THE GAT

HANDBOOK
TWELTH EDITION
 FOREWORD
Welcome to the 12th edition of the
GAT Handbook
The aim of this Handbook is to offer a catalogue of useful information
and to act as a support guide as you find your way along your
Anna Costello training pathway to your final goal, be that life as a consultant
GAT Committee anaesthetist/intensivist or an alternative end point. The routes
Elected Member available to reaching that end goal and gaining a CCT are now
plentiful (core training, acute care common stem, dual training with
intensive care medicine) and as such we have included sections
to aid any trainee choosing any training pathway. We expect and
suggest that the most useful way to use the Handbook is to dip in
and out of the sections that you feel are most appropriate for you.
As such we hope the comprehensive contents page will guide you
to the areas you need. However, we have found all the sections
very interesting during the editing phase and would encourage you
to read other sections as you may find these are also very helpful
and stimulate thought.
Satinder Dalay
GAT Committee The last few years have seen some major changes in training across
Elected Member the medical fields including our specialty. The most significant
issues being the Shape of Training Review and the political saga
regarding junior doctor contract negotiations. Both of these are
ongoing at the time of publication and therefore the most up-to-
date information may need to be sourced from elsewhere. These
issues can make life as a trainee very challenging in the current
climate and we hope the chapters in this handbook can at least
provide some direction and support in such challenging times.

We have sourced authors who we believe can give a balanced

and accurate account of their specialist field within anaesthesia.
We would like to thank all the authors who contributed to the
Handbook. We hope you find the information included helpful and
informative. As always, the GAT Committee positively encourage
feedback and, therefore, if you have any comments please feel free
to contact us (email: [email protected]). We would also like to thank
Rona Gloag, Editorial Assistant, for her help in coordinating this
edition.

Finally, we would like to end by wishing you all the best in your
training and future careers. There will be many changes and
challenges in the years ahead but we are confident you will find a
career in anaesthesia a fruitful, happy and fulfilling one.

Anna Costello and Satinder Dalay

GAT Committee Elected Members

Every effort was made to ensure that the information in this book was accurate
at the time of going to press, but articles (particularly those to do with the
organisation of training) have a tendency to go out of date, so you are advised
to check with the appropriate organisation for the most up-to-date information.

This has been designed as an interactive document and accessible links are
highlighted in blue. Weblinks were correct as of June 2016.

2 THE GAT HANDBOOK 2016-2017

 CONTENTS
WHO’S WHO OVERSEAS TRAINING

The Association of Anaesthetists of Great Britain Australia and GASACT 56

and Ireland 6 Canada 57
The Group of Anaesthetists in Training 7 New Zealand 58
Trainee Network Leads 8
The Royal College of Anaesthetists 9 THE CONSULTANT POST
The General Medical Council 10
The British Medical Association 11
The consultant post 61
Ten top tips for your first year as a consultant 62
THE TRAINING YEARS
ACADEMIC ANAESTHESIA
Anaesthetic training, competencies
and assessments 13
Getting started in research 63
Less than full-time training 16
What is an academic clinician? 64
Applying for training in England 17
Applying for training in Wales 18
Applying for training in Scotland 19 HOW TO...
Applying for training in Northern Ireland 20
Applying for training in the Republic of Ireland 20 How to tackle your e-Portfolio 67
Out of programme training/research 21 How to design a study 68
Anaesthesia training and the armed forces 22 How to conduct an audit 69
Logbooks, confidentiality, security How to conduct a quality improvement project 70
and data protection 25 The Research and Audit Federation of Trainees 71
Annual Review of Competency Progression 25 How to write a paper 71
The FRCA examination 26 How to please the editor 72

CORE TRAINING TAKING CARE OF YOURSELF

Core Training 28 Keeping out of trouble 75

Acute Common Core Stem 29 Becoming a parent 76
Training with a long-term illness 79
DEVELOPING YOUR CV FOR... Returning to practice following a
prolonged absence 80
Members’ wellbeing 81
Bariatrics 31 Social media 83
Cardiothoracics 32 Medico-legal advice and support 84
Day surgery 34 Consent and UK legislation 84
ENT, head and neck, and difficult airway 35 What consultants really earn and how they do it 86
Intensive care medicine 36 Financial planning and pensions 87
Leadership and management opportunities 38
Medical education 39
ABBREVIATIONS
Medico-legal expert 41
Neuroanaesthesia 42
Abbreviations 91
Obstetrics 43
Ophthalmics 44
Paediatric anaesthesia 45
Pain medicine 47
Plastics and burns 48
Pre-hospital emergency medicine 49
Regional anaesthesia 50
Transplant 52
Trauma 52
Vascular 54

3 THE GAT HANDBOOK 2016-2017

4 THE GAT HANDBOOK 2016-2017
 WHO’S WHO
The Association’s motto in somno securitas
encapsulates the major focus of the aagbi:
safety.

5 THE GAT HANDBOOK 2016-2017

 WHO’S WHO
The Association of Anaesthetists Separate from the Association, is the AAGBI Foundation which is
a registered charity. The AAGBI Foundation also adopted a new
of Great Britain & Ireland (AAGBI) constitution in 2014 and its objectives are:

• the advancement of public education in and the promotion

Objectives and structure of those branches of medical science concerned with
anaesthesia, including its history
The Association of Anaesthetists of Great Britain & Ireland • the promotion of study and research into anaesthesia and
(AAGBI) was founded in 1932. The AAGBI adopted a new related sciences and the publication of the results of all such
constitution in 2014. Today its objectives are: study and research
• the advancement of patient care and safety in the field of
• to advance and improve patient care and safety in the field anaesthesia and disciplines allied to anaesthesia in the UK,
of anaesthesia and disciplines allied to anaesthesia Ireland and anywhere else in the world.
• to promote and support education and research in
anaesthesia, medical specialties allied to anaesthesia and The Foundation has its own Board of Trustees, some of whom are
science relevant to anaesthesia Directors of the AAGBI and some are appointed independently.
• to represent, protect, support and advance the interests of The AAGBI Foundation also founded the Overseas Anaesthesia
its members Fund (OAF) in 2006, whose projects include the book donation
• to encourage and support worldwide co-operation between programme, support for anaesthesia fellows in Uganda, the
anaesthetists SAFE obstetric anaesthesia courses and the global pulse
oximetry project, Lifebox. The International Relations Committee
The AAGBI pursues these objectives with vigour and enthusiasm (IRC), through charitable funding by the Foundation, considers
on behalf of both anaesthetists and the general public. Current applications for travel and project grants in developing countries.
membership stands at over 11,000, which accounts for Research grants are administered through the National Institute
approximately 90% of anaesthetists in the UK. Trainees make of Academic Anaesthesia (NIAA).
up more than 3,500 of these and are represented by the Group
of Anaesthetists in Training (GAT) Committee. The headquarters Branching out from the central strategic bodies are the numerous
of the AAGBI are at 21 Portland Place, an elegant 18th century working committees of the Association and Foundation. These
Grade II listed building on London’s ‘Grandest Street’. The include Education, Standards, Safety, Wellbeing and Support
AAGBI’s Patron, HRH The Duke of York, officially opened the and a number of working parties tasked with producing national
building in November 2003. It houses meeting rooms of various equipment, pharmacological and safety guidance, popularly
sizes, a restaurant and a museum, together with the busy known as the AAGBI ‘glossies’. AAGBI representatives sit on the
administrative staff of the AAGBI. Council of the Royal College of Anaesthetists (RCoA) and other
anaesthetic specialist societies, NCEPOD and NHS Committees/
Groups facilitating collaboration and information dissemination.
The President and Officers of the AAGBI also meet regularly with
their equivalents at the Royal College of Anaesthetists, College
of Anaesthetists of Ireland and the British Medical Association.

What exactly does the AAGBI do?

A large amount of the work of the AAGBI concerns education

and development within the specialty. Three scientific meetings
are organised each year: Annual Congress takes place each
September at a venue in either the UK or Ireland. The WSM (or
Winter Scientific Meeting) is the largest meeting and is held in
London every January and includes a Core Topics day. The
GAT Annual Scientific Meeting is held in the summer and the
venue rotates around the country to provide equality of access
to trainees. This is on top of the popular Core Topics days
held regionally and the numerous seminars that take place at
Portland Place throughout the year. All events are open to all
The activities of the AAGBI are co-ordinated by the Board of anaesthetists, but members of the AAGBI enjoy discounted rates.
Directors, which meets up to six times a year. Voting members of GAT also holds several in-house seminars on topics relevant to
the Board are the Officers, elected members and also the GAT trainees and those approaching consultancy.
Chair and Honorary Secretary. The AAGBI Council consists of
all Board members as well as a number of non-voting co-opted The AAGBI has a number of working parties in progress at any
members (the Presidents of the UK and Irish Colleges, the one time to set standards and address pertinent concerns within
Convenors of the AAGBI Scottish and Irish Standing Committees, the specialty. Recommendations and guidelines are normally
a representative from the defence medical services, the Chairman produced as a ‘glossy’ publication. The ‘glossies’ are available
of the SAS Committee, a BMA representative, independent on the website, or via our Apple or Android Guidelines app.
AAGBI Foundation Trustees, a lay representative and the GAT
Committee Vice Chair). Council provides a forum for strategic In 2008, the AAGBI, together with the RCoA, the journals
discussion of issues affecting anaesthesia, and opportunity for Anaesthesia and the British Journal of Anaesthesia, formed the
high level information exchange and is advisory to the Board. NIAA, which is now the main source of funding for anaesthetic
Council meets four times a year. research in the UK. The NIAA has been awarded Partnership
status by the National Institute for Health Research (NIHR). This
means that many studies funded by NIAA Research Council

6 THE GAT HANDBOOK 2016-2017

 grants are adopted onto the NIHR portfolio and are eligible for Background of the GAT Committee
support from the NIHR Comprehensive Local Research Networks.
The AAGBI also bestows numerous grants and awards upon its The GAT Committee is a democratically elected body that
members for research and travel through the Research & Grants exists to represent trainees in anaesthesia at a national and
Committee and International Relations Committee. international level. It exists under the auspices of the AAGBI and
represents the views and perspectives of over 3,500 anaesthetic
Anaesthesia is the monthly scientific journal of the AAGBI and is trainees, accounting for over 70% of anaesthesia trainees within
circulated to all members. With Anaesthesia comes Anaesthesia the UK, and approximately one third of the AAGBI membership.
News, the newsletter of the Association. It aims to keep members
up to date with specialty news as well as taking a more light- History
hearted look at our specialty. As of 2013, the AAGBI has launched
an online resource – Anaesthesia Cases – to allow anaesthetists 1956
to upload interesting case reports and to share their knowledge • Trainees first permitted to become associate members
and experiences. of the AAGBI

Why do we have a College and an Association? 1967

• Associates in Training Group (ATG) established under
The AAGBI was responsible for introducing the Diploma of the Presidency of Dr Pinkerton
Anaesthesia and the Faculty of Anaesthetists to the Royal
College of Surgeons in 1948. This ultimately led to the formation 1970
of a separate College of Anaesthetists, which received its Royal • ATG changed to Junior Anaesthesia Group (JAG)
Charter in 1992. The AAGBI and the RCoA have many objectives • Two members of JAG were admitted to Council with full
in common. However, the AAGBI can act in areas in which voting rights
the RCoA cannot, for instance, in matters affecting the terms
and conditions of service and in representing the interests of 1992
anaesthetists. Both bodies share the setting and maintenance • JAG became GAT
of standards, the promotion of education and, more recently,
areas such as the development of guidance on the European
Working Time Regulations. Collaboration is, and needs to be, Today
close on many issues. However, the RCoA, with its Royal Charter
and Ordinances, is bound by statute to protect the public. It also Today the GAT Committee is made up of 13 elected members
has other statutory duties such as setting the Fellowship exams, and four co-opted members from other affiliated organisations.
advisory appointments committees and duties to its fellows. We maintain a firm presence on many other national bodies, such
The functions of the RCoA are therefore constrained by these as the RCoA Trainee Committee and the BMA Junior Doctors
statutes. The AAGBI, while sharing similar objectives, can act Committee, and have links with bodies in Europe, Canada,
more obviously for the benefit of anaesthetists. Fortunately, for Australia and New Zealand.
us all, the RCoA and the AAGBI work closely and in harmony.
GAT has established several networks of trainee links across
Why join the AAGBI? the country to improve information gathering and dissemination.
After raising training and political issues with the relevant
The membership fees are extremely good value, particularly for organisations, we feed information back to our membership via
trainees and offer a wide range of membership benefits. the many avenues available to us:

To join, contact the AAGBI membership department: Tel: 020 • Trainee Network Leads
7631 8801; Email: [email protected] • Less than full-time trainee network
• The @AAGBI e-newsletter
Acknowledgement • Social media, including Twitter and Facebook
I would like to acknowledge Chris Meadows (GAT Committee • The AAGBI website
Chair 2007–2009) for authoring the original version of this • Anaesthesia News
chapter and Richard Paul (GAT Committee Chair 2013–2014) for
his work on the last revision. Representation

Andrew Hartle In the summer of 2014 we sent a letter to the Secretary of State
AAGBI President for Health, Jeremy Hunt, regarding the report into the Working
Consultant in Anaesthesia & Intensive Care, Imperial College Time Regulations, which he had commissioned. In our letter we
Healthcare NHS Trust, St Mary’s Hospital outlined a number of concerns with the report, especially the
‘encouragement’ of trainees to opt out the working time directive
and the proposal to separate training from service. Our letter was
positively received by the BMA.
The Group of Anaesthetists in Training
Over the last few years the Shape of Training (SHoT) has
moved from being a concept that appeared to be an idea
I joined the Group of Anaesthetists in Training (GAT) Committee hastily proposed, to one which has been embraced by several
after passing my final exam. It was partly an attempt to fill the organisations. The GAT Committee has actively followed its
void that the exam had left behind. The other, more romantic, evolution. We have submitted evidence to the SHoT steering
reason was from an inner nag. I had never been a committee group, attended many stakeholder events and worked alongside
kind of person but was getting a little irritated by coffee room both the RCoA and the Academy of Medical Royal Colleges. We
discussions about the problems facing our profession and the have recently submitted evidence to the GMC regarding two
NHS. These conversations would generate lots of opinions and consultation exercises and have been discussing SHoT with the
(some) sensible solutions but no real way of taking those ideas BMA Multi-Speciality Working Group.
further. I saw an email from the AAGBI calling for nominations to
the committee and I thought, why not? At the time of writing, GAT has been diverting most of its attention

7 THE GAT HANDBOOK 2016-2017

 to the junior doctors contract negotiations. We have attempted Trainee Network Leads
to represent our members during this period and ensure that
information is disseminated swiftly. As soon as the Government
announced it was imposing a contract on junior doctors, GAT What is the Trainee Network Lead Scheme?
published a statement countersigned by eight other training
groups (representing over 9,000 trainees) that questioned the In 2012 GAT started an initiative aimed at improving the
logic behind this decision. As the fight raged on and many of communication between trainees at regional level and the
you became upset, and even more became disillusioned, we committee itself. The goal was to allow easy, rapid dissemination
co-wrote a wellbeing statement with the RCoA and Faculty of of information related to GAT and the AAGBI, and to allow a
Intensive Care that pointed to useful resources during that two-way dialogue to facilitate discussion around concerns,
stressful time. opportunities and local programmes that might be applicable to
all. Trainee Network Leads (TNLs) are motivated trainees within
GAT committee members are key stakeholders on various AAGBI each school of anaesthesia across the UK and Ireland that act
committees and both the GAT Chair and Honorary Secretary are as a continual point of contact and communication within the
on the AAGBI Board of Directors and are Trustees of the AAGBI network. GAT now has at least one TNL in all regions, and have
Foundation. Our opinions are always valued and carry a lot of gathered and acted upon vital information sent to us, from major
weight with the board members. The GAT committee were key national training and contract issues to regional avant-garde
contributors to the National Essential Drug List and have been educational and welfare initiatives. Despite increasing pressures
authors on several AAGBI Safety Guidelines and National Audit on time and training, there is a formidable volume of hard work
Projects. going on at local and national level by enthusiastic anaesthetic
trainees and trainers. We hope the GAT Trainee Network Lead
Education Scheme can grow and evolve to continue supporting this.

Through close work with the AAGBI Education Committee and What are the roles of a TNL?
Events team, GAT has refined the GAT Annual Scientific Meeting
(ASM). It is now recognised for its scientific content with parallel We would expect a TNL to be an enthusiastic trainee at any stage
streams catering for primary, final and post exam trainees. We of training, keen to be actively involved and quick to respond to
continue to attract high calibre oral and poster presentations, queries from GAT. The post is held for a minimum of 12 months,
which are judged by the GAT committee and AAGBI Board. With and includes a number of varied and stimulating responsibilities
the help of Dr Nancy Redfern (AAGBI Honorary Membership that, as well as improving personal and professional development
Secretary) we have introduced mentoring sessions at the ASM. in areas such as leadership and management, will make for
These sessions continue to be oversubscribed each year and engaging discussion at an Annual Review of Competency
have prompted many trainees to undertake training in how to Progression. It is a pleasure to see that several past TNLs have
become a mentor. Within the last few years, GAT has organised subsequently run for and successfully become democratically
consultant interview seminars and developed the AAGBI elected members of the GAT Committee.
Management and Leadership Course.
Formal TNL responsibilities include:
Innovation • To help raise the profile and encourage membership of the
AAGBI and GAT, by ensuring local trainees are aware of the
Trainees tend to be the creators and early adopters of multitude of services and support that are available
revolutionary ideas. We were the first in the world to introduce • To disseminate information from the GAT Committee and
the Parent and Baby Room at the ASM. This facility is now highly the AAGBI, including regular e-newsletters and ‘hot’ or
regarded, and has been embraced by other meetings such at political topics of note
the AAGBI Winter Scientific Meeting. In 2015 we organised and • To advertise and encourage trainee attendance and
chaired the Innovation session at the AAGBI Annual Congress participation at the annual GAT ASM
in Edinburgh with topics including how to develop an app and • To discuss via email, local forums or regional trainee groups
medical device patenting. We constantly reflect on how we any issues that arise within your region, and feedback
function as a committee and have invested time in developing concerns to GAT for consideration and action at a national
skills such as leadership and followership. We recently achieved level
recognition with the RCoA for Advanced Training in Management, • To keep GAT informed of local ideas, progress and examples
which allows activity we undertake on the GAT Committee to of excellence that are to be applauded and might be of
contribute to the RCoA Leadership and Management module, benefit to trainees elsewhere in the UK and Ireland
and anticipate that this type of innovation will see committee • To aim to attend the annual GAT ASM and the Linkman
members becoming future healthcare leaders of tomorrow. Conference at AAGBI Annual Congress, where TNL
meetings are held to meet the GAT Committee and to allow
We want you! networking and discussion to occur
• To complete and return an annual feedback and information
Many people become frustrated when they see problems that form
they have no way of influencing. This is much like the frustration • To ensure the role of TNL is self-sustaining by establishing
I was experiencing during my coffee breaks; the problems the next regional TNL prior to stepping down
were outside of my circle of influence. By joining a committee
and finding your voice you can slowly increase your circle. Of note, GAT does not have specific funding for the Trainee
It can be busy but it is good fun. If you are passionate about Network Lead Scheme and for the work performed by the TNLs.
your profession and have opinions you wish to share I would GAT hugely appreciates the work undertaken by the TNLs and
encourage you to join us – elections normally take place in May ensures that they have a formal letter on behalf of the AAGBI
each year. and GAT annually (and/or upon stepping down), which can be
used as portfolio evidence. In addition, as a TNL you may be
Ben Fox given the opportunity to attend meetings on behalf of GAT and
GAT Committee Chair to be involved in AAGBI/GAT-related initiatives such as working
parties, audit and research, and we would encourage TNLs to
take these up when offered.

8 THE GAT HANDBOOK 2016-2017

 How do I contact or become a TNL? Internal and external committees

The AAGBI website has an area dedicated to TNLs where you The Council also receives reports from approximately 30
can find out who represents your region. If your region does not committees that meet on a less frequent basis. These committees
have a TNL, you would like to help us to establish one, you would are responsible for considering College-related issues in more
like to contact your TNL, or you have any other enquiries and detail and making recommendations to Council for decisions to
suggestions, please email [email protected]. Each region decides be made. Specific committees include Training, Examinations,
how they will handover or identify their TNL, be that by ballot, Education (which co-ordinates the programme of seminars and
volunteer or nomination. Note that some areas have more than conferences organised by the College), Professional Standards,
one TNL, particularly if their school of anaesthesia is large or the Safe Anaesthesia Liaison Group and the Workforce Planning
disparate in geography. One size does not fit all, and the scheme Strategy Group. Trainee members of Council or representatives
remains flexible and under regular review to allow for this. from the Trainee Committee sit on all committees concerning the
interests of trainees.
Rowena Clark
GAT Committee Vice Chair and Trainee Network Lead Officer The RCoA is also represented on a large number of external
committees including the AAGBI Council, the GAT Committee,
Academy of Medical Royal Colleges and the Faculties of
Intensive Care and Pain Medicine. In addition, the College is
The Royal College of Anaesthetists asked to contribute to various working groups and publications
and consultations from the wider healthcare community such
as the GMC, NICE, Department of Health, and the National
Confidential Enquiry into Patient Outcome and Deaths.
The Royal College of Anaesthetists (RCoA) is the professional
body responsible for the specialty of anaesthesia throughout the College staff and volunteers
UK. Its principal responsibility is to ensure the quality of patient
care through the maintenance of standards in anaesthesia, pain The administrative functions of the College are undertaken by
medicine and intensive care. The College’s activities as laid approximately 80 permanent members of staff organised into
down by its Royal Charter include: operational directorates:

• Setting standards of clinical care • Training and Examinations

• Establishing standards for the training of anaesthetists • Education and Research
and those practising critical care and pain medicine (in • Clinical Quality
conjunction with the GMC) • Communications
• Setting and running examinations • Finance
• Continued medical education of all practising anaesthetists • Facilities
• IT
Organisation
In addition to the valued work of these employed staff members,
The RCoA comprises an elected Council of practising the College is only able to administer its numerous duties due
anaesthetists. The Council elects the President and two Vice to the significant contribution of a large number of volunteers.
Presidents from their members. College Council is represented The Fellowship of the Royal College of Anaesthetists (FRCA)
on a series of Committees and Working Parties and they consider examination could not run without the dedication of the volunteer
particular areas of work. examiners. Ensuring the delivery of high quality training is
the responsibility of over 300 College Tutors and 50 Regional
The College Council Advisers. College Assessors advise on consultant appointment
committees and undertake peer review for clinical standards
There are 24 elected members of Council including the President accreditation.
and two Vice Presidents. They include:
The curriculum and examinations
• Twenty consultant members who have been Fellows for
more than four years: elected for a six year term of office, The College is responsible for writing the curriculum for training
can be re-elected for a further four years. of anaesthetists in the UK. The current curriculum was approved
• Two staff and associate specialist members: elected for four by the GMC in 2010 and undergoes minor revisions annually.
years; can be re-elected for a further four years. The Training Committee oversees all aspects of training, from
Two trainee members within four years of gaining the fellowship revising the Certificate of Completion of Training (CCT) to making
elected from the Anaesthesia Trainee Representative Group recommendations to the GMC for the award of a CCT.
(ATRG).
To become a Fellow of the RCoA by examination you must pass
The RCoA is a registered charity and the 24 elected members of the Primary and the Final examinations. The examinations are set
Council are the governing Trustees. and supervised by the RCoA through a Board of Examiners who
are senior consultants and experts in their fields. The College
In addition, there are six co-opted members representing the is committed to maintaining the highest possible standards for
interests of other organisations including the Faculty of Pain its examinations. In order to maintain this position, the FRCA
Medicine, RCoA Advisory Boards for the devolved nations, the examiners and the Examinations Department rigorously quality
AAGBI, the RCoA Lay Committee and Clinical Directors. assure all processes and actively engage in research and
ongoing development work to ensure the pre-eminence of the
The College Council meet on a monthly basis for discussion FRCA.
of policy and professional issues that may require extensive
consideration, formal and ceremonial matters, granting of
diplomas, and the passing of resolutions for which the formal
authority of Council is required.

9 THE GAT HANDBOOK 2016-2017

 e-Portfolio The General Medical Council
Training in anaesthesia requires the maintenance of an
electronic portfolio, which is administered from the RCoA’s The General Medical Council (GMC) is the independent
Training Department. There is a dedicated e-Portfolio Training regulator of the medical profession in the UK. Doctors must
and Support Team based at the College to answer queries be registered with the GMC and have a licence to practise to
and offer help. Support is staffed Monday to Friday from 9.00 be able to practise medicine in the UK. The medical register is
am–5.00 pm (excluding public holidays). Tel: 0207 092 1556 available for anyone to search on the GMC website.
or email: [email protected]. More details regarding the
e-Portfolio are available in the e-Portfolio chapter. Good medical practice

E-Learning Anaesthesia (e-LA) The GMC set the standards for good medical practice. The
core guidance is Good medical practice, which sets out the
e-LA is an interactive and engaging web-based learning principles and values that doctors should follow in their work.
resource developed by the RCoA in partnership with e-Learning More detailed explanatory guidance covers issues as diverse
for Healthcare (e-LfH). as end of life care, obtaining consent from children and doctors’
use of social media. All the guidance, and a range of learning
Written and edited by anaesthetists, e-LA covers the knowledge tools including interactive case studies, is available on the GMC
and key concepts that underpin the anaesthetic curriculum website.
and will help trainees prepare for the FRCA examination. The
learning material is presented as a structured series of bite-sized The GMC’s Raising and acting on concerns about patient safety
lessons and includes access to an extensive e-Library, a self- guidance gives advice on raising a concern if a patient might be
assessment area and e-CPD to support continued professional at risk of serious harm, and on the help and support available
development in anaesthesia. to doctors. There is an online tool to help make decisions about
raising concerns and the GMC runs a confidential helpline (0161
Novice guide 923 6399, open Monday-Friday, 9.00 am–5.00 pm), staffed by
specially trained advisers, for doctors to raise concerns.
The RCoA has produced an interactive Guide for Novice Trainees
to support their first 3–6 months on the training programme. Revalidation

The guide was originally produced in August 2013, is available Revalidation was launched by the GMC at the end of 2012. This
online and is supplied on a USB drive to trainees on registration aims to ensure doctors are regularly appraised against the GMC
with the College. standards and ensures they are keeping their knowledge and
skills up to date. More about revalidation, including specific
The guide contains key documents and a step-by-step approach questions and answers for doctors in training, is available on
to help trainees get started on the training programme. It also the website.
contains Module 1 from e-LA, specifically written for novice
trainees as an introduction to anaesthesia, to support the first Standards for education and training
three months on the training programme. There are additional
learning resources and guidelines available from the AAGBI, the The GMC sets the standards for medical education and
Resuscitation Council and the Difficulty Airway Society. training and ensures that these standards are being met.
These standards, Promoting excellence: standards for medical
Trainee representation within the RCoA education and training, were updated in July 2015; effective
from 1 January 2016. This single set of standards for all stages
Elected trainee representatives from each School of Anaesthesia, of medical education and training put patient safety, quality of
together with co-opted members from the Faculties of Intensive care, and fairness at the heart of the teaching and training of
Care and Pain Medicine, make up the ATRG. This group medical students and doctors in training.
meets annually at the RCoA and provides a geographically
representative body to provide input into all areas of College An important means of the GMC ensuring training standards are
activity. From this group, a Trainee Committee and the two being met is through its national training surveys. All doctors in
trainee members of Council are elected. training are required to complete this survey annually.

The role of the College’s Trainee Committee is to: Fitness to practise

• Represent trainee opinion to the College Council In the event that a doctor is not meeting the professional
• Enhance and maintain dissemination of relevant information standards the GMC sets, the regulator has strong legal powers
to trainees to restrict or prevent them from practising medicine in the UK.
• Contribute to the RCoA Bulletin and the editing of The Gas More about how this occurs is available via the website.
newsletter
• When requested by Council, provide representation on
Council sub-committees and working parties either from
the Trainee Committee or the ATRG
• Provide anaesthetic trainee representation on various
external committees as requested, including the Academy
Trainee Doctors Group (ATDG) and GAT
• Actively participate in the professional development of
trainee anaesthetists

The Trainee Committee is always happy to hear from colleagues

at all stages of training: [email protected]

JP Lomas
RCoA Council Member

10 THE GAT HANDBOOK 2016-2017

 The British Medical Association Getting involved

Local representation
The British Medical Association (BMA) is an independent The BMA aims to accredit at least one junior doctor per employer
trade union and professional body, representing over two- as a BMA representative to represent colleagues at local level,
thirds of UK practising doctors. It is officially recognised by the and to help solve basic work-related problems for its members.
Government and the Review Body on Doctors’ and Dentists’
Remuneration (DDRB) as the only organisation representing all The role involves providing advice (e.g. on pay, monitoring,
NHS doctors employed under national agreements. The BMA accommodation standards and travel expenses) and attending
has responsibility for negotiation of pay and other conditions of local negotiating committee meetings, where both doctors
service and, as such, is ideally placed to understand doctors’ and managers meet to discuss local issues and negotiate any
day-to-day working lives and challenges. variations from the nationally agreed contract. A BMA industrial
relations officer will also be a member of the local negotiating
The BMA negotiates and maintains terms and conditions of committee.
service for doctors not only nationally, but also at a local level.
Advice and support to individual members for a wide range of Full training and access to several guides for representatives
workplace issues is provided. The BMA is heavily involved in are provided, as well as guidance on who to contact for further
protecting junior doctors’ rights and improving their working information. Training can be either in-house or arranged on an
lives through a range of initiatives such as providing a contract away-day basis, with time off granted from work under trade
checking service, rota and banding advice, and information union legislation and all costs paid for by the BMA. This time off
regarding relocation and travel expenses. The BMA also provides is separate from your allocation of study leave.
support on a much more personal level through a dedicated
counselling service. Regional representation
The regional Junior Doctors Committees (JDCs) represent junior
To join the BMA, visit our website. BMA membership is tax doctors at a regional level, with boundaries roughly aligned to
deductible (as are other professional memberships such as the Local Education and Training Boards (LETBs), previously known
AAGBI and the RCoA), and can be claimed for using the tax as Deaneries. The committees meet four times a year and all
claim form in the members’ section of the website. junior doctors living or working in the region are welcome,
whether they are BMA members or not. These meetings are
Employment support an opportunity to ask for advice, give your views to the BMA
and receive updates on local and national issues. See the BMA
If you are a BMA member with an employment query (for example, website for details of your regional JDC.
questions about contracts, pay, or rotas) then contact the BMA
on 0300 123 1233 between 8.30 am and 6.00 pm, Monday to National representation
Friday, excluding bank holidays, to speak to an adviser. They The UK JDC, comprised of juniors elected through various routes
will endeavour to deal with your query on first contact but if including regional JDCs, represents all junior hospital doctors in
necessary will assign a member of staff in the appropriate BMA the UK. It has sole negotiating rights with the government for all
office to help. You can also email an adviser once you have doctors in training employed in the NHS. If you wish to attend a
logged into the BMA site or contact them through live chat via UK JDC meeting (held at BMA House in London) as a visitor, or
the website. simply want to know more about the work of the committee, then
email [email protected]
Information services
Contacting the BMA
Membership includes access to a wide range of information,
including the weekly BMJ and BMA newsletter. For access to The BMA website contains a vast amount of information and is an
current and archived articles go to the BMJ website. invaluable resource. If you cannot find what you are looking for
or require further help and support on an employment issue then
The BMA library provides free access to over 1,300 e-books call 0300 123 1233 and speak to an adviser. If you are struggling
and more than 300 e-journals, and full access to the Medline either at work or at home, the BMA provides a confidential
database. Books and DVDs can be requested through a postal telephone counselling service – available 24 hours a day, 7 days
loans service. The library, based at BMA House in Tavistock a week – and a doctor adviser service where you can speak
Square, London, also provides computer access; scanning, to another doctor in confidence. The service can be accessed
printing and photocopying facilities, and Wi-Fi. For further by calling 08459 200 169. For doctors under investigation by
information email [email protected] the GMC, there is the BMA Doctor Support Service, offering
confidential emotional support.
Career development
The BMA maintains an active presence on social media via
There are a range of services to support lifelong learning and Facebook, Twitter and YouTube and membership provides
professional development available through the BMA. The access to the online BMA Communities, making it easy for you
BMA Careers Service provides guidance and a wide range to get involved, express your views, and keep up to date with
of continuing professional development (CPD) approved the local, regional and national changes to life in the medical
workshops and e-learning modules. profession.

Ethical advice Heidi Mounsey

BMA JDC representative
The BMA ethics department offers comprehensive advice on
an extensive variety of topics including consent, confidentiality
and working with children. Free online access to Medical
Ethics Today, the BMA’s handbook on legal and ethical issues
encountered in clinical practice, is also available to members.

11 THE GAT HANDBOOK 2016-2017

 THE TRAINING YEARS
“Put simply ‘good enough’ is not good
enough. Rather, in the interests of the health
and wealth of the nation, we should aspire
to excellence.”
Professor Sir John Tooke, Aspiring To Excellence

12 THE GAT HANDBOOK 2016-2017

 THE TRAINING YEARS
Anaesthetic training, competencies general professional knowledge, skills, attitudes and behaviours
required of all doctors. Twelve domains have been identified by
and assessments the RCoA covering professionalism and common competencies.
These are as follows:

Training • Professional attitudes and behaviours

• Clinical practice
The current curriculum for a CCT in Anaesthetics was introduced • Team working
in 2010 and aims to produce ‘well-trained, high quality clinicians, • Leadership
with the broad range of clinical leadership and management • Innovation
skills and professional attitudes necessary to meet the diverse • Management
needs of the modern National Health Service [NHS] and who • Education
can embark upon safe, independent practice as consultant • Safety in clinical practice
anaesthetists in the United Kingdom [UK]’. • Medical ethics and confidentiality
• Relationships with patients
This current anaesthetic training programme as overseen by • Legal framework for practice
the RCoA is described as ‘a competency-based, supervised, • Information technology
continuously evaluated and tightly regulated programme, with
the potential for tailoring to suit individual requirements and The anaesthetic training programme
interests’.
Foundation Years 1 and 2
A typical training period in anaesthetics lasts seven years, made Many doctors will pass through anaesthetic departments for a
up of the following four phases: few months as part of their foundation training (FT) programme,
but their numbers are limited. Some of them may return to
• Basic level training – two years (CT1 and 2) or three years anaesthesia in the future having achieved valuable competencies
if Acute Care Common Stem (ACCS) during time spent in other specialties.
o Primary FRCA gained before progressing to ST3
• Intermediate level training (ST3 and 4) – two years Important milestones in the anaesthetic training
o Final FRCA gained before progressing to ST5 programme
• Higher and advanced level training (ST 5–7) – three years
• Initial assessment of competence (within first six months)
The actual duration of training is not fixed, but will depend • Initial assessment of competence in obstetric anaesthesia
on individual needs and the rate at which competencies are (within first two years)
achieved. • Primary FRCA examination (normally acquired during CT1
and 2. Required for progression to ST3)
The objectives of training are grouped into four stages of learning • Basic level training certificate (end of CT)
(basic, intermediate, higher and advanced) and, within these, • Final FRCA examination (during ST years 3 and 4. Required
they are organised by surgical subspecialty or anaesthetic focus. for progression to ST5)
In addition, there is a group of general outcomes that is listed • Intermediate level training certificate (end of ST year 4);
separately as ‘professionalism and common competencies in • Higher essential units of training (during ST5–7)
medical practice’. • Advanced special interest units of training relevant to
ultimate area of practice (during ST6–7)
Training concepts: competency, spiral, broad-based, flexible
and experimental learning A separate career pathway for those wishing to become
academic anaesthetists is discussed below.
The RCoA defines competence as ‘possession of the knowledge,
skills and attitudes required to undertake safe clinical practice Basic level training
at a level commensurate with stated objectives’. The training
scheme is designed to ensure trainees become competent in Core Training Years 1 and 2 or ACCS years CT1, CT2a and
each area before progressing rather than moving on simply due CT2b
to the passage of time.
The detailed explanation of the competencies required to
The current curriculum is built around spiral learning where complete basic level training and how they are assessed are
trainees return to anaesthetic subspecialties a number of times found in Annex B of the CCT in Anaesthetics which can be found
over the training years, allowing them to gradually build on their at www.rcoa.ac.uk
basic knowledge. Flexibility is maintained so that the needs of
anaesthetic trainees who choose not to specialise until their There are two pathways into anaesthetic training, either as a
later years of training can be catered for; this will also allow the Core Anaesthetic Trainee or via the Acute Care Common Stem
specialty to respond rapidly to the changing face of medicine. (ACCS). If entering anaesthetics via the ACCS route, basic
Finally, practical skills are learnt through ‘hands-on’ training, with training will be extended by a year to allow time to be spent in
not all trainees being expected to acquire the same advanced emergency medicine and acute general medicine.
skills. For this reason, advanced and higher competencies have
evolved. Basic Level Anaesthetic Training is divided into two parts:

Common competencies of medical practice required • The basis of anaesthetic practice (normally 3–6 months)
of all doctors • Basic anaesthesia (including three months of intensive care
medicine (ICM)) which is normally 18–21 months
Aside from the clinical training, the trainee must also develop

13 THE GAT HANDBOOK 2016-2017

 The initial training of novice anaesthetists is an introduction to After acquisition of the ILTC, the primary aim is ‘to produce
the principles and practice of safe anaesthetic care and consists trainees competent for independent professional practice in
of the following units: their chosen consultant career path’. The RCoA highlights that
training opportunities should be balanced with anticipated
• Pre-operative assessment including history taking, clinical career vacancies. All trainees must undertake a generalist
examination and specific anaesthetic evaluation pattern of training within a broad and balanced programme, but
• Premedication this stage is designed to be more flexible and tailored than basic
• Induction of general anaesthesia and intermediate level training programmes. In order to attain
• Intra-operative care consultant status, every trainee must complete the full higher
• Postoperative and recovery room care and advanced programme of training and have undertaken
• Management of respiratory and cardiac arrest a total of at least nine months of ICM (see above). Higher and
• Control of infection advanced training would together normally take three years and
• Introduction to anaesthesia for emergency surgery can be completed in a flexible sequence. At least two of these
three years must be spent in approved training or research posts
Trainees are expected to have achieved these clinical learning within the UK. Up to one year may be spent either outside the
outcomes and obtained the Initial Assessment of Competence UK in a prospectively approved post, and/or in dedicated work
(IACC) before progressing to the remainder of basic level in a single specialty area. Only one year of full-time research can
training. This initial training will take between 3–6 months for count towards a CCT.
most trainees and the IACC must be obtained prior to trainees
undertaking anaesthetic activity without direct supervision. This Higher level (‘post-fellowship’) training lasts for two years, at least
usually occurs about three months into the training scheme, one year of which should be spent undertaking general duties. In
although the RCoA are keen to stress that the emphasis, this year, at least eight of the 13 general units of training must be
particularly during basic level training, is on competence not completed, including two mandatory units (airway management
on time. ACCS trainees from parent specialties other than and management of respiratory arrest).
anaesthesia are expected to complete the basis of anaesthesia
practice and gain their IACC. Trainees arriving in the UK having Advanced level training lasts for one year and may involve
worked elsewhere will also be obliged to pass this assessment further training in either general or specialist (e.g. paediatric,
before undertaking any solo work or participating in an on-call cardiothoracic, neuro) anaesthesia. Advanced training in
rota. general anaesthesia may involve several units or focus on one.
The trainee should aim to gain expertise in both clinical and
Basic anaesthesia training will normally last 18–21 months professional competencies.
and provides an introduction to all aspects of elective and
emergency anaesthetic practice as well as intensive care An example of a clinical programme may consist of:
medicine. Completion of RCoA workplace-based assessments
(WPBAs), passing the Primary FRCA exam and demonstration • Higher training programme – thee month blocks in a
of acceptable attitudes are required to gain the Basic Level combination of general duties and specialist duties
Training Certificate (BLTC), usually at the end of the second year (paediatric, neuro and cardiac anaesthesia). This will be
of anaesthetic training. based on the clinical work available in each department
• Advanced training programme – a 6–12 month block in
Intermediate level training one of the key unit of training areas. These are aimed at
individuals who wish to work as consultants with a significant
The detailed explanation of the competencies required to subspecialty clinical commitment
complete basic level training and how they are assessed are
found in Annex C of the CCT in Anaesthetics which can be found In order to achieve a CCT it is necessary to complete all training in
at www.rcoa.ac.uk an approved training programme, be registered as a trainee with
the RCoA and complete the minimum training to a satisfactory
ST Years 3 and 4 standard.

This period of training will normally last 24 months and is based Academic training
on the principle of ‘spiral learning’. Trainees are required to
gain intermediate level competencies in all the units of training There are a number of different routes into academic anaesthesia.
undertaken in basic level training, as well as in important new
and often complex areas of clinical practice, e.g. anaesthesia The National Institute for Health Research Pathway
for cardiac and neuro surgery. Intermediate competencies have
been subdivided into seven ‘essential’ units and three ‘optional’ A clear, integrated academic training pathway has been
units. At the end of ST Year 4, trainees will receive an Intermediate developed by the National Institute for Health Research (NIHR).
Level Training Certificate (ILTC) if they have successfully passed Trainees now have the opportunity to choose an academic
the Final FRCA, continued to demonstrate acceptable attitudes training pathway from foundation training – much earlier than
and behaviour, and passed all the required WPBAs. Some local was traditional.
flexibility may be required in order for trainees to gain adequate
exposure (usually 1–3 month blocks) to the essential units; Academic training posts are available at three stages in training:
training across anaesthetic schools or deferment of specific • Foundation level, which may involve time within academic
named units may be considered. anaesthesia departments
• Academic Clinical Fellowships (ACFs)
Higher and advanced level training • Clinical Lecturers (CLs)

ST Years 5, 6 and 7 Trainees are appointed to an academic National Training Number

(NTN(A)) (rather than the usual National Training Number (NTN))
The detailed explanation of the competencies required to jointly by the United Kingdom Research Collaboration (UKCRC)
complete higher and advanced level training and how they are together with LETBs, universities and Trusts.
assessed are found in Annex D and E respectively of the CCT in
Anaesthetics which can be found at www.rcoa.ac.uk Academic Clinical Fellowships offer a 2–3 year contract with
25% of time allocated to academic work with the remaining 75%

14 THE GAT HANDBOOK 2016-2017

 being clinical training. The aim is that during this time ACFs will • Multisource Feedback (MSF)
gain funding to support further research years towards gaining • Clinical Supervisors end of unit Assessment Form (CSAF)
a PhD or MD(Res). Skills, attitudes and behaviour are assessed using the above
tools and documentation and an up-to-date electronic logbook
Clinical Lectureships are available following the acquisition of a must also be maintained. All of these are used during appraisal
PhD or MD(Res) and offer contracts of a maximum of four years, and the ARCP (Annual Review of Competence Progression) to
with 50% of time being academic and 50% as clinical training. formulate a decision about whether each trainee can progress
The aim is that trainees will be able to complete both post- safely to the next year of anaesthetic training.
doctoral research training as well as completing clinical training
and obtaining a CCT. Avoiding the main pitfalls

Alternative routes to an academic career Documentation is of central importance to making competency-

based training work, and this cannot be overemphasised. Good
In addition to the NIHR pathway, a number of opportunities exist organisation and awareness of what is required will make a
to demonstrate and fulfil an interest in research. The National potential headache much easier to deal with. It is better to ensure
Institute for Academic Anaesthesia (NIAA) was established in that all paperwork is up to date and complete before leaving a
2008 and has a database of clinical academics who are happy post, as chasing people (and paper) once you have moved on
to be contacted if you would like to discuss options. The NIAA’s can be difficult. Incomplete paperwork may result in delays in
Health Services Research Centre offers fellowships every year, completion of your training. This advice is particularly pertinent
which can be one year or up to three or four years if you want to to trainees who transfer between LETBs and consequently,
undertake an MD(Res) (usually two years) or PhD (usually three have assessments from more than one region, and also to LTFT
years). Some of these posts can be part-funded by hospital trainees or those following an academic interest, for whom
trusts if undertaking some part-time clinical work in the NHS or in calculating training time and a subsequent CCT date accurately
private sector intensive care units. can be more difficult. Trainees in Locum Appointment for Training
(LAT) or Fixed Term Specialist Training Appointment (FTSTA)
The RCoA is very supportive of academic training but stresses posts will also need to ensure that all WPBAs are correct and
that all the usual competencies are still required to gain the complete for their time in post to be taken into consideration
CCT. It is recognised that academic trainees may have a more towards a CCT. Accurate electronic logbook data are extremely
limited time period than usual to complete the clinical training important in these days of reduced case exposure, so that any
scheme and flexibility and personalisation of training blocks is gaps in training can be highlighted and resolved promptly. In
encouraged including consideration of more training time being the current climate an up-to-date portfolio containing evidence
offered if this is felt appropriate. Academic tutors and heads of of education and training (e.g. courses attended, presentations
academic departments fulfil the supportive roles that college given) is essential and will impress upon your trainers that you
tutors and regional advisors perform in the traditional training are well organised and motivated.
pathway. If you are interested in an academic career, the most
important first step is to find a good mentor and supervisor. The e-Portfolio
NIAA website can help you to do this, as can your local training
programme director (TPD) or university academic department. The e-Portfolio is aimed at making the ARCP process more
efficient and was designed to enable trainees to keep all
For those interested in research, but only wanting necessary documentation online. It also allows educational
to dip their toe in the water… supervisors, college tutors and regional advisors to monitor each
trainee’s progress remotely. The College’s e-Portfolio support
The Research and Audit Federation of Trainees (RAFT) has team are very helpful and reply promptly to queries (e-Portfolio@
been established as an over-arching organisation to support the rcoa.ac.uk). All consultants in training hospitals should be
work of individual regionally-based trainee research and quality registered with the College and have access to the e-portfolio
improvement (QI) networks. RAFT and the trainee networks to allow them to complete requested WPBAs, for which you are
exist to support trainees who want to get involved in some high advised to complete contemporaneously.
quality research, audit and QI work, but do not want to make
research their main focus or take time out of training to pursue
academic ambitions. The RAFT and NIAA websites have lots of
useful information for those who would like to find out more. If
you would like any further details about research opportunities,
please contact the NIAA administrator through the website.

How do you know if you are competent?

Anaesthetic training requires a robust and validated assessment

programme. Knowledge and decision-making skills can be
assessed via the Primary and Final FRCA exams. Trainee
knowledge is also tested using WPBAs and simulation. The
RCoA has developed a set of WPBAs which are blueprinted
against the curriculum. Every learning outcome in the curriculum
is matched to at least one possible assessment.

The anaesthetic WPBA tools used are:

• Anaesthetic Clinical Evaluation Exercise (A-CEX)

• Anaesthetic List/Clinic/Ward Management Assessment Tool
(ALMAT)
• Acute Care Assessment Tool for ICM (ICM-ACAT)
• Direct Observation of Procedural Skills (DOPS)
• Case-Based Discussion (CBD)

15 THE GAT HANDBOOK 2016-2017

 What do I do if I have a problem with gaining my Category one:
competencies? • Disability or ill-health (may include IVF programmes)
• Responsibility for caring for children (< 18 years)
Problems are easier to solve if they are identified early and taken • Responsibility for caring for ill/disabled partner, relative or
to the appropriate people. Your first port of call should be your dependent
educational supervisor or college tutor, and regular appraisal
with them will be invaluable in this respect. If problems remain or Category two:
are not dealt with to your satisfaction then your TPD or regional • Unique opportunities for personal or professional
advisor should be able to help. The main thing is to be pro- development
active in your approach to your training. The RCoA has made • Religious commitment
it clear that ‘it is the trainee’s responsibility to ensure that their • Non-medical professional development
workplace assessments for individual units of training take place
by reminding those responsible at the appropriate time: it is not Further information is available from NHS Employers, Welsh
the trainer’s role to chase the trainee.’ Remember that there is Deanery, and NHS Education for Scotland.
only one of you, but your trainer may be responsible for several
trainees. Types of LTFT training programmes

How can I keep up to date with all the changes? The types of LTFT training programmes available are summarised
below:
Many changes have occurred to anaesthetic training and it
is vital to keep up to date with them. The RCoA website is Slot-share: A training placement divided between two trainees
regularly updated and details of the competency-based training so that all the duties of the full-time posts are covered by two
programme can be found in the training section. trainees.

Acknowledgment Supernumerary: These posts can be offered where LTFT

Many thanks to Dr Ramani Moonesinghe, Academic Training training is needed at short notice or a slot share is not suitable.
Co-ordinator at the RCoA, for her assistance with the section of
the handbook. Reduced hours in a full-time (FT) post: This arrangement was
unusual previously because of the service delivery implications
Louise Bates but as gaps on rotas increase it may become more common.
ST5 Anaesthesia, Wessex Deanery
Royal College of Anaesthetists
Elizabeth H Shewry
Past GAT Committee Vice Chair 2008–2010 It is very important that you inform the College Training
Department when you commence LTFT training, the proportion of
FT hours you will be working and the dates of any absences that
you may have had. They will use this information to recalculate
your CCT date therefore you must keep them updated regarding
Less than full-time training any subsequent absences or changes to your working pattern.

