Learning and Teaching
The organisation and delivery of postgraduate training is the responsibility of Health Education England (HEE) and its Local Education and Training Boards (LETBs), NHS Education for Scotland (NES), the HEIW and the Northern Ireland Medical and Dental Training Agency (NIMDTA). A Training Programme Director will be responsible for coordinating the ACCS and EM training programmes.
Progression through the RCEM curriculum will be determined by the ARCP process and the training requirements for each indicative year of training are summarised in the ARCP decision aid (available on the RCEM Website) Appendix 2. The successful completion of EM training will be dependent on achieving the expected standard in all SLOs. The Programme of Assessment will be used to monitor and determine progress.
The sequence of training in ACCS is flexible and will be determined locally on an individual basis: the trainees can do the indicative six-month attachments in any order.
Each trainee will be assigned a GMC approved clinical supervisor for each six-month ACCS specialty placement: this will be a consultant in an acute specialty. Where possible, trainees have an overall educational supervisor for the duration of the ACCS generic training programme, who will provide pastoral and educational support across the two years.
In EM training there will be a GMC approved Educational Supervisor and a GMC approved Clinical Supervisor in each placement if the Educational Supervisor is based elsewhere.
The training environment
This curriculum should be used to help design training programmes locally that ensure all EM trainees can develop their skills in a variety of settings and situations. It is designed to ensure that it can be applied in a flexible manner, meeting service needs as well as supporting each individual doctor- in-training’s learning and development plan. The requirements for the provision of training have not changed as a result of this new curriculum. All training must comply with the GMC requirements presented in Promoting excellence: standards for medical education and training (2017). This stipulates that all training must comply with the following ten standards:
Theme 1: Learning environment and culture
S1.1 The learning environment is safe for patients and supportive for learners and educators. The culture is caring, compassionate and provides a good standard of care and experience for patients, carers and families.
S1.2 The learning environment and organisational culture value and support education and training, so that learners are able to demonstrate what is expected in Good Medical Practice and to achieve the learning outcomes required by their curriculum.
Theme 2: Educational governance and leadership
S2.1 The educational governance system continuously improves the quality and outcomes of education and training by measuring performance against the standards, demonstrating accountability and responding when standards are not being met.
S2.2 The educational and clinical governance systems are integrated, allowing organisations to address concerns about patient safety, the standard of care, and the standard of education and training.
S2.3 The educational governance system makes sure that education and training is fair and is based on the principles of equality and diversity.
Theme 3: Supporting learners
S3.1 Learners receive educational and pastoral support to be able to demonstrate what is expected in Good Medical Practice, and to achieve the learning outcomes required by their curriculum.
Theme 4: Supporting educators
S4.1 Educators are selected, inducted, trained, and appraised to reflect their education and training responsibilities.
S4.2 Educators receive the support, resources and time to meet their education and training responsibilities.
Theme 5: Developing and implementing curricula and assessments
S5.1 Medical school curricula and assessments are developed and implemented so that medical students are able to achieve the learning outcomes required for graduates.
S5.2 Postgraduate curricula and assessments are developed and implemented so that doctors in training are able to demonstrate what is expected in Good Medical Practice, and to achieve the learning outcomes required by their curriculum.
It is the responsibility of HEE and its local offices, NES, HEIW, and NIMDTA to ensure compliance with these standards for speciality training, and to notify RCEM if further support is required in achieving this. Training delivery must also comply with the requirements of the latest edition of the COPMeD’s ‘Gold Guide’.
Teaching and learning methods
The ACCS related specialties are practical, craft specialties and much of the education and training is acquired through experiential learning and reflective practice with trainers. A variety of learning experiences enable the achievement of the learning outcomes. There will be a balance of different learning methods from formal teaching programmes to experiential learning ‘on the job’. The proportion of time allocated to each method may vary depending on the nature of the attachment within a rotation, which should be constructed to enable the doctors-in-training to experience the full range of educational and training opportunities.
