Now a number of years ago now I took the decision to resign from my training programme. To cut a long story short I wasn’t happy. In fact I was totally miserable with almost everything and I was self destructing quicker than the tape message from Mission Impossible. Luckily with the help of very patient and supportive colleagues I’m on top form and enjoying work and life again.

Following my resignation I was very lucky to be given the chance to work at Manchester Royal Infirmary and joined a programme called the SET (Senior Emergency Trainee) Programme. This was set up a number of years ago for people wanting to train in emergency medicine but for whatever reason were not on a formal training programme. Recently I’ve noticed there are a number of other hospital providing similar programs and there’s been much chatter about CESR. Having been less than conventional (that’s the term I’m sticking to) I’m at the point of applying for CESR in the coming months and I’m getting my portfolio together

CESR you say?

It’s not a roman emperor, nor is it a salad… CESR is the Certificate of Eligibility of Specialist Registration. This is the process by which people who have not undertaken formal deanery training (or those who have but not completed all of it) can show equivalence and be eligible for a substantive consultant post in the NHS.

This includes doctors who have trained outside of the UK wanting to work as a consultant in the NHS as well as those working in the NHS who haven’t got a training number.

It’s a long process, a costly process and a rather stressful one. I think it’s absolutely right however that the process is robust as it is as it’s designed for us to show that we have had an equivalent training and have accrued the correct knowledge, skills, attitudes and behaviours to enable us to function safely as a consultant in the NHS.

I came in to this thinking that it’s all a bit scary. It’s the culmination of a lot of years work and effort. Im going in pretty blind (all be it in a department that’s put a lot of people through the process) so I thought I would give you my thoughts on the whole thing. This will be the first post of a few I suspect and will be mainly about my general approach to the application. As I get further on with it I’ll do some more posts about specific parts of the CESR application.

So…What exactly do you have to evidence?

Essentially the GMC and College need you to show that you have the skills and knowledge to be a consultant. You need to provide evidence and show experience in Emergency medicine at a middle grade level and can show that you have the knowledge as set out in the curriculum. You have to show you have developed and maintained your critical care skills as well as paediatric EM (and acute medicine… and ultrasound… and anaesthesia…and have teaching experience…and management experience…and that you have a thank you card and testimonials from colleagues and the list goes on)

Seems like a massive task but if we’re being totally honest the evidence they want from you is that of a traditional trainee plus some extra stuff about the types of jobs you’ve done and the rotas of those jobs. Remember many CESR applicants are not necessarily UK/NHS trained doctors so knowing the type of emergency department and the numbers of patients you see could be important in the judgement)

It seems like a massive amount of stuff to collect but I’ve come to realise something…

YOU DON’T NEED EVIDENCE IN EVERY PART OF THE APPLICATION!!!

I really REALLY freaked out when I first saw the application. I don’t have case histories, I’ve never won a prize (unless the GMC count bingo) and I’ve never spoken at an international conference although StEms have been very good in giving me opportunities to speak at nationally. I’ve also never produced an MD, a PhD or submitted any original research… to any journal… ever. I certainly haven’t been keeping a logbook of my procedures as I’ve been too busy doing them. However, I have taught students and doctors and have good feedback from them, I’ve been on medical education courses, I’ve done my CTR (and the rest of the exams) I’m working on my MSc (which involves submitting evidence based case studies), I’ve produced and checked BestBETs and reviewed articles submitted to the EMJ for publication. I guess what I’m trying to say is recognise some of the things you have done and use them in your application. It’s easy to forget stuff you did years ago but it can all count.

SO.. after the freaking out stage I looked at the guidance more closely I have calmed down a lot since. They make it quite clear you don’t need evidence in every section of the porfolio which is good.. because I don’t. In particular having spoken to someone who has recently completed CESR  without one, I’m not panicking about my lack of a logbook. I have lists of my patients (anonymised) I’ve seen over the past few years but no detailed log book. I’ve been reassured by a CESR assessor that that’s ok.

Some things are however necessary.

Although the exams bizarrely are not a requirement, you do need to have completed ALS, ATLS (or ETC) and APLS. As well as this you have to have evidence of your anaesthetic and critical competences and to have Ultrasound evidence. I’m lucky to have got my anaesthetic competence sorted during ACCS but for those who haven’t done this I strongly advise that you find a place that will give you anaesthetic and ICU experience so that the competencies can be signed off formally and you can get a nice certificate of anaesthetic competence.

My ACCS training was some time ago and as such my anaesthetic competencies were gained some time ago too but I’ve tried to show I have maintained competence by using the ePortfolio RSI audit forms and WPBA of my RSI’s and sedations at work. The ultrasound evidence is in the form of the RCEM Learning Modules, a Level 1 course and the triggered assessments. You don’t necessarily need to go to a finishing school or get formal sign off but I’m sure it wouldn’t harm your application.

