Training ANAESTHETISTS in Europe (UK)

1. Training ANAESTHETISTS in Europe (UK) Monty G Mythen Portex Professor of Anaesthesia and Critical Care. Director, Centre for Anaesthesia, Critical Care and Pain Management. University College London, UK Centre for Anaesthesia UCL

2. “ Two Great Countries Separated by a Common Language” Oscar Wilde USA and UK

3. How convince Anesthesiologists to go outside the O.R? Is it all economics? Challenges in training and future plans? Non-physician Anesthetists? Anaesthesia in Europe (UK)

4. Marathon des Sables • Extreme endurance event- several hours/ day • Thermal challenge • Fluid loss • Electrolyte imbalance • Acute inflammatory response

5. Marathon des Tables • Extreme endurance event- several hours / days • Thermal challenge • Fluid loss • Electrolyte imbalance • Acute inflammatory response

6. How convince Anesthesiologists to go outside the O.R? Is it all economics? Anaesthesia in Europe (UK) YES – BUT!

7. Critical Care – 90% Anesthetists Pain – Acute and Chronic – 95% Anesthetists Pre-op evaluation Critical Care Outreach Management Anesthesia Outside the OR?

8. National Health Service National Pay Scale No Billing! ALL Doctors paid same Term pension Funding in UK? • Private Practice • Inflated hourly rates • Direct Patient Billing • Symbiotic relationship

9. Critical Care* – 90% Anesthetists Pain – Acute and Chronic* – 95% Anesthetists Pre-op evaluation* (replacing cardiology) – “Fit for Surgery” Critical Care Outreach* (PACU + post-op care) Management Anesthesia Outside the OR? *Doctors: Doctor *Nurses: Nurse

10. How convince Anesthesiologists to go outside the O.R? Is it all economics? Challenges in training and future plans? Non-physician Anesthetists? Anaesthesia in Europe (UK)

11. Med Student 5-6 yr PRHO (no debts) 1 yr SHO (non-anesthesia) 1-4yr Reg. (3 exams FRCA) 4 yr Research (MD/PhD) 1-3 yr Senior Registrar 4 yr Consultant Training changes in last decade – 10 yrs ago 96 hrs pre week – “undertime”

12. National Health Service Service delivery by senior trainees (post-fellowship) Consultant led Funding in UK? • Private Practice • Consultant delivered

13. PRHO 1 yr SHO (non-anesthesia) 1-4yr SHO (Anesthesia) 2 yr Reg. (3 exams FRCA) 4 yr Research (MD/PhD) 1-3 yr Senior Registrar 4 yr Consultant Training changes in last decade –10 years ago 96 hrs pre week – “undertime”

14. PRHO (Modest Debt!) 1 yr SHO 1-4yr SpR 5 yr Consultant Training changes in last decade - now 48 hrs pre week – “OVERTIME!” European Working Time Directive EU – equivalence in training

15. National Health Service Trainees Consultant delivered (48 h working week) Funding in UK? • Private Practice • Consultant delivered R.O.W ? N.P.A

16. How convince Anesthesiologists to go outside the O.R? Is it all economics? Challenges in training and future plans? Non-physician Anesthetists? Anaesthesia in Europe (UK)

17. Can only work under Physicians Same as SHO (competent – not “post-fellowship” – NOT “specialists”) Training controlled by Royal College of Anaesthetists (27 months) NOT just Nurses Can not practice independently 1 Consultant : 2 Assistants. Max 2 rooms (Private practice?) Non-Physician Anaestheitists in UK

18. Pre-op evaluation SHO, pre-fellowship SpR, NPA: PMH, drugs, allergies, airway etc. Post fellowship SpR, Consultant: Is the patient fit for surgery? MY CLINIC Special investigations (CPX) Risk evaluation Per-op technique Post –op care Non-Physician vs Physician

19. Whats new in Europe (UK)? DR Judith Hulf – Vice President R.C.A. Training?

20. Post-Graduate Medical and Education Training Board (PMETB) Single unifying framework for postgraduate medical education and training General and Special Medical Practice (Education and Qualifications) Order Approved by Parliament April 2003

21. PMETB “The order places a duty on PMETB to establish, maintain, and develop standards and requirements relating to postgraduate medical education and training in the UK.”

22. PMETB • The Board: • NHS appointees • Chairman, CEO • 25 members – 9 lay / 16 medical members • 6 Academy of Medical Royal College nominees • 4 observers, 1 from each Department of Health

23. STAPMETB * Independent * Accountable Secretary of State * Certification & regulation body * Wider remit * Devolved activity to Medical * Will run own activity Royal College * Colleges ran own visiting * Will commission own visits programme. Reported to STA to include lay members

24. PMETB and Length of Training Does competency based training still need to be time based? European minimum recommended training time Does all “training” need to be completed before the award of a Certificate Completion Training?