Intermediate & Higher Training
In intermediate training there is a requirement that trainees have experience of all aspects of the ED, including paediatric EM, minor illness and injury, major trauma and resuscitation, as well as experience of taking leadership role in individual cases, areas of the ED and eventually the whole ED. Training rotations need to ensure this breadth of experience is available during training
Practice-based experiential learning
ACCS specialty training is largely experiential in nature with any interaction in the work place having the potential to become a learning episode. The work place provides learning opportunities on a daily basis for ACCS doctors-in-training and the programme of placements is decided by the local faculty for education within a location. The nature of ACCS training in four closely related specialties provides opportunities to work in a variety of settings: the ED ‘shop floor’, on the acute medical admissions unit, the critical care unit and in theatres. It is essential that trainees spend an appropriate amount of time in each of these areas to meet their training needs and those of the programme.
Clinical experience should be used as an opportunity to undertake WPBAs and reflection. Every patient seen, in ED, in theatre, on ICU or in assessment unit/ acute medical ward provides a learning opportunity which will be enhanced by following the patient through the course of their illness. The experience of the evolution of patients’ problems over time is a critical part both of the diagnostic process as well as management. Patients seen should provide the basis for critical reading and reflection on clinical problems. Every time a trainee observes another doctor seeing a patient or their relatives there is an opportunity for learning. Ward rounds (including post-take) should be led by a more senior doctor and include feedback on clinical and decision-making skills.
To ensure patient safety, ACCS doctors in training new to each specialty must, at all times, be appropriately supervised for their level of competence and entrustment. Trainees will need direct supervision for considerable periods in the ACCS programme: during the anaesthesia placement trainees require direct supervision until they have passed the IAC. These concentrated periods of supervision are essential to ensure that these trainees complete all the required learning outcomes in a very full programme.
It is important to ensure that supervised sessions have relevance to the ACCS curriculum and training that individual doctors are undertaking at the time; the concept of a balanced programme of training is essential.
Intermediate training is geared to preparation for the responsibilities of higher training. Trainees must therefore be supported to take responsibility in the resuscitation room, including the leadership of resuscitation teams under supervision. Feedback and reflection on grey cases or where there is significant challenge are particularly helpful as the Intermediate Trainee is readied for Higher Training. Intermediate trainees should also be trained to provide support to the team, with direct feedback, such as at departmental board rounds as they begin to develop the skills of oversight and the human factors that are key to shift leadership.
In Higher Training experiential learning must continue to include development in all areas of the ED. It is important that trainees continue to receive feedback on resuscitation cases, including a growing responsibility for challenging cases and development as team leaders, in paediatric and adult emergency care. Experiential learning also includes the Supporting SLOs, and experience of presenting, active participation in quality improvement meetings and preparation for representing the speciality to others will be required.
Independent self-directed learning
EM doctors in training will use this time in a variety of ways depending upon their stage of learning. Suggested activities include:
• RCEMLearning- there is content mapped to all of the Clinical Syllabus and SLOs and maintenance of personal portfolio (self-assessment, reflective learning, personal development plan)
• audit, quality improvement and research projects
• achieving personal learning goals beyond the essential, core curriculum.
Learning with peers
There are many opportunities for trainees to learn with their peers and near-peers. Local postgraduate teaching opportunities allow trainees of varied levels of experience to come together for small group sessions. Examination preparation encourages the formation of self-help groups and learning sets.
Formal postgraduate teaching
The content of formal postgraduate education sessions and access to other more formal learning opportunities are determined by the local faculty responsible for EM education and will be based on the RCEM curriculum. There are many opportunities throughout the year for formal teaching locally and at regional, national and international meetings.