The RCoA has a Bernard Johnson Advisor with responsibility for

Anaesthesia has deservedly developed a reputation for LTFT Training who is available for support and advice. In addition
successfully managing and delivering training on a less than- there is a lot of information regarding LTFT training available on
full-time (LTFT) basis. Figures from the GMC survey in 2014 the College website. The RCoA hosted the Shape of LTFT 2015
showed that 12.8% of anaesthetic trainees were training flexibly, meeting, jointly organised by the RCoA and the AAGBI. It was
an increase from 8.5% in 2011 [1].The number of male trainees a well received and attended meeting and the resources from
training LTFT is also increasing and was reported as almost 20% it are available on the AAGBI website [1]. Further meetings are
of those training LTFT in 2014. planned and provide a good opportunity to meet other LTFT
trainees and trainers and consider how to get the best from your
Training LTFT in anaesthesia is an option for those doctors LTFT training.
who need time to care for dependents, to adjust their working
pattern if suffering from ill-health or disability, and for those who Can I achieve adequate training while working part-
wish to pursue other non-work related commitments. Ideally it time?
should make a reasonable work-life balance achievable for those
individuals; however it can also be a daunting prospect. GAT has Acquisition of a skill is easier if a procedure can be repeated
collated much of the available information into a comprehensive several times in quick succession; therefore training LTFT may
overview of LTFT training in anaesthesia. This is regularly make it harder to acquire confidence and progress competence
updated and is being extended to include training in Intensive in new skills and situations where the duration between the
Care Medicine. The guide can be downloaded from the AAGBI opportunities to perform tasks is longer than for FT colleagues.
website. The RCoA now recommends that trainees should gain their
initial three month competencies while training full-time before
The following section highlights some of the main points covered reverting to LTFT training [2].
in the A-Z guide.
An EU Directive enacted into UK legislation in 2007 set no
Eligibility and application for LTFT training minimum time proportion for training; however, in a position
statement released in October 2011, the GMC reinstated 0.5
All trainees are eligible to apply for LTFT training. Those doing WTE as a minimum requirement for LTFT training. In exceptional
so must demonstrate one of the well founded individual reasons circumstances a trainee may be allowed to train at less than 0.5
summarised below. Trainees in category one will be given WTE (0.2 WTE being the absolute minimum supported) for a
priority. The vast majority of LTFT trainees are women who have maximum of 12 months [3].
childcare responsibilities.

16 THE GAT HANDBOOK 2016-2017

 The allowed percentage of hours worked varies according to Work based placed assessments and annual review of
the LETB policy. In the past, several regions have restricted competency progression. February 2012. http://www.gmc-
LTFT hours to 0.5 or 0.6 WTE unless there are individual special uk.org/LTFT___WPBA_and_ARCP___Additional_position_
circumstances [4], but with workforce issues this may be statement___Feb_2012.pdf_48095387.pdf
changing and higher percentages allowed or indeed encouraged. 6. Bailey T, Horswill Y. A Life less Ordinary. Anaesthesia News
Other regions have always been able to accommodate a degree 2010; 271: 11–13 http://www.aagbi.org/sites/default/files/
of flexibility. Interestingly the London LTFT group conducted feb2010.pdf
a national survey of anaesthetic LTFT trainees in 2010 which 7. Pidgeon R. Getting the Balance: A Personal View of LTFT
reported that those training at 0.5 to 0.6 WTE had lower self- Training. Anaesthesia News 2011; 284: 13–14. http://www.
reported levels of confidence and competence than those aagbi.org/sites/default/files/March2011_0.pdf
working 0.7 WTE (33.5 hours/week minimum). 8. Taylor CV. Help there’s a flexi on my rota. RCoA Bulletin
2013; 77: 13–15. https://www.rcoa.ac.uk/document-store/
You will still undergo annual (in time, rather than training year) bulletin-77-january-2013
appraisal and an Annual Review of Clinical Progression (ARCP) 9. Boney O. Less than Full Time Training: Real men do it too!
assessment. Although this may seem like an additional burden of http://www.aagbi.org/sites/default/files/LTFT%20male%20
portfolio activity it should be used to your advantage to evaluate perspective%20Trainee%20Update%5B1%5D.pdf
your training needs and identify any problems early. It will also
ensure your case-mix, responsibilities and proportion of out of
hours work are educationally comparable to the FT equivalent. Applying for training in England
Your goals clinically, for workplace-based assessments and
continuing professional development should be calculated on a
pro-rata basis according to percentage of FT worked. The GMC Medical training and recruitment has undergone major change
have produced guidance on the expectations for LTFT trainees following Modernising Medical Careers in 2007. Smaller
at ARCP [5]. changes to the application process happen more frequently. The
most up to date information about the application process can
Ongoing support be found on the Specialty Training (England) website, including
the Specialty Recruitment Applicant Handbook. This covers the
It is important that you know where to seek advice when training application process for all specialty-training programmes.
LTFT. From personal experience, fellow LTFT trainees are a
valuable resource. Many schools of training have LTFT trainee Specialty recruitment is co-ordinated by the West Midlands
forums, closed Facebook groups and social LTFT get-togethers, Deanery and information is available from their website; this
which are useful for sharing experiences and resolving common includes the Anaesthetics National Recruitment Office. The
problems. As mentioned above, the national Shape of LTFT RCoA website contains excellent anaesthesia-specific advice.
meeting in 2015 was a great success and a repeat meeting took The section ‘Careers and Training’ contains advice from why to
place in March 2016 at the AAGBI. choose anaesthesia as a career and recruitment to less than full-
time training
There have been some interesting personal experience articles
offering insights into the opportunities afforded and hurdles Choosing a specialty
encountered during LTFT training in anaesthesia [6-9]. There are
chapters later in this Handbook on ‘The pregnant anaesthetist’, A careers advice service for doctors is available. If you have not
‘Training with a long term illness’ and ‘Returning to practice already been convinced that anaesthesia offers the best career
following a prolonged absence’ which may also be of relevance. choice for you, information is available on other specialties. The
website has advice for doctors at various stages of their careers
The AAGBI regularly updates the LTFT pages of its website and and useful links to other websites such as the Royal Colleges.
has recently added a map with a list of LTFT contacts across the Arranging a taster week during your FY2 year allows you to gain
country [2]. If you have any queries regarding LTFT training and experience of the specialty.
think GAT could be of assistance then please feel free to contact
us at [email protected] GAT publishes a guide called Who is the Anaesthetist?, last
updated in 2013. This guide offers advice aimed at medical
Emma Plunkett students and foundation doctors. If you would like to make more
GAT Committee Honorary Secretary 2015–16 and LTFT direct contact please feel free to email the GAT committee at
Representative [email protected] and we would be glad to help.
Sarah Gibb Points of entry to anaesthesia
GAT Chair 2014–15. Previous GAT and RCoA LTFT Representative
Foundation doctors can apply to anaesthesia training via two
References programmes; Core anaesthetic training (CAT) and Acute Care
1. Data presented at the Shape of LTFT meeting in 2015. http:// Common Stem (ACCS) training. Core training (CT) comprises
www.aagbi.org/professionals/ltft-training two years of anaesthesia while ACCS is a three year programme,
2. Royal College of Anaesthetists. Position Statement: Less including six months of Intensive Care Medicine and 18 months
Than Full Time Training. November 2015. https://www.rcoa. of anaesthesia (the other year being a combination of acute
ac.uk/careers-training/training-anaesthesia/special-areas- and emergency medicine). Anaesthesia training is uncoupled;
of-training/rcoa-position-statement after completion of basic core training it is necessary to repeat
3. General Medical Council. Position Statement on Less the application process to enter a five year specialty training
than Full Time Training. October 2011. http://www.gmc- programme (ST3-7) that leads to the Certificate of Completion of
uk.org/Less_than_full_time_training___GMC_position_ Training (CCT). There is now also a standalone CCT in Intensive
statement___18_October_2011.pdf_45023470.pdf Care Medicine. See the Faculty of Intensive Care Medicine
4. Hunningher A, Young TE, Johnston C. Evaluation of Less website for further information. It is possible to achieve dual
than Full Time Training in Anaesthesia: A National Survey CCT in anaesthesia and intensive care. There are also academic
2010. Presented at “Making Part Time Work”, Royal College clinical fellowships (ACF) in anaesthesia; see the National
of Anaesthetists, November 2010. Institute for Health Research website for further details.
5. General Medical Council. Additional Position Statement:

17 THE GAT HANDBOOK 2016-2017

 Maximising your chances Success

Preparation is the key to being successful in your application. All offers of appointment will be made via the Oriel recruitment
Information on the person specifications for CAT, ACCS and system, where offers may be accepted, held or declined.
ST posts is readily available. Review these to ensure you meet Candidates unsuccessful in the first round, but deemed
all the essential criteria and have addressed them in your appointable at interview, are eligible for clearing, and would be
application form. Some areas that score points need time and asked to preference all remaining posts (the clearing posts).
effort to achieve – you may need to start addressing these areas There is no requirement to attend another interview for clearing
as a medical student or foundation doctor. The Specialty Training posts. Offers for posts in the second round, or through clearing,
(England) website also gives details on the numbers of posts will also be made using Oriel. A separate national recruitment
available and number of applicants to each Unit of Application occurs for Locum appointed for Training (LAT) anaesthesia
(UoA). You may wish to take advantage of these numbers posts co-ordinated by ANRO. Interviews for these posts take
to guide your application. Information about each School of place in the West Midlands. Feedback is made available to any
Anaesthesia can be obtained from either an individual LETB unsuccessful candidate.
website or the corresponding School of Anaesthesia website.
Alternatively, advice may be sought from the RCoA College Good Luck!
Tutor in your hospital or the Regional Advisers and Training
Programme Directors for the schools to which you wish to apply. Claire Williams
Previous GAT Committee Member
The application process Consultant, Cambridge University Hospitals NHS Foundation Trust

In 2010 anaesthesia piloted national recruitment for CT2 and Nicola Barber
ST3 posts, co-ordinated by the West Midlands Deanery. National Deputy Regional Advisor, East of England School of Anaesthesia
Recruitment to CAT and ACCS anaesthesia has now been Consultant, Cambridge University Hospitals NHS Foundation Trust
combined and fully adopted. Posts are advertised in the BMJ, on
NHS Jobs and the Oriel online application portal.

Applications are made via a central electronic portal (Oriel) Applying for training in Wales
and co-ordinated by the Anaesthetics National Recruitment
Office. Applicants are required to rank as many UoA as they
wish to apply for. Twice yearly recruitment occurs for August Anaesthetic training in Wales presents the opportunity to train
and February starts. One application form is completed for both in diverse settings including both urban and rural environments.
CAT and ACCS; applicants can indicate on the form whether The Welsh School of Anaesthesia represents a single unit of
they wish to be considered for CAT, ACCS or both. Long listing application, with the school covering 12 acute hospitals across
is performed by ANRO to remove any applicants ineligible for Wales.
appointment on the basis of GMC status, level of experience and
standard of written and spoken English. Core training in anaesthesia

An important part of the application process is the completion of Core training in anaesthesia in Wales follows a similar path to
a self-assessment form. The score generated from this is used that described in the previous chapter ‘Applying for Training in
to determine your final ranking and in which UoA you will be England’. The recruitment process is nationally co-ordinated by
interviewed. For accuracy, the score is confirmed during the the West Midlands Deanery, on behalf of the RCoA. Core Training
interview process. Applicants will be invited for one interview can be accessed via Core Anaesthetic Training or via the longer
(see below). three year Acute Care Common Stem training programme. Core
training is normally based at a single hospital or region, such as
ACF recruitment is run by the National Institute for Health South East, South West or North Wales.
Research trainees co-ordinating centre. Importantly, if appointed
as an ACF, the candidate will also have to reach appointability in a CT3 anaesthesia
specialty clinical interview, which requires a separate application
via Oriel. An additional year of training at CT3 level has been uniquely
approved by the GMC for the Welsh School of Anaesthesia. This
This recruitment process covers the whole of Great Britain and consists of an additional six month placement in anaesthesia,
Northern Ireland. combined with a six month placement in emergency medicine,
intensive care medicine (ICM) or acute medicine. This extra year
Interviews of training is very popular among trainees, and those interested
in such a programme should apply during the early months of
A national standardised interview process was implemented in their CT2 year of training.
2011 but interviews are still conducted locally at each School
of Anaesthesia. Interviews comprise of a minimum of three Specialty training in anaesthesia
stations; a clinical interview, portfolio review, presentation, and
possibly a School specific station, each with a minimum of two The Specialty Training (ST) programme and recruitment in Wales
consultant assessors. The portfolio station will review your self- reflects that in England (please refer to the previous chapter).
assessment form and it is essential you provide evidence for all Recruitment is via a nationally co-ordinated process twice
domains from which you have claimed points. These stations annually, as at CT level. This is co-ordinated by the West Midlands
are designed to assess various aspects of your personality, team Deanery, on behalf of the RCoA, for a five year programme ST3–
working, performance under stress, past achievements and ST7. Training programme preferences are made at the time of
clinical decision-making. The interview process is transparent application and candidates are encouraged to rank all rotations
and allows for adequate preparation. available. The first three years have fixed hospital placement,
while the final two years are indicated as either South Wales
If you are unsuccessful in your interview all is not lost. Assuming or North/South Wales to allow greater flexibility for advanced
you are deemed appointable, you will be entered into a pool of training options, which are determined at the end of the ST4 year.
applicants and may be offered a post in another UoA. Access to the electronic application portal for national recruitment
is via the West Midlands Deanery website.

18 THE GAT HANDBOOK 2016-2017

 Applying for training in Scotland
Higher training opportunities

Higher training consists of one year of higher training in Despite the devolution of the Scottish NHS in terms of healthcare
general duties in a district general hospital and a further year delivery, anaesthetic training is consistent with the rest of the UK.
of subspecialty training in ICM, neuroanaesthesia, paediatric, Trainees are members of the RCoA, sit the same exams and are
cardiac and obstetric anaesthesia. awarded the same CCT when training is complete.

Advanced training options Anaesthetic training in Scotland is provided by four separate

LETBs and Schools of Anaesthesia: North of Scotland, East
Following the successful completion of intermediate training of Scotland, South-East of Scotland and West of Scotland.
(ST3 and ST4), trainees have the opportunity to apply for Scotland is incorporated into the national recruitment process
advanced training in a range of subspecialist interests as part of with competitive selection at entry into CT/ACCS and ST. The
the 2010 curriculum. application and delivery of specialty training in Scotland is
overseen by NHS Education for Scotland (NES), ensuring the
Advanced training options available at the Welsh School of standards set by the GMC and the curriculum set by the RCoA
Anaesthesia are subject to competitive entry. Popular advanced are met.
training modules include ICM, obstetrics, paediatrics, cardiac,
research and teaching, advanced airway management, pain How many jobs are there?
medicine and advanced general duties. There were 48 anaesthetic CT1 posts available in Scotland for
2015 and an additional 18 ACCS (anaesthesia) posts. At ST3
Education and research level there were 36 anaesthetic posts and 10 dual anaesthesia
and ICM posts. This number has remained fairly constant over
The University Hospital of Wales has strong links with Cardiff the past few years. All LETBs offer the opportunity to work in both
University and has a well-known reputation for research and a tertiary and district general hospital environment.
education, including a new simulation centre. Trainees with an
interest in education or research can undertake a six month What is the recruitment procedure?
placement in research or education as part of their advanced During the application process, candidates are required to
training. A clinical lecturer post option is also available in rank, in order of preference, all Units of Application in the UK,
Swansea. There is also the option of becoming involved with the including Scotland. Application form scores dictate which Unit
trainee-led Welsh Anaesthesia Audit, Research and Engagement interviews you, but candidates will only be interviewed by one
Network (WAAREN). Unit dependent on their application score. Hence, if you are
interviewed in Scotland you will not be interviewed elsewhere
Less than full-time training in the UK. Final ranking is based on performance at interview.
On applying, candidates are required to rank the four Scottish
The Wales LETB fully supports trainees who wish to train less LETBs in order of preference for both core anaesthetics and
than full-time, and there is a strong network of consultants and ACCS posts. The highest ranked candidates will be assigned
trainees that make this process straightforward. A popular return- posts in their chosen LETB. Lower ranked candidates offered
to-work course has recently been set up locally to help trainees a second or lower choice LETB can hold an offer in the hope
return to anaesthesia following a break in training. of securing their first choice in the event of a higher ranked
candidate turning down their offer, or equally they can choose to
Support for trainees accept/decline the initial offer made to them.

The Junior Anaesthetists of Wales (JAW) group is an organisation Applicants for ST3 posts
established and run by Welsh trainees with the aim of promoting
academic and social wellbeing for trainees in Wales. JAW holds Application for ST3 posts in Scotland is also part of the national
an annual meeting and offers great social and educational process. Candidates can apply for a maximum of two Units
opportunities for trainees. of Application, including Scotland, and can potentially be
interviewed by and offered a job at both. In order to apply for an
A ’Buddy Scheme’ also operates in Wales. This pairs up new ST3 post you must have achieved a pass in the primary FRCA.
anaesthetic trainees with post-fellowship trainees who can offer The pressures of achieving a pass in the primary FRCA within
guidance, encouragement and advice throughout training. This a two-year window (CT1/2) has meant that some past trainees
is in addition to the support provided by a motivated team of have not been able to progress to ST3 as planned. There is
consultant educational supervisors and college tutors. some provision from NES Scotland for trainees in this position to
undertake an additional year while completing exams in order to
Intensive care medicine be eligible to apply for an ST3 post.

In August 2012 a new curriculum for a single CCT in ICM training Seb Bourn & Tom Bloomfield
was introduced in the UK. Wales offers both Dual and Single ST4 Anaesthetic trainees, SE Scotland
CCT training in ICM with exposure to cardiac and neuro intensive
care environments. See the Faculty of Intensive Care Medicine
website for further information.

Gethin Pugh
Specialty Registrar, Anaesthesia and ICM, Welsh School of
Anaesthesia

Elana Owen
Specialty Registrar, Anaesthesia, Welsh School of Anaesthesia

19 THE GAT HANDBOOK 2016-2017

 Applying for training in Northern Successful applicants will receive offers via the Oriel online
system, through which offers may be accepted, declined or held.
Ireland
Education/advancing through training
Northern Ireland is a small but great deanery with lots to offer.
Educational courses and study days are generally coordinated
The training deanery consists of six health and social care Trusts
by the NIMDTA via the online system. Excellent teaching is
across Northern Ireland and these Trusts service a population
provided by NIMTDA to help trainees studying for the Primary
of 1.8 million. The Belfast Trust is the largest in Northern Ireland
and Final FRCA. Each year four senior trainees take up tutor
making it one of the largest Trusts in the UK. Anaesthetic training
roles, two for the Primary FRCA and two for the Final FRCA.
takes place over several acute hospital sites; these include the
These trainees coordinate compulsory teaching sessions, exam
Royal Victoria Hospital, Belfast City Hospital, Antrim Area Hospital,
practice sessions and provide excellent support for trainees
Craigavon Area Hospital, Ulster Hospital, and Altnagelvin Area
preparing for upcoming examinations. In Northern Ireland,
Hospital. The Northern Ireland Medical and Dental Training
trainees must now take the Primary and Final FRCA at the RCoA
Agency (NIMDTA) is responsible for funding, managing and
in London rather than at the College of Anaesthetists of Ireland.
supporting postgraduate medical and dental education within
the Northern Ireland Deanery. It provides a range of services
Advanced training options are available with competitive
for those engaged in the delivery of postgraduate medical and
application for fellowships including posts in the regional trauma
dental education, courses and training.
centre, obstetric anaesthesia, cardiac anaesthesia, paediatric
anaesthesia, intensive care medicine, pain medicine and
Application process
research. The Achieve Develop Explore Programme for Trainees
(ADEPT) offers an opportunity to develop organisational and
Anaesthesia is a popular specialty in Northern Ireland and this
leadership skills in healthcare by taking time out of programme
is reflected in the level of competition. It attracts applicants who
to work with senior leaders in organisations within Northern
have completed time in other specialties in addition to direct
Ireland. Queens University Belfast provides opportunities to
entry from the foundation programme. Taking time for taster
explore further education and research. Other opportunities
sessions, clinical audit and courses related to anaesthesia
include involvement within the trainee led Audit and Research
plays an important part in preparing a competitive application.
Network Northern Ireland (ARNni).
Northern Ireland participates in the national recruitment process
administered via the West Midlands Deanery. Core and specialist
The Northern Ireland School of Anaesthesia website provides
training applications are both consistent with the rest of the UK.
information on upcoming social events, links to educational
material for the FRCA examination and educational study days.
Core training
Best of luck!
Core training is a two-year programme leading to a certificate
of basic training prior to competitive application for specialist
Adam Lowe
training. Adverts for CT1 posts generally begin to appear from
Core Trainee, Northern Ireland School of Anaesthesia
November for posts commencing in August of the following year.
For each core trainee, training placements are delivered over two
Charlene McDonnell
of the hospital sites mentioned above, with one year spent in
Specialist Registrar, Northern Ireland School of Anaesthesia
each.

Specialist training

ST3 posts are advertised from February for training commencing Applying for training in
in the following August. At least 24 months experience in the Republic of Ireland
anaesthetics and/or intensive care medicine (not including
foundation modules) is expected by the time of the intended start
date of the post. However, no more than six months of these The College of Anaesthetists of Ireland (CAI) co-ordinates the
24 months should be in intensive care medicine. Successful training of Specialist Anaesthetic Trainees (SATs) in the Republic
completion of the Primary FRCA examination is also required by of Ireland. There are currently 210 SATs on the scheme, with an
the date of interview. average of 40 trainees entering the scheme every year. Entry to
the scheme is via a centralised national interview process.
The interview process
The SAT scheme is a six year programme. It is a run-through
Shortlisted candidates will be offered one interview. These scheme, provided a trainee meets the required milestones. These
interviews will be conducted by trained selectors against the waypoints include a broad selection of modules, and successful
criteria set in the personal and job specifications, and last around completion of the Membership and Fellowship examinations.
40 minutes. These interviews take place a local level generally Trainees are also required to maintain a logbook and a training
at the unit of application. Candidates are scored and ranked diary, and attend a number of mandatory simulation training
from these results. It is possible to miss out on a place at your days. The SAT will attend progression interviews at multiple time
chosen school yet be deemed appointable and therefore have points to assess progress.
the potential of an offer of appointment to a different school.
The interview format may change as national recruitment The first two years are basic training, followed by three years
evolves, but it has previously consisted of a document check of subspecialty training, and the final year is advanced training.
on initial attendance to ensure you have met all the required The SAT will have an option to pursue a special interest year in
eligibility criteria. This is a must and really helps to make the intensive care medicine, pain medicine, paediatric anaesthesia
interview run smoothly on the day. The interview itself consists or obstetric anaesthesia during their sixth year. They will rotate
of a portfolio review, a five minute unseen presentation based on through accredited hospitals recognised by the CAI every 6–12
topical issues not necessarily related to anaesthesia (five minute months to gain the required experience. The first 2–3 years of the
preparation time with either poster or acetate presentation) and rotation is regionally based within three areas: Western, Eastern
clinical interview based around a medical scenario. and Southern Ireland. Trainees will receive a Certificate of
Completion of Specialist Training (CCST) at the end of training,

20 THE GAT HANDBOOK 2016-2017

 and may then practice independently as a consultant. Post- Your decision on what to do and where to go during OOPT/
CCST fellowships are available in intensive care medicine and OOPR will depend on a number of factors – country, language,
pain medicine. Successful completion of these fellowships will subspecialty interest, research interest and supervisors. It is
result in the award of an additional CCST. important to plan when the correct time for you would be to
undertake a fellowship and this will depend on what you want
Application process to achieve, which modules you would like to complete and what
advanced training you wish to gain. In making a decision you
There is an annual recruitment process, with interested will find a wealth of knowledge about past experiences, potential
candidates submitting an application form to the training office posts and opportunities among senior trainees and consultants.
of the CAI around January every year. Eligibility depends on
successful completion of the intern year (postgraduate year). Eligibility
A maximum of 40 points will be awarded for undergraduate
achievements, postgraduate experience and exams, academic To be eligible for OOPT/OOPR you must have completed the
achievements, courses and references. final FRCA and be in training years ST5/6/7. It is important to
liaise with the training programme director to ensure that you
The interview process meet the eligibility criteria for your region or LETB. For example,
your anaesthetic school might only allow a certain number of
Candidates with the highest score on the application form will be trainees away at any one time. It also should be noted that
invited to interview around February or March. Another 60 points any OOPT cannot be undertaken in the last six months prior to
are available at interview, bringing the total maximum score to obtaining your CCT.
100 points. The top 40 candidates will be offered positions on
the SAT scheme. For the post to count towards training it has to be prospectively
approved by the RCoA and GMC. Retrospective submissions
Tips for success at interview are no longer permitted. The time permitted for OOPT is usually
one year and OOPR usually does not exceed three years.
It is important for candidates to score as many points as possible
in the application and interview process. The application form The paperwork and planning
is available online, and outlines the points awarded for various
items. Ranking in final medical school exams and awards or Organising OOPT/OOPR requires lots of planning, therefore
achievements as an undergraduate are important. Previous it is important to find a clinical/academic supervisor at least a
anaesthetic experience as an intern or SHO, and success in year prior to commencing the post. There is a large amount of
postgraduate examinations (MCAI, MRCP, MRCS) will also score paperwork which will need to be reviewed and signed and a
points. Other areas to earn points include involvement in audit meeting with your training programme director is also imperative.
and research projects in your local anaesthesia department,
presentations at an anaesthetic meeting, and attending relevant To ensure the programme is suitable for an individual’s training
courses (e.g. ACLS, ATLS). needs, the aims and objectives of training requirements should
be mapped to the RCoA curriculum. This will be done in
More detailed information on training and examinations are conjunction with your LETB, the RCoA and the department in
available on the CAI website. which you intend to work. All paperwork needs to be completed
and submitted at least six months prior to the start date. For an
Good luck! ICM/pain fellowship, approval will be required by the regional
advisor for the relevant specialty in your region.
Aoife Quinn
SAT 4, National Training Committee, CAI Once all the paperwork is complete and the timeframe confirmed,
Committee of Anaesthetic Trainees (CAT), CAI the remaining details of the year can be addressed. Although
the aim may be predominantly to form part of higher/advanced
David Moore training or completion of a higher degree it can also fulfil other
SAT 6, National Training Committee, CAI training needs and contribute to development of your CV. This
Committee of Anaesthetic Trainees (CAT), CAI can include roles within education and teaching, leadership and
management, quality improvement initiatives as well as other
relevant courses and projects. Identifying a clinical or academic
Out of programme training/research supervisor well in advance will allow you to not only organise
your research or training programme but also incorporate these
opportunities into the timeframe.
Out of programme training (OOPT) is clinical training taken out
of programme that will count towards the CCT or Certificate of
Eligibility for Specialist Registration (CESR) provided certain
conditions and requirements are met.

Out of programme research (OOPR) relates to trainees applying

to undertake research as part of their training experience.
Research projects may last up to three years and can contribute
up to one year towards the trainees CCT. Research should
usually be towards a higher degree.

The experiences and skills you develop during OOPT/OOPR

can make it an immensely exciting and satisfying opportunity. It
allows a period of time, often away from your region or LETB, to
gain experience in your specialist interest. Consultant posts are
competitive and therefore anything to make you ‘stand out from
the crowd’ is worthwhile. With the changing face of the NHS it
can also lead to exploring potential future job opportunities.

21 THE GAT HANDBOOK 2016-2017

 Practicalities
The DMAP&CC is not only responsible for anaesthesia training,
Obtaining visas and medical clearance, if applicable, may take but is also the lead for operational deployments, research, all
some months and will need to be factored in to when you will be innovations in equipment and techniques related to anaesthesia,
able to officially start. Other considerations prior to commencing pain management and intensive care medicine. The Defence
your new post include medical indemnity cover, appropriate Consultant Adviser in Anaesthesia, Pain and Critical Care and
medical council registration, criminal record check, ongoing the Defence Anaesthesia Specialty Board run the specialty on a
GMC registration and pensions payments. day-to-day basis. Also included in this team are a chief of staff
and three Defence Regional Advisers. In addition each service
On your return also provides a consultant adviser (CA) for further assistance
to consultants and trainees. The Army has independent CAs
During the year stay in contact with your training programme for anaesthetics and critical care. The Defence Professor
director to ensure that, on your return, placements and in Anaesthesia, Pain and Critical Care oversees academic
outstanding modules can be completed. Trainees are required endeavour.
to complete an OOPT/OOPR report on their return. Although
this has no set format it should include details and evidence Path to a consultant
of any research, audits, projects, courses modules completed,
assessments (DOPS, ACEX, ALMAT, MSFs) and a summary of Once a trainee has made the decision to pursue a career in
cases. Therefore it is imperative to keep copies of presentations anaesthesia, candidates must successfully gain entry into an
given, teaching feedback forms and course certificates, as well ACCS anaesthesia training programme [1]. The DMS does not
as supervisor feedback to use as supporting evidence in your currently offer core anaesthesia training numbers. Completion of
report. Conversely your supervisor for the out of programme ACCS training offers individuals greater options for change and
post will be asked to complete an appraisal report outlining what retention within the DMS.
you have achieved during the post.
Once successful in passing the Primary FRCA examination,
Despite the planning and paperwork that is required, doing DMS trainees are then eligible to apply for competitive entry into
OOPT or OOPR is a period of time that can be hugely rewarding. one of two ST3 training programmes; standalone anaesthesia
Time for completion of specialty training to CCT can go quickly or standalone intensive care medicine [2]. Application for dual
and once a consultant post is obtained it may prove more difficult anaesthesia and ICM training is currently done via a stepped
to work abroad for extended periods. Equally being granted time process over two recruitment episodes [3]. Depending on
away from clinical commitments to conduct research or explore individual choice, intermediate, higher and advanced specialty
your interest in different areas of anaesthesia can prove more training then follows a clear path according to the respective
difficult once in an established consultant post. RCoA and Faculty of Intensive Care Medicine. The examination
for the fellowship of the FICM (FFICM) mirrors that of the FRCA
The UK consultant job market is competitive; out of programme having both primary and final components. However, at present,
training can make you stand out on an application form or at those that have full FRCA are exempt from the primary FICM
interview. The time spent during OOPT or OOPR can not only examination. For standalone or dual accreditation in ICM
expand skills and knowledge but you can bring back renewed trainees must obtain the FFICM.
ideas, thoughts and enthusiasm to make you a well-rounded
individual able to contribute to a dynamic department; providing Pre-hospital emergency medicine (PHEM) is a new subspecialty
both professional and personal satisfaction. area of training with accreditation awarded via an increasing
number of approved national programmes. Due to concerns
Vanisha Patel regarding future revalidation the DMS only supports applications
Research Fellow, Heart of England NHS Foundation Trust for PHEM training from standalone anaesthesia and ICM
trainees. Selection takes place during the intermediate phase
Joyce Yeung of training [4]. For PHEM accreditation trainees must also pass
Clinician Scientist, University of Birmingham Honorary the Royal College of Surgeons of Edinburgh (RCSEd) Diploma
Consultant in Anaesthesia and Critical Care, Heart of England NHS and Fellowship exams in Immediate Medical Care [5]. The
Foundation Trust Intercollegiate Board for Training in Pre-hospital Emergency
Medicine is responsible for PHEM trainees on behalf of its parent
Colleges [6].
Anaesthesia training
and the armed forces

Background

The Defence Medical Services (DMS) recruits doctors at all

stages of training, from cadets at university through to accredited
consultants. The entry process remains stringent and places for
medical officers in acute specialties are very competitive. Each
single service requires a specific entry selection and completion
of initial training. Newly qualified medical officers receive a
first posting as general duties medical officers (GDMO) and,
depending on chosen service, specialty training commences
1–3 years later than NHS peers.

The Tri-service governing body for all military clinical training is

the Department for Defence Healthcare Education and Training.
Once accepted into anaesthesia training, trainees come under
the umbrella of the Department of Military Anaesthesia, Pain and
Critical Care (DMAP&CC) and the Defence Medical Deanery
(DMD).

22 THE GAT HANDBOOK 2016-2017

 Selection for ACCS and all subsequent career paths is performed version of a consultant appointment interview. It is conducted
in the same manner as for civilians. DMS consultants are in the same way as a civilian appointment and is approved by
involved in the interview process ensuring candidates are directly the NHS. Following this comprehensive interview, the trainee
compared and benchmarked against their civilian colleagues. If is a fully-fledged DMS anaesthetic consultant and member of
successful, trainees are then offered a place in one of 12 LETBs defence anaesthesia.
with which the DMD has links.
Operational deployments
Specialty training also follows the same path as for civilian
trainees, under the auspices of the RCoA, FICM and RCSEd with When trainees undertake an operational deployment they do so
a small number of exceptions. This includes being able to provide under the supervision of a defence anaesthesia consultant. Up
military trauma anaesthesia using military protocols. All trainees to two months of a deployment may be able to count towards
undertake mandatory annual military training to complement training, provided that prospective approval from the RCoA has
their clinical skills. Keeping fit is a requirement and annual testing been sought. Operational deployments vary, but are usually to
is undertaken. Compulsory training varies between the three a field hospital in an operational area. For Royal Navy trainees
services and includes refresher training of basic military skills this may be in support of a seaborne operation. Likewise, for
such as weapons handling, firefighting, first aid, dinghy drills, Royal Air Force Medical Service (RAFMS) trainees there may be
helicopter escape and chemical, biological, radiological, and opportunities to deploy in support of an Aeromedical Staging
nuclear warfare training to mention a few. Unit. For the most part, however, anaesthesia and critical care
trainees come under the Tri-service umbrella and work together
In 2008, the former Postgraduate Medical Education and Training in field units.
Board (PMETB) formally recognised the Military Anaesthesia
Higher Training Module [7]. This has been incorporated into the RAF trainees are supervised, as an integral part of their
CCT syllabus [8] and is designed to be flexible to allow trainees anaesthetic training, as members of CCASTs. This complements
to be up to date with new developments, while providing a other RAFMS specific training for aeromedical evacuation duties.
framework for maintaining core knowledge and skills. CCASTs are deployed and are on standby to repatriate critically
ill patients from anywhere in the world, in what is essentially a
During the recent conflict in Afghanistan, military anaesthesia fully equipped flying intensive care unit.
trainees had the opportunity to work alongside experienced
consultant colleagues and receive one to one training [9]. To Royal Navy trainees may have the opportunity to deploy to the
prevent loss of corporate experience from lessons learned, primary casualty receiving ship (hospital ship), RFA Argus, or as
the military module was recently updated offering a broader part of a small team on another maritime platform. Again, this
platform to prepare trainees for future operational deployments depends on prevailing military operations.
(hostile and peacekeeping). Competencies previously attained
on deployment are now delivered via a number of key military Anaesthetists also take an active role in management within the
courses using high fidelity simulation training and tailoring of field hospital with full participation in clinical governance and
clinical experiences. The new military module maintains the management issues specific to working in a field environment.
goal of equipping trainees with additional knowledge and skills Senior anaesthetists are often selected to become deployed
required to ensure wounded personnel receive the highest quality medical directors, advising commanders on medical matters and
of healthcare wherever they are serving. Learning objectives for assisting in the overall medical management strategy. Before
the module consist of the following: a field hospital deployment, all attend a hospital simulation
exercise (HOSPEX), which is undertaken in a mock field hospital
• The ability to deliver and organise military pre-hospital care setup. HOSPEX tests not only the team’s clinical skills and
during casualty retrieval [10,11]. decision making, but also the ‘journey’ of a patient from the
• Principles of in-hospital resuscitation and field anaesthesia arrival in the helicopter by the pre-hospital medical emergency
[12–14] response team,, through the emergency department, operating
• The management of anaesthesia and critical incidents using theatres and ICU, with evacuation back to the UK, via the CCAST.
field surgical equipment [15] Casualties are simulated by live actors from commercial firms
• Field critical care and aeromedical evacuation [16] to increase realism. This training is required because, while
• Battle casualty rehabilitation deployed, anaesthetists have duties in the operating theatres,
• Deployed military hospital management the intensive care unit and are members of the trauma team.
• Attitudes and behaviour [17,18] They may also be required to transfer critically ill patients via
helicopter or fixed wing aircraft. Anaesthetists are also key
During training, opportunities exist to develop specialist interests members of the medical emergency response team.
with potential for OOPT in the UK and abroad, provided they
complement the role of the military anaesthetist. This includes Another mandatory pre-deployment training course is the Military
areas such as intensive care, pre-hospital care, pain management Operational Surgical Training Course. This runs for a week at the
(including regional anaesthesia) and acute trauma. Overseas Royal College of Surgeons and is a team-training course with a
fellowships are used for focused training in areas relevant to focus on team resource management. There is a combination
military medicine and competition to gain these highly sought of cadaveric scenario based exercises with the trauma
after places is high. LETB funding, at this time, also includes surgeons and the opportunity to practice, during high fidelity
generous study allowances and financial help with examination simulation, some of the typical cases that will be encountered
fees. while deployed. This course gives the opportunity to become
familiar with standard operating procedures [19] and the actual
Additionally, there are the annual meetings of the Tri-service equipment used on deployment. The use of non-technical skills
Anaesthetic Society and the Society of Tri-service Anaesthetists is very important when deploying to an environment that is very
in Training. These academically focused meetings provide an different to that experienced in the course of routine NHS work
opportunity to get the latest military updates, as well as compare and the human factors required for defence anaesthesia have
notes with other military anaesthetists (consultants and trainees) recently been described [20].
across the country.
Research
Once a CCT has been obtained, trainees attend an Armed
Services Consultant Advisory Board (ASCAB); the military Defence anaesthesia trainees with an interest in academia

23 THE GAT HANDBOOK 2016-2017

 are encouraged to undertake military directed research. The Defence Consultant Adviser in Anaesthesia, Pain and Critical Care.
Defence Professor in Anaesthesia and Critical Care leads the References
academic department based at the Royal Centre for Defence 1. Royal College of Anaesthetists. The Stages of Training.
Medicine with a team of RCoA-appointed senior lecturers and http://www.rcoa.ac.uk/training-and-the-training-
foundation senior lecturers. Any trainees wishing to undertake a programme/the-stages-of-training
higher degree are encouraged and compete for limited places. 2. Royal College of Anaesthetists. Single-Specialty Training.
Trainees will be expected to complete significant projects before http://www.rcoa.ac.uk/node/2977
moving on to a higher degree and local research and audit is 3. Royal College of Anaesthetists. Dual Training in ICM
expected. and Anaesthesia. http://www.rcoa.ac.uk/intensive-care-
medicine/dual-training-icm-and-anaesthesia
Reserve medical forces 4. Royal College of Anaesthetists. The PHEM Training
Programme. http://www.rcoa.ac.uk/careers-training/
All three services provide a reserve land force for support of training-anaesthesia/special-areas-of-training/the-phem-
regular forces on missions in the UK and overseas. They carry training-programme
out the same roles to the same high standards and receive the 5. The Royal College of Surgeons Edinburgh, Faculty of
same world-class training and develop the same skills. To meet Pre-Hospital Care. Examinations. https://fphc.rcsed.ac.uk/
security challenges of the future the reserve forces are currently examinations
being revitalised with a drive for personnel to work more closely 6. The Intercollegiate Board for Training in Pre-hospital
with regular forces, bringing more opportunities to enjoy greater Emergency Medicine http://www.ibtphem.org.uk
challenges and creating an integrated force [21]. Reservists are 7. Woolley T, Birt DJ. Competencies for the Military
mobilised as individuals for their specific skills or as ready-formed Anaesthetist – A New Unit of Training. RCoA Bulletin 2008;
units to serve alongside regular forces. The Reserve Forces Act 52: 2661–5.
1996 provides the legal framework and mechanisms for training 8. The Royal College of Anaesthetists. CCT in Anaesthetics
and mobilisation of personnel, while offering safeguards to the – Higher Level Training. July 2014. http://www.rcoa.ac.uk/
NHS [22]. node/1437
9. Allcock E. Military Anaesthesia Training in Afghanistan.
Developing core skills of communication, teamwork and RCoA Bulletin 2010; 60: 9–12.
leadership, fostering a can-do attitude and continued professional 10. Hewitt Smith A, Laird C, Porter K, Bloch M. Haemostatic
development are all transferable values for NHS practice. On dressings in prehospital care. Emergency Medicine Journal
average the annual commitment for defence training is 27 days. 2013; 30: 784–9.
NHS employers provide 14 days additional paid leave and the 11. Bulger EM, Snyder D, Schoelles K, Gotschall C, et al.
remainder is paid by the armed reserve forces. Pay rates are An evidence-based prehospital guideline for external
equivalent dependent on rank, role and experience. haemorrhage control: American College of Surgeons
Committee on Trauma. Prehospital Emergency Care 2014;
Reserve trainees are not required to complete a GDMO posting 18: 163–73.
and as a result there is no delay in applying for NHS specialty 12. Russell RJ, Hodgetts TJ, McLeod J, et al. The role of
training numbers. If desired they may apply for training in core trauma scoring in developing trauma clinical governance in
anaesthesia rather than the ACCS training programme in any the Defence Medical Services. Philosophical Transactions
region. Supervision and management of specialty training is via of the Royal Society B: Biological Sciences 2011; 366:
a regional LETB and not the DMD. Completing the higher military 171–91.
module is strongly recommended and supported. Following 13. Mercer SJ, Tarmey NT, Woolley T, Wood P, Mahoney PF.
the award of a CCT there is no ASCAB but a civilian equivalent Haemorrhage and coagulopathy in the Defence Medical
interview is required for successful NHS consultant employment. Services. Anaesthesia 2013; 68 (Suppl. 1): 49–60.
14. Midwinter MJ, Woolley T. Resuscitation and coagulation
Summary in the severely injured trauma patient. Philosophical
Transactions of the Royal Society B: Biological Sciences
It is now widely expected that the recent patient outcomes 2011; 366: 192–203.
achieved in Afghanistan provide the baseline from which the DMS 15. Houghton I. The Triservice anaesthetic apparatus.
aspires to deliver on future operations. The DMS continues to go Anaesthesia 1981; 36: 1094–108.
from strength to strength, currently reconfiguring for contingent 16. Tipping RD, Macdermott SM, Davis C, Carter TE.
operations that lie ahead with sustainment of innovation in Air transport of the critical care patient. Combat
concepts, clinical techniques, education and research. A career Anesthesia: The First 24 Hours. The Borden Institute.
in military anaesthesia is exciting and challenging, demanding http://www.cs.amedd.army.mil/FileDownloadpublic.
a high level of expertise, initiative and flexibility. It gives the aspx?docid=57ab806b-df57-42d7-85b4-5f96907faf92
unrivalled opportunity to be part of a team that has previously 17. Arul GS, Pugh H, Mercer SJ, et al. Optimising
been shown to provide standards of medical care that are world- communication in the damage control resuscitation –
leading [23]. It is not for everyone, but talk to those who are part Damage Control Surgery sequence in major trauma
of it and you may be surprised that it might just be for you! management. Journal of the Royal Army Medical Corps
2012; 158: 82–4.
Major Clinton Jones 18. Easby D, Inwald D, McNicholas JJK. Ethical challenges
Royal Army Medical Corps of deployed military critical care. Combat Anesthesia: The
Specialty Trainee in Anaesthesia, Defence Medical Services First 24 Hours. The Borden Institute. http://www.cs.amedd.
army.mil/FileDownloadpublic.aspx?docid=ccddb35c-49fe-
Surgeon Commander Simon J Mercer 4ee1-ad18-06e7f69b4631
Royal Navy 19. Joint Doctrine Publication 4-03.1. Clinical Guidelines for
Consultant in Anaesthesia Operations. September 2008.
20. Mercer SJ, Whittle CL, Mahoney PF. Lessons from the
Lt Col Jonathan Round battlefield: human factors in defence anaesthesia. British
Royal Army Medical Corps Journal of Anaesthesia 2010; 105: 9–20.
Consultant in Anaesthesia 21. Ministry of Defence. Reserves in the Future Force
2020: Valuable and valued. 2013. https://www.gov.uk/
Colonel Duncan Parkhouse government/uploads/system/uploads/attachment_data/
late Royal Army Medical Corps file/210470/Cm8655-web_FINAL.pdf

24 THE GAT HANDBOOK 2016-2017

 • Be processed fairly
22. The Reserve Forces Act 1996. http://www.legislation.gov. • Be obtained only for one or more specified and lawful
uk/ukpga/1996/14/pdfs/ukpga_19960014_en.pdf purposes
23. Healthcare Commission. Defence Medical Services. A • Be adequate, relevant and not excessive
review of the clinical governance of the Defence Medical • Be accurate and, where necessary, kept up to date
Services in the UK and overseas. March 2009. http://www. • Not be kept for longer than is necessary
nhs.uk/Defencemedicine/Documents/Defence_Medical_ • Be processed in accordance with the rights of data subjects
Services_review%5B1%5D.pdf • Have appropriate technical and organisational measures
taken against unauthorised or unlawful processing of
personal data and against accidental loss or destruction of,
or damage to, personal data
• Not be transferred to a country or territory outside the
Logbooks, confidentiality, security European Union without adequate protection

and data protection Data protection and GMC confidentiality guidelines require
careful adherence. This is detailed in section 9.2 of the
Curriculum for a CCT in Anaesthetics (2010) which states:
Anaesthetists in training are required to keep a logbook to record ‘The RCoA recommends that trainees only record the age [not
their experience [1]. This does not prove competence but it does date of birth], sex and ASA grade of patients and that no other
enable trainers and College Tutors to see what a trainee has unique numbers are retained.’
done and if there are any gaps in their training. Most choose to
maintain an electronic logbook, but keeping a personal record JP Lomas
of details about patients has significant implications [2]. There RCoA Council Member
are both professional and legal obligations regarding clinical
records. Anyone keeping a logbook must be aware of these if References
they are not to fall foul of the GMC or the Courts. 1. McIndoe A, Hammond E. How to maintain an anaesthetic
logbook. RCoA Bulletin 2008; 51: 2633–7. http://www.
Software selection logbook.org.uk/pdfs/LogbookBulletin51.pdf
2. Information Commissioner’s Office. What is personal
The RCoA makes no specific recommendations as to which data? https://ico.org.uk/media/1549/determining_what_is_
logbook software to use. The College’s logbook software has personal_data_quick_reference_guide.pdf
been in use since 1996, is free to use and remains supported
by the developers.

The following criteria can be used to judge which logbook

software to use: Annual Review of Competency
1. Data format – If the logged cases are stored in a format Progression
that is recognisable to other logbook software the likelihood
of total data loss is reduced.
2. Features – An essential feature is to ensure there is a The system of assessment for all trainees, and any others in
method of exporting a summary in the RCoA CCT training posts, is called the Annual Review of Competency
approved format as described above. Other desirable Progression (ARCP).
features include a means of backing up logbook data and
an ability to import and export data to allow the user to The rules and expectations of the assessment process are
change logbook provider. detailed in the Gold Guide, as are all aspects of training.
3. Cost – This may be a one off payment or recurring charge Information on the ARCP process and outcomes is in Section 7.
subscription. Be aware that charges can change, even for All training bodies in the UK must follow this. Different regions
free software. conduct their ARCPs slightly differently, and interpretation of the
4. Data handling transparency – Ensuring the security of Gold Guide varies a little between LETBs.
data held ‘in the cloud’ is important. Likewise data are
a commodity and by using some logbook software you The ARCP is a documentation exercise to show that the trainee
may be granting a right to use your data for commercial is progressing at the appropriate rate through specialty training.
purposes. The decision of the panel is made based on the evidence
5. Support – Ensure timely support is offered, particularly provided by the trainee and their educational supervisor. It
where a fee has been paid. is an annual event for each trainee but can be more frequent
if necessary – see outcomes below. Less than full-time (LTFT)
Whatever software is chosen, consideration must be given to how trainees also have an ARCP each calendar year, although this
the logbook is backed up. Significant anxiety can result from a does not correspond with each year of training.
lost logbook and trying to recreate one from theatre records is
an onerous task. Backups should be in an appropriate format The ARCP is a summative process with clearly defined standards
that can be imported back into the original software and a format to be met and the possibility of not meeting them, hence the
which can be imported into different logbook software. range of possible outcomes. Documents submitted to the panel
for review are generated by the trainee on the e-portfolio, or
Acts of Parliament in exceptional circumstances on paper. Prior to the ARCP, the
trainee meets with his/her supervisor to review the year’s portfolio
There are two Acts of Parliament relevant to the keeping of and complete the Educational Supervisors Structured Report
logbooks: the Freedom of Information Act 2000 and the Data (ESSR). The ESSR is then submitted to the College Tutor for
Protection Act 1998. The essence of the Freedom of Information comment and then the ARCP panel for review. It is encouraged
Act is that patients have the right to know what is recorded that revalidation paperwork is completed at this time, including
about them. It is important therefore that records are factual and probity and health statements and form R which comes from
accurate. Significant inaccuracies could be regarded as fraud, the LETB, as supervisors are able to sign them off at the same
which would have serious consequences. The provisions of the meeting.
Data Protection Act can be summarised by its eight principles.
In abbreviated form these are that personal data shall: The ARCP panel includes at least three members from a list of

25 THE GAT HANDBOOK 2016-2017

 options which includes the Head of School, Training Programme or union rep to accompany them in the meeting, but not legal
Director (TPD), Dean, Lay Representative, External Assessor representation. The trainee prepares and submits their evidence
(often from the College), College Tutors and experienced trainers. and the specialty prepare their documentation also. The panels
The panel must review the documents and make a decision on will then sit in judgment of the case and decide the outcome. The
outcome before they meet the trainee – it is for this reason that Gold Guide has chapters on all aspects of training and is well
good, clear, complete documentation is essential. Think of it as worth referring to for detailed information, the table of contents
a written exam, only what is in the ESSR/in the portfolio can be has clear headings, which makes it easier to search for the
counted. If you are in any difficulty, for example you have not section you may wish to read.
passed an exam on time, this should be made known to the TPD
in advance so that this can be taken into account. There should Annual planning should take place after the ARCP assessment
be no surprises on the day. outcome is given. In the Gold Guide this is referred to as a
separate meeting with the TPD. In practice, in anaesthesia
The rules do not require a trainee to be present to meet the particularly, because many ARCPs are conducted face to face,
ARCP panel unless they have been given an outcome other than the planning discussion frequently follows the ARCP immediately.
satisfactory (outcome 1), in which case the outcome must be It should include the TPD but other trainers may also be present.
given to the trainee in person. The meeting should result in a plan to provide the trainee with
the most appropriate training for the next year.
ARCP outcomes
Susan Underwood
Satisfactory outcome: Royal College of Anaesthetists Bernard Johnson Adviser
1. Achieving progress and development of competencies at
expected rate. This is the most common outcome.
The FRCA examination
Unsatisfactory outcomes:
2. Specific competencies required, no additional time needed.
Certain competencies are missing but there is opportunity Every trainee anaesthetist who aims to be a UK consultant
to achieve them without extra time. This is essentially a needs to pass the two-part examination, set and supervised
chance to focus on certain issues or topics which are not by the RCoA to obtain the Fellowship of the Royal College of
up to standard and is generally reviewed after six months at Anaesthetists (FRCA) qualification, prior to achieving the CCT.
an (early) ARCP.
3. Inadequate progress, additional time required. This means There are two parts to the FRCA exam; the Primary, sat during
the training ‘clock’ will stop until the specific competencies CT1–2, and the Final sat before the end of ST4. Both the Primary
have been achieved. A common example would be failure and Final consist of two parts, each taken separately:
to pass an exam by the end of the relevant section of
training (e.g. Primary FRCA by end of CT2). If it is necessary Primary FRCA
to allow another sitting in the next training year, extra time • The multiple choice questions paper (MCQ) which now
will be required at that level as the trainee cannot progress includes Single Best Answers (SBAs)
to the next year without passing the exam. The maximum • The Objective Structured Clinical Examination (OSCE) and
time that the clock can be stopped is one year in total for all Structured Oral Examinations (SOEs)
of training. Only the Dean can allow more time and only then
in exceptional circumstances. Extra time may be referred to Final FRCA
as an extension of training time or as remedial training. • The MCQ paper (including SBA) and the Short Answer
4. Released from programme. Training number is withdrawn. Question (SAQ) paper
An example of this outcome would be failure to pass an • The SOE
exam by the end of maximum remedial training time. It
can also be allocated if a trainee is making insufficient and In each academic year there are generally three sittings of the
sustained lack of progress. Primary FRCA examination and two sittings of the Final FRCA
5. Incomplete evidence. The paperwork is not complete. This examination. The information about the regulations is available
is a temporary outcome that will become a 1 if the reason on the RCoA website and this should be checked prior to
is rectified within the time limit stipulated by the panel. It will attempting the exam.
become an outcome 3 if more time is required.
6. Gained all competencies for the training programme. Can Eligibility criteria are clearly explained on the RCoA website,
be awarded on completion of core training in anaesthesia and we also recommend referring directly to this if there are any
and at the final ARCP of Specialty Registrar training. individual concerns about eligibility.
7. FTSTA or LAT outcome: This is split into sections similar to
the trainee outcomes; 7.1 being satisfactory, 7.2 extra focus,
7.3 extra time, note 7.4 is insufficient evidence.
8. Out of programme: Requires a report from the out of
programme supervisor and is issued for all out of programme
training or research.

