8 week period to ensure that it does not detract from training; it is the responsibility of local supervisors to ensure that if it does interfere, time in training will have to be extended to ensure the competencies are achieved. It is unlikely that trainees who spend time outside of the Pain Medicine environment engaged in general anaesthetic duties will be able to successfully obtain all of the competences required to complete Advanced Pain Training. Therefore, the expectation is that trainees will need to spend the whole of their daytime working hours engaged in pain medicine related duties. This would not prevent pain trainees being used on occasion to provide general anaesthetic cover for unforeseen emergency cases.
Successful completion of training and assessment and achievement of the FPM’s ‘Standard for Fellowship of the Faculty of Pain Medicine [FFPMRCA]’ will contribute towards the attainment of the FFPMRCA, which also requires success in the prescribed examination of the FPM of the RCoA.
11.2.4 Intensive care medicine training
Trainees are required to complete 3 months of adult general ICM training in ST5/6. This training may be completed in ST 3/4 in accordance with the rules defined in section 188.8.131.52. A small number of trainees may wish to achieve additional experience and competences other than the mandatory blocks of ICM training in the Core, Intermediate and Higher level anaesthetic training program, to complement advanced level training in specialty areas of anaesthetic practice. Such trainees would not be following the Dual CCTs or Joint CCT programme.
The learning needs in this situation are likely to vary and so trainees in conjunction with their trainers should refer to the advanced level ICM curriculum on the FICM website and identify the competences that they plan to achieve within the period of additional ICM training. Prospective approval should then be sought by application to the RCoA Training Department. The duration of additional ICM training would not normally be expected to exceed six months, and the trainee must have completed the mandatory Higher level block of ICM training prior to undertaking additional experience [see Annex F].
11.2.5 Paediatric intensive care medicine
Trainees with an interest in Paediatric ICM [PICM] can complete three months at the higher level in lieu of the final three months adult general intensive care or three months of their 12 months general duties requirement with prospective approval of the Chair of the Training Committee. When seeking prospective approval, the Regional Adviser and the Programme Director must detail in writing the reasons why a trainee should be permitted to complete the last three months in PICM at the expense of adult general ICM or three months of general duties. Trainees who complete three months of PICM as part of their general duties must still complete eight of the thirteen options. It is important that trainees receive a balanced anaesthesia programme.
Advanced training in PICM is aimed at two different career streams. For those trainees who wish to follow a generalist career but with an interest in paediatric anaesthesia, trainees may complement their 6 month advanced paediatric anaesthesia for DGH practise with a maximum of 6 months of advanced PICM. It is also possible for a trainee to complete a standalone maximum of 6 months of PICM combined with other advanced units to make up the required 12 months of advanced training. The exceptions are advanced neuro anaesthesia, paediatric anaesthesia for tertiary practise and cardiothoracic anaesthesia, which are 12 months in duration.
For trainees who intend to pursue a career as a paediatric anaesthetist in a tertiary centre, it may be possible to complete a maximum of 3 months of PICM as part of paediatric anaesthesia training. The limitation of 3 months is governed by the minimum of 9 months required for paediatric anaesthesia training.
It may be possible for PICM training completed during the anaesthesia training programme to be credited towards recognition from the Intercollegiate Committee for Training in Paediatric Intensive Care Medicine [ICTPICM]. For more information on the recognition of PICM accreditation, contact ICTPICM at email@example.com
11.2.6 Service commitment to ICM and obstetrics
It is recognised that senior trainees contribute to the service provision to intensive care and obstetrics. Whilst this provides experience for the generalist anaesthetist, it must not be to the detriment of anaesthetic training.
Service commitment to ICM: the College recommends that, for trainees who do not wish to have a commitment to ICM post-CCT, no more than one third of their service commitment [including their three month dedicated block of higher training] in these final three years of training should be exclusively to ICM; this is to allow sufficient time for in-theatre training to gain the essential anaesthetic competencies required for independent consultant practice. The College view is that anaesthetists should normally be responsible for the care of the acutely ill patient requiring surgery from admission through to critical care post-operatively; as a consequence, it is important that trainees develop an in-depth knowledge, understanding and clinical experience of managing such patients from admission.
Service commitment to obstetrics: the College recommends that, for trainees who do not wish to have a commitment to obstetrics post-CCT, no more than a third of their service commitments in their indicative three years of higher/advanced training is exclusively 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 D. Trainees’ exposure to emergency anaesthesia should not be compromised as a consequence of service commitments to ICM and obstetric anaesthesia, and will need to be confirmed in the Completion of Unit form for each unit of training.
11.2.7 Pre-hospital Emergency Medicine (PHEM)
Trainees may undertake sub-specialty accreditation in PHEM. Entry into this programme is via a competitive national application process during ST3 or 4 for programme commencement in ST5/6. Trainees must have six months basic emergency medicine training to be eligible to apply. Those trainees who have not completed ACCS will need to complete a six month OOPE in emergency medicine prior to applying, although this does not confirm acceptance onto the PHEM programme. The College also recommends that trainees should have completed the higher neuroanaesthesia, paediatric anaesthesia and ICM units of training before commencing PHEM training.
