Futureproofing EM: Why your trainees deserve it (and your nation needs it). St.Emlyn’s

 

Future ProofingUK Emergency MedicineI suspect all Deaneries (locality branches of Health Education England as they are now known) have their traditions and meetings. In the former NW post-graduate deanery we have ours. One of these is Calman day. Until this year it was a combination of ARCPs (annual reviews of competency and progression) for the CT3 and ST4-6 trainees in Emergency Medicine and a presentation, and celebration, of trainee research. The research presentations continued in 2016 and I hear there was some really good stuff, which I’m sure Rick will be along in a bit to talk about.

But by the time this year’s Calman Day rolled around, ARCPs had been completed so it was decided by the powers that be to convene panels to deliver some pastoral care to the trainees. This was a shock to some of the more senior trainees who were expecting the usual ARCP rigour and grilling. What they got (in my panel at least) was an opportunity to rant to 2 of us (one of whom was a TPD – training program director) about problems and difficulties.

This post is a reflection on that day and how UK Emergency Medicine training is (or isn’t) working in 2016. These thoughts are mine and don’t reflect the college or even everyone in Virchester (Ed – but the St.Emlyn’s team do share the majority of them and certainly the themes).

Some common themes emerged that I will explore below, but first some thoughts from Whitney…..

 

 I believe the children are our future

Teach them well and let them lead the way

Show them all the beauty they possess inside

Give them a sense of pride to make it easier

 

Curriculum

I would concur that the Royal College of Emergency Medicine (under the supervision of the GMC) doesn’t seem to make things easy. The EM curriculum is huge (390 pages). It took me (who regards himself as a Meducationalist) over a week to read it and I still have to go back  (regularly) to check things. It’s saved on my Google Drive and Adobe DC for those nights when I have really bad insomnia.

One thing that came through was that trainees felt that trainers didn’t understand the curriculum and know what the trainees learning requirements were. I would agree that as adult learners there is a need for proactivity in seeking out WPBAs and tailoring the requests to the curriculum. However, Educational Supervisors should be aware of what their responsibilities are, particularly for ACATs and ESLEs (scroll down to page 14 in the link). Allow me to explain.

(A)CATsAcute Care Assessment ToolThis is A CAT. An ACAT is a formative educational tool to assess the performance of a trainee over time and over a range of patients (maximum 5). The case notes and management plan should be reviewed and the opinions of the wider ED team on the performance of the trainee should be sought. It’s mainly a clinical assessment tool but wider aspects such as patient safety, leadership and time management can be tested in addition. It is not summative and areas of concern should be clarified by reflection and further Work Placed Based Assessments WPBAs.

 

This is ELSIE. She is an older lady. She has a cat. An ESLE is another EM assessment tool. It is not ACAT. An ESLE is an extended event of observation in the workplace across cases. It covers interactions, decision-making, management and ESLEExtendedLearningEventsleadership, as well as the trainee’s individual caseload. It is around 3 hours in length and this comprises 2 hours of observation and then an hour of formalised feedback using the RCEM tool. It’s validated, designed to test independent practice and should generate an educational prescription for development of the trainee. Having used this tool and spoken to others, the results of such a prolonged period of observation can be surprising in both good and bad ways.

 

I acknowledge it’s difficult for educators in the Emergency Department. In Emergency Medicine we need to know the Foundation Curriculum, the ACCS curriculum (different significantly from the HST one), the PEM ST3 one (ditto), the other bit of the ST3 one (ditto), the GPST curriculum (god only knows) as well as taking care of numerous non-HEE trainees all with individual aspirations, learning needs and attitudes towards engagement. However one ES cannot know all these curricula. The only solution that I can see is to parcel up educational supervision so that some consultants take HSTs, some ACCS, some ST3 etc. It’s only fair, both to supervisor and for trainee. I acknowledge that this may be difficult in departments with fewer consultants. And please – recognise the value that WBPAs can have as teaching and learning tools, if you take the time to engage with them,

 

Feedback

The session was for ST3 – 6 EM trainees. ST3 especially is a difficult time for Emergency Medicine trainees. There is a huge increase in responsibility with the need to supervise F2 and CT1 trainees as well as the need to manage a caseload and attend to your own personal development. Several trainees commented upon the fact that they felt unloved and unsupported. This was true across all locations for training.

