In the UK, the route to Emergency Medicine Consultantdom starts after foundation training, with a three year funfest commonly known as Acute Care Common Stem, or ACCS. It’s a shared pathway for doctors wishing to specialise in emergency medicine, anaesthetics, or acute medicine. The first two years comprise four 6-month blocks of each of those plus intensive care, and the final year is a whole 12 months of your chosen specialty. The aim is to give doctors a solid grounding in the acute specialties, as there is considerable crossover, and many transferable skills regardless of where you end up.
For those trainees ‘badged’ as emergency medics, your final ACCS year (called ST3*) is therefore spent in an emergency department. Six of those months must be specifically tailored to gaining paediatric emergency medicine (PEM) experience. In much of the country this will take place in a designated Children’s Hospital, but this isn’t always possible and so otherwise you’ll likely work paediatric shifts in a general ED where there is an emergency medicine consultant who subspecialises in PEM to mentor you.
In the realms of Virchestershire, we have a fantastic introduction to ST3 programme designed and led by EM registrar and medical/simulation educationalist extraordinaire Kirsten Walthall. It’s a three day extravaganza with talks from trainees, medical discussion, leadership and teamwork building exercises, simulation and so much more. The aim is to build confidence in leadership and paediatrics, through discussion and sim based on real cases. It also gives a great chance to meet people you’ll be working more closely with during the year. Kirsten was obviously exceptionally desperate this year, so I’m giving the ‘Intro to ST3’ talk, and this is the first blog post to accompany it, focusing on the portfolio. It will be relevant to most UK trainees, but is tailored to the new EM ST3s.
Having just finished my ST3 year, here are my top ten tips for a great portfolio, hope they help.
- Print out the ARCP* Checklist, and pin it to your forehead
Ok, bit extreme, but you definitely need to know what’s on the checklist. You can find it here in glorious technicolor. There are both paediatric and adult competences you need to get completed, and if like me you did six months general followed by six months paeds, you absolutely have to get your adult competencies signed off before you forget what adult patients look like for half a year. This is what they want to see at ARCP, so just go through it.
- Don’t be afraid to ask for supervision
In a busy department, it can be all too easy to just get on and cannulate a child, drain that subungual haematoma, or glue the wound. But these are competences you need to get completed, and even if you’ve done it all before, your consultant or senior nurse will definitely have some helpful hints to make it easier or better the next time. Go and grab them, they’re there to help you learn and make you into a better doctor, and lots of them really do love teaching.
- You don’t have to wait for the really interesting cases
There are lots of presentations and DOPS to get signed off, both in children and adults. But keep it simple. You don’t need a penetrating injury with bilateral haemothoraces needing trauma drains to get your chest trauma competency signed off. That lady whose chest is a bit bruised after she fell over is suitable. Equally a pea in a nose counts for ‘ENT’, mild croup counts for ‘apnoea, stridor and airway obstruction’, and you can do an airway assessment in anyone with burns or an allergic reaction. It doesn’t have to be severe, and it’s probably better if it isn’t because you’ll have more time to get your boss to watch you do it well. If you’re an anti-sh*t-magnet like me, don’t forget you can use teaching and e-learning to fill some of the harder-to-get presentations, such as paediatric blood disorders, anaphylaxis, and cardio-respiratory arrest (the APLS is good for this too). Don’t forget to reflect on these, either informally or using a reflective tool, such as these. It adds value to your learning and makes it easier for assessors at ARCP.
- Do ESLEs properly
For me, the Extended Supervised Learning Event assessments were the most useful. I had a fantastic supervisor who took 2 hours off the shop floor for each one to follow me around exclusively and watch everything I did, whilst remaining non-clinical, not letting other people ask him questions, and staying fairly invisible. If I needed advice, I’d have to ask a different consultant so he could observe. On top of this, I really tried my absolute hardest to just work as normal.
Other assessments just provide a short, brief snapshot of what you’re doing. ESLEs, when done well, give insight into how you interact with the team, other colleagues, how you manage your workload, write your notes, prioritise patients. I gained feedback which has changed my practice and highlighted things I do well, and things I need to work on, that I would never have known about otherwise.