These outcomes are very prescriptive in nature and offer little in

the way of interpretation. Obviously the vast majority of trainees
will achieve outcome number 1 but some will require extra
time and/or support, often for failure to obtain the exam at the
appropriate time.

If a trainee is ‘asked’ to leave the programme he/she has the

right to appeal before a panel that usually includes the Dean,
a consultant from another specialty (with ARCP experience),
a local specialty representative and one from outside the
region, and a trainee representative. They are allowed a friend

26 THE GAT HANDBOOK 2016-2017

 Preparing for the Primary FRCA exam. The ideal way to prepare for the SAQ is timed practice of
the previous year’s questions. The difficulty of the SAQ section of
Preparation for the MCQ exam is best started by revising the the exam is best appreciated by attempting four SAQs in an hour
topics in the syllabus from a standard textbook such as the and having a senior colleague critically assess the answers. As
Anaesthesia and Intensive Care A to Z [1] or Fundamentals of with the other sections in the exam, a comprehensive knowledge
Anaesthesia [2]. The RCoA produce Primary and Final MCQ base is vital for smooth sailing. A SAQ course nearer the exam
books, with example questions which have been known to will help focus thoughts further and give plenty of chance for
appear in the exams. Many other MCQ books and CD-ROMs improving exam technique.
are also available for revision purposes. Reading recent
review articles of topics included in the syllabus from the The clinical SOE in the Final exam evaluates your clinical
journals British Journal of Anaesthesia, Continuing Education in judgment based on your knowledge, i.e. what an anaesthetist
Anaesthesia, Critical Care & Pain and Anaesthesia can also be does in everyday medical practice. The emphasis is on safe
useful. and competent clinical care of patients undergoing anaesthesia,
hence the quote ‘don’t change your daily practice for the exam’
The OSCE is an assessment of clinical competence in the is valid. The clinical science SOE is a scaled-down version of
context of peri-operative care, practice and clinical skills. Practice the Primary SOE, with an emphasis on clinical application of
is essential to pass this section of the exam. Prepare a list of the drugs, equipment and anatomy with relevance to regional
potential topics from the previous examinations. Have a prepared anaesthesia, and medical statistics.
plan to tackle common clinical scenarios. Practice interpreting
ECG, X-rays, and machine checks in your daily practice with Conclusions
senior colleagues.
The FRCA examination is an essential requirement for career
The SOE is an assessment of comprehension of facts previously progression in anaesthesia and is a challenging task that requires
tested in the MCQ exam. The knowledge expected is very a solid six months of revision to cover the vast syllabus. This is
similar to that needed for the MCQ, but the emphasis is on an understandably stressful time, made easier by planning and
organising your thoughts and therefore your answer. It is vital to starting early. Plan the sitting a year ahead to have adequate
practice answering questions with consultants and other senior revision time, collect revision resources, book the courses that
colleagues. It is best to start practising in exam conditions early to you want to attend (most good courses are oversubscribed) and
allow time to adjust to what is, for many, a new technique. organise study leave and life in general! Remember there is no
rationale for a trial run.
Preparation for the Final FRCA
(Derived from ‘Exam Update’ by Dr M Shankar Hari, GAT
The observations made regarding the MCQs and SOEs for the Handbook 2008-2010)
Primary exam are valid for the Final exam, with the caveat that there
is an emphasis on clinical medicine, anaesthetic management of Elizabeth H Shewry
patients with comorbidities and common problems in intensive Past GAT Committee Vice Chair 2008-2010
care.
Adam R Edwards
The SAQ is an assessment of your ability to organise thoughts ST5 Wessex
and your time management when dealing with scenarios from
everyday clinical practice. With 12 SAQs to endure in three hours, References
the average time for each question is only 15 minutes. It is worth 1. Yentis SM, Smith GB, Ip JK. Anaesthesia and Intensive Care
spending a couple of minutes planning the answer – content and A to Z: An Encyclopaedia of Principles and Practice. 5th ed.
layout (tables, labelled diagrams) to achieve decent answers. This Oxford: Elsevier, 2013.
leaves you only 10–12 minutes to write an answer, therefore use 2. Pinnock C, Lin T, Smith T, Jones R. Fundamentals of
short and snappy titles, bullet point content with well-spaced text Anaesthesia. 2nd ed. London: Greenwich Medical Media,
and paragraphs. All questions have to be attempted to pass the 2003.

27 THE GAT HANDBOOK 2016-2017

 Basic level training in anaesthesia is uncoupled and comprises
two years of focused training and assessment in basic clinical
skills and fundamental theories of anaesthesia. In Wales, it is a
three year programme.

Core training – Year 1 (CT1)

Year 1 is usually undertaken in a district general hospital, and

begins with an initial 3–6 month ‘novice’ period. During this
time, each trainee has ‘on the job’ consultant-led teaching in
order to gain the fundamental clinical, practical and theoretical
competencies required to practice independently and safely
participate in an on-call rota.

Each trainee is allocated an Educational Supervisor and

a College Tutor is present in every department to update,
support and offer guidance.

Initial competencies include:

• Basic airway skills
• Basic principles of anaesthesia
• Pre-operative assessment
• Induction and maintenance of anaesthesia for
spontaneously breathing patients
• Induction and maintenance of anaesthesia for
intubated patients
• The Rapid Sequence Induction
• Principles of the shared airway
• Introduction to acute pain and regional anaesthesia
• Clinical judgement, attitudes and behaviour
• Critical incidents and management
• Safe provision of anaesthesia for ASA I and ASA II
patients
• Workplace-based assessment tools:
o Anaesthesia Clinical Evaluation Exercise
(A-CEX): 5
o Case Based Discussion (CbD): 8
o Direct Observation of Procedural Skill

CORE
(DOPs): 6

On completion of a successful novice period, including a

TRAINING
minimum of 19 workplace-based assessments, an Initial
Assessment of Competency Certificate (IACC) is awarded.
This deems the trainee safe to practice with some autonomy
for appropriate cases with Consultant guidance.

The remainder of the first year of training focuses on gaining

more experience and confidence, building on the knowledge
and skills outlined above, and preparing for the FRCA Primary
Examination.

The FRCA Primary MCQ exam may be taken by any anaesthetic/

acute care common stem trainee. The IACC is required by the
RCoA on applying to sit the FRCA Primary SOE.

In order to progress to year 2 of core training, attendance at a

regional ARCP is compulsory. Progress and achievements are
evidenced by an ARCP report (completed by an educational
supervisor) and a trainee e-portfolio, which should typically
include:

• Anaesthetic logbook summary

• Teaching logbook
• Audit
• Courses
• Work-place based assessments: DOPs, Anaes-CEX,
CbDs and ALMATs
• Multisource feedback

28 THE GAT HANDBOOK 2016-2017

 CORE TRAINING
During core training, the trainee will also undertake a three then anaesthetics and intensive care medicine (one year in
month intensive care medicine attachment to obtain basic level total, with a minimum of three months in each). The third year is
competencies in intensive care medicine. More specialised spent in the parent specialty, and in the case of anaesthetics is
units of training, including obstetric anaesthesia, are usually equivalent of a CT2 in anaesthesia.
accomplished in year 2.
For those undertaking anaesthetics as their parent specialty,
Core training – Year 2 (CT2) the ACCS programme brings a number of benefits. It gives a
broader base of clinical skills and experience prior to starting
The main aim of year 2 is to obtain the Basic Level Training your anaesthetic career, and also a better understanding of the
Certificate (BLTC). For this to be issued, trainees must other clinical specialities with which you will be closely working
demonstrate basic level competencies in anaesthesia, intensive over the course of your training and working life.
care medicine and obstetric anaesthesia. To progress to
intermediate training the FRCA Primary Examination must be With regard to anaesthesia examinations, it is expected that
passed. This is a difficult exam, and preparation time should trainees will have passed the Primary FRCA MCQ assessment
not be underestimated. It is standard to allow 4–6 months of prior to entering CT2 anaesthetics, i.e. by the end of the first two
intensive revision in order to cover the diverse syllabus. years ACCS. The full Primary examination must be passed prior
to entry into ST3 anaesthetic training.
It is important to stress that progression in anaesthesia is
competency-based, and therefore any trainee who has been The RCoA has issued advice on examinations – 25% of ACCS
unsuccessful in gaining all the required objectives may be (anaesthesia) trainees will not start their anaesthetic module until
offered up to one year of extra time in core training. It may also the final six months of the two year ACCS course and therefore
possible to arrange an out of programme experience, usually are not obtaining the Initial Assessment of Competence in
clinical or research based, as a CT3. Anaesthesia (IAC) until 22 months into their two year ACCS
training. This could limit the opportunities such trainees have
Useful tips to sit the Primary FRCA Examination. To address the problem,
• Membership of the RCoA is mandatory at the beginning the RCoA Council has agreed to allow any registered trainee
of the training period to apply to sit the Primary FRCA MCQ examination as soon as
• Membership of the AAGBI is encouraged they start an approved training post in anaesthesia or ACCS.
• Logging applications are available for mobile phones, This replaces the previous regulation that a trainee must have
which allows timely logbook record keeping passed the IAC before applying to sit the MCQ examination.
• Courses for the FRCA Primary exam are usually of a very However, it is strongly recommended that College Tutors advise
high standard and are offered by most Deaneries. The their trainees not to attempt the MCQ exam before they have
majority of trainees find these very helpful, and indeed obtained their IAC.
essential for the OSCE/SOE component. Trainees should
book revision courses early as places are competitive There are of course workplace-based assessments for each sub-
• e-Learning Anaesthesia (e-LA) is an excellent online section of ACCS, the details of which I will not go into, but are
resource to aid FRCA revision, utilising 20 minute varied from Deanery to Deanery, and specialty to specialty.
e-learning sessions, complete with self-assessment
• Simulation courses are great fun There is now a new 2010 curriculum for ACCS which is overseen
by the Intercollegiate Committee for Acute Care Common
Louise Young Stem Training (ICACCST) and the RCoA website is helpful. The
StR, Wessex BMJ careers article by Muhummad Sohaib Nazir on the acute
common stem pathway is also worth reading.

Jon Walker
Acute care common stem StR 7 Emergency Medicine

The acute care common stem (ACCS) is a three year training

programme, and is an alternative core training programme
for those wishing to undertake higher specialist training in
anaesthetics.

It should be noted that nomination of your parent specialty must

be made on entering ACCS. However, there may be the scope
to change this depending on availability within the LETB. There
are several routes of entry into ACCS - the most frequent being:

• Entry into ACCS Year 1 from Foundation Year 2 (FY2)

• Entry into ACCS for trainees with a combined total of
less than 18 months experience in any of the four ACCS
component specialties at SHO/CT1/CT2 level
• Entry into ACCS from Core/Higher Training in a non-ACCS
specialty

The first two years of the programme involve rotating through

emergency medicine, acute medicine (six months each) and

29 THE GAT HANDBOOK 2016-2017

 DEVELOPING YOUR CV FOR...
“Patients need good doctors. Good doctors
make the care of their patients their first
concern: they are competent, keep their
knowledge and skills up to date, establish and
maintain good relationships with patients and
colleagues, are honest and trustworthy, and
act with integrity and within the law.”
Good medical practice 2013, General Medical Council

30 THE GAT HANDBOOK 2016-2017

 DEVELOPING YOUR CV FOR...
BARIATRICS and emergency lists. This means that all anaesthetists will have to
manage the obese patient at some point and the basic principles
for bariatric surgery will apply to ensure a safe peri-operative
The term ‘bariatric’ originates from the Greek root ‘bar’ meaning journey.
weight, and the suffix ‘iatr’ meaning treatment. It therefore refers
to the psychological, dietetic, medical and surgical treatment of What does work as a bariatric anaesthetist involve?
the obese patient. It is not a polite substitute for the word, ‘obese’!
The key to delivering safe bariatric anaesthesia for bariatric
Due to the limited sustained success of traditional methods, such surgery is prior planning, an appreciation of the comorbidities the
as diet and lifestyle modification, for the treatment of obesity patient may have and application of basic principles. Anaesthesia
and the epidemic of obesity overtaking the western world, the for bariatric surgery in itself can be challenging but with the
subspecialty of bariatric surgery has become firmly established ever-increasing size of our population, anaesthetists will find
in recent years in an attempt to reduce the increasing waistlines the obese patient across a whole range of surgical disciplines.
of our population. Statistics for England in 2012 suggest that This presents an opportunity to apply the principles of bariatric
24.4% of men and 25.1% of women now have a body mass index anaesthesia to the everyday theatre list but also exposes the
(BMI) greater than 25 kg/m2, i.e. obese. This epidemic looks set inexperienced anaesthetist to the complexities of this surgical
to continue despite national initiatives to reverse the trend. population.

Studies have shown that weight loss of 5–10% of initial body Training in bariatric anaesthesia
weight can improve glucose intolerance, incidence of type 2
diabetes mellitus, hypertension, and hyperlipidaemias. Bariatric Anaesthesia for bariatric surgery or for the obese patient is only
procedures may achieve weight loss of more than 50% of excess sparingly mentioned throughout the RCoA Curriculum for CCT in
weight. Bariatric surgery is relatively safe, has low morbidity Anaesthesia 2010. You may also be working in a centre or region
and mortality, and can provide long term sustained weight loss that does not carry out bariatric surgery. Therefore, as a trainee,
with significant improvement of comorbidity and quality of life in there are various options to gain experience in this growing field
the morbidly obese patient. NICE guidelines suggest the main of anaesthesia other than the random encounter with a morbidly
requirements for approval of weight loss surgery is a BMI of 40 obese patient in a district general hospital.
or over. A patient can also be considered for surgery if their BMI
is between 35 and 40 and it can be proved that after surgery Improving your CV for bariatric anaesthesia
any existing medical conditions can be improved. The types of
medical conditions that surgery can effect are type 2 diabetes Consultant job adverts are now appearing ‘with a special interest
mellitus, heart problems, high blood pressure, infertility and in bariatric anaesthesia’, so trying to develop your CV early may
sleep apnoea, to name a few. Another requirement that needs to pay future dividends if this is an area of anaesthesia you enjoy.
be met is evidence that the patient has attempted to lose weight
through all means possible and that these attempts have been Several out-of-programme or additional training bariatric
unsuccessful. fellowships exist across the country; however, they require
prior planning and preparation, much like bariatric anaesthesia!
Bariatric surgery has developed rapidly over the last few You may also consider arranging a ‘taster’ or ‘observership’
years and is now one of the fastest growing areas of surgery attachment in a centre of your choice. Contact the centre in
in terms of patient numbers. Patients can be offered a range of advance; these attachments are usually easier to arrange and
surgical options depending on their individual circumstance and the time can be taken as study leave.
underlying comorbidities. The options include adjustable gastric
bands, gastric bypass and sleeve gastrectomy procedures. Joining the Society for Obesity and Bariatric Anaesthesia (SOBA)
Surgical techniques have continued to develop such that these has numerous benefits for trainees. SOBA has been an AAGBI
procedures are now predominantly carried out laparoscopically. affiliated society since late 2008 and aims to educate and support
anaesthetists involved in bariatric anaesthesia. SOBA runs two
Bariatric anaesthesia has developed alongside the surgery as educational meetings a year aimed at the consultant or senior
a subspecialty. The safety record of bariatric surgery (gastric trainee embarking upon bariatric practice. SOBA runs a poster
bypass mortality 0.5% and laparoscopic band 0.1%) is partly competition at the annual scientific meeting. This is a golden
due to the allocation of experienced anaesthetists to these lists opportunity for anyone interested in bariatric anaesthesia, or
and partly due to a multidisciplinary team approach including obese patients, to present at an international meeting.
psychologists, dieticians and endocrinologists.
The SOBA committee recognises the significance of trainees and
In truth, any major case-competent anaesthetist could be a has two trainee representatives appointed to it annually. SOBA
bariatric anaesthetist as many skills are transferable, specifically provides a valuable source of information and also a discussion
management of the pneumoperitoneum. There are however forum via its website and Twitter.
a few areas that require special attention. These include the
management of peri-operative obstructive sleep apnoea/obesity Some useful resources and further reading can be found below:
hypoventilation syndrome, assessment of cardiovascular
function with awareness of obesity-related pathology with the use • Health & Social Care Information Centre. Statistics on
of intra-operative cardiac output monitoring, manual handling Obesity, Physical Activity and Diet - England, 2014. http://
and positioning to avoid airway, ventilation and pressure-point www.hscic.gov.uk/catalogue/PUB13648
problems, knowledge of pharmacokinetics in the obese, and • Sabharwal A, Christelis N. Anaesthesia for bariatric surgery.
appropriate thromboprophylaxis. Continuing Education in Anaesthesia, Critical Care & Pain
2010; 10: 99–103.
With the increase in obesity in the general population all • NICE. Obesity: identification, assessment and management.
disciplines of surgery will find an obese patient on their elective November 2014. https://www.nice.org.uk/guidance/cg189
• NICE. Implantation of a duodenal–jejunal bypass sleeve for

31 THE GAT HANDBOOK 2016-2017

 managing obesity, 2012. https://www.nice.org.uk/guidance/ the seven essential units for intermediate level training in ST
ipg471/resources/implantation-of-a-duodenaljejunal- years 3–4 and one of the five for higher training in ST years
bypass-sleeve-for-managing-obesity-1899869926370245 5–7. However, in each case, the minimum requirement of four
• Humphrey V, Stobbs S, Kennedy N. Seeing the bigger weeks is really only a taster to allow trainees exposure to the
picture: training in obesity and bariatric anaesthesia. RCoA issues and management of patients with cardiothoracic disease.
Bulletin January 2016; 95: 42–4. Cardiothoracic anaesthesia is also one of the eight advanced
• Thomas M. A Bulletin Debate (Motion Proposed) All units of training in ST years 5–7 with a maximum of one year in
consultant anaesthetists have the skills to anaesthetise a single unit or six months in each of two units. Many trainees
patients for bariatric surgery. RCoA Bulletin May 2012; 73: looking for a career in the specialty will follow this with a further
33–6. fellowship, which commonly takes place post-CCT. Advanced
• Nightingale C. A Bulletin Debate (Motion Opposed) All training is vital to any trainee wishing to pursue a career in
consultant anaesthetists have the skills to anaesthetise cardiothoracic anaesthesia and it is essential that trainees gain
patients for bariatric surgery. RCoA Bulletin May 2012; 73: a wide and varied clinical experience but also build a CV for
37–9. consultant appointment.
• Lomax S. Doing it large in the USA A bariatric observership
at Massachusetts General Hospital, Boston. RCoA Bulletin How then does one build a CV to become a
May 2010; 61: 19–21. consultant in cardiothoracic anaesthesia and
• Avery S. An OOPE in bariatric anaesthesia. My year as intensive care, and what will influence success?
clinical fellow. RCoA Bulletin May 2011; 66: 9–11.
Become a member of the Association of Cardiothoracic
Satinder Dalay Anaesthetists (ACTA). ACTA was founded in 1984 to encourage
ST5 Anaesthetics, Birmingham School of Anaesthesia the professional development of consultants and trainees.
GAT Committee Elected Member They hold an annual scientific meeting in the spring and
an educational academy meeting in the autumn to further
Sean Chadwick education, promote international links and encourage the
Consultant in Anaesthesia and Intensive Care, Worcestershire presentation of original scientific research. ACTA is dedicated
Acute Hospitals NHS Trust to its involvement in the curriculum development and training
of cardiothoracic anaesthetists and intensivists. For the trainee
Mike Margarson wishing to pursue a career in the specialty, ACTA is an invaluable
Consultant Anaesthetist and Director of Intensive Care, St resource providing career advice and networking, academy
Richard’s Hospital Chichester and educational meetings, a comprehensive list of courses
Vice Chairman, SOBA and workshops in echo, one lung anaesthesia and all aspects
of cardiothoracic anaesthesia. Their website also provides a
Claire Nightingale source of educational material. ACTA has recently established a
Consultant Anaesthetist, Bucks Healthcare NHS Trust trainee representative position on the committee as a direct link
Ex-Treasurer, SOBA between the organisation and interested trainees.

TOE imaging is now a central component of cardiac anaesthesia

and evidence of training and experience in TOE is essential for
Cardiothoracics your CV. This should consist of formal TOE certification and
accreditation. In the UK there is currently an accreditation process
run by the British Society of Echocardiography (BSE) consisting
Cardiothoracic anaesthesia and intensive care is an exciting, of an exam (two MCQ papers) and logbook submission of 125
challenging and dynamic specialty choice. It is certainly not cases over two years. Accreditation is also possible through
‘service provision’ anaesthesia and requires a specific and the European Association of Cardiothoracic Anaesthesiologists
unique set of skills. A career choice in the specialty means you (EACTA) or the National Board of Echocardiology (NBE) and
will be at the forefront of anaesthetic, surgical and technological Certification from the American Society of Echocardiography
advances. (ASE)/Society of Cardiovascular Anaesthesiologists (SCA). TOE
accreditation requires not only time to study for the exam but
In the last 10–20 years we have seen a number of changes in access to sufficient patients to undertake the required number
the patient population including an increase in the number of of examinations, and the latter may be difficult to achieve unless
patients, an increase in the age and comorbidity of patients and you do a full year of advanced CCT training and probably post-
an increase in the complexity of our procedures. However, this CCT fellowship.
is coupled with an improvement in outcome and mortality and a
decrease in hospital stay. Our patients are the most audited group During or before entering advanced training or post-CCT
in medicine pushing a continual drive to improve our practice. fellowships, an introduction to TOE can be gained by attendance
We have also seen the development of cardiology procedures, at one of the many TOE courses run by cardiac centres in the
particularly arrhythmia therapy and transcatheter aortic valve UK. A list can be found on the ACTA website. Both EACTA and
implantation (TAVI) procedures, and the increase in minimally the SCA also run annual foundation courses in TOE and there
invasive thoracic surgery. The technological developments are an increasing number of meetings in the UK devoted to TOE.
have been instrumental in the success of the specialty. We Attendance at these courses and meetings would strengthen
have led the way in peri-operative echocardiology (echo), both your CV. Registrar’s case presentations are also now a regular
transoesophageal (TOE) and transthoracic (TTE). We have part of the ACTA echo meetings and such a presentation would
seen improvements in cardiopulmonary bypass techniques look good and get your name and face known in the ACTA
and the reduction in the use of blood and blood products in community.
cardiac surgery with the development of cell salvage, synthetic
clotting agents and point of care testing. There have also been Evidence of training in TTE is desirable, especially if applying
considerable advances in mechanical cardiorespiratory support for a post with sessions in critical care. Focused intensive care
such as extracorporeal membrane oxygenation (ECMO) and echocardiology (FICE) accreditation can be completed during
ventricular assist devices. a 6-month placement on intensive care. On commencing the
module the trainee must register with the intensive care society
The RCoA Curriculum for CCT in Anaesthesia 2010 lays out the (ICS) and identify an approved mentor. They must then attend a
requirements for training. Cardiothoracic anaesthesia is one of FICE-approved basic echo workshop and collect a logbook of

32 THE GAT HANDBOOK 2016-2017

 50 cases over a one year period followed by a final ‘triggered Cardiothoracic intensive care is an ever-expanding specialty that
assessment’ by their mentor. Other ‘focused’ echo courses has undergone many significant changes and developments in
such as FEEL-UK (focused echo in emergency life support) or the last 10 years. The increasing age and comorbidities of our
ICE-BLU (intensive care echo and basic lung ultrasound) are patients together with aggressive and innovative surgical and
available. The BSE and ICS working group has also defined cardiology techniques and the expansion of ECMO, mechanical
criteria for advanced accreditation in critical care TTE comprising assist devices and transplantation services has significantly
of a written exam and a logbook of 250 reports. This is not an increased the workload. This, together with the developments in
essential requirement but would certainly allow you to stand out, the wider field of intensive care, has forced a review process of
especially if applying for a cardiothoracic intensivist post. how cardiothoracic intensive care is delivered and now there is
increasing recognition of cardiac intensive care as a subspecialty
In the past, research experience, especially with publications area. In most centres there has been a shift from the traditional
in reputable scientific journals, would have been a core surgical-led recovery unit to an intensivist-led specialist critical
characteristic of a successful applicant. While it remains a feature care unit. Although in 40% of units around the UK there is now
of an outstanding candidate, it is generally recognised that the a separate on-call rota for cardiac intensive care and theatre
opportunities for undertaking research during CCT training are anaesthesia, an overlap still exists. It remains a substantial
now much more limited than in the past and is not essential part of many cardiothoracic anaesthetists’ job plans and the
for a successful application. However, scientific presentations, majority of cardiac intensivists will still also have some sessions
now often based on audit rather than research, at specialty in cardiothoracic anaesthesia. The cardiac intensivists in ACTA
meetings such as ACTA or EACTA remain an important feature (CIA) group was established six years ago to improve clinical
of a successful applicant’s CV. Co-authoring a book chapter or a quality, training, education and promote research and audit in
review may be more readily achievable, as it can be done flexibly cardiothoracic intensive care. This group is working closely with
in one’s own free time and will make an applicant’s CV stand the faculty of intensive care medicine (FICM) to develop the field.
out, especially if they are about cardiothoracic anaesthesia. Ask At present, a dual CCT in anaesthesia and critical care is not
your senior colleagues if they have any opportunities available essential but those who wish to be involved in the delivery of
in these areas. both services in the future should consider this training pathway.
As a minimum, intermediate training in intensive care medicine
While not essential, clinical experience in cardiothoracic should be obtained with experience in cardiothoracic intensive
anaesthesia gained in more than one centre is desirable. care during advanced or post-CCT specialty training.
Training in a single centre has the potential to narrow one’s
clinical outlook and exposure to more than one centre can lead Without doubt, paediatric cardiac anaesthesia is a super
one to question some anaesthetic dogma and, alternatively, subspecialisation. Currently, there is considerable debate
reinforce the relevance of another. In addition, it gives insight about what training should be required for a consultant post.
into different approaches to delivering the same healthcare, Clearly anyone who is going into paediatric cardiac anaesthesia
which may be valuable when service reconfiguration occurs needs to have a sound training in both cardiac and paediatric
in your future career. Furthermore, experience in specialised anaesthesia. Given the complexity and current lack of clarity as
centres may benefit your CV, for example those offering ECMO, to the training requirements, anyone interested in a career in this
heart failure treatment and heart and lung transplant centres. area should seek out specialist advice early in their career to
Undoubtedly, valuable training will be gained in all the UK know how to develop the relevant experience and hone their CV.
cardiothoracic centres, but experience in other countries, such The CCT in the anaesthesia curriculum also advises that pre-
as the USA, Canada or Australasia, adds to your CV. While this CCT training for such posts has to be arranged on an individual
may be possible as an out-of-programme experience during trainee basis in conjunction with the medical secretary and
CCT training, it seems more likely that working abroad will be training committee to ensure it complies with the requirements
an experience that can only realistically be obtained post-CCT. of a training programme leading to CCT.

As with most consultant posts in anaesthesia, what a selection A career in cardiothoracic anaesthesia is both challenging and
committee will be looking for on your CV is the added value enjoyable. Don’t be put off by the extra training and exams. If
that you will contribute to the department, over and above you think you may be interested in cardiothoracic anaesthesia it
your clinical skills. Teaching and management experience would certainly be advisable to spend a bit of time in the specialty
are two common areas that may be valuable to a department early in your training. The training you will receive will certainly not
and hospital, and that does not mean supervising junior go to waste, with the ability to manage high-risk patients, hone
colleagues and running a trainee rota. Like TOE, some formal communication and teamworking skills and develop advanced
qualification such as a Certificate in Medical Education would procedural, echocardiography and lung isolation techniques.
be ideal for teaching, but perhaps unrealistic for everyone to All of which are very valuable and desirable skills in any field of
achieve during training in anaesthesia. However, evidence of anaesthesia or intensive care.
interest should be demonstrated by attendance at teaching or
management courses. Consider participating in undergraduate Good luck in whatever you choose to do!
teaching. Supervising problem-based learning is a good
way into undergraduate teaching, as it is now an important Jo Irons
component of the undergraduate curriculum of many medical Consultant, Papworth Hospital
schools. Because it is taught in small groups a large number
of tutors are needed. In addition, the output of such teaching
can often be presented at a scientific meeting and even result
in a published paper. Again, ask your senior colleagues if they
would be interested in sharing their teaching commitment in
this area or have suggestions for other appropriate teaching.
Acting as faculty on in-house courses is also an easy way to gain
teaching experience. Courses such as advanced life support
(ALS), advanced trauma and life support (ATLS) and care of
the critically ill surgical patient (CCrISP) are ideal but there are
specific cardiothoracic courses such as cardiac advanced life
support (CALS) that you can get involved with during advanced
training.

33 THE GAT HANDBOOK 2016-2017

 Day surgery Those you work with heavily influence your life as a consultant
and those involved in day surgery are a dedicated cheerful
bunch. The best lists are where the ‘team’ includes the surgeon
In the last few years, elective surgery has undergone a revolution and anaesthetist as well as the rest of the staff – this may sound
with the introduction of minimally invasive techniques meaning strange but I believe in day surgery we break down many of the
that traditional lengths of stay are falling. This is evident ‘traditions’ in medicine. Hence, we all help getting the patients
with the development of the national Enhanced Recovery through efficiently and safely and remove the ‘that’s not my job’
Programme where patients having major procedures such as mentality.
joint replacements or hysterectomy who previously needed up
to a week of postoperative recovery in a hospital ward are now Developing your CV
going home after two or three days. In the same way, operations
that traditionally needed one or two days care have moved into It seems that the British Association of Day Surgery (BADS) is one
the day surgery arena, and much that currently takes place of the best kept secrets in anaesthesia. It is a multidisciplinary
within day units is moving into outpatients or soon, even into the society and the members are nurses, anaesthetists, surgeons
community. and managers. Anaesthetic trainees benefit from a reduced
membership fee and the Annual Scientific Meeting held over two
We are already seeing examples of this, with hysteroscopy and days each June is a brilliant opportunity to learn more, socialise,
female sterilisation increasingly being carried out as an outpatient network and gossip with like-minded folk.
procedure and ‘traditional’ diagnostic arthroscopy being replaced
by MRI scanning. Laparoscopic cholecystectomy, tonsillectomy My first recommendation to anyone wishing to establish their
and shoulder arthroscopic surgery are now commonplace credentials in day surgery would be to join BADS and attend this
as day case operations, with some hospitals in England now meeting. However, even better would be to submit an abstract
performing up to 70–80% of them on an ‘ambulatory’ basis. But and try to get an oral presentation or at least a poster accepted.
did you know that units in the UK are already doing thyroid [1] The audience are extremely friendly and those presenting are
and parathyroid [2] surgery, prostate resection [3] and even not given a hard time. Learning which topics are popular at these
laparoscopic nephrectomise [4] as day cases? There is no doubt meetings and so being successful with submitting an abstract
that anaesthesia for short stay surgery will form an increasingly takes preparation. This is best achieved either by working with a
important part of most anaesthetists’ lives. It has been shown consultant colleague who has attended previous meetings and
that day surgery can account for 75% or more of elective general so knows the scene, or simply by attending one year to get a feel
surgery in the average district general hospital, if we then look for how it all works. Listening to colleagues presenting their work
at what is left then at least another 20% can be dealt with on a gives insight to the competition but also fires you up and gives
23-hour basis. Furthermore, only a minority of patients require a you ideas for the following year. The BADS website is a useful
hospital stay of longer than 48 hours. source of day surgery information and offers a discussion area
where you can ask questions. It also offers a wealth of additional
Currently, many hospitals are looking to streamline these patient resources in the members area that is invaluable for anyone with
flows, as patients managed through designated day surgery a commitment to day surgery.
and 23-hour stay surgery areas have a better chance of going
home at the right time, with the right drugs and with appropriate In preparation for a consultant post that includes a day surgery
information for their carers. component, it’s also very useful to have a few relevant audits
on your CV showing your interest in this area of anaesthetic
What would your life be like as a consultant? care. Within the latest edition of the RCoA Compendium of Audit
Recipes is a section on Day Surgery providing a few examples
This depends on the mix of lists and management duties that of tried and tested work that you could use in your own hospital.
you have. The best day surgery units have one thing in common
and that is medical leadership; across the country, anaesthetists Training in day surgery forms part of the essential training units
are recognised as individuals with the expertise and knowledge in the CCT in anaesthetics higher level training and is one of
to optimise a ‘joined up’ day surgery pathway that includes pre- the options for advanced level training. Details can be found
operative assessment, development of appropriate guidelines on the RCoA website. These documents provide guidance to
for anaesthetic care, liaison with surgeons across a wide range trainers and trainees and are useful for those wishing to spend
of specialties, and working as a team member with nursing and time within day surgery. The advanced level training document
managerial teams. Even if a day surgery unit is managed by a states that ‘Advanced training in anaesthesia for day surgery
surgical colleague, most have an anaesthetist leading the pre- should be delivered in centres with a dedicated day surgical
operative assessment service, so if you show interest, there are unit with a designated director/lead clinician who has sessional
opportunities to develop your management and teamwork skills. commitment to the role’. It goes on to say ‘It is recommended
Managing day surgery can be extremely satisfying as it involves that between three and six months are spent on this advanced
working across all specialties to ensure the provision of a quality unit of training. While mastery in clinical skills will be achieved,
service; the main secret is to ensure that it does not feel like a much of the benefit gained from this unit of training will be in
production line for the large numbers of patients treated. developing leadership and management skills related to the
organisation of a day surgery unit, in conjunction with all other
members of the multidisciplinary team’.

These ideals may still be some way from being met and provision
of dedicated training time within the day surgery arena often
proves difficult. However, continued pressure from trainees will
help ensure that suitable time is allowed for such attachments.
BADS has links via the International Association for Ambulatory
Surgery with exemplary Day Surgery Units across the world
and would be happy to provide contacts for anaesthetic trainee
members, should you wish to try and organise time out from
CCT to visit or work at an international centre of excellence.

Overall, there is no doubt that any consultant post you apply for
over the next few years is likely to have a day surgery session

34 THE GAT HANDBOOK 2016-2017

 or two within the job plan. What better way, therefore, to start general hospitals where consultants regularly manage complex
preparing your CV for the ‘dreaded’ final interview, showing major ENT and maxillofacial patients, it is natural for these same
that you have the credentials, knowledge and expertise to offer personnel to take on the above roles. That said, those working
something special to your potential employers? What’s more, in other specialised areas of anaesthesia may regularly be
working in the Day Surgery environment provides one of the involved in difficult airway management and in particular, those
most unique clinical challenges to use state of the art evidence- in paediatric anaesthesia and neuroanaesthesia.
based techniques of anaesthesia to ensure rapid recovery and
street fitness within hours with a multidisciplinary team who are With an interest in head and neck anaesthesia there is the
renowned for their support and ‘let’s get it done’ ethos. potential for a very stimulating consultant career, particularly if
your job plan incorporates a degree of flexibility. Each week’s
I hope that I have provided some useful insights within this article, lists might include ENT, maxillofacial and dental surgery, often
however if you require further information or feel that I have left a involving elements of paediatric anaesthesia, anaesthesia for
question unanswered then please contact me via BADS (bads@ day surgery and anaesthesia for complex major surgery. As
bads.co.uk). the airway is shared, surgeons take a particular interest in your
skills and if you are involved in the management of major head
Mark Skues and neck reconstructive surgery then this interest extends even
Consultant Anaesthetist, Countess of Chester NHS Hospital further. A sense of belonging always seems to develop in head
Foundation Trust and neck theatre teams.
Immediate Past President, British Association of Day Surgery
Once identified as someone with difficult airway skills you might
References be called on to assist other members of your department with
1. Addison S, Salanke U, Khaira H. Day Case Thyroid Surgery complex cases; a situation which calls for a cool head and an
in a Midlands Hospital. http://www.daysurgeryuk.net/ agreed plan of action. Your support will also be needed by
media/208828/16.1.7-8_addisonthyroid.pdf nursing staff in pre-operative assessment and sometimes by the
2. Parameswaran R, Allouni K, Varghese P, Misra multidisciplinary team caring for patients with head and neck
R, Charlesworth C, McLaren A. Day Case cancer. Not only can you provide support but there also exists
Parathyroidectomy in a District General Hospital: Safe the possibility to shape services.
and Feasible http://www.daysurgeryuk.net/media/149860/
parameswaran_20.1_p20-22.pdf Aside from direct clinical work there is still much to do. Airway
3. Brady C, Thwaini A, Cook J, Thilagarajah R. Daycase equipment requires organising and maintaining, trainees and
KTP Laser Prostatectomy for Symptomatic Benign other members of the department require airway training,
Prostatic Enlargement. http://www.daysurgeryuk.net/ guidelines and protocols must be written and airway practice
media/208792/16.2.51-54_brady_greenlight.pdf requires auditing. It is also important to maintain your own skills
4. Lever A-M. Kidney removal as day case surgery. BBC through local, regional or national airway courses and through
News 7 December 2009. http://news.bbc.co.uk/1/hi/ attendance at the annual meeting of the Difficult Airway Society
health/8385142.stm (DAS). Some regions have also formed their own airway groups
whose meetings provide a good forum to discuss current airway
ENT, head and neck, issues.

and difficult airway It can clearly be seen that life in head and neck anaesthesia is very
fulfilling. If you also incorporate other branches of anaesthesia
into your job plan then your working life will never be dull.
The ‘head and neck’ specialties of ENT and maxillofacial surgery
are increasingly being identified in job descriptions as specific Developing your CV
subspecialty interests. Patients and the types of surgery involved
are hugely variable and range from otherwise fit and healthy Since the introduction of the 2010 curriculum for a CCT in
young people undergoing functional and aesthetic procedures, anaesthesia, post-FRCA trainees are required to do a further
to the elderly and medically compromised requiring extensive period of training in difficult airway management. This is included
surgery for cancer. Major head and neck surgery may typically in the General duties essential unit of Advanced training and is
demand anaesthesia to suit the delicate haemodynamic mandatory. Also included in the ‘general duties’ unit is further
requirements of free-flap construction while at the same time training in ENT, maxillofacial and dental anaesthesia which,
accommodating intermittently stimulating bone and soft tissue though not obligatory, is obviously desirable, if not essential, for
resection. The skill mix required of the anaesthetist also takes anyone looking to incorporate a regular commitment to head and
account of the fact that not only the proximal airway, but in many neck surgery into their work. Approximately one in three schools
cases (laryngeal surgery), the distal airway is shared with the of anaesthesia offer fellowships in advanced airway management
surgeon. Airway management is often difficult from the outset for senior trainees of between 3–12 months duration. Advanced
because of pathology or previous surgery. The types and airway fellows have considerably greater opportunity to become
complexity of airway surgery taken on by hospitals depend practised in difficult airway techniques and to take on roles
largely on their size and whether or not they actually have ENT training others. These posts may also present the opportunity
and maxillofacial surgery departments. The skills to deal with a to become involved in airway management research but are
difficult airway may nevertheless be called upon at any time in usually, as with other specialist fellowships, subject to tough
any hospital. Departments of anaesthesia must therefore have competition either internally or externally.
enough consultants to be available who can plan safe treatment
for, and deal with, such cases. The 4th National Audit Project of Regular attendance at airway meetings and courses are
the RCoA goes far to emphasise this. probably more readily attainable by the interested trainee. DAS
was established in 1995 to further the development of difficult
Adequate members of staff specialising in advanced airway airway anaesthesia. Although not limited to those performing
management must also be available to train others. Moreover, anaesthesia for major head and neck surgery, membership of
the RCoA now recognises the need for airway-lead clinicians the organisation is a good place to start for those aspiring to
who should be responsible for ensuring that departments are specialise in this branch of anaesthesia. The society has one
stocked with appropriate airway management equipment and academic meeting per year, usually in November, consisting of
have local guidelines which are consistent with current national two days dedicated to lectures and presentations but also an
recommendations. In teaching hospitals and larger district extra day of workshops for teaching difficult airway skills. Difficult

35 THE GAT HANDBOOK 2016-2017

 airway courses are also now in abundance in most regions also enables an improved level of patient care to be delivered. As
throughout the country. Many consist of workshops in which the such, consultants in ICM often work a rota with a full week on the
use of equipment is taught on manikins, however there are now unit away from other duties followed by a number of weeks with
also a number of courses on which candidates may go on to less input in to the unit with their skills utilised in other parts of the
practice awake intubation on one another. It goes without saying hospital. It can be guaranteed that well trained consultants in ICM
that anything trainees can submit to national or regional meetings will continue to be in great demand as the specialty is continuing
whether in poster, abstract or verbal form will count for a lot when to expand. The Faculty of Intensive Care Medicine website is a
it comes to competition for posts later. Virtually anything from useful resource.
case reports to audits or research may be accepted. Airway audits
are very easily planned and carried out, even in hospitals which What are the negatives?
do not take on major head and neck work on a regular basis.
All hospitals have policies and equipment for the unanticipated Intensive care units are increasing in size, which has enabled on-
difficult airway and such things make for easy yet important local call frequency to reduce as consultant teams expand. However
audit material. Having sought as much experience as possible in the demands on ‘out of hours’ working are inexorably rising,
techniques for the management of the difficult airway, the natural with morning and evening ward rounds seven days a week now
progression is then to get involved in the teaching of others. as standard practice. You are very likely to be called at night
Anaesthetic trainees in hospitals of all sizes have an important as intensive care has become a consultant delivered service,
role to play in the teaching of many groups of people, e.g. medical although the necessity to attend does depend on local on-call
students, who need training in basic airway techniques as well arrangements and the adequacy of middle grade cover. Resident
as others, e.g. paramedics who require regular updating of their intensive care consultants may become necessary in the future,
intubation competencies. Trainees in airway fellow positions are but at present this is rare.
likely to have a wider involvement in teaching and instruction and
may be involved in courses run by the RCoA, the AAGBI and DAS. All of this has led to the perception that intensive care is such
hard work that intensivists will ‘burn out’ during their career.
Kevin D Johnston The emphasis on robust job planning has changed this, but the
Consultant, Leeds Teaching Hospital NHS Trust reality is intensivists now spend more of their contracted time
outside normal working hours. As this counts as ‘time and a third’
Peter Walsh they should have more non-clinical time during the week. This
Consultant, York Teaching Hospital NHS Foundation Trust provides a great opportunity to get involved in education, training,
management or research.

Intensive care medicine Training in intensive care medicine

Since 2012 it has been possible to train in the specialty of ICM

Why do intensive care? alone. However, programmes have been developed to enable
and encourage trainees to train in ICM in partnership with a range
Intensivists will give many different answers to this question. of specialties. While anaesthesia and ICM has been the most
Personally, I most enjoy the opportunity to work as part of an popular combination historically, it is now possible to train in ICM
energetic team of doctors, nurses and other professionals all with acute medicine, respiratory medicine, emergency medicine
focused on doing their best to save a patient’s life at a time of or renal medicine. But trainees should only train in two specialties
absolute need. For others it is the combination of leading patient if they are fully committed to both of them because posts for
care and applying a wide variety of treatments in a complex consultants with single CCT ICM will become more common in
environment where patients can, and do, respond very quickly. the future.

The intensive care unit has now become the centre of the hospital As a foundation doctor there are rotations that include an
with an ever-increasing percentage of total hospital beds. The opportunity to work in ICM, which gives an excellent opportunity
modern hospital cannot function without an effective unit that is to experience this career before committing to it. Most trainees
able to support its referring clinicians to deliver radical treatments who are seriously thinking of a career in ICM at this early stage
to an ageing population with multiple comorbidities and should consider a post in an ACCS programme. However, this is
sometimes profound physiological compromise. Most intensivists by no means essential, because the ICM programme has been
enjoy the opportunity this provides to interact with specialists specifically developed to enable trainees to enter directly from a
from all parts of the hospital; from cardiologists to oncologists, core medical, core anaesthetics programme or equivalent. There
obstetricians and surgeons. There is no hospital specialist who is no core programme aimed solely at a career in ICM with the
does not at some point need to seek intensive care assistance programme entry being at ST3. During core training you should
and the intensivist must similarly be prepared to visit all corners complete and retain any evidence of competencies which would
of the hospital. This all offers great potential for future career be relevant should you be appointed to the CCT ICM training
development particularly in hospital management. Boredom is programme. At present it is not possible to commence the ICM
never a problem; indeed the ability to cope with uncertainty and e-portfolio until you begin ICM training. Do therefore look at the
the late unpredictable referral is vital! assessment system for the CCT in ICM during your core training.

In common with anaesthesia there is a focus on physiological safety, Entry to the ICM programme itself is via a national selection
attention to detail and the ability to undertake practical procedures and interview process held once a year in April, with a separate
skilfully. However, bedside diagnostic skills are also required if the selection process necessary for partner specialties of dual CCT
multiple physiological and pharmacological treatments available training. Two years post foundation training must have been
are to be applied appropriately and successfully. As a result, skills satisfactorily completed, along with the requisite exam necessary
in echocardiography and ultrasound are now becoming essential. for completion of the first two years of training, e.g. Primary FRCA,
MRCEM or MRCP(UK).
One of the highlights in intensive care medicine (ICM) is the
interaction with patients and their families. All walks of life are There is, at present, a staggered approach to appointment to
represented and good communication skills are essential, as your dual CCT ICM training with a necessity to be appointed to the two
words will be remembered for many years. Providing continuity of programmes independently at separate rounds of recruitment.
ICM in weeks or blocks of days facilitates this communication and You cannot commence ICM dual training later then the end of
ST5.