So why has this occurred? Well, ACCS is a 2 year programme that has EM/Acute med/ICU/Anaesthesia. I’d suggest that the delight of attaining a training post mitigates against the crap shifts and hard graft of EM and AM in the first year. Unfortunately (for EM at least), trainees are then released into anaesthesia where they are usually spending their days (and not nights/twilights/evenings/weekends that EM and AM need to deal with their caseload) directly supervised and taught by a consultant anaesthetist. As much as I love (and have always loved) EM, I cannot deny that the 2 years I spent as an anaesthetist were deeply seductive because of the training and support I received. This is true (and possibly more so) today for the current trainees.Screenshot 2016-08-18 10.28.12

I completely understand the brain drain to anaesthesia. It’s a speciality with variety, controlled risk, good educational structure and a good work-life balance. EM has one of these (in spades) but a poor Work Life Balance (as a trainee), risky practice and competent and committed educators who are unfortunately distracted by pressures such as targets and workload from delivering the education that we would like to (and I am as guilty of this as all of us are).

So what’s the solution? St Emlyn’s blog has covered feedback extensively and I hope you are implementing some of our ideas in your Emergency Department. This will help. Another tool that I try and do (I fail, as we all do, but I’m (very) trying) is to make a point of going round after the shift to say “thank you” to the group (as it’s #TeamED) and to individuals. Saying “well done” when something has been done well is also good, but the feedback from today suggests that this doesn’t happen as often as it ought to. Be a human. Forget the pressures of the ED and remember that, quite like Edmund Blackadder, your trainees will follow you to chaos and uncertainty. Love them and praise them. Take time to understand them. They are worth it.

 

We’re in this together

I don’t know what your job plan is, if you are an Emergency Medicine consultant. I don’t even know what my colleagues’ job plans are (but that’s a different story entirely). What I do know is that trainees can feel that they are on their own, with no support, especially when EDs are busy and it’s (significantly) out of hours. There are many reasons for this. I have blogged elsewhere about the need for free-range consultants before. I am yet to revisit this, but I suspect that there has been a (minimal) change over time. The next change comes in creating vampire consultants who are happy to work in the hours of darkness. This will not be easy!

Our trainees spend an insane proportion of their lives working in non-plain time. This comes with the job and only the most naïve would expect to be a 9-5 emergency physician. So why does this automatically change with the award of a CCT/CESR? (Ed- the certificates at the completion of UK training in emergency medicine.) As Emergency Physicians we need to look at ourselves, our patient population and presentations, and our trainees and re-evaluate. I would suggest that if the predominance of your trainees’ hours are antisocial and without direct consultant accessibility then you are not going to be able to provide adequate training.

So what should you do if your Emergency Department is in a parlous state at 8/10/midnight when you are due to leave? Suck it up, you’re paid a shed load of cash (Consultants, in the UK at least, are 1%ers, like it or not) and help out. You can see patients quicker, better and with less subsequent problems than any of your juniors. It’s an investment in not dealing with problems occurring later and better performance from, and loyalty of, your juniors. No one wants a boss that they have no respect for. Don’t be that guy. However, if it’s a regular problem, that’s not sustainable. Manage it. Diarise and renegotiate your job plan. Negotiation is one of the core skills of an EP. You need to be able to provide support without killing yourself or your patients through burnout and tiredness.

I’d suggest that if you’re in a department that’s struggling, having the majority of your consultants doing day shifts is anachronous and poor management. If you can show your trainees that you are all in it together (Ed – as demonstated in this video of an Alan Grayson led handover in Virchester) then they are more likely to join you as consultants in addition to engaging in QI and management (ie the stuff that takes up all your time), as well as being better doctors.

 

Rotas

This is a separate blog post in itself. In the short term, ask yourself this: if I was a trainee, would I think my rota was fair? Can I get study leave or get away to my best mate’s wedding? If not JFDI and sort it. These are either enshrined in law, entitlements or just basic human decency. Make the rota decent so that the juniors aren’t utterly knackered and peri-burnout and their engagement and performance will be significantly better.

Make sure your trainees monitor. If they are working unpleasant shifts, they deserve paying for it. A Band 3 rota will make the exec and the BMA take action. It may not be pleasant, but you reap what you sow. It’s also the law.

Also, publish the rota well in advance. No one appreciates unpredictable shift changes and a night shift with 2 days notice to organise child care.

 

Learned helplessness

I would be amongst the first to admit that EM is tough presently. There are increasingly high numbers through the front door and increasing difficulties in moving them through the back door. Many trainees mentioned practising corridor medicine and their discomfort with the associated risk as well as the lack of apparent solutions from Executive boards.