I would highly recommend you follow the same approach with yours, and where possible do both ESLEs with the same supervisor, as this can allow them to focus more on different aspects in each encounter. You can always do more than two as well…
- Make sure your ‘A’ courses are up to date
To pass ST3, you need to have all three of ALS, ATLS (or ETC), and APLS (or EPLS), and they all must be in date! It’s highly likely therefore that at least your ALS will be up for revalidation, so make sure you check it and book it early as it can sometimes be difficult to get a place. It’s a good opportunity to potentially become an ALS instructor as well if you aren’t already, which can really help with your confidence in the resus room, and teaching generally, if that’s your sort of thing.
- Book your exams
If you’re not already up to date with MRCEM*, or FRCEM* Primary/Intermediate, then you need to be by then end of ST3. You’ve only got 2 chances for MRCEM Part C before the ST3 ARCP next year, and only 1 to complete the FRCEM Intermediate. Get on it. Upload your certificates and get your supervisor to verify them.
- Safeguarding Children Level 3
Can be done online at the e-Learning for Health website, or there are some great face-to-face courses. Depending on where you work, some deaneries are keen that trainees attend the face-to-face days, so just check early as again, they book up quickly and you’ll need to work it into your study leave. Remember to upload your certificates and again, get them verified.
- Practical procedures
Some of the paediatric practical procedures are things you’ll likely never do. Intubate a child. Thoracostomy and chest drain. Even some of the consultants I work with at a large tertiary children’s hospital have never defibrillated a child, because it’s so rare they’re in a shockable rhythm. But don’t forget you did all these things on your APLS course, so link it in. The ARCP panel want to see things linked to each point on the curriculum, so if you find you’re missing a few, do some reading, watch some videos on the internet, write a reflection on your learning, and link that.
- Audit and Management
You’ll need an audit, so start it early, which is something I’m sure you think every year and then rush to get it completed in the last few weeks. Have a think now what audit you might like to do, email your next supervisor to see if they have anything that needs doing, and if all else fails, get involved in the college audits.
The checklist also lists ‘evidence of management project(s)’, which can be something as deceptively simple as organising the rota for a block, or something as deceptively boring as investigating a complaint and writing a formal response. I’ve done both so far as a trainee, and really found responding to a complaint interesting and educational, as well as making me think more about what I write in the notes.
- Organise your library
A good ST3 folder in your personal library on the portfolio will help greatly when it comes to ARCP, not only for you to easily see what you’ve uploaded and what you’re missing, but also for the panel to do the same. This is what mine looks like, so feel free to copy or choose your own setup, but definitely put in an ‘ARCP’ folder with things like your Form R, GMC survey confirmation, and the completed ARCP checklist.
Hopefully this gives you some tips on how to use your portfolio and making the most of the learning opportunities you can get out of the next twelve months. Please feel free to comment below if you’ve got further advice for your colleagues, on anything you think I’ve missed, and look out for the next post with some clinical hints and life pointers to get you through your ST3 year.
All the best, good luck, and look after yourselves and your team,
*Quick note on some of the terms used for our non-UK readers
ST3 means specialty trainee grade 3, which is the third year of specialty training and happens after two foundation years (i.e Foundation 1 and 2, then ST1, 2 and 3 etc…). Emergency Medicine trainees can choose to have a full “run-through” training program, in which case will be labelled ST, or to do what most other specialties do where after two or three years of core training, they reapply for a registrar (resident) post. These trainees will therefore be labelled CT and so some trainees at this level will be CT3 rather than ST3. It is essentially a technicality and there is no difference between the two for the purpose of this post.
ARCP stands for Annual Review of Competence Progression which all trainees must pass to move onto the next year of training. There are guidelines as to what each grade of trainee must achieve to pass their ARCP. Alan has written about this for St.Emlyn’s a few years ago and you can check this out here.
MRCEM and FRCEM are our Membership (old) and Fellowship (new) examinations of the Royal College of Emergency Medicine. The FRCEM is made up of several components which are spread over the course of training and must all be passed to complete training and become a consultant.
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