36 THE GAT HANDBOOK 2016-2017

 Training in ICM is still an essential part of the seven year interest and commitment to the specialty, will they be good at
training programme in anaesthesia, with all anaesthetic trainees it, and are they better than their competitors? The first two are
undertaking a minimum of nine months ICM, and with many vital; it doesn’t matter how good you are on paper if you cannot
gaining more ICM experience than this. Advanced training in reassure the appointments process that you have an enthusiasm
ICM within a CCT in Anaesthesia still remains possible. Trainees and aptitude for ICM. Although assessing enthusiasm is
are strongly advised to check the latest training arrangements subjective there is no substitute for evidence of enthusiasm
on the FICM website as the routes of entry into ICM at ST3 are spread over a period of time. Enthusiasm is something that a
liable to change. candidate’s manner can and should convey, but enthusiasm
without achievement is less convincing.
The ICM training programme
There is now a standardised application form followed by a
ICM is a seven year programme in total, of which two years are series of interview stations at the national selection centre in
completed prior to entry at ST3 level. Birmingham. The application form is anonymised and you are
very unlikely to be interviewed by anybody with whom you have
The ICM programme is split into 3 stages: worked. As a result a carefully detailed application form and a
• Stage 1 ICM training is complete after a minimum of four good interview are the route to success.
years training during which every trainee must complete
one year ICM, one year anaesthesia, one year medicine It is well worth studying the application form a year or so in
(of which 6/12 can be emergency medicine) and another advance as there are many ways of improving your chance of
year of any of these specialist areas. This time can include success. While an additional postgraduate qualification, e.g.
training time spent in a core programme prior to being MRCP, is well worth achieving, it will take considerable effort over
appointed to the ICM programme a number of years, compared with activities such as participation
• Stage 2 ICM training consists of a specialist ICM year in a teaching programme, involvement in research or undertaking
(neuro, general, cardiac and paediatric intensive care) regular audits (with a critical care slant). Such things can often
and a year during which a range of special skills can be have just as big an effect on your shortlisting score. There are
further developed, e.g. research, cardiology, paediatrics, also sections within the application form for you to reflect on
education. Dual trainees will undertake training in their critical incidents, teamwork and patient care. Do ask colleagues
second specialty instead of a special skills year. The and supervisors to look at your application form to ensure your
prerequisite to enter Stage 3 ICM is the completion of the responses are on the right track and English is clear. Finally as
Fellowship exam of the FICM the scoring system is also standardised a rounded application
• Stage 3 ICM training consists of a final year of general ICM form is vital, so do try hard not to leave any boxes empty!
during which the individual will be aiming to acquire all the You must then bring your portfolio to the interview as you will
skills required to be a consultant and should typically be be expected to provide evidence to justify your application form.
working in a sub-consultant fashion.
The interview format consists of a portfolio review station, a
The FFICM exam presentation station and a clinical scenario station, with an
opportunity to prepare for the presentation and the clinical
The final FFICM exam was first held in January 2013 and has scenario before meeting the assessor. In addition there are two
taken place every six months since then. Candidates for the 30 minute unmanned OSCE stations in reflective practice and
final FFICM should have completed stage 1 ICM training and task prioritisation in which written work is formally assessed
passed the MRCP, MCEM or Primary FRCA to be eligible. The once the work has been completed. You can be reassured that
final FFICM consists of a multiple choice exam paper that needs a selection process of this type is a more valid approach to
to be passed to sit the oral exams, which are made up of 13 selecting doctors well suited to ICM than a traditional interview
OSCE stations and eight structured oral questions. approach.

This exam is now compulsory for all trainees on the CCT ICM The target competencies considered to be most important for
training programme. As a result, the numbers of candidates ICM are communication, conceptual thinking, problem solving,
sitting the exam has increased, with about 160 individuals sitting time management, decision making, professional integrity,
the FFICM MCQ exam each year. empathy, sensitivity, team working and managing others. If you
can demonstrate competence in these areas you should do well.
Less than full-time training
A common misunderstanding is that references will carry a major
Less than full-time training in ICM has been gradually increasing, influence in your chances of being appointed. It is important that
a trend that is set to continue with the changes to the ICM training these are good but more importantly they should be easy to
programme and consultant job plans that are taking place. Less obtain from referees because they are generally only read after
than full-time training must be applied for at LETB level and it is any decision has been made when they have the power to veto
advisable to give your TPD as much notice as possible of your any appointment.
request. As all units have their own working patterns, trainees
should tailor their job plan to accommodate their training needs In conclusion, if you are interested in ICM and can show your
and service commitment to the hospital, while ensuring continuity commitment to the panel you will be rewarded with a fulfilling
of patient care. Close liaison with the rota master is essential! career that will continue to interest and challenge you for many
years to come.
How can you secure an ICM training post?
Jeremy Bewley
The number of CCT ICM training posts in England and Wales Regional Advisor for Intensive Care Medicine, Severn Deanery
has increased from 72 in 2012 to 137 in 2015 and is likely to Consultant in Intensive Care and Anaesthesia, University Hospitals
increase further in 2016. There are an additional ten posts Bristol NHS Foundation Trust
in Scotland, though not all of these are available through the
national recruitment process.

When trainees applying for an ICM post are being considered,

three key questions have to be asked; do they have a strong

37 THE GAT HANDBOOK 2016-2017

 Leadership and management Luckily for us, leadership and management are not the dirty
words they used to be. The Royal Colleges, LETBs and many
opportunities hospital Trusts are all aware that an engaged clinician can help
deliver a more effective and financially stable organisation, as
well as enhance patient care and experience. Furthermore, the
Our NHS is clearly changing. We’ve all read the headlines:
evidence is building to those wanting published proof. There
the most optimistic forecast predicts that an additional £8
are an abundance of leadership and management programmes
billion per year will be needed to fund our healthcare system
available if you are prepared to seek them out, and many
by 2020. The reasons behind this are multiple, but include the
Trusts will jump at the chance to involve you in management
fact that healthcare is simply costing too much, compounded
and leadership challenges. Anaesthetists in particular are well
by an increasingly ageing population, further technological
placed to take up roles within senior management teams as
developments, and increasing patient expectations. It is realistic
they find themselves interacting with a wide variety of other
to assume that the NHS will not see any real funding increases
specialty doctors and healthcare professionals. Furthermore,
for the foreseeable future, which represents a dramatic change
they are used to running a service with measurable outcomes,
for a service used to 3–7% increases year on year in the past.
instinctively work in teams and have no ‘turf’ to lose, thus they
It sounds all doom and gloom, but there has been a shift in
are less likely to feel threatened by structural change.
thinking over the years that doctors can have a real contribution
to developing high-quality care in the midst of these huge
financial challenges.

Across all hospitals, junior doctors and consultants, in particular,

command great clinical resources and are already experiencing
increased pressure to make clinically effective and cost-
sustainable services. We all have a role in driving ‘value’, i.e.
in striving to achieve the best outcome, and experience, while
maintaining, or ideally reducing, the cost of achieving that
outcome. Consultants, now and in the future, are expected to
become managerially, even business, minded. Doctors need to
understand how to ensure best value, be it through an integrated
pathway, for example, or through effective use of competition in
tendering services.

Common questions asked at consultant interviews are likely to

challenge applicant knowledge about the bigger picture, asking
how they would set about either generating revenue, or saving
money, while maintaining or increasing the quality of care for
patients. These types of questions are alien to doctors, who
Opportunities include:
have often been led to expect that as long as they look after the
patient in front of them, someone else will look after the system.
Formal fellowships or programmes
Unbeknown to most trainees, doctors, particularly consultants,
• Clinical Leader Fellowships (previously known as Darzi
are key players in improving and running ‘the system’.
Fellowships). Usually taken as an OOPE over 12 months,
they usually allow the Fellow to undertake a large service
Medical training doesn’t always prepare doctors for these types
improvement project within a hospital Trust
of roles. Clinicians are excellent at finding the solution to an
• NHS Medical Director Clinical Fellowship Scheme
individual puzzle, but are less happy dealing with managerial
(previously known as Chief Medical Officer’s Clinical Advisor
or system ‘problems’, especially those within large complex
Scheme). This is another 12-month fellowship, taken as an
organisations. It’s often difficult for them to see the bigger picture
OOPE. It allows the Fellow to participate in a large project
because they don’t fully understand the larger NHS culture and
within an organisation such as the Department of Health,
ever changing organisation in which they exist. They are also
the Royal College of Physicians, NICE, MHRA or at the BMJ
less strategic in their thinking because they are less inclined to
think in terms of long-term system impact. But doctors are highly
NHS Leadership Academy programmes
intellectual, evidence-based creatures that excel in learning new
• Currently on offer are four programmes to which doctors
things and in making difficult decisions. They are trained to deal
can apply (Edward Jenner, Mary Seacole, Elizabeth Garrett
with complex high-risk issues, and possess the necessary skills
Anderson and Nye Bevan). Doctors in training are suited
to manoeuvre through the complex and adaptive system that is
to the first two as they often do not hold formal authority
healthcare. Being in constant contact with their patients enables
positions. These are year long programmes which require
doctors to be strong patient advocates, but also helps to ensure
the participant to complete online modules of learning, write
that patients themselves are first and central to all decisions.
formal dissertations and often participate and complete
Both doctors and their non-clinical manager counterparts have
some form of ‘leadership initiative’. All of this can be done
much to learn in co-operation with each other, but both need to
in training. At the time of writing these programmes were
challenge their own knowledge and behaviours.
free of charge when sponsored by your anaesthetic school,
although applicants are warned that leaving the scheme
The GMC already highlights that leadership is part of a doctor’s
early would incur a personal cost of around £5,000
professional work. The GMC’s Tomorrow’s Doctors states: ‘It is
• The Edward Jenner programme leads to a NHS Academy
not enough for a clinician to act as a practitioner in their own
Award in Leadership Foundations. The Mary Seacole
discipline. They are expected to offer leadership and to work with
programme leads to a PG Certification in Healthcare
others to change systems when it is necessary for the benefit of
Leadership with the opportunity to complete the Elizabeth
patients.’
Garrett Anderson programme and its Masters qualification
in Healthcare Leadership
But how does one ‘change the system’? Will a one-day leadership
course really prepare us to face the challenges within our own
Trusts, within our own NHS? A much more holistic approach
is required to really gain the knowledge, skills and behaviours
expected of a clinical leader of the future.

38 THE GAT HANDBOOK 2016-2017

 Other formal qualification examples which can be found E-Learning
online • E-Learning for Healthcare (e-LfH) and LeAD (Leadership for
• Postgraduate Certificate in Clinical Leadership, e.g. The Clinicians)
Open University • Clinical Leadership 360 degrees (multisource feedback)
• MBA or MSc in Medical Leadership, e.g. From Southampton
or Birmingham Universities By flexing their leadership and management muscles, doctors
may not only become more effective, but happier in their roles if
Leadership and management courses – ranging from one to they feel a renewed sense of loyalty and ownership of the NHS.
several days This would not only benefit our profession, but more importantly,
• The AAGBI offer an interactive two-day course in leadership the patients we serve.
and management which culminates in a networking dinner,
and is mapped to the RCoA curriculum Nathalie Turpin
• The RCoA offer an interactive one-day course in leadership ST7 Anaesthetics and Intensive Care, PG Cert in Healthcare
and management aimed at senior anaesthetic trainees and Leadership, President of Leadership Development for
consultants Anaesthetists, North Central London School of Anaesthesia
• Leadership and management courses offered by The King’s
Fund can run from a few days to a year Jonathan Fielden
• Local LETBs also offer programmes which can be found Medical Director & Consultant, University College London Hospital,
through their websites, although without an emphasis on NHS Foundation Trust
anaesthesia

In-house training: (Don’t be afraid to ask. People are more Medical education
receptive than you think!)
• Get to know your Trust and its management structure. This
can be as easy as looking through your local Trust’s intranet With the decreased training time available due to the European
site Working Time Directive there is an increasing focus on the quality
• Ask to meet departmental leads, medical directors and of training, teaching and the learning environment. Teaching and
operation managers. This will be a useful exercise when you training competencies are part of the RCoA CCT Curriculum and
come to making those important pre-consultant interview are described in Annex G. There are basic, intermediate and
visits higher/advanced competencies. The curriculum lays out clearly
• Your Trust may operate a type of mentoring or shadowing the skills and attributes all anaesthetic trainees should achieve.
programme in which you can observe the work of the At a basic level the focus is on one’s own role as a learner with
Trust behind the scenes, such as an executive shadowing the emphasis moving to one’s role as an educator at advanced
programme or paired learning programme with a member levels. The challenge remains: if you want to stand out as a
of the junior management team medical educator what can you do in addition to these required
• Manage your department’s rota and familiarise yourself with competencies?
local and union employment policies
• Get involved in quality improvement and management Being an effective learner
projects to aid the Trust change. Note that this is part of the
2010 CCT Curriculum (see Annexe G for more details) Teaching begins with learning; some educationalists believe
that there is no teaching but rather the facilitation of learning.
Become a representative While some readers might not agree with this, for all of us our
• Anaesthetic representative to a junior doctor forum first experience of education was as learners and this experience
• Junior doctor representative on your Trust’s local negotiating must necessarily inform our views and opinions. We know
committee who the inspirational teachers are, and by thinking about their
• Join the BMA and act as a representative at local or national teaching style, attitudes and behaviours we may be able to
level mirror these qualities in our own teaching style. Likewise we can
• Apply for other representative roles within the RCoA, AAGBI, avoid the mistakes of the poor ones!
ICS or similar societies
Both the trainee e-portfolio and consultant online CPD system
Join the faculty allow for personal reflection. Reflection can be first used as a
• The Faculty for Medical Leadership and Management learner to reflect upon the quality of teaching received in theatre,
(FMLM) was set up in January 2011. It has a wide-ranging the value of attendance at an external course etc. By reflecting
membership from medical students to chief executives. on some positive and negative features one can incorporate
There are a wide variety of resources to access including them into future delivery of teaching and training.
frequent webinars on leadership topics
Teaching opportunities
Follow a curriculum
• The Medical Leadership Competency Framework (MCLF) Within medicine and anaesthesia there is a huge range and
Curriculum offers a structured approach to learning. It also variety of teaching opportunities. The courses and qualifications
offers self-assessment tools, which are very useful to use as described later are costly, but getting involved in teaching on a
part of a personal development plan. practical level costs no money, just your time. Teaching may be
• The RCoA curriculum (Annexe G) gives guidance as to what formal or informal, organised or opportunistic. It is important to
they expect trainees to become familiar with gain experience in all these different settings and to maintain a
record of your teaching activity. If you supervise a more junior
Read all about it online trainee this can be recorded within the RCoA logbook, you can
• Twitter is a great source of new information reflect upon teaching sessions in your e-portfolio and collecting
• NHS Leadership Academy feedback from those you teach provides powerful evidence.
• King’s Fund
• Institute for Healthcare Improvement a) Local teaching sessions
• Faculty for Medical Leadership and Management Many anaesthetic departments run regular teaching
• BMA website, BMJ, Anaesthesia News, RCoA website sessions, journal clubs or both. These may be led or

39 THE GAT HANDBOOK 2016-2017

 facilitated by a consultant, but often involve trainees g) Exam courses
preparing and delivering content. The content is often exam Once you have gained your Primary and then Final FRCA
focused but depends on the needs of trainees in a you may be able to teach on exam revision courses. These
department. If such teaching does not exist within your may be run within your department or region. Acting as
department, why not set it up? faculty and an examiner is a good way of keeping your own
knowledge fresh.
All trainees will spend some time at a teaching hospital and
depending on local arrangements medical students will Social media
have an anaesthetic, ICU or acute care attachment. These
attachments will involve formal and informal teaching While various models of distributed peer learning have existed for
sessions, and, if my clinical lecturer is like everyone else’s, many years, the advent of widespread use of social media has
they are desperate for help in delivering educational led to a vibrant, dynamic and distributed education community.
content. In very broad terms this phenomenon has been termed FOAMed
(Free Open Access Medical Education) a description which was
b) Regional study days first articulated in 2012 [1]. However, the concept, that social
In addition to local teaching, regional study days are also media and web 2.0 technologies could be used to generate
common. These may be run by one hospital in a LETB educational material, is not new.
or rotate around departments. Seek out your college tutor
and volunteer your services to help organise one of these In fact it is hard to really define FOAMed as different to any other
days, help is usually very gratefully received and a bit of form of educational activity which exists outside of traditional
initiative is very impressive. educational institutions. The difference now, however, is that for
the first time the means to produce, distribute, consume and
c) School of Anaesthesia opportunities critique educational material lies in the hands of the consumer/
Training is overseen by Schools of Anaesthesia and many student rather than with universities, hospitals, and postgraduate
will appoint a trainee representative. If you are interested hospitals.
in education this is a way to get involved in the organisation
of training at a higher level. Arrangements vary between This represents great opportunities for education in anaesthesia
schools so again speak to your college tutor. Observing at and critical care which has, in fact, with emergency medicine, led
interviews may feel like it falls into the category of the development of FOAMed.
management but an interview panel is trying to select
trainees who will fit in with their training programme and The benefits of a free, vibrant, worldwide community of people
show potential to learn and develop. If you see yourself interested in anaesthesia and critical care education are difficult
as college tutor, programme director or regional advisor in to overstate. However the risks and disadvantages are not so
the future it is these people that run the interview panels. well understood and this will evolve over the next few years;
for example, peer review is poor, although there are two sides
d) In-theatre teaching to this debate [2]. FOAMed is now an essential, fascinating,
Most opportunistic teaching takes place in theatre and stimulating and altruistic community and should be embraced
even as a new trainee you have skills and knowledge by anaesthesia and critical care. It still needs to evolve into an
that you can help others to develop. There are always enduring, objective, coherent educational model of distributed
medical students, student ODPs and paramedics in learning and can only do that if trainees engage and contribute.
theatre. These people are often desperate for someone
to give them some time, show them things and answer their Articles and reviews:
questions (just as you are). As a more senior trainee you • Globalization of continuing professional development by
may be allocated other trainees on your list; a little journal clubs via microblogging: a systematic review
preparation can make this a useful educational experience • Innovative strategies in critical care education
for both of you. • Social media, medicine and the modern journal club
• Ten steps for setting up an online journal club
e) Simulation • The social media index: measuring the impact of
For a variety of reasons the use of simulators in medical emergency medicine and critical care websites
education is increasing. If you are interested in simulation • Integration of social media in emergency medicine
teaching many of the centres require you to first undergo residency curriculum
faculty development. These courses may require a • Five strategies to effectively use online resources in
registration fee or be free. Contact individual simulation emergency medicine
centres for details. If your interest in simulation is more • Free Open Access Meducation (FOAM): the rise of
longer-term teaching fellowships. This may be something emergency medicine and critical care blogs and podcasts
you wish to consider for an OOPE. (2002–2013)

f) Resuscitation courses Some of the established sites which contain content relevant
Anaesthetists are popular as teaching faculty on to anaesthesia and critical care:
resuscitation courses. The usual way into this is to be • http://www.wessexics.com/The_Bottom_Line
selected when completing a course as a candidate; those • http://intensivecarenetwork.com
with potential are selected. If you are interested in gaining • http://stemlynsblog.org
instructor status make this known to the course director • http://lifeinthefastlane.com
before the course, they may have helpful hints to aid your • http://www.smacc.net.au
selection. Once selected it is necessary to complete the
generic instructor’s course and commit to teaching a There are many other resources both in the UK and wider world
certain number of courses per year. Details can be sought and the Twitter hashtag #FOAMed is one way to keep track and
from the Resuscitation Council. find new material.

Alternatively, the ALERT course is run in-house by many

hospital resuscitation departments. This course is taught
to many medical students and nurses and involves
recognition and treatment of the unwell patient; just where
the skill of the anaesthetist lies. Speak to your Resuscitation
Officer to see if your help is needed.

40 THE GAT HANDBOOK 2016-2017

 Workplace-based assessments References
1. Life in the Fast Lane blog. http://lifeinthefastlane.com/foam
The way in which trainees are assessed and appraised has 2. Life in the Fast Lane. Why FOAM? Facts, Fallacies and
changed over the past few years, with the introduction of training Foibles. http://lifeinthefastlane.com/foam-facts-fallacies-
portfolios and workplace-based assessments. Senior trainees foibles
are usually able to assess other trainees once they themselves 3. Academy of Medical Educators. A Framework for
have been suitably trained. This training is often available in- the Professional Development of Postgraduate
house but is also available at the RCoA. Medical Supervisors. November 2010. http://www.
medicaleducators.org/index.cfm/linkservid/C575BBE4-
‘How to teach’ courses F39B-4267-31A42C8B64F0D3DE/showMeta/0

In addition to gaining training in assessment there are a variety

of teaching courses available. These are available within many Medico-legal expert
LETBs and may be free or cost up to £500 per module. The
RCoA runs a series of events under the title ‘Anaesthetists
as Educators’. Annex G of the 2010 curriculum states that The term ‘expert’ is widely misunderstood. It absolutely does not
attendance at a ‘How to Teach’ course is expected at the higher mean ‘this person knows more about anaesthesia than you do’.
level of training. Now that this is mandatory the issue still remains It does mean ‘this person is considered an appropriate individual
of how to stand apart. For that you may need a higher level to advise the court on the standard of practice that would be
teaching qualification. expected from an anaesthetist in the particular circumstances
which pertain to this case’. The standard of care which the
Teaching qualifications practitioner needs to have achieved to avoid being found
negligent is that which is ‘accepted as proper by a responsible
Qualifications in medical education range from a postgraduate body of medical men skilled in that particular art’ (the well-known
certificate to diploma, and on to masters level and beyond. Bolam test) and which is amenable to logical analysis (the so-
These qualifications are available at several institutions. The called Bolitho rider). It is the expert’s job to represent the views of
University of Dundee runs a distance-learning course focused on that responsible body to the highly intelligent but medically naïve
anaesthesia, while most other courses are directed at healthcare lawyers and judge. What do you need to be an expert? From the
in general and include contact days. Distance learning probably point of view of the CV, you only really need to show that you
fits with most people’s working life but there are advantages maintain a clinical practice in the field under scrutiny and, ideally
to courses with contact days. The course I undertook at the but not critically, that you have been doing so successfully for
University of Bedfordshire included contact days learning with some time. It is much more important to have the right skill set
trainees from other medical disciplines, dentists, vets and and personality traits for this sort of work.
other healthcare professionals. Contacts made with trainees in
complimentary disciplines allowed for joint teaching, observation • Ability to work to deadlines – time factors can be critical
and, importantly, feedback. Qualifications with fixed terms also when submitting reports or comments
focus the mind and a deadline might make some people more • Ability to write clearly and concisely – try explaining the
productive. relationship between vaporiser setting, MAC, end-tidal and
arterial volatile agent concentrations to a lay person who is
These qualifications represent a significant financial and interested in anaesthetic awareness
time investment but, as with many things, if you see this as a • A logical mind – the legal process is relentlessly logical,
worthwhile investment in your career you need to go for it. A and you will need to be as well
PgCert will cost in the order of £1,500. I am aware of one LETB • A thick skin – the lawyers for whom you are preparing a
that offers a PgCert to a selected group of its trainees. College report will try very hard to pick holes in it, but this is nothing
tutors and regional advisors should be able to provide local compared to what can happen in court when the opposing
information on this. barrister gets his teeth into you
• Complete control of your temper – see above
Other resources • Knowledge of your limitations – nothing diminishes an
expert’s standing more than when they stray outside their
The Society of Education in Anaesthesia runs an annual area of expertise
meeting and many joint events with other anaesthetic societies • A degree of anal retentiveness – when every comma
throughout the year. counts, as it does in legal argument, then slapdash is not
a good look
The Association for the Study of Medical Education deals with
medical education in general and publishes, among other things, If these are your strengths, then all well and good. If not, there
the journal Medical Education. As with all areas of interest, a is equally good, if not better, income to be had at the private
study and publication always helps the CV. hospital down the road, and you already know that you’re a
good anaesthetist!
The Academy of Medical Educators is an organisation for those
with a role in medical education to ‘provide leadership, promote While it used to be acceptable to learn on the job, nowadays
standards and support all those involved in the Academic some form of training is, understandably, considered useful. Bond
discipline of medical education’. They have recently published a Solon, a legal training firm, run one-day courses in report-writing,
report on behalf of the Department of Health [3]. This document, courtroom skills and civil law and procedure. Alternatively, Action
which is acceptable to the Department of Health and the GMC, against Medical Accidents (AvMA) and the Academy of Experts
will form appraisal of clinical and educational supervisors, a also provide training, usually for a lower fee. Once trained, how
process that should be of interest to senior trainees. do you get your first case(s)? Unless you are fortunate enough
to find yourself on AvMA’s recommended list, your best bet is
Claire Williams to attach yourself to the coat-tails of an established expert. Ask
Past GAT Committee Member them for a few cases to study and to prepare mock reports; they
Consultant, Cambridge University Hospitals NHS Foundation Trust may well recommend you when they are offered a case with too
short a deadline, an increasingly frequent occurrence as the
Ronan O’Leary workload builds up.
Consultant, Cambridge University Hospitals NHS Foundation Trust
David Bogod
Consultant, Nottingham University Hospitals NHS Trust

41 THE GAT HANDBOOK 2016-2017

 Neuroanaesthesia Trainees looking to specialise in neurocritical care as well as
neuroanaesthesia should ideally complete three months of
neurocritical care as part of their stage 2 training in intensive care
Are you looking for a dynamic and rapidly advancing subspecialty medicine. Under the new stand-alone ICM training programme
where your anaesthetic technique can have a real impact on both of the FICM, development of specialist skills in neurocritical
operative conditions and patient outcome? Where advanced care can be obtained through augmented learning in stage 2
airway skills, multimodal monitoring and the management of of the programme. Although the majority of neurocritical care is
challenging and complex cases are required on a regular basis? undertaken within general intensive care units there are some
Do you enjoy bringing physiology and pharmacology to life while single specialty units in the UK.
working as part of a dedicated team when managing critically ill
patients? If so, neuroanaesthesia and/or neurocritical care may Developing your CV
be the career choice for you.
You should get involved with projects in neuroanaesthesia
Neurosurgical units are based within 37 teaching hospitals in or neurocritical care. Examples include presenting topics on
major centres of the UK and Ireland. These act as tertiary referral neuroanaesthesia at journal clubs, teaching, audits and surveys.
centres within a set geographical area. Many of these hospitals You could discuss relevant morbidity and mortality cases that
also act as Major Trauma Centres, at the hub of a system of occur in your neurosurgical unit. You should read the relevant
regional trauma networks that went live in April 2012. Most journals and other topical subjects from the AAGBI glossies and
neuroanaesthetists will also have sessions where they carry out RCoA Bulletins. These might give you a simple idea to audit and
non-neurosurgical lists or work in intensive care. may lead to implementing change in your department. Even
if you are not currently in a neuroanaesthesia placement you
Training could initiate projects related to neuroanaesthesia, for example
an audit of transfers of patients with severe traumatic brain
As with other subspecialties, the training in neuroanaesthesia injury. Anything leading to service improvement or improving
and neurocritical care has become increasingly standardised the patient pathways will allow you to develop key management
following the introduction of competency based training. There competencies, and demonstrate that you are motivated and
are now intermediate, higher and advanced training modules, enthusiastic. Above all, you should be proactive: keep your
details of which can be viewed on the Neuro Anaesthesia & eyes open for any interesting cases that could be written up and
Critical Care Society of Great Britain and Ireland (NACCS) submitted for publication. Often the simplest ideas are the best.
website and the RCoA website. Apply for local and national prizes because you will be surprised
how many trainees don’t!
If neuroanaesthesia has appealed during your basic training then
express an interest to your programme director at an early stage Ability to communicate effectively and sympathetically with
so they can arrange a placement for your advanced training. patients and their relatives may be demonstrated through A-CEX
or ALMATs, or via cases on your ICU module. Working effectively
Intermediate training in a multidisciplinary team and leading this team when chaos is
surrounding you, is another skill to try and demonstrate through
This requires between one and three months spent at specialist case based discussion.
centre, building on competencies and skills obtained during
basic training (CT1 and CT2). How to use your study leave effectively

Higher training Not every hospital can provide all the areas of training you will
need to complete your advanced training, for example only 19
Anaesthesia for neurosurgery, neuroradiology and neurocritical centres carry out paediatric neurosurgery. Take the initiative,
care is one of the essential units of higher training for the make your CV different, and show that you are interested and
CCT in anaesthesia. Between one and three months is spent experienced in all aspects of neurosurgery. A few days spent in
becoming more independent in managing a range of cases for another centre looking at a specific area can be a very efficient
neurosurgical anaesthesia. use of your study leave. This will require early planning to set
up an honorary contract, but should be quite easy to arrange,
Advanced training and has the advantage of being free! Look on the training
section of the NACCS website where you will find information
Advanced training in neuroanaesthesia takes 6–12 months about what other neuro centres have to offer. Here are a few
and is often taken as an OOPE or fellowship. The majority of suggestions that will make it clear that you are serious about
the time should be spent in neuroanaesthesia, although some your neuroanaesthesia training:
experience in neurocritical care is also desirable. Many national
and international centres offer advanced training and in addition • Improve your advanced airway skills: teach on a local
may offer opportunities for research. Trainees are encouraged airway course and make friends with a respiratory physician
to gain experience in more than one neuroscience centre and if or maxillofacial team to increase your exposure to fibreoptic
unable to do so should consider at least visiting other units. With intubations. Don’t forget to document these cases in your
this in mind, the NACCS offers a travel fellowship of £2,500. This logbook
fellowship is awarded annually to trainee or consultant members • Ensure you have a broad experience of spinal surgery
to help with travel and accommodation costs. The Society also including major orthopaedic spinal surgery such as scoliosis
has a network of linkmen, who can help arrange such visits. repair
Clinical fellowships (both in UK and abroad) are often advertised • Spend some time in an X-ray department which performs
on the website. interventional radiology for aneurysms, arteriovenous
malformations and strokes. This is a very specialised but
For those considering subspecialising in paediatric fast expanding area
neuroanaesthesia, the recommended route is to undertake • Ensure you have done some paediatric cases even if this is
advanced training in paediatric anaesthesia and either gain not your intended area of practice; time spent broadening
neuroanaesthetic experience during that programme or your training is never wasted
undertake a further six months of training. This is in recognition • Offer to organise pre- and post-fellowship study days
of the fact that knowledge of two major anaesthetic specialties on neuroanaesthesia. This will make you popular in your
is required. department and look good on your CV. You can teach

42 THE GAT HANDBOOK 2016-2017

 juniors about the safe transport of head injury patients partner, the stressed obstetrician and the busy midwife
and the principles of neurosurgical anaesthesia while you • Be skilled with a needle – you’ll need to be skilled at neuraxial
are on-call. Multidisciplinary trauma teams in DGHs and anaesthesia and analgesia in some of the most challenging
Major Trauma Centres may benefit from simulation-based (and mobile!) subjects
training in neurosurgical emergencies. You may have been • Stay cool when all around are losing theirs – providing
involved in neurosurgical cases in your obstetric module, safe and effective resuscitation, pain relief and general
and teaching the obstetric team and midwives could follow anaesthesia requires calmness under pressure, rapid
naturally. decision- making, and leadership qualities
• Be a teacher trainer – providing up-to-date guidelines for the
Become a trainee member of NACCS labour ward staff and information for mothers
• Be committed to keeping up standards – audit has a
This is strongly recommended. The NACCS exists as a forum large to role to play in obstetrics, both locally, and with
for the discussion and exchange of ideas, the promotion of internationally established projects, such as Mothers and
clinical excellence and the encouragement of research. Attend Babies – Reducing Risk through Audits and Confidential
the NACCS Scientific Meeting. Trainee membership is actively Enquiries across the UK (MBRRACE-UK) (formerly Centre
encouraged and costs £10. The ASM is a two-day scientific for Maternal and Child Enquiries (CMACE))
meeting with a session dedicated to trainee presentations and
posters. There are many prizes on offer. The Harvey Granat prize Training
is awarded to the best oral presentation. The NACCS awards two
further prizes, for runner up in the oral presentation and the best Obstetric anaesthesia is a core topic in anaesthetic training and as
trainee poster. All short listed oral presentations are published such every trainee spends a significant proportion of their training
in the Journal of Neurosurgical Anesthesiology. All good stuff for and on-calls dealing with pregnant women. However, a career
smartening up your CV and it’s a great place to network, put out in obstetric anaesthesia demands more. A trainee considering
feelers and to socialise. a career in obstetric anaesthesia should aim to complete an
advanced obstetric anaesthetic training module, while securing
In summary, neuroanaesthesia is a dynamic and rewarding a clinical or research fellowship for six or 12 months.
subspecialty that offers opportunities for everyone. It
encompasses patients of all ages, from the most straightforward Arguably, of all the subspecialties, obstetric anaesthesia
to the most complex… so go for it! provides the most fascinating opportunities for OOPT, whether
it’s in the UK or overseas. If you do choose to go to a low to
The authors would like to thank members of the NACCS for middle income country, keep in mind that it may have training
reviewing this chapter. implications. These positions are rarely advertised and often
require a thorough internet search and/or a useful contact. Most
Dominic Jansen of all, trainees should discuss their intentions with their training
Consultant in Neuroanaesthesia and Neurocritical Care, North programme director or head of school early, as posts can be
Bristol NHS Trust competitive to obtain, and notice needs to be given to take up
an OOPT.
Samantha Shinde
Consultant Neuroanaesthetist, North Bristol NHS Trust Trainees contemplating a career with a major commitment
AAGBI Honorary Secretary to obstetric anaesthesia should read Annex E from the 2010
CCT Curriculum. The RCoA website also provides practical
information on OOPTs.
Obstetrics
Audit

An increasing multicultural maternal population, the complexity Audit is relatively easy to achieve in obstetrics and you should
of medical problems, the obesity epidemic and the expectation certainly aim to complete at least one audit project which could
of women to be able to successfully and safely give birth when have a major impact on clinical care during your obstetric
they may not have done in the past, are all challenges to training. Aim to complete the audit loop and, if possible, present
obstetric anaesthetists. Additionally, working with a wide range of this as a poster or oral presentation at a national or international
professionals including midwives, obstetricians, neonatologists conference, such as the Obstetric Anaesthetists’ Association
and obstetric physicians can test your communication and (OAA) and the Society for Obstetric Anesthesia and Perinatology
prioritisation skills. There are a range of interactions for the (SOAP), or a regional meeting such as Wessex Obstetric
obstetric anaesthetist in the antenatal clinic, for labour analgesia, Anaesthetists (WOA), or the Society of Mersey Obstetric
for operative delivery, and in the extreme emergency situations, Anaesthetists (SOMOA).
meaning that your professional life is not only demanding and
varied, but ultimately very rewarding. Our subspecialty is actively involved in MBRRACE-UK, a
perinatal audit that is the envy of the world. The philosophy of
The obstetric anaesthetist should: MBRRACE-UK is to recognise every maternal death as a young
woman who died before her time and to use the lessons to save
• Be able to work with anyone, anywhere – this might include future mothers and babies. Since 2014 they have produced an
seeing selected women antenatally, liaising with specialist annual report to provide recommendations and guidance. The
physicians and obstetricians, and working alongside Report’s recommendations rapidly become the gold standard for
midwives and obstetricians to care for women during labour, perinatal care across the UK, Ireland and internationally, so make
in theatres and on the postnatal ward sure that you are up to date with them.
• Understand other people’s concerns, as well as your own
– knowing what the obstetricians and midwives ‘are getting Research
up to’ will help you to head off trouble early! You need to
understand the process of childbirth, learn how to read a Becoming involved in obstetric research can be difficult, as the
cardiotocography (CTG) and be able to interpret fetal blood availability of suitable obstetric patients does not occur on a
gases, etc regular basis, and ethical constraints make it difficult to complete
• Communicate effectively with people experiencing the whole research during a clinical fellowship. However, opportunities are
range of human emotion – the mother in pain, the anxious highly sought after so if a chance presents itself, grab it.

43 THE GAT HANDBOOK 2016-2017

 Research posts are usually 12 months long. They are becoming Management
increasingly popular and are usually appointed by competitive
interview. The OAA website is an excellent source of information This can be a bit tricky to achieve, as it usually has to be organised
for many of these fellowships in the UK, as well as abroad. out of your own time – not many hospitals can spare trainees to
Once you identify the fellowship you are interested in, contact be allocated on ‘management’ days. However, you do not need
the supervising consultant to declare an early interest. It is many of these sessions – just attending a couple of meetings can
good practice to visit the hospital if you have not worked there give you a flavour of how things are run ‘behind the scenes’. You
before and talk to current and previous fellows, to give you more can attend a Maternity Matters or an Obstetric Risk Management
information about the post. This will help you confirm that this is meeting. Not only will this be educational but it will prepare you
the post for you, and will demonstrate that you have a serious for the consultant interview. Also, spending some time with the
interest in the fellowship local maternity Clinical Negligence Scheme for Trusts specialist
can give you an idea of the current management goals and aims
Courses and society memberships of a given maternity service.

You should certainly demonstrate your interest in obstetric You can also attend guidelines meetings and get involved in
anaesthesia by becoming a member of the OAA. The OAA has updating or writing a guideline for your maternity department.
a global membership of more than 2,500 members (of which An ideal opportunity would be to link this to an audit or quality
over 350 are trainees) and aims to promote the highest standard improvement project. Get in touch with the obstetric lead in your
of anaesthetic practice in the care of the mother and baby. In hospital who will no doubt have a list of guidelines that need
addition, the OAA has excellent links with SOAP (its equivalent updating.
organisation in North America) and many other countries around
the world. Try to attend one of the SOAP annual meetings, which The future
are normally hugely interesting and are usually held in very
attractive US venues. The workload of maternity services has never been higher. The
caesarean delivery rate has increased from 10% in the 1980s to
The OAA offers preferential rates for trainees, and you should nearer 30% today. However, changes to workforce deployment
aim to present a paper or a poster at one of its annual meetings may be around the corner. The current 8–9 hour consultant
during your trainee years; the lucky trainee winner of the oral anaesthetist cover on the labour ward may soon become 12
presentation wins a cash prize. Membership of the OAA also hours, and ultimately 24 hours, to match consultant obstetrician
includes access to the specialist journal, the International work patterns. The European Working Time Directive and the
Journal of Obstetric Anesthesia. In addition, do not forget about continuing shortage of midwives will continue to impact on our
the Royal College of Obstetricians & Gynaecologists’ website. ability to deliver an efficient and safe maternity service.
It provides excellent information, much of which is of interest
to anaesthetists. Many regions have local obstetric anaesthetic Alexandra Reeve
societies and they hold regular meetings on selected obstetric Obstetric Anaesthesia Research Fellow, University College London
anaesthetic topics and membership is usually free of charge. Hospitals NHS Foundation Trust

Perhaps the most important course to attend as a senior trainee Selina Patel
with an interest in obstetric anaesthesia is the Managing Obstetric Obstetric Anaesthesia Research Fellow, University College London
Emergencies and Trauma (MOET) course. This is a tough but Hospitals NHS Foundation Trust
enjoyable course, aimed at post-fellowship trainees in obstetrics
and anaesthetics. Roshan Fernando
Consultant Anaesthetist, University College London Hospitals NHS
Foundation Trust
OAA President & AAGBI Council Member

Ophthalmics

Anaesthesia for ophthalmic surgery is a recognised subspecialty

of anaesthetic practice. A broad spectrum of patients will be
encountered, ranging from premature neonates to the very
elderly who, because of their age, frequently require optimisation
of concomitant systemic disease prior to surgery. Ophthalmic
surgery is also commonly required for ocular manifestations of
systemic disease and in ‘syndromic children’, hence a relatively
high proportion of patients are seen with relatively uncommon
medical conditions, making this a subspecialty that presents the
opportunity to encounter a wide range of disease conditions. For
these reasons, pre-operative patient assessment is particularly
Teaching important and is being performed increasingly in centralised
pre-operative assessment clinics staffed by trained nurses with
There are ample opportunities to get involved with teaching in consultant anaesthetic input. During consultations, decisions are
and around the labour ward. Local teaching programs often also made about appropriate patient selection for day surgery
include small group discussions on analgesia in labour in and choice of local or general anaesthesia.
antenatal classes, teaching on skills and drills for midwives, and
getting involved in courses for novice and junior anaesthetists. In the operating theatre, the anaesthetist performing any local
Many hospitals now have simulation centres, which afford the anaesthetic block is responsible for checking the consent form
chance to get involved in multidisciplinary training in obstetric with the patient, especially with regards the laterality of the eye to
emergencies and crisis resource management. be operated on in accordance with stringent guidelines, hence
vigilance and attention to detail is essential. A certain degree

44 THE GAT HANDBOOK 2016-2017

 of manual dexterity is advantageous in performing regional anaesthesia are advised to complete all six sessions in this
ophthalmic blocks. Good and effective communication skills are module. You can access these sessions by logging in or
vital both in assessing the patient and in communicating with the registering at http://www.e-lfh.org.uk
surgeon to ensure optimal operating conditions.
Ophthalmic anaesthetists who intend to work regularly with
The ophthalmic anaesthetist has a key role in the following areas: children will need appropriate training in paediatric anaesthesia
in addition to specialist experience in ophthalmic anaesthesia.
• Pre-operative patient assessment – to assess patients and Any trainee who wishes to develop an interest in ophthalmic
optimise existing medical conditions prior to surgery anaesthesia should make this known to their training programme
• Provision of local anaesthesia; typically sub-Tenon’s (blunt director at the earliest opportunity so that appropriate training
needle technique) or peribulbar (sharp needle technique) may be facilitated.
blocks
• Provision of general anaesthesia when appropriate Improving your CV
• Administration of intravenous sedation when indicated
• Patient monitoring during the operation, whether local or BOAS organises an annual scientific meeting in the UK which
general anaesthesia performed provides useful specialist continuing education and professional
• Management of any peri-operative complications, including development. In addition, a World Congress of Ophthalmic
management of any haemodynamic instability and Anaesthesia is held once every four years; the next scheduled
cardiopulmonary resuscitation meeting will be in India in 2016. These events are also excellent
• Teaching and training of other staff opportunities for trainees to submit case reports and the results
• Participation in audit and research projects of audit or research work for verbal or poster presentation.
• Development of the ophthalmic anaesthesia service for the
future Both Anaesthesia and the British Journal of Anaesthesia publish
articles and original research relating to ophthalmic anaesthesia.
Training in ophthalmic anaesthesia In addition, there is the British Journal of Ophthalmology.
Attendance at specialist ophthalmic regional anaesthesia
Over recent years, the trend has been for ophthalmic surgery workshops on local anaesthesia for ophthalmic surgery will
and anaesthesia to be undertaken on a day case basis and provide trainees with additional experience to further enhance
an increasing number of procedures are carried out under and refine their local anaesthetic techniques.
local anaesthetic. To facilitate this anaesthetic provision, an
understanding of the relevant orbital anatomy, physiology and K-L Kong
pharmacology is essential, together with the more clinical aspects Immediate Past-President, British Ophthalmic Anaesthesia Society
of patient care including experience in day case anaesthesia. Consultant Anaesthetist, Birmingham and Midland Eye Centre
All trainee anaesthetists with an interest in ophthalmic
anaesthesia should complete competency-based assessment References
of knowledge, skills, attitudes and behaviour in ophthalmic 1. RCoA. Guidelines for the Provision of Anaesthetic
anaesthesia in accordance with the 2010 RCoA Curriculum for Services (GPAS). Chapter 13 – Guidance on the provision
a CCT in Anaesthetics. The training in ophthalmic anaesthesia is of ophthalmic anaesthesia services. 2015. http://www.
delivered in optional units at both intermediate and higher levels rcoa.ac.uk/document-store/guidance-the-provision-of-
within schools of anaesthesia. Currently, ophthalmic surgery is ophthalmic-anaesthesia-services-2015
undertaken in a range of settings including general hospitals, 2. RCoA and RCOphth. Local anaesthesia for ophthalmic
isolated ‘stand-alone’ units and large single-specialty centres. All surgery. Joint guidelines from the Royal College of
such settings must have appropriate staffing levels, skill mix and Anaesthetists and the Royal College of Ophthalmologists.
facilities. RCoA and RCOphth. 2012. http://www.rcoa.ac.uk/
document-store/local-anaesthesia-ophthalmic-surgery
Some supra-regional tertiary referral units such as the
Birmingham and Midland Eye Centre offer advanced training
modules in ophthalmic anaesthesia [2]. Such advanced training Paediatric anaesthesia
provides specialist training opportunities for a senior trainee to
gain further knowledge and experience in:
Paediatric anaesthesia involves the provision of anaesthetic
• General and regional anaesthesia for the range of ophthalmic and pain management services to the whole spectrum of the
surgical procedures including cataract, strabismus, paediatric population, from extremely premature babies on the
glaucoma, vitreoretinal, oculoplastic and corneal transplant Special Care Baby Unit weighing around 500 g, to 16–18 year
surgery olds weighing 100 kg or more. The provision of, and training for,
• Anaesthesia for elective and emergency ophthalmic surgery general paediatric intensive care medicine is usually obtained
• Pre-operative ophthalmic patient assessment through a general paediatric training scheme via the national
• Audit and research grid, the details of which are outside the scope of this article. It
• Levels of service provision required in ophthalmic is possible to work entirely within the subspecialty of paediatric
anaesthesia including staffing requirements, equipment, anaesthesia, or to combine it with adult anaesthesia as a special
support services and facilities [1] interest area. It enables you, as an anaesthetic trainee, to
• Recent guidelines and protocols in ophthalmic anaesthesia, combine working with children on a regular basis without the
such as the joint report by the RCoA and the Royal College need to complete general paediatric training or achieve a dual
of Ophthalmologists [2] certificate of completion of training. But how do you know if it’s
for you?
The British Ophthalmic Anaesthesia Society (BOAS) has
collaborated with the RCoA and Health Education England Foundation training incorporating a paediatric job is available
eLearning for Health to produce an eLearning module in but limited, although it should be considered if you are reading
ophthalmic anaesthesia (e-LA Module 09 – Ophthalmic this chapter early enough in your medical career. It is often a
Anaesthesia) covering anatomy, physiology, pharmacology, challenge to arrange time out of structured training programmes
pathology, regional anaesthesia and general anaesthesia. This to undertake additional specialty training. There is more flexibility
is a very useful learning resource and trainees in ophthalmic offered at the end of each stage of training. There may be

45 THE GAT HANDBOOK 2016-2017

 opportunities between foundation and core training posts, or All anaesthetic trainees must complete the essential higher
between core and specialty training posts, to gain experience unit of training in paediatric anaesthesia as per the RCoA 2010
in paediatric posts. Many departments are very keen to have curriculum document. Undertaking this module as early as
motivated trainees in LAT posts, and have busy rotas to fill. This possible during higher training will allow you to confirm your
experience is not essential however, and there are many other own interest in this career path while increasing your clinical
places to start, such as with a CT1 post in anaesthetics. experience and exposure to audit and research opportunities.
State your interest in paediatric anaesthesia early and liaise with
There is no harm in declaring an early interest in paediatric your TPD to organise this.
anaesthesia, but before you can make any realistic progress
you must complete your basic and intermediate level training in Whether you are a ST who is about to start the higher training
anaesthetics. For more detail about the current CCT Curriculum module or a CT1 looking for inspiration, meet and befriend your
please see the RCoA website. During these early years in your local paediatric anaesthetists as soon as possible. This will allow
career you will be developing your CV, and there is ample you to get a feel for the job and whether it might suit you in years
opportunity to put a paediatric slant to it and bring credibility to come, and investigate the future potential within the paediatric
to your claims. Volunteer to help with as many paediatric cases anaesthesia workforce in your region. It is a subspecialty which
and lists as you can to increase your general exposure and is becoming increasingly centralised; some district general
experience, and hence your logbook numbers, over and above hospitals have reduced their paediatric workload with a resulting
those required to achieve your basic and intermediate level impact on the more traditional role of anaesthetic jobs ‘with
training certificates. Any previous paediatric jobs or student an interest in paediatrics’. However, these things often come
placements, including work with children outside the clinical full circle and there will be future development opportunities
environment, should be particularly emphasised. within your Regional Managed Clinical Network, something else
about which your local paediatric anaesthetists may be able to
Complete at least one audit cycle of a paediatric-themed audit inform you. An early insight into these longer-term issues should
and present it at a local or national meeting, preferably with enable you to consider fully any conflicts of interest between
an accompanying protocol or guideline that you have written. subspecialisation and geographical location that may arise
Explore local opportunities to participate in paediatric anaesthetic for you and your family and which could influence your career
research; many deaneries have academic/research fellowship decisions. Along similar lines, you will also need to investigate
posts which could be invaluable in allowing you to pursue this whether your LETB offers an advanced training programme in
in more depth. Along similar lines, try to get involved in a project paediatric anaesthesia, and if so how to access it. Previously,
which could lead to a publication. You can also read relevant it may have been sufficient within some LETBs to declare an
journals such as Pediatric Anaesthesia (for which you are entitled interest (backed up by your logbook and CV) and put your name
to a reduced trainee subscription rate) and see if you can get down, but this is increasingly being superseded by competitive
involved in the correspondence pages. Ensure you have done application and interview, especially for the 12 month posts
the basic training courses – European Paediatric Life Support/ within specialist paediatric centres. Not every LETB has the
Advanced Paediatric Life Support/Managing Emergencies scope to offer an advanced training programme in paediatric
in Paediatric Anaesthesia or other simulation courses – and anaesthesia, and if yours does not then you will need to explore
become an instructor if you can. Get involved in local teaching; the feasibility of taking time out of programme and compete for
for example, can you help your Trust Resuscitation Officers a fellowship post. Overseas fellowship positions (commonly
deliver basic paediatric life support updates? Join any relevant in Canada, the USA and Australia) require early application
local societies and attend their meetings. Seize the initiative as there are often waiting lists, and must be prospectively
and if there is nothing relevant in your area then expand the approved by your regional advisor. There is a list of overseas
management section of your CV and set something up. You fellowship posts on the APAGBI website. Evidence of long term
should certainly join the Association of Paediatric Anaesthetists paediatric interest and commitment on your CV will support your
of Great Britain and Ireland (APAGBI), contact your local APA application and increase your chances of success. If it turns out
Linkman via the APAGBI website for more information, and not to be a realistic option, then another consideration is one of
explore the possibilities of their annual scientific meeting which the increasingly popular post-CCT Fellowships. If you consider
is an excellent platform for exhibiting your work in either oral or all your options in advance, discuss them with the appropriate
poster format. There is a trainee representative on the APAGBI people and prepare properly, the choice could be all yours.
Council – could it be you one day? Don’t forget the GAT ASM
is also a great national forum for presenting or displaying your Achieving your ultimate aim is a question of identifying it,
hard work. declaring it, getting the relevant and important people on your
side and listening to their advice and direction. Ensure you cover
the basic essentials well in advance, and then any exciting extras
you can add will be truly beneficial. If paediatric anaesthesia
interests you then go for it – it is an immensely challenging and
rewarding job.