I doubt that the numbers in will change soon. We have an ageing population that are sicker and a social care service that seems designed to fail. I could rant about the underfunding of Public Health but this is an EM blog (Ed – although arguably we ED clinicians do have a public health role to play!). Apart from by voting every 5 years, writing to our MP and filling in incident forms when it is harmful, we cannot control central underfunding. We should be mindful of things beyond our control; be concerned, be reactive (and proactive), but it’s not worth having a stroke over. Control that which is within your gift and escalate (and make sure it’s on the risk register) that which is not.

Trust the triage system. It’s validated. Trust your colleagues. They have good intentions, even though their skills aren’t comparable to your own. See the sick patients first. I’d be really sad to go back to the days where a green ?ankle fracture (likely sprain) waited 12 hours to be seen or left without being seen, but I, and you, have a responsibility to the sick where time critical interventions are both lifesaving and saving of time down the line.

It’s no secret that I was a fairly poor medical student. I paid for my degree working in bars and in kitchens where there was a preponderance of idiots in charge. One of my favourite books, for its description of the crazy life we lead, is Kitchen Confidential by Anthony Bourdain. It’s an autobiography of a bloke who started out well, went wrong and ended up lucky, working in a high end kitchen in New York. I see amazing parallels with my life (without the major drug misuse) as the lifestyle of unending pressure, antisocial hours and demand for perfection are similar if not the same. Bourdain speaks of the pose that experienced cookies adopt; hunched, guarded, defensive, ready for the next beating. Sound familiar? The counterpoint to this is the beauty of the teamwork, the unfailing performance under pressure, the pride in the finished product as well as the development and education of team members with mentoring, support and opportunities. I probably took more from it into medicine than I did from House of God. Have a read.

 

Conclusion

So what has this been about?

I make no secret of the fact that you should #loveyourtrainees and #loveyourjuniors. I have no affinity with Whitney Houston, but I do believe that the children (trainees) are the future and that market forces apply – no trainee will want to go on to be a consultant in a department if they feel unvalued and unsupported – they have to work with those unsupportive, exploitative folk for the next three decades.

You might not even be the best educator in the world or even your trust. I’m not, by any stretch of the imagination. I do care though, about trainees being valued, and about being contactable (all of the registrars, my EM trainees that I educationally supervise and all 96 hospital foundation trainees have my mobile number and personal email address). This matters, more than you would believe.

If you are a trainee reading this, I’d ask for your time (in HENW all educational supervisors should get paid for the role). Mutually work out how this will work, we’re all adults after all.

If you are a trainer, I hope that there’s some inspiration to actually do what you do best. I know you’ve got clipboard-wallahs pecking your head about breaches but realistically, the DoH and NHSE have given up on the FHT. WE need to concentrate on education and quality care and if we were allowed to get on with that then the targets may fall into place. At least the pressure on Emergency Department would diminish.

We have the best job in the world. Time to show the world why. We can only control that which is within our gift and that’s huge.

Thanks for reading.

vb

AliG

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10 Comments

  1. Lizzie

    This is spot on. Thanks for posting.
    I really fear the current situation in EM puts off/ destroys good people. We need to focus on what can be changed, ie rotas, and what we can’t ie numbers of patients, at least not directly or completely!
    I’m glad it’s not just me that feels it’s a struggle and fears for future trainees.
    Lizzie Robinson

    Reply
  2. Pete

    Really excellent post that crystallises what are the key areas for improvement! Thanks!

    Reply
  3. Rhiannon

    Recruitment is also being hampered by clunky processes. I’m an emergency Reg is Auckland. For family reasons I’m keen to come back to the UK and work emergency (despite knowing the pay is worse, the hours are longer and the work load is harsher- but I really enjoy my work). However, I’ve found making enquiries about transferring training and getting firm answers from the college is proving very difficult. I have two years of EM training time left to complete in NZ, but the UK college are saying I will need to go to back to CT2 year, and may need to repeat my exams and my research component. I thought they’d be keen to welcome middle grades back – i’m sure my husband and I could both fill some rota gaps and feel we have had good training under the ACEM system. I’m in touch with the training manager at the royal college. Does anyone have any one else that would be useful to contact? (else I’m just going to quit and do GP- cause its a 3 year scheme, and application is much simplier– which is a shame)– I know of 3 other doctors in a similar position.