PHEM is a 12 month whole time equivalent [WTE] programme preferably delivered in two six month WTE blocks for anaesthetic trainees. The actual proportion of a training period reserved for PHEM and anaesthesia training will depend on the programme delivered by the deanery/LETB in consultation with the Intercollegiate Board for Training in Pre-hospital Emergency Medicine [IBTPHEM]. Competencies achieved in the PHEM programme can be counted against the required competencies for ‘transfer medicine’ at the higher and advanced levels. It may be possible for trainees to complete the PHEM component of training within the indicative 8 years programme for ACCS trainees or 7.5 years for core anaesthesia trainees.
For more details on PHEM, see www.ibtphem.org.uk.
11.2.8 Professionalism and Common Competencies
By this stage the trainee is expected to focus on the aspects of professionalism required to undertake independent clinical practice. Thus, evidence of medical leadership, a clear understanding of management responsibilities, the ability to teach, train, supervise and show an enquiring mind are all necessary. These aspects of professionalism have been present throughout training, however at the advanced level, specific generic descriptors have been written to identify the competencies that must be demonstrated in all these areas to allow final ‘sign off’ at the end of training. Six generic domains have been identified as follows:
- Domain 1 – Clinical Practice
- Domain 2 – Team working
- Domain 3 – Leadership
- Domain 4 – Innovation
- Domain 5 – Management
- Domain 6 – Education
Each domain has a series of detailed descriptors identifying the competencies expected by this point in training. They have then been summarised in learning outcomes identified in each of the individual advanced units.
11.3 Recommendation to the GMC for the award of a CCT or CESR[CP]
The College monitors the progress of all trainees within the training programme. The purpose of this monitoring is to ensure that trainees receive a balanced programme and that on completion of the GMC approved programme, a recommendation for the award of a CCT or CESR[CP] can be made to the GMC. At the end of their higher/advanced level training, to be able to be recommended for the CCT or CESR[CP], a trainee must have:
- Satisfactorily completed all the ‘essential’ units of higher training and the advanced unit(s) chosen to suit their particular career aims as evidenced by the ‘Completion of Unit of Training’ for each.
- Demonstrated the ability to teach, supervise and assess trainees; and
- Demonstrated the ability to design, complete and evaluate audits/quality improvement projects related to their chosen special interest area[s] of practice.
Estimated completion dates are calculated when the trainee commences ST5. The calculated completion date is based on the current known circumstances of the trainee, and is amended throughout the last indicative three years in accordance with any factors influencing trainee progression. All prospective completion dates are approved by the Chair of the Training Committee and/or Deputy.
When a trainee is within six months of their completion date, trainees should complete the College form [Notification of completion of training29] and send it to the Training Department at the College. Once the form and the ARCP Outcome 6 has been received, the College will formally recommend to the GMC the award of a CCT or CESR[CP]. The trainee will also receive a letter from the Training Department, advising them of the recommendation for the CCT/CESR[CP]and the trainee will receive an email from the GMC inviting them to complete the online application.
The trainee has 12 months from the expected end of training date to submit their application. If an application is submitted more than 6 months after the trainee was eligible, the GMC may ask for additional evidence to be provided in support of their application. After 12 months from the expected end of training date the trainee will have to apply for a Certificate of Eligibility for Specialist Registration (CESR) to gain entry onto the specialist register30.
11.4 Requests to complete training as a locum consultant
Time spent in a Locum Consultant appointment does not count toward the CCT/CESR[CP]: only time spent in a GMC approved training programme counts toward the CCT/CESR[CP]. It is recognised, however, that some trainees towards the end of their training benefit from being allowed to ‘act up’ in a consultant capacity.
If the period of acting up as a consultant is deemed by the Deanery/LETB/College to be a normal part of the anaesthetic CCT training programme and is intended to count towards the trainee’s CCT/CESR[CP] then GMC approval is not needed because this is already an approved element of the training programme. Acting up should usually only be allowed within the trainee’s own programme with the agreement of the local Training Committee, the Programme Director and the Clinical Director of the hospital concerned. The trainee will retain their NTN and continue to be supervised by and be responsible to the local Training Committee. It is essential that at all times the trainee has immediate access to consultant advice and understands that he or she is still in training until completion of the CCT/CESR[CP].
Such a post can only occur within the last three months of training with the proviso that the trainee must have satisfactorily completed all other aspects of the training programme. Trainees wishing to take up this option should apply directly to the Training Department at the College with the support of their Programme Director.
If, however, the period of acting up as a consultant is not deemed to be a normal part of the anaesthetic CCT training programme and the trainee still wishes this to count towards their CCT/CESR[CP], then prospective approval must be sought from the GMC in the same way as other out of programme training [see Section 12].
11.5 Leaving the training grade
Employment in the training grade will not end for “a period of six months after the date of completion of training, or six months after the date on which the trainee is notified formally by the Postgraduate Dean, taking advice from the Royal College of Anaesthetists, that his/her training is complete and that he/she is eligible for the award of a CCT/CESR[CP], whichever date is the later.”
11.6 Applying for a consultant post
Interviews for consultant posts can take place up to six months before a trainee’s expected CCT/CESR[CP] date. Trainees should take this into account when planning off-rotation training overseas [section 12]. The expected CCT/CESR[CP] date is interpreted by the DH to mean the date calculated by the College’s Training Department for the completion of training.