Tom Moses
Advanced Trainee in Paediatric Anaesthesia, Children’s Hospital for
Wales, Cardiff

Felicity Howard
Past GAT Committee Chair
Consultant Paediatric Anaesthetist, Children’s Hospital for Wales,
Cardiff

46 THE GAT HANDBOOK 2016-2017

 Pain medicine This training time will equip the trainee with the necessary skills to
be able to practice pain medicine as a consultant. During this time
it is essential to complete the advanced pain medicine syllabus,
Questions, questions…What is it like to be a consultant in pain including the more specialised areas of cancer pain, paediatric
medicine? Is it better to combine pain and anaesthesia or should pain, pain management programmes and spinal cord stimulation.
I go solo? Do I have to sit an examination? If any of these are not provided in your region, external placements
can be arranged.
Pain medicine crosses all branches of medicine and all age groups.
It requires a lively mind, a thirst for knowledge and a real interest As with the rest of the syllabus, there are mandatory assessments
in people. It ‘describes the work of specially qualified medical during this time with DOPS, A-CEX, CBD etc. It is also necessary
practitioners who undertake the comprehensive management to complete quarterly assessments with your educational
of patients with acute, chronic and cancer pain using physical, supervisors and two case reports. All trainees must complete the
pharmacological, interventional and psychological techniques in FFPMRCA exam, which is divided into two parts: written and viva.
a multidisciplinary setting’ [1]. It is ideal for someone who wants The written exam is a multiple choice, single best answer and
a bit more variety and awake patient contact than with pure extended matching exam, based on the syllabus. The viva exam
anaesthetics. cannot be taken until six months of advanced training have been
attained and successful completion of the written exam. There
The Faculty of Pain Medicine at the RCoA is the professional body are many exam resources available and the RCoA runs exam
responsible for the training, assessment, practice and continuing tutorials. Passing this examination will be compulsory in the future
professional development of specialist medical practitioners in the for those wanting to become fellows of the faculty, although the
management of pain in the UK. It is there to make pain medicine, examination does not affect the award of your CCT.
and pain training, better and its website is the most useful resource
for pain training. It contains all the information about how to apply Is it possible to seek a career in pain medicine without doing
for pain medicine, how to prepare beforehand as well as career advanced pain training? This is not recommended unless you
stories and training syllabuses. There are contact details for the have gained substantial experience in other reputable pain training
faculty, local regional advisors for pain medicine and the current colleges, such as Australia and New Zealand, which are the only
trainee representative, if you have any queries. The faculty and ones currently recognised by the RCoA. It is not mandatory for a
LETBs work closely together and there are regional programmes Trust to appoint a consultant with FFPMRCA at the present time,
such as the Pan-London Pain Training Advisory Group. but the college advisor would strongly recommend it and any
candidates without it would be non-competitive.
In the past it was possible to become a fellow of the faculty by
either having a consultant post or by completing suitable pain The role of the acute pain consultant is changing; it is no longer
fellowships. Nowadays in order to produce consultants with sufficient just to perform a postoperative ward round as most of
internationally recognised skills, the training is much more formal this routine work can be nurse led. Many patients with acute pain
and is based heavily on the Australian system of pain training such as sickle cell crisis also have chronic pain and a detailed
which has been very successful. Examinations were introduced to knowledge of pain medicine is required. Many Trusts have only
ensure that standards were being met. consultants in pain medicine who all do a blend of complex acute
and chronic work.
Pain doctors usually come from the specialty of anaesthesia.
However doctors from other specialities such as neurology and Pain management today has a strong emphasis on a
palliative care can undergo pain training and gain the diploma of multidisciplinary approach and all training should include
the Faculty of Pain Medicine. This reflects the broader nature of the exposure to pain clinics, interventional sessions, physiotherapy
specialty. To be a good pain doctor you must also be interested in and psychological therapies as well as formal pain management
people, be prepared to listen, and to develop skills in the ‘talking programmes. It is very useful to make time in your training to
therapies’. It is no longer sufficient just to perform a nerve block. go to clinic with other related specialties such as neurology,
You will work as a member of a multidisciplinary team; there is no rheumatology, orthopaedics and spinal surgeons. Trainees should
room for paternalism. seek out these opportunities if they are not immediately available.

All anaesthetists undertake a minimum of basic and intermediate After training as an anaesthetist, most trainees will want to
pain training as part of their anaesthetic training. Basic training is combine anaesthesia and pain medicine at the start of their
done at CT1/2 and is mainly aimed at intra- and postoperative pain consultant career. This is often a good idea as it keeps all options
management with safe use of regional anaesthesia, analgesics, open. However, keeping up to date in both areas is a significant
patient-controlled analgesia and epidurals. However, trainees are challenge and you will have to revalidate in both subjects. In time,
expected to gain a basic understanding of the management of some pain doctors drop their anaesthetic commitment, although
chronic pain and pain in special circumstances such as children, most do not. Relieving pain and distress is a great privilege,
the older person and those with communication difficulties. despite its challenges. It requires good technical and diagnostic
skills and an ability to communicate effectively, often in areas of
Intermediate pain training is done after the Primary FRCA. The great uncertainty.
experience extends out of theatres and includes pain clinics,
interventions lists and hospice visits. All trainees should have a James Wilson
good knowledge of the multidisciplinary management of pain and Consultant in Anaesthesia and Pain Medicine, Maidstone and
should be effective members of the acute pain team. If you wish Tunbridge Wells NHS Trust
to do chronic pain or any acute pain as part of your consultant
role or consider advanced pain training then you need to do three Richard Griffiths
months of higher pain training. As is often the case, competition for Consultant in Anaesthesia and Pain Medicine, Maidstone and
specialist posts can be substantial so it is sensible to demonstrate Tunbridge Wells NHS Trust
your enthusiasm for pain medicine with audit and research. Regional Advisor in Pain Medicine

Those who want to specialise in pain medicine will then do 15 Reference

months pain training (higher and advanced modules) in the final 1. RCoA. Pain Medicine. http://www.rcoa.ac.uk/careers-
two or three years of anaesthetic training. This time is spent entirely training/training-anaesthesia/special-areas-of-training/
in the pain management department (except for on-calls). The training-pain-medicine
trainee is there to learn, rather than providing service provision.

47 THE GAT HANDBOOK 2016-2017

 Plastics and burns The AAGBI and RCoA provide useful CPD topic guidance.
Demonstrate commitment by presenting at journal clubs on
relevant cases you have seen. There are regional and national
Anaesthesia for burns and plastic surgery is varied and rewarding meetings and ABRA offer a trainee prize. The specialty is
and there is huge potential to make a visible difference to the lives often underrepresented at departmental level so offer to run
of children and adults. The caseload is mixed and is not limited some specific pre- and post-fellowship teaching sessions,
to any one age group or site. This is one of the few areas of an interesting area may be the choice of fluids and how they
anaesthesia where you meet the same patients many times over may affect survival of free tissue transfer. Audit activity is made
your career and develop your own professional relationship with easier as our surgical colleagues are only too keen to have an
them. It is frequently fast-moving, advanced and the anaesthetist anaesthetist’s collaboration. There are a number of collaborative
often uses the latest technology and techniques. Developments areas to make a contribution to research and development such
such as the first facial transplant are making it an increasingly as pain relief following burns or the effects of anaesthesia on
exciting area. This specialty is different and flourishes by forging grafts.
collaborative links with a host of specialities including ENT,
gynaecology, maxillofacial and orthopaedics. There is still the You cannot be an excellent anaesthetist without knowing what
misconception that this is an aesthetic specialty, however there the surgeons are up to, therefore it is vital to work closely with
is likely to be at least one area in your hospital in which you can and attend some local surgical teaching sessions so that you
carve a niche. Potential patient groups may include: know the difference between a TRAM and a DIEP flap! The
British Association of Plastic and Reconstructive Surgeons
• Burns (resuscitation, intensive care management and (BAPRAS) have twice yearly scientific meetings. ABRA have a
transfer) free paper section at their annual conference which provides
• Breast surgery (reconstruction following cancer, cosmetic a good opportunity to submit a poster for a prize; this is not
breast surgery) oversubscribed and you stand a good chance of winning. The
• Skin cancer (excision and reconstruction, management of British Burns Association (BBA) meets annually during the spring
metastasis) for a multidisciplinary meeting and is another excellent meeting
• Head and neck (oral cancer reconstruction, craniofacial to aim for with either a poster or oral presentation. If the study
surgery) budget allows, there is always the European Burns Association
• Children (cleft lip and palate, hypospadias, ear anomalies, meeting.
congenital anomalies)
• Hand and upper limb surgery (hand trauma, degenerative Team working and the capacity to remain focused during long
conditions such as arthritis) lists are essential. A background in paediatrics or intensive care
• Lower limb trauma reconstruction would be useful for any list but is particularly relevant if you are
• Microsurgery for bone and soft-tissue reconstruction and going to be working in a tertiary referral unit for reconstruction or
free tissue transfer major burns resuscitation. Similarly, plastics and burns patients
have often suffered trauma so it is useful to update your APLS
How to develop your CV and ATLS courses. Patients requiring head and neck surgery,
those with face and neck scarring from burn injuries or congenital
The ability to balance an extremely varied workload and a capacity deformities will require an anaesthetist skilled in management of
to foster good working relationships as part of a multidisciplinary the difficult airway and time spent developing these skills will be
team make this specialty a particular challenge. If you have invaluable. The BBA runs an Emergency Management of Severe
an interest in plastics and burns, let your training programme Burns course, which is vital if you are to work with major burn
director or clinical lead know early on. Training doesn’t have to patients. Some upper limb reconstructions are done entirely
be in a dedicated block, it could be performed piecemeal over under regional anaesthesia so it is advantageous to book
time. Some larger centres may offer dedicated blocks and one yourself on an ultrasound course. Circumstances may allow
year fellowships either as OOPE or post-CCT positions. The travel overseas; for example, SMILE is an international charity
RCoA provides general guidance and the Association of Burns dealing with cleft lips and palates that welcomes specialty input.
and Reconstructive Anaesthetists (ABRA) is helpful in providing
a syllabus, but it may be possible to put together an interesting It is worthwhile having an extra string to your bow. Educate your
module yourself which would look all the more impressive on surgical colleagues on anaesthetic techniques on their study
the CV. days, join paediatric airway lists and use your study leave to
visit tertiary referral centres for burns and see how the dedicated
intensive care is run. There is a National Burn Bed Bureau and
burn patients are often transferred so make sure your transport
skills are up to date in this area. Take the initiative, be pro-active
and demonstrate interest and expertise.

The future

The specialty is a small one and many departments will be

looking for candidates with an active interest. The number of
consultant posts has increased in the last 20 years and plastics
and burns anaesthetics has become an integral part of hospital
practice. This rise is expected to continue as demand grows,
which in turn will open up additional posts in the future to one
of the most innovative and exciting specialities which you could
become part of. Good luck!

Simon Law
Consultant in Pain Medicine and Anaesthesia, Gloucester

Patricia Richardson
Consultant, St Andrew’s Centre for Plastic Surgery and Burns,
Broomfield Hospital, Chelmsford

48 THE GAT HANDBOOK 2016-2017

 Pre-hospital emergency medicine Supervision varies between regions with some offering ongoing
100% consultant supervision until fully ‘signed off’. Once
the service providing the training is confident in the abilities
This subspecialty training, open to anaesthesia, emergency and knowledge of the trainee, they may authorise indirectly
medicine, intensive care and acute medicine trainees, was supervised shifts where the trainee can access immediate advice
approved by the GMC in July 2011. The first trainees started from a PHEM consultant by radio or by telephone. Even at this
training in February 2013 and have since completed the stage a proportion of the duty periods (minimum of 20%) will still
programme successfully. There are currently eight regions within involve direct supervision to enable formative workplace-based
the UK offering training places, and more may open in time. assessments to take place.
At the time of writing, completion of Pre-Hospital Emergency
Medicine (PHEM) training is rapidly becoming a requirement for Duty shifts usually involve being available for primary response
application to posts in many of the UK air ambulance and pre- to incidents by rapid response vehicle or air ambulance. There
hospital services. will also be exposure to secondary response involving the critical
care transfer of patients from local hospitals to regional centres.
The role of the pre-hospital physician At the end of Phase 1 the trainee will sit the National Summative
Assessment (NSA) Part 1. This is now the Diploma in Immediate
PHEM training aims to supply knowledge, technical and non- Medical Care administered by the Royal College of Surgeons
technical skills to doctors to allow them to reliably provide of Edinburgh. This is held twice a year and costs approximately
optimal care to severely injured or critically ill patients in the £680.
challenging pre-hospital environment. This early delivery of
advanced care and management allows teams to deliver Successful completion of the NSA Part 1 will enable the trainee to
such patients to definitive care quickly, safely and in the best enter Phase 2 of training during which they build and expand on
physiological condition possible. Specific examples of treatment areas learnt in Phase 1. Phase 2 also contains some distinct and
include the provision of procedural sedation, pre-hospital specialist areas which are not covered in Phase 1. These include
emergency anaesthesia and delivery of surgical techniques training in the provision of remote clinical advice and fulfilment of
such as thoracostomy, thoracotomy or amputation if the a ‘Medical Incident Officer’ role at major incidents. This second
circumstances demand it. This level of clinical care is beyond the stage will also allow the opportunity for solo practice, education
current scope of most paramedic practice. The ability to operate and research experience. At the end of Phase 2 the NSA Part 2
in environmentally challenging and resource poor locations, and is taken. This is the Fellowship of Immediate Medical Care, again
make decisions with limited information demands a high level of administered by the Royal College of Surgeons of Edinburgh
additional experience and training. at a cost of around £1,050. This two day exam consists of
a written knowledge test and an OSPE with a complex high
Throughout the programme the PHEM trainee will attend incident fidelity case simulation assessment. Successful completion of
scenes by land or air, initiate immediate critical care and then this examination and a sufficient number of workplace-based
facilitate a safe transfer to the most appropriate hospital, which assessments (minimum of 117) will allow the trainee to apply for
may not be the closest. In some cases the PHEM team may subspecialty recognition.
need to organise and/or conduct a secondary transfer from one
hospital to another to allow access to specialist or definitive care. How to develop your CV for a PHEM post

The PHEM role extends well beyond direct clinical care – the Start by looking at the personal specification for the advertised
PHEM physician will also be expected to provide remote clinical posts which are subject to an annual national recruitment
advice to ambulance and hospital colleagues, respond to major process. Before undertaking PHEM training, anaesthetic trainees
incidents in a clinical or command role, and support development must have done at least six months of emergency medicine in an
of policy and procedures in a rapidly changing area of medicine. approved training post at CT1 or above.
There is also a significant research, management and education
role built in to the training and this will be evidenced within the Previous experience in pre-hospital care is desirable but can
portfolio. be difficult to gain at a junior level. There may be opportunities
for observer roles with your local ambulance Trust or the British
The training Association for Immediate Care Scheme (BASICS). Motorsport
or event medicine experience can also provide a limited
Training involves spending one year, whole time equivalent, in the introduction to the pre-hospital environment. It is recognised that
pre-hospital environment during higher or advanced anaesthetic experience outside of PHEM is difficult to achieve, but even with
training (ST5+). Typically the programme runs over two years no actual experience the candidate must be able to demonstrate
with trainees spending some time in their base specialty and an understanding of the role, the environment and the challenges
some time in PHEM. The way it is delivered will depend on the of emergency medicine outside the hospital.
local LETB and the ambulance/air ambulance services to which
it is attached.

The training is separated into different phases. Trainees start

in Phase 1A which typically lasts a month. There is an intense
period of training both within their local PHEM organisation and
at a national level. There will also be operational shifts under
direct supervision. At the end of Phase 1A trainees undergo
a ‘Local Formative Assessment’ that is similar to the ‘Initial
Assessment of Competence’ in anaesthetic training. It usually
entails a locally administered written assessment, an objective
structured practical examination (OSPE) and high fidelity case
simulations.

On passing this assessment, Phase 1B commences, during

which trainees undertake predominantly clinical duties with
exposure to governance, case review and educational meetings.

49 THE GAT HANDBOOK 2016-2017

 Applicants should be current providers in Advanced Life Support, and offers a rewarding, skill-based career path. Below are some
Advanced Trauma Life Support/European Trauma Course and of the opportunities that are available to trainees to further their
Advanced Paediatric Life support. Instructing on these courses interest and add valuable advantages to their CV.
is another way of demonstrating some of the non-technical
skills required so it is worth mentioning your interest in being an ESRA Diploma in Regional Anaesthesia
instructor to the faculty at the start of such a course.
The European Society of Regional Anaesthesia (ESRA) started a
There are several relevant training courses you might consider, Diploma in Regional Anaesthesia in 2006. This two-part, (MCQ
such as the Pre-Hospital Emergency Care course run by BASICS, and VIVA), examination initially had a low uptake (four applicants
the Pre-hospital Trauma Life Support course run by the Royal in its first year) and also received criticism for poor standards.
College of Surgeons, the Safe Transfer and Retrieval course or Times have changed and it has become a popular method for
the Major Incident Medical Management and Support course UK-based trainees to demonstrate their continued enthusiasm
(both hosted by the Advanced Life Support Group). Take any for regional anaesthesia. However, the ESRA diploma does not
opportunity to be involved in audit or research in pre-hospital prove clinical expertise and you should be prepared to produce
care. a log book to demonstrate this convincingly.

If you are interested in doing PHEM training you should discuss University of East Anglia MSc in Regional
this with your educational supervisor, anaesthetic TPD and contact Anaesthesia
your local PHEM TPD. These are listed on the Intercollegiate
Board for Training in Pre-Hospital Emergency Medicine website. The University of East Anglia MSc is a three-year distance
It would be very worthwhile meeting with current PHEM trainees e-learning degree course, developed by regional anaesthesia
to discuss application and training. It will certainly take time to enthusiasts and the national regional anaesthesia society,
organise your training opportunities and it may be necessary to Regional Anaesthesia UK (RA-UK). Six compulsory modules are
arrange a temporary inter-deanery transfer if the PHEM training delivered over 16 weeks in the first two years, using innovative
is offered away from your core scheme. Speaking to the RCoA ‘Virtual Learning Environment’ and ‘Problem Based Learning’
and/or the Intercollegiate Board for Training in Pre-hospital approaches in a flexible manner. Candidates attend training and
Emergency Medicine can be very helpful. examination days at the end of each module. The third year is
spent preparing a dissertation. A practical assessment is also
included, using a system of local and regional mentors, leading to
Nick Crombie accreditation based on logbook proven experience. Candidates
Consultant Trauma Anaesthetist, Queen Elizabeth Hospital can complete the first three modules only to obtain a certificate,
Birmingham the first six modules and the practical module to achieve the
Clinical Lead, Midlands Air Ambulance/West Midlands Ambulance PGDip and will be awarded an MSc if they successfully complete
Service MERIT the whole programme.
DipIMC/FIMC Examiner, Royal College of Surgeons of Edinburgh
Fellowship programmes

High profile academic centres for regional anaesthesia (New

Regional anaesthesia York, Vienna and Toronto) offer competitive out of programme
fellowships. Many trainees are seeking time abroad out of
programme with the added value of seeing a different country
Why should I develop my skills in regional as well as being trained by some of the world’s leading experts.
anaesthesia? This can be a valuable experience and is an impressive addition
to your CV. There are several UK based fellowships available, for
The ability to locate, image and block a central or peripheral varying periods and with varying degrees of experience offered.
neuronal structure is not just a skill for regional anaesthetists. RA-UK can provide contact details for some of these fellowships.
In fact almost all anaesthetic subspecialties utilise, to some
extent, regional or local anaesthesia either as a sole anaesthetic Society memberships
technique or for postoperative pain management. In this respect,
regional anaesthesia is a core skill for all anaesthetists. By joining ESRA you will automatically be invited to join RA-UK
as well and will also receive the Regional Anaesthesia and Pain
The increasingly ageing population has increasing comorbidities, Medicine journal. There are significant discounts for trainees.
and in many instances regional anaesthetic techniques optimise The main European meeting is held in September and the RA-
anaesthesia and are associated with improved outcomes. Recent UK meeting is in May each year. Both ESRA and RA-UK provide
developments in ultrasound guided visualisation and peri-neural a variety of excellent training courses, which are discounted
catheter techniques have led to an increased interest in this field. for members. You would be expected to be at least a RA-UK
member, in support of any claim to be a regional anaesthesia
Current training enthusiast.

In the RCoA 2010 CCT Curriculum, regional anaesthesia Publications and research
maintains its importance from the start to the end of training.
Many Deaneries offer advanced training modules in regional Many trainees struggle to participate in regional anaesthesia
anaesthesia, with competitive entry. research and subsequently fail to get published in this area. Both
RA-UK and ESRA accept poster and verbal presentations at their
Develop your CV annual meetings. By attending one of the ESRA annual meetings
many trainees can get several posters (including completed
There are many opportunities to develop your CV, by improving audit cycles), sit the diploma examination and receive expert
your skill and experience in regional anaesthesia. As regional tuition on a cadaver or ultrasound workshop.
anaesthesia is a generic skill associated with many specialities, it
can be useful for those who are in training but have not decided
on a specific career path, as these skills are readily transferable.
For others, regional anaesthesia is more than just an interest,

50 THE GAT HANDBOOK 2016-2017

 New developments: ultrasound and catheter Consultant careers in regional anaesthesia
techniques
Where can you work as a consultant with an interest in
Interest in ultrasound guided regional anaesthesia (USGRA) regional anaesthesia?
has increased in the last few years. Ultrasound machines have
become more powerful, cheaper and more portable. Augmented One of the many good things about regional anaesthesia is
by the growth in the evidence base, many trainees are expressing that, in contrast to ‘centralised’ subspecialties such as neuro,
an interest to be trained in this technique. This is currently a very cardiac, transplant or vascular, regional anaesthesia expertise
popular area. Training in USGRA is also becoming standardised can be equally valued in teaching hospitals and district centres,
by the presence of nationally supported courses and published allowing a greater degree of flexibility when targeting a potential
recommended training pathways. consultant job. Any hospital, whether it is a district or a teaching
hospital, can become a regional anaesthesia centre with your
Catheter techniques provide continuous postoperative pain help; you can either build on an existing team or strive to put the
relief, promote more ambulatory surgery and may reduce hospital on the national/international map yourself.
inpatient duration of stay.
What can a job as a regional anaesthetist offer you?
What does regional anaesthesia training involve?
• The satisfaction of having the expertise to offer a full range
Regional anaesthesia training starts very early. As a junior trainee, of anaesthetic skills to your patient in their best interest,
regional anaesthesia can be used on a wide range of theatre providing superior analgesia without reliance on opioids
lists from orthopaedics and trauma to general surgery. Common • The opportunities for service development, enhanced
early blocks include femoral, fascia iliaca and transversus recovery, audit, research and training
abdominus plane, later progressing to more complex deep • Promoting teamwork with your surgeon, the acute pain
blocks, (e.g. infra-clavicular) and blocks with close proximity to service and physiotherapists
vital structures, (e.g. supra-clavicular). • Teaching others by your expert example

Regional training involves a degree of self-directed learning. What will the job require from you?
Your knowledge of anatomy and pharmacodynamics should be
excellent. The increasing use of enhanced recovery protocols ‘Knowledge, skills and attitude’. However, there are a few things
has made the use of regional blocks and local anaesthetics which are of particular importance for a successful career as a
essential for early mobility and recovery. It is vital during regional regional anaesthetist, such as:
anaesthesia training to put regional anaesthesia in context and • Good technical skills, wide experience and high success
regular sessions with the acute pain service to follow up and rates
trouble shoot postoperative problems are just as important • Keeping up with new developments (CPD), through
as the block itself. This also allows further regional training meetings, courses, workshops, books and software etc.
opportunities where rescue blocks can be used for failed or A subspecialty qualification (national or European) may
difficult postoperative analgesia. become a standard requirement in future
• Learning how to cope with a failed block or difficult regional
The use of ultrasound has also renewed enthusiasm for regional case
techniques. The introduction of new technology and didactic • Good communication skills. Successful regional techniques
skills can pose a challenge for regional trainers and trainees require communication with your surgeon and theatre
alike. It is important not to become over focused on just needle staff (particularly for awake cases). You will need to be a
technique. An ultrasound (US) block can be split into four confident communicator to take consent for, and perform
phases from US image generation and device optimisation, to regional anaesthesia, particularly in the nervous patient. It is
interpretation and then needling and block performance. It must important that any regional technique is an experience that
be remembered that the first two phases are equally important a patient would be willing to have again
to the latter two phases [1]. It is useful to be competent in both • Good management skills of your surgical lists. Regional
US and non-US techniques; evidence suggests that the use of blocks may require ‘cooking time’. It is often the responsibility
both modalities may be safer [2]. Regional anaesthesia training of the anaesthetist to rearrange the list in such a manner that
requires you to be proactive, in order to maximise opportunities. there are no unnecessary delays
Practice scanning can be carried out on any list, on yourself and • Being a good trainer to your theatre assistant. A well trained
colleagues. You do not need to wait for a dedicated regional list; assistant is vital for success and safety, whether it is keeping
for example, on-call cover of emergency lists will often present a patient with a fractured neck of femur in a reasonable
cases that might benefit from a regional anaesthetic technique. position for a spinal or understanding the importance
of negative aspiration and incremental injection of local
The UK CCT in anaesthesia offers a wealth of regional anaesthesia anaesthetic
training opportunities. At the end of training you can become
proficient in a variety of blocks that will allow anaesthesia and/ Wherever you get your dream job, it is sensible to keep in touch
or analgesia for the majority of procedures. If you want further with like-minded ‘regional’ anaesthetists in your area, nationally
experience, advanced training modules exist around the country and internationally; keep your eyes and mind open to new
allowing training in technically more difficult blocks and catheter developments, present your projects and just enjoy swapping
techniques. It is vital to befriend your local regional ‘gurus’. As a few stories from the front line. RA-UK, provides a national
an advanced trainee, rotation to other centres within your region forum, together with many other societies, e.g. British Society
can be advantageous to learn different techniques with a variety of Orthopaedic Anaesthesia, British Association of Day Surgery
of tutors. Before you start your advanced training module, do and the Obstetric Anaesthetists’ Association.
your research and plan which lists/consultants/centres you
would like to attend. Thanks to Drs Brooks, Crowley and Galitzine for their work on
Developing your CV for Regional Anaesthesia, GAT Handbook
2011–2012, from which this chapter is derived.

Sean Tighe
Consultant Anaesthetist, Countess of Chester Hospital
AAGBI Vice President
Past President, RA-UK

51 THE GAT HANDBOOK 2016-2017

 References transplant may require can escalate quite quickly. This includes
1. Sites B, Chan V, Neal JM. et al. The American Society of a wide range of haemostasis adjuncts, organ support systems
Regional Anesthesia and Pain Medicine and the European like intra-aortic balloon pumps, extra-corporeal life support
Society of Regional Anaesthesia and Pain Therapy Joint (including ventricular assist devices or extracorporeal membrane
Committee Recommendations for Education and Training oxygenation), additional means of removing carbon dioxide,
in Ultrasound-Guided Regional Anesthesia. Regional astute microbiology input in an immunocompromised patient,
Anesthesia and Pain Medicine 2009; 34: 40–6 transfer of very sick patients to diagnostic radiology and back
2. Neal JM, Wedel DJ. Ultrasound guidance and peripheral and various other organ preservation or support systems. The
nerve injury - is our vision as sharp as we think it is? environment is challenging and there is very little room for error.
Regional Anesthesia and Pain Medicine 2010; 35: 335–7. Managing and learning from such a complex array of conditions
with confidence, maintaining good communication skills and
staying enthusiastic, definitely makes a trainee stand out from
Transplant the crowd.

These centres are often actively involved in research. There are

Transplantation has evolved into a well-established management robust audit and outcome activities and these provide immense
strategy for end stage organ failure. It not only saves life in the opportunities to get involved and to enhance a trainee’s CV.
short term but makes substantial improvement in quality of life Although these units are well supported by research grants and
for patients. personnel, there is always room for contributing to the programme
positively. There is always a need for writing protocols, revising
The UK transplant programme is overseen by National Health and auditing their implementation and practice. Due to the case
Service for Blood and Transplant (NHSBT) which is a strategic complexities and novel, evolving techniques, these attachments
health authority accountable to the Department of Health. It was are unique opportunities to present at conferences and publish
formed by the merger of the National Blood Service and UK case reports in peer-reviewed literature.
Transplant in October 2005. It is closely governed by the Care
Quality Commission, the Medicines and Healthcare products The success and survival of transplant patients is increasing and
Regulatory Agency and the Human Tissue Authority. these specialist activities are always related to a core specialist
programme. These programmes are tailor made for trainees who
Currently (2015 data) there are almost 7,000 patients waiting on are keen to become specialised in these areas. Transplantation
transplant lists and the NHSBT is committed to increase both needs doctors with a high degree of commitment who are
quality and quantity of the programme which is elucidated in a willing to go that extra mile. Their reward is a special sense of
strategic document Taking organ transplant to 2020. The five year satisfaction from involvement in this noble activity, nurturing the
survival rate is close to 90% in some programmes such as for recipients of a special gift.
kidney and pancreas transplantation, whereas there is room for
improvement in some other areas such as lung transplantation. Harjot Singh
Consultant Anaesthetist, Queen Elizabeth Hospital Birmingham
Currently, there are six centres for heart and lung transplant,
seven for liver, eight for pancreas and two for adult intestine
transplant. The renal transplant programme is most widely spread Trauma
and spans across 23 centres. These centres are throughout the
country offering a tertiary level service.
The establishment of regional major trauma networks in England
The vast majority of trainees will rotate through a tertiary has re-organised the provision of trauma care [1]. Patients
centre and have some exposure to the challenges anaesthesia with severe injuries are now usually transferred directly to a
for transplantation brings. The specialist programmes are Major Trauma Centre (MTC) where there are consultant-led
accessible through either advanced level training or dedicated multidisciplinary trauma teams and the facilities to provide
fellowship programmes and are often part of hepatobiliary or massive transfusion, emergency surgery, interventional radiology
cardiothoracic training programmes at such centres. Becoming a and immediate access to operating theatres. Patients with less
specialist in one of these groups certainly puts an anaesthetist in severe injuries are taken to hospitals designated as Trauma
a numerically select group. There are inter-deanery placements Units. These lack specialist services, such as neurosurgery or
that can be arranged through the TPD if one wants to pursue a cardiothoracic surgery, but are capable of treating and stabilising
career into these specialist areas. patients with life-threatening conditions for onward transfer to the
MTC. Local emergency hospitals provide general accident and
While some transplants have moved to daytime activity, the vast emergency services but do not have the facilities for receiving
majority remain as emergency work out of hours and the existing patients with major trauma.
consultants appreciate an enthusiastic trainee to lend a helping
hand. This provides a trainee with a unique opportunity to see There are many opportunities for anaesthetists in trauma care
the management of sick patients first hand. Although several and the nature of the injuries you will have to manage will depend
skills like history taking and institution of invasive monitoring on where in the network you work. Pre-hospital emergency
are directly transferable from those learnt in general anaesthetic medicine (PHEM) is now a recognised subspecialty and, for
training, additional skills such as an appreciation of the degree of those who lead the MTC trauma teams, a new subspecialty of
physiological derangement, learning to do advanced ultrasound, trauma resuscitation anaesthesia is developing [2].
echocardiography and close involvement in multidisciplinary
management makes one acutely involved in patient care within A consultant anaesthetist with an interest in trauma who works at
a unique environment. a Trauma Unit hospital is likely to have to contribute to the out-
of-hours provision of this service in order to meet target times.
The overall care of these patients allows an anaesthetist a unique Trauma cases are part of the hospital’s emergency workload and
opportunity to practice peri-operative medicine in patients often so operating lists will lack routine and be difficult to plan and
needing multi-organ support and pre-anaesthetic optimisation. you will need to be able to cope with a wide range of clinical
This also gives an opportunity to interact with other specialist challenges in changing circumstances. The patients can range
physicians in the hospital. When things do not go according from small children to centenarians, from those with extensive
to plan, the array of support that a sick patient waiting for a comorbidities who are considered unfit for elective surgery to

52 THE GAT HANDBOOK 2016-2017

 ultra-fit athletes. They may require procedures ranging from a medical problems in the peri-operative period
simple manipulation to complex fixation of several fractures. You • Work in a pre-operative assessment clinic. This is an
will also have to be prepared to assist with resuscitating patients opportunity to evaluate the risks of surgery in elective
with immediately life-threatening conditions and stabilising them patients with multiple comorbidities and plan their peri-
before they are transferred to the MTC. operative management away from the pressure of providing
an emergency service
There are many opportunities to work as a peri-operative • Take the opportunity to be out-of-programme. This could
physician but pre-operatively one must be pragmatic and be a fellowship at a MTC or in PHEM. Alternatively, time
balance the desire for extensive investigation with the need for working in the developing world demonstrates an ability to
expediency. In theatre, the anaesthetist is essential to a large practice independently with limited resources. There are
multidisciplinary team and often works encumbered by a gown some useful resources for organising a year abroad on the
and a face mask. One must use ones knowledge and skills AAGBI website
to facilitate surgery in patients who often have potentially life- • Develop a skill that is useful in trauma orthopaedics, such
threatening medical problems about which the other staff are as focused transthoracic echocardiography to identify aortic
unaware. Postoperatively, in addition to ensuring the patient stenosis [4]
is alive and pain-free in recovery, the trauma anaesthetist is • Demonstrate an interest in regional anaesthesia but
often asked to assist with the medical management of other remember there are fewer opportunities to provide
orthopaedic patients on the ward. Don’t expect to receive any anaesthetic blocks in trauma cases than in elective
recognition for doing this; just remember your training has given orthopaedics
you a holistic view of patients!
Diana Jolliffe
Patients with proximal hip fractures are likely to constitute a large Consultant Anaesthetist, Northampton General Hospital and
proportion of your caseload. They have a high postoperative Associate Post-Graduate Dean, East Midlands LETB
mortality (8% die within 30 days of surgery and up to 30%
die within a year) and you need to accept that, despite your References
anaesthetic management, your postoperative mortality rate will 1. McCullough AL, Haycock JC, Forward D P, Moran CG. Major
be higher than that of colleagues who only do elective work. trauma networks in England. British Journal of Anaesthesia
The National Hip Fracture Database is a clinical audit project 2014; 113: 202–6.
designed to facilitate improvements in the quality of hip fracture 2. Oakley P, Dawes R, Rhys Thomas GO. The Consultant in
care and the Hip Fracture Perioperative Network (HipPeN) Trauma resuscitation and anaesthesia. British Journal of
promotes high quality care for these patients. In 2013 a 3-month Anaesthesia 2014; 113: 207–10.
Anaesthetic Sprint Audit of Practice collected data for 16,904 3. Wiles MD. ATLS: Archaic Trauma Life Support? Anaesthesia
hip fracture patients treated in 182 hospitals. Their care was 2015; 70: 893–906.
compared with the standards of peri-operative care described 4. Heyburn G, McBrien ME. Pre-operative echocardiography
in the 2011 AAGBI Safety Guideline on Management of Proximal for hip fractures: time to make it a standard of care.
Femoral Fractures 2011. Anaesthesia 2012; 67: 1189–93.

How to develop your CV

Here are some suggestions for how you might demonstrate that
you have an interest in trauma and so increase your chances
of being short-listed for a consultant post with a commitment to
orthopaedic trauma.

• Perform a relevant audit or quality improvement project.

There are many possibilities to review your hospital’s
practice against one of the published standards of care.
Take a look at the National Hip Fracture Database website
and the AAGBI Safety Guideline on Management of Proximal
Femoral Fractures 2011.
• Find out the TARN (The Trauma Audit Research Network)
data for your hospital. This multidisciplinary audit of the
management of trauma cases (excluding elderly neck of
femur fractures) identifies the unexpected survivors and
deaths
• Do a trauma course. ATLS is the traditional course and
provides a useful introduction to the language of trauma.
However, the course content and structure is becoming
increasingly irrelevant to the current practice of managing
trauma cases, particularly in MTCs [3]. More recent courses
such as the Anaesthesia Trauma and Critical Care Course
and the European Trauma Course place more importance
on management principles and team working
• Undertake training in leadership and/or human factors, as
team working and good communication skills are essential
to the provision of safe and effective trauma care
• Complete a paediatric resuscitation course, such as EPLS
or APLS, as this will help your confidence in managing basic
emergency paediatric care
• ACCS training or gaining additional general medical
experience by working in an acute medicine, accident and
emergency or intensive care unit post will help you manage

53 THE GAT HANDBOOK 2016-2017

 Vascular and the fact that vascular surgery is now a distinct surgical
specialty recognised by the Royal College of Surgeons. Until a
formal training programme is created, trainees wanting to pursue
Vascular anaesthesia is a challenging subspecialty which a career in vascular anaesthesia are advised to spend as much
essentially involves three operations: aortic aneurysm repair, time as possible with vascular anaesthetists. It is not for everyone
carotid endarterectomy and lower-limb revascularisation as it is challenging but it can be very rewarding.
procedures. Vascular patients have significant cardiorespiratory
comorbidity thus there is significant morbidity and even Some teaching centres offer vascular fellowships or advanced
mortality associated with the procedures – so it is not for the training modules in vascular anaesthesia which are highly
faint-hearted! In recent years there has been a trend towards recommended. In addition, there are several centres abroad
endovascular repair of aortic aneurysms (EVAR) instead of which are particularly suitable, including in North America
open repair, which may take place in the endovascular suite or (University of Michigan, Duke University, etc) and Australasia.
radiology department. Early mortality is reduced by EVAR but Research and/or audit projects are obviously recommended for
late morbidity and mortality means that EVAR catches up with boosting your CV in this respect.
open repair eventually, plus the patient needs a CT scan every
year. Thoracic aortic aneurysms are now usually treated by What does work as a vascular anaesthetist involve?
endovascular repair as well.
Vascular anaesthetists would expect to have one full day of
A national screening programme for men over 65 years vascular surgery a week in their job plan, which might have
of age means that more open abdominal aortic aneurysm both open and/or endovascular operations on it. In addition to
procedures take place in younger patients. Emergency this, there may be cross-cover for colleagues who are away on
vascular procedures include ruptured aortic aneurysm repair, leave in a ‘flexi’ session. All patients undergoing aortic aneurysm
lower limb revascularisation and, increasingly, ‘urgent’ carotid repair need to have a pre-operative assessment by a vascular
endarterectomy. Vascular surgery is being centralised into large anaesthetist so a pre-assessment clinic may be part of the job
vascular units as there is good evidence that vascular surgeons plan as well as attendance at the vascular multidisciplinary team
and anaesthetists with higher volumes of cases have better meeting.
outcomes than ‘occasional’ operators. This process is not yet
fully complete nationally. Most hospitals undertaking vascular surgery do not at this stage
have specific vascular anaesthetic on-call rotas – however this
What training is required? could change in the future as larger centres are formed. In
addition, many ‘anaesthetic’ intensive care consultants take a
There is no formal training programme in vascular anaesthesia vascular session as part of their job plan.
as yet. The Vascular Anaesthetic Society of Great Britain and
Ireland is currently in negotiations with the RCoA about this, Mark Stoneham
particularly because of the centralisation of vascular services Consultant, Oxford University Hospitals Foundation NHS Trust

54 THE GAT HANDBOOK 2016-2017

 OVERSEAS TRAINING
“An NHS framework for international
development should explicitly recognise the
value of overseas experience and training for
UK health workers and encourage educators,
employers and regulators to make it easier to
gain this experience and training.”
Lord Nigel Crisp, Global Health Partnerships – The UK contribution to health in developing
countries

55 THE GAT HANDBOOK 2016-2017 THE GAT HANDBOOK 2016-2017

55
 OVERSEAS TRAINING
AUSTRALIA AND GASACT recently been changed with the roll out of our new curriculum.
The current exam now examines applied physiology,
pharmacology, anatomy, measurement, equipment, and quality
What is GASACT? and safety. The exam comprises a written paper (MCQ and SAQ)
and, if successfully negotiated, is followed by three 20 minute
The medical professions love affair with acronyms does not viva sessions.
respect boundaries, and the land ‘down under’ is no exception.
Introducing GASACT, the Group of Australian Society of The Final exam comprises MCQ and SAQ papers and two medical
Anaesthetists Clinical Trainees – the Australian equivalent of vivas, followed by, if successful, eight anaesthetic vivas. Both
GAT. Although our acronym is larger we are smaller in number exams have two sittings a year. There is also a modular system
and are structured a little differently, but our aims are similar: covering areas of clinical experience and other components of
to advocate for trainees and promote professionalism among the curriculum that need to be completed; 12 modules in total.
our members, providing an independent voice for trainees.
GASACT is represented by a committee comprised of members
from each state in Australia. From the bigger states there are
two delegates on the GASACT Committee. Collectively, we
act as a voice for Australian trainees at state and national
levels among the Australian Society of Anaesthetists and also
through collaborations with other trainee bodies, including the
New Zealand Society of Anaesthetists, the Australian and New
Zealand College of Anaesthetists (ANZCA) Trainee Committee
and the Australian Medical Association Council of Doctors in
Training. In 2010, inspired by the activities of other trainee groups
including GAT, GASACT ran its inaugural trainee congress, a one-
day event which was combined with the ASA National Scientific
Congress in Melbourne.

In Australia, many of the advocacy issues affecting trainees are

championed through the Australian Medical Association (AMA).
Issues such as safe working hours, and pay and conditions for
junior doctors are negotiated on a state-wide basis. There are
seven states and territories and medical funding and pay and Working in Australia during your anaesthetic
conditions vary in different state jurisdictions. GASACT takes a training: why go?
limited role in negotiating these issues but, as mentioned, has
a good relationship with the trainee body of the AMA and works Many UK trainees make the journey to Australia or New Zealand
with the AMA to further causes affecting anaesthetic trainees. during their training years and most training schemes nationwide
have a UK trainee working within them. Having worked with
Anaesthetic training in Australia many UK trainees there seems to be a variety of reasons which
motivate their time in Australia. Predictably the reasons are often
Anaesthetic training in Australia and New Zealand is relatively multifactorial and centre on the themes of CV-polishing, change-
well regarded, but differs from that of the UK in its length and of-scene, weather and lifestyle.
structure. The body responsible for education, training, and
continuing professional development in Australasia is ANZCA. A common theme is that the job market is becoming increasingly
The College of Intensive Care Medicine has recently become an competitive in the UK. Work experience in a different country
independent college, with its own training programme. shows that you have initiative to undertake and follow through
with the big task of moving countries, welcoming change and
There are undergraduate and postgraduate basic medical being able to adapt and adjust to a new environment, people
degrees with varying models in Australia. The initial 12 months of and culture. Hopefully, this makes a candidate an attractive
postgraduate training is spent as an intern and is hospital based, addition to any anaesthetic department.
with mandatory rotations through general medicine, surgery
and emergency medicine. A further 12 months of pre-vocational There is no need to look exclusively towards the anaesthetic
medical education and training is required before approved departments of the ‘flagship hospitals’ – these are big and
training in anaesthesia may commence. Many trainees do more similar to the hospitals with which UK trainees are accustomed.
than these minimum two years of postgraduate resident years, The medical retrieval networks within Australia are very well
and it is common to do a year or two as an anaesthetic or critical organised and equipped to accept UK trainees. There is the
care resident and senior resident before entering the anaesthetic option of working in regional and remote Australia where the
training programme. work is challenging and the tyranny of distance that plagues
Aussie medicine can be appreciated. Being immersed in a
Anaesthesia training itself is five years in duration and is regional community can be a very rewarding experience and
composed of two years basic training which includes 26 weeks a real change to urban medicine. The only advice is that the
of introductory training, two years advanced training and one department should be accredited by ANZCA so you know that
fellowship year. There are two major exam hurdles: the Primary the work environment is suitably supervised.
exam, undertaken during basic training, and the Final exam, for
which you are not eligible until you have completed introductory UK trainees seem to like Australian cities. Urban Australia and
training, basic training and six months of advanced training. New Zealand are similar to the UK; similar culture, language, etc.
There are established, although perhaps informal, links between
The Primary exam has an infamously low pass rate. It has just some centres in the UK and Australia and many trainees in the

56 THE GAT HANDBOOK 2016-2017

 UK know a colleague who has been to Australia or New Zealand as previously each state/territory had a different medical
previously. Beware, however, that different cities and states are practitioner’s board
often dissimilar, and vary in terms of their regulations, pay and
conditions and certainly experience different climates. • English certification
English competency is required. There is an exam, although
Warning: not all parts of Australia offer the iconic beach lifestyle exemptions from sitting this may be granted for those from
for which we are known. Of the cities, Melbourne is probably the English-speaking countries. For this you need to be able to
most similar to European cities. It has abundant good coffee and prove your GCSE in English
a cosmopolitan buzz, but is not as warm as the more northern
states. Western Australia, Queensland and New South Wales • Medical indemnity cover
probably have the best sun and beach lifestyles on offer, if that’s This can be obtained once you get here and some have
what’s attracted your attention. It might pay to be clear when noted that it may be cheaper in Australia than UK
organising your job: are you coming for a tropical climate, or so
you can go to the beach every day? (not necessarily the same • Finances
things!) Or perhaps you are coming for the people, the change It is recommended that you see an Australian accountant
or the experiences you will get at work? soon after you get here to facilitate your tax return, maximise
tax deductions and advise on salary packaging advantages
Coming with a family: Australia is a place where you can certainly
do that. Fellows who come with families can often arrange to put Many UK trainees have been to Australia before you and so
kids in playgroups and settle in to the community. Organising this may make the transition process smoother. In some places
childcare can be difficult and waiting lists can exist in some hospital administration and human resources staff will be familiar
centres. It is sensible to enquire beforehand, once you know with the processes required and may be able to advise you. For
where you might choose to live. Finding a house to live in once more information, please visit the ANZCA website.
you get here can be more difficult than in the UK, allow three
to four weeks. There are limited furnished properties, with most Broadening your experience can be very valuable both
rentals being unfurnished. personally and professionally. Australia is well-known for its laid-
back attitude, its sporting culture, its outback centre and urban
Pay and cost of living coast. There are many reasons to come as a trainee. Being close
to Europe is not one of them. In fact being close to anywhere is
Australian trainees are paid according to their hours rather than unlikely to be one of them. But once you get all the way out here:
a set salary. The number of hours is based around a standard you might even like it (unless we are winning in the cricket).
fortnight, which varies in different states but is usually around
a 38-hour week over the fortnightly cycle. Compared to the UK Dr Ben Piper
there are similar clinical hours, which vary with the position, but GASACT Chair (Newcastle trainee)
you may also get paid non-clinical or training time. There are
some extra perks, e.g. salary packaging which can increase your Dr Natalie Kruit
real income quite substantially. Going out to dinner, coffee or GASACT Chair Ex Officio (Sydney trainee)
having a car here can be cheaper than in the UK but previous
trainees have found their weekly shopping more expensive.