Where appropriate formal teaching and meetings should include the multi-professional team. Access should also be provided to key meetings within the service. Suggested activities include:
• a programme of formal ‘bleep-free’ regular teaching sessions
• attendance and presentation at mortality and morbidity meetings
• case presentations
• research, audit and quality improvement projects
• attendance and presentation at governance and risk meetings
• lectures and small group teaching
• clinical skills demonstrations and teaching
• critical appraisal and evidence-based medicine and journal clubs
• joint specialty and multi-professional meetings
• attendance at training programmes organised on a deanery or regional basis, which are designed to cover aspects of the training programme outlined in this curriculum.
Procedural competency training, using simulation aimed at achieving technical competence for certain procedures should be provided as early as possible in in ACCS training and continue through all 3 stages of training. Scenario-based immersive simulation training is expected to be undertaken in all relevant Specialty Learning Outcomes, with human factors incorporated into the scenarios where appropriate.
Examples of simulation courses that should be used to deliver aspects of the curriculum include, but are not limited to:
• Novice Anaesthesia Skills and Drills
• Assessment of failed intubation drill
• Vascular access
• Human factors
• Critical thinking
Intermediate and Higher Training
• Paediatric sedation
• Procedural skills- including emergency thoracotomy; emergency caesarean section, surgical airway
• Resuscitation team leadership
• Dealing with challenging situations in the work place
• Human factors
• Critical thinking
Formal study courses
Time to be made available for formal courses is encouraged, subject to local conditions of service, in line with local study leave policy.
Protected time for Trainee Development
To facilitate the acquisition of the essential generic capabilities required for safe, effective and high quality medical care as prescribed by the GMC GPC framework, and to recognise the contribution doctors in training make outside of the clinical setting, the ICACCST recommends that local Schools of ACCS consider mechanisms to enable and encourage trainee involvement in research, audit and quality improvement, as well as allowing time for them to work on publications and presentations and participate in teaching and aspects of hospital management. One way to do so is to allow ‘Supporting Professional Activities’ (SPA) time to help the development of these important skills and recommended that all ACCS doctors in training receive this, although the amount of time required may vary throughout the training programme.
Intermediate and Higher Training
The curriculum for intermediate and higher training includes the requirement to develop in the four supporting SLOs. The expectation on trainees, as outlined in the ARCP guidance, is that they are proficient in the key skills in these areas. To gain this experience it is recommended that full time trainees receive the equivalent of half a day a week, to be put towards curricular activities within their own departments. For less than full time trainees this would be pro-rata.
In higher training there is a requirement for trainees to take more responsibility and contribute to the ED in the Supporting SLOs as senior members of the team. There is a greater requirement for experiential learning of these aspects of EM work compared to intermediate training. It is therefore recommended that full time trainees in Higher Training receive the equivalent of a day a week.
This time, in both intermediate and higher training would also be used to cover the broader aspects of the new curriculum including but not limited to:
• attendance at handovers
• local departmental/ shop-floor ” bedside” teaching/ in situ simulation – (as educator role or as learner)
• critical appraisal activity i.e. journal clubs (either as educator or learner)
• quality improvement projects
• maintenance of critical care and procedural skills – anaesthesia/ ICM/ respiratory
• development as educator or learner of Ultrasound skills
• development of management portfolio- e.g. complaints, serious incident investigation, training or governance meetings etc
• to ensure coverage of broader skills within EM e.g. normal delivery, ophthalmology/ ENT/ fracture clinics
There should be a timetabled log of activity and skills recorded and uploaded to the ePortfolio to be reviewed by educational/ clinical supervisor at every quarterly meeting. Areas for development should be detailed in the trainee’s personal development plan and progress monitored. It is expected that this time will be spent in the Emergency Department unless there is prior agreement with the ES/CS.
Trainees may train in ACCS specialties as an academic clinical fellow (ACF) or equivalent. Academic trainees may be recruited during ACCS training – i.e. at CT1 or CT2.
Some trainees may opt to do research leading to a higher degree without being appointed to a formal academic programme. This new curriculum should not impact in any way on the facility to take time out of programme for research (OOPR) but as now, such time requires discussion between the trainee, the TPD and the Deanery as to what is appropriate together.