25. PMETB and the CCT CCT=CCST Level of assessed competence in one or more areas of training What is the minimum training time for a CCT? “The standard for the award of a CCT should be the same as that currently required for a CCST”

26. Foundation Years -2 year planned programme of general training -Series of placements - number of specialties - number of healthcare settings Demonstration of competence against set standards Started in August 2005

27. Foundation Years F1 and F2 are generic training F1 normally works on 3 x 4 month posts F2, more variety, 3 x 4/12 or 4 x 3/12, but can be individually tailored Feeds into “general” specialty training Level of service commitment? Some specialities have lost their Junior Residents!

28. Specialist or GP training Medical school Two Year Foundation Programme Provisional Registration GMC Full Registration GMC

29. F2 Curriculum Case mix suited to be taught by; Critical Care A&E Acute Medicine Anaesthesia Oct 2005

30. F2 assessments Overall Pass or Fail – no grades Mini-Cex (clinical evaluation exercise – 6 observed encounters) DOPS ( direct observed procedural skills) Mini-PAT (peer assessment tool) CbD (case-based discussion) Expect to identify doctors in difficulty early

31. Specialist Training To be streamlined Years following F1/2 are Specialist Training (ST) years 1,2 etc Specialist training years to be “seamless” ST1 starts in August 2007 Selection process for ST1 will start in December 2006

32. Specialist Training PMETB sets the standards Apply direct from F2 Competency based curriculum Defined levels of competence for service delivery End point is a CCT “Accredited doctor”

33. MMC – Possible Foundation Accredited Specialist (CCT) Accredited GP (CCT) Accreditation Accreditation Competency Threshold 2 Level 2 Service Posts (Reformed SAS Grades) Accredited SpecialistTrainingProgrammes Accredited GeneralPracticeTrainingProgrammes Run Through Training Competency Threshold 1 CompetencyBased Programmes Level 1 ST Non ProgrammePosts Enhanced ServiceAppointments ESA ST Foundation Year 2 Foundation Year 1

34. Seamless specialty training Direct Path Broad-based Path - Common stem programme

35. ST1 common stem programmes ICM A&E Acute medicine Anaes thesia surgery neuro sciences non acute medicine GP paeds community medicine FY2 FY1 Oct 2005 ICM,acute medicine, anaesthesia,A&E

36. ST1 and beyond Anaesthesia ICM,acute medicine, anaesthesia,A&E FY2 FY1 Oct 2005

37. Seamless training Choice of specialty needs to be correct for the trainee Currently 50% drop-out from Anaesthesia at SHO Choosing a doctor with correct attributes Selection criteria as yet un-validated

38. Keys to Success Manpower planning Managing competency-based training Stopping continual change

39. Article 14 and Equivalence Previously: judged equivalence under Article 9 of the ESMQO Under the new medical order and PMETB Article 14 takes over the comparison with CCT training Oct 2005

40. Article 14 Country of origin is immaterial Considers training and experience from anywhere Ratio T:E is unclear

41. Equivalence 144: experience of the applicant measured against the CCST(CCT) 145: experience of the applicant measured against a non-UK specialty This could equate to a “generic” consultant or A non-UK specialty e,g. a cardiac anaesthetist

42. 145 Have to have done training abroad to fit into this category ( to stop UK trainees taking this route)

43. “Any fool can give an Anaesthetic” Nuffield Chair at Oxford University “Yes, that’s what worries me!”

44. Anaesthetic Grant Application Dear Sirs: Despite there never having been any meaningful investment in Anaesthetic research, Anaesthetics always work and are incredibly safe (mortality < 1:100,000). Therefore, please give us millions of Medical Research Council pounds so that we may indulge ourselves in intellectual frippery. Yours etc. p.s. if you ever need an operation you will be safe with us

45. Cardiology Grant! Dear Sirs: Despite having invested millions of Medical Research Council Pounds in Cardiology, heart disease remains the commonest killer in the UK. Little or no progress has been made despite having the most Professors and the biggest departments. However, I have just noticed that very few nematodes die from heart disease and we have just decoded the human genome. Therefore, please continue to give us millions of Medical Research Council pounds so that we may continue to indulge ourselves in intellectual frippery. Yours etc. p.s: you will probably die from heart disease

46. Hospital Mortality (%) following Major Surgery and Intensive Care in UK 7/99 TO 01/00 ICNARC

47. Patients in Hospital with Morbidity Following Major Surgery at UCLH

49. Survival of The Fittest