Organising a year in Australia CANADA

So there will be some paperwork, a lot of paperwork, and it
is expensive. An approximate figure is £1,000 (in paperwork Canada is a large country with an ethnically diverse population
alone), which covers application fees, credentialing, witnessing and a challenging physical environment. From a healthcare
of documents, etc. Allow at least six months for this process. perspective this means delivering health services across a large
urban-rural divide, complicated by an expansive geography with
• When do you want to come? large areas of low population density and huge distances. Medical
Australians have a provisional fellowship year in their training takes place within 17 medical schools across Canada
final year of training, designated advance training year 3. (three are Francophone within the province of Québec, the others
For UK trainees, you should probably be at ST5 level or are either bilingual or Anglophone), mostly within larger urban
above, and have your FRCA. The Australian academic year centres. While some programs allow entry into medical school
runs from January or February through the calendar year. after two or three years of undergraduate university studies, the
Many postings in Australia can work on six-month rotations, majority require a full undergraduate degree, typically in the
so a start date in July or August may be possible sciences, but sometimes from as disparate disciplines as music
and political science. A basic sciences course requirement must
• Which state you want to come to? Which city? Which be met.
hospital?
You will need a ‘sponsorship contract’ before you can get a There are currently 17 anaesthesiology training programs within
visa. Ask if this can be handled by human resources in 17 medical faculties. In 2015, there were 104 anaesthesiology
Australia training positions available for Canadian graduates and
approximately nine dedicated positions for international medical
• Australian Medical Council graduates. Access to these training positions is managed
Overseas trained doctors must be credentialed with the through the Canadian Resident Matching System, which is a
Australian Medical Council to practice as a medical centralised service that controls and allocates all specialist and
practitioner in Australia. This can be complicated, expensive generalist residency positions in the country.
and time-consuming. You will need lots of copies of forms
and credentials, which may have to be sent backwards and Anaesthesiology is a five year training path in Canada. Throughout
forwards to the UK for verification this time, trainees are called ‘residents’ and proceed through
postgraduate years 1–5. Training across the anaesthesiology
• Medical registration programmes tends to provide a dominant focus on education
There is now a national medical board. This makes things a and a secondary one on service provision. Trainees are both
little easier if you plan to work in more than one place,

57 THE GAT HANDBOOK 2016-2017

 enrolled as postgraduate students within their respective typically between $300,000–500,000 depending on the province.
faculty of medicine and employed by their academic healthcare Of course many people choose to seek further fellowship
organisation, or hospital. Most anaesthesiology programmes training in a subspecialty, often within Canada or the USA but
provide strong clinical training environments. Separate from increasingly further abroad. Historically, there tended to be a
the usual activities of academic clinical departments (e.g. grand good amount of community and academic jobs for new general
rounds, mortality and morbidity rounds, local conferences, etc.), anaesthesiologists, although this trend has been changing
anaesthesia training programmes provide a comprehensive somewhat in the past few years with a tighter job market.
curriculum for residents with formal teaching at least weekly, and
often daily during morning rounds. Acknowledgment
Thank you to Tracey Kok and Jaclyn Gilbert who had previously
Over the five years, anaesthesia residents must complete edited this section and on whose previous work this chapter is
minimum requirements for training set by the Royal College of based.
Physicians and Surgeons of Canada.
Andre Bourgeois
The criteria are as follows: University of Toronto Anaesthesia Graduate, 2015

• 12 month basic clinical year

• 18 months in adult anaesthesiology
• Three months in paediatric anaesthesiology NEW ZEALAND
• Two months in obstetric anaesthesiology
• One month of chronic pain management
• 12 months of internal medicine training (six months internal New Zealand (or Aotearoa – Maori for ‘Land of the long white
medicine subspecialties, including at least one month each cloud’) may be a little country but it has a lot to offer. It has the
of cardiology and respiratory medicine, and typically six benefits of an established and well-resourced public health
months of ICU) system as well as a fantastic lifestyle with good work-life balance.
• 12 months of senior rotations in anaesthesia, critical care,
research, pain or palliative medicine, including up to six In most cities and towns you are always within a short drive of
months of elective rotations beautiful beaches, snow-capped mountains and regional parks
where you can explore this land of hidden treasures and unspoilt
Most training programmes exceed these minimum requirements beauty. New Zealand’s urban centres have all the excitement
in anaesthesiology and ICU. There is also some time during and convenience you would expect from a thriving city: fabulous
residency for electives, community rotations, and research if food festivals, shopping, arts and culture, sports, museums and
desired. Residency culminates in taking the Royal College of everything in between.
Physicians and Surgeons of Canada examination in the spring
of the fifth year. This consists of MCQs, SAQs and an oral Many overseas health professionals who have come across
examination. This is inevitably a harrowing and stressful task to New Zealand have chosen to make this their home. New
but most Canadian residents (over 90%) are successful on their Zealand has a truly multicultural society where everybody is
first try. However, the success rates for international medical welcome, and our workforce reflects this amazing diversity; here
graduates from select approved training programmes (US, UK, knowledge and skills are openly shared and gained.
Ireland, Switzerland, South Africa, Australia and New Zealand
only), while not officially published, appear to be much more The New Zealand Society of Anaesthetists (NZSA) is the New
variable. Zealand equivalent of the AAGBI and is a membership-based
organisation that has supported and represented the interests of
There are many similarities and differences between Canadian anaesthetists in New Zealand since its inception in 1948. Its tasks
training and that in the UK or Ireland. At a more granular level, include advocacy, supporting research, political representation
the focus on education in Canadian programmes cannot be and overseas aid work.
overstated. As residents, the typical work day mirrors that of a
consultant teacher. Residents are assigned to a consultants list Overview of anaesthetic training in New Zealand
and work with the consultants (or they with us!). Residents cover
on-call no more than one in four days, with up to two weekends There are four anaesthesia training rotations in New Zealand –
per month. On-call is usually 14–24 hours long depending on Northern, Midland, Central and Southern. Commencing training
the rotation and the programme. In most centres, regardless involves two initial tasks: getting an anaesthetic Resident Medical
of level of training, residents are not permitted to do a case Officer position with one of the 20 district health boards (DHBs)
entirely independently (i.e. without direct available support). in an accredited hospital, and registering with the Australian and
Consultants typically have to be in the hospital before any case New Zealand College of Anaesthetists (ANZCA) who administer
starts. This reflects two issues: the first is the understanding training. Please note that not all hospitals are accredited for
that anaesthesiology training programmes see education as a training by ANZCA.
priority over service provision. Second, this reflects the Canadian
medico-legal environment and the level of vigilance that the It is usual to have completed two years of Pre-vocational Medical
profession has evolved towards in Canada. Education and Training (PMET) and have secured a job in an
ANZCA accredited hospital before registering with the College.
Training culminates in certification as a Fellow of the Royal However, applying to the College after only one year of PMET is
College of Physicians of Canada and a license to practice acceptable and this can streamline the registration process and
independently by a provincial (not national) licensing authority. allows access to some online resources prior to registration.
At this point, one becomes a ‘staff’ anaesthetist and would
typically be paid the same as even the most senior clinician in In New Zealand, there are no ‘non-training jobs’ for registrars but
the department. The majority of Canadian anaesthesiologists are there are some for senior house officers. Junior registrars in New
on a fee-for-service scheme, whereby each anaesthetic is billed Zealand are the equivalent of more senior core trainees in the
directly to the provincial government (healthcare in Canada UK/Ireland and it is possible to become a junior registrar as early
is governed independently by each province). Some more as in the third postgraduate year.
infrequent institutions have chosen to be salaried by agreement
with the provincial government. Full-time average salaries are

58 THE GAT HANDBOOK 2016-2017

 Anaesthesia specialisation consists of a minimum of five years of is welcoming and there are no steep hierarchical boundaries in
supervised training, which is divided into four periods: communication between anaesthetists, nurses or other allied
health staff.
• Introductory training (26 weeks/6 months)
• Basic training (78 weeks/18 months) Currently DHBs employ junior doctors under the Multi-Employer
• Advanced training (104 weeks/2 years) Collective Agreement (MECA), which is negotiated between the
• Provisional Fellowship (52 weeks/1 year) Resident Doctors Association (RDA), our union, and the DHBs.
Although 98% of the junior doctor workforce are RDA members,
After the initial six months of introductory training, a formal sign it is not compulsory to join. Non-RDA members retain the option
off is required (Initial Assessment of Anaesthetic Competence) of negotiating their own contract with individual DHBs.
before passing onto less supervised practice. The Primary exam
needs to be completed prior to commencing advanced training In its current form, the MECA entitles junior doctors, including
and the Final exam must be completed before you can move those on a work visa, to the following:
onto a provisional fellow position. Your ‘letters’ are only awarded
at the end of training and not immediately after completion of the • Paid meals while on duty
Final exam. • 30 days annual leave
• Full reimbursement of the cost of your Annual Practicing
The curriculum is based around the completion of a number of Certificate from the medical council
competencies that have to be achieved to complete training, • Full reimbursement of annual medical indemnity insurance
as well as completing five years of recognised training time as fee
described above. These competencies can be broadly classified • 12 weeks of paid study leave for the duration of your
as relating to one of three areas: specialty training
• Full reimbursement of all costs of specialty training
1. ANZCA Roles in Practice – abilities and attitudes that you (textbooks, college fees, exam fees, course fees, travel and
are to develop during training. There are seven roles based accommodation for courses/exams)
on the CanMeds approach. Examples include medical
expert, communicator, health advocate and scholar. Salaries are competitive and are based on a set amount rather
2. ANZCA Clinical Fundamentals – these are clinical skills and than on hours worked, which is detailed in the MECA contract.
knowledge that are required of anaesthetists across all areas This is based on where you work, with different urban and
of anaesthesia. Examples include airway management, rural rates, and according to seniority by postgraduate years.
general anaesthesia and sedation, and resuscitation. Annual salary progression is built into the contract and increases
3. Specialised Study Units – skills and knowledge relating each hospital year. Additional un-rostered duties, such as if a
to subspecialty areas of anaesthesia, such as obstetrics, colleague is sick or away on unexpected leave, are paid at an
paediatric anaesthesia or cardiac anaesthesia. additional rate.

Each Role in Practice, Clinical Fundamental, and Specialised Although medical indemnity insurance is compulsory, annual
Study Unit has a list of requirements associated with it that must fees (which are reimbursed by the DHBs) are kept low by New
be met during training. These include formative and summative Zealand legislation that prevents patients from taking direct
assessments such as workplace-based assessments, mini- legal action against medical practitioners. Cases of medical
clinical examinations, case based discussions, and volumes of negligence are referred to the Health and Disability Commission
practice. and recommendations may range from an apology to being
struck off the Medical Register. Affected patients are classified as
Progression through the training years also requires a number of having a ‘treatment injury’ and their care will be handled by the
core unit reviews, clinical performance reviews, as well as exam Accident and Compensation Corporation, a government agency
completion. Trainees keep track of their training progression and which provides comprehensive, no-fault injury cover. Criminal
log cases on the online training portfolio system. practice will attract the attention of the police.

Getting overseas time accredited When to apply for a job

If applying part way through training in the UK/Ireland, some The working year in New Zealand starts in the final week of
training time may be accredited. Completion of the RCoA Primary November for interns, house officers and senior house officers,
exam does not exempt you from sitting the ANZCA Primary. and two weeks later (early December) for registrars. Jobs for the
However, completion of the RCoA Primary and Final exams next working year are usually advertised in April or May although
may allow exemption from the ANZCA Primary but not the Final. many departments welcome enquiries throughout the year.
Completion of all UK training requirements allows registration in Applications are made to individual DHBs, but be aware that not
New Zealand as a Specialist, usually requiring an interview with all anaesthetic departments in New Zealand are accredited for
the Medical Council and ANZCA. training by ANZCA.

It would be advisable to apply and register with ANZCA prior Registration

to starting your position in New Zealand. This will allow you to
get any retrospective time accredited and will mean you won’t To practice as a doctor in New Zealand you will require a
commence your time in New Zealand in introductory training. Practicing Certificate from the Medical Council of New Zealand
Check out the ANZCA website for further information. (MCNZ). Graduates of medical schools accredited by the GMC
or Irish Medical Council will be eligible for registration after their
Benefits of training in New Zealand FY1 or intern year spent working under the jurisdiction of that
Council. Doctors without British/Irish medical degrees who have
Rostering practices and supervision are generally very good within worked for three of the last four years in the UK/Ireland and have
the New Zealand anaesthesia fraternity, with some variation from full (unconditional) registration with the GMC or Irish Medical
department to department. The vast majority of trainees will be Council will usually also be eligible. The ‘provisional general
granted leave as requested but with the priority being for courses scope of practice’ registration category that is awarded to the two
and exams. The majority of consultants are approachable, keen groups above allows entry into vocational training in anaesthesia
to teach, and supportive of trainees. The theatre environment in New Zealand. Some applicants may need to sit an English

59 THE GAT HANDBOOK 2016-2017

 test depending on their background. For more information and
to register contact the MCNZ.

Work visas

To work in New Zealand requires a visa and there are a number

of different visas depending on whether residency is planned as
permanent or on a temporary basis. These are issued by the New
Zealand Immigration Service and can be obtained by applying to
the nearest New Zealand High Commission or Embassy.

To work and live in New Zealand permanently, an application

under the Skilled Migrant Category could be appropriate and
many doctors come to New Zealand as skilled migrants. The
Work-to-Residence visa allows application for a temporary work
visa as a step towards gaining permanent residence. Alternatively,
if planning to work temporarily in New Zealand a work visa is all
that is required. For more information about the requirements
needed, go to the Immigration New Zealand website.

Coming to New Zealand from the UK and Ireland can be a

daunting process for many as it is about as far as you can travel
from home! However there have been many who have made the
journey and loved the adventure, experiencing a new place and
culture, broadening their skills and have made many new friends
along the way. So don’t let the distance stop you, the summers
here are long, the winters mild (relatively speaking) and there
really is no place quite like it.

Kia ora!

Dr Ghassan Talab
Trainee Representative
New Zealand Society of Anaesthetists (NZSA)

THE
CONSULTANT
POST

60 THE GAT HANDBOOK 2016-2017

 THE CONSULTANT POST
THE CONSULTANT POST In addition, your perfect job may be advertised at short notice
and you will be eligible for interview six months prior to CCT.
Having an updated CV may also save time when completing
In general, there are two main approaches to securing a your application form and can highlight your strengths for pre-
consultant post. Ideally your preparation should begin during interview visits.
training, rather than in ST7 when your CCT date is looming. Each
approach requires dedication and a time commitment similar to Borrow CVs from recently successful candidates to determine
that of revising for a professional exam. the structure, layout and content that appeal to you. We have
all done much more than we think and it is essential to present
1. Going for your absolute dream job: This means that it’s all this information in a clear, logical manner that sells your skills
about the job description and location becomes secondary. appropriately. For a small fee, numerous websites provide
You may be more likely to have a specialist interest such detailed advice on structure, formatting and useful descriptive
as ITU/cardiac/paediatrics/pain. Securing your dream job phrases and it may be worth investing if you need help in this
requires a CV that is bursting at the seams with skills and area. Ask a few trusted colleagues or friends to proofread your
experience specific to your chosen specialty. It may be CV but be realistic about making changes – there will always be
more difficult to apply for such posts outside your region improvements suggested and at some point you need to stop!
of training, as you will often be competing against internal Very few people will scrutinise your CV in intense detail; most will
candidates. In this situation, working as a locum consultant or only flick through it, so be mindful of devoting adequate time to
post-CCT fellow within the department may be of significant the other parts of the application process.
benefit, providing you with an understanding of how the
department functions and what the substantive post may Application form – Most consultant posts are advertised through
entail. Obtaining a locum consultant job is usually a less NHS Jobs and this website also hosts the online application
formal process and although this undoubtedly becomes a process. As with your CV, it’s worth setting aside adequate
prolonged audition, you are in a strong position, working time for completion. Start by entering your personal details and
in the hospital to which you are applying. In addition, employment history (which may well be extensive) and be sure
applying for a locum post provides invaluable insight to save your profile. This will prevent you from wasting time and
into the whole application process before the real deal. duplication re-entering the same information, should you apply
for subsequent posts. Otherwise, each individual Trust has a set
2. Going for a job in your dream location: This usually means application form, with a word limit for each section. It may be
that you are more of a generalist and requires a different difficult to fit all your achievements into a particular category but
approach. Your dream location will often be the place of your as far as possible, mention everything relevant to each area even
training and therefore you will have been on an extended if you have mentioned it in previous sections of the form because
interview over the past five years or more, though you may it may only be seen in separate parts by different people during
not have realised this at the time! Existing consultants will short-listing.
have a very definite view on whether they would like you
as a colleague but in order to successfully secure the job, Although a word limit will be specified, there is no limit to spacing
you must ensure that you are the best candidate ‘for the allowed. You should therefore layout your answers in a clear and
Trust’ and the best candidate at interview on the day. In this logical format, making the most of your strengths. You can double
situation, it may be more difficult to have a ‘stand out CV’ check your layout by printing out your application form prior to
from the outset and your approach must address how you submission to gauge how potential short-listers will view it. There
can fill a service requirement for that Trust. This may come can be a huge difference between one continuous paragraph
about fortuitously or it may be planned, because you have of prose and a bulleted list of your achievements. Crucially, you
asked the Trust what is happening to service provision over must relate your application to the person specification of that
the next few years – the latter is the better approach as most job and include all essential and desirable criteria that you can
successful appointments solve a problem for the Trust. legitimately claim to possess.

Regardless of whether you are going for your dream job or dream Pre interview visits – These can be a daunting prospect; from
location, the crucial message is that the application/interview how to arrange them to what to say! You need to ask to meet
process for a consultant post is unlike any other you will have everyone on the panel except the College representative and
experienced during your training. Specialist training is about chairman and try to meet as many members of the department
meeting a standard; the consultant interview involves a Trust as possible. It is sensible and efficient to email those you know
employing an individual for the skills and experience that make and request meetings, while going through the PAs of executive
them stand out, so your CV must exemplify this. Unfortunately, board members to make appointments. Often clinical staff will
even if you have been a fantastic trainee, excelled in a locum or say you don’t need to meet them unless you especially feel you
post-CCT fellow post and have an appropriate CV, on the day of need to – this is not a trick and it can be annoying if you then
the interview you may still not be successful. There are two main push for an appointment with no real reason. Having questions
reasons for this; you may perform suboptimally (which usually prepared is useful in case conversation dries up, but as far as
means you haven’t prepared properly) or the best candidate in possible try to chat naturally. It is much easier to gain a rapport if
the world may apply from out of region (and that’s just unlucky!). you are not continuously writing things down during the meeting
but do jot down notes sparingly or immediately after the meeting
Here are some tips for putting the most into the application and to remember for the interview. Try to research the person you
interview process: are meeting (often there is information on the Trust website). If
there is a presentation to give, this is an important topic to gather
CV – Update your CV early; ideally 6–12 months ahead of opinions on during your visits and can be an easy way to get
your CCT date because editing may take longer than you first conversation flowing.
anticipate. This will also enable you to identify and improve
any weak sections to an appropriate standard in good time.

61 THE GAT HANDBOOK 2016-2017

 Presentation – Often you may be asked to give a presentation 2. Be open-minded. There are some roles that you may never
prior to the interview. This is rarely required to be longer than have imagined yourself doing while you were training and
ten minutes but tends to take up a disproportionate amount of there are roles that may be perceived as being ones that
time in terms of your preparation. Although jobs rarely hinge should be given to the ‘new recruits’ as nobody else wants
on the presentation this is the one part of the interview that you to do them. Remember that everyone has their niche and
can control; practice it and make it perfect. If it goes well, it can you may find that as a consultant you might have a bit more
generate significant confidence in the less predictable interview. freedom and influence to really make some roles work for
Limit your number of slides and keep them simple (minimal you. You can always have a chat with the person who has
writing). Everyone’s presentation skills vary but practice as many performed this role previously and then make a decision
times as possible to ensure a polished delivery and accurate about whether it suits you.
timing. 3. Keep a work diary. Try to start from day one and log all
clinical AND non-clinical activity. The BMA work diary is
Interview practice – This is vital. The answers that are best widely used but there are other versions and it is worth
received are those that are patient-centred so try to think of a few asking colleagues which diary they use. It is a helpful tool for
cases and scenarios that have been good and bad and be able you to record exactly what you are doing and whether you
to talk about them concisely as they will often come in handy need to ask for exposure to other areas of practice. It is also
when your mind is otherwise blank. With adequate preparation useful for appraisal/revalidation and future job planning.
you should also be able to talk about the NHS, management 4. Check your contract and job plan. It is recommended
and clinical issues in a simple and believable way that relates to you have your contract checked by the BMA if you are a
everyday working and always refers back to your CV. This comes member. The BMA and AAGBI have published guidance on
across infinitely better than dry descriptions of processes. You working as a consultant.
are trying to demonstrate that you are not just regurgitating 5. You will revalidate with your final ARCP but you must keep
NHS documents you have read, but you understand them and up to date with annual appraisals and record all supporting
have implemented them in your practice. Again there are useful evidence towards these. Most Trusts use, or are introducing,
websites that offer excellent ways of structuring answers, but you an e-portfolio and it is easier to become familiar with the
often need a few weeks to work through and get the best out of system from the beginning. As with the ARCP process, it is
them. stressful if you leave collecting all the necessary evidence
until two weeks before your appraisal!
Although it is by no means essential, some may benefit from 6. Ask for help. You may well find you are asking more
attending one of the many consultant interview courses available. questions in your first few months as a consultant than when
These provide additional interview practice and often incorporate you were finishing your training. This is normal as you settle
a summary of the current political issues and hot topics in the into your new role and/or new department. It is expected
NHS – especially useful for those who have not managed to keep that you will continue to take advice or need an extra pair
up to date with the many changes that have occurred nationally of hands on occasion. During the initial period of joining the
in recent years. It is most useful to get as much interview practice on-call rota, colleagues will often offer to be available for
from consultants as possible and crucially to watch and listen to help with difficult decisions. Most are happy to be called out
their responses to certain questions. This can often refresh your of hours for advice too.
own style of answering. Practice in the mirror or car and have 7. Get to know the department, especially the secretaries, as
useful phrases to discuss any part of your CV in an interesting they will be organising your work life for the next 30 plus
and natural way. years! Early on is when you can easily introduce yourself
to new faces but after some time it can get embarrassing
On the day: look smart and smile! If you don’t understand when you can’t remember names. It is best to make an effort
or know the answer to a question, say so. Bluffing is usually to meet all your co-workers and participate in departmental
obvious and rarely works. In fact, asking for the question to social occasions.
be repeated or admitting you don’t know once in an otherwise 8. Book away days. These are an excellent way to get to know
good performance can be a likeable quality and demonstrates colleagues better and dates are planned well in advance
integrity. Good luck! requiring leave applications. They tend to cover a large
proportion of essential training and therefore will keep you
Natasha Joshi and Kajan Kamalanathan up to date with what the Trust feels is important knowledge.
Consultant Anaesthetists, University Hospitals Bristol NHS 9. You will have to work with trainees who you will potentially
Foundation Trust know well. In fact due to people undertaking fellowships,
sickness and flexible training you may find yourself with a
trainee who actually used to be more senior to you which
can sometimes lead to difficulty. You must remember that
Ten top tips for your first year as you are the consultant and the best thing to do is chat at
the start of the day about what you’re happy for them to do.
a consultant Usually they will be quite senior and will be able to manage
most things with you there as backup.
10. Don’t get rid of your interview paperwork and preparation.
1. Try to enjoy yourself as you embrace your new role. Some It is always useful to hang on to these things for several
people will take time off before starting, which can be a reasons. It is unusual for consultants to move jobs, but it
useful cooling off period. This isn’t always possible but it is does happen occasionally, especially for family reasons.
worth asking your department lead if this is something you Future colleagues may greatly appreciate your advice and
would like to do, as most Trusts will try to accommodate insights and you may one day be invited to write an article
your request if possible. When you start, take some time on the process of becoming a new consultant!
to adjust and think about what responsibilities may suit
you. Often members of the department will suggest roles
for you and it is important not to overload yourself. Take on Kaj Kamalanathan and Natasha Joshi
anything you are comfortable with but it is also acceptable Consultant Anaesthetists, University Hospitals Bristol NHS
to concentrate on settling in while indicating that you may Foundation Trust
be interested in a few months. Remember that you may
have ongoing projects that need to be completed before
getting involved in something new.

62 THE GAT HANDBOOK 2016-2017

 Getting started in research

Training as a specialist is challenging with many calls on your

time and effort. So, why should you get involved with research?
The most obvious reason for an ambitious trainee is that it will
improve your CV and enhance your chances of a first-class
consultant job in a fiercely competitive market.

However, there are other reasons just as important. If you

become involved in research you will:
• learn analytical and other skills
• be able to assess the evidence-base and make appropriate
decisions on how it affects your practice
• understand the principles of project management
• get to know, and learn from, a wide and diverse group of
colleagues
• become a true expert in a particular area
• preserve the academic base of our specialty so that it is
not perceived as merely a service delivered by technicians;
and
• (honestly) you will have fun

To appreciate where we are now with respect to trainees and

research, you need to understand where we have come from.
In my day (immediately post Ice Age), it was relatively easy to
get involved in research as a trainee. Indeed, in order to get
shortlisted for a senior registrar job, a CV with several published
studies was almost essential. Every training centre had
numerous ongoing research projects led by large academic
departments or research active NHS consultants. This meant
that nearly every consultant had research experience and many
trainees who never would have dreamt of acquiring an academic
interest became full-blown, card-carrying clinical academics.

Unfortunately, for the time being at least, those halcyon days have
gone. Factors responsible for this are many and varied. They
including: massive bureaucracy involved in study approval and
data recording; reduction in the number of clinical academics;
reduction in trainee hours; inflexible training programmes; and
the fact that, until recently, trainees did not require research
outputs to be short-listed for consultant jobs.

ACADEMIC Fortunately, there are real signs that the Department of Health
has become aware of the near demise of clinical research within

ANAESTHESIA
the NHS and the real damage that this has caused; they are
determined to reverse it. An example of their commitment is
the creation and generous funding of the National Institute for
Health Research (NIHR). This is a good time to be involved with
research; the future is more promising than it has been for some
years.

Getting started may not be easy but it is definitely achievable if

you are pro-active and committed. Here are some top tips:

• Find a mentor: This could be anyone who is involved with,

or has experience of, research; ideally, an enthusiastic
consultant
• Have realistic ambitions: Don’t try to cure cancer in
your first study. Make sure that your project is simple, well
designed and achievable
• Get involved with established teams: Are there any active
research teams on your patch that need a pair of hands?
This could be commercial or non-commercial research
• Consider working in the laboratory: Are there any local
opportunities here? Laboratory work is very demanding
and satisfying; it can be scheduled more easily than clinical
research
• Apply for a local research fellowship: Most centres have
a number of these posts. They are ideal for the research
novice
• Apply for a small grant: The NIAA awards a number of

63 THE GAT HANDBOOK 2016-2017

 grants suitable for small projects and holds meetings for Pros and cons of a research career
those interested in research. Have a look at the website and
make an application with your mentor Academic medicine is an interesting and rewarding career but is
• Get writing: Review articles are a good start and teach you not without drawbacks and is not for everyone.
many research skills. Are there any consultants who are
interested in working with you on these? Pros Cons
• Show commitment: Research does not fit well with
inflexible timetabling. Be prepared to go the extra mile when Opportunity to make new
Lack of financial security and fierce
scientific discoveries and change
contributing to a research team medical practice
competition for research funding
• NIHR research training scheme: Those of you who have
Intellectually stimulating and
serious academic ambitions should get involved in the NIHR Prolongs training time
varied
academic training scheme. For this, you need to talk to your
local academics and have a look at the website. However, Interesting work with researchers Hard work to perform good quality
across disciplines research and maintain clinical skills
remember you can still have a rewarding academic career in
the NHS without being enrolled in this scheme Administration, grant applications
Opportunities for international
• Do not get downhearted: Research is not easy; things travel for research collaborations
etc. are time-consuming and limit
the available time for practical
go wrong, projects get delayed, the paper work is often a and conferences
research
real challenge. Be persistent and positive, your efforts will
eventually pay off High degree of autonomy

Trainees are the future of our specialty. You must become the new
generation of research active consultants who will safeguard the Despite the difficulties of a career in academic medicine, it
academic base of anaesthesia and its related specialties. remains an attractive career primarily because of the opportunity
to make a long term impact on healthcare.
So, grasp the nettle, get involved and get started.
Training in academic anaesthesia
(Derived from ‘Getting started in research’ by Professor David
Rowbotham, GAT Handbook 2011–2012) 1. Integrated Academic Training Path
Prior to 2007, there were no structured training programmes
Ravi Mahajan in academic medicine and individual researchers
Professor and Head of Division, Anaesthesia and Intensive Care, carved out their own career paths. The Walport report
Queen’s Medical Centre, Nottingham of 2005 identified this lack of transparency in training as
a key problem in recruiting trainees to academic medicine
[3]. Therefore, as part of Modernising Medical Careers,
more structured training path was introduced. Academic
clinical fellow (ACF) posts were created that provided
What is an academic clinician? specialist clinical training with a quarter of the time
protected for academic work over a three-year period [4].
The level at which these jobs are offered varies from
Academic clinicians are both active researchers and practising specialty to specialty, but in anaesthetics they tend to be at
clinicians and comprise around 6% of the UK medical workforce. ST3 level. During the ACF, post trainees are expected
Academic clinicians bridge the divide between practical to prepare an application for a three year training fellowship,
medicine and the research environment, using their clinical a period of full-time research leading to a higher degree. In
experience to formulate pertinent research questions. Most common with the small number of academic anaesthesia
academic clinicians are university employees with honorary NHS posts at senior levels, there are also a limited number of
contracts. Job plans vary with regard to the proportion of time anaesthesia ACF posts; only seven of the 268 ACF jobs
spent on patient care responsibilities and that spent in academia, available for 2013 were in anaesthetics.
and some academics give up clinical work altogether. Academic
clinicians are also expected to teach students, manage academic Following the ACF post and completion of a higher degree,
departments and take on leadership roles. trainees can apply for a clinical lectureship. These are posts
with time split equally between clinical training and
Academic anaesthesia academia. Trainees can hold these posts for up to four
years, during which time they are expected to continue with
Academic anaesthetists are a select group in the UK. Only 51 full- their own research and to apply for research funding from
time equivalent senior anaesthesia academics were identified by major bodies. The final objective of the integrated training
the annual review of the Medical Schools Council in 2011 [1]. In path is to produce consultants who are equipped to
comparison, 1,271 physicians and 275 surgeons were identified become academic clinicians with funding for their own
in senior academic roles. The reasons for this are multiple and research groups.
were analysed by the RCoA in 2005 [2]. Both external factors
relating to the way in which academic medicine as a whole is 2. Alternative academic paths
funded and internal factors specific to anaesthesia were identified For trainees who are not able to secure an ACF post or
as contributing to the low status of academic anaesthesia. The who decide to pursue a research career at later points in
NIAA was founded in 2008 to raise the profile of anaesthesia their career, there remain several other options for pursuing
research, facilitate high quality research in anaesthesia and a career in academic medicine or becoming a clinician with
support training in academic anaesthesia. Despite being a an interest in research (Figure 1).
small academic specialty, anaesthesia research is diverse and
wide-ranging. Researchers are active in the basic sciences that
underpin the specialty, as well as in clinical research covering all
anaesthesia subspecialties, critical care and pain.

64 THE GAT HANDBOOK 2016-2017

 Figure 1: Options for research involvement outside the integrated • University courses. Many universities run courses covering
academic career path particular aspects of research project design and analysis.
Trainees, especially those employed in academic posts, can
Medical Foundation Specialty often enrol in courses at their local institution
Core training
student years training

Intercalated Academic F2 Research skills Research skills

Sources of research funding
BSc post courses courses
Deciding where to apply for funding will depend on the
Involvement
Intercalated
Involvement in
in clinical
Involvement in requirements of a research project. Funding a higher degree
clinical research clinical research requires financing three years of salary as well as the costs of
PhD research and
and audit and audit
audit research, whereas other projects may only need a small project
Special study In-programme/ grant. Applying for funding is time-consuming, so decide
module with out of carefully where to apply and start the process early. Major
research programme funders include:
component research

• Medical Research Council. Publicly funded organisation

Designing and obtaining ethical approval for a clinical supporting medical research. Funds PhD studentships for
research project is a lengthy process, so it helps to organise clinicians as well as a range of programmes for more senior
research posts and projects as far in advance as possible. academic clinicians
• Wellcome Trust. Major independent medical research
• Research posts charity. Funds PhD studentships for clinicians as well as a
Some Deaneries offer one-year in-programme research range of programmes for more senior academic clinicians
posts. These offer an opportunity to develop your research • National Institute for Health Research (NIHR). Funded
skills and experience, to find out if research is for you, and by the Department of Health to support medical research
possibly to prepare an application for a formal research within the NHS. Funds ACF and CL posts as well as doctoral
training fellowship. Similar posts are also advertised fellowships and awards for more senior researchers
nationally; trainees appointed to these posts have to apply • National Institute of Academic Anaesthesia. The NIAA
to their Deanery and the RCoA for permission to take time administers a number of grants for anaesthetic research
for OOP research. Six months of full-time research may be in association with bodies including the RCoA, BJA, the
counted towards the CCT or up to one year if the trainee AAGBI and specialist anaesthetic societies. Most of these
also has clinical duties during this time. are smaller project grants but larger grants and fellowships
are sometimes offered
• Other opportunities • Other charities. If the research being conducted is
The number of anaesthetists involved in research far exceeds particularly relevant to a disease or group of patients, there
the number employed in academic posts. The NIAA aims to may be specific funding available, for example from Cancer
support not only academic anaesthetists but also those who Research UK and the British Heart Foundation. Details of
are research interested and the RCoA 2010 CCT Curriculum many charities can be found on the Association of Medical
defines academic and research competencies. All trainees Research Charities website. Some hospital Trusts also have
are expected to attain basic and intermediate research charitable funds that may be able to support small research
competencies with higher level competencies available projects.
for interested trainees. Options for research involvement
include contributing to ongoing research projects, research Eleanor Carter
skills development and presenting work at national and Clinical Research Fellow, Division of Anaesthesia, University of
international conferences. Cambridge

Information and guidance about careers in academic References

medicine: 1. Fitzpatrick S. A Survey of Staffing Levels of Medical
Clinical Academics in UK Medical Schools as at 31 July
• Anaesthetic Research Society 2011. A report by the Medical Schools Council. October
• The Academy of Medical Sciences 2012. http://www.medschools.ac.uk/Publications/Pages/
• NIHR Trainees Coordinating Centre ClinicalAcademicStaffSurvey2012.aspx
• Medical Schools Council Academic Job Opportunities 2. RCoA. A National Strategy for Academic
• NIAA Anaesthesia. 2005.
3. Medically- and dentally-qualified academic staff:
Research courses Recommendations for training the researchers and
educators of the future. Report of the Academic Careers
Attending research courses can help with design of studies, Sub-Committee of Modernising Medical Careers and the
understanding research ethics applications, statistical analysis UK Clinical Research Collaboration. March 2005. http:/
and writing research papers. Examples of courses available are: www.ukcrc.org/wp-content/uploads/2014/03/Medically
and_Dentally-qualified_Academic_Staff_Report.pdf
• Good clinical practice (GCP). GCP is an internationally 4. NIHR. NIHR Integrated Academic Training Programme
recognised set of scientific and ethical principles that for Doctors and Dentists. http://www.nihr.ac.uk/funding/
clinical trials should adhere to. Attending a GCP course is integrated-academic-training-programme.htm
mandatory for individuals working in clinical research. This
may be done in person or online
• Anaesthetic Research Society research methodology
workshop. Run in conjunction with the RCoA and covers
principles of study design, project management, data
analysis and presentation of results
• Scientific methods and research techniques (SMART)
course. Three day research methodology course for
anaesthesia trainees run in Cambridge annually

65 THE GAT HANDBOOK 2016-2017

 HOW TO...
“We believe that involvement in academic
activity is a cornerstone of anaesthetic training
and this leads to improved clinical care at
both a local and national level.”
National Institute of Academic Anaesthesia

66 THE GAT HANDBOOK 2016-2017

 HOW TO...
How to tackle your e-Portfolio
ARCP Records: This lists your current open and previous
ARCP records. In here you will find a list of assigned items to
Background the current ARCP with the date of the ARCP (although this may
not be accurate as the dates can be corrected by the school
The RCoA e-Portfolio was launched in August 2011. This administrator just prior to ARCP) as well as a summary of
coincided with the move of the majority of trainees from the 2007 progress against the core requirements for each stage of training
to the 2010 CCT Curriculum. (Basic, Intermediate and Higher/Advanced).

Despite the perception of anaesthetists utilising technology, Planning: This section allows creation of PDPs or Learning
until this point trainees in anaesthesia had to maintain a paper Agreements. Initially you should create the plan, e.g. PDP
portfolio containing the evidence of their training. Workplace- CT1 Hospital A, and then create individual PDP objectives in
based assessments (WBAs) forms were completed on paper the plan. To create a Learning Agreement you follow a similar
and the mandatory yearly multisource feedback (MSF) had to process by ticking the Learning Agreement box. Any objectives
be collated by hand. Prior to their ARCP the trainee would meet added will appear as a task for your supervisor to approve and
with their educational supervisor to review all of their WBAs and subsequently mark as completed. Once all the objectives have
other evidence which had been collected throughout the year been completed then the PDP can be locked.
before writing their report. In some areas the portfolio had to be
submitted to the ARCP panel in advance. Qualifications: Any qualifications can be listed here with
associated evidence and approved by your supervisor.
For the majority of trainees who will have completed a UK
Foundation Programme prior to entering anaesthesia, there are Diary: Lists the date that WBAs or activities have been
similarities between the e-Portfolios. However, the Anaesthesia undertaken.
e-Portfolio is developed by a different provider to Foundation,
Emergency Medicine, Medicine and Intensive Care Medicine Assessment Tools: This is where you request assessments,
and therefore has a totally different look and feel. Completion of Unit of Training forms, Interim Progress Reports,
Educational Supervisors Structured Report (ESSR) or a MSF.
How do I get access to the e-Portfolio? It is possible to view assessments requiring action, completed
assessments or associate these to the open ARCP panel. It is
Accounts for trainees are created by the e-Portfolio team at the also possible to recall unapproved assessments if they have
RCoA on receipt of the appropriate trainee registration form. For been associated to incorrect units of training when being
trainers, details need to be sent to the e-Portfolio team via your instigated or if the assessment has not been completed after a
school administrator with details of access required. There are significant period of time.
multiple roles identified which allow varying degrees of access
to the trainees in a particular school of anaesthesia, e.g. TPD With the exception of MSF, in order for a trainer to complete the
or RA roles can view the e-Portfolio of all the trainees, whereas assessment, they must have an e-Portfolio account. For MSF
college tutors can view trainees who have assigned themselves the trainee can select either previously used assessors, select
to a specific hospital. Educational supervisors (ES) can view only assessors from the e-Portfolio system or input email addresses
trainees whom they are supervising. for external assessors such as nurses, ODPs etc. A minimum of
eight and up to 30 assessors can be chosen for MSF. Once the
On first login as a trainee you will be asked to select your ES assessors have been chosen then the list has to be sent to the
before you can go any further. This then allows your ES to view educational supervisor for approval. Unlike other e-Portfolios,
all the activity in your e-Portfolio with the exception of private the MSF is locked to both the ES and trainee for 30 days from
entries. You should also ensure that you update your current approval. It is not possible to add further assessors to the list
hospital as this then allows your college tutor to view your once approved by the educational supervisor. The trainee can
e-Portfolio. see who has responded, so that non responders can be chased
up.
What’s what in the e-Portfolio?
The different sections of the e-Portfolio can be located on the An advantage of the RCoA e-Portfolio is the integrated ESSR
banner bar at the top of the webpage. On the homepage you which is completed immediately prior to the ARCP. The ESSR
will also find an ‘Alerts’ section within which news and other will auto-fill activities undertaken during the ARCP period as well
information appears. In the centre of the page is a tasks list as a list of all associated WBAs, from the library, hence saving
which shows items which need action. The best way to initially time if you have input information throughout the year.
navigate the e-Portfolio is to work from the right hand side of the
banner bar. Unlike other e-Portfolios this does not have separate forms for
meetings with your ES. You can record them in the activities
Library: Documents (up to 2MB) can be stored here and section, or individual schools of anaesthesia may have
then associated with other parts of the e-Portfolio. There is no documents that can be uploaded into the library and associated
restriction as to the number of documents that can be uploaded. as supervisor meetings. The Interim Progress Report can also be
used for end of placement meetings or as a summary of training
Activities: Details of any activities or events undertaken are during the year when trainees rotate hospitals.
recorded in this section. Reflective practice or further information
can also be added if required. It is also possible to link supporting View Portfolio: This section shows the Units of Training for each
evidence from your library, e.g. a CPD certificate or a weblink level of training and the associated WBAs, evidence or activities.
to the activity, following the addition of reflective practice. If the
activity relates to a personal development plan (PDP) objective Where to get help
you can also link the activity directly to that PDP. There are multiple guides which have been written by the

67 THE GAT HANDBOOK 2016-2017

 e-Portfolio team to help with various sections of the e-Portfolio – finding that drugs A and B have similar effects could mean either
http://www.rcoa.ac.uk/trainee-e-portfolio/guidance-notes that they’re equally effective or that they are equally ineffective.

Each school of anaesthesia has an administrator and most have The practicalities
a named clinical lead who can offer advice – http://www.rcoa.
ac.uk/node/20324 Many a good idea has to be abandoned because the study is
just impractical in that setting. For example, anything involving
Also contact more senior colleagues or your college tutor; if you extensive data collection by other parties, (e.g. ward nurses,
have a problem then it is likely that someone else has had a midwives) is likely to fail because such people are busy and
similar problem and they may be able to help you. furthermore have no interest (in the ‘ownership’ sense) in the
study. Studies of rare outcomes require huge sample sizes
If all else fails the e-Portfolio helpdesk is available Monday to and are probably not worth the effort on a local level. Some
Friday from 9.00 am–5.00 pm (excluding public holidays). Tel: measurements are just too difficult to obtain. I always tell
0207 092 1556 or email: [email protected] those embarking on a project that there are two golden rules
of research: (i) everything takes four (not three or even two)
Ian Whitehead times longer than you think it will as times are getting harder;
Consultant in Anaesthesia & Critical Care, HENE (ii) you cannot rely on other people to do anything for you; and
(iii) life gets in the way. You have to be realistic about being able
to complete the study before starting, since giving up halfway
How to design a study through is a waste of everyone’s time.

The numbers
The strength of a study depends on its design. Rather than
classify the different types of study and get bogged down in This isn’t the place for an account of statistical methods but
statistics, I’m going to approach it from a practical point of view. it’s worth considering a few basic questions. The first is ‘How
many participants?’, and for a comparison study, in order to
The idea answer it you need to decide: (i) what you’re expecting to see
in your control group; and (ii) what difference is worth looking
Some ideas arise from clinical cases, (e.g. ‘Is my anaesthetic for in the experimental group. This, and subsequent questions
technique better than yours?’), while others come from reading like how to present or compare the data really do require the
or discussing published papers, conferences, or just out of the input of someone who has done it before – and not necessarily
blue. Sometimes a small-scale project like a local audit becomes a statistician. So time spent discussing the statistics is not only
much more interesting than expected and can be expanded useful – it’s vital. Sometimes the complexity of the statistics or the
into a full paper. Many ideas fall by the wayside because of the sample size required is such that a study has to be abandoned at
practicalities (see below), and it’s always worth testing the idea this stage because the practicalities don’t stack up.
to see whether it has a good chance of running before investing
too much time and energy. Sometimes an idea stands up to all The regulations
the challenges, only to fall at the ‘PubMed hurdle’ – someone
has done it before (not that this is a fatal flaw; most studies are These are increasingly seen (by investigators) as barriers put
worth repeating. In fact, an easy way to think of a project is to in the way of honest folk whose only wish is to improve the
repeat someone else’s). world, but history is littered with dreadful abuses of research
and publication ethics, as well as plenty of bad science. The
The question most useful advice, as before, is to seek useful advice from
someone who has done it before. In general, studies require
It may be surprisingly difficult to narrow down a general idea ethical approval, hospital R&D approval, directorate/department
to a specific question or questions that might be answerable approval, and possibly MHRA approval, depending on the type
by a study. For example, ‘Is my anaesthetic technique better of study. Funding requirements add another layer of paperwork.
than yours?’ could raise questions about individual drugs,
combinations of drugs, practical procedures and even individual (Revised, with permission, from Anaesthesia News 2009, 267:
anaesthetists. Even if one were to decide upon ‘Is drug A better 13–4.)
than drug B?’, the matter of what ‘better’ means must also be
defined, (e.g. less pain, faster recovery, shorter hospital stay, Steve Yentis
lower cost, etc). For most outcomes there are also different Editor-in-Chief, Anaesthesia, 2009–2015
measurements from which to choose – e.g. ‘less pain’ might be Vice President, AAGBI
measured as lower pain scores, less morphine requested, or
a longer time before requests. Defining the question is crucial
since it determines the type of data collected and therefore sets
the scene for the entire project.

The design

By ‘design’ I mean what is actually done during the study. For

example, is any intervention happening, (e.g. giving a drug) or
is it simply observational, with measurements being recorded
but nothing ‘done’ to the participants? Is data collection
prospective or retrospective? The latter is weaker since the data
were collected without the study in mind, so one can be less
certain about their accuracy or completeness. An important
consideration is the choice of appropriate controls, for example
drug A versus drug B, where drug B is the standard treatment
(thus control) and drug A the newer (experimental) one. But even
here, unless there is good evidence that drug B is effective, a

68 THE GAT HANDBOOK 2016-2017

 How to conduct an audit Ethics committee approval

Strictly speaking it is not necessary to seek ethical approval for

What is clinical audit? audit projects. However at times there is a fine line between audit
and research. Most Trusts have a policy regarding approval for
‘Clinical audit is a quality improvement process that seeks to audit projects and you are advised to follow Trust policy in this
improve patient care and outcomes through systematic review regard. In practice a submission to the Trust’s audit committee
of care against explicit criteria…where indicated, changes via the clinical audit lead is sufficient and for simple projects the
are implemented…and further monitoring is used to confirm chairman’s approval should suffice.
improvement in healthcare delivery.’
Principles for Best Practice in Clinical Audit (2002, NICE/CHI) Planning the audit

An audit is a well-established pillar of clinical governance, Careful planning is the key to finishing an audit project
whereby an individual or a group of individuals review current successfully. Any aspect of healthcare delivery can be a suitable
practices and processes, and strive to improve them if possible. subject for an audit. You may choose to start a new audit project
Clinical audit relates to clinical practice, and not only helps from scratch. The RCoA Raising the Standard: a compendium of
to improve the quality of care delivered to patients but is also audit recipes for continuous quality improvement in anaesthesia
invaluable in helping to maintain and monitor standards of care. is a great starting point to find an area you may find interesting.
Alternatively there may be an opportunity to join an existing audit
The audit cycle project that is already in progress in the department which you
are working in or are planning to join. You may consider taking
Clinical audit is a cyclical process where standards are agreed over from a colleague who is moving on to another hospital and
and data collected. Analysis of these data shows whether the is perhaps unable to complete the project they have started, or
standards are being met. If not, changes are planned and you may choose to re-audit a subject that has been looked at in
implemented and data collected for a second time and analysed the past. Your first port of call should be the clinical lead for audit
to see if any improvements have resulted from these changes within the department. This may not necessarily be a medical
(Figure 1). It is important to realise that data are collected and doctor but he or she will have the support of the department as a
analysed on two occasions (‘closing the audit loop’). A single whole and will have been given responsibility to co-ordinate and
data collection exercise does not constitute audit. The first data monitor audit projects within the department. They may be able
collection is to establish the current position and the second is to to suggest a possible subject that needs looking at, perhaps
see if any improvements have been made. something that needs auditing or re-auditing which has been of
concern to the department. They will also ensure that, should
you have a subject in mind, it is not already in the process of
being audited nor already been audited by someone else
recently. The other group of people to talk to are the permanent
members of staff in the department who will be familiar with what
has been done over the recent months or years and may have
suggestions for what needs to be audited.

Undertaking the audit

Audit should be done openly and transparently and should never

be confrontational or threatening. Talk to as many people as you
can about your plans and get others involved with the project.
You have to carry your colleagues with you. This is especially
important if the likely outcome is going to have an impact on
their practice. Keep the project simple and stay focused. Do not
be distracted by irrelevancies and minutiae. There is a tendency
to collect far too much irrelevant data. This is counter-productive,
wasteful and slows everything down. Confine data collection to
what is pertinent to the audit project. Select a topic that is relevant
and exhibits potential benefit to the patients, to the department
Why should I do an audit? or to the hospital, and if the topic falls within your area of interest
or expertise, so much the better. High risk, high turnover, high
Best practice and best outcome should be the goal of every cost practices are particularly good to audit as improving them
clinician. Voluntary critical self-appraisal of one’s performance can have a profound impact on the quality of care or the quality
is a useful way of ensuring this. Clinical audit enables one to of service and can at times make a real difference. Do not tackle
achieve these goals. All consultant contracts in the NHS have a topic where the likelihood of improvement is questionable or
clinical audit as part of their job descriptions, hence it is a good beyond control of yourself or the department. You should try and
idea to get into the habit early. There is now a clear expectation work within a given time frame. Audit projects that are started and
that trainees will complete a yearly audit or quality improvement never finished are a waste of time, effort and resources. If you feel
project during their training and that permanent clinical staff will that a project cannot be finished by you, e.g. because you have
undertake continuing audit during their NHS careers. to move on to a different hospital as part of your rotation, recruit a
colleague to take over so that the project can be completed. As a
Audit or research? trainee this shows real dedication, motivation and assertiveness.

There is a difference between audit and research. Research Presenting your work
is a process that tries to find out what you should be doing to
your patients. Audit is a process that tells you whether you are Present your work at a departmental or a Trust audit or quality
actually doing what you are supposed to be doing. Research improvement meeting. This may be necessary if changes
seeks new knowledge or refines existing knowledge and audit involve the whole department or other specialties. Invite as many
reviews current practice to stimulate change. participants as you can. Don’t be inhibited to come back and

69 THE GAT HANDBOOK 2016-2017

 present your findings to the host department if you have moved Improvement science and models for improvement
on to another hospital.
Similar to the well-recognised audit cycle as a model of the
Implementing change process, several models exist for continuous quality improvement.
However, it is imperative to remember that models only provide
If you have demonstrated that changes in your personal practice a structured approach to facilitate improvement. The most
can enhance your clinical practice then implementing changes commonly quoted model is the Model for Improvement which
are not an issue. On the other hand, if changes are indicated was developed by Associates in Process Improvement. Part
across the whole department (or the whole hospital or Trust) of the model uses a simple ‘Plan-Do-Study-Act’ (PDSA) cycle.
senior clinicians and senior managers will need to get involved This cycle is analogous to a rapid-cycle audit. You begin with
in implementing the change at such a high level and this can a short cycle of data collection, then analyse the data looking
take some time. It is crucial that the effect of any changes specifically for immediate flaws and obstacles. Changes which
implemented is re-evaluated after a given period of time, and in may involve structures or processes can then be made before
doing so completing the audit cycle. repeating the cycle. Larger quantities of data are collected by
repeating the PDSA cycle numerous times. These small, frequent
Conclusion samples allow more proactive changes to be made regularly
until improvement in outcome is attained.
Audit is part and parcel of modern clinical practice and plays
an important role in improving quality of patient care. It has A comprehensive description of improvement science and
tremendous potential benefits for the clinician, patients and the models for improvement are beyond the scope of this chapter.
organisation(s) in which we work. High standards and good However, the Institute for Healthcare Improvement website and
quality of service are desirable goals and clinical audit is an the RCoA’s Raising the Standard provide valuable resources for
invaluable tool in achieving best practice in our modern clinical those interested.
environment.
How to get involved in a quality improvement project
Acknowledgment
With thanks to Dr Ranjit Verma (Consultant Anaesthetist, Royal Most trainees are expected to complete at least one audit or
Derby Hospital, Past AAGBI Council Member, RCoA Council quality improvement project per year. Similar to a clinical audit
Member) for his original article, upon which this chapter is based. (see previous chapter) you may decide to get involved in an
ongoing quality improvement project within your department, or
Satinder Dalay start a new project.
ST5 Anaesthetics, Birmingham School of Anaesthesia
GAT Committee Elected Member When thinking of a new topic try to choose an area that has
been identified as being a problem within the department, poses
Sean Chadwick a risk to patient safety, or where processes are inefficient and
Consultant in Anaesthesia and Intensive Care, Worcestershire Acute waste resources. Also, choose a topic area where you as an
Hospitals NHS Trust anaesthetist can have the most influence. Discuss your project
with a senior colleague who may be able to help drive the
needed change.
How to conduct a quality
Unlike an audit, the key to a quality improvement project is an
improvement project understanding that each project is unique to the hospital it takes
place within, and that what works well in one hospital may not
in another.
‘Every system is perfectly designed to get the results it gets, the
only way to get real change is to change the system; to do this The most important factors in success of your quality
you need will, ideas and execution.’ improvement project are your perseverance, motivation,
commitment and ownership of the project. Although the PDSA
• You must have the will to make the system better – this cycle requires organisation and resources, the improvement
may be because you have identified poor performance or in outcome should lead to the sustained success and ultimate
outcome through audit or patient experience longevity of the project.
• You must have ideas about how you could change things
for the better Satinder Dalay
• You must have skills to make it happen – execution ST5 Anaesthetics, Birmingham School of Anaesthesia
GAT Committee Elected Member
Paul Batalden, Institute for Healthcare Improvement
Reference
What is quality improvement? 1. Farrell C, Hill D. Time for change: traditional audit or
continuous improvement? Anaesthesia 2012; 67: 699–702.
Quality improvement is by no means a new concept. However,
it is a concept which is currently being, and will continue to be,
embraced within anaesthesia. Continuous quality improvement
methodologies focus on making improvements in outcomes.
This is in contrast to audit, where making a change is one of the
key cornerstones in the audit cycle, regardless of whether there
has been any real improvement in outcome. Although, within
quality improvement changes are often made, these are less
important than the improvement itself [1].