Start getting your evidence EARLY.. like 6 years ago.

The indicative length of training is 6 years so showing that you’ve been able to accrue the knowledge a trainee would over that period of time is a must. Older evidence does not hold as much weight as newer evidence (something I’m acutely aware of since my initial anaesthesia and ICU is from some time ago). Similarly evidence over a number of years rather than all in the last year looks better. I’ve kept a CPD diary with the college and used the College ePortfolio for my WPBA. This was incredibly sensible of me although I didn’t realise it at the time. I would suggest anyone thinking about training non-conventionally and applying for CESR should use the college ePortfolio and collate CPD using the RCEM Learning platform (don’t forget StEmlyns blogs/ videos and the ebooks all count towards CPD when you reflect on it!). The College and GMC guidance advocates for the use of RCEM Learning modules as a good source of evidence.

The GMC and College have websites… use them

I found this pdf on the GMC website which has been really useful. It tells you what sort of things are appropriate for evidence and importantly where failed attempts go wrong. Surprisingly the most common problem is failing to show knowledge of emergency medicine (go figure). This could be avoided by passing the exams I suspect and having spoken to a few doctors who have gone through the process (some with the exams and some without them) it seems that having the MRCEM and FRCEM (or rather just the new Fellowship exam) makes the whole application a lot easier. 75% of the application is dedicated to Domain 1: knowledge, skills and performance. Having exams showing your knowledge is a huge part of this. Without the exams you have to have multiple bits of evidence for every single bit of the entire curricula and triangulate this with patients you’ve seen and CPD.. all very hard work and very time consuming.

“Domain 1” you say…what’s that?

This is where I should probably explain how the portfolio is arranged. The CESR portfolio is split into different dividers  (currently 54) which hold different types of evidence e.g appraisals, awards and prizes, teaching etc. Multiple evidence dividers then come together to form the evidence for a Domain. There are four domains that you need to provide evidence for which are

1.Knowledge, Skills and Performance
2.Safety and Quality
3.Communication, Partnership and Team work
4.Maintaining Trust

If they sound familiar (and they should do) it’s because they form the basis of the GMC’s Good Medical Practice guidelines. Although you don’t need evidence in every divider you most certainly need to provide evidence for each Domain.

Working in the UK has it’s benefits.

Believe it or not part of the portfolio is showing evidence of regular appraisal and assessment. I guess this is because regular appraisal and assessment will (or should) highlight issues with doctors and more importantly give a long term view of a doctors practice. Everyone in the UK has to have a yearly appraisal so this part is easy. Just download you appraisal documents and stick ‘em in the divider. Having said that, some online portfolios are geared specifically for revalidation. This will often allow you to split your appraisal and revalidation evidence into different dividers which means that you may be able to provide evidence in multiple GMCs domains. if you can’t split the evidence then you can just cross reference it in the on line application.

Online application?

Yep… so I didn’t realise this but as well as collating a paper portfolio  (paper?… I’ll get to that) you need to complete an online application which outlines all the bits of evidence in each divider that you’re putting into the portfolio. It’s quite simple to do although I’ve found that you can run out of space in the boxes if you put too many words in. To combat this I’ve taken to writing ‘RCEM Learning certificates x 60’ etc. rather than being explicit about each certificates content.

I thought I could just send them my RCEM ePortfolio and be done.

Although I have an ePortfolio the GMC expect us to send paper copies of evidence in the dividers that they suggest. There are a total of 54 separate dividers which form the evidence for the four different domains. There is some overlap and it’s important to cross reference things. For instance the results of your MSFs over the years will provide evidence for your clinical competence, but will also show the assessor evidence of your ability to work in a MDT setting. Cross referencing is key here and be brazen about about.

Paper is a bit old fashioned ain’t it?

A paper portfolio is easier for many applicants as many won’t have access to an ePortfolio. Also there’s actually more to the CESR application than just the college ePortfolio.

You have to check each piece of paper to ensure it has no patient identifiable details on it. I have been told that a black crayon is the best way to obscure the details as a black marker may not fully mask the details when it gets photocopied. Previously the GMC guidance mandated we get each piece of paper validated by a hospital stamp, a signature of the consultant and their role. This is rather burdensome I can tell you having stamped half of my portfolio already, however from March this year things have changed (D’oh).