    Reply
  4. Rob

    Thanks for the excellent post. Just a few comments to make on the issue of oversized curricula. Why not, collectively, campaign to have them radically downsized? I suspect the useful information contained in a curriculum could be distilled to 1 side of A4, and should relate more to the structure of training e.g. X amount of time for an EM trainee in paeds, DGH, trauma centre etc. There are long-standing debates about the utility of curricula even in formal educational institutions. In the context of apprenticeships, where the ‘lessons’ are dictated by work demands (in our case, patient presentations) and not scheduled classes, their purpose is especially questionable. Much like the wider concept of competency-based assessment which curricula underpin, there is little meaningful evidence that they improve trainee or patient outcomes (see here for a couple of good critiques of competency-based assessment: http://www.apagbi.org.uk/sites/default/files/images/Dorman,%20Teresa.pdf, http://www.pedsig.co.uk/wp-content/uploads/2015/04/Competency-based-training-Brightwell.pdf). Instead of grumbling about the burden of our clunky training framework, why don’t we propose and advocate for radical changes?

    Reply
  5. Nicola Wilson

    This is a pretty accurate and awesome summary of the main issues facing EM trainees. Even more awesome as it comes from a senior who appears to have heard what we are saying!

    The curriculum is a, literally, massive challenge. I honestly admit that the only time that I have come to study it in any great depth is when I have sat down to hit the books (we all know I mean the net) in time for exam revision. It is more than a little overwhelming, but actually reasonably didactic. In an environment which can feel like chaos at times going from the very minor to very sick at the drop of a hat (or likely heavier object in the case of our trauma centre), some structure and guidance on learning is welcome!

    Similarly the assessment structure…. I truly welcome revisions of the curriculum and applaud (loudly) the college for looking at the way we are assessed. Particularly modifying the way in which HSTs are assessed compared to the more junior years, including aspects of people/department management is a great idea! Getting to grips with any newness is always a challenge and one that should be a joint responsibility of both the supervisor and the trainee. After all, we want these assessments to be both meaningful and worthwhile rather than the ‘box ticking’ exercises that they often feel.

    And finally. I was once the EM trainee who was going to give it up. At the end of my first year. Long before being seduced by the bright lights of the (operating) theatre. My main issue? I felt out of my depth ALL of the time. I was the only ACCS EM trainee at my hospital. There were none of my tribe to ‘bounce off’. My educational supervisor was an Anaesthetist. He was lovely. But I am still not entirely sure that he got what I/EM training was all about. And my time in EM that year was pretty tough. I didn’t feel like I had many opportunities to learn, whilst my colleagues in other specialties seemed to be thriving. What made the difference was changing jobs and finding myself in a new environment where I was supported and my educational requirements where considered important. OK, so that involved those months in Anaesthetics. But it had the opposite effect for me… I concluded that the issues around workload, work life balance, rotas…. well they were outbalanced by the fact I really do love EM. It is what I was built for and worth the sacrifice!

    Reply
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  7. Tom

    I think EM consultants have to step up their skills if they’re to inspire their juniors and keep them in the programme. If they’re not able to RSI children etc etc then why would their trainees respect them as doctors who can can look after critically unwell or ‘Emergency’ patients? EM consultants should be forced to re-educate themselves if they come from an old school non-critical care background through appraisal/GMC mechanisms, and RCEM should change the HST Reg curriculum to focus on critical care (add a further mandatory year of anaesthesia/ICU/HEMS) to make sure newly minted consultants know what they’re doing. If we can’t do Emergencies properly then we shouldn’t be called Emergency Physicians.

    Reply
    1. Simon Carley

      Tough love from you Tom.

      Whilst it’s not all about RSI I agree that you need to be competent in the resus room to be considered a true emergency physician. Not everyone agrees…..

      vb

      S

      Reply
      1. Tom

        RCEM and the UK EM consultant body need to either accept that they will never be a proper critical care speciality or implement reforms at HST and consultant level to make the ‘true Emergency Physician’ vision a reality. Until this time, trainees brought up on the resuscitationist philosophy of Weingart, Reid, Carley et al will leave for specialities or countries where they can become ‘complete’ critical care physicians.

  8. Simon

    Tom, I have been an EM consultant for 14 years and managed countless cardiac arrests, trauma calls, sick children, dying elderly patients, serious poisonings, major burns, surgical catastrophes and orthopaedic emergencies, using both my own skills and utilising those of others around me. Unfortunately, during that time, we’ve been badly understaffed in consultant, junior doctor and nursing rotas so I have had to spend much of my time covering the shop floor. I’ve had to make a choice about where my time would be best spent and I decided that given I had great, consistent, timely anaesthetic cover, learning to RSI children wasn’t a priority.

    It makes me sad that you imply you do not respect my ability to look after critically unwell or ‘Emergency’ patients just because of this one gap in my skills/knowledge.

    I am hopeful that your colleagues, both senior and junior, will be more forgiving should you ever find yourself short of their standards either currently or in the future.

    Simon

    Reply

Thanks so much for following. Viva la #FOAMed

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