The RCoA recognises this shift away from audit towards

quality improvement, such that the concept of improvement
was introduced in the latest edition of Raising the Standard: a
compendium of audit recipes for continuous quality improvement
in anaesthesia.

70 THE GAT HANDBOOK 2016-2017

 The Research and Audit Federation How to write a paper
of Trainees
You’ve done the easy and interesting part and completed your
Over the last 24 months we have seen the development of study, but now you have to sit down, put fingers to keyboard
multiple regional anaesthetic trainee-led audit and research and write the paper! Perhaps you see this as a daunting task but
collaboratives. There are now 16 regional trainee research it shouldn’t be because you’ve actually already written most of
networks (TRNs) in the UK including SWARM, WM-TRAIN, the paper. A well-written protocol should have the Introduction,
NWRAG, STAR, SPARC, SHARC, WAAREN, PLAN, AARMY, Methodology and a lot of the Discussion ready for a bit of cutting,
INCARNNET, ARNni, SQuARes and SEARCH with new groups pasting and editing. Your literature search should contain most of
developing in Ireland (CAT-RAN), Mersey (MAGIQ), the East the references you’ll need and hopefully they have been entered
of England deanery (NEACTAR) and the Oxford deanery into a reference management system ready to merge with your
(OxCCARE). The National Institute of Academic Anaesthesia, manuscript.
RCoA and GAT have recently lent their support to a new, trainee-
led, national umbrella group, the Research and Audit Federation Where to begin?
of Trainees (RAFT), to network these regional groups into a
national collaboration. Before sitting at your computer, you should first give careful
consideration as to which journal you intend to submit. Take
RAFT aims to facilitate trainee-led, anaesthesia-related projects advice from experienced colleagues on this question. Also, ask
on a national scale. It hopes to improve the opportunities for yourself who is the intended audience for your paper? Is it for a
clinical trainees to engage in high quality, multicentre audit, broad church of anaesthetists (think Anaesthesia, British Journal
quality improvement and research. It champions the newly of Anaesthesia or European Journal of Anaesthesia), or only of
evolving UK collaborative model – this model requires many interest to a small subspecialty group (either an anaesthetic
clinicians over many UK Trusts to work together to recruit large subspecialty journal or a relevant surgical journal)? Is it basic
numbers of patients for ‘big data’ studies. ‘Team UK anaesthesia’ science or animal work (consider a basic science journal such
has already had significant success in this and RAFT hopes to as Nature)? Is it of interest to non-anaesthetists (perhaps suitable
continue to push these boundaries while working in collaboration for the BMJ or The Lancet)? Sometimes a case report will have a
with its partner organisations, including the Health Sciences greater impact on anaesthetic practice than a large randomised
Research Centre and National Research Collaborative. A key trial – for example descriptions of novel oxygenation techniques
element of this model is to recognise the contribution made by or unusual complications related to common conditions or
all and to publish as a group rather than individuals. The RAFT drugs. If you feel a case report is an option for your research then
committee comprises two representative members from each you could consider submitting to Anaesthesia Cases.
regional group. It is managed by an elected chair, two vice-chairs
and a communications lead. If any further regional collaborative Once you’ve chosen the journal, read it, get an idea of its style
groups are formed then they will be invited to represent their and layout and most important of all, carefully read the journal’s
group within RAFT. The RAFT executive committee has now guidance for authors. Then read the guidance for authors again
been supplemented by a RAFT IT reference group – the remit and keep a copy handy to consult frequently during writing; it
of this team is to drive forward innovative IT solutions that will should become worn and dog-eared by the end.
support our national projects.
Although acceptance of your paper will depend on its scientific
RAFT was initially founded on 2 December 2013 at a meeting value, it is helpful to make a good impression with reviewers.
hosted by the RCoA, where representatives from the majority A poorly written paper with careless typos, misspellings and a
of the existing regional groups met in order to discuss terms disregard of the guidance for authors will leave a bad impression
of engagement. Since then, RAFT has held their Annual Winter on reviewers. A sloppily written paper will suggest that the study
Meeting at the College and their Summer Project Development has been carelessly conducted, lowering its scientific value.
Meeting during the GAT Annual Scientific Meeting with the
presence of a GAT elected member. At this meeting our annual A common misconception of budding authors is that a long
project is chosen following a rigorous long and short-listing paper is more impressive than a short one. Like many things
process. The aim of this GAT hosted meeting is to provide a in life, size isn’t everything! Keep your writing succinct, use
mechanism by which regional projects can be evolved into plain English, avoid over use of the passive voice, (e.g. ‘we
national studies – any trainee can submit an idea to this meeting administered fentanyl to the patients…‘ is better than ‘fentanyl
through their local TRN. Our first successful project involved was administered to the patients…’), take care with punctuation
quantifying the availability and use of cardiac output monitors and avoid excessive abbreviations; all of which will help to make
within UK anaesthetic departments on a national scale (Cardiac it easier to read.
Output Monitor Survey – COMS). Our next annual project
(targeted for 2016) is IHypE (Intra-operative Hypotension in the Now it’s down to the writing. Start with the Introduction,
Elderly) – this will be a snapshot observational study that will which should have three clear messages: i) what is already known
quantify the size of the problem and will be accompanied by a about the subject, ii) what is not yet known, i.e. the questions
survey to investigate the perceptions of anaesthetists towards needing answering, iii) and what does your study intend to
hypotension and its importance. Data on certain outcome answer? Keep it simple; three short paragraphs answering these
measures will also be captured and we hope we will collect data questions.
from nearly all UK acute Trusts. Any trainee who does not have a
local TRN can lead the project at their local Trust if they express The Methods should already have been written and can be lifted
an interest. directly from the protocol and edited, keeping it simple so that
it contains enough detail for anyone else to repeat your study.
For further information on RAFT please visit If someone has described part of the methodology before, you
http://www.raftrainees.com and follow us on Twitter do not need to repeat the description but clearly reference it.
Include at the end a succinct but accurate description of the
Sally El-Ghazali statistical methods you used for your analysis. Where relevant,
GAT Committee Elected Member you should include enough detail of your power analysis to allow
the reader to confirm how you arrive at your sample size.
Clarity is essential in the Results section. Use clear group names,

71 THE GAT HANDBOOK 2016-2017

 (e.g. group morphine and group fentanyl rather than groups A How to please the editor
and B or groups M and F). Make sure that you retain a consistent
order of reporting, particularly when there are more than two
groups. Avoid unnecessary duplication of results: perhaps use There are many ways of pleasing an editor but let’s confine it here
a table to provide details of numbers and simply give a brief to submitting an article for publication. I won’t go into the reasons
summary of main or important findings in the text. It is important why it’s important to conduct and write up projects, or how to
to ensure that tables are laid out as per guidance for authors. If design studies; let’s assume that you’ve completed your study
there are figures or photographs, make sure they are of sufficient and are now preparing it (and yourself) for the final challenge:
resolution for printing (again refer to the guidance). Most journals convincing the reviewers/editors that it’s worthy of inclusion in
reproduce images in black and white and it is important to check a reputable journal. First, a little about how the process works.
that the image remains clear with important detail retained when
it is converted from colour. How to submit a manuscript and what happens
when you do
Keep the Discussion simple; don’t be tempted to draw it out for
the sake of it, believing that a long discussion is more impressive. Nowadays submissions are almost all electronic, either by
You should consider what your results mean, how they fit in with email plus attachment or a web-based system of filling in blank
existing knowledge and why, not if, they don’t fit. It is important boxes and uploading files. Each has its own advantages and
to be up front and point out the flaws in your study as no study disadvantages – to both the journal and the author. Either way,
is perfect and it is better to acknowledge these flaws and try to you should receive a notification confirming receipt and giving
convince the reader why they do not distract from the validity of you the number assigned to your manuscript; make sure you
your finding. Finish your discussion with a concluding paragraph, quote this number whenever you contact the editorial office. You
reinforcing the main findings and suggesting areas for future may have to submit a declaration form at this stage, vouching
research. for your work’s originality and that it’s not being considered by
another journal – if the journal asks for one, make sure you send
Inserting references should be straightforward, especially if one. A particular area of confusion is the submission of a letter
you’ve been entering the results of your literature search into based on work already published as an abstract, e.g. a poster at
Reference Manager or Endnote, which should allow you to a conference or meeting – in general, this isn’t allowed, unless the
format the references correctly for any journal at the click of a two items are sufficiently different as to constitute two separate
mouse. Don’t feel that you have to use every reference in your pieces of work. As ever – if in doubt, ask the Editor-in-Chief.
search; keep to those that are directly relevant to your paper and
discussion. Your manuscript will then be reviewed by a number of people,
depending on the journal. For some journals, the editor-in-chief
Finally, think of a simple, accurate title (avoid newspaper will screen all manuscripts first and reject the hopeless, unethical
headline style titles) and write the Abstract using a structured or and unintelligible ones at this stage. For others, they’ll all be
unstructured format as prescribed by the journal. Your Abstract reviewed by two or more editors and/or external reviewers, with
is the gateway to your paper; it may in fact be the only thing the final verdict made by the editor-in-chief, taking the others’
read by many but can also draw the reader into exploring further. opinions into account. This process can be lengthy, especially if:
It therefore needs to summarise why you did the study, your the paper is complicated; there are only a few experts in the topic
methods, main results and conclusions, keeping the order of to ask for an opinion and they’re all busy; the external reviewers
groups as described in the paper and ensuring that the results are slow to provide an opinion; the reviewers disagree and it has
are the same – it’s surprising how often there are discrepancies to go for a further opinion(s); the editorial office is dealing with a
because of transcription errors. large backlog or even a crisis, (e.g. technical); or your email (or
the one to/from reviewers) gets lost in the ether. Most journals
There, it’s all done and ready to be sent off to your chosen journal. should be able to give you a verdict within one to two months at
Eh, no…, not yet. Re-read your paper, get all co-authors to read the most; in general, if you’ve not heard anything then a polite
and edit in turn, and lastly, get a lay person to read it (partner or enquiring email to the editorial office won’t offend anyone.
friend); they may not be able to understand the technical aspect
of the paper but they will be able to tell you whether it is clearly Rejection
written.
Rejection is never easy to take and one usually goes through
After submission, you can heave a big sigh of relief and await the classic stages of shock, denial, anger, depression and
the verdict. If it is not accepted, do not despair or take it as a acceptance (not by the journal, alas). There are two bits of advice
personal rejection. It does not necessarily mean that your paper I can offer at this stage: first, remember that reviewers and editors
is worthless; there are many reasons for rejection. Despite your do miss the point sometimes, but they are very experienced at
careful selection, it may be felt inappropriate for that particular what they do and have seen hundreds of manuscripts. If they
journal, or you may have just been unlucky with the choice of have missed the hidden value of your manuscript then it’s
reviewers; the difference between acceptance and rejection is probably because you haven’t made it clear enough. Take the
sometimes a fine one and quite subjective. Hopefully, the editor comments you receive, use them to improve your manuscript,
has given you constructive comments and an explanation of and submit it somewhere else – or even to the same journal if you
why it was rejected. If not, it is worth writing back and politely feel strongly enough. Second, the good journals have a very low
requesting feedback. Use these comments to revise your paper acceptance rate (for Anaesthesia it’s about 15–20%), so there
and prepare for submission elsewhere, but only after you’ve may well be nothing actually wrong with your manuscript, it’s just
carefully read the new journal’s guidance for authors and that it’s been felt to be not quite as good (or interesting) as other
reformatted your paper accordingly! submissions.

(Reproduced, with permission, from Anaesthesia News 2010; Acceptance

273: 16–7.)
If your manuscript is accepted the work doesn’t stop there. You’ll
Paul Clyburn get a list of requirements from the editor, e.g. removing this or
Former Editor, Anaesthesia explaining that – do exactly as the editor asks, and don’t take too
President Elect, AAGBI long. Despite the conviction of many authors that journals are
slow, ponderous beasts (admittedly, some are; mind you, so are

72 THE GAT HANDBOOK 2016-2017

 some editors), the most common reason for delays in publishing 3. Seek help
papers is a lack of response, or a very slow response, from the You simply must seek the advice of someone who has
authors. The same applies to proofs, which will usually be sent to done it before. What else can I say?
you a month or so after the final version of your manuscript has
been sent to the publishers. Make sure you turn them around 4. Give yourself time but get on with it
quickly, or your editor will be displeased (see chapter title...). Most people cannot churn out good, readable text in a
day. If you’ve set out in the right way, you’ll have written a
How to do it decent protocol before you started the study and you can
use that as a basis for constructing the final manuscript.
Having rambled on about the process, I’ll now give you my guide But it takes time. My advice is always to start off by writing
to how to please the editors. stuff down as it comes to you, and not to worry too much
about structure etc to begin with – just get it down. You can
1. Follow the instructions shape it later, with an experienced person’s input. Often it’s
You’d have thought this was self-evident, wouldn’t helpful to leave it alone for a couple of weeks, and then take
you? Amazingly it’s very common for authors to send a fresh look. Having said that, you cannot leave it too long –
in manuscripts without the required accompanying first, because someone else may publish on the same topic
declaration, with the wrong reference style and the wrong before you, and second, because a study done several
units, with American spelling, and the graphs and tables years ago will be of less relevance and therefore interest
in the wrong format. At best this will irritate everyone at to the reviewers/editors. Third, you will not please your co-
the journal and could influence the verdict; at worst, it authors, especially the one guiding and mentoring you. I
might even lead to an instant rejection. All journals have speak from experience: there are few things more irritating
instructions/guidance on their websites; find them and read than junior colleagues who promise to write up their study
them. Then read them again. Then download or print them but then disappear overseas without even starting, taking
and read them at intervals while preparing your manuscript. all the data with them.
Then read them once more before you send it in. If there’s a
checklist to complete before submission, use it and make 5. Be ethical
sure you’ve done everything required. I’m referring to two areas that cause problems: first, research
ethics: ensuring that your study has the appropriate ethical
2. Construct your paper well approval; and second, publication ethics: making sure that
I won’t go on here about what to say in each section of you haven’t copied any text from another source, haven’t left
the manuscript; go and take a look at Anaesthesia’s out authors who should be included, or included those who
Guidelines for Authors. Or you could look at any other shouldn’t, and certainly haven’t made up or manipulated
journal’s guidance; they all tend to say the same thing. At any data. You can get into serious trouble for this kind of
Anaesthesia we’ve tried to make our guidance helpful too, thing, as can your colleagues, so take care. Anaesthesia’s
rather than just prescriptive. Remember, the aim of your website has some guidance that we hope will be useful.
writing is to explain clearly to the editor/reviewer/reader
what you did and why it might be important; if it’s not clear 6. Follow the instructions
then that in itself can be a reason for rejection, or at best it’ll
lead to a request(s) to clarify various aspects of your work. 7. FOLLOW THE INSTRUCTIONS!
The best papers are simple and easy to follow; they avoid
complicated sentence structures and refer to the groups 8. Have fun
and outcomes in the same order throughout the text, so the Yes, it is possible. And good luck.
reader doesn’t get confused where they are.
Steve Yentis
Editor-in-Chief, Anaesthesia, 2009–2015
Vice President, AAGBI

73 THE GAT HANDBOOK 2016-2017

 TAKING CARE OF YOURSELF
“Wellbeing requires four components: a good
working environment and work arrangements,
support for staff to maintain good physical
and mental health, good working relationships
and good personal support; we can all
contribute to this.”
Nancy Redfern, Chair of the Wellbeing and Support Committee, AAGBI

74 THE GAT HANDBOOK 2016-2017

 TAKING CARE OF YOURSELF
KEEPING OUT OF TROUBLE times in the professional career of every anaesthetist, whether
they are a consultant, specialty doctor or trainee, that their skills,
knowledge and experience will not be sufficient to provide a
It is time for a confession – even I have been in trouble during my patient with the best care available. When this happens to you
30-year career in anaesthesia. There have of course been lots of (and note that I say ‘when’, not ‘if’), you must seek help and
minor episodes of trouble, like the time I accidentally dissolved advice from others. There should be a consultant available to
an antibiotic in a long-acting non-depolarising neuromuscular you 24/7 to offer advice and practical support. Okay, some
blocking drug (pancuronium) instead of water and gave the consultants get a little grouchy when called at 4.00 am. However,
resulting mixture five minutes before the end of the operation. I just think how much grouchier they will be if you call them at
was stuck in PACU ventilating the patient’s lungs for two hours 5.00 am having messed up a case with which they could easily
afterwards and was the butt of not a small amount of ridicule have helped you. Practise within the boundaries of your abilities
from my peers, and subsequently the subject of a trip to the Lead and when you think that you may be getting out of your depth,
Clinician’s office for a rap across the knuckles. There have also be completely honest about it. Both you and your patients will
been more serious episodes, including one accusation of gross benefit as a result.
professional misconduct and one of attempted murder – I kid
you not! Tempt me into a pub one day and ply me with a beer ‘Fess up
or several and I will reveal all. Suffice to say, in summary, that
I was innocent of both charges but learned a lot about life in This is an obvious one: if you mess up, ‘fess up. Take
the process of defending both cases. The truth in anaesthesia responsibility for your victories and your mistakes. It is an entirely
(and critical care and pain medicine and any other medical natural tendency to avoid contact with a patient whom you may
subspecialty) is that it is much better to keep out of trouble than have harmed or annoyed as a result of an error. Don’t do this.
it is to learn to be adept at getting out of trouble once you are Patients and their relatives will understandably see this as you
in it. I have a few tips for keeping out of trouble that I will share being evasive and defensive. Talk to a consultant about what
with you. happened, then go and see the patient and their relatives and
explain the situation honestly. Sometimes it may be appropriate
Look after your patient and yourself for you to face the patient alone; but usually you should have
a consultant or other senior member of staff with you and this
Although a relatively recent novitiate into the motorcycling meeting, you should apologise for what happened. This does
fraternity, I have already learnt some of its mantras. One of my not amount to an admission of negligence, and your honesty
favourites is: don’t ride drunk, don’t ride tired, don’t ride sick, and and openness will often satisfy the patient and persuade them
don’t ride upset. The principle is that riding a motorbike requires not to take any further action.
a great deal of concentration if you are going to stay on it and
avoid an impromptu flying lesson that will undoubtedly end in pain No one’s perfect
and physical damage. You cannot concentrate on this important
task if you are drunk, tired, sick or distressed. There are obvious This follows on from the above point. No one is perfect; everyone
parallels to treating patients, with one notable difference. With makes mistakes. Making a mistake doesn’t usually mean you
motorcycling, you risk your own life; when treating patients you are a bad person or a bad doctor; it just means you are human.
risk their lives – but you also risk your career. If you find yourself By all means make every effort to avoid mistakes, but do not
required to work but feeling impaired for whatever reason, tell be too hard on yourself if you do make a mistake under difficult
someone and see if you can find a way of not treating patients circumstances. Similarly, be understanding of others who make
until you feel well enough to do so. As a trainee, there should honest mistakes.
always be a consultant to whom you can turn and who can
rearrange service cover to make sure that patients are protected Don’t get proud
and that you are given the chance to recover.
A wise man (my father-in-law) once told me: ‘never, ever think
However, looking after yourself goes beyond just making sure you are the best anaesthetist in the world, just be very grateful
that you are fit to work on a particular day. It extends to developing indeed that you are not the worst – there will always be people
a lifestyle that means that you are as fit as you can be all the better and worse than you are’. Even if you are very good indeed,
time. You need enough sleep, a reasonable amount of exercise, there will be days when nothing goes right – when it feels like you
time for friends and family, a good diet, a passion outside of are wearing boxing gloves and none of the lines will go in. Don’t
medicine and a lifestyle free from drugs, smoking and anything get proud – get someone else to help you. The person you ask
more than a modest amount of alcohol. These may seem like to help you doesn’t always have to be more experienced than
trite recommendations, but a visit to the GMC’s website, and in you. I have often had difficulty putting a line in and have asked
particular the judgements of the Fitness to Practise panel, will a trainee to help, only to watch the trainee put it in at their first
show you that many of the doctors who get into serious difficulty attempt. This is good for the trainee and good for the patient and,
find it impossible to comply with these recommendations. Your after a while, your confidence will become immune to the odd
health and sanity is very much conducive to the wellbeing dent, which will do it a deal of good.
of your patients. If you find yourself failing to live up to these
recommendations, I would strongly advise you to seek help Keep good records
of some sort, even if it is talking to a sympathetic friend who
knows you well enough to support you and point you in the right When you make clinical decisions, you are – I am sure – going
direction. through a problem-solving process and reaching logical
conclusions that dictate your management. However, years
Don’t get out of your depth down the line, if something goes wrong and you have to defend
your practice, your memory will have faded. If you are a good
No anaesthetist can do everything and no anaesthetist should practitioner, then good, contemporaneous record keeping is
be expected to be able to do everything. This is true for all your best protection. Good records will also mean that the next
anaesthetists but is particularly true for trainees. There will be doctor who sees your patient will know what’s going on and will

75 THE GAT HANDBOOK 2016-2017

 be able to provide continuity – especially important in an age of Listen to the GMC (really)
shift-working. A good rule of thumb is that an anaesthetist who
does not know you but who has read your anaesthetic chart The very first line of the GMC’s key document Good medical
should be able to give an identical anaesthetic based on the practice says this: ‘Make the care of your patient your first
information in the chart. A good, tidy and complete anaesthetic concern’. This is the best advice available if you wish to keep
chart, in particular, is often the mark of a good, tidy and complete out of trouble.
anaesthetist.
I am sure that you could add to this list pieces of advice that will
Treat consent seriously help others keep out of trouble. However, I will leave you with
one more morsel of advice that is worth heeding if you want to
From both the ethical and legal viewpoint, the process of consent stay out of trouble: treat others as you would wish to be treated
is very important. You are responsible for explaining what you yourself – and this holds true for both your patients and those
are going to do to your patient, telling them what you hope to with whom you work.
achieve by it, what might go wrong, and what the alternatives
are. Be guided by this simple question: ‘If I were this patient, Be safe out there!
in their position and with their concerns, what would I want to
know in order to make a decision about this treatment?’. The William Harrop-Griffiths
debate between written and verbal consent is too complex to Past President, AAGBI
consider here (read the AAGBI guidance on the subject), but
the most important precaution is to keep a record of what has
been discussed. Patients have notoriously terrible memories
about what they’ve been told and, if a recognised complication
occurs, you’ll want to be able to demonstrate that you warned
them about it in advance.

Follow guidelines

You may think you know best – and, to be fair, sometimes you
do – but a lot of experts went to a lot of trouble to draw up those
guidelines, and it’s their support that you want and need when
things go wrong. They are more likely to look favourably on you
if you weren’t following some maverick path of your own at the
time. Of course you are a professional, and of course guidelines
can’t deal with every situation, but if you are going to deviate,
make sure that (a) it’s for a good reason and (b) you make a
good note of why you did it.

Communicate
Becoming a parent
No anaesthetist is an island. We can only work well if we work
with others, so ensure that lines of communication between you,
the surgeon, the theatre staff, the wards, the labs and the myriad Having a baby is an exciting time. Planning your future at the
of other essential members of the team do not break down. The same time as working in a demanding job can be challenging,
anaesthetist is arguably best placed to act as the hub for sharing especially if pregnant. Negotiating your way through the maze
and disseminating information. It’s a noble and important role; of paperwork surrounding your rights and benefits on maternity
fill it with distinction. leave, and maternity support can be difficult to fit in between
antenatal appointments, busy shifts and preparing for a new
Never refuse a coffee break arrival.
When I started anaesthesia, I was told that there were three This chapter aims to clarify some of the main issues facing
golden rules (in the following order): the parent-to-be and provide guidance on your rights and
responsibilities towards your employer.
• Never refuse a coffee break
• Maintain a clear airway Maternity leave and pay
• Give oxygen
• You are entitled to 52 weeks of maternity leave. Two weeks
I have often thought the order might not be entirely correct, but in the period immediately after the birth is compulsory. You
I have never knowingly refused a coffee break when it was safe may be entitled to both Statutory Maternity Pay (SMP) and
to leave the patient with another anaesthetist. You never know NHS occupational maternity pay. The former is a statutory
when your next break will come and you will function better if you right [1] and the latter a contractual right [2], the details of
have frequent breaks. which are summarised below
• You must notify your employer in writing before the end
Be nice of your 25th week of pregnancy of your intention to take
maternity leave, and the date when you wish this to
It is a fact of life that the nice doctor who makes an error is far commence. This can be any date after the beginning of
more likely to come out of it smelling of roses than the nasty week 29 of your pregnancy. You can change the start date
doctor. You are bound to need the help and support of your provided you give your employer 28 days notice
colleagues at times, and they won’t rush to help you if you’ve • If you are not intending on taking 52 weeks of maternity
alienated them. The same applies to patients, who seem to be leave then you must also inform your employer of when you
far more forgiving if they like you. plan to return to work. You can change your mind about this
date later on as long as you give eight weeks notice
• You should also include the original copy of your Maternity

76 THE GAT HANDBOOK 2016-2017

 (MATB1) certificate with any documentation to your
employer. This states your expected date of delivery. Your Occupational hazards
midwife or GP can issue it from the 21st week of your
pregnancy. Proof of pregnancy is needed to claim SMP Anaesthetists work in many different areas of the hospital and
• SMP is claimed by your employer on your behalf. They thus face a variety of potential hazards.
can only do this if you have 26 weeks continuous service
within your current employing Trust by the end of your 25th • Shift working/on-call commitments: On-call commitments
week of pregnancy. This entitles you to 39 weeks SMP paid can be very demanding for the pregnant anaesthetist. There
regardless of whether you intend to return to work or not is little information guiding expectant anaesthetists as to
• If you have rotated Trusts and do not qualify for SMP then when it is reasonable to cease out of hours work. There
you are entitled to claim maternity allowance via your local is some evidence to suggest that long hours (> 40 hours/
Job Centre Plus, as long as you have been employed for week) may pose a low to moderate risk to mother and/or
26 of the 66 weeks up to the week before your due date. baby. However there is insufficient evidence that this is the
Maternity allowance is the lesser of 90% of average weekly case for shift work, although it may become exhausting in
earnings or SMP later pregnancy [3]. A survey conducted by anaesthetic
• If you take Shared Parental Leave (SPL) you will get Statutory trainees found that in one region the median for trainees
Shared Parental Pay. stopping daytime on-call was 32.5 weeks gestation and
• To be eligible for NHS occupational maternity pay you night shifts was 30 weeks gestation [4]. In some cases it
must have one year’s continuous service in the NHS (can may be necessary to give up on-call commitments at an
include a break of up to three months) by week 29 of your earlier gestation to ensure a healthy pregnancy. A letter
pregnancy. If you have rotated Trusts during this time but from your midwife or GP will support your case for a change
have continuous NHS service you will remain eligible for to your working pattern. This may mean, however, that
occupational maternity pay. This entitles you to eight weeks those months without an on-call commitment do not count
full pay followed by 18 weeks half pay then 26 weeks unpaid towards your CCT and this should be discussed with your
leave. By prior arrangement this can be paid in a different training programme director
way, e.g. a fixed monthly amount over the entire leave • Anaesthetic gases: With the advent of scavenging, the
period [2] risks associated with anaesthetic gases, spontaneous
• During maternity leave you retain all your contractual rights abortion and pre-term labour have reduced considerably
and benefits except pay [5,6]. Exposure may be increased in certain areas, such
• You are entitled to a reasonable amount of paid time off as paediatrics. The most significant period is the first eight
to attend antenatal appointments. What is considered weeks of pregnancy [7]
reasonable is not defined in law and so common sense and • Radiation: Ionising radiation is both toxic and teratogenic.
consideration to the working of your department should be The most dangerous period is the first eight weeks of
applied gestation. The Ionising Radiation Regulations Act [8] states
• You can work up to ten days during maternity leave. These that once your employer knows you are pregnant your
‘keeping in touch days’ are optional and both employer and occupational exposure should be controlled so that the
employee must agree to them dose to your baby is less than 1 mSv for the remainder of
• Annual leave continues to accrue during maternity leave but your pregnancy (one chest X-ray is approximately 0.1 mSv).
you may not be able to carry leave over into the next leave In practice, if normal safety precautions are followed the
year. It is common for people to add annual leave to the exposure at work is likely to be considerably less than this
start or end of maternity leave but you need to discuss this even for staff such as radiographers. A 5 mm lead apron
in advance with your employer should be worn if within six feet of an X-ray source. If in
• If, after maternity leave, you do not wish to return to work, doubt consult your local Occupational Health department
your NHS employer is entitled to retrieve the occupational for advice but, in general, limiting exposure by avoiding
maternity pay awarded. To avoid this you must return to certain theatre lists is not always possible, practical or
work for at least three months within 15 months of the start necessary. No evidence of any harmful effects of magnetic
of your maternity leave resonance imaging to the foetus has been demonstrated.
• Be aware that salary sacrifice schemes (e.g. childcare However, there is lack of evidence regarding long term
vouchers) may affect the amount of SMP and occupational effects of this [8]
maternity pay. These are calculated by looking at your • Methylmethacrylate (bone cement): There have been
average weekly earnings based on income subject to concerns regarding the possible teratogenic effects of
national insurance contributions. Often salary sacrifice is exposure to bone cement although there is little evidence in
taken prior to national insurance contributions. The relevant humans to support this [9]
period for the calculations is usually the eight weeks prior • Manual handling: the hormonal changes of pregnancy
to the qualifying week (i.e. weeks 17–25). This is relevant make the pregnant body more susceptible to injury. It is also
for maternity support, adoption and shared parental pay [2] associated with a small risk to the foetus. Manual handling
should be avoided where possible. Prolonged standing
Employer’s responsibilities should also be limited [4]

• The laws that protect you at work only apply once your Medical Defence/GMC/AAGBI/pensions
employer knows you are pregnant
• Once your employer knows you are pregnant, a risk • The medical defence organisations (Medical Defence Union,
assessment should be conducted. If any risks are identified Medical Protection Society, Medical and Dental Defence
they must be removed or alternative working arrangements Union of Scotland) regard maternity leave as a career break
agreed to protect the safety of you and your baby at work. and therefore you are not required to pay your subscription
It is important to do this – otherwise you may expose your fee as you are not undertaking any medical practice. It may
baby to an illness that is devastating to a foetus (e.g. be possible to claim this retrospectively if you were unaware
cytomegalovirus) of this. You must remember to reinstate your cover on your
• Once you have informed your employer in writing of return to work
your intention to take maternity leave they are obliged to • The AAGBI offer a reduced subscription rate for members
confirm in writing within 28 days your paid and unpaid on maternity leave. Contact the membership department at
leave entitlements, annual leave owed and expected date [email protected]
of return to work • It is worth also contacting the GMC and RCoA to find out if

77 THE GAT HANDBOOK 2016-2017

 you are entitled to a reduced fee/subscription rate for the Returning to work
period of your maternity leave
• You and your employer continue to contribute to the NHS For information on returning to work following maternity leave
pension scheme for the period of your maternity leave if you refer to the chapter in this Handbook about ‘Returning to practice
are a member following a prolonged absence’. Breastfeeding mothers must be
risk assessed upon return to work and suitable facilities provided
Maternity support (paternity) pay and leave [14].

• If eligible, this entitles father’s or the mother’s spouse/ For more information on maternity rights the following
partner who will be responsible for the baby to one or two provide useful up-to-date information:
weeks paid paternity leave [10]
• This needs to be taken in one go, starting after the birth and • BMA. Guidance for working parents
ending within 56 days of it • https://www.gov.uk
• To be eligible for leave, you must be an employee and have • NHS Staff Council. NHS terms and conditions of service
worked for your employer continuously for at least 26 weeks handbook
by the end of the 15th week before the expected week of
birth Acknowledgement
• To be eligible for pay you must also be employed by your Thanks to Susan Williams (previous GAT LTFT representative)
employer up to the date of birth and Sarah Gibb (previous GAT Chair) for the original articles on
• To claim, you need to inform your employer at least 15 which this chapter has been based.
weeks before the week the baby is due, when you want the
leave to commence (e.g. the birth day or a set time after), Surrah Leifer
and if you want one or two weeks leave. Check with your GAT Committee Member
employer as to any forms that need submitting for pay
• Employers need 28 days’ notice if you wish to change the References
start date
• If you have 12 months continuous NHS service at the start 1. NHS Staff Council. NHS terms and conditions of service
of the week in which the baby is due you are entitled to two handbook. http://www.nhsemployers.org/your-workforce/
weeks’ occupational ordinary maternity support pay (full pay-and-reward/nhs-terms-and-conditions/nhs-terms-and-
pay less any statutory pay received) [2] conditions-of-service-handbook
• You are entitled to time off to accompany the mother to two 1. GOV.UK. Statutory Maternity Pay: manually calculate your
antenatal appointments of up to six hours each. It may be employee’s payments. https://www.gov.uk/guidance/
unpaid statutory-maternity-pay-manually-calculate-your-
employees-payments
Shared parental leave 2. Royal College of Physicians and the Faculty of
Occupational Medicine. Pregnancy: occupational aspects
• If eligible you can end maternity leave early and take the rest of management. Clinical Medicine 2013; 13: 75–9.
of the 52 weeks as SPL [11] and the rest of the 39 weeks of 3. Fulton L, Savine R. The pregnant anaesthetist on-call
maternity pay as Statutory Shared Parental Pay – A survey of trainee experience. Presented at AAGBI
• SPL can be taken in up to three blocks rather than in one go. GAT Annual Scientific Meeting, Glasgow 2012. http://
It does not have to be shared with a partner but, if it is, each www.aagbi.org/sites/default/files/The%20pregnant%20
can take leave at different times or both together anaesthetist%20on-call%20%20GAT%20ASM.pdf
• Up to 20 optional ‘Shared Parental Leave in touch’ days can 4. Symington IS. Controlling occupational exposure to
be taken anaesthetic gases. BMJ 1994; 309: 968–9.
5. Lawson CC, Rocheleau CM, Whelan EA, et al.
Adoption and surrogacy [12] Occupational exposures among nurses and risk of
spontaneous abortion. American Journal of Obstetrics &
• Statutory adoption leave is 52 weeks and pay for up to 39 Gynecology 2012; 206: 327.
weeks in line with maternity arrangements 6. AAGBI. Occupational Health and the Anaesthetist. 2014
• Only one person in an eligible couple may take it http://www.aagbi.org/publications/guidelines/occupational-
• It can start up to 14 days before the child starts living with health-and-anaesthetist-2014
you, or within 28 days of the child arriving in the UK in 7. The Ionising Radiations Regulations 1999. http://www.
overseas adoptions. If using a surrogate it is the day or the legislation.gov.uk/uksi/1999/3232/contents/made
day after the child is born 8. Keene RR, Hillard-Sembell DC, Robinson BS, Novicoff
• SPL (as above) could be applied for WM, Saleh KJ. Occupational hazards to the pregnant
• For hospital doctors employed under national terms and orthopaedic surgeon. Journal of Bone and Joint Surgery
conditions, adoption leave and pay will be in line with the 2011; 93: e1411–5.
maternity leave and pay provisions documented earlier 9. GOV.UK. Paternity Pay and Leave. https://www.gov.uk/
• Adoption of a family member, stepchild or private adoptions paternity-pay-leave/overview
do not qualify 10. GOV.UK. Shared Parental Leave and Pay. https://www.gov.
uk/shared-parental-leave-and-pay
Loss of a baby 11. GOV.UK. Adoption Pay and Leave. https://www.gov.uk/
adoption-pay-leave
You can still claim leave and/or pay if your baby is stillborn from 12. Anon. Year 2007. Anaesthesia News 2015; 332: 19.
24 weeks of pregnancy or born alive at any point in pregnancy. 13. Health and Safety Executive. Working safely with ionising
It is important to make use of this; loss of a baby is a traumatic radiation: Guidelines for expectant and breastfeeding
experience [1,13]. mothers. 2015. http://www.hse.gov.uk/pubns/indg334.pdf

78 THE GAT HANDBOOK 2016-2017

 Training with a long-term illness lead to a profound sense of loneliness, loss of confidence,
feelings of worthlessness and depression
• For a multitude of reasons, the impact of your illness may
By and large, young doctors enjoy the privilege of good health precipitate strain in your closest relationships, rendering
so most have little experience of what it is like to be the patient. your usual support systems less useful at a time when you
Many will not be accustomed to this role or the multitude of, need them most. Contact with work colleagues can be lost,
often, conflicting emotions and anxieties which illness brings leaving you without that network of support
with it. For many it will be the first time we confront these feelings • Do not underestimate the knock-on effects of all of this on
despite dealing with patients every day of our working lives. For you and your life as it was. Be open to the idea of talking
those anaesthetists unfortunate enough to be in this situation I to someone neutral about how you’re feeling. It might be
hope this chapter will address some of the concerns you have your training scheme mentor, it might be a senior medical
about your absence from work and getting back to work where colleague. You may consider approaching the BMA’s
possible. Some of it is the nuts and bolts of your responsibilities Doctors for Doctors advisory service, or you may choose a
and rights as an employee, some of it just common sense and professional counsellor
what was helpful to me. • Occupational health can assist you in accessing the services
available within your Trust and LETB, e.g. confidential in-
Contractual obligations house counselling sessions with a clinical psychologist that
are free of charge to employees
• You are able to self-certify a leave of absence due to illness
of up to seven calendar days. This should be submitted after Getting back to work
the absence extends beyond the third calendar day
• Beyond this you are required to submit medical certificates, • Your health, recovery and wellbeing should undoubtedly
completed by a doctor other than yourself, covering the be your priority. Your responsibilities to your family, your
duration of your absence friends, your colleagues and your employer will weigh
• You should inform your line manager of your expected heavily on you, but without your health you will not be able
duration of absence as soon as possible. Timely to sustain any of these
communication will greatly facilitate the rearranging of rota • Do not even consider returning to work before you feel
commitments and other responsibilities completely ready. Take your time. Doctors, particularly, are
• Although the details of your illness are entirely confidential, prey to an irrational sense of indispensability. The truth is
if you can, it is helpful to communicate with your employer that when you’re back, it is as if you were never away. Once
in a transparent and honest way. It is much easier for people you are present on the shop floor the work environment
to help you when they know and understand your situation will overtake you and, in practice, there is simply no half
• You are not obliged to involve occupational health at the measure in clinical medicine
outset, although your line manager might suggest it. From • It is essential that you undertake a phased return to work.
experience, there is much to be gained from involving the In this regard, advice from occupational health is essential.
occupational health consultant physician early in the course They do know what they’re talking about, even if you think
of events. Details of your situation are strictly confidential, that a month (or several) building up to full-time duties is
unless you give express permission for the sharing of this ludicrous. Listen to them. Everyone who returns describes
information. Only the impact of your illness on your ability to a feeling of immense tiredness in the first days and weeks
carry out your duties will be communicated, and this will be after return to work; building up stamina takes time
undertaken directly with your line manager • You do not have to resume working in an identical role.
• Your line manager is entitled to refer you to occupational Again the consultant occupational health physician can
health for an assessment, particularly with regards to your assist and advise you. Less than full-time training or specific
return to work exclusions to your duties might be appropriate
• You are not going to be operating at your usual peak
Sick leave entitlement performance immediately. Don’t place yourself under undue
pressure by committing to new projects or taking on new
• This is formally laid out in the terms and conditions of service responsibilities. For a period of time just adjust to working
of your contract again, and coping with it physically. In my experience, it
• In general, sick leave entitlement depends on your duration took longer than I thought
of service. The maximum benefit within the NHS is achieved
after five years of completed service. This entitles you to six There are various websites that provide useful resources on this
months’ full pay (including supplements e.g. banding) and topic:
six months’ half pay
• Injury on duty, accidents sustained due to sport (professional) • Terms and Conditions of Service: NHS Medical and Dental
or a case in which contributory negligence is proved, are Staff (England) 2002
dealt with individually. Specific conditions apply to absence • BMA Junior Doctors’ Handbook
where an injury has occurred resulting from violent crime • Doctors for Doctors or tel: 08459 200169 (this is now a 24/7
• Unpaid sick leave may be negotiated service)
• Due to the relatively short period during which you are • AAGBI. Wellbeing and Support
entitled to full pay on sick leave, it is important to consider
an income protection policy that will serve to top up your
salary when, and if, your organisational benefit expires. Kate O’Connor
Long-term illness is usually unexpected so, particularly if ST7 Bristol School of Anaesthesia
you have dependants, please consider this seriously

Psycho-social considerations

• Serious illness can be very isolating. The world around you

carries on apparently seamlessly without you despite the
events taking place in your life. This happens at a time when
you have new anxieties and are physically frail and can

79 THE GAT HANDBOOK 2016-2017

 Returning to practice following a Think about the things you can do during your maternity leave
to keep up to date. This may simply be making the effort to do
prolonged absence some reading. However, you may also wish to attend some
courses or meetings or take advantage of keeping in touch days.
You are contractually entitled to up to 10 keeping in touch days
As a trainee, returning to practice following a prolonged absence
during your maternity leave. These must be agreed prospectively
from anaesthetics can be daunting – especially with the prospect
with your employer and can be used to have some supervised
of solo lists and on-calls. This may apply regardless of whether
clinical time or to attend courses etc. appropriate to your stage of
you are returning to work from maternity leave, following a period
training. You can negotiate with your employer to be paid at the
of ill-health or have been pursuing other professional goals such
basic daily rate for each keeping in touch day taken.
as research or a period of intensive care medicine training. In the
past, information about the effect of taking time out of work was
Prior to your return to work it is important you make contact
limited to anecdote. Recently, however, several regional surveys
with your Training Programme Director and College Tutor/
on this subject have been completed. Examples include a survey
Educational Supervisor at the hospital you will be working at to
from the West Midlands in 2012 which found that the length of
ensure your return is as smooth as possible. The level of support
time trainees felt it took for their confidence to return ranged
you will require will depend on various factors including length of
from a couple of weeks to six months [1]. Another example from
absence and stage of training. It is useful to agree an appropriate
a survey of trainees in London in 2014 noted a trend towards
period of supervised practice prior to returning to out of hours
lower levels of self-reported skills, knowledge and, especially,
work. Identify your training needs early to ensure you receive the
confidence in trainees who had had time away from work,
correct training placement. If you are returning to work less than
compared with those who had maintained professional activity
full-time it may take you longer than you expect to regain your
[2].
clinical confidence – this is not unusual.
In 2012 the Academy of the Medical Royal Colleges (AoMRC)
The Bulletin of the RCoA has published articles with more advice
published guidance on returning to practice, including those
on preparing for maternity leave [9] and a personal view of
returning to their usual practice after working in a different clinical
returning to work following maternity leave [10].
field. The AoMRC was concerned that there was a perceived
lack of guidance on supporting a return to practice, potentially
Returning to work following an illness or with a
compromising patient safety, and so established a working party.
disability
The recommendations of the working party define a prolonged
absence as more than three months and give examples of
Returning to work following an illness or with a disability is more
checklists which should be used pre and post absence to allow
complex and trainees in this situation are likely to need more
an individualised action plan to be formulated to support the
support than those returning from maternity leave. The type of
doctors’ return to practice [3]. The RCoA subsequently updated
absence is likely to be unpredictable in its onset and length
their return to work guidance using the framework suggested by
and pre-leave planning will not be possible. Early and regular
the AoMRC [4].
communication with your Training Programme Director and
Human Resources department is advisable.
Return to work programmes
Occupational Health will manage your situation in confidence
Since the publication of this guidance, many regions have now
and may prove very useful in helping to arrange an individually
introduced return to work programmes. The idea of a programme
tailored return to work programme. The consultant occupational
is that it provides structure to the return to work process, and
physician’s expertise is on the impact of health on work and of
enables development of a mutually agreeable plan for both the
work on health, so they are a very useful source of advice and
individual and the department. Programmes are usually divided
support. The chapter ‘Training with a long term illness’ offers
into several stages, each involving a meeting between the person
further advice. In addition there have been several articles
returning and their supervisor. For anticipated leave, a pre-leave
detailing a return to work following illness or disability through
planning meeting should occur to discuss ways of keeping in
the eyes of those who have experienced it: Returning to work in
touch. For all periods of leave a meeting should occur at least
a wheelchair [11]; Returning to work – as a disabled anaesthetist
a month before the return date to discuss what preparation will
[12]; Returning to work – a personal view [13].
be needed and confirm the arrangements for the return to work
period and then there should be a record of the re-introduction
Returning to work courses
period. A good example of a return to work programme is the
one used by the Wessex School of Anaesthesia which is used
There are increasing numbers of courses specifically for
for anaesthetists with no ongoing health, conduct or capability
anaesthetists returning to work after a break. The Giving
issues who expect to return to practice in a short period of time.
Anaesthesia Safely Again (GASagain) course was established
You can read about it in Anaesthesia News [5] and access
in 2011 and is a national multicentre (London, Bradford
examples of the paperwork (flowchart, pre-absence and return
and Bournemouth) return to work course which focuses on
to work forms) used to support a successful return to work on the
confidence building through scenario-based simulation and
AAGBI website [6]. The West Midlands have a return to training
interactive tutorials. Many other regions have developed their
policy with a similar structure [7], and the London LTFT Forum
own return to work course and if you would like help finding out
also has information about how they manage a return to work on
where these are run please contact [email protected]
their website [8].
Your CCT date
Returning to work following maternity leave
The RCoA will need to be informed of your intention to take
This is the most common reason for trainees to have a prolonged
maternity leave (or any other leave). Your CCT date will be
period of absence from training. Most will expect, or be expected,
suspended until your actual return to work, allowing any
to return to practice within a short space of time. As this is a
unplanned extension to your maternity leave to be factored in.
planned absence it is worth giving your return to work some
Upon returning to work you must notify the training department
thought even before you go off. In particular think about whether
of your return date and whether you are returning on a less than
you plan to return to work less than full-time as the application
full-time basis, and a new CCT date will be calculated. If you are
for this will take some time. (See chapter on ‘Less than full-time
returning after illness, the occupational physician may suggest a
training’).
period of ‘therapeutic return to work’ where you are not yet ready