Instead of posting all your evidence to the various hospital in the hope it gets to the right doctor, you have to complete a further form for each hospital at which you generated evidence. This form needs to outline the evidence you are providing for  that hospital placement and the name and contact details of the validator at that hospital. This is so the GMC can contact them.Although this is a change I think it will be as equally robust and far less onerous for the validators. Validation has always been the most onerous part of the application but probably the most important. Doctors applying for CESR may be from outside of the UK with a less standardised appraisal process and no revalidation. I also understand that some people are not honest and may fake evidence. Ultimately the GMC have a responsibility for patients safety and if they can’t guarantee the provenance of the evidence they wont accept it.

Validator or Authenticator?

A Validator is anyone who can confirm that the evidence is yours and a true reflection of you at the time. For instance, your educational supervisor can validate your WBPA for the year you spent at that hospital but not at the other hospital. A trust administrator would be able to validate your employment contract but not your arterial line DOPS. The validator has to be from the hospital in which the evidence was accrued on the whole. An Authenticator however is someone (usually a solicitor) who can confirm the provenance of a significant piece of evidence. This might be a post graduate examination or PhD. If you have non-RCEM exam or degree certificates these need to be authenticated by a Solicitor (which costs money). Luckily the College will confirm the authenticity of your membership and fellowship exams and if you’re already registered with the GMC they will have seen your original medical degree certificate so there’s no need to shell out for that at least.

What about over in Australia..? Here’s where I hand over to Natalie May

Getting FACEM recognition in Australia after FRCEM is a similar process, so I definitely empathise!

Once arriving in Australia as a UK-trained consultant, there are a couple of things you need in place in order to work – scratch that – in order to be paid as a consultant (lots of places will happily employ you on a temporary basis, on their consultant roster, because until you have specialist registration you don’t qualify for staff specialist [consultant] pay and you are ineligible to apply for visiting medical officer [VMO; casual or locum consultant] posts).

You’ll need to start the process with general registration with AHPRA – this requires an allocated supervisor, a few forms and 12 months of “supervision”. Not a huge deal assuming you have a job set up before you come (which you will need in order to get a sponsored visa, the quickest way in).

Getting FACEM involves sending a load of paperwork to the Australasian college of EM, something you can start while you are being supervised with provisional registration. Their website has a list of exactly what they want, but similar to the CESR pathway it involves a lot of translation of stuff you already have (CV, list of jobs you’ve done) into ACEM’s pre-specified format. They want things like job descriptions, numbers of attendances at departments you’ve worked at, and that sort of thing. They’ll also want evidence you understand research processes – I sent my MSc dissertation, which was based on my CTR, but there are tales of the CTR alone being insufficient so this may cause further issues in future when UK trainees have QIPs instead of CTRs. Time will tell…

The paperwork I posted weighed 2.1kg (I remember from the time I took it to the post office!). With the submission of this paperwork comes a hefty fee, for assessment of your paperwork (a smaller proportion), and for your structured interview (a larger proportion). The college will then send you an interview date – these occur a few times a year and are limited in number, so you might have to wait a number of months for your assessment. At the interview, a panel of fellows of the college take you through the elements you have submitted with the aim of establishing whether you are truly equivalent to an Australian trained EM physician.

It may then take a few months to hear the outcome of the panel (mine was in October, I received a decision in December – fortuitously before Christmas, as much of Australian admin shuts down for Dec/Jan, the main summer holiday of the year). The outcome of equivalence is usually conditional upon a further period of supervised practice in an ED. The minimum the college will suggest is 3/12 but in reality this is exceptional – almost everyone must do 6/12 supervised practice. If you are already working in an ED (which might be on a consultant roster but will be at registrar pay), you may be able to arrange the supervision element – the college has to sign off on your supervisors and you must then complete a number of assessments during your supervision period. Most are “shift reports” (similar to an ACAT), plus some structured references and a DOPs for intubation/RSI/ED airway management is usual, since this is the responsibility of the EM team in Australia (rather than anaesthetics/ICU).

Once your supervised period is completed, and your paperwork is in, it is reviewed at the next meeting of the committee of the college that deals with international medical graduates (IMGs), which might be soon… or not. If they accept your application to fellowship (hurrah!) there’s another few thousand dollars to pay (boo!) but ACEM will recommend to AHPRA (the registration people) that you are eligible for specialist registration. This is a relatively painless process, much like when RCEM recommends your entry to the specialist register to the GMC.

Then all you need is a job…!

Cheers Natalie…back to the UK now…

Guess I’d better get started then!

Over the coming months I’m going to be collating, filing, printing (thankfully no longer stamping) a lot of paper. Hopefully my portfolio will be good enough and as I get the various dividers coming together I’ll blog a bit more about the types of evidence I’ve put in. Eventually I’ll pay the £1600 to get it assessed and If it’s not ok I’ll be a shining example of how not to approach the CESR process… either way hopefully the blogs will be useful.

Gareth (and Nat)

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