Progression through the pandemic
The current situation that we are facing with the impact of COVID-19 has had a major impact on the way we live and work. These are exceptional times affecting our specialty, our profession and all of our lives. The disruption we are all facing is on a global scale. Despite this, the response of individuals and the profession in changing their scope of practice and accommodating the current crisis has been incredible, and it has been awe inspiring to see the efforts made by everyone and the community spirit that has been forged.
Understandably there have been major changes to the way we work and the way we train. While I totally understand these changes and had no issues in working in these surge rotas, at some point we have to reflect upon our current situation in training and look at the disruption it has caused. I personally have felt claustrophobic without being able to see an end point to the situation. With this in mind, we need to start thinking about the way our working and educational lives have changed and look at ways of ensuring our training commitments are maintained.
A fundamental disruption is the impact of module based training. Throughout our programme, we learn, experience and gain competences in various subsets of anaesthesia. We rotate around these special interest areas and achieve a grounding in each discipline. It is vital for us to gain experience to understand the nuances of each surgical or medical specialty, how different procedures affect human physiology and what adaptations are required in our anaesthetic.
In the current situation, our clinical experience has been challenged in two ways. First, many anaesthetists in training agreed to support ICM during the first peak of COVID-19, and some are being asked to do so again as many regions of the UK experience further peaks. This of course comes at the expense of time in theatre, with anaesthetists in training having to “catch up” in what is left of their training program. The Royal College of Anaesthetists has offered guidance (https://icmanaesthesiacovid-19.org/anaesthetic-training-updatejune-2020 ) as to how some of the experience gained on ICU during COVID-19 can be evidenced against the ICM units of training, so at least some of this unexpected additional experience can be counted towards training. However, anaesthetists in training may still be required to honour future ICM rotations to maintain safely staffed rotas, which many find contentious. The College has encouraged local flexibility and pragmatism – for example, anaesthetists in training could undertake the required on-call for ICU, but during the day could attend training lists in theatre to catch up on other modules.
Second is the issue of reduction in elective surgeries, an acute issue at the height of the first peak with variable returns towards “normal” across the country, which could be further hampered by regional peaks. Of course, the most important effects of this are for the patients having their surgery delayed and having to adapt and deal with the consequences of their surgical problems for longer. But looking at this with a training viewpoint, some anaesthetists in training may be unable to achieve specific competences if their hospital cannot offer a sufficient range and numbers of certain cases.
Clinical experience and gaining professional competences is paramount to anaesthetic training. Going forward, there is a danger of either losing out on some of these experiences or requiring extensions to training in order to achieve them.
Furthermore, our current 2010 curriculum follows a spiral learning pathway. With the ongoing disruption, there is danger in potentially missing out on one level of valuable specialty experience. We need to consider when we will be able to recoup these experiences, perhaps by negotiating with areas where we have had extra experience during the pandemic.
Another major consideration should be with anaesthetists in training who have been required to shield in this period. Unfortunately, they are likely to have missed elements of training and those who have returned have to do so with specific restrictions and in specific areas to ensure personal safety. This will also have a significant impact on their case numbers and case type, with potential restrictions reducing exposure to “hot” patients, for example on CEPOD lists or on-call experience.
The independent sector has been used to help support NHS healthcare delivery and some elective surgical work has been occurring in this environment. It is worth noting that this may move this work away from our training rotations unless adaptations are made to gain access to training in these locations. As per the HEE/NHSEI guidelines, education and training should happen wherever NHS provision is situated.
Anaesthetists have shown themselves to be extraordinarily flexible and adaptable in supporting sick patients and their departments throughout COVID-19, so when the pandemic is sufficiently controlled within each of our regions, we may need our departments to reciprocate this flexibility to allow us to access as many lost training opportunities as possible, potentially outwith our usual trust, rotations and even outwith the NHS.
The beauty of anaesthetic training is that we learn how to adapt our skills in different environments and systematically build on these skills each year. We have all had to adapt the way we work and missed out on training opportunities over the past few months, and we must take care to avoid any situation where we leave the training programme with gaps in our knowledge. This may cause us further stress and anxiety as we try to make up for time and experience missed, and so we must work together with our trainers to achieve a pragmatic and achievable plan to recoup lost training experience without significant delays to our CCT.
As a trainer, this is a difficult time too. The workload has increased, needing additional organisational time to maintain educational supervision standards and provide support for anaesthetists in training. Providing time and opportunities for workplace based assessments is difficult and can be more infrequent when rotas are stretched. Modifications and new solutions are needed when looking at evidence for progression. Training Programme Directors will find themselves under growing pressure to rotate trainees through specialties they need in time for ARCPs and important progression points. This needs to be balanced alongside the new way of working we all face. The challenge will be to create new and innovative ways of teaching, from the use of video conferencing teaching and perhaps an adapted, socially distant form of simulation. A personal, pragmatic and flexible approach is needed to support the achievement of required competences, and this has been demonstrated already by trainers throughout the UK.
I want to end on a positive note. I appreciate that the current changes are unprecedented and inevitable to ensure we maintain the highest quality care that we can provide. I know we are not alone in the disruption - all of our colleagues in the NHS and every member of our society have been affected. It is a privilege to work in this healthcare system and the response to this global crisis has been incredible. There have been many positives in the way we work from the rapid upskilling of relevant clinical skills, the use of telecommunications to provide teaching and training, and the general support of seniors, peers and the public to build a heart warming community spirit. This experience will affect the way we train, the way we work and the way we fundamentally provide anaesthesia and critical care. There is no doubt we will come through this experience stronger and more resilient.
Dr Soumen Sen, KSS/RCoA Education Fellow, RCoA Anaesthetists in Training Committee member
1 Cook et al, June 2020. Workplace shielding and doctors at higher risk of harm working in anaesthesia and critical care during the COVID-19 pandemic. https://static1.squarespace.com/static/5e6613a1dc75b87df82b78e1/t/5f117…
2 HEE/NHSEI Joint Position Statement: Ensuring Education and Training in the Independent Sector