80 THE GAT HANDBOOK 2016-2017

 to return to training, but building up your stamina and identifying ltftlondongas.org.uk/practicalites/returning-to-work
what you find easier or more difficult. 9. Cullis K. Pregnancy and preparing for maternity leave.
RCoA Bulletin 2011; 66: 12–4. http://www.rcoa.ac.uk/
In 2012 the GMC released a position statement giving guidance document-store/bulletin-66-march-2011
on the management of absences from training and their effect 10. Cullis K. Returning to work after maternity leave. RCoA
on a trainee’s CCT date. From 1 April 2013 any trainee who Bulletin 2011; 65: 20–1. http://www.rcoa.ac.uk/document-
has been absent for more than 14 days in any 12 month period store/bulletin-65-january-2011
(excluding annual leave or study leave) will have a review to 11. Rugen J. Returning to work in a wheelchair. Anaesthesia
decide whether they need to have their CCT date extended. News 2011; 291: 8–9. http://www.aagbi.org/sites/default/
This review of absence will occur at ARCP and LETBs will files/October%20ANews%20Final_0.pdf
administrate the process in consultation with the RCoA. LETBs 12. Fossati N. Returning to work – as a disabled anaesthetist.
are expected to implement this guidance flexibly to reflect the RCoA Bulletin 2011; 66: 26–8. http://www.rcoa.ac.uk/
nature of the absence, the timing and the effect of the absence document-store/bulletin-66-march-2011
on the individual’s competence [14]. 13. Jobling L. Returning to work – a personal view. RCoA
Bulletin 2011; 66: 29–31. http://www.rcoa.ac.uk/document-
Historically three months of one maternity leave could be counted store/bulletin-66-march-2011
as exceptional leave without affecting a trainee’s CCT date. 14. GMC. Time Out of Training. GMC Position Statement.
Although exceptional leave will cease to exist providing a trainee November 2012. http://www.gmc-uk.org/20121130_Time_
can demonstrate that all the necessary competencies have been out_of_Training_GMC_position_statement_Nov_2012.pdf.
achieved and provide evidence of CPD, the RCoA may still allow pdf_56438711.pdf
some maternity leave (or other leave) to be ‘counted’. 15. GMC. Develop and maintain your professional
performance. In Good medical practice 2013. http://www.
Tips to improve your return to work gmc-uk.org/guidance/good_medical_practice/maintain_
performance.asp
As mentioned above, returning to work is likely to be associated
with some degree of apprehension. We would recommend that
you use a structured return to work programme to help to ensure
you are supported at this time. You might also want to consider
approaching a trained mentor. The GMC recommends that
structured support opportunities, such as mentoring, are used
at periods when your role changes during your career and we Members’ wellbeing
would suggest that this is one such period [15]. Support from
family, friends and colleagues is invaluable and if GAT can help
you with anything then please get in touch by emailing gat@ Anaesthesia attracts many different personalities, and we
aagbi.org all respond in different ways to the challenges of daily work,
professional development requirements, and responsibilities
Good luck. outside work. Gaba [1] describes anaesthetists as being attracted
to a job that offers excitement and fast paced work with danger
Sarah Gibb lurking just below the surface. However, excitement is inevitably
GAT Chair 2014–15 accompanied by stress. A degree of stress is good for all of us,
but, like many doctors, anaesthetists can exhibit symptoms of
Emma Plunkett chronic stress and burnout [2]. Female anaesthetists reported
GAT Committee Honorary Secretary higher stress levels [3], and female trainees with young children
working full-time report stress levels above the threshold at
References which people start to make errors [4]. This may be due to the
1. Plunkett EV, Baxendale CL, Osborn N, Budd J, Cullis conflicting responsibilities of work and domestic commitments.
K, Malins A. Returning to work: a survey of recent
trainee experience and introduction of a return to work
programme. Anaesthesia 2013; 68: 991 (abstract).
2. Hoogenboom E, Hunningher A, Illingworth J, et al.
Returning to anaesthesia training. RCoA Bulletin 2015; 94:
68–71. http://www.rcoa.ac.uk/document-store/bulletin-94-
november-2015
3. AoMRC. Return to practice guidance. April 2012. http://
www.aomrc.org.uk/doc_view/9486-return-to-practice-
guidance
4. RCoA. Returning to work after a period of absence.
May 2012. http://www.rcoa.ac.uk/document-store/career-
breaks-and-returning-work
5. King W, Haigh F, Aarvold A, Hopkins D, Smith I. Returning
to work the Wessex way. Anaesthesia News 2012;
299: 18–9. http://www.aagbi.org/sites/default/files/
JuneAnaesthesiaNews_Web_0.pdf
6. AAGBI Trainee Updates: Returning to work after a
prolonged period of absence. December 2012. http://www. The compounding pressures of inexperience, training,
aagbi.org/professionals/trainees/gat-news examinations and competition for jobs may make trainees more
7. Health Education West Midlands LETB. Returning vulnerable to stress [5] and emotional exhaustion (burnout) [6].
to work. Return to training. April 2013. http://www. The 2010 GAT welfare survey identified two important stressors:
westmidlandsdeanery.nhs.uk/Portals/0/Key%20Doc%20 examinations and undertaking work about which the trainee
for%20Homepage/Return_to_Training_approved%20 may feel less than confident. Post-fellowship trainees have the
May%202013.pdf added pressure of trying to get good jobs in an increasingly
8. LTFT London Anaesthesia. Returning to Work. http://www. competitive market, in the face of restrictions on NHS funding

81 THE GAT HANDBOOK 2016-2017

 and consequent staffing restrictions. The feelings of uncertainty and ask to be put in contact with a mentor. Mentoring can help
and perceived lack of control that this engenders contribute you develop assertiveness, good communication skills, effective
enormously to stress. conflict management, time management and reflection on your
work life balance, which are all helpful in managing the dilemmas
Current working environments, with large departments, short and problems of everyday life and training.
term rotational placements and poorer team structures, have
weakened traditional networks of support. We all know that, If you are enjoying your work, you keep up to date, give safe
when we work with a good team in an organisation that values anaesthetics and enjoy domestic and social-life, you are having
and respects us, we provide better quality care. There is much a successful career and life. But there will be times when we ALL
management literature to confirm this [7]. NHS organisations need a sympathetic ear and good counsel. So do not be afraid to
that pay attention to the wellbeing of staff deliver higher quality seek help. You are not alone. If you can, seek local help initially,
care, make better use of resources, have lower patient mortality or alternatively, contact the AAGBI Secretariat at wellbeing@
and have more satisfied patients [8]. aagbi.org who will contact a member of the Wellbeing and
Support Committee. Further details can be obtained from the
Some trainees fear that informing colleagues that they are AAGBI website.
struggling might have a negative impact on their future career.
Asking for help can be a brave thing to do, and it is important that Other resources that you may find useful are as follows:
trainee and senior colleagues provide good informal support,
and help an individual who is under significant stress to get to • AAGBI. Wellbeing and Support
the right source of advice. Wellbeing requires four components; • Doctors for Doctors or tel: 08459 200169
a good working environment and work arrangements, support • The Sick Doctors Trust or tel: 0870 444 5163
for staff to maintain good physical and mental health, good • The British Doctors and Dentists Group or tel: (North of
working relationships and good personal support [9]. We can all England) 07976 717 211; (South of England) 07711 197
contribute to this. 850, or via the Sick Doctors Trust helpline: 0870 444 5163
• BMJ Medical Careers Information
Individuals respond to pressure in various ways; some use • Alcoholics Anonymous or tel: 0845 769 7555
constructive coping strategies, while others may suffer from • Narcotics Anonymous
altered mood [10], or display changes in behaviour such as
aggression. Sadly, some resort to alcohol or drug misuse, often
as a result of depression [11]. Achieving a reasonable work- Nancy Redfern
life balance can, at times, be devilishly difficult. Doctors do not Consultant Anaesthetist, Newcastle-upon-Tyne
behave like other patients when accessing healthcare and it Honorary Membership Secretary AAGBI
is well known that we are reluctant to seek help or admit that
something is amiss. There is evidence that medical personnel References
(including anaesthetists) are less likely to recognise or admit to 1. Gaba D. Human error in dynamic medical domains. In:
the effects of uncontrolled stress and fatigue on performance, Bogner MS, ed. Human Error in Medicine. New Jersey:
compared to other professional groups [8]. This has implications Lawrence Erlbaum Associates, 1994.
for patient safety. 2. Kain ZN, Chan KM, Katz JD, et al. Anesthesiologists and
acute perioperative stress: a cohort study. Anesthesia &
The AAGBI Wellbeing and Support Committee recognises that Analgesia 2002; 95: 177–83.
our lives are stressful. It encourages all members to regard their 3. Kluger MT, Townend K, Laidlaw T. Job satisfaction,
own wellbeing, and that of colleagues, as an important priority stress and burnout in Australian specialist anaesthetists.
and provides practical support and resources for individuals and Anaesthesia 2003; 58: 339–45.
departments. They are pleased to answer queries and concerns 4. Firth Cozens J Bonnano D, Redfern N. What training is like?
and to put you in contact with relevant experts. – A study of the Experiences of Specialist Registrars in the
Northern Deanery. Newcastle: University of Northumbria at
The AAGBI website is being developed to provide links to a wide Newcastle, 2000. ISBN 978 1861350763
range of information, including AAGBI information and guidelines, 5. Larsson J, Rosenqvist U, Holmstrom I. Being a young and
material from other organisations and relevant articles. The inexperienced trainee anaesthetist: a phenomenological
AAGBI is pleased to respond to e-mail and phone queries. If you study on tough working conditions. Acta Anaesthesiologica
want immediate help, the AAGBI is also very well supported by Scandinavica 2006; 50: 653–8.
the BMA’s ‘Doctors for Doctors’ helpline, which gives immediate 6. Nyssen AS, Hansez I, Baele P, et al. Occupational stress
access to trained counsellors, who can support an individual in and burnout in anaesthesia. British Journal of Anaesthesia
identifying the causes of their difficulties, recognising the impact 2003; 90: 333–7.
that stress is having on them and accessing expert help more 7. West M, Dawson J, Admasachew L, Topakas A. NHS
locally, should this be appropriate. Three anaesthetists work as Staff Management and Health Service Quality. August
voluntary advisors for BMA Doctors for Doctors. If you need to 2012. London: Department of Health. https://www.gov.
speak to someone outside your hospital, call the Doctors for uk/government/publications/nhs-staff-management-and-
Doctors advisory service where you will be given advice and health-service-quality
a sympathetic ear. The service is available to all doctors, and 8. NHS health and well-being review. Final report, November
contact details are below. 2009. London: Department of Health
9. Harrison J. Orchestrating the health and wellbeing
The Wellbeing and Support Committee also has formal links with of doctors. Occupational Health [at Work] June /July
the Royal Medical Benevolent Fund to help anaesthetists who 2011; 8/1: 14–7. https://www.atworkpartnership.co.uk/
have experienced financial difficulties during their career or who occupationalhealthatwork.php/issue/8_1/article/154
are seeking practical help and advice in other areas. 10. Mental health and ill health in doctors. 2008. London:
Department of Health.
A national survey of members reported that local support for 11. AAGBI. Drug and Alcohol Abuse amongst Anaesthetists.
anaesthetists in difficulty was sometimes extremely helpful. A 2011. https://www.aagbi.org/sites/default/files/drug_and_
few LETBs also have successful mentoring systems in place alcohol_abuse_2011.pdf
and the AAGBI has a mentoring system. You can have a one off
‘taster’ mentoring session at the GAT ASM, the Winter Scientific
Meeting and the Annual Congress or you can contact the AAGBI

82 THE GAT HANDBOOK 2016-2017

 Social media with an anaesthesiologist in Tennessee on the topic of enhanced
recovery while I was working in Bedfordshire.

In the future, everyone will be world-famous for 15 minutes So how do you plug in? Below is an infographic by Dr Sandra
Viggers (@StatSkaterDK) on how to set up your account and
Andy Warhol how the various functions work.

Over the past few years, social media has taken off in medical Twitter: Getting Started. Viggers S. Reproduced with permission.
circles as a method of sharing up to date information and for
professional networking. It has now become so engrained into
our way of working that almost all of our professional bodies have
a social media profile and the GMC has produced guidelines on
how we should run our avatars.

Key features of the GMC guidance include:

• If identifying yourself as a doctor, you should identify yourself

by name
• Maintain patient confidentiality
• Treating colleagues fairly and with respect – you should
assume that the professionals that you network with are
well-trained and well-intended

When using social media you should weigh up your priorities.

Is your aim social or professional? If posting lots of work-related
content you may find your school friends cull you quite promptly.
On the other side of the spectrum, if your profile is mainly made
up of YouTube cat videos and food selfies then professional
posts may not be taken seriously.

TED speaker Juan Enriquez likened social media to a digital

tattoo. More permanent than an actual tattoo and so widespread
that Andy Warhol’s 15 minutes of fame has now flipped on its
head and it is 15 minutes of anonymity that we can claim. This
highlights an important warning about social media – posts tend
to be permanent, even if deleted.

Technology is constantly evolving and so it is likely that the

next big thing may replace some of the tools discussed below.
Nevertheless, the following covers some of the current popular
platforms.

Facebook

The strength of Facebook is that it is one of the most popular

social media platforms. Many schools of anaesthesia have Hashtags (#) go hand-in-hand with Twitter. When added to the
capitalised on this popularity to set up regional groups where body of your text, a hashtag groups tweets together. People
topics such as the arrangements for teaching sessions or plans that are interested can search for and then keep an eye on that
for social events can be shared. Beyond this organisational particular hashtag. For example, last year #GATASM15 was
role, Facebook can be a medium to distribute broader medico- used to group all of the tweets that pertained to the conference.
political and wellbeing content. Those that wanted to keep abreast of the conference (even if
stuck at home working), could follow events by searching for
A few words of warning. Be careful what you post on Facebook #GATASM15.
and assume all your data are in the public domain regardless
of your privacy setting. Think twice when making derogatory If you’ve not dipped your toe in the social media pool yet, I hope
comments about other members of staff or the institution you this has inspired you to investigate. Have fun!
work for. Potential employers will not take kindly to you moaning
about a previous Trust and you don’t want colleagues accusing Ben Fox
you of bullying or defamation of character. Chair of the GAT Committee

Twitter Reference

Twitter is a fantastic way to share information hot-off-the-press 1. McKendrick D. Twitter – surely it’s not for me? Anaesthesia
within the limits of 140 characters. The content can range from News 2013; 312: 12–4.
how to do a particular procedure through to sharing the most
up to date study. A good example of the power of Twitter is the
distribution of knowledge at medical conferences [1]. Information
that was previously restricted to the delegates in attendance, and
whatever trickled back via word of mouth, can now be shared
instantaneously, around the world. Discussions and debates
can be started with individuals with whom you may not have
normally crossed paths. Indeed one of my first discussions was

83 THE GAT HANDBOOK 2016-2017

 Medico-legal advice and support be left to the doctor’s clinical judgement, irrespective of the
practices of other clinicians in the field. In a move away from
Sidaway [2] and the Bolam [3] test we must now consider
It is wrong to assume that NHS indemnity schemes will provide what the ‘reasonable patient’ would want rather than what the
enough cover for your practice. It will cover vicarious liability ‘responsible doctor’ might do.
during clinical negligence claims, but remember Trusts may
have their own agenda when settling with claimants: potentially Patients must be warned of any ‘material risk’ of a procedure
accepting a breach of duty to settle a claim early to reduce costs. and advised of any reasonable alternatives. As with other recent
It will not necessarily fight an action in order to defend your good decisions, the rule comes with a very limited caveat called the
standing or reputation. ‘therapeutic exception’ whereby a doctor may withhold from the
patient information of a risk if they reasonably consider that its
Advice or assistance relating to criminal or disciplinary disclosure would be seriously detrimental to the patient’s health.
proceedings will not be provided, nor will any referral to the GMC I am sceptical about the inclusion of these ‘exceptions’ to rules,
if questions arise concerning your fitness to practise. Referrals to as I believe it makes the job of the physician potentially more
the GMC can be made not only by disgruntled patients but by the difficult and opens them to litigious scrutiny with customary
Responsible Officer in your hospital who has a positive obligation 20:20 legal hindsight.
to tell the GMC if they are made aware of any potential breach of
the GMC’s Good medical Practice. There is nothing in this judgment that should come as a surprise
to any practicing physician as it merely enforces principles that
A contract of employment does not just mean you have to turn have been in the GMC’s guidance on consent. What I believe
up for your allocated duties but includes a whole raft of detailed it does do, however, is alter the way that anaesthesia as a
obligations relating to issues of note keeping, communication or specialty should deal with the issue of consent. It makes clear
behaviour that can, without too much difficulty, lead to conflict. that the important consideration is not the rarity of the risk but
the significance of the complication to an individual patient.
The impact of the stress involved in finding yourself suddenly Although not a unanimous view, my own belief is that anaesthesia
investigated for a potential breach of your employment contract, needs a specific and separate consent process, which must
or your fitness to practise, cannot be overemphasised, and culminate with the patient’s signature rather than just a note by
medical organisations are available to provide immediate advice the anaesthetist of the discussions that have taken place. The
and support from people who are used to dealing with doctors ‘duty’ of consent, however, is not fulfilled simply by providing
in these circumstances. Paragraph 63 of the GMC’s Good technical information that the patient may not understand or by
medical practice states: ‘You must make sure you have adequate the presence of a signature on a consent form.
insurance or indemnity cover so that your patients will not be
disadvantaged if they make a claim about the clinical care you The AAGBI guideline Consent for anaesthesia 2016 is due to
have provided in the UK.’ be published shortly and will be available from the publications
section of the AAGBI website.
New healthcare legislation in 2013, which came into effect on 1
August 2015, gives the GMC powers to check whether doctors Peter Townsend
have appropriate insurance in place depending on the type of Consultant Anaesthetist and Intensivist, Queen Elizabeth Hospital,
work they do. Independent insurance cover is not just necessary Birmingham
for consultants indulging in private practice. The GMC can now
remove a doctor’s licence to practise if it is felt that their cover is References
inadequate or they fail to provide the information requested of 1. Montgomery v. Lanarkshire Health Board [2015] UKSC 11
them. 2. Sidaway v Board of Governors of the Bethlem Royal Hospital
and the Maudsley Hospital [1985] AC 871
The law on consent 3. Bolam v Friern Hospital Management Committee [1957] 1
WLR 582
In 2015, the Supreme Court case of Montgomery v. Lanarkshire
Health Board [2015] UKSC 11 [1], saw an important reminder
about the way doctors must address the issue of consent. Briefly,
the facts of the case involve failing to give adequate warnings or
Consent and UK legislation
alternative treatments to Mrs Montgomery, who was pregnant, of
small stature and diabetic. She suffered shoulder dystocia and
Principle of consent
a 12-minute delay in delivery, after which her son was born with
brain damage and paralysis of an arm.
‘It is a general legal and ethical principle that valid consent must
be obtained before starting treatment, physical investigation, or
Mrs Montgomery had expressed concern to her obstetrician
providing personal care’ for a patient [1]. Health professionals
about whether or not she would be able to deliver vaginally
who carry out procedures without valid consent are liable to legal
but, despite this, the risks of shoulder dystocia (9–10%) and
action by the patient and investigation by the GMC or equivalent
subsequent potential for a poor outcome were not discussed.
professional bodies.
Mrs Montgomery claims she would have opted for a caesarean
section if the risks and treatment options had been fully explained
Consent is an important part of the process of discussion and
to her.
decision-making by patients and their doctors. You should
‘share information in a way the patient can understand and,
Her obstetrician explained that she did not warn about shoulder
whenever possible, in a place and at a time when they are best
dystocia because the risk of a serious problem ensuing was very
able to understand and retain it’ [2]. When deciding how much
small (approximately less than 1 in 1000 risk of cerebral palsy).
to disclose to individual patients you should take account of their
Independent experts supported this approach. It was argued that
wishes but ensure all relevant information and the nature and
an expression of concern was not the same as a direct question
level of risk are included to enable them to make an informed
requiring a direct answer.
decision. In addition, it is good practice to provide written
information leaflets for patients prior to admission for elective
The Supreme Court found in favour of Mrs Montgomery. The
surgery and anaesthesia. Doctors should check patients have
information to be provided to the patient should not ultimately
understood all the information and encourage them to ask

84 THE GAT HANDBOOK 2016-2017

 questions, which should be answered fully and honestly. This Advance decisions, previously termed living wills or advance
has been further reinforced by a recent Supreme Court ruling directives, are legally binding advance refusals of specific
(Montgomery v Lanarkshire Health Board [3]): ‘A risk should treatments by a competent individual of 18 years or older in case
be considered material if a reasonable person in the patient’s of future incapacity. They may be verbal or written. Refusal of
position would be likely to attach significance to it.’ life sustaining treatments must be in writing and signed in the
presence of a witness. In an emergency, treatment should not be
Valid consent implies that a competent and informed person delayed by looking for an advance decision but if one has been
gives it voluntarily and not under duress. All adults should be made, and is likely to be relevant, the healthcare professional
presumed to have capacity to consent unless there is contrary should ‘endeavour to assess its validity and applicability as soon
evidence. To have capacity for consent, the patient must be as possible’ [5,8].
able to comprehend and remember the information provided,
weigh up the risks and benefits of the proposed procedure, Children and young adults
and consider the consequences of not having the procedure in
order to make a balanced decision. They must also be able to Doctors must safeguard and protect the health and wellbeing
communicate this decision [4,5]. Doctors must respect patient of children and young people. The law relating to children
autonomy and their right to be involved in decisions that affect and young people is complex and differs across the UK. The
them. You must respect a patient’s decision regarding treatment capacity to consent depends more on young people’s ability
even if you think it is irrational or unwise and ‘may result in death to understand and consider options than on their age. You
of the patient (and/or the death of an unborn child, whatever the should involve children and young people as much as possible
stage of the pregnancy)’ [1,6]. in discussions about their care and treatment [10]. In England
and Wales, the Children’s Act 1989 summarises who may have
Consent may be expressed as either written, verbal or implied, parental responsibility and can give consent on behalf of a child
e.g. holding out one’s arm for a blood test. At present a separate [1,11]. Those with parental responsibility (PR) include the child’s
formal written consent form for anaesthesia is not required if part mother or father, a legal guardian, the local authority or a person
of another treatment, but anaesthetists should record details of with an emergency protection order for the child.
their pre-operative discussion with patients in the medical record,
‘noting what risks, benefits and alternatives were explained’ [7]. In England and Wales, young adults over the age of 16 are
automatically presumed competent in law to give consent for
Patients who lack capacity any treatment without obtaining separate consent from a person
with PR, unless it involves research (in which case consent by
The treatment of patients who lack capacity is governed in a person with PR may be required until age 18). However you
England and Wales by the Mental Capacity Act 2005 (MCA) [5], should encourage young people to involve someone with PR
and in Scotland by the Adults with Incapacity (Scotland) Act when appropriate. In Scotland there is no requirement to gain
2000 [8]. In Northern Ireland, decision making for these patients additional consent from a parent as long as the young person
is currently governed by common law, requiring decisions to be is deemed competent and understands what is being proposed
made in the patient’s best interests. [11]. If the young person is not considered competent, (e.g. has
learning difficulties) then in England, Wales and Northern Ireland
In the MCA there is a two stage test of capacity, namely: a parent may give consent until 18 years old, but in Scottish law
the concept of parental responsibility ceases at 16 years old [12].
1. Does the person have an impairment of the mind or brain
or is there some sort of disturbance affecting the way their Children under 16 who demonstrate the ability to fully appreciate
mind or brain works, whether temporary or permanent? the risks and benefits of the planned intervention, can also
2. If so, does that impairment or disturbance mean the person be considered competent to give consent – so called ‘Gillick
is unable to make the decision in question at the time it competency’ [13]. The decision of a competent child to accept
needs to be made? treatment cannot be overridden by a person with PR [14].
Children with capacity, and young adults who refuse treatment,
If the patient lacks capacity, then it is lawful for treatment to may have their decision overridden in the courts ‘if it would in
be given if it is in the patient’s best interests. The definition of all probability lead to the death of the child/young person or
‘best interests’ is assumed not to be limited to best medical to severe permanent injury’ [1]. If a competent child refuses
interests, but considered to include welfare, social, emotional, treatment, the courts have said that, in exceptional cases,
psychological and other interests. persons with PR may consent on their behalf and the treatment
can lawfully be given. For young adults the law on parents and/
The Independent Mental Capacity Advocate (IMCA) Service or medical professionals overriding young people’s competent
in England and Wales supports vulnerable people who lack refusal is complex and you should seek legal advice [9].
capacity to make decisions about providing, withholding or
stopping ‘serious treatment’ (e.g. major surgery) where there are If a child lacks the capacity to consent, you should ask for consent
no friends or family members available, or willing, to be consulted from a person with PR or from the court [9]. For children who lack
about those decisions. Responsibility for instructing an IMCA in a capacity, the law only requires consent from one person with PR
case of serious medical treatment lies with the NHS organisation even if another person withholds consent. However, clinicians
providing the patient’s healthcare. However, in an emergency, should try to obtain a consensus if persons with PR disagree.
treatment can proceed if it is in the patient’s best interests without If it is still unclear as to whether a procedure is in the child’s
instructing an IMCA [9]. best interests then it is advisable to refer the decision to the
courts. When the child is a ward of court, any significant medical
Lasting powers of attorney (LPA) may be appointed by a person intervention requires prior consent from the court [1].
with capacity to act on their behalf in health decisions should
they lose capacity in the future, including ‘giving or refusing In an emergency, if treatment is vital to the survival or health of
consent to the carrying out or continuation of a treatment by a the child and it is impossible to obtain consent in time, a child
person providing healthcare’ (England and Wales) [5]. When who lacks capacity may be treated without the consent of a
the attorney is uncontactable, if an urgent healthcare decision person with PR. It is good practice to fully document this process
is required in relation to a patient with a LPA, treatment should in the medical notes [14].
proceed if it is in the patient’s best interests.
Doctors have a responsibility to respect the confidentiality

85 THE GAT HANDBOOK 2016-2017

 of competent young people and to not generally disclose What consultants really earn and
information, e.g. to a parent, without permission to do so.
how they do it
Conclusions
Few medical students chose their career on the basis of what
Doctors have a professional, legal and ethical obligation to
they’re going to earn, but most are probably quietly confident
respect patient autonomy and obtain valid consent for medical
that they won’t be poor. As you approach your CCT you need to
treatment. The consent process in individual cases may be
start thinking about what sort of job you want; teaching or general
complicated and a sound understanding of the law is essential
hospital, subspecialty, location? What’s generally not well known
to know how to proceed. Documentation of discussions and
among trainees is the silent ‘M’ – money! NHS consultants are
decisions on consent are important and should include how the
well paid; even on appointment at around £75,000 basic a year
decision was made, who was present and what was said, as
this is in the top 5% of earnings. The top of the scale extends to
clearly as possible.
about £100k – well above the 97th centile. However, consultants
received no annual pay rise for three years from 2010, only to
Acknowledgment
receive a 1% uplift in 2013, and only those consultants at the
With thanks to Dr Kathy Wilkinson, Consultant Anaesthetist,
top of the scale received a (non-consolidated, non-pensionable)
Norfolk and Norwich University Foundation NHS Trust who
increase in 2014 and again in 2015. Consultants in Scotland
advised on the section on children and capacity.
received the full 1% increase recommended by the Review Body
on Doctors and Dentists Remuneration (DDRB) in 2015 and 2016.
Paul Barker
Consultant Anaesthetist, Norfolk and Norwich University Foundation
But how can you earn more than the basic scale? There are
NHS Trust
four main ways of doing this; private practice, clinical excellence
AAGBI Council member
awards, additional NHS work and medico-legal practice.
Whichever, if any, you choose, take sound financial advice, don’t
References
live beyond your means, and remember that all good things can
1. Department of Health. Reference guide to consent for
come to end (a bad fall on the ski trip could stop you earning for
examination or treatment. 2009. https://www.gov.uk/
months!)
government/publications/reference-guide-to-consent-for-
examination-or-treatment-second-edition
Private practice
2. GMC. Consent: patients and doctors making decisions
together. 2008. http://www.gmc-uk.org/guidance/ethical_
Approximately 60% of consultants, who are members of the
guidance/consent_guidance_index.asp
AAGBI, undertake some independent practice [1]. How much
3. Montgomery v Lanarkshire Health Board (Scotland). 11
will depend on where you are, which surgeons you work with,
March 2015. https://www.supremecourt.uk/decided-cases/
and whether you want to do it. It’s not the land of milk and honey
docs/UKSC_2013_0136_Judgment.pdf
though and can be unpredictable. There may be a syndicate or
4. Re C (Refusal of medical treatment) [1994] 1 All ER 81
partnership in your hospital or it may be each anaesthetist does
5. Mental Capacity Act 2005. Code of Practice 2007. https://
their own thing. The role of Anaesthetic Groups was recently
www.gov.uk/government/publications/mental-capacity-act-
reviewed by the Competition and Markets Commission, and
code-of-practice
then subjected to an appeal by private medical insurers, and are
6. Re B [2002] 1 FLR 1090
deemed not to be anti-competitive – the AAGBI played a major
7. AAGBI. Consent for Anaesthesia. 2nd edn. 2006. http://
role in achieving this outcome. You’ll need to pay additional
www.aagbi.org/sites/default/files/consent06.pdf
professional indemnity insurance, (depending on your income),
8. Adults with Incapacity (Scotland) Act 2000
keep good figures and get an accountant (definitely advised).
9. MDU guidance and advice. The Mental Capacity Act 2005.
You must be certain to ensure no conflict with your NHS
February 2008. http://www.themdu.com/guidance-and-
commitments (SPA time is not time for private patients!), ensure
advice/latest-updates-and-advice/the-mental-capacity-act-
your availability to your patients postoperatively or arrange cross-
2005#Proposed%20changes
cover. If private practice is something you’re considering, make
10. GMC. 0-18 years: guidance for all doctors. 2007. http://
sure to ask (discreetly) while investigating any possible jobs.
www.gmc-uk.org/guidance/ethical_guidance/children_
Probably not during the interview!
guidance_index.asp
11. Children’s Act 1989
Clinical excellence awards
12. The Age of Legal Capacity (Scotland) Act 1991
13. Gillick v West Norfolk and Wisbech AHA [1986] AC 112
Clinical excellent awards [2] recognise significant contributions
14. NHS Choices. Consent to Treatment – Children and
over and above contracted work. Different systems operate
young people. http://www.nhs.uk/Conditions/Consent-to-
within the four NHS organisations, but in general terms they are
treatment/Pages/Children-under-16.aspx
divided into employer based and national awards. Application
is by self-nomination on a standard form (the CVQ) and awards
are competitive between all specialties. Contributions to the
NHS are assessed in the areas of care delivery, development,
management, research and education. Local awards (Levels
1–9) are worth between just under £3,000 to about £35,000
per year. There are no local awards in Wales, where a system
of seniority payments exists. National awards (Levels 9–12)
are worth between £35k and £75k a year; all are currently
pensionable. Approximately 40% of consultants have no award,
40% have 1–4 points and just fewer than 9% have 5–8 points. At
the higher awards the numbers fall away quickly; approximately
8% have level 9, approximately 4% have levels 10/11, and less
than 1% have level 12.

Competition for these awards is fierce, and they are not given out
lightly. They are not bonuses, but additional payment for significant

86 THE GAT HANDBOOK 2016-2017

 and sustained contributions to the NHS. There is as much skill like, and they may not be as well off as they were. There are
needed in completing the form as there is in delivering the work. a number of ways of augmenting the consultant salary, all with
The best way to improve your chances of obtaining an award is their advantages and disadvantages. The benefits of one against
to become an academic and/or a physician – they are four times the other may be subject to significant change in the near future.
more likely to have one than anaesthetists! Anaesthetists pro rata Never assume any additional income will last forever, keep good
have always done badly in local and national awards, something records and get an accountant. And whatever you choose to do,
which the AAGBI has made representations about to the Advisory or not to do, be nice about it; there are two things that cause
Committee on Clinical Excellence Awards (responsible for the disharmony in departments and they’re both money!
national scheme) at length and for many years, but with little
evidence of improvement. Andrew Hartle
AAGBI President
The future for these awards is extremely uncertain. The DDRB
reported on the Clinical Excellence Award Scheme in December References
2012 and made wide-ranging recommendations. The number of 1. Independent Practice. http://www.aagbi.org/sites/default/
national clinical excellence awards (CEAs) approximately halved files/independent_practice_08_1.pdf
for England and Wales in 2010 and there have been no new 2. Clinical Excellence Awards. https://www.gov.uk/
national awards in Scotland or Northern Ireland for many years. government/organisations/advisory-committee-on-clinical-
Many Trusts in England have not run employer award rounds for excellence-awards
one or more years. The consultant contract for England is about
to be renegotiated by NHS Employers and the BMA, based
on observations made by the DDRB 2015 Report into doctors
contracts. The DDRB also made several observations about CEAs Financial planning and pensions
(which are not a contractual entitlement) in this report, including
completely separating the employer and national schemes, and
it is highly likely that a new scheme or schemes will emerge from In today’s fast paced world, managing your finances and
the negotiations. negotiating the financial barriers that inevitably arise at every
stage of your life and career can be a challenge. Having a financial
There is now greater risk in applying for national awards. Failure expert who understands you, your career, your NHS pension and,
to successfully renew a national award has resulted in the loss of most importantly, is someone whom you can trust, is essential.
the entire award since the removal of pay protection in 2014. In Excellent quality, holistic advice should be a given, but this is not
future rounds it may be possible to renew a national award at a always the case and choosing your financial adviser has never
lower level. This results in an obvious loss of earnings, but also will been as important. A good financial adviser will guide you and
impact on the final salary element of pension if this occurs more assist you in taking advantage of their advice and expertise, but
than three years before retirement. Such a change will impact also offer a range of ongoing services to assist you in achieving
less on a career averaged pension. Recent changes to pension and maintaining your long term goals and objectives.
rules (the lifetime and annual allowances) mean that receipt of a
CEA may result in a significant additional tax liability, especially if There are basically two types of financial adviser. Those who
it occurs within three years of pay increment; however, there are are independent and have thus met the requirements to provide
a number of Trusts in England that no longer support the local unbiased advice based on a comprehensive and fair analysis of
CEA award system. the whole of the market; and restricted advisers who can generally
only recommend certain products, product providers, or both. In
Additional NHS work my experience, the vast majority of doctors tend to select the
independent route so that they can benefit from unrestricted
Often known as ‘waiting list initiatives’ this is work for the NHS, on advice, which in my opinion has to be the preferred option.
NHS patients, although not necessarily done on NHS premises.
It should all be covered by the NHS Litigation Authority, so January 2013 saw the biggest ever change to the way financial
should not affect your indemnity payments (but check that advice is provided as the Retail Distribution Review was
managers arranging the contracts know this). It is Department of implemented. This now embedded change was the brainchild
Health policy, supported strongly by the AAGBI, that payments of the industry regulator and in simple terms its objective is to
for additional NHS work should be on the basis of parity (equal ensure that consumers are offered a transparent and fair charging
pay, for equal work), but there are often attempts to introduce structure for the advice they receive, that they are clear about the
pay differentials between surgeons and anaesthetists. Further services they are paying for, and that the advice is delivered by
advice can be obtained from the AAGBI. Additional NHS work highly qualified professionals. It is indeed difficult to argue with
is unpredictable, and may be one of the first things to be cut in that rationale.
times of economic pressure.
So what should you be considering as part of a
Medico-legal work financial plan for life?

This may include work related to civil claims, or the coronial We will start with the fundamentals: your NHS pension. This
system. It is not to be entered into lightly. The role of the expert is should be the foundation not only for your future retirement but
to provide advice to the court, and anyone considering this should also needs to be considered when you are looking to protect
prepare themselves carefully as to their duties and obligations. your loved ones. The scheme offers fantastic benefits. However,
Familiarity with the legal process and the rules of evidence is whenever we are looking at holistic planning these benefits
essential, as is the ability to write accurate and logical reports, need to be considered alongside any other complementary
and to give evidence. Professional training courses are available, arrangements you may have in place, or may need to put in
and for those with an interest it can be a fascinating experience. place, to make up any shortfalls identified during the advice
You are as professionally liable for medico-legal work as you are process.
for your clinical practice, and the witness box can be a lonely
place if you’re unprepared. The basics!

Despite what you may hear in the coffee room, there are no poor The NHS Pension scheme saw its biggest ever change on 1
consultants; although some may not be as well off as they’d April 2015 with the introduction of a brand new pension scheme
known as ‘The 2015 Scheme’.

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 For those members within 10 years of normal pension age as moving to the 2015 scheme will remain in the 1995 section or
at 1 April 2012 the changes in 2015 had no impact. There is 2008 section as appropriate. At retirement these benefits will be
some transitional protection for those who were aged between treated separately and calculated in accordance with the rules of
10 and 13 years and five months of their normal pension age the 1995 or 2008 section as stated above. If you choose to draw
on 1 April 2012 and these individuals will transfer to the new your 1995 benefits you will not be able to continue membership
scheme at a later stage on a transitional basis giving them of the 2015 Scheme, however if you have benefits in the 2008
additional protection. However, anyone younger than this will section, and choose to draw these, further membership in the
have transferred to the new NHS Pension scheme automatically 2015 scheme can continue.
on 1 April 2015.
Anyone who has added years in place will be able to continue
For those members with full or transitional protection the date at with this arrangement until the normal contract end date at 60
which you originally joined the scheme determines the section or 65. You will be able to draw these benefits in isolation and
of which you will be a member. If you joined the NHS pension continue to accrue benefits in the 2015 scheme if you wish.
scheme for the first time before 1 April 2008 then you will be a
member of the 1995 section. If you joined after this date then you The 2015 pension scheme will have a normal pension age which
will be a member of the 2008 section. All 1995 members were is linked to your state pension age, which for some will be 68
given the choice of moving to the 2008 section when it was first (this can of course change in the future), and your benefits at
introduced and 1995 members who hadn’t got ‘full protection’ retirement will be calculated based on your career average
were given a second chance to retrospectively move their 1995 earnings rather than your final salary. These earnings will be
service to the 2008 section. They would then have service in the revalued by inflation (CPI) plus 1.5%.
2008 section up to 31 March 2015 and move into the new 2015
scheme on 1 April 2015. It is very important to note that it is certainly not all bad news. As
stated above, all benefits accrued up until 1 April 2015 are fully
While the two sections have some specific variables they are protected and will continue to be linked to your final salary at or
widely similar and are final salary defined benefit schemes. near retirement unless you have a continuous break in service of
This means that your pension at retirement is based on two key five years or more. This is known as final salary linking. The final
factors: your whole time equivalent pensionable income in the salary is the best of the last three years pensionable pay in the
years leading to retirement, and your years of scaled service. The 1995 section or the average of the best three consecutive years
benefits are guaranteed, index-linked and carry no investment pensionable pay out of the last ten in the 2008 section.
element. Overall both sections offer excellent benefits. As well
as offering a superb pension income in retirement, both sections With careful forward planning this means that you can still
offer additional benefits for spouses, partners and dependents. retire at a time of your choosing but you really do need to start
In addition, in the event of permanent illness which renders you thinking ahead. The NHS pension scheme offers an option to
unable to work, an enhanced pension can be payable for life, enable retirement at age 65 known as ERRBO (early retirement
and in the event of a terminal illness your whole pension can be reduction buy out). This is an option for you or your employer
taken as a lump sum which is normally tax free. to pay additional contributions to buy out the reduction that
would apply if benefits were claimed before normal pension age.
While there are some small variations, the key differences Normal pension age in the 2015 scheme is the same as state
between the 1995 and 2008 sections of the NHS pension scheme pension age and as such can rise during membership if the state
are the age at which you can draw benefits without penalty and pension age rises. The agreement can be for early retirement up
also the way in which the benefits accrue. to three years before your normal pension age but no earlier than
age 65. The rate of additional contributions is based on your age
In the 1995 section you can draw your benefits without penalty at at the effective date of your agreement and costs can be sought
age 60, albeit you have a protected right to draw these benefits from the relevant NHS pensions agency.
from the age of 50, with an actuarial penalty, as long as you were
an active member of the pension scheme on 5 April 2006. These ERRBO is only one of a number of planning considerations which
taxable benefits accrue at a rate of 1/80th of your pensionable may or may not be appropriate, and a combination of solutions
pay for each year of service. Your pensionable pay is deemed may offer the most flexible outcome. This is particularly the case
to be the best of the last three years’ notional whole-time pay. In if you would like to retain the flexibility or choice to retire at age
addition you will receive a tax-free lump sum of three times the 60.
amount of your pension. Each day of service is counted towards
this and if you are working part-time you can rest assured that The benefits available in the 2015 scheme in the event of ill health
you are not penalised, as your part-time service is scaled to its and death are broadly similar to those available in the 1995 and
whole-time equivalent. This gives great options for those who 2008 sections. However, any lump sum and/or any adult or
want more flexible careers. At retirement you can take a larger survivor pensions payable are calculated using relevant earnings
lump sum if you wish, but in doing so you will forego part of your in the 2015 scheme only, rather than in accordance with the
pension. This decision is not taken until retirement so you can relevant 1995 or 2008 section regulations. This means that any
determine the best course of action at that time depending on complementary protection you have arranged privately will need
your personal circumstances and wishes. to be reviewed to ensure it is still at an appropriate level.

In the 2008 section you can draw benefits without penalty at age On a separate, but related, point there were further announcements
65; albeit you can take these at any time from age 55 if you are in the Chancellor’s 2014 Autumn Statement and 2015 Budgets
prepared to accept a penalty for doing so. These taxable benefits around the way in which pension benefits are taxed. While many
accrue at a rate of 1/60th of your reckonable pay at retirement assume this only affects the very high earners or those nearing
and there is no automatic lump sum payable although, as with retirement this is not necessarily the case.
the 1995 section, you can give up part of your pension for a tax
free lump sum. Reckonable pay is the average of the best three There are two key allowances we need to consider. These are the
consecutive years in the last ten, increased in line with inflation. lifetime allowance and the annual allowance.

Around 75% of pension scheme members transferred to the The lifetime allowance does not have an impact until retirement
new pension scheme on 1 April 2015 which runs alongside the and is measured based on the amount of pension benefits you
existing NHS pension scheme. The benefits you built up prior to build up over your lifetime. This allowance has been reduced to

88 THE GAT HANDBOOK 2016-2017

 £1.25m on 1 April 2014 and is set to reduce again to £1m on 1 financial adviser that they understand the benefits provided and
April 2016. While on first observation this seems like a significant how they will impact on your long term financial future. Your
amount of pension benefit, for a member of the 1995 section career path will undoubtedly have an impact on your future
retiring after 1 April 2016 this equates to a pension of £43,478 per pension entitlement and taking advice from a specialist who
annum. While no one will argue that this is a healthy pension, it understands the intricacies of this is paramount.
is now below the average pension for an anaesthetist, and does
not make any allowance for any private pension arrangements, Other areas for consideration
added years, or additional pension purchase you may have. If
you are making any private pension arrangements it is therefore Financial planning should always be viewed on a holistic basis
essential that you assess the future suitability of these plans. as when any plan of action is implemented it will almost certainly
Rash decisions to cancel plans should not be made, but you have an impact on other areas. Protecting yourself and your
must check your current position to ensure you do not incur any loved ones is of vital importance. Ask yourself the question, how
unnecessary and unexpected tax charge at retirement. Various would you or your family cope financially if you were seriously ill
protections are available against reductions to the lifetime or even passed away?
allowance and advice should be sought if you believe you could
be affected by these changes. So what do you have in place already?
You will be entitled to a period of sick pay from your employer
The annual allowance is potentially more of a concern for all depending on your length of service. This builds up to a maximum
ages of doctor. The annual allowance limits the amount of tax of six months’ full pay followed by six months’ half pay once you
allowable pension benefits you can accrue and the method of have attained five years’ continuous service within the NHS. If
calculating this in the NHS pension scheme is complex. The you are still incapacitated after this point you can be assessed
annual allowance limit was reduced to £40,000 on 1 April 2014. for a long term ill health pension but the illness must be deemed
While a tax charge for a doctor in training is not common, those to be of a permanent nature.
individuals who receive an increment or promotion will need to
check their position carefully. In the event of your death your NHS pension also provides your
family with some excellent additional benefits such as a death
The NHS pension scheme will inform any member who exceeds in service lump sum, plus a short term pension of six months’
their annual allowance so they can incorporate this information pensionable pay. If you have more than two years’ pensionable
on their self-assessment tax return. It is possible to utilise any service, your spouse, partner and dependent children will also
unused allowance from up to three previous years and for the subsequently be entitled to a long term pension, which can be
vast majority of trainees this should cover any excess and as a invaluable. If you are not in a legally recognised relationship (i.e.
result avoid a tax charge. If, however, anyone is in the position marriage or civil partnership) and want to ensure your partner
where they have incurred a tax charge of more than £2,000, receives these benefits it is essential that you complete a
which is unaffordable, they can opt to have this tax charge taken nomination form and register this with the NHS pension scheme
from their future pension benefits at retirement. This should not as this entitlement is not automatic.
be a decision that is taken lightly as there are punitive interest
charges applied and any decision, once taken, is irrevocable. While these benefits are excellent will they be enough?
A quality financial adviser will calculate the financial value of the
A further and more complex announcement was made in the above benefits and discuss and determine with you whether
2015 Summer Budget for higher earners. From April 2016 a these are sufficient to maintain your lifestyle in the event of an
tapered reduction to the annual allowance will be introduced illness, or even death.
where an individual meets two specific criteria. The first is if
the ‘threshold income’ (total income before tax less individual It is often necessary to protect yourself further, and equally as
pension contributions) exceeds £110,000. The second is if the important to consider protection needs for your spouse or
‘adjusted income’ (total income before tax, plus all pension partner, even if they are not working themselves.
contributions, including the value of employer contributions)
exceeds £150,000. If both of these criteria are met, the individual • Mortgage protection – You will almost certainly need to
will have their annual allowance tapered down. For every £2 of consider ensuring any mortgage and liabilities are protected
adjusted income in excess of £150,000 the annual allowance will against death and/or critical illness
be reduced by £1 down to a minimum of £10,000. In other words,
anyone with adjusted income in excess of £210,000 will have a • Income protection – As a priority in the event of any long
reduced annual allowance of £10,000. term illness which stops you working, you should consider
protecting your income with a plan which complements
In addition, for all pension scheme members, all pension input your NHS sick pay benefits. This should certainly offer
periods will be aligned with the tax year. A pension input period ‘own occupation’ terms which reflect your career as an
is the period over which the amount of pension saving (pension anaesthetist and in the event of a claim will continue until
input amount) under an arrangement is measured. Currently you are fit enough to return to work, reach retirement age
within the NHS pension scheme this period is 1 April to 31 March. under the plan, or die. If you have transferred, or will be
This area is incredibly complex, particularly the transitional transferring, to the 2015 pension scheme, any existing
arrangements relating to the 2015/16 tax year. Anyone affected income protection should be reviewed to ensure it is still at
by these changes should seek advice from their accountant in an appropriate level. This is simply because the method of
the first instance. calculating any ill health retirement benefits has changed
under the new scheme, and in addition your pension
In recent press coverage there has been lots of talk of members benefits will not be paid until you are older meaning your
leaving the NHS pension scheme and considering alternative income protection will need to cover you for longer
solutions, however this is certainly NOT the most appropriate
choice for the majority of people and should only be considered • Serious illness cover – This complements your income
in the most exceptional of circumstances. protection cover and pays out a lump sum on diagnosis
of one of a specific list of serious illnesses. This will pay
The NHS pension scheme (and the equivalent Scottish and out even if you are able to continue working. If however
Northern Ireland versions) and the legislation surrounding you are not able to work, a long term or permanent illness
them, are extremely complex. It is essential when choosing your means your pension will not continue to accrue and you

89 THE GAT HANDBOOK 2016-2017

 may need to consider providing yourself with a means to Finally it is very important to ensure you have made a will. Many
maintain your lifestyle and income in retirement, once assume that their estate will pass to their loved ones automatically
your income protection plan’s benefits cease. This type in the event of their death. This is not always the case, and in any
of cover also gives you significant lifestyle choices. If event dying intestate causes much unnecessary stress for those
you recover you may want additional time off work to left behind.
recuperate from a serious illness such as cancer, or may
want the option to return to work in a part-time capacity As you can see financial advice can be complex, but a well
until you feel stronger following a heart attack, for example qualified, independent financial adviser who is a specialist in
dealing with doctors will be able to guide you and assist you in
• Life insurance to protect your loved ones – While the NHS making a plan for life.
provides a death in service benefit, you need to ensure this
is sufficient to maintain the lifestyle of your family should you Andrea Sproates
pass away Head of BMA Independent Financial Advice at Chase de Vere

90 THE GAT HANDBOOK 2016-2017

 ABBREVIATIONS
AAGBI Association of Anaesthetists of Great Britain and Ireland

ABRA Association of Burns and Reconstructive Anaesthetists

ACCS Acute Care Common Stem

ACTA Association of Cardiothoracic Anaesthetists

APA Association of Paediatric Anaesthetists

ANZCA Australian and New Zealand College of Anaesthetists

ARCP Annual Review of Competency Progresison

ASCAB Armed Services Consultant Advisory Board

BADS British Association of Day Surgery

BLTC Basic Level Training Certificate

BMA British Medical Association

BOAS British Ophthalmic Anaesthesia Society

CAI College of Anaesthetists of Ireland

CCT Certificate of Completion of Training

CT/CAT Core Training/ Core Anaesthetic Training

DAS Difficult Airway Society

DMAP&CC Department of Military Anaesthesia, Pain and Critical Care

DMS Defence Medical Services

DPMD Defence Postgraduate Medical Deanery

EACTA European Association of Cardiothoracic Anaesthesiologists

ESRA European Society of Regional Anaesthesia

FCAI Fellowship of the College of Anaesthetists of Ireland

FFPMRCA Fellowship of the Faculty of Pain Medicine at the RCoA

FICM Faculty of Intensive Care Medicine

Fellowship of the Royal College of Anaesthetists
MCQ Multiple Choice Question
OSCE Objective Structured Clinical Exam
FRCA
SAQ Short Answer Question
SOE Structured Oral Examination
SBA Single Best Answer
FTTA/FTSTA Fixed Term (Specialty) Training Appointment

FY1/2 Foundation Year 1/2

GASACT Group of Australian Society of Anaesthetists Clinical Trainees

GAT Group of Anaesthetists in Training

GMC General Medical Council

IACC Initial Assessment of Competence Certificate

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 ABBREVIATIONS
ICACCST Intercollegiate Committee for Acute Care Common Stem Training

ILTC Intermediate Level Training Certificate

IRC International Relations Committee

JDC Junior Doctors Committee (BMA)

LAT Locum Appointment for Training

LETB Local Education and Training Board

LTFT Less Than Full Time

MA Maternity Allowance

MCAI Membership of the College of Anaesthetists of Ireland

MMC Modernising Medical Careers

NACCS The Neuro Anaesthesia & Critical Care Society of Great Britain and Ireland

NIAA National Institute of Academic Anaesthesia

NIMDTA Northern Ireland Medical and Dental Training Agency

OAA Obstetric Anaesthetists Association

OAF Overseas Anaesthesia Fund

OOPE/T/R Out of Programme Experience/Research/Training

PHEM Pre Hospital Emergency Medicine

RA-UK Regional Anaesthesia UK

RCoA Royal College of Anaesthetists

SAT Specialist Anaesthesia Trainee

SCA Society of Cardiovascular Anaesthesiologists

SMP Statutory Maternity Pay

SOBA Society for Obesity and Bariatric Anaesthesia

ST Specialty Trainee

STAT Society of Tri-Service Anaesthetists

TSAS Tri-Service Anaesthetic Society

UKOFF UK Offers System

VASGBI Vascular Anaesthetic Society of Great Britain and Ireland

Work Place Base Assessments
A-CEX Anaesthetic Clinical Evaluation Exercise
ALMAT Anaesthetic List Management Assessment Tool
ICM-ACAT Acute Care Assessment Too for ICM
WPBA
DOPS Directly Observed Procedural Skills
CBD Case Based Discussion
MSF Multi Source Feedback
CSAF Clinical Supervisor’s End of Unit Assessment Form
WTE Whole Time Equivalents

92 THE GAT HANDBOOK 2016-2017

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AAGBI www.aagbi.org
GAT [email protected]

www.aagbi.org/professionals/trainees